nanaokunote

700263053

240830

[exam findings] (not completed)

• 2024-08-19 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A (minimal)
    • Esophageal varices, F1CbLi. RCS (-) White nipple sign (-)
    • Esophageal post-EVL scars, lower esophagus
    • Suspicious Gastric varices, GOV-2
    • Portal hypertensive gastropathy, s/p CLO test
    • Gastric ulcers, multiple, H1-2, antrum and pylorus
    • Duodenal ulcer, Forrest classification III, SDA.
  • CLO test:
    • Positive
  • Suggestion:
    • PPI use
    • Pursue the CLO test result
• 2024-08-12 Tc-99m MDP bone scan
  • Faint hot spots in both rib cages, the nature is to be determined (early bone mets, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
  • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, and knees.
• 2024-08-09 SONO - abdomen
  • Diagnosis:
    • Suspected cirrhosis with splenomegaly
    • Liver tumors, bil
    • Invisible right PV. Propable tumor invasion
    • Poor assessment of biliary tract
    • Small amount ascites
    • Pancreas and GB not shown
    • Suboptimal examination of liver, especially the subcostal view due to poor echo window (disruption of the transmission of US waves by bowel gas and patient’s body habitus)
  • Suggestion:
    • Please correlate with other image
    • Follow liver function test and AFP, CA-199, HBV, HCV
    • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
    • Because of cirrhosis and poor echo window, please regularly follow sono abd
• 2024-07-29 Patho - liver biopsy needle/wedge
  • PATHOLOGIC DIAGNOSIS
    • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated and see description
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consists of two small pieces of yellow gray soft tissue, labeled liver, measuring up to 1.0 x 0.1 x 0.1 cm. All for section.
  • MICROSCOPIC EXAMINATION
    • The sections show adenocarcinoma, poorly differentiated, composed of nests of large pleomorphic neoplastic cells, arranged in solid pattern with subtle glandular differentiation, embedded in fibrous stroma. Tumor necrosis is present.
    • IHC, tumor cells reveal: CK7(+), CK20(+), Hepa-1(-) and Arginase-1(-). the finding is compatible with cholangiocarcinoma.
• 2024-07-23 MRI - liver, spleen
  • History and indication:
    • Liver tumor
  • With and without contrast MRI of liver revealed:
    • Poor enhancing tumors in S1, S4 and right hepatic lobe. Liver cirrhosis with ascites and splenomegaly. Partial thrombosis of main portal vein. Thrombosis of right portal vein. Dilatation of right IHD.
    • Some LNs at retroperitoneum.
    • Multiple nodules at bil. lungs.
    • Small bowel ileus.
  • IMP:
    • Liver tumors with LNs and lung metastases, hypovascular HCCs or hepatocholangiocarcinomas should be ruled out.
    • Liver cirrhosis with ascites and splenomegaly. Partial thrombosis of main portal vein. Thrombosis of right portal vein.
    • Small bowel ileus. Dilatation of right IHD.
• 2024-07-23 KUB
  • Presence of ileus.
  • Degeneration and spondylosis of L-S spine.
• 2024-07-23 SONO - abdomen
  • Cirrhosis of liver
  • Multiple hepatoma with portal vein thrombosis
  • Splenomegaly
  • Accessory spleen
  • Ascites, moderate
• 2024-07-19 CT - abdomen
  • History and indication:
    • Abdominal Pain
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Poor enhancing tumors in S1, S4 and right hepatic lobe (up to 4.1cm). Liver cirrhosis with ascites and splenomegaly. Partial thrombosis of main portal vein. Thrombosis of right portal vein.
    • Some LNs at hepatic hilar region and retroperitoneum.
    • Multiple nodules at bil. lungs.
    • Small bowel ileus.
    • Atherosclerosis of aorta, iliac arteries.
  • Addendum Imaging Report Form for Cholangiocarcinoma
    • Impression (Imaging stage) : T:T2(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)

[chemotherapy]

• 2024-08-29 - gemcitabine 1000mg/m2 900mg NS 100mL 1hr + cisplatin 25mg/m2 23mg NS 500mL 3hr + KCl 15% 5mL MgSO4 10% 20mL NS 500mL 4hr (Gemzar 50% and Kemoplat 50% due to liver cirrhosis)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-08-12 - gemcitabine 1000mg/m2 900mg NS 100mL 1hr + cisplatin 25mg/m2 23mg NS 500mL 3hr + KCl 15% 5mL MgSO4 10% 20mL NS 500mL 4hr (Gemzar 50% and Kemoplat 50% due to liver cirrhosis)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

==========

2024-08-30

[Morphine and Tramacet Dosage Guidelines for Patients with Liver Impairment]

Morphine Dosage Adjustments for Patients with Liver Impairment:

• Child-Turcotte-Pugh Class A:
  • Oral, Parenteral, Rectal: No dosage adjustment is necessary; however, the dosing interval should be extended to a clinically appropriate frequency based on the indication and route of administration (e.g., extending the interval from every 2 to 4 hours to every 4 to 6 hours).
• Child-Turcotte-Pugh Class B:
  • Oral, Parenteral, Rectal: Reduce the dose to 50% of the usual indication-specific dose and extend the dosing interval to a clinically appropriate frequency (e.g., reducing the dose from 2 mg IV every 2 to 4 hours to 1 mg IV every 4 to 6 hours).
• Child-Turcotte-Pugh Class C:
  • Oral, Parenteral, Rectal: Use is not recommended; consider alternative agents that do not have active metabolites. If morphine use is necessary, reduce the dose to at least 50% of the usual indication-specific dose and extend the dosing interval (e.g., reducing the dose from 2 mg IV every 2 to 4 hours to 1 mg IV every 6 to 8 hours).

Tramacet (tramadol, acetaminophen) for adults with liver impairment: - Use is not recommended due to extensive hepatic metabolism of both acetaminophen and tramadol.

700293310

240830

[lab data]

2024-03-01 HBsAg Nonreactive
2024-03-01 HBsAg Value 0.39 S/CO
2024-03-01 Anti-HBs >1000.00 mIU/mL

2024-03-01 Anti-HBc Reactive
2024-03-01 Anti-HBc Value 5.37 S/CO

2024-03-01 Anti-HCV Nonreactive
2024-03-01 Anti-HCV Value 0.08 S/CO

[exam findings]

• 2024-07-29 CT - abdomen
  • Imp:
    • s/p LAR.
    • No evidence of recurrent/residual tumor in the abdominal cavity.
    • Non-specific lymph nodes at mediastinum.
• 2024-04-18 CT - abdomen
  • History and indication:
    • Adenocarcinoma of proximal S-colon, cT4aN2aM0, status post laparoscopic adhesiolysis and sigmoidectomy on 2024-01-18, pT3N0M0(0/15), G2, LVI(-), PNI(+), CRM(-), stage IIA (high risk), S/P FOLFOX
  • IMP:
    • S/P colon operation. No evidence of tumor recurrence.
    • Right renal cyst (1.2cm). Grade 4 fatty liver.
• 2024-01-19 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, sigmoid colon, sigmoidectomy —- Adenocarcinoma, moderately differentiated
      
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection —- Negative for malignancy (0/15)
    • Lymph node, IMA / SMA, dissection —- Not receivd
    • AJCC 8th edition Pathology stage: pStage IIA, pT3N0 (if cM0)
  • Gross Description:
    • Operation procedure: sigmoidectomy
    • Specimen site: sigmoid colon
      
    • Specimen size: 10.2 cm in length
      
    • Tumor size: 3.2 x 3.0 cm
    • Tumor location: 6.4 cm and 0.8 cm away from the two resection margins, respectively.
    • Depth of invasion grossly: mesocolic soft tissue
      
    • Mucosa elsewhere: congested
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as:
      • A1: colon, non-tumor; A2-5: tumor; A6-11: lymph node, mesocolic; B: proximal resection margin; C: distal resection margin.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved, Distance of tumor from margin: 7 mm
        
    • Lymphovascular Invasion: Not identified
    • Perineural Invasion: Present
    • Tumor Budding: Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 0/15
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        
      • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
      • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
      • Distant Metastasis (pM): if cM0
    • Additional Pathologic Findings (select all that apply): None identified
• 2023-12-29 Patho - colorectal polyp
  • Colorectum, sigmoid colon, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (-, loss), MSH6 (+), MSH2(+), MLH1 (+).
• 2023-12-29 CT - abdomen
  • Health exam and She is nearly asymptomatic. 20231229 colonoscopy: An annular tumor with lumen narrowing at S-colon. Indication: S-colon cancer, for staging.
  • Findings:
    • There is segmental circumferential asymmetrical wall thickening at the sigmoid colon, 5 cm in size, with irregular contour.
      • Adenocarcinoma of the sigmoid colon (T4a) is highly suspected.
    • There are four enlarged nodes in the adjacent mesocolon that are c/w regional metastatic nodes (N2a).
    • Two renal cyst 1.2 cm and 0.6 cm in right lower pole is noted.
    • There is fatty liver, grade 4.
    • S/P hysterectomy
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2023-12-29 Bone densitometry
  • Hip BMD performed by DXA revealed:
    • Left hip, BMD is 0.597 gms/cm2, about 2.3 SD below the peak bone mass (70%) and 1.1 SD below the mean of age-matched people (84%).
  • Impression
    • Osteopenia
• 2023-12-29 Colonoscoppy
  • The scope had been inserted up to cecum. An annular tumor with lumen narrowing was noted at sigmoid colon. biopsy was done

[MedRec]

• 2024-07-26 ~ 2024-07-29 POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • Adenocarcinoma of proximal S-colon, pT3N0M0(0/15), G2, LVI(-), PNI(+), CRM(-), stage IIA (high risk), status post laparoscopic adhesiolysis and sigmoidectomy on 2024-01-18, status post FOLFOX
    • Chronic viral hepatitis B without delta-agent
    • Insomnia
    • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
    • Polyp of stomach and duodenum
    • Polyp of colon
    • Type II diabetes mellitus
    • Encounter for antineoplastic chemotherapy
  • CC
    • For chemotherapy with C4D1 FOLFOX Q2W x10.
  • Present illness
    • This is a 59 year-old female without any underlying disease.
    • According to the patient, she noticed abdominal pain and fatigue 2 weeks, so she visited OPD for help. At OPD, health examniation was recommened and colonoscopy conducted on 2023/12/29 accidentally showed an annular tumor with lumen narrowing ar sigmoid colon, and biopsy was conducted at the same time, which showed adenocarcinoma of sigmoid colon. Abdomen CT on 2023/12/29 showed segmental circumferential asymmetrical wall thickening at the sigmoid colon, 5 cm in size, cT4aN2aM0, with irregular contour. The sigmoid colon biopsy showed Adenocarcinoma. IHC stains: EGFR (+); PMS2 (-, loss), MSH6 (+), MSH2(+), MLH1 (+).
    • She received the operation of laparoscopic adhesiolysis and sigmoidectomy on 2024/01/18 under general anesthesia. Under the impression of proximal S-colon cancer, cT4aN2aM0, stage IIIC, s/p adjuvant chemotherapy with FOLFOX x10 cycles, C1D1 on 2024/03/04, C1D15 on 2024/03/28, C2D1 on 2024/04/15, C2D15 on 2024/05/14.
    • The port-a was done on 2024/02/22, the Anti-HBc: reactive s/p Vemlidy.
    • CEA (NM): 2.597ng/mL(2024/01/03), 1.732ng/mL(2024/03/01), 3.087ng/mL(2024/03/19), 3.263ng/mL(2024/04/12), 2.581ng/mL(2024/04/30), 1.983ng/mL(2024/05/27), 3.138ng/mL(2024/06/20), 2.693ng/mL(2024/07/12)
    • CA-199 (NM): 35.681U/ml(2024/01/03), 30.581U/ml(2024/03/01), 36.982U/ml(2024/03/19), 36.982U/ml(2024/04/12), 35.677U/ml(2024/04/30), 32.017U/ml(2024/05/27), 29.131U/ml(2024/06/20), 25.879U/ml(2024/07/12)
    • Abdomen CT (2024/04/18) revealed: S/P colon operation. No evidence of tumor recurrence. Right renal cyst (1.2cm). Grade 4 fatty liver.
    • This time, she is admitted for adjuvant chemotherapy with C4D1 FOLFOX on 2024/07/26.
  • Course of inpatient treatment
    • After admission, she receive chemotherapy with C4D1 FOLFOX were given on 2024/07/26-07/28.
    • Hydration, Mosapin was given for nausea and vomiting, Vemlidy for Anti-HBc reactive.
    • After chemotherapy, she denide having a fever, vomiting, diarrhea, or any uncomfortable.
    • Abdomen CT was done on 2024/07/29, pending the report.
    • She can be discharged on 2024/07/29, the OPD follow-up will be arranged.
  • Discharge prescription
    • BaoGan (silymarin 150mg) 1# QD 9D
    • Mosapin (mosapride citrate 5mg) 1# TID 9D
    • Uformin (metformin 500mg) 1# BID 9D
    • Through (sennoside 12mg) 1# BID 9D
    • Nincort Oral Gel (triamcinolone 1mg/gm) BID TOPI 9D

[surgical operation]

• 2024-01-18
  • Surgery
    • Laparoscopic adhesiolysis and sigmoidectomy     
  • Finding
    • A depressed ulecrative 3cm tumor is located at proximal S-colon    
    • Much adhesions over rectum, S-colon and pelvic wall was found and meticulous dissection was done. It is casued by previous GYN surgery.    
    • Sigmoidectomy was achieved smoothly and blood loss was minimal (less than 20ml)    
    • Anastomosis was achieved using endo-GIA/green/60+ CDH-29+ TISSEEL 4ml. Both cutting ends are even and intact. Air test is ok without bubbles.    
    • 4DF anti-adhesion powder was used.    
    • A drain in pelvis   

[chemotherapy]

• 2024-08-13 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4450mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-07-26 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4460mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-06-27 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-06-04 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4450mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-05-14 - (FOLFOX)
• 2024-04-15 - (FOLFOX)
• 2024-03-28 - (FOLFOX)
• 2024-03-04 - (FOLFOX)

==========

2024-08-14

[assessing FOLFOX treatment with no contraindications, normal lab results and continuation of Vemlidy]

Lab results on 2024-08-13 were generally normal, and Vemlidy (tenofovir alafenamide) has been prescribed for her reactive Anti-HBc (2024-03-01). There is currently no data indicating that FOLFOX treatment is contraindicated. No issues with the current medication regimen were identified.

700882275

240830

[chemotherapy]

• 2024-08-29 - oxaliplatin 85mg/m2 80mg D5W 250mL 2hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2800mg/m2 2700mg NS 500mL 46hr (FOLFOX 60%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-08-07 - oxaliplatin 85mg/m2 60mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2800mg/m2 2200mg NS 500mL 46hr (FOLFOX 50%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-08-30

[gradual FOLFOX dose increase maintains renal stability, dapagliflozin dosing guidelines for CKD patients]

FOLFOX was administered at 50% of the standard dose on 2024-08-07 and 60% on 2024-08-29. With this gradual dose increase, serum creatinine has remained around 2 mg/dL, and eGFR has stayed approximately at 30, indicating stable renal function.

Additionally, for patients with CKD and an eGFR below 25, it is recommended that Forxiga (dapagliflozin) not exceed a daily dose of 10 mg.

• 2024-08-29 Creatinine 1.99 mg/dL
  

• 2024-08-09 Creatinine 2.02 mg/dL
  

• 2024-08-07 Creatinine 2.27 mg/dL
  

• 2024-08-01 Creatinine 1.99 mg/dL

• 2024-08-29 eGFR 34.63 ml/min/1.73m^2
  

• 2024-08-09 eGFR 34.03 ml/min/1.73m^2
  

• 2024-08-07 eGFR 29.75 ml/min/1.73m^2
  

• 2024-08-01 eGFR 34.63 ml/min/1.73m^2

701503613

240830

[exam findings]

• 2024-08-26 ECG
  • Sinus rhythm with short PR
• 2024-08-02 ECG
  • Sinus rhythm with short PR
  • Abnormal QRS-T angle, consider primary T wave abnormality
  • Abnormal ECG
• 2024-07-11 Holter 24hr ECG
  • Sinus rhythm
  • A few isolated apcs
  • Rare episodes short run atrial tachycardia (longest: 3 beats)
  • No long pause
  • No significant tachyarrhythmia
  • Frequent sinus tachycardia even in mid-night, please correlate with clinical and drug history (anemia, thyrotoxicosis etc.)
• 2024-06-27 Patho - lymphnode biopsy
  • Labeled as “right lymph node”, right neck lymph node excision — compatible with Hemophagocytic lymphohistiocytosis.
  • Section shows piece of soft tissue with proliferation of fibroblasts, chronic inflammation, and one nodule full of histiocytes engulfing cell debris. The pathological findings, in conjuction with clinical, image, hemogram, and laboratory findings, are compatible with Hemophagocytic lymphohistiocytosis.
  • ADDENDUM: Acid fast bacilli stain (+).
• 2024-06-25 PET
  • The FDG PET findings suggest that ymphoma involving multiple lymph node regions on the same side of the diaphragm. No prominent abnormal focal FDG uptake was noted in the abdominal left paraaortic space.
  • Mildly increased FDG uptake in some focal areas in the spleen and diffusely increased FDG uptake in the bone marow of the skeleton. Lymphoma involving the spleen and bone marrow can not be ruled out. Please correlate with other clinical findings for further evaluation.
  • Increased FDG uptake in a small focal area in the upper lobe of right lung. The nature is to be determined. Please also correlate with other clinical findings for further evaluation.
  • Mildly increased FDG uptake in the right lateral chest wall. Inflammation may show this picture.
• 2024-06-21 CT - abdomen
  • CC: fever with unknown origin.
  • Findings:
    • There are multiple enlarged nodes in right lower neck, paratracheal space, and subcarinal space. Malignant lymphoma is highly suspected.
      • Please correlate with PET scan.
      • US-guided lymph node biopsy at right lower neck (Srs:601 Img:23) may be possible if the lymph node can be visualized by sonography.
    • Splenomegaly (the greatest cranial-caudal dimension: 13 cm) and one enlarged node in left para-aortic space (3.5 x 2.2 cm) is noted.
      • Malignant lymphoma is highly suspected.
    • Peri-portal lucency is noted that may be acute hepatitis secondary to CMV infection.
    • There is bilateral pleura effusion with passive atelectasis in bilateral posterior basal lung.
      • S/P pigtail catheter implantation at right CP angle.
      • In addition, there is minimal pericardial effusion.
    • There are several hepatic cysts in both lobes (up to 1.1 cm in S7).
    • S/P cholecystectomy.
    • A renal cyst 1.3 cm in left middle pole is noted.
  • Impression:
    • Malignant lymphoma is highly suspected.
      • Please correlate with PET scan.
      • US-guided lymph node biopsy at right lower neck (Srs:601 Img:23) may be possible if the lymph node can be visualized by sonography.
    • Splenomegaly (the greatest cranial-caudal dimension: 13 cm) and one enlarged node in left para-aortic space (3.5 x 2.2 cm).
      • Malignant lymphoma is highly suspected. 1.
        
    • Peri-portal lucency is noted that may be acute hepatitis secondary to CMV infection.
• 2024-06-21 Transesophageal echocardiography, TEE
  • LVEF = (LVEDV - LVESV) / LVEDV = (125 - 36) / 125 = 71.20%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • No intracardiac vegetation was found by TEE study.
    • Normal LV filling pressure; mildly dilated LA.
    • Normal LV and RV systolic function.
    • Degenerative changes of mitral valve with mild MR; mild TR; mild PR; aortic valve sclerosis.
    • Minimal amount pericardial effusion ( < 50ml).
• 2024-06-17 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Normocellularity for age. IHC stains: CD117:1 %; CD34: 1 %; MPO: 30-40%, CD61: 5-10 %; CD71: 50% (of the nucleated cells). CK (-).
  • Section shows piece(s) of bone marrow with 30% cellularity and M:E ratio of approximately 1:2. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number.
  • IHC stains: CD117: 1%; CD34: 1%; MPO: 30-40%, CD61: 5-10%; CD71: 50% (of the nucleated cells). CK (-).
• 2024-05-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (84 - 32) / 84 = 61.90%
    • M-mode (Teichholz) = 61
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • Preserved RV systolic function
• 2024-05-15 SONO - abdomen
  • Hepatic cyst
  • Post cholecystectomy
  • Left renal cyst
  • No evidence of cirrhosis or significant splenomegaly
• 2024-05-14 Neurosonography
  • Mild atheromatous lesions in left proximal ECA and right SCA.
  • Normal extracranial carotid, vertebral arterial flows.
• 2024-05-14 Electroencephalogram, EEG
  • Abnormal, generalized slowing with theta waves, indicated mild cortical dysfunction bilaterally, besides, generalized increased beta activity, suspect medication effects, suggest clinical correlation.
• 2024-05-12 MRA - brain
  • Multiple small T2 hyperintensities in bilateral subcortical white matter.
  • Old lacunar infarcts.
  • Brain atrophy.
• 2024-05-10 Patho - intradermal nervus
  • Labeled as “bilateral knee”, excisional biopsy — skin with mild perivascular bland lymphocytic infiltration in the upper and middle dermis.
  • Section shows skin with mild perivascular bland lymphocytic infiltration in the upper and middle dermis.
• 2024-05-09 CT - brain
  • Cranial CT scans from the vertex to the mid-maxillary level were performed without i.v. contrast injection.
  • Impression:
    • The brain shows normal grey and white matter attenuation without evidence of focal lesion. There is no intracranial hemorrhage seen.
    • The size of the lateral and third ventricles appears normal.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal.
• 2024-03-09 CT - abdomen
  • IMP:
    • Liver and renal cysts (up to 1.1cm).
    • S/P cholecystectomy. R/O tiny stones in CBD.
    • Partial atelectasis at RML and left lingual lung.

[chemotherapy]

• 2024-08-29 - etoposide 150mg/m2 220mg NS 550mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-08-15 - etoposide 150mg/m2 220mg NS 550mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-08-08 - etoposide 150mg/m2 220mg NS 550mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-08-30

[neutropenia recovery and worsening anemia after etoposide]

The third dose of etoposide was administered on 2024-08-29. Neutropenia improved, with ANC increasing from 1.16K/uL on 2024-08-28 to 2.25K/uL on 2024-08-30. However, despite elevated ferritin levels, normocytic anemia worsened (HGB dropped from 9.1 g/dL to 8.4 g/dL), leading to a blood transfusion on 2024-08-30. HGB is expected to improve following the transfusion.

• 2024-08-30 WBC 2.75 x10^3/uL

• 2024-08-30 Neutrophil 78.0 %

• 2024-08-30 Band 4.0 %

• 2024-08-28 WBC 2.21 x10^3/uL

• 2024-08-28 Band 1.0 %

• 2024-08-28 Neutrophil 51.6 %

• 2024-08-30 HGB 8.4 g/dL

• 2024-08-30 MCV 93.1 fL

• 2024-08-28 HGB 9.1 g/dL

• 2024-08-28 MCV 91.7 fL

• 2024-08-28 Ferritin; 989.1 ng/mL

• 2024-08-28 Procalcitonin (PCT) 0.07 ng/mL

[liver enzymes decline, indicating improved liver function]

Follow-up shows that the elevated liver enzymes have started to decline, and bilirubin levels remain within the normal range, indicating an improvement in liver function.

• 2024-08-28 ALT 114 U/L

• 2024-08-26 ALT 167 U/L

• 2024-08-28 AST 25 U/L

• 2024-08-23 AST 44 U/L

2024-08-27

[dose adjustments and liver safety for rifampicin, clarithromycin, and ethambutol]

Liver Dose Adjustments:

• Rifampin (rifampicin):
  • Hepatic impairment prior to treatment: No specific dosage adjustments are provided in the manufacturer’s labeling; use with caution.
  • Hepatotoxicity during treatment: Discontinue rifampin if new or worsening hepatic damage occurs.
• Klaricid (clarithromycin):
  • No dosage adjustment is necessary if renal function is normal. However, in patients with hepatic impairment and concomitant severe renal impairment, consider dosage reduction or prolonged dosing intervals.
• Epbutol (ethambutol):
  • No specific dosage adjustments are provided in the manufacturer’s labeling; use with caution.

Hepatotoxicity:

• Rifampin (rifampicin):
  • Hepatotoxicity of hepatocellular, cholestatic, and mixed patterns has been reported, ranging from asymptomatic abnormal hepatic function tests to fulminant hepatic failure and death. Severe reactions, including fatalities, have occurred in patients with preexisting hepatic failure or those receiving concurrent hepatotoxic agents.
  • Mechanism:
    • Not clearly established; possible mechanisms include hypersensitivity or metabolic idiosyncratic reactions.
  • Onset:
    • Most cases occur within 4 weeks.
  • Risk factors:
    • Longer duration of therapy
    • Age >60 years
    • Alcohol use disorder
    • Concurrent use of other hepatotoxic agents (e.g., isoniazid, pyrazinamide)
    • Female sex
    • Low body mass index
    • Malnutrition
    • Preexisting liver disease (e.g., chronic viral hepatitis)
    • HIV
• Klaricid (clarithromycin):
  • May cause abnormal hepatic function tests.
• Epbutol (ethambutol):
  • May cause abnormal hepatic function tests.

Among these three medications, rifampin appears like to have a higher likelihood of causing liver damage. The patient’s ALT levels are currently trending upward.

The rifampin package insert indicates that caution should be exercised when administering this drug to patients with alcoholism or hepatic impairment. It is recommended that SGOT and SGPT levels be monitored monthly or more frequently before, during, and throughout treatment. However, elevated serum levels do not necessarily predict clinical hepatitis, and they may return to normal with continued treatment.

• 2024-08-26 ALT 167 U/L

• 2024-08-23 ALT 154 U/L

• 2024-08-16 ALT 110 U/L

• 2024-08-12 ALT 64 U/L

• 2024-08-02 ALT 30 U/L

• 2024-08-23 AST 44 U/L

• 2024-08-16 AST 30 U/L

• 2024-08-12 AST 24 U/L

• 2024-08-02 AST 15 U/L

2024-08-12

[blood count trends and chemotherapy effects]

Etoposide was administered on 2024-08-08. Since then, WBC has slightly decreased, while PLT has actually increased. A review of the patient’s previous records, prior to the use of etoposide, shows that WBC and PLT levels were even lower at times. Therefore, the neutropenia and thrombocytopenia observed cannot be entirely attributed to chemotherapy alone.

• 2024-08-12 WBC 1.45 x10^3/uL

• 2024-08-10 WBC 1.75 x10^3/uL

• 2024-08-08 WBC 1.57 x10^3/uL

• 2024-08-05 WBC 1.69 x10^3/uL

• 2024-08-12 PLT 53 *10^3/uL

• 2024-08-10 PLT 52 *10^3/uL

• 2024-08-08 PLT 42 *10^3/uL

• 2024-08-05 PLT 41 *10^3/uL

701528803

240830

[exam findings]

• 2024-08-29 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A-
    • Superficial gastritis, pangastritis
    • Gastric erosions, antrum, s/p biopsy at prepyloric antrum, PW
• 2024-08-28 Abdomen - Standing (Diaphragm)
  • Hepatomegaly is suspected. please correlate with clinical condition.
  • Fecal material store in the colon.
  • Compression fracture of T12 vertebral body.
• 2024-08-27 ECG
  • Atrial fibrillation with rapid ventricular response
  • Right axis deviation
• 2024-08-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (39 - 25) / 39 = 35.90%
    • LVEF (%) = 53
    • M-mode (Teichholz) = 36
    • 2D (M-Simpson) = 53
  • Conclusion:
    • LV chamber obliteration; borderline LV systolic function with abnormal septal wall motion due to post open heart srugery.
    • LV posterior wall thickening, dilated LA; LV diastolic dysfunction.
    • Dilated RA; impaired RV systolic function with free wall hypokinesia.
    • Aortic valve sclerosis with mild to moderate AR; s/p mitral valve replacement (bioprosthetic valve) with no MS (MVA(Doppler) = 4.4 cm² , Mean pressure gradient = 4 mmHg), mild MR; severe TR.
    • Possible moderate pulmonary hypertension, estimated PASP: 57 mmHg.
    • Engorged IVC without inspiratory collapse.
    • Bilateral pleural effusion.
    • Atrial fibrillation with rapid ventricular rate; pacemaker leads in RA/RV.
• 2024-08-26 Chest PA (Erect)
  • S/P implantation of the pacemaker.
  • S/P median sternotomy with metalic wires fixation. Please correlate with clinical history.
  • S/P mitral valve replacement?
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch -Enlargement of cardiac silhouette. -There are several nodular opacities projecting in the right lung. Please correlate with CT. -Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom. -Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-08-21 ECG
  • Atrial fibrillation with rapid ventricular response with premature ventricular or aberrantly conducted complexes
  • Right axis deviation
  • low voltage of limb leads
  • Nonspecific T wave abnormality
• 2024-07-29 Chest PA/AP
  • S/P pace-maker implantation.
  • S/P Port-A infusion catheter insertion.
  • Surgical wires over the sternum.
  • S/P cardiac valve replacement.
  • Multiple nodules at bil. lungs.
  • Compression fracture of T12.
• 2024-06-28 CT - chest
  • Indication:
    • Malignant neoplasm of connective and soft tissue of unspecified lower limb, including hip.
    • Age 71 (20240620) Rt Bulky axillary tumor
    • ECOG 4 sitting on wheel chair
  • Chest CT with and without IV contrast ehnancement shows:
    • Exophytic soft tissue mass at right axillary region measuring 11.2cm in largest dimension. Sarcoma is favored.
    • Diffuse nodularity with tree in bud distribution at bilateral lung fields is found. Lung meta is favored.
    • Cardiomegaly is noted.
    • s/p sternotomy with metalic wire fixation of the sternum.
    • Prior transevenous pacemaker inserted with pacing lead in RV and RA.
    • Right renal cyst up to 2.57cm is found.
  • Imp:
    • Right axillary soft tissue mass and bilatral lung nodules. Sarcoma meta is considered first.
• 2024-06-20 CXR erect
  • S/P implantation of the pacemaker.
  • S/P median sternotomy with metalic wires fixation. Please correlate with clinical history.
  • S/P mitral valve replacement?
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • There are several nodular opacities projecting in the right lung. Please correlate with CT.
• 2024-06-20 ECG
  • Atrial fibrillation with rapid ventricular response with premature ventricular or aberrantly conducted complexes
  • Right axis deviation
  • Abnormal ECG

[chemotherapy]

• 2024-08-09 - epirubicin 70mg/m2 90mg NS 100mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

701528942

240830

[lab data]

2024-08-05 Anti-HBc Reactive
2024-08-05 Anti-HBc Value 5.42 S/CO
2024-08-05 HBsAg Nonreactive
2024-08-05 HBsAg Value 0.77 S/CO
2024-08-05 Anti-HCV Nonreactive
2024-08-05 Anti-HCV Value 0.12 S/CO

[exam findings]

• 2024-08-29 ECG
  • Normal sinus rhythm
  • Right bundle branch block
  • Left anterior fascicular block
• 2024-08-14, -08-12 CXR erect
  • Few nodular opacities projecting in right middle and lower lung are noted that is c/w metastases after correlate with prior CT.
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Spondylosis of the T-spine
• 2024-08-12 ECG
  • Sinus rhythm with Premature atrial complexes
  • Right bundle branch block
  • Left anterior fascicular block
  • Bifascicular block
  • Abnormal ECG
• 2024-07-26 Patho - colon biopsy
  • Colon tumor, descending, biopsy — Adenocarcinoma
  • Microscopically, the section shows a picture of adenocarcinoma characterized by tumor cells arranged in tubular or cribriform patterns infiltrated in desmoplastic stroma.
  • Immunohistochemistry shows EGFR(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
• 2024-07-23 Colonoscopy
  • Findings
    • 30cm to cecum, some stool in right colon
    • 30cm to D colon tumor obstrution site, biopsy.
    • 40cm to DS colon infalmmation over DS colon and much solid stool in S colon.
  • Diagnosis:
    • suspect D colon cancer with obstruction s/p T loop colostomy
    • can not evaluate RS colon.
• 2024-07-12 PET
  • A glucose hypermetabolic lesion in the descending colon, compatible with primay colon malignancy.
  • Glucose hypermetabolism in some regional lymph nodes, compatible with metastatic lymph nodes.
  • Glucose hypermetabolism in multiple focal areas in both lobes of the liver and in three focal areas in the right lung, compatible with multiple liver and lung metastases.
  • Mild glucose hypermetabolism in a focal area in the left anterior chest wall and in some paraaortic lymph nodes. The nature is to be determined (metastases of low FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
• 2024-06-19 ECG
  • Sinus tachycardia
  • Left anterior fascicular block
  • Right bundle branch block
  • Possible Anterolateral infarct, age undetermined
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2024-06-19 CT - abdomen
  • Findings:
    • There is segmental circumferential asymmetrical wall thickening at the descending colon with irregular contour, adjacent omentum invasion, and severe lumen narrowing, 9 cm in size.
      • Adenocarcinoma of the descending colon (T4b) causing near total obstruction and equivocal perforation is suspected.
      • Please correlate with colonoscopy.
    • There are seven kissing soft tissue nodules in the adjacent mesocolon that is c/w regional metastatic nodes (N2b).
    • There are multiple poor enhancing masses on both hepatic lobes (up to 4.3 cm in S8) that are c/w liver metastases (M1a).
      • In addition, there are several soft tissue nodules in right lung that is c/w lung metastases (M1b). Please correlate with chest CT.
      • There are few enlarged nodes in para-aortic space that may be non-regional metastatic nodes.
    • S/P hysterectomy
    • There are several renal cysts on both kidney (up to 0.7 cm).
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)

[chemotherapy]

• 2024-08-29 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4050mg NS 500mL 46 hr (FOLFIRI 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
• 2024-08-12 - ………………………………….. irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4050mg NS 500mL 46 hr (FOLFIRI 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-08-30

[using Avastin and FOLFIRI in patients with RBBB and LAFB: risks and monitoring]

Avastin (bevacizumab) in combination with FOLFIRI is not specifically contraindicated in patients with ECG (2024-08-12, 2024-08-29) findings such as right bundle branch block (RBBB) and left anterior fascicular block (LAFB). However, using this combination therapy should be approached with caution, particularly considering the patient’s cardiovascular status.

Considerations:

• Cardiovascular Risk:
  • Bevacizumab (Avastin) is associated with an increased risk of hypertension, arterial thromboembolic events, and congestive heart failure.
  • The presence of ECG abnormalities such as RBBB and LAFB may indicate underlying structural heart disease, potentially increasing the risk of cardiovascular complications during treatment.
• Close Monitoring:
  • While RBBB and LAFB are not absolute contraindications, they can suggest underlying heart disease, making it crucial to monitor the patient closely for any signs of worsening cardiovascular status during treatment.
  • Baseline and periodic cardiovascular evaluations, including echocardiography, may be warranted.

Suggested Titles:

1. “Cardiac Considerations for Avastin (bevacizumab) + FOLFIRI in Patients with ECG Abnormalities”

2. “ECG Findings and the Safe Use of Avastin (bevacizumab) with FOLFIRI”

3. “Managing Cardiovascular Risk in Avastin (bevacizumab) + FOLFIRI Therapy with ECG Abnormalities”

4. “Safety and Monitoring of Avastin (bevacizumab) + FOLFIRI in Patients with Conduction Abnormalities”

2024-08-13

[first session of FOLFIRI with adjusted dosage and ongoing management]

The first session of FOLFIRI started on 2024-08-12, with 80% of the standard dose administered. Hypomagnesemia (Mg 1.5 mg/dL on 2024-08-12) and reactive Anti-HBc (Anti-HBc value 5.42 S/CO on 2024-08-05) were noted, so the patient is currently receiving injectable MgSO4 and oral Vemlidy (tenofovir alafenamide).

Blood pressure was 144/65 mmHg at 20:34 on 2024-08-12 under Estengy (amlodipine, valsartan) and blood glucose was 158 mg/dL at 06:54 on 2024-08-13 under Uformin (metformin) and Amepiride (glimepiride). Both blood pressure and blood glucose are under control. No medication discrepancies were identified.

700696571

240829

[exam findings]

• 2024-08-28 Abdomen - Standing (Diaphragm)
  • s/p percutaneous endoscopic gastrostomy
  • Fecal material store in the colon.
  • Compression fracture of T11 vertebral body.
• 2024-08-28 CXR PA (erect)
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
• 2024-07-27 MRI - brain
  • Indication:
    • upper third of esophagus, cT3N3M1 with bone and brain metastasis, stage IVB
    • Left lower lobe lung adenocarcinoma with bone and brain metastasis, cT4N3M1c, stage IVB
  • Without- and with-contrast multiplanar cerebral MRI reveal:
    • Several small faintly enhancing tumors in left frontal lobe (5 mm) and right temporal lobe (3 mm and 7 mm). C/W metastases. Smaller in size as compared with MRI on 20240406.
    • Mild degree of general enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
    • Diffuse T2-hyperintensities in periventricular deep white matters, indicating leukoaraiosis.
  • IMP:
    • Brian metastases. Stationary in number (total = 3) and smaller in size (3 mm, 5 mm and 7 mm) as compared with MRI on 20240406.
• 2024-07-09 CT - chest
  • Indication:
    • upper third of esophagus, cT3N3M1 with bone and brain metastasis, stage IVB
    • Left lower lobe lung adenocarcinoma with bone and brain metastasis, cT4N3M1c, stage IVB
  • MDCT of the chest and abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows: comparison: prior CT on 2024/04/02
    • Lungs: interval slightly decrease in size of a large LLL tumor and resoltuion satellites nodules, involving inferior pulmonary artery. extensive patchy and centrilobular GGOs in LUL and RUL.
    • Mediastinum and hila: multiple small LNs in visceral space.
      • old calcified LNs in visceral compartment and hila, sequela of previous TB infection.Rt lateral esophageal wall thickening at M/3 of thoracic esophagus, in regression, causing luminal narrowing and food material stasis above.
      • moderate coronary arterial calcification.
    • Aorta: dilated ascending aorta (4.7 cm in caliber). mild atherosclerotic change.Central pulmonary arteries: normal caliber.Heart: normal in size of cardiac chambers.
      • mild calcified mitral annulus
    • Pleura: no effusion.
    • Visible abdominal contents: partial rim-calcified lesion (17 mm) at anterior spleen. unremarkable of the liver, adrenal glands, pancreas, and kidneys.
    • Visualized bones: no lytic or blastic lesion.
  • Impression: LLL lung cancer and M/3 thoracic esophageal cancer, in regression compared with CT on 2024/04/02. LUL and RUL infection or drug-related toxicity.
• 2024-06-08 Standing KUB
  • S/P gastrostomy.
  • Compression fracture of T11-L3.
• 2024-04-17 PD-L1 (SP263)
  • Study Type: PD-L1 immunostain (clone: SP263)
    • Study Purpose: requested by clinician for treatment reference
    • Block Tested: S2024-7176
    • Tumor type: adenocarcinoma
    • Tumor location: lung
    • Testing assay: SP263 Assay (Ventana)
    • Testing platform: BenchMark ULTRA
    • Detection system: OptiView DAB IHC Detection Kit
  • For non-small-cell lung carcinoma
    • Specimen Adequacy: Adequate
      
    • Staining Quality: Acceptable (positive and negative control works)
      
    • Result:
      • Tumor cell (TC) staining score: 5%
• 2024-04-17 CXR erect
  • A poorly defined large tumor mass over Lt lower lobe with satellites nodules
• 2024-04-15 ROS1 IHC
  • Cellblock No. S2024-07176
  • RESULT: 1+
• 2024-04-15 EGFR
  • Cellblock No. S2024-07176
  • Result: A point mutation was detected at exon 21 (L858R) of EGFR gene in this specimen.
• 2024-04-11 CXR erect
  • A poorly defined large tumor mass over Lt lower lobe with satellites nodules
  • marked elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • Coronary arterial calcification indicating CAD
• 2024-04-11 Patho - lung transbronchial biopsy
  • Lung, LLL, CT-guide biopsy — adenocarcinoma, moderately differentiated
  • Sections show solid nests and acinar glandular cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal CK7(+), CK20(-), TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
• 2024-04-09 PET
  • A glucose hypermetabolic lesion in the middle portion of the esophagus, compatible with primary esophageal malignancy.
  • A glucose hypermetabolic lesion in the lower lobe of left lung. Primary lung malignancy should be watched out.
  • Glucose hypermetabolism in the T11 spine and sacrum. Bone metastases may show this picture.
  • Glucose hypermetabolism in some bilateral paratracheal lymph nodes and in some A-P window lymph nodes. Metastatic lymph nodes can not be ruled out. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes and in a left supraclavicular lymph node. Inflammatory process is more likely.
  • Mildly to moderately heterogenous FDG uptake in the cerebral cortex. Please correlate with brain MRI for further evaluation.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
• 2024-04-06 MRI - brain
  • Indication: lung tumor with esophageal cancer staging
  • With- and without-contrast multiplanar cerebral MRI revealed
    • unremarkable change in the intraventricular and extraventricular CSF spaces
    • old lacunar infarction in the bilateral basal ganglia and left thalamus; mild bilateral periventricular leukoaraiosis.
      
    • unremarkable change in the skull base
    • several heterogeneous enhancing lesions in the right temporal and left frontal lobe. The largest one, about 11mm, was noted on the right temporal lobe.
  • IMP:
    • three brain metastasis.
• 2024-04-03 Tc-99m MDP bone scan
  • Two hot spots in the right aspect of sternal manubrium and T11 spine, respectively, cancer with bone metastases may be considered, suggesting PET scan for further evaluation and follow-up with bone scan in 3 months.
  • Suspected benign lesions in some T- and L-spine, bilateral shoulders, and knees.
• 2024-04-03 Patho - esophageal biopsy
  • Esophagus, 20-24 cm incisor, biopsy — moderately differentiated squamous cell carcinoma
  • Microscopically, it shows moderately differentiated squamous cell carcinoma composed of nest of non-keratinizing squamous tumor cells with invasive growth pattern and lymphocytic infiltrate. The tumor shows nuclear hyperchromasia, nuclear pleomorphism, mitoses and prominent nculeoli.
  • IHC stain — p16: negative, CK: positive
• ECG
  • Normal sinus rhythm
  • Nonspecific ST and T wave abnormality
• 2024-04-02 CT - lung/mediastinum/pleura
  • Findings
    • Lungs: an irregular LLL tumor with air-bronchograms and pleural tails (about 62mm in largest axial dimension) with satellites nodules, involving inferior pulmonary arter, consistent with primary lung cancer. minimal paraspinal fibrosis at RLL
    • Mediastinum and hila: mildly enlarged LNs in visceral space.
      • old calcified LNs in visceral compartment and hila, sequela of previous TB infection.
      • Rt lateral esophageal wall thickening at M/3 of thoracic esophagus (33mm in length), causing luminal narrowing and food material stasis above.
      • moderate coronary arterial calcification.
    • Aorta: dilated ascending aorta (4.7 cm in caliber).
      • mild atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
      • mild calcified mitral annulus
    • Pleura: trace Lt-sided effusion.
    • Visible abdominal contents: partial rim-calcified lesion (17 mm) at anterior spleen. unremarkable of the liver, adrenal glands, pancreas, and kidneys.
      • mild enlarged prostate.
      • Uniformly increased air in nondistended small bowel over and colon, could be paralytic ileus.
    • Visualized bones: no lytic or blastic lesion.
  • Impression:
    • LLL lung cancer T4N? in progression compared with CT on 2021/08/08.
    • suspect M/3 thoracic esophageal tumor.
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:M1c(M_value) STAGE:____(Stage_value)
• 2024-04-02 EGD
  • Diagnosis:
    • Suboptimal EGD exam for esophagus area, due to much food residue at upper esophagus
    • Esophagus stricture, cause unknown, 20-24cm from incisors, s/p biopsy
    • Reflux esophagitis LA Classification grade A(minimal)
    • Superficial gastritis
  • CLO test: not done
  • Suggestion:
    • Pursue the pathology report
    • Consider to arrange CT (C+/-) if no contraindication
• 2021-08-17 CT - chest
  • Findings:
    • Lungs: normal appearance of LUL and Rt lung.
      • an irregular LLL tumor with air-bronchograms and pleural tails (about 38 mm in largest dimension) consistent with primary lung cancer
    • Mediastinum and hila: no enlarged LN.
      • old calcified LNs in visceral compartment and hila, sequela of previous TB infection.
    • Vessels: moderate coronary arterial calcification.
    • Aorta: dilated ascending aorta (4.7 cm in caliber).
      • mild atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
      • mild calcified mitral annulus
    • Pleura: no effusion or nodule.
    • Chest wall: unremarkable.
    • Visible abdominal contents: partial rim-calcified lesion (17 mm) at anterior spleen.
      • no abnormal density visible portion of the liver, adrenal glands, pancreas, and kidneys.
    • Visualized bones: no lytic or blastic lesion.
  • Impression:
    • LLL lung cancer T2aN0Mx
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T2a(T_value) N:N0(N_value) M:M0(M_value) STAGE:IB(Stage_value)
• 2021-08-08 CXR lateral LT
  • Irregular opacity at LLL, suspect infection or lung tumor. Suggest further evaluation.
• 2021-08-08 CXR erect
  • Irregular opacity at left lower lung field, suspect infection or lung tumor. Suggest further evaluation.
• 2021-08-08 CT - brain
  • Head CT without contrast enhancement shows:
    • brain atrophy with prominent sulci, fissures and dilated ventricles.
    • confluent hypodensity at bilateral periventricular white matter, indicating leukoaraiosis.
    • multiple old lacunar infarcts at bilateral basal ganglia and left thalamus.
    • no acute intracranial hemorrhage.
    • normally preserved gray and white matter differentiation.
    • no definite skull lesion.
    • left posterior scalp hematoma.
  • Impression:
    • Brain atrophy, leukoaraiosis, and multiple old lacunar infarcts.
    • No acute intracranial hemorrhage.
    • Left posterior scalp hematoma.
• 2020-08-20 SONO - neurology
  • Mild atheromatous lesions in R CCA bifurcation and R ICA.
  • Smaller caiber with decreased flow in R cervical VA, possible R VA hypoplasia.
  • Normal extracranial carotid, L vertebral, and intracranial vertebral, basilar arterial flows.
  • Poor temporal windows for transcranial insonation.

[MedRec]

• 2024-04-02 ~ 2024-04-24 POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • Squamous cell carcinoma, upper third of esophagus, cT3N3M1, stage IVB, status post port-A catheter implantation and percutaneous endoscopic gastrostomy on 2024/04/17
    • Left lower lobe lung adenocarcinoma, cT4N3M1c, stage IVB
    • Esophageal obstruction
    • Vomiting
    • Type 2 diabetes mellitus without complications
    • Sequelae of cerebral infarction
    • Mixed hyperlipidemia
    • Chronic viral hepatitis B without delta-agent, Anti-HBc reactive
  • CC
    • Difficulty in swallowing solid food for 2 months.
  • Present illness
    • This 73-year-old man, a heavy smoker and alcoholism, had past history of type 2 diabetes mellitus, old cerebral infarction, and hyperlipidemia under conrtol. His activities of daily living were independent. He had suffered from difficulty in swallowing solid food for 2 months. No body weight loss was noticed.
    • According to his statement, he had felt difficulty in swallowing for 2 months. The symptom had got worse since this month, and severe vomiting was also noted. There was no exacerbating factor or relieving factor. There was no abdominal pain, abdominal bloating, diarrhea, epigastric pain, body weight loss, easy choking, dysphonia, hoarseness, chest pain, dyspnea, or hemoptysis. He didn’t pay much attention to it in the beginning. The patient denied trauma or esophageal injury history.
    • He visited our emergency department for help. Panendoscopy was done and esophageal stricture over 20cm to 24cm from incisors was noted. Biopsy was done. Chest CT revealed LLL lung cancer in progression as compared with the CT on 2021/08/08. Upper third esophageal tumor was also suspected. Physical examination showed clear breathing sound, regular heart beats, and soft abdomen with no tenderness. There was no palpable tumor over neck. He was admitted for further evaluation and management for suspected double primary cancers of lung and esophagus.
  • Course of inpatient treatment
    • After admission, nutrition was supported with PPN and Taita No.5. For cancer staging work-up, whole-body bone scan and brain MRI were arranged.
    • Whole-body bone scan on 2024/04/09 revealed two hot spots in the right aspect of sternal manubrium and T11 spine, respectively, cancer with bone metastases may be considered.
    • Brain MRI on 2024/04/06 showed three brain metastases.
    • After discussing with the patient and his family, they agreed with further work-up of lung cancer. As a result, examinations of bronchoscopy, EUS, whole-body PET scan, CT-guided biopsy, and brain MRI were all arranged.
    • Bronchoscopy on 2024/04/10 releaved endotracheal small polyp lesion near carina, s/p bronchial forceps biopsy, and the pathology showed mild chronic inflammation.
    • EUS on 2024/04/10 showed cancer over upper esophagus, at least cT3N3, and luminal stricture, s/p biopsy at 32cm(A) and 29cm(B), and the pathology showed chronic esophagitis.
    • CT-guided biopsy on 2024/04/11 showed LLL adenocarcinoma.
    • We consulted Hematology Oncology and Radiation Oncology for definitive CCRT on 2024/04/12.
    • After discussion with the patient and his family about further treatment, port-A catheter implantation and percutaneous endoscopic gastrostomy on 2024/04/17.
    • After all examinations, the cancer staging revealed squamous cell carcinoma, upper third of esophagus, cT3N3M1, stage IVB and left lower lobe lung adenocarcinoma, cT4N3M1c, stage IVB.
    • After port-A catheter implantation and percutaneous endoscopic gastrostomy on 2024/04/17, we started PEG feeding with element diet on 2024/04/18, and feeding well.
    • He transferred to Hematology Oncology ward on 2024/04/19 for further definitive CCRT.
    • Radiotherapy 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area. Then boost the U/3 esophageal tumor and LAPs to 50.4 Gy/ 28 fx start on 2024/04/18~.
    • He received chemotherapy with PF (Cisplatin 75mg/m2 D1, 5-Fu 1000mg D1-D3, 1st all 50%) on 2024/04/18~2024/04/20, N/S for hydration.
    • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
    • For Left lower lobe lung adenocarcinoma, cT4N3M1c, stage IVB, sent EGFR pending, ROS pending, PD-L1(SP263):TC:5%.
    • Diet control and check finger sugar for Type 2 diabetes mellitus, was treated with Amepiride 2mg/tab 1# PO BIDAC, Pioglit 30mg/tab 1# PO QD, Uformin 500mg/tab 1# PO TID.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was give for Anti-HBc reactive.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2024/04/24 and OPD followed up later.
  • Discharge prescription
    • Romicon-A
    • Promeran
    • Baraclude
    • Tramacet
    • Crestor

[chemotherapy]

• 2024-06-29 - cisplatin 75mg/m2 60mg NS 500mL 4hr + fluorouracil 1000mg/m2 830mg 24hr D1-3 (PF 50%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-23 - cisplatin 75mg/m2 60mg NS 500mL 4hr + fluorouracil 1000mg/m2 860mg 24hr D1-3 (PF 50%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-20 - cisplatin 75mg/m2 60mg NS 500mL 4hr + fluorouracil 1000mg/m2 860mg 24hr D1-3 (PF 50%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-08-29

[iron supplementation recommended for microcytic anemia management]

Neutropenia (ANC = 2.35K/uL) and microcytic anemia were noted, while other lab results on 2024-08-28, including electrolytes, liver, and renal functions, were generally normal.

The most common cause of acquired microcytic anemia is iron deficiency. Lab results on 2024-05-27 showed decreased transferrin and relatively low ferritin levels, indicating that iron supplementation is recommended.

• 2024-08-28 WBC 3.48 x10^3/uL
  

• 2024-08-28 Neutrophil 67.8 %

• 2024-08-28 HGB 9.7 g/dL
  

• 2024-08-28 MCV 71.9 fL

• 2024-05-27 Ferritin 110.1 ng/mL
  

• 2024-05-27 Transferrin 195.5 mg/dL
  

• 2024-05-27 Fe (Iron-bound) 100 ug/dL

2024-07-01

[microcytic anemia and potential cisplatin involvement]

The 50% dose reduction of cisplatin in the PF regimen has not prevented the HGB levels from decreasing, and the microcytic anemia continues to gradually worsen. The involvement of cisplatin in this condition cannot be ruled out.

The patient is also taking Giotrif (afatinib) 30mg QOD. However, the incidence of anemia with this drug has not been reported (UpToDate), making it less likely to be associated with the anemia.

• 2024-06-29 HGB 10.8 g/dL

• 2024-06-14 HGB 11.3 g/dL

• 2024-05-31 HGB 12.5 g/dL

• 2024-05-27 HGB 8.8 g/dL blood transfusion on 5/27

• 2024-05-22 HGB 7.9 g/dL blood transfusion on 5/23

• 2024-06-29 MCV 71.8 fL

• 2024-06-14 MCV 71.1 fL

• 2024-05-31 MCV 71.3 fL

2024-05-24

[Reduced-Dose PF3 Regimen and Microcytic Anemia Management - Iron Deficiency Likely, Testing Recommended]

A reduced-dose PF3 chemotherapy regimen was initiated on 2024-04-20, with the second session commencing on 2024-05-22.

Notably, the patient’s anemia pre-dated the start of chemotherapy. Therefore, chemotherapy cannot be definitively identified as the sole cause of the anemia.

However, it is important to acknowledge that the anemia worsened after initiating the reduced-dose regimen. While the lower dose may have mitigated some effects, the chemotherapy might still be contributing to the severity of the anemia.

To address the anemia, leukocyte-poor red blood cell (LPRBC) transfusions were administered. This is considered an appropriate intervention.

The anemia has been identified as microcytic, a type of anemia commonly associated with iron deficiency.

To determine if iron supplementation is necessary, testing iron stores is recommended.

• 2024-05-22 HGB 7.9 g/dL

• 2024-05-13 HGB 9.8 g/dL

• 2024-05-06 HGB 9.6 g/dL

• 2024-04-23 HGB 9.6 g/dL

• 2024-04-19 HGB 9.0 g/dL

• 2024-04-08 HGB 10.0 g/dL

• 2024-04-01 HGB 10.0 g/dL

• 2022-11-10 HGB 11.0 g/dL

• 2024-05-22 MCV 68.5 fL

• 2024-05-13 MCV 68.8 fL

• 2024-05-06 MCV 68.8 fL

• 2024-04-23 MCV 67.3 fL

• 2024-04-22 MCV 68.8 fL

• 2024-04-19 MCV 66.1 fL

• 2024-04-08 MCV 67.7 fL

• 2024-04-01 MCV 68.3 fL

• 2022-11-10 MCV 68.3 fL

700787909

240829

[exam findings]

• 2024-07-11 CT - abdomen
  • History and indication: Adenocarcinoma of ascending colon
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon operation. Colonic diverticula. Mild wall thickening of upper rectum. Wall edema of terminal ileum. Focal fat stranding at RLQ with some LNs.
    • Bil. renal and liver cysts (up to 3.4cm).
    • Some calcifications in prostate.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • Partial atelectasis at left basal lung.
  • IMP:
    • S/P colon operation. Colonic diverticula. Mild wall thickening of upper rectum. Wall edema of terminal ileum. Focal fat stranding at RLQ with some LNs.
    • Bil. renal and liver cysts (up to 3.4cm).
    • Some calcifications in prostate.
• 2024-05-17 Uroflowmetry
  • Q max : low
  • flow pattern : obstructive
• 2024-05-17 Transrectal Ultrasound of Prostate, TRUSP
  • Prostate
    • Size of prostate: 4.1 (T) cm x 2.2 (L) cm x 3.9 (AP) cm = 19.3 cc
    • Size of adenoma: 3.2 (T) cm x 1.8 (L) cm x 3.2 (AP) cm = 10.5 cc
  • Seminal vesicles
    • Size: L’t 1.8 x 0.8 cm
    • Size: R’t 2.1 x 0.7 cm
• 2024-05-17 Bladder Sonography
  • PVR: 4.86 mL
• 2024-03-27 CT - abdomen
  • History: Adenocarcinoma of A-colon, s/p hemicolectomy on 2024/01/24, pT4bN0M0, stage IIc. with pelvic wall involvement. Radiotherapy to the preOP tumor bed region deliver 50 Gy/ 25 fx from 2024/02/19~ plus Adjuvent chemotherapy with FOLFOX from 2024/02/19~
  • Indication: for FU
  • Findings:
    • There is long segmental edematous wall thickening of the terminal ileum. Radiation enteritis is highly suspected. please correlate with clinical condition.
    • There is a small poor enhancing lesion 5 mm in S5/8 of the liver that may be pseudo-lesion or true tumor.
    • S/P right hemicolectomy
    • There are several renal cysts on both kidney (up to 3.3 cm).
  • Impression:
    • There is long segmental edematous wall thickening of the terminal ileum. Radiation enteritis is highly suspected. please correlate with clinical condition.
    • here is a small poor enhancing lesion 5 mm in S5/8 of the liver that may be pseudo-lesion or true tumor.
• 2024-03-26 Patho - stomach biopsy
  • Gastric polyp, body, biopsy — Compatible with hyperplastic polyp with intestinal metaplasia, Helicobacter Pylori NOT present
• 2024-03-26 SONO - abdomen
  • Renal cyst, left kidney
  • Splenomegaly
  • Enteritis, suspect small bowel
• 2024-03-25 KUB
  • S/P autosuture projecting at RLQ abdomen.
  • S/P clips projecting at right upper pelvis area.
• 2024-01-25 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Tumor, cecum, SILS R’t hemicoloectomy — Adenocarcinoma
    • Resection margins, bilateral, ditto — Free of tumor invasion
    • Radial margin, tumor, ditto — Tumor involved
    • Lymph nodes, mesocolic, dissection — Free of tumor metastasis (0/29)
    • AJCC pathologic stage — pT4bN0, if cM0, stage IIC
  • MACROSCOPIC EXAMINATION
    • Operation procedure: SILS right hemicolectomy
    • Specimen site: ascending colon and terminal ileum
    • Specimen size: (a) A-colon: 14 cm in length, 3.7 cm in diameter, (b) Terminal ileum: 3.5 cm in length, 1.8 cm in diameter and appendix is not found
    • Tumor size: 7 cm in diameter
    • Tumor location: cecum, 4 and 5 cm away from bilateral resection margins
    • Tumor appearance: annular mass with perforation
    • Depth of invasion grossly: radial margin
    • Representatively embedded for section as A1: bilateral resection margins, A2-A8: tumor + radial margin(ink), A9-A13: lymph nodes
  • MICROSCOPIC EXAMINATION
    • Histology: adenocarcinoma
    • Histology Grade: G2, moderately differentiated
      
    • Depth of invasion: tumor perforation with direct invasion to RLQ abdominal wall (OP note)
    • Angiolymphatic invasion: not identified
    • Perineural invasion: present
    • Discontinuous extramural tumor extension: not present
    • Circumferential (radial) margin: tumor involved
    • Lymph node metastasis, mesocolic: Free of tumormetastasis (0/29)
    • Lymph node metastasis, IMA / SMA: N/A
    • Extranodal involvement: N/A
    • Pathological TNM Stage: pT4bN0
    • Type of polyp in which invasive carcinoma arose: N/A
    • Additional pathologic findings: abscess formation
    • TNM descriptors: N/A
      
    • Tumor regression grading S/P CCRT: N/A
• 2024-01-08 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Bilateral renal cysts are found.
    • Soft tissue mass at cecum measuring 6.78cm with blurring fat plane and regional lymph nodes (n > 7, Se301 IM89) is found.
  • Imp:
    • Cecal cancer with regional lymph nodes.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-12-28 Patho - colon biopsy
  • Colorectum, ascending colon, s/p biopsy(A) — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

• 2024-03-18 ~ 2024-03-28 POMR Hemato-Oncology Yang MuJun
  • Course of inpatient treatment
    • After admission, adjuvant chemotherapy with C2 FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) this time dose as 50% due to GI tract side effect on 2024/03/20~2024/03/22.
    • IVF with NAKO no.5 500ml bid plus N/S 500ML plus b-complex 1mg/amp for supportive.
    • Kept OPD medication with GEMD 600mg(Gemfibrozil) 0.5# QD, Irbesartan 300mg/tab 1# QD.
    • Consult rehabilation for bedside rehabilation.
    • Fever up to 38.4 was noted on 3/22, follow up fever routune and the empirical antibiotic with cefepime IVD since 3/22.
    • Nausea and vomitting with Decan IV from prn.
    • Due to stool OB 4+, arrange PES painless on 3/26 and diagnosis: Reflux esophagitis LA Classification grade A (minimal), Atrophic gastritis, s/p CLO test, Gastric polyps, fundus and body, s/p biopsy, Suggestion: Pursue CLO and biopsy results, no active bleeders were noted in this study. PPI with nexium oral form use.
    • Due to RLQ pain intermitten, arrange abdominal CT on 3/27 and there is long segmental edematous wall thickening of the terminal ileum. Radiation enteritis is highly suspected.
    • The pathology of stomach was compatible with hyperplastic polyp with intestinal metaplasia, Helicobacter Pylori: not present.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2024/03/28 and OPD followed up later.
  • Discharge prescription
    • Aprovel (irbesartan 300mg) 1# QD
    • Smecta (dioctahedral smectite 3gm) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • diphenidol 25mg 1# TID
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Scrat (sucralfate 1g/10mL) 1# QIDAC
    • Megejohn (megestrol acetate 160mg) 1# QD
    • loperamide 2mg 1# PRNBID if stoll passage >= 3 per day
    • Emend (aprepitant 125mg) 1# QD
    • Ceficin (cefixime 100mg) 2# Q12H
• 2024-02-05 SOAP Hemato-Oncology Yang MuJun
  • S: CCRT with FOLFOX *12 doses, refer to GS for port A insertion, add entecavir, arrange admission for C/T
• 2024-01-23 ~ 2024-01-28 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Advanced ascending colon cancer perforation and direct invasion to right lower quadrant abdominal wall, cT3N2bM0 stage IIIC status post 3 dimensions single incision laparoscopic surgery right hemicolectomy on 2024/01/24
    • Hypertension
  • CC
    • Intermittent migrating abdominal cramping pain with dizziness for about 6 months.
  • Present illness
    • This is a 72-year-old male with underlying diseases of hypertension and hyperlipidemia, both under medical control, and with past history of (1) colon polyp s/p polypectomy 10+ years ago and (2) gastric polyp s/p polypectomy on 2019/03/06 and 2023/08/23, respectively. He denied family history of colonorectal cancer. He was admitted for intermittent migrating abdominal cramping pain with dizziness for about 6 months.
    • According to the patient and medical record, fecal occult blood test positive noticed at the local clinic in 2023/11. Then, he visited Dr. Chen’s OPD in GI department on 2023/11/23 for further assessment. He denied anal bleeding, body weight loss, or tarry stool. He had good appetite. PE showed no anemic conjunctiva, soft abdomen, and no tenderness. The colonoscopy was done on 2023/12/27 and it showed colon polyps and colon cancer at ascending colon, and therefore, biopsy was done. Later, he was referred to Dr. Xiao for pathology results and further treatment.
    • The colon biopsy proved adenocarcinoma at ascending colon. Abdominal CT disclosed soft tissue mass at cecum measuring 6.78cm with blurring fat plane and regional lymph nodes (n > 7), T3N2M0 on 2024/01/08. At Dr. Xiao’s OPD on 2024/01/15, it was suggested that he admit for single-incision laparoscopic surgery right hemicolectomy.
    • Under the impression of adenocarcinoma of ascending colon, cT3N2bM0, stage IIIc, he was admitted to our ward for preoperative preparation and single-incision laparoscopic surgery right hemicolectomy.
  • Course of inpatient treatment
    • After admission with ward routine and blood examination were done. Operation of 3D SILS right hemicolectomy general anesthesia were performed on 2024/01/24. IV fluids support. The wound healing well and no erythema change. Chewing cookies, toast, rice with gum was started at op day. No nausea and no vomiting, flatus passage. On low residual diet was started at post-op day 1. Well bowel movement and stools passage (+) with diet well tolerated. No fever and no complication.
    • Discharged in general condition stable on 2024/01/28 and will follow up in our out-patient department next week.    
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
• 2023-09-07, 2019-05-06 SOAP Gastroenterology Chen JianHua
  • Diagnosis
    • Gastro-esophageal reflux disease with esophagitis [K21.0]
    • Polyp of stomach and duodenum [K31.7]
    • Dizziness and giddiness [R42]
  • Prescription x2
    • Pariet (rabeprazole sodium 20mg) 1# QDAC

[consultation]

• 2024-05-16 Urology
  • Q
    • For BPH Hx without treatment, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • We were consulted for BPH related LUTS. The patient has suffered from weak stream, intermittency and nocturia 3-4 times for about 2 years. He occasionally has urgency with incontinence. We suggest that you check serum PSA during next blood examination. We will arrange uroflowmetry and TRUSP for evaluation. Please start Harnalidge for treatment and arrange Dr. Li’s OPD for follow up.

[surgical operation]

• 2024-01-24
  • Surgery
    • 3D SILS right hemicolectomy        
  • Finding
    • Advanced A-colon cancer perforation and direct invasion to RLQ abdominal wall; Large area dense adhesion and invasion between the tumor and abdominal wall, retroperitoneum localized abscess was noted R2 resection and labeled the residual tumor/fibrotic tissue by using metalic clips

[chemotherapy]

• 2024-08-01 - oxaliplatin 85mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 430mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-07-09 - oxaliplatin 85mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 430mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 2800mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-06-19 - oxaliplatin 85mg/m2 75mg D5W 250mL 2hr + leucovorin 400mg/m2 350mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-31 - oxaliplatin 85mg/m2 75mg D5W 250mL 2hr + leucovorin 400mg/m2 350mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 2100mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-17 - oxaliplatin 85mg/m2 75mg D5W 250mL 2hr + leucovorin 400mg/m2 350mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 2100mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-26 - oxaliplatin 85mg/m2 75mg D5W 250mL 2hr + leucovorin 400mg/m2 350mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 2100mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-11 - oxaliplatin 85mg/m2 75mg D5W 250mL 2hr + leucovorin 400mg/m2 350mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 2100mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-20 - oxaliplatin 85mg/m2 75mg D5W 250mL 2hr + leucovorin 400mg/m2 350mg NS 250mL 2hr + fluorouracil 400mg/m2 350mg NS 100mL 10min + fluorouracil 2400mg/m2 2100mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-02-26 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 400mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-08-29

[cleared for FOLFOX treatment: stable labs and vitals]

Lab results on 2024-08-28 were generally normal, and vital signs are stable, indicating no contraindications for the planned FOLFOX treatment. No medication issues were identified.

2024-05-17

The patient underwent a PSA test as recommended by the urologist. The results were within normal limits. Additionally, no discrepancies were identified in the current medication regimen.

• 2024-05-17 Free PSA 0.533 ng/mL
  
• 2024-05-17 free PSA/PSA 46.296 %
  
• 2024-05-17 PSA 1.152 ng/mL
  
• 2024-05-17 CEA 1.53 ng/mL
  
• 2024-05-17 CA199 7.16 U/mL

2024-04-11

[bolus 5-fu omitted; oxaliplatin and diarrhea; microcytic anemia]

In the current treatment cycle started on 2024-04-11, the bolus dose of 5-FU was excluded from the dose-reduced infusional 5-FU in the FOLFOX regimen, with no records of bowel movements post-treatment available yet.

Both oxaliplatin and fluorouracil, components of FOLFOX, are associated with diarrhea, with oxaliplatin showing a 46% incidence rate for this side effect.

Persistent microcytic anemia has been noted with no sign of improvement.

If oral MgO supplementation fails to correct hypomagnesemia, intravenous MgSO4 could be considered as an alternative for magnesium supplementation.

• 2024-04-10 Mg (Magnesium) 1.6 mg/dL

• 2024-04-10 HGB 11.0 g/dL
  

• 2024-04-10 MCV 70.8 fL

2024-03-19

[microcytic anemia - possible iron deficiency]

The patient had four bowel movements on 2024-03-18. Loperamide was added to his medication regimen to help manage this.

Lab findings are consistent with microcytic anemia. Iron supplementation may be beneficial to address this.

• 2024-03-18 HGB 10.5 g/dL
• 2024-03-18 MCV 71.9 fL

700268435

240828

[lab data]

• 2024-04-12 HBsAg (NM) Negative
  
• 2024-04-12 HBsAg Value (NM) 0.407
  
• 2024-04-12 Anti-HBc (NM) Positive
  
• 2024-04-12 Anti-HBc Value (NM) 0.009
  
• 2024-04-12 Anti-HCV (NM) Negative
  
• 2024-04-12 Anti-HCV Value (NM) 0.039
  
• 2024-04-12 Anti-HBs (NM) Positive
  
• 2024-04-12 Anti-HBs value (NM) 92.6 mIU/mL

[exam findings]

• 2024-08-05, -08-13 KUB
  • S/P metalic stenting at the rectosigmoid junction.
  • Compression fracture of L1.
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4 and L4-5.
• 2024-07-05 CT - brain
  • Impression:
    • Still presence of one extra-axial calcified mass lesion over right temporal region, favor one meningioma.
    • The brain shows age-related cortical atrophy, sulcal space widening, proportionate ventricular dilatation. There is no intracranial hemorrhage seen.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
    • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
• 2024-06-17 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 38) / 88 = 56.82%
    • M-mode (Teichholz) = 56
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA. concentric LVH
    • Trivial MR, trivial TR and trivial PR
    • Preserved RV systolic function
    • Aortic valve calcification without AS
    • Sinus with PAC in bigeminal pattern at the exam.
• 2024-06-04 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Duodenal ulcers, bulb to SDA
  • CLO test:
    • Negative
• 2024-06-02 KUB
  • S/P colon stenting.
  • Compression fracture of L1.
  • Stool retention in the bowel.
  • A calcification at left pelvic cavity.
• 2024-04-26 KUB
  • S/P colon stenting.
  • Compression fracture of L1.
  • Disc space narrowing at L3/4.
• 2024-04-25 Sigmoidoscopy
  • Findings:
    • Rectosigmoid cancer with nearly complete obstruction
    • SEMS (self expandable metallic stent) was placed under colonoscope, through the guildwire , the stent was 12cm in length
  • Diagnosis:
    • Rectosigmoid cancer with nearly complete obstruction s/p SEMS
• 2024-04-17 MRI - pelvis
  • Findings:
    • There is segmental asymmetrical wall thickening at the middle and high rectum, 8 cm in size, that is c/w rectal cancer.
      • This tumor directly attached the left posterior aspect of the mesorectal fascia (4-5 o’clock direction) (Srs:8 Img:18).
      • This mass directly invades the peritoneal reflection and the dorsal aspect of the uterus (T4b) (Srs:15 Img:51).
    • There are eight enlarged nodes in the perirectal space and sigmoid mesocolon that is c/w regional metastatic node (N2b).
  • IMP:
    • Adenocarcinoma of the rectum is noted.
    • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4b N2b M0; stage: IIIC.
• 2024-04-11 CT - abdomen
  • History and indication:
    • Advanced rectal cancer with partial obstruction s/p biopsy
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent fat stranding and regional LAP.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • Compression fracture of L1.
  • Imaging Report Form for Colorectal Carcinoma
    • A. Tumor location / Size
      • Location:
        • □ Cecum (A1) □ Ascending (A2) □ Hepatic flexure (A3) □ Transverse (A4)
        • □ Splenic flexure (A5 □ Descending (A6) □ Sigmoid (A7) ■ Rectum (A8)
        • □ Others (A9) ____(A10)
      • Size：
        • □ Non-measurable (A11)
        • ■ Measurable: (A12) 1.7cm in thickness (A13) (largest diameter)
    • B. Tumor invasion
      • □ Tx: primary tumor cannot be assessed (B1)
      • □ T0: no evidence of primary tumor (B2)
      • □ Tis: carcinoma in situ (B3)
      • □ T1: tumor invades submucosa (B4)
      • □ T2: tumor invades muscularis propria (B5)
      • □ T3: tumor invades through the muscularis propria into pericolorectal tissue (B6)
      • ■ T4: tumor invades the visceral peritoneum or invades or adheres to adjacent or structure (B7)
        • ■ T4a: tumor invades the visceral peritoneum (B8)
        • □ T4b: tumor directly invades or adheres to adjacent or structure, location: (B9) ____ (B10)
    • C. Regional nodal metastasis
      • □ Nx: regional lymph node cannot be assessed (C1)
      • □ N0: no regional lymph node metastasis (C2)
      • □ N1: 1-3 lymph nodes are positive (C3)
        • □ N1a: one regional node is positive (C4)
        • □ N1b: 2-3 lymph nodes are positive (C5)
        • □ N1c: no regional lymph node is positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/ mesorectal tissue (C6)
      • ■ N2: four or more regional lymph nodes are positive (C7)
        • □ N2a: 4-6 regional lymph nodes are positive (C8)
        • ■ N2b: 7 or more regional lymph nodes are positive (C9)
      • number of suspicious lymph node 11 (C10) (C11)and location(specified as below):
        • ■ Pericolic/perirectal (C12) □ Ileocolic (C13) □ Right colic (C14) □ Middle colic (C15) □ Left colic (C16) □ Superior rectal (C17)
        • □ Superior mesenteric artery (C18) □ Inferior mesenteric artery (C19) □ Others (C20) ____ (C21)
    • D.Distant metastasis (In this study)
      • ■ M0: no distant metastasis (D1)
      • □ M1: metastasis to one or more distant sites or organs or peritoneal metastasis , location: (D2) ____(D3)
        • □ M1a: metastasis to one site or organ without peritoneal metastasis (D4)
        • □ M1b: metastasis to two or more sites or organs without peritoneal metastasis (D5)
        • □ M1c: metastasis to the peritoneal surface alone or with other site or organ (D6)
    • Impression ( Imaging stage ): T:T4a(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2024-04-11 CXR
  • Linear density at RLL.
  • Atherosclerosis of the aorta.
  • Compression fracture of L1.
• 2024-04-09 Patho - colorectal polyp
  • Colorectum, rectum, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2024-03-20 Bladder Sonography
  • Report: PVR: 60 mL
• 2024-01-06 CT - brain
  • No definite intracranial hemorrhage
  • Suspect right clinoidal meningioma or osteoma

[MedRec]

• 2024-05-02 SOAP Gastroenterolgy Chen ZhiXiang
  • S
    • Refer for HBV prophylaxis
    • Prepare for neoadjuvant C/T for rectal ca.
    • Current stage: immunotolerance/immunoclearance/carrier/reactivation
    • Last viral markers
      • HBsAg: , anti-HBs: , anti-HBc:
      • HBeAg: ,anti-HBe: ,
      • HBV DNA:
    • Coinfection: HDV(), HCV(), HIV()
  • O
    • PH:
      • Resolved HBV or OBI
      • Rectal cancer
      • T2D
      • Frequent UTI
    • FH: denied
    • Surgical history: denied
    • Smoking/alcohol/betal nut: denied
    • Allegy: NKA
    • ETV prophylaxis. RTC 3M. Check baseline HBV DNA
  • A/P
    • FU LFT, AFP, echo Q6M, HBsAg Q1Y, HBeAg Q6M
  • Prescription x3
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2024-05-02 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • TNT: CCRT with short infuion 5-FU x 2 courses -> FOLFOX x 8 (12-16 weeks)
• 2024-04-29 SOAP Radiation Oncology Wang YuNong
  • Plan: CT-simulation will be arranged on 5/6.
    • Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx.
    • RT will start around 5/9.
• 2024-04-25 ~ 2024-04-26 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Advanced rectal adenocarcinoma with nearly complete obstruction, cT4bN2bM0, stage IIIC status post self-expandable metal stents (SEMS) on 2024-04-25
    • Advanced rectosigmoid adenocarcinoma with nearly complete obstruction, cT4bN2bM0, stage IIIC status post self-expandable metal stents (SEMS) on 2024-04-25
    • Chronic kidney disease, stage 3 (moderate)
    • Type 2 diabetes mellitus
    • Essential (primary) hypertension
    • Mixed hyperlipidemia
  • CC
    • Bloody stool occasionally during defecation for over 4 years. Mild RLQ pain, mucous stool, tenesmus, and fecal incontinence several times a day for the past year.
  • Present illness
    • This 79-year-old female patient has had the history of diabetes mellitus, hypertension, hyperlipidemia, bilateral cataract, and repeatedly UTI.
    • According to the patient and previous medical record, she suffered from bloody stool occasionally during defecation for over 4 years. Mild RLQ pain, mucous stool, and fecal incontinence several times a day for the past year. She visited our outpatient department for help on 2024-04-08.
    • The colonoscopy performed on 2024/04/09 and revealed one mass at rectum above anal verge 12cm with partial obstruction. Pathology proved adenocarcinoma.
    • The abdominal CT conducted on 2024/04/11 and showed wall thickening of rectum with adjacent fat stranding and regional LAP, cT4aN2bM0, STAGE:IIIC.
    • The pelvic MRI was arranged on 2024/04/17, which showed 1) segmental asymmetrical wall thickening at the middle and high rectum, 8 cm in size, 2) tumor directly attached the left posterior aspect of the mesorectal fascia and invades the peritoneal reflection and the dorsal aspect of the uterus (T4b), 3) there are eight enlarged nodes in the perirectal space and sigmoid mesocolon that is c/w regional metastatic node (N2b).
    • We had made explanation of her disease condition and treatment plans to the patient and her family. A diverting stomy or colonic stent first followed by CCRT is recommended. But the patient don’t want any treatment. Because of the patient agreed to undergo colonic stenting, she came to CRS OPD on 2024/04/25. Therefore she was admitted to our ward for further management and care.
  • Course of inpatient treatment
    • This 79-year-old female patient was a case of rectosigmoid adenocarcinoma with nearly complete obstruction. She admitted on 2024/04/25 and colonic self-expandable metallic stents treatment was performed on the days of admission. Hospital course was relatively smooth without complication. She had passed stool and oral intake is fine. She was discharged on 2024/04/26 and will schedule our out-patient department follow-up next week.
• 2024-04-25 SOAP Colorectal Surgery Xiao GuangHong
  • A/P
    • Suggest colostomy due to nearly obstruction
    • Suggest CCRT then OP but she strongly refused
      • The patient don’t want any treatment
      • Depressive mood
    • Refer for hospice
    • Admission and arrange colonic stent for nearly obstruction
    • Suggest pre-op TNT then OP
• 2024-03-04 SOAP Metabolism and Endocrinology Qiu QuanTai
  • Prescription x3
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# QDAC
    • Pravafen (pravastatin 40mg, fenofibrate 160mg) 1# QDAC
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Amepiride (glimepiride 2mg) 1# QDAC
    • Micardis (telmisartan 80mg) 1# QDAC
    • Norvasc (amlodipine 5mg) 1# QDAC
• 2023-12-27, -09-27 SOAP Urology Li MingWei
  • Prescription x3
    • Betmiga (mirabegron 50mg) 1# QD
    • Cero (cefaclor monohydrate 250mg) 2# Q8H, TID
• 2023-07-05, -04-12 SOAP Urology Li MingWei & Zhang ShangRen
  • Prescription x3
    • Betmiga (mirabegron 50mg) 1# QD
    • Ceficin (cefixime 100mg) 1# Q12H
• 2023-01-11 SOAP Urology Zhang ShangRen
  • Prescription x3
    • Betmiga (mirabegron 50mg) 1# QD
    • Cero (cefaclor monohydrate 250mg) 2# Q8H

[radiotherapy]

[chemotherapy]

• 2024-08-26 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-08-05 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-07-16 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 440mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-06-11 - fluorouracil 400mg/m2 600mg D5W 500mL 10min D1-4 (CCRT)
• 2024-05-23 - fluorouracil 400mg/m2 600mg D5W 500mL 10min D1-2,5-6 (CCRT)

==========

2024-08-28

[Post-Transfusion Hemoglobin Level to be Monitored]

Normocytic anemia was observed on 2024-08-22 (HGB 7.9 g/dL), and a LPRBC transfusion was administered on the same day. The patient received FOLFOX chemotherapy on 2024-07-16, 2024-08-05, and 2024-08-26.

Previous records indicate a low hemoglobin level of 7.3 g/dL on 2024-06-10. The possibility that FOLFOX chemotherapy contributed to the anemia cannot be ruled out.

Given the recent blood transfusion, the hemoglobin level is expected to have increased. A repeat CBC is recommended to confirm this.

• 2024-08-22 HGB 7.9 g/dL

• 2024-08-13 HGB 9.1 g/dL

• 2024-08-05 HGB 9.4 g/dL

• 2024-07-30 HGB 9.8 g/dL

• 2024-07-15 HGB 8.9 g/dL

• 2024-08-22 MCV 91.4 fL

• 2024-08-13 MCV 86.3 fL

• 2024-08-05 MCV 88.2 fL

• 2024-07-30 MCV 87.9 fL

• 2024-07-15 MCV 83.7 fL

2024-08-23

[anemia management, stable vital signs, and controlled blood glucose]

Lab results on 2024-08-22 indicated anemia and a left-shifted WBC count. LPRBC transfusion was performed the same day. Other lab results were unremarkable, and vital signs remain stable. Blood glucose levels are slightly above 100 mg/dL and are under control. No medication issues were identified.

• 2024-08-22 WBC 7.67 x10^3/uL

• 2024-08-22 HGB 7.9 g/dL

• 2024-08-22 Band 3.8 %

• 2024-08-22 Neutrophil 67.6 %

• 2024-08-22 Lymphocyte 3.8 %

• 2024-08-22 Monocyte 10.5 %

• 2024-08-22 Eosinophil 1.9 %

• 2024-08-22 Basophil 0.0 %

• 2024-08-22 Metamyelocyte 3.8 %

• 2024-08-22 Myelocyte 7.6 %

• 2024-08-22 Promyelocyte 1.0 %

• 2024-08-22 Atypical Lymphocyte 0.0 %

2024-05-22

[AKI detected, diclofenac switch considered; hold chemotherapy for AKI resolution]

On 2024-05-21, the patient’s serum creatinine (SCr) level rose significantly, meeting the criteria for AKI as defined by the KDIGO guidelines.

• 2024-05-21 Creatinine 1.62 mg/dL
• 2024-05-20 Creatinine 1.10 mg/dL

Due to this AKI, switching the current medication Meitifen (diclofenac) to Tramacet (tramadol, acetaminophen) might be a suitable course of action.

Chemotherapy administration should be postponed until the AKI has resolved to minimize any further risk to kidney function.

701113969

240828

[exam findings]

• 2024-07-26 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Lateral spreading tumor, middle transverse colon, laparoscopic R’t hemicolectomy — Tubular adenoma with low grade dysplasia
    • Bilateral cutting ends, ditto — Free of dysplastic cell
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of one segment of colon measuring 6.5 cm in length, up to 4.2 cm in circumference, fixed in formalin. Grossly, one elevated tumor measured 2.0 x 1.3 cm with tatoo was found, which was 3.5 and 1.0 cm away from bilateral resection margins. Representatively embedded for sections as A1: bilateral margins, A2-A4: tumor and A5: pericolonic fat
  • MICROSCOPIC EXAMINATION
    • Lateral spreading tumor: tubular adenoma composed of colonic mucosal tissue with atypical glands lined by low grade dysplastic columnar cells, in tubular or focal villous arrangement, without stromal invasion
    • Bilateral cutting ends: free of dysplastic cell
    • Pericolonic fat: fat tissue only
• 2024-07-23 ECG
  • Sinus rhythm with 1st degree A-V block
• 2024-07-17 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in the right acetabulum, maxilla, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, knees and feet.
• 2024-07-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (70 - 26) / 70 = 62.86%
    • M-mode(Teichholz) = 62.4
• 2024-06-17 Patho - colon biopsy
  • DIAGNOSIS:
    • Colorectum, T-colon, s/p tattoo, biopsy (A) — Tubular adenoma with low grade dysplasia
  • GROSS DESCRIPTION:
    • Specimen submitted in formalin consists of 2 piece(s) of tan, polypoid tissue measuring 0.2 x 0.2 x 0.2 cm. All for section in one cassette.
  • MICROSCOPIC DESCRIPTION:
    • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with low grade dysplasia.
• 2024-06-14 CT - abdomen
  • Findings:
    • There is no focal wall thickening at the transverse colon at clip position. Please correlate with pathology.
    • There is hepatic flexure colon interposition in right anterior subphrenic space with passive compression S4 of the liver.
• 2024-06-14 Colonoscopy
  • A flat lateral spreading polypoid lesion (2.5cm in size) is located at T-colon
• 2024-06-14 Bladder Sonography
  • PVR: 22.6 ml
• 2024-06-07 ECG
  • Sinus rhythm with 1st degree A-V block
  • T wave abnormality, consider anterior ischemia
  • Abnormal ECG
• 2024-06-06 Patho - colon biopsy
  • PATHOLOGIC DIAGNOSIS
    • Colon polyp, 80 cm above anal verge, polypectomy — Tubular adenoma with low grade dysplasia
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of one small piece of colonic tissue measuring 0.9 x 0.5 x 0.1 cm in size, fixed in formalin. Grossly, it was grey in color and soft in consistence. All embedded for section.
  • MICROSCOPIC EXAMINATION
    • Microscopically, the section shows a picture of tubular adenoma, composed of colonic mucosal tissue with atypical glands lined by low-grade dysplastic columnar cells, in tubular arrangement. Follow up.
• 2024-05-24 ENT Hearing Test
  • Tymp:
    • R’t type B; L’t type As.
  • ART:
    • Bil absent.
  • PTA:
    • Reliability FAIR
    • Average RE 49 dB HL; LE 36 dB HL
    • R’t normal to severe SNHL.
    • L’t normal to moderately severe SNHL.
• 2024-04-02 RRIV and SSR
  • Findings
    • RR Interval variation/RRIV
      • The RRIV study showed normal RR interval variation at rest and during deep breathing.
    • Sympathetic Skin Response/SSR
      • The SSR study showed equivocal response at the palm and sole
  • Conclusion
    • The results of SSR and RRIV studies were within normal limits.
• 2024-04-02 Motor Nerve Conduction Velocity, MNCV
  • Findings:
    • Upper limb MNCV study:
      • Prolonged distal latency, Normal CMAP amplitude & Reduced MNCV in bilateral median nerves & ulnar nerves.
    • Lower limb MNCV study:
      • Prolonged distal latency, Dampened CMAP amplitude & Reduced MNCV in Lt peroneal nerve & Lt tibial nerve.
      • Normal distal latency, Dampened CMAP amplitude & Reduced MNCV in Rt peroneal nerve & Rt tibial nerve.
    • SNCV study:
      • Prolonged distal latency, Dampened SNAP amplitude & Reduced SNCV in right median nerve, bilateral ulnar nerves & bilateral sural nerves.
      • Prolonged distal latency, Normal SNAP amplitude & Reduced SNCV in Lt median nerve.
    • F wave study:
      • Prolonged F wave-latency in bilateral peroneal nerves & tibial nerves.
    • H reflex study:
      • Prolonged H reflex latency in Lt tibial nerve.
      • Absence of signal in Rt tibial nerve.
    • The thermal quantitative sensory testing (QST) study showed :
      • increased warm thermal perception thresholds in the left lower extremity.
  • Conclusion: The above findings suggest
    • sensorimotor polyneuropathies, demyelinating type,
    • bilateral lumbosacral radiculopathies,
    • abnormal QST finding.
    • Advise clinical correlation.

[MedRec]

• 2024-07-23 ~ 2024-07-29 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Lateral spreading tumor at transverse colon status post Laparoscopic-assisted partial colectomy on 2024-07-24 ( pathology: Tubular adenoma with low grade dysplasia)
    • Benign neoplasm of transverse colon
    • Coronary artery disease
    • Type 2 diabetes mellitus
    • Chronic kidney disease, stage 3
    • Hypertension
    • Gout
  • CC
    • Postive stool occult blood noted 3 month ago and lateral spreading tumor at transverse colon was told        
  • Present illness
    • This 75-year-old male had history of
      • Prostate adenocarcinoma, cT1c, GS4+3, iPSA 80, with bone metastasis status post transurethral resection of the prostate on 2021/10/14, T3bN1M1b, status post radiotherapy, Leuplin (2021/11/05~) and Xgeva (2024/03/22~)
      • Bladder tumor status post transurethral resection of bladder tumor on 2021/10/14
      • Coronary artery disease status post stent on 2002 and 2019
      • Diabete mellitus, type 2
      • Chronic kidney disease, stage III
      • Hypertension
      • Gout
      • Cataract OU status post operation
    • According to his medical record, postive stool occult blood noted 3 month ago.
    • Colonscopy on 2024/06/05 revealed 1. Colon polyp, ascending colon, status post biopsy removal 2. Colonic lateral spreading tumor, transeverse colon, 65cm AAV, status post tatoo 3. Rectal angiodysplasia 4. Melanosis coli.
    • Abdominal CT on 06/14 revealed no specific bowel wall thickness.
    • After discussion with patient, laparoscopic segmental resection of transverse colon will be arranged.
    • Lung function test and cardiac sonography was done on 2024/07/11 then normal ventilatory function and fair left ventricle ejection fraction (62.4%) was noted.
    • Under the impression of lateral spreading tumor at transverse colon, he was admitted for laparoscopic segmental resection of transverse colon. 
  • Course of inpatient treatment
    • After admission, pre-op and anesthesia assessment was done.
    • Laparoscopic-assisted partial colectomy was done smoothly on 2024/07/24.
    • After operation, try small ammount of food, adequate pain and IV fluid supply, prophylactic antibioitcs as Cefoxitin, PPI was given.
    • Mild dizziness noted when high blood sugar noted on 07/25, subsided by insulin.
    • Flatus passage noted on 07/25, try semi-liquid diet since 07/26. Removal of foley on 07/26. Stool passage noted on 07/27.
    • Mild shoulder tendenress noted on 07/28, Flurbiprofen was prescribed. Wound was clean and no ozzing.
    • Under relative stable condition, we arranged his discharge on 2024/07/29 and OPD follow up.
  • Discharge diagnosis
    • MgO 250mg 2# BID 8D
    • Acetal (acetaminophen 500mg) 1# PRNQ6H

[chemotherapy]

• 2024-08-28 - docetaxel 75mg/m2 100mg NS 250mL 1hr (docetaxel 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

701533947

240828

==========

2024-08-28

[fluconazole dosing strategy for candida albicans in low-weight patient]

Sputum culture results identified Klebsiella pneumoniae and Candida albicans. The former has been treated with Tapimycin (piperacillin/tazobactam), to which the Klebsiella is sensitive, and fluconazole was prescribed this evening for the Candida infection.

Directed Therapy (Candida albicans identified): Fluconazole is recommended at a loading dose of 800 mg (12 mg/kg), followed by 400 mg IV/PO daily once blood cultures have cleared and the patient is clinically stable.

The patient weighs 46.5 kg, which approximates a loading dose of 558 mg (equivalent to 3 to 4 capsules of 150 mg each), followed by a maintenance dose of 2 capsules (300 mg) daily.

701535745

240828

[lab data]

2024-08-24 G-6-P-D 0.2 U/gHb

[exam findings]

• 2024-08-27 SONO - abdomen
  • Symptoms
    • Ascites:
      • Fluid collection was noted at arround GB and between liver and left lobe of liver
    • Others:
      • Bilateral pleural effusion was noted
  • Diagnosis:
    • GB sludge
    • Fluid collection beside GB
    • Ascites, minimal, between liver and left lobe liver
    • Pleural effusion, bilateral
• 2024-08-26 SONO - nephrology
  • Interpretation:
    • Parenchymal renal disease
    • Simple cysts, bilateral
• 2024-08-21 EGD
  • Reflux esophagitis LA Classification grade A-
  • Heterotopic gastric mucosa, upper esophagus
  • Superficial gastritis
• 2024-08-19 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Segmental wall edema of sigmoid colon, suggest clinical correlation.
    • Left renal cyst, 1.9cm.
    • R/O liver cyst, 1cm in S2.
    • Presence of duodenal diverticulum.
    • Enlarged prostate gland.
    • Minimal ascites in the pelvic cavity.
    • Calcifications of abdominal aorta and iliac arteries.
• 2024-08-19 ECG
  • Sinus rhythm with 1st degree A-V block
  • Left axis deviation

==========

2024-08-28

[recommendations for managing G6PD deficiency with current medications]

The nurse practitioner informed me this morning that the patient has G6PD deficiency.

The following medications are likely to be UNSAFE in moderate to severe G6PD deficiency, as cited from UpToDate (https://www.uptodate.com/contents/image?imageKey=HEME%2F74254):

• Chlorpropamide
• Dabrafenib
• Dapsone (diaminodiphenyl sulfone)
• Fluoroquinolones (ciprofloxacin, moxifloxacin, norfloxacin, ofloxacin)
• Methylene blue (methylthioninium chloride)
• Nalidixic acid
• Nitrofurantoin, nifuratel, and nitrofurazone (nitrofural)
• Phenazopyridine (pyridium)
• Primaquine and tafenoquine
• Rasburicase and pegloticase
• Sulfonylureas (e.g., glipizide, glyburide [glibenclamide])

The active medication list has been reviewed. Amamet contains both metformin and glimepiride, the latter being a sulfonylurea. If G6PD deficiency is confirmed (2024-08-24 G6P 0.2 U/gHb, ref: 6.4 ~ 12.9 U/gHb), it is recommended to temporarily discontinue this medication.

[combination therapy for BPH: doxazosin and dutasteride]

It has been noted that the patient also has BPH. Since Doxaben XL (doxazosin 4mg/tab) 1# HS is currently being used, if clinical results remain unsatisfactory, two options can be considered:

• Increase Doxaben XL to 8mg daily (2#) after three weeks of use.
• Alternatively, add Avodart (dutasteride 0.5mg/cap) 1# daily.

These medications can be used together as combination therapy to manage BPH, effectively reducing symptoms, improving urinary flow, and potentially slowing disease progression.

Considerations of the combination therapy: doxazosin, an alpha-1 blocker, can cause blood pressure reduction, especially with the first dose. This effect may be more pronounced when combined with dutasteride, particularly in patients on antihypertensive therapy, so careful monitoring of blood pressure is essential when starting this combination. Additionally, the risk of orthostatic hypotension may increase, so patients should be advised to rise slowly from sitting or lying down to avoid dizziness or fainting. Extra caution is required if the patient’s liver function is deteriorating, as both medications are metabolized by the liver.

[addressing anemia and hemolysis in G6PD deficiency with biliary concerns]

An ultrasound performed on 2024-08-27, revealed the presence of gallstones (GB sludge), fluid collection near the gallbladder, and minimal ascites between the liver and the left lobe of the liver. As well as other lab results listed below:

• 2024-08-28 Bilirubin total 1.35 mg/dL
  

• 2024-08-28 Bilirubin direct 0.31 mg/dL

• 2024-08-26 FLEAR/CD24 Type III <0.1 %
  

• 2024-08-26 FLEAR/CD24 Type II <0.1 %
  

• 2024-08-26 FLEAR/CD16 Type III <0.1 %
  

• 2024-08-26 FLEAR/CD16 Type II <0.1 %

• 2024-08-28 HGB 7.1 g/dL

• 2024-08-26 HGB 7.9 g/dL

• 2024-08-24 HGB 6.5 g/dL

• 2024-08-24 HGB 6.6 g/dL

• 2024-08-22 HGB 7.0 g/dL

• 2024-08-20 HGB 8.0 g/dL

• 2024-08-19 HGB 9.6 g/dL

• 2024-08-26 CRP 27.5 mg/dL
  

• 2024-08-24 CRP 17.1 mg/dL
  

• 2024-08-24 G-6-P-D 0.2 U/gHb
  

• 2024-08-22 Haptoglobin <5.81 mg/dL
  

• 2024-08-21 Haptoglobin <5.81 mg/dL
  

• 2024-08-21 Ferritin; 1971.6 ng/mL
  

• 2024-08-20 Fe (Iron-bound) 142 ug/dL
  

• 2024-08-20 TIBC 207 ug/dL
  

• 2024-08-20 UIBC 65 ug/dL
  

• 2024-08-20 Reticulocyte Ratio 9.210 %

Comments:

• Biliary and Hepatic Concerns: The sonographic findings and slightly elevated bilirubin levels suggest early biliary dysfunction, potentially with inflammation or mild obstruction, but without severe hepatic dysfunction at this stage.
• Anemia: The progressive drop in hemoglobin levels alongside very low haptoglobin and high reticulocyte ratio indicates ongoing hemolysis, potentially exacerbated by G6PD deficiency. This is a significant concern, particularly in the context of anemia that may require intervention.
• Inflammatory State: The elevated CRP indicates a significant inflammatory or infectious process, which may be contributing to both the biliary issues and the hemolysis.
• Iron Metabolism: The iron studies suggest adequate iron stores, but the elevated ferritin and normal iron may point towards an inflammatory anemia rather than a classic iron deficiency.

Recommended Actions:

• Address Anemia: Consider blood transfusion or other supportive measures to manage the anemia, especially given the ongoing hemolysis and low hemoglobin levels.
• Evaluate and Treat Underlying Hemolysis: Investigate and manage potential causes of hemolysis, including addressing G6PD deficiency and any contributing oxidative stressors.
• Manage Biliary and Hepatic Complications: Further assess the gallbladder and liver function, considering potential interventions for biliary stasis or early cholecystitis.
• Monitor and Treat Inflammation: Continue monitoring inflammatory markers and treat any underlying infections or inflammatory processes.

700073662

240827

[exam findings]

• 2024-07-09 Patho - stomach subtotla/total (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Tumor, stomach, laparoscopy converted to open nearly total gastrectomy — Adenocarcinoma
    • Resection margins, bilateral, ditto — Free of tumor invasion
    • Proximal cutting end, frozen — Free of tumor invasion
    • Lymph nodes, LN 1, dissection — Fat only
    • Lymph nodes, LN 3, ditto — Metastatic carcinoma (2/6)
    • Lymph nodes, LN 4, ditto — Metastatic carcinoma (2/8)
    • Lymph nodes, LN 5, ditto — Free of tumor metastasis (0/5)
    • Lymph nodes, LN 6, ditto — Free of tumor metastasis (0/6)
    • Lymph nodes, unlabelled, ditto — Free of tumor metastasis (0/18)
    • Lymph nodes, LN 12a, ditto — Fat only
    • Lymph nodes, lesser curvature, ditto — Metastatic carcinoma (1/1)
    • Omentum, omentectomy — Free of tumor invasion
    • AJCC Pathologic staging — pT1bN2, if cM0, stage IIA
  • MACROSCOPIC EXAMINATION
    • Specimen type: stomach, lymph nodes, omentum
    • Specimen size: (a) stomach: GC: 18 cm; LC: 9 cm, (b) Omentum: 50 x 13 x 2 cm
    • Number of lesions: solitary
    • Tumor site: middle body, GC to lower body, PW
    • Tumor size: 8.8 x 6.5 cm
    • Tumor configuration: ulcerative protruding mass
    • Representatively embedded for sections as A1-A2: bilateral resection margins, A3: proximal margin + tumor, A4-A5: tumor, A6: tumor + distal margin, A7-A10: tumor, A11: fat at greater curvature, A12: fat at lesser curvature, B: omentum, C: LN 1, D: LN 3, E1-E2: LN 4, F: LN 5, G: LN6, H1-H2: LNs, unlabelled and I: LN 12a [Reference: F2024-00275 frozen section, one small piece of gastric proximal cutting end with staples measured 8.8 x 0.8 x 0.7 cm in size, all embedded for section]
  • MICROSCOPIC EXAMINATION
    • Histologic type: adenocarcinoma
    • Histologic grade: Grade 2, moderate differentiation
    • Depth of tumor invasion: submucosal layer
    • Lymph nodes: metastatic adenocarcinoma (5/44) in total number
      • Extracapsular extension: absent, (0/5)
    • Omentum: free of tumor invasion
    • AJCC Pathologic Staging: pT1bN2
    • Bilateral Margins: Free of tumor invasion, 2.1 / 3.3 cm away from bilateral margins
    • Additional pathologic findings: tumor necrosis, intestinal metaplasia
    • Perineural invasion: present
    • Lymphovascular space invasion: present
    • Immunohistochemistry (S2024-13930 D): CK (+) for metastatic carcinoma of necrotic calcified lymph node
• 2024-07-01 Patho - stomach biopsy
  • PATHOLOGIC DIAGNOSIS
    • Stomach, GC of middle body, biopsy — Adenocarcinoma
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of multiple small pieces of gastric tissue measuring up to 0.4 x 0.2 x 0.2 cm in size, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for section.
  • MICROSCOPIC EXAMINATION
    • Microscopically, the section shows a picture of adenocarcinoma of the gastric tissue characterized by tumor cells arranged in villotubular or cribriform patterns with enlarged, hyperchromatic nuclei infiltrating in ulcerative stroma with subtle desmoplasia. Immunohistochemistry of CK(+) and Her2/neu (+, Dako score 3+) for tumor.
• 2024-06-28 CT - abdomen
  • CC: epigastric pain with hunger pain for recent 6 months
  • 20240628 gastroscopy: One over 5cm ulcer with elevated mucosa and nodular surrounding surface from middle to low body of the stomach, GC, PW, s/p biopsy.
  • Findings:
    • There is lobulated irregular wall thickening at the middle to low body of the stomach, 6.7 cm in size, with irregular contour.
      • Adenocarcinoma of the stomach (T4a) is highly suspected.
    • There are nine enlarged nodes in peri-gastric area and gastrohepatic ligament (up to 2.8 x 1.7 cm) that are c/w regional metastatic nodes (N3a).
    • A hepatic cyst 1.5 cm in S2 is noted.
    • Abdominal aorta shows atherosclerosis and mild intramural thrombus formation.
    • There are few cysts on both kidney (up to 1 cm).
    • There are few lymph nodes in paratracheal space, subcarinal space and para-aortic space. Follow up is indicated.
      
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N3a(N_value) M:M0(M_value) STAGE:III(Stage_value)
• 2024-06-28 EGD
  • Diagnosis:
    • Suspect gastric malignancy, from middle body, GC to lower body, PW, s/p biopsy, Borrmann type III, if tissue proved.
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, antrum, s/p CLO test
  • CLO test:
    • Negative
  • Suggestion:
    • Pursue CLO test and pathology report
    • PPI use
• 2024-06-28 SONO - abdomen
  • Diagnosis:
    • Fatty liver, mild
    • Renal cyst, right
    • pancreatic body and tail masked by gas.
  • Suggestion:
    • encourage exercise and diet adjustment.
    • ultrasound follow up.

[MedRec]

• 2024-07-07 ~ 2024-07-19 POMR General and Gastroenterological Surgery Wu ChaoQun
  • Discharge diagnosis
    • Gastric adenocarcinoma, pT1bN2cM0, stage IIA, status post Laparoscopic radical subtotal (85%) gastrectomy with D2 lymph node dissection on 2024/07/08
    • Essential (primary) hypertension
    • Mixed hyperlipidemia
  • CC
    • Epigastralgia with hunger pain in recent 6 months
  • Present illness
    • This is a 67-year-old male with medical history of:
      • Hypertension
      • Hyperlipidemia
    • He was within his usual status until 6 months ago in 2024/01, when epigastralgia with hunger pain was noticed. He initially went to local clinic, where EGD was done and revealed big ulcer at lower body. Pathology showed adenocarcinoma. He then visited Dr. Wu’s outpatient clinic on 2024/06/25 for second opinion. EGD was performed once again and disclosed one over 5cm ulcer with elevated mucosa and nodular surrounding surface from middle body to lower body. Biopsy was done and further pathology confirmed adenocarcinoma. CT on 2024/06/28 showed suspicious gastric cancer, cT4aN3aM0.
    • As a result, admission for surgical intervention was suggested and accepted after well explanation of pros and cons.
    • This time, under the impression of gastric adenocarcinoma, he was admitted on 2024/07/07 for Laparoscopic subtotal gastectmy + Lymph node dissection.
  • Course of inpatient treatment
    • After admission, laboratory test was checked and showed anemia (Hb 8.9), so pRBC 2U was transfused. Laparoscopic radical subtotal (85%) gastrectomy with D2 lymph node dissection was performed on 2024/07/08.
    • Further pathology confirmed Gastric adenocarcinoma, pT1bN2cM0, stage IIA.
    • Sore throat and productive cough was noticed, while medication was prescribed and the symptoms partially relieved.
    • Follow-up hemogram showed improved anemia. Flatus and stool passage was noticed so NG was removed on 2024/07/13.
    • Oral intake was titrated as tolerance. Lab test was rechecked on 07/15 and showed no abnormaly. Drainage tube and CVC was removed.
    • Under stable condition, the patient was discharged on 2024/07/19 with OPD follow-up.        
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Pariet FC (rabeprazole 20mg) 1# QDAC
    • Mosapin (mosapride citrate 5mg) 1# TID

[surgical operation]

• 2024-07-08 - Op Method:
  • laparoscope radical subtotal (85%) with D2 LN dissection
  • Finding:
    • 10 x 6cm ulcerative mass at posterior wall with LN3, 4, 6, 9 enlarge+

[chemotherapy]

• 2024-08-26 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX 90% for 2nd time)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-08-09 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (FOLFOX 80% for 1st time)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

700128306

240827

[exam findings]

[MedRec]

• 2024-08-20 SOAP Hemato-Oncology Xia HeXiong
  • S
    • For elevated WBC
    • Initial presentation with UTI and admission to Infection on 2024-07-14 at Cheng Hsin Gnenral Hospital
    • Hx of left mastectomy since 921 earthquake due to early cacner s/p H/T 10+ years
    • Pituitary adenoma s/p R/T (r-knife) 4-5 years ago
    • Thyroid gioter s/p OP
  • O
    • PE: mucocutenous pigmention over oral and lips since 20 years ago
    • 2024-07-26 WBC 15700 Hb 12.4 Plt 286K N 79 L 14.7 M 4.2 E 0 B 0 Myelocyte 2.1
  • A/P
    • Not fit the criteria - Peutz-Jeghers syndrome
      • Family history (-)
      • Oral pigmentations (+)
      • Hamartomatous polyps (-)
    • Arrange admission for BM study, R/O CML, including BCR-ABL, Chromosome, JAK2, Infection
• 2024-08-14 SOAP Obstetrics and Gynecology Zeng LunNa
  • S
    • P2
    • refered from metbolic dept due to CT revealed rt adnexa with 0.5cm calcified spot.
    • RLQ pain on and off noted
  • O
    • 2024/08/14 SONO - gynecology
      • Uterus: 6.1x3.9cm
      • Myometrum: Anterior/Posterior wall: 1.67/1.72 cm
      • EM: 0.25cm
• 2024-08-12 SOAP Family Medicine Chen ZhengYu
  • S
    • TzuChi’s senior female fellow apprentices (ShiJie)
    • Patient was admitted to Cheng Hsin General Hospital through ER last month, Dx UTI and suspect bacteremia, s/p Abx tx
    • She felt malaise, myalgia, intermittent dizziness, no fever after discharge
    • Her WBC elevates persistently during OPD F/U later
    • 2024/08/09 Lab: WBC 14.5 10^3/uL, neu 75.7 %
    • U/C and B/C(?) showed GNB
  • O
    • 2024/07/14 CT impression: Wall thickening of bilateral ureters and UB, suggest follow up urine conditions.
• 2021-07-20 ~ 2021-07-28 POMR Nephrology Hong SiQun
  • Discharge diagnosis
    • Bacteremia (Escherichia coli)
    • Acute Pyelonephritis (Escherichia coli)
    • Renal and perinephric abscess, left
    • Acute kidney failure with tubular necrosis
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Chronic kidney disease, stage 2 (mild)
    • Obstructive hypertrophic cardiomyopathy
    • Nontoxic goiter, unspecified
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Chronic kidney disease, stage 2 (mild)
  • CC
    • generalized chillness with weakness for 3 days. Nausea with vomiting sensation was also noted.
  • Present illness
    • This 72 y/o female with history of DM, HTN, dyslipidemia under medication control. This time, she suffered from generalized chillness with weakness for 3 days. Nausea with vomiting sensation, very hungry but unable to eat well. She mentioned upper abdominal dull pain with tenderness. Urinary frequency and urgency noticed. She was brought to our ER for medical attention. At MER, There was no fever, no hemodynamic instability. Lab data revealed marked leukocytosis (30K) with left shift, urinalysis showed pyuria. Glucose showed 273 mg/dL. She remained clear and alert.
    • After COVID PCR negative, under the impression of APN, she was admitted for further care on 2021/07/21. Upon arrival, PE revealed right flank tenderness, and fever developed, we change antibiotic to ceftriaxone.
  • Course of inpatient treatment
    • After admission, empirical antibiotics was given with Rocephin.
    • We hold OHA shift to insulin due to acute kidney injury.
    • Urine culture and blood culture shpwed E.coli.
    • We arranged renal cyst aspiration due to persistent leukocytosis.
    • Her clinical condition in stable status post medical therapy, she was discharged on 2021/07/28.
  • Discharge prescription
    • …
• 2021-01-18 ~ 2021-01-21 POMR General and Gastroenterological Surgery Lai JieWen
  • Discharge diagnosis
    • Nontoxic goiter status post Near-total thyroidectomy + re-implant of parathyroid gland on 2021-01-19
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Chronic kidney disease, stage 2 (mild)
    • Obstructive hypertrophic cardiomyopathy
    • Malignant neoplasm of unspecified site of unspecified female breast
    • Disorder of pituitary gland, unspecified
    • Pure hypercholesterolemia
  • CC
    • Progressively increased thyroid goiters in recent months
  • Present illness
    • This is a 72-year-old woman with history of DM, hypertension under regular medication control, neck hematoma with partial airway compression after sono-guided thyroid biopsy in 2018.
    • According to her statement, she was diagnosed with DM and under regular control with follow-up at Dr. Yu’s OPD. The multiple thyroid goiters were found during thyroid sonography in 2014. She mentioned there was about 6 MNGs in the beginning, however, it has increased to 12 MNGs during the latest follow-up. Owing to the progression of She was referred to GS Dr. Lai’s OPD for further evaluation. After detailed explaination, she agreed with surgical intervention.
    • On admission, She denied of having obvious symptoms and signs of tracheal or esophageal compression like shortness of breath, dysphagia, sound hoarseness. PE revealed no hand tremor, no obvious palpable mass over neck, no arrythmia. Bilateral thyroidectomy was arranged on 2021-01-19.
  • Course of inpatient treatment
    • After admission, preoperative preparation and evaluation was done completely.
    • Near-total thyroidectomy + re-implant of parathyroid gland was performed on 2021-01-19. The operation was completed successfully. After OP, there was mild surgical site pain without signs of infection or hematoma. Swallowing discomfort was tolerable. Due to stable and improved condition, she was arranged discharge on 2021-01-21 and further OPD follow-up. 
  • Discharge prescription
    • …
• 2018-06-21 ~ 2018-06-25 POMR Metabolism Yu LiJiao
  • Discharge diagnosis
    • R22.1 - Subcutaneous ecchymosis and hematoma, neck.
    • D34 - Thyroid gland
    • E11.9 - Diabetes mellitus
    • I10 - Essential hypertension
  • CC
    • progressive swelling and respiratory distress after thyroid gland biopsy
  • Present illness
    • This is a 69-year-old woman with history of HTN and DM under regular OPD follow up at our hospital. This time she accepted thyroid gland biopsy by sonography at our hospital on 6/19. After biospy, progressive swelling and respiratory distress was noted. She was brought to our ER. At ER, neck hematoma with partial airway compression was noted. However, she was stable without respiratory distress under nasal cannula support. Due to the concern of hematoma progression with airway compression, she was admitted to MICU for close monitor.
  • Course of inpatient treatment
    • After admission, neck swelling and tenderness with ecchymosis were found, respiratory pattern smooth and no desaturation under nasal cannula support. Transamin 500mg IV Q12H and ice packing use for hematoma. Neck swelling was improved and no any discomfort after treament, thus she was transferred to Meta. ordinary ward for further treament on Jun 21.
    • At ward, neck swelling gradually improved and vital sign stable. Thyorid sona was arranged, the result was pending. Under the stable condition, she was discharged on Jun 25 and OPD follow-up was arranged.
  • Discharge prescription
    • …

[surgical operation]

• 2021-01-19
  • Op Method:
    • Near-total thyroidectomy + re-implant of parathyroid gland
  • Finding:
    • Enlargement of bil. thyroid glands with multiple well-defined goiters lesion noted
    • Thyroid remnant : about 1 gm

700888080

240827

[exam findings]

• 2024-08-21 CT - abdomen
  • History: cholangiocarcinoma with peritoneal, LNs, lung metastasis and small amount ascites S/P CT guiding liver biopsy on 2023/11/13.
  • Findings - Comparison: prior CT dated 2024/05/21.
    • Prior CT identified multiple poor enhancing masses on both hepatic lobes (the largest one occupied entire left lobe) with left lobe portal vein encasement is noted again, stationary.
      • It is c/w cholangiocarcinoma S/P C/T with stable disease.
    • There is massive ascites and soft tissue lesions in the omentum that is c/w carcinomatosis. Please correlate with ascites cytology.
      • In addition, there is lobulated soft tissue lesions in the lower pelvis peritoneum that is c/w tumor seeding.
    • Right pleural effusion with mild thickening in the parietal pleura is noted. Pleura metastases is highly suspected.
      • Please correlate with pleura effusion cytology.
        
    • Prior CT identified multiple lung metastases are noted again, mild increasing in size.
      • Prior CT identified several lymph nodes in para-aortic space and para-tracheal space are noted again, mild increasing in size.
    • There is mild left hydroureteronephrosis and equivocal delayed contrast excretion of left kidney.
      • Please correlate with retrograde pyelography.
    • The spleen shows prominence in size (long axis: 11 cm).
  • Impression:
    • Cholangiocarcinoma at both hepatic lobe S/P C/T show stable disease.
    • Carcinomatosis is noted. Please correlate with ascites cytology.
    • Right pleura metastases is suspected. Please correlate with pleura effusion cytology.
      
    • Prior CT identified multiple lung metastases are noted again, mild increasing in size.
• 2024-08-01 Anoscopy
  • Impression : DRE: no blood over the gloves and no palpable mass in the distance of finger length
  • Anoscopy: normal color stool, normal rectal mucosa, Prolapsed mixed hemorrhoids, GII at 3.7 and 11 o’clock region, normal anal tone and weakness of levator muscle
• 2024-07-09 CXR
  • Ground glass opacity at right lower lung zone.
  • Multiple nodules at bil. lungs.
• 2024-05-21 CT - abdomen
  • Clinical history: 71 y/o male patient with Malignant neoplasm of biliary tract, unspecified; Secondary malignant neoplasm of liver and intrahepatic bile duct; Secondary malignant neoplasm of unspecified lung
  • With and without contrast enhancement CT of abdomen–whole:
    • There are diffuse tumors in both lobes of the liver, c/w cholangiocarcinoma.
    • Presence of left portal vein thrombosis.
    • Presence of ascites with peritoneal nodules, r/o carcinomatosis.
    • Right pleural effusion.
    • Bilateral lung nodules, r/o lung metastasis.
  • Impression:
    • Persistent cholangiocarcinoma with portal venous thrombosis, peritoneal carcinomatosis, lung metastasis, right pleural effusion.
    • Ascites with progression.
• 2024-04-09, -03-19, -03-06, -02-27, -02-20, -02-06 CXR
  • Atherosclerotic change of aortic arch
  • Lung metastases are suspected after correlate with CT.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-04-02 SONO - abdomen
  • Sonography of hepatobiliary system revealed:
    • A calcification (0.38cm) at right hepatic lobe. Heterogeneous echogenicity of liver. Hypoechoic nodules (up to 3.36cm) in both hepatic lobes.
    • Right pleural effusion.
    • Ascites.
• 2024-01-15, 2023-12-25, -12-18, -12-15, - 12-10 CXR erect
  • Atherosclerotic change of aortic arch
  • Lung metastases are suspected after correlate with CT.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-12-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (63.1 - 20.2) / 63.1 = 67.99%
    • M-mode (Teichholz) = 68.0
    • 2D (M-Simpson) = 65.1
  • Conclusion:
    • Thickened AV with trivial AR
    • Normal MV with no MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
• 2023-12-25 Bronchodilator Test
  • Severe restrictive and moderate obstructive pulmonary function impairment.
  • Negative bronchodilator test.
  • Suggested COPD
• 2023-11-23, -11-10 CXR
  • Multiple nodules at bil. lungs.
  • Atherosclerosis of the aorta.
• 2023-11-23 KUB
  • Lumbar spondylosis and scolisis.
• 2023-11-13 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with intrahepatic cholangiocarcinoma
  • The specimen submitted consists of two strips of yellow gray soft tissue, labeled liver, measuring up to 1.5 x 0.1 x 0.1 cm. All for section.
  • The sections show a picture of adenocarcinoma, moderately differentiated, composed of nests and cords of polygonal neoplastic cells with moderate amount cytoplasm in fibrous stroma. Focal glandular differentiation and tumor necrosis are present.
  • IHC shows: CK7(+), CK19(+), CK20(-), Arginase-1(-), and Hepatocyte(-). The finding is compatible with intrahepatic cholangiocarcinoma.
• 2023-11-11 EGD
  • Diagnosis:
    • Reflux esophagitis,Gr A
    • Superficial gastritis, antrum
    • Gastric erosion, GCS of lower body
  • CLO test: not done
  • Suggestion:
    • Medication and OPD f/u
    • EGD was suggested for erosion f/u 3 months later
    • EGD was suggested annually for GERD f/u
• 2023-11-11 SONO - abdomen
  • Diagnosis:
    • Liver tumors, suspected metastatic tumors
    • liver parenchymal disease
    • mild gallbladder wall thickening
    • ascites: small amount
  • Suggestion:
    • correlate with other image study result such as CT scan/MRI
• 2023-11-04 CT - abdomen
  • History and indication: hepatic tumors R/O mets.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Poor enhancing tumors (up to 11.5cm) in both hepatic lobes.
    • Multiple lung nodules.
    • Increased soft tissues in peritoneal cavity with ascites.
    • Hyperplasia of left adrenal gland.
    • Mild splenomegaly.
    • Small caliber of left portal vein.
    • Some LNs at hepatic hilar region and retroperitoneum.
    • Atherosclerosis of aorta, iliac arteries.
  • Addendum Imaging Report Form for Cholangiocarcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)

[MedRec]

• 2023-11-29 ~ 2023-12-29 POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • intrahepatic cholangiocarcinoma with lung, peritoneal, lymph nodes metastasis, T3N1M1,Stage: IV
    • pneumonia at right lower lung, sputum culture: Candida albicans 3+
    • Severe Ascites status post pig-tail insertion on 2023/12/6.
    • Reflux esophagitis, grade A
    • Essential (primary) hypertension
    • Chronic obstructive pulmonary disease
    • Type 2 diabetes mellitus without complications
    • Chronic viral hepatitis B without delta-agent
    • Hypercalcaemia
    • hyperuricemia
    • hyperkalemia
    • hypomagnesemia
  • CC
    • For chemotherapy, and tapping ascites.
  • Present illness
    • This 71 year-old male has the histories of 1); Hypertension 2 Diabetes Mellitus; 3) Chronic obstructive pulmonary disease.
    • He suffered from epigastric pain for days. Poor appetite and body weight loss 4 kg in 1 month were noted. He visited local medical clinic for help. Abdominal sonography showed liver tumor. So he transfer to our GI OPD for help.
    • Abdominal CT was performed on 2023/11/4 and revealed In favor of liver cholangiocarcinomas with peritoneal seeding, LNs and lung metastases. Abdomen echo (2023/11/11) showed liver tumors, suspected metastatic tumors, liver parenchymal disease, mild gallbladder wall thickening, ascites: small amount. Esophagogastroduodenoscopy (2023/11/11): Reflux esophagitis,Gr. Superficial gastritis,antrum. Gastric erosion,GCS of lower body.
    • The liver biopsy via CT-guide (2023/11/13) revealed: Adenocarcinoma, moderately differentiated, compatible with intrahepatic cholangiocarcinoma. IHC shows: CK7(+), CK19(+), CK20(-), Arginase-1(-), and Hepatocyte(-). The finding is compatible with intrahepatic cholangiocarcinoma. Under the impression of Hepatic tumors, favor cholangiocarcinoma with peritoneal, lymph nodes, lung metastasis and small amount ascites, s/p chemotherapy with CDDP+Gemzar.
    • Anti-Hbc: reactive on 2023/11/14. Port-a catheter insertion on 2023/11/23.
    • This time, he came to our Hema OPD for or C1D1 chemotherapy with CDDP+Gemzar, and after chemotherapy was done, he was transferred to ER for tapping ascites. At ER, vital signs were blood pressure:120/74; pulse rate:77 次/分; body temperature:35.9 ℃; respiratory rate:18 次/分; Con’s:E4V5M6; SpO2:92%. Lab data showed hypercalcemia, hyperkalemia, leukocytosis, elevated CRP, BUN and Creatinine. Treatment for hyperkalemia was done at ER. Under the impression of: Hepatic tumors, favor cholangiocarcinoma with peritoneal, lymph nodes, lung metastasis and small amount ascites status post CT quiding liver biopsy on 2023/11/13, he was admitted for further evaluation and management.
  • Course of inpatient treatment
    • After be admitted, he received hydration with N/S plus Rolikan for alkalized urine, Feburic 1tab QD by self-paid, Fasturtec 1.5mg once for hyperuricemia, Miacalcic 100Unite Q8H–> Q12H, Lasix st for hypercalcaemia, and Kalimate 1pk TID for hyperkalemia. After treatment, the symptom of hyperuricemia, hypercalcaemia, and hyperkalemia improved , and gave nasal cannula support, albumin by self-paid for ascits, edema control. Re-checked the e- of Ca showed Hypercalcemia (Ca: 3.11mg/dL), and he suffered from shortness of breathing, severe ascited, pitting edema noted, followed-up chest x-ray revealed pneumonia at right lower lung, so gave Zometa st for Hypercalcemia, empiric antibiotic with Tapimycin for pneumonia control, and consulted 放射診斷科 for pig-tail insertion to drainage ascites (EXUDATE) 1500ml daily, Albumin by self-paid plus Lasix for edema treatment. After treatment, the symptom of Hypercalcemia, SOB, edema improved.
    • The lab of CBC/DC showed thrombocytopenia , so gave blood transfusion with LRP, he received C1D8 chemotherapy with CDDP+Gemzar on 2023/12/05. Then, he suffered from diarrhea, suspected side of Tapimycin, so shiftted to Cefim for pneumonia control, and antitussive. Consulted Chest for COPD with asthma drug evaluation, suggested: spiolto respimat 2 puff QD to replace relvar. Followed-up heart echo (2023/12/25) showed LVEF(%): 68.0%, 1. Thickened AV with trivial AR, 2. Normal MV with no MR, 3. Concentric LVH, 4. Preserved LV and RV systolic function, 5. Mild PR, mild TR, normal IVC size. 肺功能支氣管擴張劑試驗檢查 (2023/12/25): Severe restrictive and moderate obstructive pulmonary function impairment. Negative bronchodilator test. Suggested COPD.
    • After treatment, the symptom of pneumonia, and diarrhea improved. The family verbally expressed that they will sign the DNR when the patient is in a coma.
    • After treatment, he denide having a fever, chillness, shortness of breathing or any unconfortable, so he received C2D1 chemotherapy with CDDP+Gemzar on 2023/12/20, C2D8 on 2023/12/27. After chemotherapy, he denide having a fever, chillness, vomiting, or diarrhea. He can be discharged on 2023/12/29, the OPD follow-up will be arranged.
  • Discharge prescription
    • …
• 2023-11-10 ~ 2023-11-14 POMR Gastroenterology Wang JiaQi
  • Discharge diagnosis
    • Hepatic tumors, favor cholangiocarcinoma with peritoneal, lymph nodes, lung metastasis and small amount ascites status post CT quiding liver biopsy on 2023/11/13.
    • Reflux esophagitis, grade A
    • Essential (primary) hypertension
    • Chronic obstructive pulmonary disease
  • CC
    • epigastric pain and BW loss 6 KG in 1 mo
  • Present illness
    • This 71 year-old male has the histories of 1) Hypertension, 2) DM, 3) COPD.
    • This time, he suffered from epigastric pain for days. Poor appetite and body weight loss 4 kg in 1 month were noted. He visited local medical clinic for help. Abdominal sonography showed liver tumor. So he transfer to our GI OPD for help.
    • Abdominal CT was performed on 2023/11/04 and revealed In favor of liver cholangiocarcinomas with peritoneal seeding, LNs and lung metastases.
    • There was no headache or dizziness, no sorethroat or rhinorrhea, cough or dyspnea, no chest tightness or pain, no myalgia/arthralgia found.
    • Physical exam showed pink conjunctiva, breath sound: coarse, Heart soudn: RHB w/o murmur, abdomen: soft, epigastric tenderness, normoactive bowel sound without metallic sound, no flank knocking pain, no lower leg pitting edema, no wound or skin rash found.
    • Under the impression of 1) Suspect liver cholangiocarcinomas with peritoneal seeding, LNs and lung metastases, he was admitted to ordinary ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, hepaptitis markers (HBsAg, Anti HCV) and tumor markers (CEA, CA19-9) were all checked.
    • Upper GI endoscopy and abdominal sonography were all performed which revealed liver tumors, suspected metastatic tumors and minimal ascites on Echo.
    • EGD showed Reflux esophagitis, Gr A. In addition, oral form PPI with Nexium 1# po QDAC was given.
    • Because he still complained about intermittent Lelt epigastric pain, painkiller with scanol 1# po TID was used for symptoms relief.
    • We explained this condition to himself and his family, they understood. Informed the needs and the risks of CT quiding liver biopsy, they understood and agreed. CT quiding biopsy was done on 11/13 without complications.
    • Another hepatitis markers with Anti-HBc, Anti-HBs and LDH were checked.
    • Oncologist was consulted for management of favor CCC with intra-hepatic, peritoneal, LN and lung mets s/p biopsy who suggested OPD follow up and pending pathology.
    • There was no more epigastric pain nor fever after treatment. Under a stable condition, he was discharged on 11/14 and further GI/Oncology OPD follow up was arranged.
  • Discharge prescription
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Acetal (acetaminophen 500mg) 1# TID

[chemotherapy]

• 2024-08-27 - (FOLFOX)

• 2024-08-06 - (FOLFOX)

• 2024-07-10 - (FOLFOX)

• 2024-06-18 - (FOLFOX)

• 2024-05-28 - (FOLFOX)

• 2024-04-17

• 2024-04-11

• 2024-03-19

• 2024-02-27

• 2024-02-20

• 2024-01-31

• 2024-01-17

• 2024-01-10 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP) (Two weeks on, one week off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-12-27 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-12-20 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-12-05 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-11-29 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + cisplatin 50mg/m2 50mg NS 500mL 1hr (gemcitabine + cisplatin; Q4W)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-08-27

[considering next steps as tumor markers rise and metastases increase]

Over the past three months, CA199 levels have doubled, and CEA has tripled (though CA199 has been above the reference range, while CEA remains within it). Additionally, the CT scan on 2024-08-21 suggests possible carcinomatosis, right pleura metastases, and multiple lung metastases with mild increases in size. Overall, the disease appears to be progressing slowly, even after the initiation of FOLFOX in May 2024.

Lab results indicate decreased renal function (eGFR 52, with no rapid deterioration), normal liver function, anemia (HGB 9.4 g/dL), and suboptimal but acceptable blood sugar control.

No current medication issues have been identified. It may be time to consider the next line of treatment or regimen adjustments if the disease shows signs of rapid progression.

• 2024-08-09 CA-199 (NM) 64.092 U/ml

• 2024-07-12 CA-199 (NM) 41.629 U/ml

• 2024-06-20 CA-199 (NM) 37.733 U/ml

• 2024-05-29 CA-199 (NM) 32.722 U/ml

• 2024-05-03 CA-199 (NM) 25.762 U/ml

• 2024-04-17 CA-199 (NM) 24.911 U/ml

• 2024-04-12 CA-199 (NM) 28.871 U/ml

• 2024-04-03 CA-199 (NM) 24.195 U/ml

• 2024-03-27 CA-199 (NM) 19.936 U/ml

• 2024-03-22 CA-199 (NM) 24.314 U/ml

• 2024-03-12 CA-199 (NM) 22.997 U/ml

• 2024-03-08 CA-199 (NM) 18.399 U/ml

• 2024-03-01 CA-199 (NM) 23.074 U/ml

• 2024-02-06 CA-199 (NM) 28.001 U/ml

• 2024-02-02 CA-199 (NM) 29.461 U/ml

• 2024-01-25 CA-199 (NM) 25.929 U/ml

• 2024-01-12 CA-199 (NM) 33.372 U/ml

• 2024-08-09 CEA (NM) 2.847 ng/ml

• 2024-07-12 CEA (NM) 1.328 ng/ml

• 2024-06-20 CEA (NM) 1.247 ng/ml

• 2024-05-29 CEA (NM) 0.972 ng/ml

• 2024-05-03 CEA (NM) 0.933 ng/ml

• 2024-04-17 CEA (NM) 0.574 ng/ml

2024-01-16

[combining immunotherapy with chemotherapy in biliary tract tumors] - Ref: 2024-01-16 - https://www.uptodate.com/contents/systemic-therapy-for-advanced-cholangiocarcinoma

The current treatment regimen for advanced or metastatic biliary tract tumors for this patient is gemcitabine plus cisplatin.

Adding durvalumab to this regimen, as seen in the TOPAZ-1 trial, can enhances OS and response, without notably increasing toxicity. Similarly, pembrolizumab combined with gemcitabine and cisplatin, as demonstrated in the KEYNOTE-966 trial, also improves OS and is well-tolerated.

However, due to non-coverage by NHI and potential reimbursement issues, the addition of durvalumab or pembrolizumab may be more suitable for patients who can financially manage the costs.

2023-11-30

[hyperuricemia, hyperkalemia, hypercalcemia]

Hyperuricemia, hyperkalemia, hypercalcemia were observed.

• 2023-11-30 K(Potassium) 5.1 mmol/L
  
• 2023-11-30 Ca (Calcium) 3.51 mmol/L
  
• 2023-11-30 Uric Acid 12.2 mg/dL
  
• 2023-11-30 BUN 50 mg/dL
  
• 2023-11-30 Creatinine 1.64 mg/dL
  
• 2023-11-30 Na (Sodium) 134 mmol/L
  
• 2023-11-29 Ca (Calcium) 3.68 mmol/L
  
• 2023-11-29 Uric Acid 11.4 mg/dL
  
• 2023-11-29 K(Potassium) 5.2 mmol/L

Hyperuricemia is treated with Fasturtec (rasburicase), Februic (febuxostat) and Rolikan (sodium bicarbonate).

Hyperkalemia is treated wtih Kalimate (calcium polystyrene sulfonate).

Hyperuricemia and hyperkalemia are frequent symptoms of tumor lysis syndrome. Another typical symptom is hyperphosphatemia, so it’s recommended to also monitor serum phosphate levels.

Hypercalcemia is treated with Miacalcic (calcitonin).

For severe hypercalcemia, the maintenance dose of calcitonin can be up to 8 units/kg (2023-11-29 70kg => 560 units) Q6H to Q12H, starting with an initial dose of 4 units/kg (280 units) Q12H. Since the current administration of 100 IU Q6H is below the recommended dosage, this might extend the duration of therapy. It’s advisable to limit calcitonin therapy to a period of 24 to 48 hours to avoid tachyphylaxis.

Given that the serum calcium level has exceeded 3.5 mmol/L (14 mg/dL) and if the reading does not obviously trend downwards, the combined use of calcitonin with bisphosphonates for a longer effect might be an option.

700936681

240827

[exam findings]

• 2024-08-12 Bronchodilator Test
  • r/o small airway obstruction
  • with significant response to bronchodilator
• 2024-08-04 CT - abdomen
  • A patchy density (5.6cm) at LLL. Some GGO at bil. lungs.
  • Some LNs at mediastinum.
  • Liver and renal cysts (up to 1.6cm).
• 2024-05-04 MRI - nasopharynx
  • Findings comparison: 2024/01/29, 2023/01/06, 2022/01/08, 2020/11/26 MRI
    • Generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • The interhemispheric fissure is centered on the midline.
    • Abnormal patch symmetrical bright up signal intensities in bilateral periventricular white matter seen on T2WI and FLAIR images.
    • Sella and pituitary are normal. The parasellar structures are unremarkable.
    • Right CP angle and IAC and pons surface enhancing mass or nodules, slightly regressed size and perifocal edema, when compared with 2024/01/29 MRI.
      
    • Post Op change at right occipital skull.
  • Imp
    • Right CP angle and IAC and pons surface enhancing mass or nodules, slightly regressed size and perifocal edema, when compared with 2024/01/29 MRI
    • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
• 2024-01-29 MRI - nasopharynx
  • History: This 53 years old male patient had past history of hepatitis B carrier; suffered from right abducens palsy with right tinnitus and head heaviness for months and progressively deterioration.
    • Nasopharyngeal carcinoma, cT4N1M0, s/p CCRT on 2012/9/17 s/p 2nd PF on 2012/11/30.Recurrence over Rt CP angle s/p palliative CCRT on 2023/2/13.
  • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed and showed:
    • heterogeneous enhancing tumors in the right pons, right CPA and right ICA. As compared with previous study on 20231025, there was increase in soft tissue.
    • unremarkable change in the nasopharynx, oropharynx and hypopharynx.
    • several relatively enlarged lymph nodes in the submental and right submandibular spaces
  • IMP:
    • tumors in the right IAC, right CPA and right pons, increase in sizes.
• 2024-01-29 SONO - abdomen
  • Impression:
    • Liver cysts.
    • Wall edema/thickening of gallbladder. Suggest follow up.
    • Calcification in right lobe liver.
    • Renal cysts and stone.
• 2023-10-25 MRI - brain
  • r/o recent focal ischemic infarction in the left pons
  • r/o residual tumor in the right CPA, mild increase in size.
• 2023-07-26 MRI - brain
  • mild increased enhancement in the right CPA, no interval change.
• 2023-04-29 MRI - brain
  • Right CP angle and IAC mass, regressed size and perifocal edema, when compared with 2023/01/06 MRI
  • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
• 2023-01-06 MRA - brain
  • History: This 53 years old male patient had past history of hepatitis B carrier; suffered from right abducens palsy with right tinnitus and head heaviness for months and progressively deterioration.
  • With- and without-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial FLAIR images and axial DWI; using 4 mm thickness for sagittal section and 5 mm thickness for the others) revealed
    • an multi-lobulted extraaxial tumor, about 29.7mm, in the right IAC and right CPA with invasion to the right pons. Severe perifocal edemea was noted. Due to rapid progression, malignent change was considered.
    • post-OP change in the right occipital lobe and right cerebellar hemisphere.
  • IMP: an extra-axial tumor with intra-axial invasion in the right IAC and right CPA
• 2023-01-06 CXR
  • Tortous aorta with calcification is noted.
  • Emphysematous change over both lungs.
• 2022-10-04 MRI - brain
  • Clinical information: Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p CCRT
  • Findings:
    • Still presence of the enhancing lesions at right CP angle and IAC, associating with perifocal edema in right cerebellum, as compared with MRI on 2022/07/07.
    • Mildly dilated ventricles.
    • Moderate periventricular small vessel disease. NO acute ischemic infarct.
• 2022-07-07 MRI - brain
  • Indication: Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p CCRT PF
  • Without- and with-contrast multiplanar MRI studies of the brain (including axal and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
    • Regressive change of the enhancing lesion at right CP angle and IAC, associating with perifocal edema in right cerebellum, as compared with MRI on 20220315.
    • General enlargement of ventricles and cisterns, indicating general brain atrophy.
    • Multiple small well-defined FLAIR-hyperintensities at deep cerebral white matters, indicating leukoaraiosis.
    • Post-operation change at right sub-occipital neck.
    • No abnormal intensity at nasopharynx.
  • IMP: Right CPA/IAC tumor s/p treatment, with residual lesion. Suggest close follow-up.
• 2022-03-18 ENT Hearing Test
  • PTA
  • Reliability FAIR
  • Average RE >120 dB HL; LE 55 dB HL.
  • RE profound SNHL
  • LE mild to profound SNHL
• 2022-03-17 MRI - nasopharnyx
  • Right IAC and CPA tumor, stationary as compared with MRI on 20223015. Metastatic LAP with ENE at right neck.
• 2022-03-15 MRI - brain
  • Right CP (cerebellopontine) angle and IAC (internal auditory canal) mass, regressed size and perifocal edema, when compared with 20220108 MRI.
  • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
• 2022-01-08 MRI - posterior fossa, brain stem
  • A multi-lobuled lesion in the right IAC and right CPA with severe mass effect on the right brain stem, marked increase in size.
• 2022-01-03 Tc-99m MDP whole body bone scan
  • A hot spot in the left aspect of the maxilla, the nature is to be determined (dental problem or other nature?), suggesting follow-up with bone scan in 3-6 months for investigation.
  • Suspected benign lesions in the mandible, some C-, T- and L-spine, right sternoclavicular junction, bilateral shoulders, S-I joints, and hips.
• 2021-10-06 SONO - abdomen
  • There are several hepatic cysts in right lobe and the largest one measuring 1 cm in size at segment 8.
    
  • A renal cyst 1.35 cm on right kidney middle pole is noted.
• 2021-06-30 MRI - posterior fossa, brain stem
  • Right CP angle and IAC mass, slightly regressed size DDx: Neuroma, meningioma or metastasis.
  • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
• 2020-12-30 MRI - brain
  • Tumor at right CPA and IAC. Mild enlargement as compared with MRI on 20201126. Suspected metastasis. Meningioma or Schwannoma is less likely.
• 2020-11-26 SONO - abdomen
  • Right liver cysts and calcification. Left renal cyst and bil. renal stones.
• 2020-11-26 MRI - nasopharynx
  • C/W NPC s/p treatment without local recurrence, but with a metastatic lesion involving right IAC and CPA
• 2020-04-15 SONO - abdomen
  • There are several hepatic cysts in right lobe and the largest one measuring 1.08 cm in size at segment 8.
  • A renal cyst 1.27 cm on right kidney middle pole is noted.
• 2020-04-15 MRI - nasopharynx
  • C/W NPC s/p treatment without evidence of recurrence. An enhancing lesion in right IAC and cochlea. Suspected post-RT neuropathy. Metastasis is unlikely. Stationary as compared with previous MRIs.
• 2019-09-26 MRI - liver, spleen
  • Post RT change of right lobe liver.
  • Hepatic simple cysts.
• 2019-05-20 MRI - nasopharynx
  • C/W NPC s/p treatment with complete remission and no evidence of recurrence. Stationary as compared with MRI on 20190108.
• 2019-05-20 SONO - abdomen
  • Liver cysts.
  • Right renal stone.
  • Right renal cyst.
• 2019-01-08 MRI - nasopharynx
  • Right NPC, post CCRT. No evidence local recurrent tumor. No neck LAP.
• 2019-01-08 SONO - hepatobiliary
  • There are several hepatic cysts in right lobe and the largest one is measured about 0.91 cm in size at segment 8.
    
  • A renal cyst 1.33 cm on right kidney middle pole is noted.
• 2018-09-05 Whole body PET scan
  • In comparison with the previous study on 20180118, the glucose hypermetabolic tumor in the liver dome had disappeared in this study, suggesting response to current treatment.
  • Glucose hypermetabolism in the right alveolar process of the maxilla had been stationary since the previous study, suggesting benign conditions such as dental inflammatory lesion.
  • Moderate glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change in response to locoregional inflammation may show such a picture. Please correlate with clinical findings and keep follow-up, however, to exclude the possibility of more significant clinical problems.
• 2018-08-21 MRI - upper abdomen
  • Liver metastasis in segment 4/8 dome Status post R/T with inflammatory fibrosis is highly suspected.
• 2018-05-21 CT - abdomen
  • Much regression of liver dome lesion.
• 2018-01-24 CT - abdomen
  • A poor enhancing nodule (1.7cm) at liver dome c/w metastases.
• 2012-07-12 Pathology
  • Nasopharynx, right: Non-keratinizing carcinoma, undifferentiated (WHO-2B).

[MedRec]

• 2022-10-12 SOAP Hemato-Oncology Xia HeXiong
  • Due to 7 cycles of PF4, now F/U Q4W since 2022-10-12

[consultation]

• 2024-07-23 Ear Nose Throat
  • Q
    • This 65 year-old man with the underlying of 1) Hepatitis B carrier, 2) Acoustic neuroma, 3) NPC, 4) Liver metastasis s/p SBRT on 2018/2/09 was admitted due to brain mass from following MRI that revealed a metastatic lesion involving right IAC and CPA on 2020/11/26. The patient had the diagnosis of nasopharyngenl carcinoma, T4N1M0(IVA) s/p radiotherapy and chemotherapy (2018), this time, he admitted for chemotherapy.
    • due to family members said there was bleeding from the right ear (2024/07/22), we need your consultation for evaluation. Thanks a lot!!!
  • A
    • The patient and his family members said there was no bleeding from the ears.
    • S:
      • right otorrhea noted for 3 days
      • painless
      • NPC s/p CCRT
    • O:
      • right EAC pus and cerumen s/p L/T, right TM visable part seemed intact
      • left TM intact
    • A: right otitis externa
    • Plan:
      • earflo - it have been taught how to use it
      • well education
      • I have been told that he need to return to ENT regularly. After RT, there may be sequelae of hearing, middle ear, and sinus.
      • ENT OPD f/u
• 2023-01-31 Rehabilitation
  • Q
    • Brain MRI on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA. Now, he was admitted for concurrent chemoradiotherapy. This time, for evaluate “limb and bedside rehabilitation exercises”
  • A
    • Physical examination
      • 2023/01/31 13:10 T/P/R: 35.8℃ / 84bpm / 20bpm BP:145/89mmHg
      • Body weight: 56.2
        
      • Consciousness: clear
      • Cognition: intact, oriented, could follow orders
      • Speech: no aphasia, no obvious dysarthria
      • Swallowing: oral diet
      • Sphincter: urinary and stool continence
      • MP: RUE/RLE: 3/2-3, LUE/LLE: 3/2-3
      • Functional status: could sit up under modA with fair-poor sitting balance
      • BADL: needs mod assistance
      • MRS: 4 (need follow-up)
    • Assessment
      • Malignant neoplasm of nasopharynx
      • Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and right retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of extra-axial tumor with intra-axial invasion
      • Fever
      • Chronic viral hepatitis B without delta-agent
      • Gout
    • Plan
      • Rehabilitation programs: Bedside first PT, OT rehabilitation programs
      • Goal: Ambulation with/without device ID, BADL ID
• 2023-01-19 Family Medicine
  • Q
    • Brain MRA on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA. Now, under brain tumor radiotherapy, for combined care need your evaluate. Thank you.
  • A
    • 63 y/o gentaleman advanced NPC for brain palliative RT .
    • Our share care would follow up.
• 2023-01-09 Radiation Oncology
  • Q
    • This 63-year-old man patient is a case of Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and right retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of extra-axial tumor with intra-axial invasion.
    • This time, General weakness and difficulty in urinating for one week and vomiting after excercis for three days. Brain MRA on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA. Now, for evaluate brain tumor radiotherapy. Thank you.
  • A
    • S
      • This 63-year-old man patient is a case of nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and right retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy (72 Gy/36 fx) on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p SRS (14 Gy) on 2020/12/31 s/p surgical resection on 2022/1/21, s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of extra-axial tumor with intra-axial invasion. This time, progressive general weakness and difficulty in urinating for one week and vomiting after exercise has been noted for three days. Brain MRA on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA.
        
      • Previous RT: as above; s/p SBRT to single liver metastasis on 2018/2/09.
    • O
      • General Condition-ECOG: 2.
      • PE, 2023/01/09: No neck or SCF LAPs. General motor weakness; on bed ambulation.
      • Pathology, 2022/01/21: Rt CP angle, metastatic carcinoma.
      • Images:
        • Brain MRI, 2023/01/06: a multi-lobulated extraaxial tumor, about 29.7mm, in the right IAC and right CPA with invasion to the right pons. Severe perifocal edema was noted. Due to rapid progression, malignant change was considered. Post-OP change in the right occipital lobe and right cerebellar hemisphere. IMP: an extra-axial tumor with intra-axial invasion in the right IAC and right CPA
        • CXR, 2023/01/06: No lung metastasis; no pneumonia.
        • EBV DNA titer, 2022/11/16: Equivocal.
          
    • Diagnosis: Nasopharyngeal carcinoma, cT4N1M0, stage IV, s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p SRS on 2020/12/31 s/p surgical resection on 2022/1/21, s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of Rt CP angle tumor with invasion to the right pons; ECOG =2.
    • Plan: Palliative RT to Rt CP angle tumor for 4400cGy/20 fx is suggested for locoregional control. CT simulation was arranged on 2023/01/10, 09:30am. Possible radiation toxicity (white matter injury and pons injury) is told. Diet education is given. Poor prognosis is expected due to limited radiation dose.

[surgical operation]

• 2022-01-21 at TuCheng ChangGung Hospital

[radiotherapy]

• 2018-01-30 ~ 2018-02-09 - 5000cGy/5 fractions (6 MV photon) to metastatic tumor at liver dome
• 2012-07-31 ~ 2012-09-17 - CCRT was performed on 2012/07/31, 2012/08/07, 2012/08/14, 2012/08/21, 2012/08/28, 2012/09/04, 2012/09/11. RT completed on 2012/09/17.

[chemotherapy]

• 2024-08-26 - carboplatin AUC 4 450mg NS 250mL 2hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (PF Q4W)
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-07-18 - carboplatin AUC 4 450mg NS 250mL 2hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (PF Q4W)
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-06-03 - cisplatin 80mg/m2 130mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF)
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-25 - cisplatin 80mg/m2 130mg NS 500mL 24hr (Y-sited 5-FU) D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF)
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-02-27 - cisplatin 80mg/m2 130mg NS 500mL 24hr (Y-sited 5-FU) D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF)
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-02-03 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-01-27 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-01-18 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-01-12 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-09-29 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-08-30 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-08-04 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-07-08 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-05-25 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-04-22 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-03-18 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2024-08-27

[improvement in renal function after switch to carboplatin from cisplatin in PF regimen and monitoring electrolytes]

Since 2024-07-18, the platinum component in the PF regimen has been switched from cisplatin to carboplatin, with the patient’s eGFR improving from 40 ml/min/1.73m² on 2024-07-05 to 90 ml/min/1.73m² on 2024-08-21. Other lab results on 2024-08-21 were generally normal.

However, it is noteworthy that since July, hypokalemia has been more frequent, with potassium levels dropping below 3.5 mmol/L and even below 3.0 mmol/L at times. This may indicate a declining ability to maintain electrolyte balance. The patient is currently receiving appropriate oral potassium supplementation for hypokalemia and Baraclude (entecavir) for HBV reactivation prevention, with no medication issues identified.

• 2024-08-21 eGFR 90.01 ml/min/1.73m^2

• 2024-08-13 eGFR 87.76 ml/min/1.73m^2

• 2024-08-04 eGFR 72.16 ml/min/1.73m^2

• 2024-07-18 eGFR 93.60 ml/min/1.73m^2

• 2024-07-15 eGFR 70.66 ml/min/1.73m^2

• 2024-07-10 eGFR 54.51 ml/min/1.73m^2

• 2024-07-05 eGFR 40.71 ml/min/1.73m^2

• 2024-06-18 eGFR 91.18 ml/min/1.73m^2

• 2024-08-21 K (Potassium) 4.0 mmol/L

• 2024-08-13 K (Potassium) 2.7 mmol/L

• 2024-08-04 K (Potassium) 3.9 mmol/L

• 2024-07-18 K (Potassium) 3.3 mmol/L

• 2024-07-15 K (Potassium) 2.7 mmol/L

• 2024-07-10 K (Potassium) 3.1 mmol/L

• 2024-07-05 K (Potassium) 4.0 mmol/L

2024-03-26

[reconciliation]

Lab assessments conducted on 2024-03-25 indicated mostly normal results, with the exception of hypomagnesemia (1.6 mg/dL), which are being managed with oral MgO supplements. The patient’s vital signs have also consistently been stable during their hospitalization. Given these findings, there seems to be no contraindication to continuing with the current PF4 treatment regimen.

2023-02-16

Cisplatin is assciated with the potential hematologic and oncologic side effects as the following (ref: UpToDate)

• Anemia may occur in up to 40% of patients receiving the treatment.
• Leukopenia may occur in 25% to 30% of patients, with the lowest levels (nadir) typically occurring between days 18 and 23 of treatment. White blood cell counts typically recover by day 39. The incidence and severity of leukopenia may be related to the dose of the treatment.
• Thrombocytopenia may also occur in 25% to 30% of patients, with the lowest levels (nadir) typically occurring between days 18 and 23 of treatment. Platelet counts typically recover by day 39. The incidence and severity of thrombocytopenia may be related to the dose of the treatment.

Reducing the dosage of cisplatin (which is dose-dependent) can alleviate thrombocytopenia. Although the patient’s decrease in neutrophils and hemoglobin is not as significant as the decrease in platelets, platelet transfusions may trigger immune responses, infections, and other complications. Therefore, a balance between the expected therapeutic effect and adverse reactions should be sought while considering treatment options. One possible approach is to first reduce the cisplatin dosage to a level where the patient’s platelet count can still recover, and then proceed with further consideration.

2023-01-26

Recent lab data showed a significant downward trend in PLT, indicating that the patient has developed thrombocytopenia. Please closely monitor the patient for any signs of bleeding.

• 2023-02-13 PLT 45 *10^3/uL
• 2023-02-10 PLT 59 *10^3/uL
• 2023-02-03 PLT 81 *10^3/uL
• 2023-01-27 PLT 128 *10^3/uL
• 2023-01-18 PLT 260 *10^3/uL
• 2023-01-12 PLT 292 *10^3/uL

Actively bleeding patients with thrombocytopenia should be transfused with platelets immediately to keep platelet counts >50K/uL in most bleeding situations including disseminated intravascular coagulation (DIC), and >100K/uL if there is central nervous system bleeding. (ref: Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. 2009;145(1):24-33. doi:10.1111/j.1365-2141.2009.07600.x)

2022-08-05

The patient had a marginally high uric acid level (2022-07-05 7.7 mg/dL) prior to last chemotherapy, which could be followed up in order to determine the need for an uric acid lowering drug (e.g. febuxostat).

EBV DNA PCR results on 2022-01-17 indicated equivocal 120 copies/mL, which could be updated as well.

There is no issue with active prescriptions.

2022-04-25

For nonkeratinizing and/or undifferentiated histology, consider testing for EBV in tumor and blood. The EBV DNA load may reflect prognosis and change in response to therapy.

Stereotactic proton radiosurgery might be effective in treating brain metastases. reference: Proton Stereotactic Radiosurgery for Brain Metastases. https://pubmed.ncbi.nlm.nih.gov/29976494/

5-Fu plus cisplatin has been the current regimen since 2022-03-18. PD-1 inhibitors (e.g. pembrolizumab or nivolumab) might be an additional treatment option for cancers that are recurrent, unresectable, or metastatic (without surgery or radiation therapy).

Chronic viral hepatitis B is managed with Baraclude (entecavir) currently.

700987267

240827

[exam findings]

[MedRec]

• 2024-03-29 ~ 2024-04-01 POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • Rectal adenocarcinoma with regional lymph nodes, cT4aN2aM0, Stage IIIC, s/p concurrent chemoradiotherapy with infusional 5-FU from 2024/02/08 to 2024/03/18 (5 cycles), radiotherapy with 5040cGy/28 fractions (15 MV photon) to upper rectal from 2024/02/01 to 03/19, s/p chemotherapy with FOLFOX from 2024/03/30~
    • Liver cell carcinoma RFA (?) in 2019
    • Hypomagnesemia
    • Other secondary thrombocytopenia
    • Essential (primary) hypertension
    • Insomnia, unspecified
    • Chronic viral hepatitis B without delta-agent
    • Encounter for antineoplastic chemotherapy
  • CC
    • for total neoadjuvant therapy with FOLFOX
  • Present illness
    • This 77 y/o female has a medical history including 1) Hypertension, 2) Myoma s/p ATH 30 yr ago, 3) HCC s/p RFA (?) in 2019, 4) Rectal adenocarcinoma with regional lymph nodes, cT4aN2aM0, Stage IIIC, s/p concurrent chemoradiotherapy with infusional 5-FU from 2024/02/08 to 2024/03/18 (5 cycles), radiotherapy with 5040cGy/28 fractions (15 MV photon) to upper rectal from 2024/02/01 to 03/19.
    • She had been under regular medical supervision. Initial, bright red color was noted on tissue paper in 2023/12, she was referred to to our GI OPD for help. She also noted for difficult defecation and rectal bleeding for 2-3 months, BW loss (51 kg to 47.5 kg) in 2-3 months.
    • Sigmoidoscopy was arranged on 2023/12/22 showed rectal tumor, highly suspected rectal cancer status post biopsy and referred this patient to CRS OPD. CRS arranged Pelvis MRI and Abdominal CT was done.
    • Abdomina CT on 2024/01/10 showed 1. Adenocarcinoma of the rectosigmoid junction is highly suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4a N2a M0; stage: IIIC. Pelvis MRI on 2024/01/11 showed Rectal cancer with regional lymph nodes T4aN2aM0. However, pathology on 2023/12/26 showed Tubulovillous adenoma with high-grade dysplasia, at least.
    • So repeat sigmoidoscopy on 2024/01/23, pathology on 2024/01/26 showed Colorectum, 15 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+). After discussion, suggested total neoadjuvant therapy for Rectal adenocarcinoma. Tumor marker analysis indicated CEA at 2.55 ng/mL and CA199 at 10.72 U/ML on 2024/02/15.
    • Due to CT show may be lung metastasis, arrange PET scan on 2024/02/16 showed no lung meta.
    • She received concurrent chemoradiotherapy with infusional 5-FU from 2024/02/08 to 2024/03/18 (5 cycles), radiotherapy with 5040cGy/28 fractions (15 MV photon) to upper rectal from 2024/02/01 to 03/19. Check all RAS and BRAF (Detected NRAS codon 61 CCA＞AGA, p.Q61R).
    • Under the impression of Rectal adenocarcinoma with regional lymph nodes, cT4aN2aM0, Stage IIIC, s/p concurrent chemoradiotherapy with infusional 5-FU from 2024/02/08 to 2024/03/18 (5 cycles, Hold chemotherapy due to cytopenia, blood transfusion 2024/03/25), radiotherapy with 5040cGy/28 fractions (15 MV photon) to upper rectal from 2024/02/01 to 03/19. Port-A insertion on 2024/02/07. Denied TOCC history in recent three months.
    • This time, she was admitted to our ward for total neoadjuvant therapy with FOLFOX.
  • Course of inpatient treatment
    • After admission, thrombocytopenia was noted, BT LPH 2unit on 2024/03/30 for correction.
    • She receive total neoadjuvant therapy with FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5-Fu 2400mg/m2, due to WBC:2640, Plt:65000, reduce bolus and regimen with half discount) from 2024/03/30 to 2024/04/01 (C1D1) smoothly.
    • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
    • Magnesium Sulfate 10%, 20mL/amp 1amp IVD QD for hypomagnesemia.
    • Hypertension was treated with Norvasc 5mg/tab 1# PO QD. Insomnia with Eurodin 2mg/tab 1# PO HS.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for AntiHBc (+).
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/04/01 and OPD followed up later.   
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC

[radiotherapy]

• 2024-02-01 ~ 2024-03-19 - 5040cGy/28 fractions (15 MV photon) to upper rectal

[chemotherapy]

• 2024-08-27 - oxaliplatin 85mg/m2 48mg D5W 250mL 2hr + leucovorin 400mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2000mg D5W 500mL 46hr (neoadjuvant FOLFOX Q2W, Oxa 40%, Lv 60%, 5FU 60%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-08-10 - oxaliplatin 85mg/m2 47mg D5W 250mL 2hr + leucovorin 400mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2000mg D5W 500mL 46hr (neoadjuvant FOLFOX Q2W, Oxa 40%, Lv 60%, 5FU 60%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-07-18 - oxaliplatin 85mg/m2 47mg D5W 250mL 2hr + leucovorin 400mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2000mg D5W 500mL 46hr (neoadjuvant FOLFOX Q2W, Oxa 40%, Lv 60%, 5FU 60%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-06-27 - oxaliplatin 85mg/m2 47mg D5W 250mL 2hr + leucovorin 400mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2000mg D5W 500mL 46hr (neoadjuvant FOLFOX Q2W, Oxa 40%, Lv 60%, 5FU 60%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-06-03 - oxaliplatin 85mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2000mg D5W 500mL 46hr (neoadjuvant FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-09 - oxaliplatin 85mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2000mg D5W 500mL 46hr (neoadjuvant FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-15 - oxaliplatin 85mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2000mg D5W 500mL 46hr (neoadjuvant FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-30 - oxaliplatin 85mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2000mg D5W 500mL 46hr (neoadjuvant FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-02-20 - leucovorin 20mg/m2 25mg NS 100mL 10min + fluorouracil 400mg/m2 550mg NS 100mL 10min (CCRT 5-FU QW)
  • dexamethasone 4mg + NS 250mL
• 2024-02-19 - leucovorin 20mg/m2 25mg NS 100mL 10min + fluorouracil 400mg/m2 550mg NS 100mL 10min (CCRT 5-FU QW)
  • dexamethasone 4mg + NS 250mL
• 2024-02-15 - leucovorin 20mg/m2 25mg NS 100mL 10min + fluorouracil 400mg/m2 550mg NS 100mL 10min (CCRT 5-FU QW)
  • dexamethasone 4mg + NS 250mL
• 2024-02-08 - leucovorin 20mg/m2 25mg NS 100mL 10min + fluorouracil 400mg/m2 550mg NS 100mL 10min (CCRT 5-FU QW)
  • dexamethasone 4mg + NS 250mL

==========

2024-08-27

[frequently neutropenia despite reduced oxaliplatin dosage]

Granocyte (lenograstim 250ug) was administered on 2024-08-26, and currently, there is no evidence of neutropenia.

This patient appears to have a tendency towards neutropenia with the FOLFOX regimen. Despite oxaliplatin being used at only half the standard dose initially, and further reduced to 40% since late June, neutropenia continues to be frequently observed.

• 2024-08-27 WBC 6.54 x10^3/uL

• 2024-08-26 WBC 1.86 x10^3/uL

• 2024-08-27 Neutrophil 87.3 %

• 2024-08-26 Neutrophil 78.3 %

[febuxostat treatment for hyperuricemia]

The patient’s elevated serum uric acid levels are being managed with Feburic (febuxostat). The treatment is well-tolerated, and no issues or adverse effects have been identified.

• 2024-08-26 Uric Acid 7.0 mg/dL

2024-08-12

[WBC count returns to normal after neutropenia]

Neutropenia has resolved, and the WBC count is now within the normal range.

• 2024-08-10 WBC 6.69 x10^3/uL

• 2024-08-09 WBC 1.59 x10^3/uL

• 2024-08-10 Neutrophil 90.6 %

• 2024-08-09 Neutrophil 64.8 %

2024-06-03

[potential impact of earlier radiotherapy on pancytopenia; assessing patient tolerance to transfusion and G-CSF]

Lab data showed persistent pancytopenia, with fluctuations in severity but almost never returning to normal levels. Even on the day of receiving CCRT on 2024-02-08, the values were below normal, suggesting that earlier radiotherapy (from 2024-02-01) may also be a contributing factor. The patient began neoadjuvant FOLFOX treatment on 2024-03-30 (with all three sessions at a reduced dose), and pancytopenia has worsened since then.

If the patient tolerates LPRBC or LRP transfusion and G-CSF administration, the reduced dose regimen might be continued. However, if the patient cannot tolerate it and there is no substantial improvement in pancytopenia, alternative regimens or treatment approaches may need to be considered.

• 2024-06-03 WBC 2.33 x10^3/uL Neutrophil 83.2 %

• 2024-05-31 WBC 1.43 x10^3/uL Neutrophil 81.0 %

• 2024-05-27 WBC 1.80 x10^3/uL Neutrophil 68.4 %

• 2024-05-09 WBC 2.29 x10^3/uL Neutrophil 75.5 %

• 2024-04-15 WBC 2.35 x10^3/uL

• 2024-04-08 WBC 1.86 x10^3/uL

• 2024-03-29 WBC 2.64 x10^3/uL

• 2024-03-25 WBC 2.12 x10^3/uL

• 2024-03-18 WBC 2.32 x10^3/uL

• 2024-02-20 WBC 3.94 x10^3/uL

• 2024-02-15 WBC 2.81 x10^3/uL

• 2024-02-08 WBC 2.77 x10^3/uL

• 2024-06-03 HGB 13.9 g/dL

• 2024-05-31 HGB 7.1 g/dL

• 2024-05-27 HGB 11.2 g/dL

• 2024-05-09 HGB 9.9 g/dL

• 2024-04-15 HGB 9.7 g/dL

• 2024-04-08 HGB 10.7 g/dL

• 2024-03-29 HGB 10.0 g/dL

• 2024-03-25 HGB 11.0 g/dL

• 2024-03-18 HGB 11.4 g/dL

• 2024-02-20 HGB 11.5 g/dL

• 2024-02-15 HGB 11.4 g/dL

• 2024-02-08 HGB 11.9 g/dL

• 2024-06-03 PLT 61 *10^3/uL

• 2024-05-31 PLT 44 *10^3/uL

• 2024-05-27 PLT 62 *10^3/uL

• 2024-05-09 PLT 59 *10^3/uL

• 2024-04-15 PLT 68 *10^3/uL

• 2024-04-08 PLT 75 *10^3/uL

• 2024-03-29 PLT 65 *10^3/uL

• 2024-03-25 PLT 59 *10^3/uL

• 2024-03-18 PLT 56 *10^3/uL

• 2024-02-20 PLT 86 *10^3/uL

• 2024-02-15 PLT 79 *10^3/uL

• 2024-02-08 PLT 85 *10^3/uL

701073389

240827

[exam findings]

• 2023-06-24 CT - abdomen
  • Pancreatic head cancer (3.7*2.7cm), in regression
  • s/p biliary stents
  • Liver hypodensity; DDx: fatty liver, hepatitis
• 2023-05-04 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • No bloody material nor coffee ground material during this examination
    • Gastric mucosa swelling, antrum, PW site
    • C/W pancreatic cancer with duodenal involving
    • Duodenal orifices, ampulla and periampulla, need to r/o pancreatic cancer involving duodenal causing perforation
    • Duodenal plastic stent inplace
    • Superficial gastritis
    • Deformed antrum
  • Suggestion
    • PPI use
• 2023-04-29 Embolization (TAE) - abdomen
  • Embolization of gastroduodenal artery via right femoral artery puncture revealed:
    • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
    • No definite active bleeding during the celiac axis and SMA injections.
    • Prevention emobilization of gastroduodenal artery was periformed with 2 coils. Nearly total obliteration of gastroduodenal artery after embolization.
    • No procedure related complication.
  • Impression
    • c/w TAE of gastroduodenal artery
    • A Fr.5 sheath was placed in right common femoral artery. Please remove it in 3 days.
• 2023-04-29 Esophagogastroduodenoscopy, EGD
  • Duodenum
    • One 3mm clean base ulcer with pigmentation was found at SDA. Active oozing, suspect the previous ulcer(2022/12/15), near the major papilla was noted, due to unable to tolerate, hemostasis is not done.
  • Diagnosis
    • Incomplete study due to much blood and intolerace
    • Duodenal oozing lesion, suspicious previous ulcer, 2nd portion
    • Duodenal ulcer, Forrest classification IIc, SDA, AW
  • Suggestion
    • Arrange TAE for hemostasis
    • Admission to ICU and then repeat EGD in the future
    • High dose PPI and NPO
• 2023-03-13 CT - abdomen
  • Indication: Pancreatic head cancer, stage III, with common bile duct obstructive jaundice, status post Endoscopic Retrograde Biliary Drainage revision
  • Abdominal CT with and without enhancement revealed:
    • Cystic lesion at pancreatic head measuring 5.7cm in largest dimension obliterating CBD and causing dilated biliary tree is found. In comparison with CT dated on 2022-11-30, the tumor size is stationary.
    • Marked fatty liver is found.
    • s/p biliary tree stent placement.
    • The GB is well distended without soft tissue lesion
    • No evidence of abnormal soft tissue mass at pelvic cavity.
    • No definite inguinal or pelvic sidewall LAP
    • The urinary bladder is well distended without soft tissue lesion.
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • Imp:
    • Cystic lesion at pancreatic head measuring 5.7cm in largest dimension obliterating CBD and causing dilated biliary tree is found. In comparison with CT dated on 2022-11-30, the tumor size is stationary.
• 2023-03-09 CXR
  • Atherosclerotic change of aortic arch
  • Scoliosis of the T-spine with convex to right side.
• 2023-01-12 Endoscopic Retrograde CholangioPancreatography, ERCP
  • Indication
    • pancreatic head cancer post ERBD, malfunction of ERBD
  • Diagnosis
    • Pancreatic head cancer with CBD obstructive jaundice, post ERBD revision
    • Duodenal ulcer, c/w, tumor invasion.
  • Suggestion
    • On diet tonight
    • f/u Hb, serum AST/ALT, T-bil, lipase on the next morning
• 2023-01-11 Abdomen - standing (diaphragm)
  • S/P CBD stenting.
• 2023-01-11, 2022-12-26 CXR
  • Presence of scoliosis of the T-L spine.
• 2022-12-30 Whole body PET scan
  • There was inhomogenously increased FDG uptake in the region about the pancreatic head (SUVmax early: 7.43, delay: 6.38) and there was increased FDG uptake in the left shoulder joint (SUVmax early: 8.51, delay: 5.94). Besides, there was increased FDG accumulation in the colon, both kidneys and right ureter.
  • IMPRESSION:
    • Inhomogenously increased FDG uptake in the region about the pancreatic head, compatible with primary pancreatic malignancy. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in the left shoulder joint, compatible with active arthritis.
    • Increased FDG accumulation in the colon, both kidneys and right ureter. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2022-12-23 SONO - abdomen
  • Liver tumor, S6 and S7, suspicious Liver hemangioma
  • Fatty liver, mild
  • post ERBD.
  • Dilated left IHD.
• 2022-12-16 T-tube cholangiography
  • Cholangiography via PTCD catheter administration revealed:
    • Patency of the catheter.
    • Poor drainage function of CBD stent.
• 2022-12-16 Patho - duodenum biopsy
  • Labeled as “duodenum, major papilla (A)”, biopsy — adenocarcinoma.
    • IHC stains: CA19-9 (+), CK19 (+), CK7 (+), CK 20 (focal +), Ki-67 (60-70%)
  • Labeled as “duodenum, postbulb (B)”, biopsy — adenocarcinoma.
    • IHC stains: CA19-9 (+), CK19 (+), CK7 (+), CK 20 (focal +), Ki-67 (60-70%)
• 2022-12-16 Patho - pancreas biopsy
  • Labeled as “Pancreas”, EUS biopsy — adenocarcinoma.
    • IHC stains: CA19-9 (+), CK19 (+), CK7 (+), CK 20 (focal +), Ki-67 (60-70%)
• 2022-12-15 Endoscopic Retrograde CholangioPancreatography, ERCP
  • Indication
    • pancreatic head cancer with obstructive jaundice
  • Diagnosis
    • pancreatic head cancer with obstructive jaundice, s/p EST, CBD dilatation + ERBD
    • duodenal ulcer, suspicious tumor invasion, s/p biopsy(A) at major papilla, biopsy(B) at postbulb
    • post PTCD
  • Suggestion
    • On NPO except water tonight
    • f/u Hb, serum AST/ALT, T-bil, lipase on the next morning
    • PPI Rx
• 2022-12-15 Endoscopic Ultrasonography, EUSDiagnosis：
  • Diagnosis: Pancreatic head cancer with obstructive jaundice and duodenal invasion, s/p CHE-EUS-FNB
  • Suggestion: pursue pathology.
• 2022-12-13 MRI - pancreas
  • Pancreatic head tumor (5.4cm).
  • S/P PTCD. Some nodules in liver.
  • Bil. pleural effusion with adjacent lung collapse.
• 2022-12-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (138 - 48) / 138 = 65.22%
    • M-mode (Teichholz) = 65
  • Borderline dilated LA and LV; Adequate LV systolic function with normal resting wall motion
  • Trivial MR and trivial TR
  • LV diastolic dysfunction, Gr 1
  • Preserved RV systolic function
• 2022-12-08 Visceral Angiography 2 vessels
  • DSA of celiac trunk, SMA and common hepatic artery via right common femoral artery puncture revealed:
    • S/P PTCD.
    • Liver cirrhosis.
    • Patency of hepatic arteryies and portal vein. No evidence of active bleeding.
    • No procedure-related complication during the whole procedure.
  • IMP: No evidence of active bleeding.
• 2022-12-08 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
  • Dilatation of the biliary tree (by CT images).
  • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
  • No procedure-related complication during the whole procedure.
• 2022-11-30 CT - abdomen
  • Findings:
    • There is a well-defined hypodense mass at the pancreatic head, measuring 6 cm in size (the largest dimension), causing dilatation of bile ducts and pancreatic duct. During contrast-enhanced dynamic study, this mass shows poor enhancement in arterial phase and portal venous phase images, and mild enhancement in delayed phase images.
      • Adenocarcinoma of the pancreatic head is highly suspected.
      • The differential diagnosis include acinar cell carcinoma.
      • In addition, There is loss of normal fat plane between the pancreatic head mass and superior mesenteric vein that may be tumor direct invasion superior mesenteric vein (T4).
    • There are several ill-defined mild enhancing lesions in both hepatic lobes at arterial phase images. However, all lesions are not identified (isodensity) in portal venous phase and delayed phase images. The largest one 2.4 x 1.2 cm in S7 of the liver.
      • Pseudolesions (flow artifacts) are highly suspected.
      • The differential diagnosis include metastases.
      • Please correlate with sonography and MRI.
    • A renal cyst measuring 1 cm in left middle pole is noted.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T4 (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:III(Stage_value)
• 2021-05-11, -02-23 CXR
  • There is scoliosis of the T-spine with convex to right side.
  • Atherosclerotic change of aortic arch
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura thickening or effusion?
• 2020-03-04 Treadmill exercise test (BRUCE protocol)
  • The patient exercised according to the BRUCE for 08:00 min:s, achieving a work level of max METS: 10.1. The resting heart rate of 96 bpm rose to a maximal heart rate of 169 bpm. This value represents 107 % of the maximal, age-predicted heart rate. The resting blood pressure of 145/71 mmHg, rose to a maximum blood pressure of 201/61 mmHg. The exercise test was stopped due to Target heart rate maximal, Dyspnea, Fatigue.
  • Conclusion:
    • Resting ECG: normal
      
    • Arrhythmia: Nil
    • No significant ST-T change during exercise and recovery phases.
  • Impressions
    • Negative for myocardial ischemia
• 2022-12-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 35) / 93 = 62.37%
    • M-mode (Teichholz) = 63
  • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
  • Subendocardial scarring of inferior and inferoseptum with preserved wall motion and normal LV systolic function.
  • Normal RV systolic function.
  • Mild AV sclerosis; trivial MR.
  • Sinus tachycardia.
• 2017-01-07 SONO - Nephrology
  • Finding:
    • Size Shape
      • R’t :10.69 cm, smooth
      • L’t :10.87 cm, smooth
    • Cortex
      • R’t :Echogenicity: normal; Thickness: normal
      • L’t :Echogenicity: normal; Thickness: normal
    • Pyramid:
      • R’t : visible
      • L’t : visible
    • Sinus
      • Not Dilated
    • Cyst
      • None
    • Stone
      • None
    • Mass
      • None
  • Interpretation:
    • No signficant abnormality from echography for both kidneys.

[MedRec]

• 2023-07-25 SOAP General and Gastroenterological Surgery
  • Prescription x3
    • Protase (pancrelipase 280mg) 1# TIDCC
• 2023-06-06 SOAP Cardiology
  • Prescription x3
    • Plavix (clopidogrel 75mg) 1# QD
    • carvedilol 6.25mg 1# BID
    • Cabudan (captopril 25mg) 1# QD
    • Alpraline (alprazolam 0.5mg) 1# HS
• 2023-05-17 SOAP Gastroenterology
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Genurso (ursodeoxycholic acid 100mg) 1# BID
    • BaoGan (silymarin 150mg) 1# TID
    • Dexilant (dexlansoprazole 60mg) 1# QD
• 2023-01-03 SOAP Hemato-Oncology
  • O:
    • Cancer Multidisciplinary Team Meeting Conclusion, meeting date: 20230103
      • Neoadjuvant C/T -> OP.
  • S
    • will give pre-Op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 12.
    • RTC 1 wk later on 20230109 for LFT & arrange adm for #1 pre-Op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 12.

[consultation]

• 2022-12-20 Radiation Oncology
  • Q
    • Diagnosis: Pancreatic head cancer, adenocarcinoma, cT4N1M0 at least, with obstructive jaundice on 2022/12/08, s/p ERCP + ERBD / EUS-FNB on 2022/12/15; severe BW loss; ECOG =1.
    • Plan: Pre-operative CCRT to pancreatic head tumor & regional LAPs for 5040cGy/28 fx is suggested for locoregional tumor control. Possible treatment toxicity is told. CT simulation is arranged on 2022/12/21. Psychological support & diet education is given to him and his daughter. Please consult dietician for diet education, medical oncologist for systemic chemotherapy and surgeon for PortA implantation.

[surgical operation]

• 2023-11-09
  • Surgery
    • Roux-en Y Hepaticojejunostomy
    • GJ side to side anastomosis
    • cholecystectomy
  • Finding
    • pancreatic uncinat process tumor direct invasion SMV long segment
    • liver mets not found by intraoperative echo
    • fatty liver cirrrhosis
    • ascite + minimal

[radiotherapy]

• 2023-01-27 ~ 2023-02-20 - 5040cGy/28 fractions (15 MV photon) to pancreatic tumor/LAPs

[chemotherapy]

• 2024-08-26 - liposome irinotecan 70mg/m2 100mg D5W 500mL 2hr + leucovorin 400mg/m2 600mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-08-06 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-07-16 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-07-02 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-06-18 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-06-11 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-28 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-14 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-07 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-04-23 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-04-16 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-04-02 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-03-19 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-03-12 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-02-21 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-02-07 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-24 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-10 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-02 - oxaliplatin 70mg/m2 80mg D5W 250mL 2hr + irinotecan 150mg/m2 160mg NS 500mL 2hr + leucovorin 400mg/m2 400mg NS 500mL 2hr + fluorouracil 2800mg 3000mg NS 500mL 46hr (FOLFIRINOX, Oxa 70%, Iri 70%, LV 70% 5FU 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-07-11 - oxaliplatin 70mg/m2 80mg D5W 250mL 2hr + irinotecan 150mg/m2 160mg NS 500mL 2hr + leucovorin 400mg/m2 400mg NS 500mL 2hr + fluorouracil 2800mg 3000mg NS 500mL 46hr (FOLFIRINOX, Oxa 70%, Iri 70%, LV 70% 5FU 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-06-23 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2800mg 3500mg NS 500mL 46hr (FOLFIRINOX, Iri 90%, 5FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-05-31 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg NS 500mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2800mg 4320mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-04-07 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 235mg NS 500mL 2hr + leucovorin 400mg/m2 625mg NS 500mL 2hr + fluorouracil 2800mg 4375mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-03-09 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 235mg NS 500mL 2hr + leucovorin 400mg/m2 625mg NS 500mL 2hr + fluorouracil 2800mg 4385mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-02-13 - fluorouracil 225mg/m2 340mg NS 500mL 24hr D1-5 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-02-06 - fluorouracil 225mg/m2 340mg NS 500mL 24hr D1-5 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

==========

2024-08-27

[Onivyde Fu/Lv regimen: first administration review, follow-up needed for elevated liver enzymes]

Onivyde (liposomal irinotecan) NALIRIFOX was not used as the initial treatment regimen for this patient. When using the Onivyde Fu/Lv regimen after gemcitabine treatment, the recommended administration steps are as follows: (Ref: https://www.onivyde.com/en-us/for-patients/learn-about-onivyde/how-onivyde-is-given)

Onivyde should be administered IV at 70 mg/m² over 90 minutes, with leucovorin given over 30 minutes and fluorouracil over 46 hours, once every 2 weeks; continue until disease progression or unacceptable toxicity occurs.

There were no issues with the first administration of the Onivyde Fu/Lv regimen, which began on 2024-08-26. Additionally, please note that liver enzyme levels are elevated, warranting follow-up.

• 2024-08-26 ALT 46 U/L

• 2024-08-21 ALT 24 U/L

• 2024-08-06 ALT 13 U/L

• 2024-08-26 AST 40 U/L

• 2024-08-21 AST 27 U/L

• 2024-08-06 AST 18 U/L

2024-08-22

[electrolyte correction and chemotherapy cancellation]

Hypoalbuminemia, hypokalemia, and hypocalcemia were noted. Plasbumin (human albumin), Bfluid (amino acids), and both oral and injectable KCl have been administered. The balancing process shows no issues identified. The scheduled Onivyde + 5-FU prescription has been cancelled.

• 2024-08-21 K (Potassium) 3.0 mmol/L
  
• 2024-08-21 Albumin (BCG) 2.8 g/dL
  
• 2024-08-21 Ca (Calcium) 1.84 mmol/L

2024-08-21

[tracking HGB decline during ongoing chemotherapy]

According to HIS5 records, the patient has undergone chemotherapy every month since Feb 2023, except for the period between Sep and Dec 2023.

Lab results show a downward trend in HGB levels this year, decreasing from a high of 12 g/dL in Jan to below 8 g/dL recently, suggesting that chemotherapy has likely contributed to worsening anemia.

A transfusion was appropriately administered on 2024-08-21, when HGB reached its lowest point. An improvement in HGB levels is expected.

• 2024-08-21 HGB 7.9 g/dL ***
• 2024-08-06 HGB 9.6 g/dL *
• 2024-07-16 HGB 8.7 g/dL **
• 2024-07-02 HGB 8.5 g/dL **
• 2024-06-18 HGB 8.2 g/dL **
• 2024-06-11 HGB 8.8 g/dL **
• 2024-05-28 HGB 9.2 g/dL *
• 2024-05-14 HGB 9.6 g/dL *
• 2024-05-07 HGB 9.3 g/dL *
• 2024-04-23 HGB 9.6 g/dL *
• 2024-04-16 HGB 9.9 g/dL *
• 2024-04-02 HGB 9.7 g/dL *
• 2024-03-19 HGB 10.3 g/dL
• 2024-03-12 HGB 10.5 g/dL
• 2024-02-21 HGB 11.5 g/dL
• 2024-02-07 HGB 10.2 g/dL
• 2024-01-24 HGB 12.0 g/dL
• 2024-01-17 HGB 10.8 g/dL
• 2024-01-10 HGB 11.6 g/dL

2023-08-04

All repeat prescriptions issued by our gastroenterologist on 2023-05-17, cardiologist on 2023-06-06, and general surgeon on 2023-07-25 have been consistently refilled. These medications have been added to the active medication list, and no reconciliation issues have been identified.

2023-06-26

• Based on the PharmaCloud database, it appears that our hospital has been exclusively providing all necessary medical services and medications for this patient in the past few months. As such, we’ve found no issues regarding medication reconciliation.

2023-03-10

• The 2023-03-09 lab results indicate elevated levels of AST, ALT, direct bilirubin readings, and hypoalbuminemia. Plasbumin (human albumin) and BaoGan (silymarin) have been prescribed properly.
• As this is the patient’s first time receiving FOLFIRINOX, he is are undergoing a modified regimen, which involves a lower dose of oxaliplatin (reduced from 85mg/m2 to 70mg/m2) and irinotecan (reduced from 180mg/m2 to 150mg/m2), and the 5-FU bolus dose is skipped, with the same dose added to the 5-FU infusion.
• The active prescription does not appear to be an issue.

2023-02-09

• Cancer Multispecialty Team Meeting on 2023-01-03 concluded: Neoadjuvant C/T (CCRT) then op. For the time being, the patient is receiving CCRT.
• There has been a weight loss of 3kg in the past month for the patient (54.4kg 2022-12-07 -> 51kg 2023-02-07). The addition of some appetizers, such as megestrol, might be beneficial.
• The patient has a history of DM. As all data points of fasting blood sugar level during this hospital stay exceeded 110 mg/dL, metformin 500mg BID could be added, since the patient’s renal function appears to be in good working order.
• Other underlying conditions caused by HBV and cardiovascular disease are managed with corresponding medications appropriately.

701495433

240827

[exam findings]

• 2024-05-30 MRI - liver, spleen
  • Indication
    • Intrahepatic bile duct carcinoma
    • Carrier of viral hepatitis B
    • Inflammatory liver disease, unspecified
    • Chronic hepatitis, unspecified
  • Abdominal MRI with and without IV contrast enhancement shows:
    • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
    • Hypervascular hepatic tumors at S6 measuring 3.98cm, (SE15 Im51), S7 measuring 3.32cm (SE15 Im34), and S5 measuring 0.89cm (Se15 Im43). In comparison with CT dated on 2024-02-20, the lesions enlarged.
    • MRCP shows no dilatation of the IHDs, CBD nor pancreatic duct
  • Imp:
    • Liver cirrhosis.
    • Multiple enhancing hepatic tumors up to 3.98cm at S6. Cholangiocarcinomas are compatible. In enlargement.
• 2024-05-21 SONO - abdomen
  • Symptoms:
    • Liver:
      • Coarse echotexture. A 2.8 cm hypoechoic lesion at S7
    • Spleen:
      • Measured 5.8 x 5.2 cm
  • Diagnosis:
    • Cirrhosis of liver
    • Hepatic tumor, rule out hepatoma, rule out metastatic tumor
    • Splenomegaly
    • Hydronephrosis, left
• 2024-05-20 Patho - Urinary Bladder TUR
  • DIAGNOSIS:
    • Urinary bladder, bladder neck, 11-12 o’clock, TURBT — Non-invasive papillary urothelial carcinoma, low-grade
    • Urinary bladder, random biopsy, biopsy — chronic cystitis
    • Urinary bladder, bladder neck, 1 o’clock, TURBT — chronic cystitis
• 2024-04-17 SONO - abdomen
  • Symptoms:
    • Liver:
      • Coarse echotexture. A 2.8 cm hypoechoic lesion at S7
    • Spleen:
      • Measured 6.1 x 5 cm
  • Diagnosis:
    • Cirrhosis of liver
    • Hepatic tumor, rule out hepatoma, rule out metastatic tumor
    • Splenomegaly
• 2024-03-22 Aspiration Cytology - liver
  • Labelled “A” was for the FNB at the hyperechoic lesion at segment 2/3 of the left lobe of liver: atypia.
    
  • Labelled “B” was for the FNB at the hypoechoic lesion at segment 2 of left liver: atypia
• 2024-03-22 Patho - liver biopsy needle/wedge
  • PATHOLOGIC DIAGNOSIS
    • Liver, segment 2/3, left, EUS-FNB — Benign liver tissue with chronic hepatitis
    • Liver, segment 2, left, EUS-FNB — Benign liver tissue with chronic hepatitis
      
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consists of (1) multiple small pieces of yellow gray soft tissue, labeled segment 2/3, left liver, measuring up to 0.1 x 0.1 x 0.1 cm. All for section as: A. (2) multiple small pieces of yellow gray soft tissue, labeled segment 2, left liver, measuring up to 0.1 x 0.1 x 0.1 cm. All for section as: B.
  • MICROSCOPIC EXAMINATION
    • The sections of “segment 2/3, left liver” show a picture of chronic hepatitis, composed of moderate lymphocytic portal infiltrate, mild piecemeal necrosis, mild lobular inflammation, moderate fatty change (40%), large cell change of hepatocyte, and septal fibrosis.
    • The sections of “segment 2, left liver” also show a picture of chronic hepatitis, composed of mild portal inflammation, mild piecemeal necrosis, mild lobular inflammation, mild fatty change (10%), large cell change of hepatocyte, and no fibrosis.
    • IHC for both specimens (1) and (2) shows no overexpression of Glypican-3, HSP70 and Glutamine synthetase. Focal sinusoidal capillarization (CD34+) can be found.
    • There is no evidence of malignancy in the sections examined.
• 2024-03-19 PET
  • A glucose hypermetabolic lesion in the segment 7 of the liver, compatible with a malignant tumor.
  • Mild glucose hypermetabolism in some right axillary lymph nodes. Inflammation is more likely. Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2024-03-08 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Esophageal varices, F1CbLi. RCS(-) White nipple sign(-)
    • Superficial gastritis
    • Hyperemic polypoid and patches lesions, cardia and high body
    • R/o gastric intestinal metaplasia, antrum, angle and low body, s/p biopsy at angle
    • Duodenitis, bulb to 2nd portion
• 2024-03-07 Patho - liver biopsy needle/wedge
  • PATHOLOGIC DIAGNOSIS
    • Liver, S7, CT-guided biopsy — Adenocarcinoma, moderately differentiated, and see description
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consists of two strips of yellow gray soft tissue, labeled liver, S7, measuring up to 1.0 x 0.1 x 0.1 cm. All for section.
  • MICROSCOPIC EXAMINATION
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of cords of low columnar neoplastic cells with mucin secretion, arranged in glandular and cribriform patterns, embedded in fibrous stroma.
    • IHC shows: CK7(-), CA19-9(+), CK20(+), CDX2(focal +), and Hepatocyte(-). Because CK7-/CK20+ cholangiocarcinoma is very rare, metastatic adenocarcinoma from GI tract can not be excluded.
• 2024-02-20 MRI - liver, spleen
  • History and indication:
    • HBV carrier
  • With and without contrast MRI of liver revealed:
    • Liver cirrhosis with portal hypertension and splenomegaly. Poor enhancing tumors (up to 3.1cm) in both hepatic lobes.
  • Imaging Report Form for Cholangiocarcinoma
    • Impression (Imaging stage) : T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:II(Stage_value)
• 2024-02-07 Cystoscopy - urology
  • BPH
  • No tumor recurrent
• 2024-01-30 SONO - abdomen
  • Symptoms:
    • Liver:
      • Coarse echotexture. A 2.8 cm hypoechoic lesion at S7
    • Spleen:
      • Measured 6.1 x 5 cm
  • Diagnosis:
    • Cirrhosis of liver
    • Hepatic tumor, rule out hepatoma, rule out metastatic tumor
    • Splenomegaly
• 2023-11-02 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • S/P double J cathter placement from pelvic cavity into renal region over left renal pelvis is found.
    • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
    • Abnormal space occupying lesion inside the urinary bladder is found without enhancement. Blood clot is considered.
    • s/p Foley catheter placement.
    • Heterogeneous appearance at right lobe liver is found. Suggest correlate with sonography.
    • No evidence of abnormal filling defect along the course of bilateral ureters and urinary bladder.
  • Imp:
    • Liver cirrhosis with splenomegaly.
    • S/P double J cathter placement from pelvic cavity into renal region over left renal pelvis is found.
    • Abnormal space occupying lesion inside the urinary bladder is found without enhancement. Blood clot is considered.
    • No evidence of abnormal filling defect along the course of bilateral ureters and urinary bladder.
• 2023-10-23 Patho - urinary bladder TUR
  • Urianry bladder, “bladder neck tumor”, TURBT — Chronic cystitis
    
  • Urinary bladder, “previous TURBT scar”, TURBT — Chronic cystitis with foreign body granuloma
  • Urianry bladder, “right side”, biopsy — Chronic cystitis
• 2023-10-18 MRI - liver, spleen
  • HBV carrier without regular follow uphealth exam 2022/11/31. HBsAg (+), AFP 35.6 (normal < 7.0), AST/ATL = 46/54, GGT 186. CT showed rule out cirrhosis. 2023/10/02 AFP 28, no change, close monitor, arrange MRI
  • Abdominal MRI with and without IV contrast enhancement shows:
    • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
    • No evidence of abnormal enhanced tumor at both lubes of liver is found. However, the cirrhotic nodules are visible. Suggest closely follow up.
  • Imp:
    • Liver cirhrosis with splenomegaly
    • No evidence of HCC in the study but follow up is suggested.
• 2023-10-02 SONO - abdomen
  • Liver cirrhosis, with splenomegaly
  • Hydronephrosis, left kidney
• 2023-08-31 Patho - Urinary Bladder TUR
  • PATHOLOGIC DIAGNOSIS
    • Ureter orifice, right, TURBT — Non-invasive papillary urothelial carcinoma, low-grade
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consists of a small piece of gray-white soft tissue, labeled “right ureter orifice”, measuring 0.3 x 0.2 x 0.1 cm. All for section.
  • MICROSCOPIC EXAMINATION
    • Histologic type: Papillary urothelial carcinoma, non-invasive
    • Histologic grade: Low-grade
    • Tumor configuration: Papillary
    • Muscularis propria: Absent
    • Lymphovascular invasion: Not identified
    • Microscopic tumor extension: Tumor is non-invasive
• 2023-08-31 Patho - Urinary Bladder TUR
  • PATHOLOGIC DIAGNOSIS
    • Urianry bladder, “tumor”, left, TURBT — Non-invasive papillary urothelial carcinoma, low-grade
    • Urinary bladder, “tumor base”, left, TURBT — Free
      
  • MACROSCOPIC EXAMINATION
    • The specimen submitted in two parts. Part (1) consists of multiple small pieces of gray-white soft tissue, labeled “left bladder tumor”, measuring up to 0.8 x 0.4 x 0.3 cm. Representative parts are taken for sections as: A1-A2. Part (2) consists of three small pieces of gray-white soft tissue, labeled “left tumor base”, measuring up to 0.4 x 0.2 x 0.2 cm. All for sections as: B.
  • MICROSCOPIC EXAMINATION
    • Histologic type: Papillary urothelial carcinoma, non-invasive
    • Histologic grade: Low-grade
    • Tumor configuration: Papillary
    • Muscularis propria: Present
    • Lymphovascular invasion: Not identified
    • Microscopic tumor extension: Tumor is non-invasive
    • Specimen labeled “tumor base”: Free of tumor
• 2023-08-29 CT - abdomen
  • History and indication:
    • bladder tumor Hx of blood clots in urine
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A tumor (3.4cm) at left lateral bladder wall.
    • Small liver cysts (up to 9mm).
    • Some calcifications at LLQ.
    • Atherosclerosis of aorta, iliac arteries.
  • Imaging Report Form for Urinary Bladder Carcinoma
    • Impression (Imaging stage) : T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:II(Stage_value)
• 2023-08-28 Cystoscopy - urology
  • R/O Bladder tumor
• 2023-08-28 Bladder Sonography
  • PVR: 36 ml

[MedRec]

• 2023-08-29 ~ 2023-09-02 POMR Urology Xu JunKai
  • Discharge diagnosis
    • Non-invasive papillary urothelial carcinoma, low-grade, urinary bladder, status post transuretral resection of bladder tumor on 2023/08/30, status post Mitomycin-C infusion on 2023/09/01
    • Enlarged prostate with lower urinary tract symptoms
  • CC
    • blood clots during micturition in this week
  • Present illness
    • This is a 58-year-old male with medical history of:
      • Type II diabetes mellitus, latest HbA1C 6.2% (2023/08/28)
      • HBV carrier
    • He visited our urologic clinic on 2023/08/28 due to noticed blood clots during micturition. Health examination last year showed enlarged prostate and a 2.4-cm lesion at bladder, suspect bladder tumor or stone. According to his statment, there was mild voiding difficulty in recent 1 year, no body weight loss.
    • Urine examination showed pyuria (WBC:6-9/HPF, bacteria -/HPF), hematuria(RBC>100/HPF, OB:3+).
    • Bladder echo on the same day showed PVR 36ml.
    • Cystoscopy revealed suspicious bladder tumor.
    • As a result, surgical intervention was suggested and accepted after well explanation of pros and cons.
    • This time, under the impression of suspicious bladder tumor, he was admitted on 2023/08/29 for transurethral resection of bladder tumor and bilateral URS exam.
  • Course of inpatient treatment
    • After admission, laboratory test was done and showed no contraindication for surgical intervention. TURBT, Right URS and double J stenting were performed on 2023/08/30, and the patient tolerated well.
    • Mitomycin-C infusion was done on 09/01 and foley removal was done on the same day, while the patient presented with fair self-urination. Under stable condition, the patient was discharged on 2023/09/02 with OPD follow-up.    
  • Discharge prescription
    • Oxbu (oxybutynin 5mg) 1# QD
    • Acetal (acetaminophen 500mg) 1# QID
    • Urief (silodosin 8mg) 1# QD
    • cephalexin 500mg 1# QID

[consultation]

• 2024-06-11 Radiation Oncology
  • Q
    • This 58-year-old man has a medical history of:
      • Intrahepatic cholangiocarcinoma, cT2N0M0, stage II, ICG31%, high surgical risk, [Next-Generation Sequencing (NGS): IDH2, PIK3CA] s/p gemcitabine + TS-1 2024/3/22-2024/5/12, with disease progression, change to 2 line Gem + CDDP + pembrolizumab since 6/11-, also applying SBRT (due to unresecatble) for S7 lesion
      • Chronic hepatitis B with liver cirrhosis with splenomegaly, esophageal varices and thrombocytopenia under TAF
      • Non-invasive papillary urothelial carcinoma, low-grade, urinary bladder, status post transurethral resection of bladder tumor on 2023/08/30, 2023/10/23 and 2024/05/20. s/p C/T with BCG and MMC
      • DM, HbA1c:7.7 under metformin
      • History of Left hydronephrosis status post left double-J insertion on 2023/10/23.
    • This time, he was admiited for C1D1 Gem + CDDP + Pembrolizumab.
    • For SBRT, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • CT simulation of SBRT is arranged on 2024/06/11 13:30. Possible treatment toxicity had been told. Treatment will be started 3-4 days later.
    • RT planning: 5000cGy/5 fx if feasible, QOD.
    • Please avoid concurrent chemotherapy and SBRT on the same day.
    • Thanks for your consultation.

[surgical operation]

• 2024-05-20
  • Surgery
    • TURBT        
  • Finding
    • Two small papillary tumors with hypervascularity was noted in 11-1 o’clock position of bladder neck.
    • Previous scar near left UO
    • Intact bilateral UO
    • Random biopsies was taken.
    • Risk evaluation:
    • Tumor size: <=3cm (V), >3cm()
    • Multifocality: Multifocal(V), solitary()
    • Recurrence within 1 year: Yes(V), No()
• 2023-11-09
  • Surgery
    • Blood clot evacuation        
  • Finding
    • Blood clots was about 700 ml       
    • No significant active bleeder was found but much blood clot coating around the left DBJ     
• 2023-10-23
  • Surgery
    • TURBT
    • Left DBJ insertion       
  • Finding
    • No tumor was noted at previous TURBT scar    
    • Left ureter orifice was successfully identified    
    • A small papillary tumor (0.3cm smaller than loop) was noted at 12 o’clock position of bladder near neck  
• 2023-08-30
  • Surgery
    • TURBT        
    • Right URS and double J stenting    
  • Finding
    • Multiple bladder tumors at the left lateral wall of bladder
    • Risk evaluation:
      • Tumor size: <=3cm (V), >3cm()
      • Multifocality: Multifocal(V), solitary()
      • Recurrence within 1 year: Yes(), No(V)    
    • No tumor was noted in the right ureter    
    • A papillary tumor was noted at the right ureter orifice    
    • The left ureter orifice can not be identified

[chemotherapy]

• 2024-08-26 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 20mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)

  • dexamethasone 4mg IV + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-08-12 - ………………………………….. cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr …………………………………….. (………. Kemoplat ……… CDDP 50% ………..)

  • dexamethasone 4mg PO + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-07-29 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)

  • dexamethasone 4mg IV + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-07-15 - ………………………………….. cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (………. Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)

  • dexamethasone 4mg PO + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-07-03 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)

  • dexamethasone 4mg PO + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-06-17 - ………………………………….. cisplatin 25mg/m2 37mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (………. Kemoplat + Gemzar. CDDP 80%, Gemzar 50%)

  • dexamethasone 4mg PO + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-06-11 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 37mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 80%, Gemzar 50%)

  • dexamethasone 4mg PO + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-05-21 - mitomycin-C 30mg/m2 30mg BI 1hr (MMC)

• 2024-05-06 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2024-04-22 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2024-04-15 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2024-04-01 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2024-03-22 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-10-24 - mitomycin-C 30mg/m2 30mg BI 1hr (MMC)

• 2023-10-16 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)

• 2023-10-09 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)

• 2023-10-02 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)

• 2023-09-25 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)

• 2023-08-18 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)

• 2023-09-11 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)

• 2023-09-01 - mitomycin-C 30mg/m2 30mg BI (bladder irrigation) 1hr (MMC)

==========

2024-08-27

[Long-Term Decline in Platelet Levels and Thrombocytopenia Risk]

The patient’s platelet (PLT) levels have shown a gradual decline over the past year, with all values falling below the normal range since August 2023. Initially around 50K/uL, PLT levels have frequently dropped below 40K/uL and even 30K/uL since July 2024.

Each medication in the current regimen is associated with a risk of thrombocytopenia, and it is possible that one or more of these drugs are contributing to or exacerbating the condition:

• Pembrolizumab: Thrombocytopenia (12% to 34%; grades 3/4: 4% to 10%)
• Cisplatin: Thrombocytopenia (25% to 30%; nadir: Day 18 to 23; recovery: By day 39; dose-related)
• Gemcitabine: Thrombocytopenia (24%; grades 3/4: 1% to 4%)

If the clinical risk of bleeding increases, platelet transfusion may be considered.

• 2024-08-26 PLT 35 *10^3/uL
• 2024-08-12 PLT 26 *10^3/uL
• 2024-08-05 PLT 25 *10^3/uL
• 2024-07-29 PLT 41 *10^3/uL
• 2024-07-15 PLT 23 *10^3/uL
• 2024-07-03 PLT 103 *10^3/uL
• 2024-06-17 PLT 45 *10^3/uL
• 2024-06-10 PLT 51 *10^3/uL
• 2024-05-27 PLT 59 *10^3/uL
• 2024-05-19 PLT 53 *10^3/uL
• 2024-05-13 PLT 47 *10^3/uL
• 2024-05-06 PLT 57 *10^3/uL
• 2024-04-22 PLT 55 *10^3/uL
• 2024-04-15 PLT 72 *10^3/uL
• 2024-04-01 PLT 40 *10^3/uL
• 2024-03-27 PLT 48 *10^3/uL
• 2024-03-25 PLT 52 *10^3/uL
• 2024-03-18 PLT 52 *10^3/uL
• 2024-03-06 PLT 45 *10^3/uL
• 2024-01-27 PLT 54 *10^3/uL
• 2023-11-30 PLT 56 *10^3/uL
• 2023-11-02 PLT 57 *10^3/uL
• 2023-10-22 PLT 60 *10^3/uL
• 2023-08-29 PLT 59 *10^3/uL
• 2023-08-28 PLT 54 *10^3/uL

700201588

240826

[exam findings]

• 2024-06-26 RAS + BRAF (massarray)
  • Cellblock No. S2023-22416 A4
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 12 GGT > AGT, p.G12S)
    • BRAF: There was no variant detect in the BRAF gene.
• 2024-05-09 PET
  • Glucose hypermetabolism in multiple focal areas in both lobes of the liver, compatible with multiple liver metastases.
  • Mildly increased FDG accumulation in the colon and rectum. Physiological FDG accumulation is more likely.
• 2024-02-03 CT
  • History and indication:
    • Adenocarcinoma of S-colon
  • Non-contrast CT of abdomen-pelvis revealed:
    • S/P operation.
    • Hypodense nodules (up to 2.4cm) in liver and kidneys.
    • R/O right ovary cyst (2.6cm).
    • Gallbladder and CBD stones (4-10mm).
    • A lipoma (0.5x1.8cm) in left hip region.
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • Cardiomegaly. Compression fracture of L1.
  • IMP:
    • S/P operation. No evidence of tumor recurrence.
• 2023-12-18 Pelvis THR
  • Osteoarthritis change of both hip joints with joint space narrowing (more at superior aspect), subchondral sclerosis and marginal spur formation. Prominent vascular calcifications.
• 2023-11-10 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, sigmoid colon, sigmoidectomy —- Adenocarcinoma, moderately differentiated, arising from tubulovillous adenoma
      
    • Resection margins: free
    • Lymph node, mesocolic, dissection —- Negative for malignancy (0/17)
    • Lymph node, IMA / SMA, dissection —- Not received
    • AJCC 8th edition Pathology stage: pStage I, pT1N0 (if cM0)
  • Gross Description:
    • Operation procedure: sigmoidectomy
    • Specimen site: sigmoid colon
      
    • Specimen size: 10.4 cm in length
      
    • Tumor size: polypoid, 3.5 x 3.0 x 2.5 cm
    • Tumor location: 7.3 cm and 2.5 cm away from the two resection margins, respectively.
    • Depth of invasion grossly: submucosa,
      
    • Mucosa elsewhere: congestion
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as: A1: colon, non-tumor; A2-5: tumor; A6-8 and X1-6: lymph node, mesocolic; B: proximal resection margin; C: distal resection margin.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades submucosa
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved, Distance of tumor from margin: 7 mm
        
    • Lymphovascular Invasion: Not identified
    • Perineural Invasion: Not identified
    • Tumor Budding: Low score (0-4)
      
    • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 0/17
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pT1: Tumor invades the submucosa (through the muscularis mucosa but not into the muscularis propria)
        • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        • Distant Metastasis (pM): if cM0
          
    • Additional Pathologic Findings (select all that apply):
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2023-11-07 SONO - abdomen
  • Real-time sonographic evaluation of the abdomen was performed - Findings:
    • The liver shows normal in size and echogenicity.
      • There are multiple hepatic cysts in both lobes (up to 1.4 cm).
        
      • Portal vein flow: patent.
    • Bile ducts: not dilated.
    • The gallbladder appears normal in wall thickness and size.
      • Several gallstones (up to 1.4 cm).
        
    • The pancreatic head and body shows normal in size and texture.
      • The pancreatic tail is obscured by overlying bowel gas.
    • The spleen shows normal in size and echogenicity without focal lesion.
    • Abdominal aorta and IVC show unremarkable finding.
    • There is no evidence of para-aortic lymphadenopathy or ascites.
    • Both kidney show normal echopattern and size.
      • There is no evidence of stone or hydronephrosis.
      • There are several renal cysts on both kidney (up to 2.5 cm).
  • Impression:
    • There are multiple hepatic cysts in both lobes (up to 1.4 cm).
      
    • Several gallstones (up to 1.4 cm).
    • There are several renal cysts on both kidney (up to 2.5 cm).
• 2023-10-23 Sigmoidoscopy
  • Findings
    • The scope reach the descending colon.
    • One large 3.5cm polypoid tumor lesion was noted in the sigmoid colon (20cm AAV), tattoo in front of it was done.
    • Mixed hemorrhoid was noted.
  • Diagnosis:
    • One large 3.5cm polypoid tumor lesion was noted in the sigmoid colon (20cm AAV)
  • Suggestion:
    • F/U. suggest laparoscopic colectomy
• 2023-10-17 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (173 - 54.4) / 173 = 68.55%
    • M-mode (Teichholz) = 68.6-63.7
  • Conclusion:
    • Sclerosis of AV, trivial AS, no AR (AVA 1.71, Vmax 2.71)
    • Thickened MV with mild MR
    • Concentric LVH, dilated LV
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
    • Dilated LA
• 2023-10-13 CT - abdomen
  • Hx
    • CC: low GI bleeding
    • 20231009 sigmoidoscopy: A 2.5 cm polyp was noted at sigmoid colon. Biopsy and pathology: Tubulovillous adenoma with high grade dysplasia.
  • Findings:
    • There is a soft tissue mass in right lateral wall of the sigmoid colon, measuring 3.5 cm in size (the largest dimension).
      • Adenocarcinoma (T3) is highly suspected.
      • The differential diagnosis includes villous adenoma.
      • Please correlate with colonoscopy.
      • In addition, there is no enlarged node in the adjacent mesocolon (N0).
    • There are multiple hepatic cysts in both lobes (up to 1 cm).
    • There are several gallstones （up to 1 cm).
    • Both kidneys show small size, few cysts, and thin parenchyma that are c/w ESRD.
    • There is ascites in the abdomen and pelvis, nature?
      • please correlate with clinical condition.
    • There are few cysts in RML and RLL of the lung.
    • There is a cystic lesion 2.7 cm in right adnexa without wall thickening, septum, and mural nodule.
      • Simple right ovarian cyst is highly suspected.
    • Follow up is indicated.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIA(Stage_value)
• 2023-10-11 Patho - colon biopsy
  • Sigmoid colon, biopsy, polypectomy — Tubulovillous adenoma with high grade dysplasia
  • The sections show tubulovillous adenoma, composed of colonic mucosal tissue with atypical glands lined by pseudostratified, high-grade dysplastic columnar cells, in tubular, villous, and cribriform patterns. Suggest colosely follow up and polypectomy.
• 2023-10-09 Colonoscopy
  • Findings
    • The scope had been inserted up to sigmoid colon. An about 2.5 cm polyp was noted at sigmoid colon. Biopsy was done. Large amount stool in rectum and sigmoid colon. Insertion above the lesion site is difficult and exam was stopped
    • Internal hemorrhoid was noted
  • Diagnosis:
    • Advanced colon polyp, sigmoid colon, s/p biopsy
    • Internal hemorrhoid
    • Poor colon preparation, incomplete study
• 2023-10-06 EGD
  • Diagnosis:
    • No active bleeder or blood clot during exam
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis
    • Antral deformity
  • CLO test: not done
  • Suggestion:
    • No active bleeder or blood clot during exam
    • Please corealate with clinical condition
• 2021-02-04 Patho - colorectal polyp
  • Diagnosis
    • Intestine, large,sigmoid colon, biopsy — hyperplastic polyp
      
    • Intestine, large,sigmoid colon, polypectomy —tubular adenoma
      
  • Microscopically, section A shows hyperplastic polyp with hyperplastic crypts and lymphocytic infiltrate. Section B shows tubular adenoma composed of a proliferation of tubular pattern of adenomatous glands lined by elongated nuclei.

[MedRec]

• 2024-07-09 SOAP Hemato-Oncology Xia HeXiong
  • P: Arrange admission for Chest/Abd/Pelvis CT frist, then HD for contrast and then C/T with FOLFIRI
• 2024-06-25 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • Due to suspicious recurrence of liver by PET, consider C/T with FOLFIRI +/- bevacizumab (consider the bleeding tendence becuae of patient on HD)
    • RTC 2 weeks for checking the Port-A
• 2024-06-25 SOAP Colorectal Surgery Chen ZhuangWei
  • A:
    • Adenocarcinoma of S-colon status post laparoscopic sigmoidectomy on 2023/11/09, pT1N0M0 (0/17), G2, stage I
    • Multiple liver metastases, stage IVa (unresectable)
  • P:
    • liver metastases developed, suggest chemotherapy + target therapy, refer to ONC, RAS gene?
• 2024-04-30 SOAP Colorectal Surgery Chen ZhuangWei
  • P:
    • still high CEA > 200, arrange PET
• 2023-11-28 SOAP Colorectal Surgery Chen ZhuangWei
  • A:
    • Adenocarcinoma of S-colon status post laparoscopic sigmoidectomy on 2023/11/09, pT1N0M0 (0/17), G2, stage I
  • P:
    • F/U CEA (2024-01), CXR, CT, colonoscopy (2024-10)
• 2023-11-05 ~ 2023-11-21 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Adenocarcinoma of S-colon status post laparoscopic sigmoidectomy on 2023/11/09, pT1N0M0 (0/17), G2, stage I
    • End stage renal disease
    • Gastro-esophageal reflux disease with esophagitis
    • Anemia, unspecified
    • Systemic lupus erythematosus, unspecified
    • Unspecified systolic (congestive) heart failure
  • CC
    • Tarry stool for 1 day.        
  • Present illness
    • This 65-year-old lady with end stage renal disease under hemodialysis QW135, heart failure, atrial fibrillation, and systemic lupus erythematosus.
    • This time, she presented to our emergency department on 2023/11/05 with bloody stools for 1 day. She followed up at our Colorectal Surgery clinic and already scheduled for a sigmoidectomy on 2023/11/09 because of tubulovillous adenoma with high grade dysplasia of S-colon. Her vital signs were notable for hypertension (162/75 mmHg) without tachycardia. She appeared distressed. Physical examination was remarkable for a distended non-tender abdomen. A chest X-ray showed ground glass opacity in bilateral lower lungs. Blood labs revealed anemia (7.7 mg/dL). She received 2 units of packed red blood cells and two doses of tranexamic acid in the Emergency Department.
    • Under the impression of colon tumor with bleeding, she was admitted to our Colorectal Surgery ward for a further evaluation and management.
  • Course of inpatient treatment
    • After admission, we closely monitor her vital sign and keep her hemodynamically stable. We arranged hemodialysis on W1,3,5 for her ESRD. Pre-op assessment was done.
    • Sigmoidectomy with anastomosis was performed on admission day 5 (as original schedule). Her post-operative course was relatively smooth. There was no nausea, vomit, dizziness, fever, abdominal tenderness after the operation. Operation wound was clean and no infection sign also the pain was tolerable.
    • However, acute high fever, diarrhea, and sharp abdominal pain over right lower quardant on 12/14. Fever survey was done and infection control with Brosym. Blood culture revealed Enterococcus faecalis Growth, Klebsiella pneumoniae Growth, Citrobacter freundii.
    • There was no fever after since the use of antibiotics. We closely monitor the Jackson prait drain, it was clean and the amount decrease day by day. We removed JP drain on 11/21 and arranged discharge. We educated her diet about low residue diet. We encourage ambulation and also aware of fall prvention. Patient would be discharge today with oral antibiotics cravit, ceficin, linezolid and OPD follow up next week.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H if BT > 38
    • MgO 250mg 2# BID
    • Takepron (lansoprazole 30mg) 1# QDAC
    • Through (sennoside 12mg) 1# HS
    • Zyvox FC (linezolid 600mg) 1# BID 7D
    • Ceficin (cefixime 100mg) 1# BID 7D
    • Cravit (levofloxacin 500mg) 1# QOD
• 2023-10-21 SOAP Colorectal Surgery Chen ZhuangWei
  • A:
    • Large polypoid tumor (Tubulovillous adenoma with high grade dysplasia) of S-colon
  • P:
    • sigmoidoscopy with tattoo
    • admission (11/07), consult NEP for hemodialysis, ERAS?, prepare colon, Exp. Lap with sigmoidectomy (11/09)
• 2023-10-05 ~ 2023-10-18 POMR Gastroenterology Li ZhongXian
  • Discharge diagnosis
    • Carcinoma in situ of colon
    • Benign neoplasm of colon, unspecified
    • Gastro-esophageal reflux disease with esophagitis
    • End stage renal disease
    • Anemia, unspecified
    • Systemic lupus erythematosus, unspecified
    • Unspecified systolic (congestive) heart failure
    • Other peripheral vertigo, unspecified ear
    • Atypical atrial flutter
    • Embolism of vascular prosthetic devices, implants and grafts, initial encounter
  • CC
    • bloody stool for 3 days
  • Present illness
    • This is a 65 years-old female with underlying disease of … presents with bloody stool for 3 days.
      • ESRD under HD on QW1,3,5
      • HTN
      • Atrial flutter with 2:1 conduction post electrophyiologic study and radiofrequent catheter ablation on 106/04/03
      • Congestive heart failure
      • SLE
    • According to the patieint, she suffered from bloody stool and dizziness for 3 days. Bloody stool was up 5 times today. Besides, LLQ abdominal pain was noted.
    • At ER, vital sign including BP:119/56; PR:58; BT:36.4’C; RR:18; Con’s:E4V5M6; SpO2:96%. Laboratory data showed decreased Hb level (8.3mg/dl).
    • Under the impression of gastrointestinal bleeding, she was admitted for further evaluation and management.
  • Course of inpatient treatment
    • After admission, NPO with adequate IV fluid, PPI pump and transamin were given for GI bleeding.
    • Panendoscopy was arranged on 10/06 and showed esophagitis, gastritis and antral deformity.
    • We arranged the colonoscopy on 10/09. Internal hemorrhoid and an about 2.5 cm polyp at sigmoid colon were noted. Polyp biopsy was done and pathology revealed tubulovillous adenoma with high grade dysplasia.
    • CT of abdomen also revealed a soft tissue mass in right lateral wall of the sigmoid colon, measuring 2.5 cm in size.
    • CRS specialist was consulted and may arrange laparoscopic sigmoidectomy.
    • There was no more bloody stool after medical treatment. Due to stable vital sign, she was allowed to discharge on 10/18 and OPD follow-up arranged.
  • Discharge prescription
    • Pariet (rabeprazole 20mg) 1# QDAC 8D

[consultation]

• 2023-11-06 Nephrology
  • Q
    • This 65 y.o lady with ESRD with AV shunt on left hand received regularly HD on W1,3,5. / Heart failure / SLE / Atrial fibrillation
    • She experienced tarry stool related to colon tumor came to ED for help. Hb noted 7.7mg/dl. Blood transfusion PRBC 2 U was given in ED then admitted to ward. Colectomy would be performed on 11/08.
    • We need your expertise opinion and arrange HD for this patient. Thank you very much.
  • A
    • We will arrange H/D QW135. Please prescribe EPO 5000U QW if Hb < 11.
• 2023-10-13 Colorectal Surgery
  • Q
    • Colonoscopy was arranged on 10/09. Internal hemorrhoid and an about 2.5 cm polyp at sigmoid colon were noted. Polyp biopsy was done and pathology revealed tubulovillous adenoma with high grade dysplasia. CT of abdomen was arranged today. Due to suspected colon cancer (CIN), we need your expertise for further evaluaion and management. Thank you!
  • A
    • O:
      • CT
      • There is a soft tissue mass in right lateral wall of the sigmoid colon, measuring 2.5 cm in size.
        • The differential diagnosis includes adenocarcinoma and villous adenoma.
        • Please correlate with colonoscopy.
      • There are multiple hepatic cysts in both lobes (up to 1 cm).
      • There are several gallstones（up to 1 cm).
      • Both kidneys show small size, few cysts, and thin parenchyma that are c/w ESRD.
      • There is ascites in the abdomen and pelvis.
      • There are few cysts in RML and RLL of the lung.
      • There is a cystic lesion 2.7 cm in right adnexa without wall thickening, septum, and mural nodule that may be simple right ovarian cyst. Follow up is indicated.
    • A:
      • Large difficult polyp (AIS at least) of S-colon
    • P:
      • Laparoscopic sigmoidectomy is indicated
      • However, due to many comorbidities, surgical risk is high, and pre-op evaluation including of echocardiography and pulmonary function test are needed
      • We’ll visit the patient soon
• 2023-10-05 Nephrology
  • Q
    • This patient is consult for arranging hemodialysis QW1,3,5. Thanks for your expertise!
  • A
    • We will arrange hemodialysis QW135 for the patient during the course of hospitalization. Please prescribe EPO 5000 IU QW if Hb < 11.
    • Feel free to contact us should you require further assistance.

[chemotherapy]

• 2024-08-26 - irinotecan 120mg/m2 150mg D5W 250mL 90min D1 (before HD 1hr) + leucovorin 300mg/m2 500mg NS 250mL 2hr D2 (after HD) + fluorouracil 2200mg/m2 3600mg NS 500mL 46hr D2 (after HD) (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2024-08-07 - irinotecan 120mg/m2 150mg D5W 250mL 90min D1 + leucovorin 300mg/m2 500mg NS 250mL 2hr D2 + fluorouracil 2200mg/m2 3600mg NS 500mL 46hr D2 (FOLFIRI)
  • dexamethasone 4mg + palonosetron 250ug + atropine 0.3mg + NS 250mL + aprepitant 125mg PO D1-3
• 2024-07-17 - irinotecan 120mg/m2 150mg D5W 250mL 90min D1 + leucovorin 300mg/m2 500mg NS 250mL 2hr D2 + fluorouracil 2200mg/m2 3600mg NS 500mL 46hr D2 (FOLFIRI)
  • dexamethasone 4mg + palonosetron 250ug + atropine 0.3mg + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-08-26

[Considerations for Irinotecan Dosing and Timing with Hemodialysis]

Irinotecan, a prodrug, is hydrolyzed into the active metabolite SN-38, which is further metabolized into the inactive glucuronide conjugate SN-38G. While the primary elimination route is biliary, approximately 32% of the dose is excreted via urine (~22% as unchanged drug, ~3% as SN-38G, and <1% as SN-38). SN-38 is highly protein-bound (~99%), primarily to albumin. Ref: https://doi.org/10.1200/JCO.2022.40.16_suppl.e1351

• Half-life elimination for adults:
  • Irinotecan: 6 to 12 hours; SN-38: ~10 to 20 hours.
• Time to peak:
  • SN-38 reaches its peak following a 90-minute infusion at ~1 hour.
• Excretion:
  • Urine: Irinotecan (11% to 20%), metabolites (SN-38 <1%, SN-38 glucuronide, 3%).
• Hepatic function impairment:
  • Decreased clearance of irinotecan and increased exposure to SN-38 proportional to the degree of hepatic impairment.

Considering that liver function results on 2024-08-25 were normal and the patient is currently undergoing hemodialysis, administering irinotecan 1 hour before dialysis might result in the drug being partially dialyzed before it fully converts to SN-38, potentially reducing the actual effective dose of SN-38. Currently, the FOLFIRI regimen has already reduced irinotecan from 180 mg/m² to 120 mg/m². Please consider the possibility of unintentional underdosing of irinotecan.

2024-07-16

[managing FOLFIRI regimen in HD patients]

Systemic treatment has not yet been initiated, and tumor markers continue to show a rising trend.

• 2024-06-26 CA199 501.51 U/mL
• 2024-06-26 CEA 802.99 ng/mL
• 2024-04-30 CEA (NM) 386.710 ng/ml
• 2024-01-19 CEA (NM) 60.140 ng/ml
• 2023-10-13 CEA 13.31 ng/mL

The planned FOLFIRI regimen includes fluorouracil, which is used for the patient on intermittent hemodialysis (thrice weekly). Fluorouracil itself is not significantly dialyzable; however, its metabolite FBAL may be substantially removed by dialysis (extraction ratio 0.73 to 0.84). No dosage adjustment is necessary for fluorouracil. When the scheduled dose falls on a hemodialysis day, it should be administered after hemodialysis. Patients must be monitored closely for the potential development of hyperammonemic encephalopathy associated with FBAL accumulation in those with end-stage kidney disease. Removing FBAL by hemodialysis can be effective in preventing or treating hyperammonemia.

However, the use of irinotecan in the patient on intermittent hemodialysis poses risks. Irinotecan may be partially dialyzable, but its active metabolite, SN38, is not. The manufacturer does not recommend its use due to the higher risk of toxicity in patients with end-stage kidney disease (ESKD). Initially, if benefits outweigh the risks, it may be started at 50% to 66% of the usual recommended dose. Given the variability in patient responses, when the usual indication-specific dose is 100 to 150 mg/m2 once weekly, it may be safest to start at 50 mg/m2 once weekly. Doses may be cautiously increased if tolerated; however, severe toxicity at 80 mg/m2 weekly (grade 4 neutropenia and death in a patient with UGT1A polymorphism) and 100 mg/m2 weekly (grade 4 diarrhea) has been reported. Irinotecan should be administered after hemodialysis or on non-dialysis days.

Currently, the patient’s multiple liver metastases have not affected AST, ALT, or bilirubin readings, and there is no need to adjust the FOLFIRI dosage for liver function at this time.

700563554

240826

[lab data]

2023-09-13 HBV-DNA-PCR Target Not Detected IU/mL

2023-09-11 HBsAg Nonreactive
2023-09-11 HBsAg Value 0.49 S/CO
2023-09-11 Anti-HCV Nonreactive
2023-09-11 Anti-HCV Value 0.12 S/CO
2023-09-11 Anti-HBc Reactive
2023-09-11 Anti-HBc Value 5.99 S/CO

[exam findings]

• 2024-05-24 PTCD (percutaneous transhepatic cholangial drainage)

• 2024-05-18 CT - abdomen

  • With and without contrast enhancement CT of abdomen shows:
    • s/p cholecystectomy and liver S4/5 resection.
    • Multiple mass lesions in liver. An infiltrating mass lesion in hepatic hilum, causing IHDs dilatation.
    • Several peritoneal mass lesions.
    • Minimal ascites in pelvis.
    • No bony destructive lesion on these images.
  • Impression
    • Gallbladder neuroendocrine carcinoma with liver metastasis, s/p operation
    • New metastatic lesions in liver and peritoneum
    • IHDs dilatation

• 2024-04-02 Nerve Conduction Velocity, NCV

  • Findings
    • Normal cold & warm threashold in right upper and left lower extramities.
  • Conclusion
    • This is a normal QST study.

• 2024-04-02 Nerve Conduction Velocity, NCV

  • Findings
    • Prolonged distal latencies in right medial CMAPs.
    • Slowed MCVs in right medial SNAPs.
    • Normal F-wave latencies followed all sampling nerve stimulations.
    • Normal H-reflex study in both legs,
  • Conclusion
    • This abnormalNCv study suggested right medial distal neuropathy.

• 2024-02-19 Tc-99m MDP bone scan with SPECT

  • Increased activity in the right parietal region of the skull, the nature is to be determined (post-traumatic change or other nature ? ), suggesting follow-up with bone scan in 3 months for investigation.
  • Suspected benign lesions in both rib cages, some T- and lower L-spine, bilateral shoulders, elbows, and knees.

• 2024-02-17 CT - abdomen

  • History and indication:
    • Gallbladder neuroendocrine carcinoma with liver metastasis
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P liver operation and cholecystectomy. Hypodense lesions (up to 1.9cm) in S5 of liver without interval change.
    • Hourseshoe kidneys.

• 2024-01-24 Patho - stomach biopsy

  • Stomach, fundus, biopsy — Chronic gastritis, H pylori NOT present

• 2024-01-24 EGD

  • Diagnosis:
    • Reflux esophagitis LA Classification grade A(minimal)
    • Superficial gastritis
    • Gastric polyps, fundus, s/p biopsy
  • CLO test: not done
  • Suggestion:
    • Pursue the pathology report

• 2024-01-23 MRI - brain

  • Imp: Mild cortical brain atrophy. No brain nodule or metastasis.

• 2023-12-14 ENT Hearing Test

  • Reliabilty Fair
  • PTA
    • R’t : 28 dB HL, normal to moderate SNHL
    • L’t : 29 dB HL, normal to moderately severe SNHL
  • Tymp
    • Bil Type A
  • ART
    • Bil Ipsi 4k Hz absent, contra absent.

• 2023-11-14 CT - abdomen

  • Clinical history: 58 y/o female patient with Gallbladder neuroendocrine carcinoma with liver metastasis, high grade pT2aN0M1 stage IV status post S5/S4b resection on 2023/08/28.
  • With and without contrast enhancement CT of abdomen - whole:
    • S/P resection of the liver.
      
    • R/O liver cyst, 1.7cm in right lobe liver.
    • Presence of horseshoe kidney.
  • Impression:
    • S/P resection of the liver.
      
    • R/O liver cyst. Suggest follow up.
    • Horseshoe kidney.

• 2023-08-29 Patho - liver partial resection

  • PATHOLOGIC DIAGNOSIS
    • Liver, S5 and S4b, S4b/5 resection — Metastatic neuroendocrine carcinoma
      
  • MACROSCOPIC EXAMINATION
    • Procedures: S4b/5 resection
      
    • Specimen Size: 12 x 8.0 x 4.8 cm and 185 gm
      
    • Tumor Focality: Multiple (number: 2)
      
    • Tumor Site: S5 and S4b
      
    • Tumor Size: 5.0 x 4.5 x 4.0 cm (S5) and 4.0 x 3.0 x 2.5 cm (S4b) respectively
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Not cirrhotic
      
    • Sections are taken and labeled as: A1-A2= S5 tumor, A3-A4= S4b tumor, A5= non-neoplastic liver
  • MICROSCOPIC EXAMINATION
    • Diagnosis: Metastatic neuroendocrine carcinoma
      
    • Histologic grade: High grade
      
    • Tumor growth pattern: Infiltrating
      
    • Tumor pseudocapsule: Absent
      
    • Tumor necrosis: Present
      
    • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 0.8 cm (S5) and 0.9 cm (S4b), respectively
        
    • Vascular invasion: Present
      
    • Perineural invasion: Not identified
      
    • Non-neoplastic liver parenchyma: Mild lymphocytic portal inflammation
    • Fatty Change: Present (5%)

• 2023-08-14 PET

  • No previous study for comparison.
  • At least four focal lesions of increased FDG uptake in the right lobe of the liver, highly suspected metastatic tumors, suggesting biopsy for investigation.
    
  • Increased FDG uptake in the peritonium of middle lower abdomen, the nature is to be determined (inflammation or other nature ?), suggesting follow-up.
    
  • Increased FDG accumulation in bilateral kidneys and in the right ureter, probably physiological uptake of FDG.
    
  • Malignant neoplasm of gallbladder s/p treatment with highly suspected metastatic tumors in the liver, by this F-18 FDG PET scan.

• 2023-07-19 CT - abdomen

  • Findings:
    • S/P cholecystectomy. There is a cystic lesion 3 cm in S5 of the liver that may be biloma S/P surgical resection.
    • There are two kissing poor enhancing mass 2.5 cm and 1.6 cm in S4/8 and a poor enhancing mass 3.5 x 2.2 cm in S4 of the liver.
      • Metastases are highly suspected.
        
  • Impression:
    • There is a cystic lesion 3 cm in S5 of the liver that may be biloma S/P surgical resection.
    • Three metastases 2.5 cm and 1.6 cm in S4/8 and 3.5 x 2.2 cm in S4 of the liver are highly suspected.

• 2023-07-04 SONO - abdomen for follow-up

  • There is a hypoechoic lesion 2.53 x 1.85 cm in S5 of the liver that may be metastasis? Please correlate with contrast enhanced dynamic CT.
    • In addition, there is another suggestive cystic-like lesion with echogenic content 3.29 x 2.85 cm in S5 of the liver, near the gallbladder, that may be post-operative biloma?
      
  • S/P cholecystectomy.

• 2023-03-30 Patho - liver partial resection

  • PATHOLOGIC DIAGNOSIS:
    • Gallbladder, laparoscopic cholecystectomy— Neuroendocrine carcinoma, high-grade
    • Liver, S5, laparoscopic S5 rsection— Negative for malignancy
    • Cut-end, cystic duct— Free of tumor
    • Lymph node, LN8, regional LN dissection— Negative for malignancy ( 0 / 1 )
    • Lymph node, 12A, regional LN dissection— Negative for malignancy ( 0 / 5 )
    • Lymph node,12C regional LN dissection— Negative for malignancy ( soft tissue only )
    • Pathologic Staging (AJCC): pT2aN0 (if cM0); AJCC prognostic stage IIA
  • MACROSCOPIC EXAMINATION
    • Specimen Type — laparoscopic cholecystectomy+ laparoscopic S5 rsection
      
    • Specimen Size: Gallbladder: 7.5x 4x 3.5 cm; Liver: 11.5x 6x 4.5 cm
      
    • Tumor Size : 3.5x 2.8x 2.2 cm — Solitary
    • Liver Tissue — Non-cirrhotic
    • Sections are taken and labeled as: F2023-140: cut end of cystic duct, A1:right IHD cut end, A2:tumor with S5, A3-11:tumor, A12: non-tumor part, B: LN8, B:12A, C:12C
  • MICROSCOPIC EXAMINATION
    • Histologic Type — Neuroendocrine carcinoma
    • Histologic Grade — High grade
    • Gross tumor patterns: poorly defined and solid
    • Microscopic Tumor Extension — Tumor invades the perimuscular connective tissue on the peritoneal side, without involvement of the serosa (visceral peritoneum).
    • Margins (check all that apply)
      • cystic duct Margin—- free
    • Lymph-Vascular Invasion — Present
    • Perineural Invasion — Not identified
    • Regional Lymph Nodes
      • Lymph Node Examination (required only if the lymph nodes present in the specimen)
      • LN 8: 0 / 1 (Number involved / Number examined)
      • LN 12A: 0 / 5 (Number involved / Number examined)
      • LN 12A: negative for malignancy (soft tissue only)
    • Additional Pathologic Findings (select all that apply) — cholelithiasis, high grade dysplasia
    • Immunohistochemical stain reveals CD56(+), CK19(+), CK20(-), CK7(+), CA19-9(-).

• 2023-03-17 CT - abdomen

  • Findings:
    • There is an irregular soft tissue mass at the gallbladder fundus, measuring 3.2 x 1.9 cm in size.
      • Adenocarcinoma of the gallbladder is highly suspected.
      • Please correlate with contrast-enhanced CT to evaluate if there is lymph node and peritoneum metastasis.
    • There is horse-shoe kidney.
  • IMP:
    • Adenocarcinoma of the gallbladder is highly suspected.
    • Please correlate with contrast-enhanced CT to evaluate if there is lymph node and peritoneum metastasis.

[MedRec]

• 2023-03-28 ~ 2023-04-03 POMR General and Gastroenterological Surgery Wu Chaoqun
  • Discharge diagnosis
    • Gallbladder neuroendocrine carcinoma, high-grade pT2aN0(cM0) status post laparoscope cholecystectomy and S5 resection and lymph node dissection on 2023/03/29. ECOG:1
    • Gastro-esophageal reflux disease with esophagitis
    • Essential (primary) hypertension
    • Pure hypercholesterolemia
  • CC
    • Epigastric discomfort and dyspepsia for half a year.
  • Present illness
    • This is a 57 year old woman with the history of hypertension, hyperlipidemia, GERD and atrophic gastritis. This time, she was admittied due to epigastric discomfort and dyspepsia for half a year.
    • She had epigastric discomfort and dyspepsia in recent months. She denied of having nausea or vomiting sensations. Abdominal discomfort without pain. There was no fever, no tea color urine, or tarry stool. She went to LMD and was found to have a big gallbladder polyp (1.2 cm) with increased thickness of focal gallbladder wall on 2023/02/25. Thus, she came to our GI OPD on 2023/03/03 for further evaluation.
    • At GI OPD, her vital signs were stable. PE showed no icteric sclera and soft abdomen. Her blood test revealed overall no significant findings or abnormal results. Abdominal CT revealed an irregular soft tissue mass at the gallbladder fundus, measuring 3.2 x 1.9 cm in size. Adenocarcinoma of the gallbladder is highly suspected. Due to the above reasons, she was transferred to GS OPD then ward on 2023/03/28 for further treatment.
  • Course of inpatient treatment
    • After admission, preoperative survey was done and no contraindication was found against operation.
    • Laparoscopic cholecystectomy, parital S5 resection and lymph node dissection were performed on 2023/03/29. The operation went uneventfully and she was brought back to ward afterwards. After the operation, the patient complained about severe operation wound pain and improved after taking analgesics.
    • Tolerable oral diet and ambulation were noted after operation. Under stable condition, she was discharged today and OPD follow up was arranged.
  • Discharge prescription
    • BaoGan (silymarin 150mg) 1# TID
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
    • Celebrex (celecoxib 200mg) 1# PRNQD
    • ammoxicillin 250mg 2# TID

[consultation]

• 2024-05-24 Diagnostic Radiology
  • Q
    • for PTGBD evaluation.
    • This 58 year old female had history of Gallbladder neuroendocrine carcinoma with liver metastasis, high grade pT2aN0M1 stage IV status post S5/S4b resection on 2023/08/28, and s/p CDDP + VP-16 x8.
    • Followed-up abdomen CT (2024/05/18) revealed Gallbladder neuroendocrine carcinoma with liver metastasis, s/p operation, New metastatic lesions in liver and peritoneum, IHDs dilatation.
    • The jaundice, and poor liver function noted. We need your help for PTGBD evaluation, thanks a lot.
  • A
    • According to the clinical condition and imaging findings, PTCD is indicated.
• 2024-01-22 Ophthalmology
  • Q
    • for the patient saw black lines in her lower left visual field for about 6 days, suspect floaters evaluation.
    • This 57 year old female had history of gallbladder neuroendocrine carcinoma, high-grade pT2aN0 (cM0) status post laparoscope cholecystectomy and S5 resection and lymph node dissection on 2023/03/29 with under regular OPD follow up. She had epigastric discomfort and dyspepsia in recent months.
    • She regularly follows abdominal ultrasound and returns to our hospital abdomen echo (2023/07/04) showed a hypoechoic lesion 2.53 x 1.85 cm in S5 of the liver that may be metastasis. The abdominal CT (2023/07/19) revealed metastases 2.5 cm and 1.6 cm in S4/8 and 3.5 x 2.2 cm in S4 of the liver are highly suspected.
    • Whole body PET (2023/08/14, self-paid) showed four focal lesions of increased FDG uptake in the right lobe of the liver, highly suspected metastatic tumors.
    • The Liver, S5 and S4b, S4b/5 resection (2023/08/29) proved metastatic neuroendocrine carcinoma.
    • Under the impression of gallbladder neuroendocrine carcinoma with liver metastasis, stage IV, S/P chemotherapy with EP (Cisplatin + Etoposide).
    • She suffered from tinnitus, and mild hard of hearing for 1 month, and complaints seeing black lines in her lower left visual field for about 6 days, suspect floaters, so we need your help, thanks a lot!!
  • A
    • S: Acute floater os at inf VF for 6 days, improved
      • phx: gallbladder neuroendocrine carcinoma
      • ophx: corneal scar os
    • O:
      • BCVA: OD 0.04(0.3X-5.00/-1.50X65) OS 0.02(0.3X-5.00/-1.25X95)
      • PT: 14/15mmHg
      • Pupil: 3mm, light reflex + ou, no RAPD
      • Conj: np ou
      • k: clear od, peripheral linear scar os
      • a/c: deep/clear ou
      • lens: clear ou
      • c/d 0.4 ou
      • fundus: no break od, inferior few faint VH, no break os
    • A:
      • Faint vitreous hemorrhage r/o acute posterior vitreous detachment os
    • P:
      • eyehelp 1gtt QID ou
      • informed the risk of new break
      • oph opd f/u within 1M, if increased floater come back earlier
• 2023-12-11 Ear Nose Throat
  • Q
    • for tinnitus, and muld hard of hearing for one week
    • This 57 year old female had history of gallbladder neuroendocrine carcinoma, high-grade pT2aN0(cM0) status post laparoscope cholecystectomy and S5 resection and lymph node dissection on 2023/03/29 with under regular OPD follow up. She had epigastric discomfort and dyspepsia in recent months.
    • She regularly follows abdominal ultrasound and returns to our hospital abdomen echo (2023/07/04) showed a hypoechoic lesion 2.53 x 1.85 cm in S5 of the liver that may be metastasis.
    • The abdominal CT (2023/07/19) revealed metastases 2.5 cm and 1.6 cm in S4/8 and 3.5 x 2.2 cm in S4 of the liver are highly suspected.
    • Whole body PET (2023/08/14, self-paid) showed four focal lesions of increased FDG uptake in the right lobe of the liver, highly suspected metastatic tumors.
    • The Liver, S5 and S4b, S4b/5 resection (2023/08/29) proved metastatic neuroendocrine carcinoma.
    • The tumor marker showed CA-199:12.279U/ml, CEA:0.794 ng/ml on 2023/05/23 and CA-199:10.434U/ml, CEA:0.928 ng/ml on 2023/09/19. Hepatitis marker showed Anti-HBc: positive under Vemlidy treatment since 2023/09/11.
    • Port-A was inserted on 2023/09/06.
    • C1 chemotherapy with EP (Cisplatin 70mg/m2 D1) + Etoposide (100mg/m2 D1-D3) was given on 2023/09/11, C2 on 2023/10/3, C3 on 2023/10/23, C4 on2023/11/13. Today, she was admitted for C5 chemotherapy with EP.
    • Due to patient suffered from tinnitus, and muld hard of hearing for one week (suspect to side effect of cisplatin), so we need your help for evaluation, thanks a lot!!
  • A
    • S
      • Tinnitus (left > right) with poor hearing for about a week.
    • O
      • Local finding: bilateral ear drum intact without middle ear effusion.
      • Normal Rinne’s and Weber’s tests.
    • A
      • Unspecified hearing impairment with tinnitus
    • P
      • Please give ginkgo 1# TID first.
      • After discharge, return to the ENT clinic for follow-up and then schedule a hearing test.

[surgical operation]

• 2023-08-28
  • Surgery
    • S4b/5 liver resection
    • laparoscope exam
  • Finding
    • S5 : 5 x 4 x 3.5cm tumor
    • S4b : 4 x 3 x 2.5cm protruding tumor
    • no gossly peritoneal seeding
    • no ascite
    • no other tumor at liver
• 2023-03-29
  • Surgery
    • Laparoscope S5 rsection
    • LC
    • regional LN dissection 8, 12
  • Finding
    • 4 x 3 x 1.5 cm fungating mass at GB dome anteriore wall to posterior wall
    • regional LN enlarge at station 12a

[chemotherapy]

• 2024-08-26 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX 90%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-08-09 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX 90%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-07-23 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX 90% due to WBC 2890, ANC 1757)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-07-03 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-06-18 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-28 - leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-05-27 - topotecan 1.5mg/m2 2.5mg D5W 80mL 30min D1-4 + carboplatin AUC 2 250mg NS 250mL 2hr D1
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-02-16 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 120mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 155mg NS 500mL 2hr D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-01-24 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 150mg NS 500mL 2hr D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-01-02 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 150mg NS 500mL 2hr D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-12-11 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 150mg NS 500mL 2hr D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-11-13 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 145mg NS 500mL 2hr D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-10-23 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 145mg NS 500mL 2hr D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-10-03 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 120mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 160mg NS 500mL 2hr D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-09-11 - NS 1000mL 4hr (before CDDP) + furosemide 20mg (after NS) + cisplatin 70mg/m2 105mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) + furosemide 20mg (after NS) + etoposide 100mg/m2 150mg NS 500mL 2hr D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-08-26

[stable WBC and improved bilirubin levels under FOLFOX]

Since the chemotherapy started in late May, WBC levels have consistently remained above 2.5K/uL, with no severe neutropenia occurring. The current FOLFOX regimen is being administered at 90% of the standard dose.

The elevated conjugated bilirubin levels have shown a downward trend, indicating improvement.

Additionally, there has been no recent elevation in CEA, and the CA199 spike observed in late July has decreased by mid-August.

Overall, the treatment appears to be effective, with no major adverse reactions and an improvement in jaundice symptoms. No medication issues have been identified.

• 2024-08-25 WBC 2.69 x10^3/uL **

• 2024-08-20 WBC 3.32 x10^3/uL *

• 2024-08-09 WBC 2.86 x10^3/uL **

• 2024-08-07 WBC 3.95 x10^3/uL

• 2024-07-30 WBC 5.60 x10^3/uL

• 2024-07-23 WBC 2.89 x10^3/uL **

• 2024-07-17 WBC 2.93 x10^3/uL **

• 2024-07-03 WBC 2.98 x10^3/uL **

• 2024-06-24 WBC 3.61 x10^3/uL

• 2024-06-20 WBC 6.35 x10^3/uL

• 2024-06-18 WBC 4.75 x10^3/uL

• 2024-06-16 WBC 4.62 x10^3/uL

• 2024-06-12 WBC 10.93 x10^3/uL

• 2024-06-03 WBC 2.68 x10^3/uL **

• 2024-05-30 WBC 3.89 x10^3/uL

• 2024-05-27 WBC 4.73 x10^3/uL

• 2024-08-25 Bilirubin direct 0.32 mg/dL

• 2024-08-09 Bilirubin direct 0.29 mg/dL

• 2024-07-23 Bilirubin direct 0.43 mg/dL

• 2024-06-24 Bilirubin direct 0.47 mg/dL

• 2024-06-20 Bilirubin direct 0.65 mg/dL

• 2024-06-18 Bilirubin direct 0.77 mg/dL

• 2024-06-16 Bilirubin direct 1.66 mg/dL

• 2024-06-03 Bilirubin direct 1.10 mg/dL

• 2024-05-30 Bilirubin direct 1.40 mg/dL

• 2024-05-27 Bilirubin direct 1.83 mg/dL

• 2024-05-23 Bilirubin direct 4.71 mg/dL

• 2024-08-13 CA-199 (NM) 60.189 U/ml

• 2024-07-22 CA-199 (NM) 104.381 U/ml

• 2024-07-09 CA-199 (NM) 77.640 U/ml

• 2024-06-14 CA-199 (NM) 47.320 U/ml

2024-06-17

[Post-PTCD Concerns: Elevated Bilirubin & Rising CA-199 Marker]

Recent PTCD and Follow-up Concerns: The patient recently underwent percutaneous transhepatic cholangiodrainage (PTCD) on 2024-05-24. However, her total bilirubin level has since risen to 2.71 mg/dL. This elevation may warrant consideration of another PTCD procedure if symptoms reappear.

• 2024-06-16 Bilirubin total 2.71 mg/dL

• 2024-06-12 Bilirubin total 1.62 mg/dL

• 2024-06-03 Bilirubin total 1.96 mg/dL

• 2024-06-16 Bilirubin direct 1.66 mg/dL

• 2024-06-03 Bilirubin direct 1.10 mg/dL

Rising CA-199 Marker:

Additionally, the patient’s CA-199 tumor marker level appears to be increasing.

• 2024-06-14 CA-199 (NM) 47.320 U/ml
• 2024-05-21 CA-199 (NM) 30.801 U/ml
• 2024-04-26 CA-199 (NM) 12.852 U/ml

2023-10-03

[drug identification]

Since the drug to be identified is an unpackaged tablet, its quality and expiration date cannot be confirmed, so the response is that the drug cannot be identified.

An in-hospital porter will be sent to deliver the tablets to the ward.

700759225

240826

[exam findings]

• 2024-08-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (92.4 - 24.4) / 92.4 = 73.59%
    • M-mode (Teichholz) = 73.6
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Moderate TR, mild AR, MR and PR
    • Impaired LV relaxation
    • Dilated LA; thick IVS and LVPW
• 2024-08-12 SONO - abdomen
  • Diagnosis:
    • Liver parenchymal disease (incomplete exam of liver)
    • Dilatation of CBD and bilateral IHD, C/W post plastic stent insertion in CBD, with pneumobilia
    • dilatation of main pancreatic duct (most parts of pancreas obscured by bowel gas)
  • Suggestion:
    • pneumobilia is an indirect sign, which may imply patency of stent
    • however, it may be difficult to evaluate the patency of stent according to image by abdominal sonography, please correlate with clinical condition (such as symptoms and signs, lab data)
• 2024-08-05, -07-18 KUB
  • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
  • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s).
  • S/P percutaneous vertebroplasty at several level of the visible lumbar or thoracic spine.
  • S/P screws fixation in or at the area of left SI joint.
  • S/P plastic stent implantation in between CHD and duodenum.
• 2024-07-18 CXR erect
  • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Borderline cardiomegaly
• 2024-07-17 EEG
  • Findings
    • The background activities were composed by alpha rhythm at 8-9 Hz, 20-40 uV in bilateral posterior head areas and beta rhythm at 13-15 Hz, 15-30 uV in bilateral anterior head areas.
    • There were intermittent diffuse slow waves at 4-6 Hz, 20-50 uV in bilateral hemispheres. No obvious photic driving response was noted.
    • This EEG suggests mild diffuse cortical dysfunction. Advise clinical correlation.
  • Conclusion: Abnormal EEG.
• 2024-07-14 MRA - brain
  • Brain atrophy.
  • Occlusion or hypoplasia of left ACA.
• 2024-07-14 CT - brain
  • Brain atrophy.
• 2024-06-20 Patho - pancreas biopsy
  • Pancreas, EUS FNA/B — Ductal adenocarcinoma, poorly differentiated
  • The sections show a picture of ductal adenocarcinoma, poorly differentiated, composed of nests, cords, and single large pleomorphic neoplastic cells, embedded in fibrous stroma. Subtle glandular differentiation is present.
• 2024-06-19 Endoscopic Ultrasonography, EUS
  • Diagnosis
    • Pancreatic head cancer s/p EUS/FNB
    • CBD stent in situ
    • Ascites
    • Esophageal varices, F2CbLi, red color sign (-), nipple sign (-)
  • Suggestion:
    • Follow up pathology report
• 2024-06-12 Body fluid cytology - bile duct brushing
  • Clinical finding
    • suspected pancreatic head cancer with obstructive jaundice
  • Cytology
    • Atypia
  • MICROSCOPIC DESCRIPTIO
    • Smears show predominant bland ductal epithelial cells and some atypical cells with enlaged and irregular nuclei. Please correlate with the clinical presentation.
• 2024-06-11 Patho - duodenum biopsy
  • Duodenum, 2nd portion, biopsy — high-grade adenocarcinoma, in favor of pancreas origin
    • NOTE: Clinical correlation is necessary.
  • Microscopically, it shows high-grade adenocarcinoma composed of proliferation of neoplastic cells arranged in solid to glandular architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei, pleomorphism and high N/C ratio.
    • Immunohistochemical stain demonstates CA19-9(+), CDX-2(-), CK20(-), CK7(+), CD56(-) at tumor..
• 2024-06-11 Endoscopic Retrograde Cholangiopancreatography, ERCP
  • Diagnosis:
    • Distal CBD stricture (C/W pancreas tumor invasion or compression): post TPS (Transpancreatic Sphincterotomy) / EST (endoscopic sphincterotomy) and brushing cytology, ERBD (endoscopic retrograde biliary drainage) and ERPD (endoscopic retrograde pancreatic drainage)
    • Dilatation of CBD and bilateral IHD
    • Suspected papillitis (or tumor invasion) of major papilla: post biopsy
  • Suggestion:
    • keep post EST/ERCP care; observation of symptoms
• 2024-06-07 EGD
  • Diagnosis:
    • Fragile mucosa, 2nd portion, s/p biopsy
    • External compression and lumen narrowing, 2nd portion
    • Reflux esophagitis LA Classification grade A
    • Hiatal hernia, severe
  • CLO test: not done
  • Suggestion:
    • Pursue pathology report
• 2024-06-06 CT - abdomen
  • History and indication: obstructive jaundice
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A poor enhancing lesion (3.4cm) at pancreatic head/ ucinat process with SMA/ SMV and duodenum invasion. Cystic lesions (2.7cm, 0.9cm, 0.7cm) at pancreatic head and body. Distention of gallbladder. Dilatation of biliary tree and p-duct.
    • Liver cirrhosis with portal hypertension and splenomegaly.
    • Hiatal hernia of stomach.
    • S/P left pelvic operation.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P VP. Compression fracture of spine.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T4(T_value) N:N0(N_value) M:M0(M_value) STAGE:III(Stage_value)
• 2024-06-05 ECG
  • Low voltage QRS
  • Possible Anterolateral infarct, age undetermined
  • Nonspecific T wave abnormality

[MedRec]

• 2024-06-05 ~ 2024-06-21 POMR Gastroenterology Xiao ZongXian
  • Discharge diagnosis
    • Pancreatic head ductal adenocarcinoma, with suspicious invasion of superior mesenteric artery/ superior mesenteric vein and duodenum, cT4N0M0 stage III; post endoscopic sphincterotomy, brushing cytology, and endoscopic retrograde biliary drainage and stenting on 2024/06/11; post endoscopic ultrasound-guided fine needle biopsy on 2024/06/19
    • Obstructive jaundice causing by pancreatic head cancer
    • Septicemia due to Klebsiella aerogenes and Acinetobacter baumannii
    • Cystic lesions (2.7cm, 0.9cm) at pancreatic head and body.
    • Liver cirrhosis with portal hypertension and splenomegaly.
    • Hiatal hernia of stomach.
    • Chronic viral hepatitis B without delta-agent
    • Unspecified dementia without behavioral disturbance
  • CC
    • yellowish skin discoloration noted for 2 wk
  • Present illness
    • This 76-year-old female patient has past history of 1) Hepatitis B with cirrhosis s/p entecavir treatment, with loss of follow-up since 2018/11; 2) L5 compression fracture s/p vertebroplasty on Aug. 6, 2015. 3) S/P removal of L spine instrument on 2015-12-21; 4) OA change of SI joint s/p RF on 2016-01-25.
    • This time, she suffered from yellowish skin discoloration noted for 2 wk and she was brought to our GI OPD, where blood analysis showed elevated hepatobiliary enzyme and marked hyperbilirubinemia (AST 88 U/L, ALT 52 U/L, TBI 27.56 mg/dl, GGT 375 IU/L), elevated lipase level (524 U/L) and elevation of CA19-9 (319 U/L).
    • Under the impression of obstructive jaundice suspect malignant biliary obstruction, she was admitted to ward for further evaluation and management.       
    • In addition, she was found to be easy forgetful for a period prior to admission. She was just brought to the neurologic OPD on 2024/06/05. Dementia was suspected, and some blood exam and brain CT had been arranged.
  • Course of inpatient treatment
    • After admission, we keep on Urso and gave adequate IV fluid supplementation.
    • Abdominal CT reported a poor enhancing lesion (3.4cm) at pancreatic head/uncinate process with possible invasion of SMA, SMV and duodenum, which was highly suspected to be malignancy; cystic lesions (2.7cm, 0.9cm) at pancreatic head and body; distention of gallbladder and dilatation of biliary tree and p-duct; liver cirrhosis with portal hypertension and splenomegaly; and hiatal hernia of stomach.
    • EGD showed fragile mucosa and external compression with luminal narrowing in the 2nd portion of duodenum; biopsy revealed pathology of high-grade adenocarcinoma in favor of pancreatic origin.
    • The serologic exam showed positivity of HBsAg with detectable serum HBV DNA; antiviral agent of Vemlidy was prescribed on the indication of decompensated liver function.
    • She underwent ERCP on 6/11 and reported distal CBD stricture (C/W pancreas tumor invasion or compression).
    • Endoscopic sphincterotomy was done, followed by brushing cytology and placement of biliary stent.
    • Biopsy was done at the papilla for the finding of papillitis, and it showed no malignancy. The brushing cytology showed inconclusive result.
    • She developed fever on 6/13, and received empiric antibiotic treatment of Brosym.
    • Blood culture reported growth of Klebsiella aerogenes and Acinetobacter baumannii, and the antibiotic was changed to cefepime since 6/17.
    • Surgeon and medical oncologist were consulted for the treatment plans on the pancreatic head cancer.
    • EUS-FNB was recommended and was performed on 6/19 in order to obtain more tissue for the definite diagnosis and possible NGS in the future.
    • Blood transfusion was given on 6/20 to correct anemia.
    • Hypoalbumin infusion and diuretics were administered for the occurrence of ascites.
    • Under relative stable condition, she was discharged on 6/21 and will return to Oncology/GI/GS OPD on 6/25.
    • The final pathology report of EUS-FNB reported poorly differentiated ductal adenocarcinoma.
  • Discharge prescription
    • Megejohn (megestrol acetate 160mg) 1# QD
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Spiron (spironolactone 25mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# QID
    • Uliden (ursodeoxycholic acid 100mg) 1# TID
    • Uretropic (furosemide 40mg) 0.5# QD

[MultiTeam]

• 2024-08-19 Multidisciplinary Team Recommendation - Palliative Care
  • Consultation Date: 2024-08-16
  • Response Summary:
    • The patient was diagnosed with pancreatic cancer with duodenal invasion in June this year. The patient was admitted due to poor appetite and widespread pain. Two days ago, the patient developed shortness of breath, altered consciousness, and thrombocytopenia. The family has agreed to a do-not-resuscitate (DNR) order. During the palliative care consultation, the patient briefly opened her eyes but was unable to respond, showing signs of jaundice, using nasal cannula for oxygen, and having edema in both hands. The concept of palliative care was explained to the family outside the ward. The family agreed to palliative care but expressed that they do not want to transfer the patient to a palliative care unit at this time. The palliative care consultant’s contact information was provided for any palliative-related inquiries, and follow-up care will continue.
  • Conclusion and Recommendation: Palliative care co-management
  • Responder: Chen Hui
  • Response Date: 2024-08-16 17:05
  • Physician’s Response:
    • 08/19 08:51, Xia HeXiong: Proceed as recommended. Acknowledged.
• 2024-08-16 Multidisciplinary Team Recommendation - Discharge Planning
  • Consultation Date: 2024-08-14
  • Reason for Consultation: Other: Readmission after 14 days
  • Consultation Status: Case admitted within the hospital
  • 2024-08-15 08:11 - Xie SuQin
    • Patient Details: 76 years old, diagnosed with pancreatic cancer, impaired consciousness, no disability, long-term care application submitted. The patient has an NC tube in place, lives on the first floor, is accompanied by a caregiver, and has home assistive devices (cane, wheelchair, walker, commode chair, electric bed, air mattress). Further assistance will be provided as needed based on the situation.
  • Physician’s Response:
    • 08/16 08:16, Xia HeXiong: Acknowledged. Proceed as recommended.

==========

2024-08-26

[improving bilirubin and albumin levels with ongoing hyponatremia]

Following the weekend, both hypoalbuminemia and elevated bilirubin have shown improvement. However, there has been no significant change in hyponatremia; continued sodium supplementation is recommended.

• 2024-08-26 Na (Sodium) 129 mmol/L

• 2024-08-22 Na (Sodium) 128 mmol/L

• 2024-08-26 Albumin (BCG) 2.5 g/dL

• 2024-08-22 Albumin (BCG) 1.9 g/dL

• 2024-08-26 Bilirubin total 7.19 mg/dL

• 2024-08-22 Bilirubin total 13.06 mg/dL

• 2024-08-19 Bilirubin total 19.65 mg/dL

• 2024-08-26 Bilirubin direct 4.26 mg/dL

• 2024-08-22 Bilirubin direct 7.91 mg/dL

• 2024-08-19 Bilirubin direct 11.05 mg/dL

2024-08-21

[to adjust Panzolec administration frequency]

The Panzolec Lyo (pantoprazole) package insert states that if the daily dose exceeds 80mg, it should be divided into two doses per day. The current administration is 200mg once daily. It is recommended to consider administering the medication twice daily.

2024-08-20

[medication review: QT prolongation and PPI duplication]

The patient is currently taking Emetrol (domperidone 10mg) 1 # PO TIDAC and Flucon (fluconazole) 200mg IVD QD.

Domperidone may enhance the QTc-prolonging effects of moderate risk QT-prolonging CYP3A4 inhibitors. Additionally, these inhibitors may increase the serum concentration of domperidone.

The product labeling for domperidone lists this combination as contraindicated. It is recommended to avoid using moderate risk QT-prolonging CYP3A4 inhibitors with domperidone.

Moderate risk QT-prolonging CYP3A4 inhibitors that may interact with domperidone include crizotinib, erythromycin (systemic), fluconazole, nilotinib, and ribociclib.

If this combination is necessary and unavoidable, close monitoring with ECG is required.

Additionally, the patient is also prescribed Pariet FC (rabeprazole 20mg) 1 # PO QDAC and Panzolec (pantoprazole) 200mg IVD QD. Since both medications are PPIs, please reconsider the need for using them together.

[considering BID dosing for pantoprazole due to short half-life]

Please recheck for any ongoing signs of gastrointestinal bleeding, such as occult blood in the stool.

The half-life elimination of pantoprazole in adults is relatively short at about 1 hour. Given this, the current once-daily dosing regimen could be reconsidered, and this high dose (current 200mg) might be divided into at least BID to optimize efficacy.

2024-07-15

[monitoring fluid status in patients with liver issues]

Both hyperbilirubinemia and hypoalbuminemia are showing improvement, and Uliden (ursodeoxycholic acid) is being administered currently.

However, there is a lack of body weight and fluid input/output data on the TPR panel. It is advisable to obtain this data to monitor whether edema is developing or resolving, given the patient’s low albumin levels and the use of diuretics (furosemide 40mg QD, spironolactone 25mg BID).

• 2024-07-14 Bilirubin total 4.37 mg/dL

• 2024-07-02 Bilirubin total 6.82 mg/dL

• 2024-06-25 Bilirubin total 8.53 mg/dL

• 2024-06-20 Bilirubin total 11.20 mg/dL

• 2024-06-17 Bilirubin total 13.45 mg/dL

• 2024-06-13 Bilirubin total 23.72 mg/dL

• 2024-06-12 Bilirubin total 21.29 mg/dL

• 2024-06-11 Bilirubin total 25.05 mg/dL

• 2024-06-04 Bilirubin total 27.56 mg/dL

• 2024-07-02 Albumin (BCG) 3.0 g/dL

• 2024-06-25 Albumin (BCG) 2.9 g/dL

• 2024-06-20 Albumin (BCG) 2.3 g/dL

701010836

240826

[exam findings] (not completed)

• 2024-08-23 CT - chest
  • Indication: Fever/chills: Fever (looks ill), fever, cough, chest pain
  • CC: chest pain for 2 hours. radiation to backright subcostal pain
  • Chest and Abdominal CT with and without enhancement revealed:
    • s/p esophagogastric stent placement is found. Enhanced mass inside the stent at the lower part with surrounding soft tissue is noted. Tumor growth is considered.
      • In comparison with CT dated on 2024-06-20, enlarged tumor growth is considered.
    • Consolidation of right lower lobe is found.
    • Small lymph nodes at both side of the paratracheal region is noted.
    • There is stone at dependent portion of GB. GB stone(s) are noted.

[consultation]

• 2024-08-26 Thoracic Surgery
  • Q
    • The 46M has Adenocarcinoma of esophagogastric junction, status post laparotomy partial gastrectomy, thoracostomy partial esophagectomy with gastric tube reconstruction and feeding jejunostomy on 2022/07/18, post endoscopic esophageal stent implantation on 2024/03/27, pT3N2M0 stage IIIB under TS-1 control.
    • This time, he has worsening pain at Rt abdomen to back for 2 days. He also suffered from dysphagia.
    • Chest CT showed s/p esophagogastric stent with enhanced mass inside the stent at the lower part with surrounding soft tissue is noted.
    • Tumor growth is considered.
    • We need your expertise on his dysphagia and possible stent narrowing due to tumor obstruction. Thank you very much!
• 2024-05-21 Thoracic Surgery
  • Q
    • for chest CT showed Right lung pneumonia with abscess. r/o esophageal leakage or recurrent tumor. evaluation and suggest
    • A 46-year-old man had past history of gallstones and HBV infection. His surgical history were esophageal cancer status post partial gastrectomy, VATS partial esophacectomy with gastric tube reconstruction, jejunostomy and port-A placement on 2022-07-18 pT3N2M0 stage IIIB, Left 7th to 10th ribs fracture with hemothroax status post VATs with ORIF decortication on 2018-02-26, Esophageal obstruction status post laparoscopic jejunostomy and endoscopic balloon dilatation on 2024/03/19 and post endoscopic esophageal stent implantation on 2024/03/27.
    • He just discharged due to abscess of right lung with pneumonia (Sputum culture: Pseudomonas aeruginosa).
    • According to his statement, he suffered from fever up to 38 degree since 2024-05-11. He also complains of productive cough with greenish-yellow sputum and went to LMD for help where antibiotic was administrated but in vain. There is no TOCC or trauma hisory. He had no previous allergy to food or drug. There is no UTI symptom in recent days.
    • He was brought to our ED for help. At ED, vital signs showed tachycardia (BP:101/59; HR:105; BT:35.9’C; RR:20).
    • Laboratory data showed leukocytosis (29650/uL), elevated CRP (21.8mg/dL), and normal liver and renal function.
    • CXR showed right pleural effusion. Ground glass opacity in right lung. Fracture of right clavicle.
    • Chest CT revealed right lung pneumonia with abscess. r/o esophageal leakage or recurrent tumor.
    • Under the impression of right lung pneumonia with abscess, he is admitted to the Chest ward for evaluation and management on 2024-05-19.    
    • Due to chest CT report showed Right lung pneumonia with abscess. r/o esophageal leakage or recurrent tumor, we sincerely need your help for evaluation and suggset. Thansk a lot !!!
  • A
    • Please keep broad-spectrum antibiotics for lung abscess and localized empyema. I will follow up this case. Thanks for your consultation!!
• 2024-03-15 Thoracic Surgery
  • Q
    • Triage Level: 3. General weakness/fatigue > Acute weakness/unable to ambulate. History of gastrectomy and esophagectomy . Family reports inability to eat for a week
    • CC: worsening dysphagia for one week
      • intermittnet dysphagia was noted after ballon dilation on 2024/02/19
      • however the symptoms worsened for one week and unable to drink water since this Wendnesday due to vomit
      • right chest wall? RUQ? pain
      • cough and sore throat for days
      • chill yesterday
    • O
      • no dyspnea, no cold sweating
      • no fever
      • no tarry stool
      • no dysuria
      • allergy: none
    • PHx:
      • Adenocarcinoma of esophagogastric junction status post laparotomy partial gastrectomy, thoracostomy partial esophacectomy with gastric tube reconstruction and feeding jejunostomy on 2022/07/18, pT3N2M0 stage IIIB s/p Endoscopic Balloon Dilatation for Esophageal Strictures on 2024/02/19.
      • Unspecified viral hepatitis B without hepatic coma
      • Abnormal results of liver function studies
      • Gastro-esophageal reflux disease with esophagitis
      • Functional dyspepsia
        • S/P C5 chemotherapy with FOLFOX (20221012), for recheck and continue therapy,
      • Calculus of gallbladder without cholecystitis without obstruction
  • A
    • I will take over this case. Thanks for your consultation!!!
• 2024-02-06 General and Gastroenterological Surgery
  • Q
    • For vomiting after meals and CT saw gallstones
    • A 46-year-old man had past history of gallstones and HBV infection. His surgical history were esophageal cancer status post partial gastrectomy, VATs partial esophacectomy with gastric tube reconstruction, jejunostomy and port-A placement on 2022-07-18 pT3N2M0 stage IIIB; Left 7th to 10th ribs fracture with hemothroax status post VATs with ORIF decortication on 2018-02-26. Additionally, he didn’t quit smoking.
      
    • Recently, he felt exertional dyspnea and weakness for about a month and occasional vomitting after eating for about 3 weeks. The postprandial vomiting persisted in recent 3 days and his weight decreased about 10kg in a month. Therefore, he came to this emergency department for help. He denied abdominal pain, tenderness and distension. This time, under impression of postprandial vomiting, exertional dyspnea and weakness, he was admitted for further management.
    • Now, PPN was used
    • Postprandial vomiting got improvment
    • Epigastric discomfort after eating was told.
    • Lab were neutrophilia but normal WBC, CRP, T-BIL, r-GT, ALP
    • Abd CT: Gallstones
    • Due to above condition, we need your expertise to help us to mange the patient. Thank you very much.
  • A
    • O
      • NO postprandial epigastric pain.
      • No Murphy sign.
      • No tenderness. soft and flat.
      • CT showed gallstone but gallbladder is normal. small intestine is not dilate.
    • Impression：
      • symptomatic gallstone or cholecystitis is not favored. Thanks for consultation
• 2022-09-12 Thoracic Surgery
  • Q
    • The patient is an 44-year-old male with a history of adenocarcinoma of esophagogastric junction status post laparotomy partial gastrectomy, thoracostomy partial esophacectomy with gastric tube reconstruction and feeding jejunostomy on 2022/07/18, pT3N2M0 stage IIIB. He presented with dysphagia with liquid material for one week. Esophagography was done showed luminal narrowing at midportion esophagus. We need your further evaluation and management.
  • A
    • I will arrange UGI scope for this patient. Thanks for your consultation!!

[surgical operation]

• 2024-03-19
  • Surgery
    • Laparoscopic jejunostomy and endoscopic balloon dilatation
  • Finding
    • Jejunostomy tube: 18-French silicon Foley catheter.
    • Stricture over esophagogastrostomy, about 30cm below incisor, with one nearby diverticulum.
    • Estimated blood loss: 20ml.
• 2024-02-19
  • Surgery
    • Endoscopic eso. dilatation.
  • Finding
    • Ballon dilator to 54 Fr. 
• 2022-09-12
  • Surgery
    • UGI scope
  • Finding
    • There was no visible tumor within PES.
    • No stricture over previous esophagogastrostomy site.
• 2022-07-18
  • Surgery
    • laparotomy partial gastrectomy + VATS partial esophacectomy with gastric tube reconstruction (Ivor-Lewis converted to thoracostomy); jejunostomy
  • Finding
    • a central necrotic solid mass with central located at EGJ with diatal esophagus and cardia gastric and fundus invasion
    • intact gatric serosa and esophagus advantitia with no tumor involvement in gross
    • distal esophagus removed at proximal azygus vein level
    • partial gastrectomy was done with 3-5cm safe margin, the residaul distal stamoch used for esophagus reconstruction in chest cavity at proximal azygus vein level
    • just half circle anastomosis success due to poor EEA formation therefore converted to thoracotomy, hand-sewn the other half poor anastomosis circle
    • a 24 Fr. chest tube inserted in 8th ICS

[chemotherapy]

• 2022-10-26 - (FOLFOX. Wan XiangLin)
• 2022-10-12 - (FOLFOX. Wan XiangLin)
• 2022-09-28 - (FOLFOX. Wan XiangLin)
• 2022-09-14 - (FOLFOX. Wan XiangLin)
• 2022-08-31 - (FOLFOX. Wan XiangLin)
• 2022-08-17 - (FOLFOX. Wan XiangLin)

==========

2024-08-26

701118846

240826

{colon cancer - mucinous adenocarcinoma}

[lab data]

2020-09-30 NRAS/KRAS detected
2020-09-30 KRAS 12/13 Not detected
2020-09-30 BRAF Not detected

2020-08-28 HBsAg (NM) Negative
2020-08-28 HBsAg Value (NM) 0.365
2020-08-28 Anti-HBs (NM) Negative
2020-08-28 Anti-HBs value (NM) <2.00
2020-08-28 Anti-HBc (NM) Negative
2020-08-28 Anti-HBc Value (NM) 2.15
2020-08-28 Anti-HCV (NM) Negative
2020-08-28 Anti-HCV Value (NM) 0.0382
2020-08-28 HBsAg (NM) Negative
2020-08-28 HBsAg Value (NM) 0.365
2020-08-28 Anti-HBs (NM) Negative
2020-08-28 Anti-HBs value (NM) <2.00
2020-08-28 Anti-HBc (NM) Negative
2020-08-28 Anti-HBc Value (NM) 2.15
2020-08-28 Anti-HCV (NM) Negative
2020-08-28 Anti-HCV Value (NM) 0.0382

[exam findings]

• 2024-08-25 ECG
  • Sinus rhythm with Premature supraventricular complexes
  • Low voltage QRS
  • Septal infarct, age undetermined
• 2024-08-25 CT - abdomen
  • Findings
    • suspicious segmental wall thickening in the gastric antrium. dilated small bowel in the lower abdomen. r/o small bowel ileus.
    • a heterogeneous rim-enhancing lesion, about 37mm, in the midline of the lower anterior abdominal wall.
    • mild ascites in the pelvic cavity
    • heterogeneous enhancing nodular lesions in the uterine cervix and the lower uterus body.
    • nodular lesions in the bilaeral thyroid gland.
    • mild dirty fat planes in the right middle abdomen.
• 2024-08-15 EGD
  • Diagnosis
    • No active bleeders, no oozing blood sites, nor blood clots was noted.
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis
    • Duodenal ulcer scar, S2, bulb, AW
  • CLO test: not done
• 2024-07-19 Patho - hernia sac
  • Soft tissue, ventral hernia, repair — metastatic adenocarcinoma, consistent with metastatic appendiceal adenocarcinoma
  • Section shows fibroadipose tissue with metastatic adenocarcinoma.
  • The immunohistochemical stains reveal CK7(-), CK20(focal +), CDX2(focal +), CK5/6(-), and Calretinin(-). The results are consistent with metastatic appendiceal adenocarcinoma.
• 2024-07-17 CT - abdomen
  • FINDINGS: Comparison: prior CT dated 2024/05/20.
    • Incarcerated incisional hernia in the midline middle pelvic wall induce mechanical high grade small bowel obstruction is suspected. please correlate with clinical condition.
    • Prior CT identified an enhancing soft tissue nodule 1.86 cm in the umbilical area is noted again, increasing in size to 8.4 x 4.1 cm.
      • please correlate with clinical condition.
      • S/P drainage tube insertion within the tumor area.
    • Prior CT identified another soft tissue nodule 1.6 x 0.7 cm in right upper pelvis wall is noted again, decreasing in size to 1.3 x 0.7 cm.
      • Follow up is indicated.
        
    • S/P right hemicolectomy.
    • There are several hepatic cysts in both lobes (up to 2.2 cm in S8).
      • A calcified gallstones 1 cm is noted.
      • In addition, there is a soft tissue nodule 9 mm at the gallbladder fundus that may be focal type adenomyomatosis.
    • Minimal pericardial effusion is highly suspected.
• 2024-07-11 Patho - soft tissue tumor, extensive resection
  • Soft tissue, abdominal wall, RLQ, excision — Metastatic mucinous carcinoma, compatible with appendix primary
  • The sections show a picture of metastastic mucinous carcinoma, compatible with appendix primary, composed of nests and cords of neoplastic cells floating in mucin pools. Fibrous stromal reaction can be found focally. All the surgical margins are free of tumor. The closest margin from carcinoma is < 1 mm (deep margin).
• 2024-07-09 ECG
  • Sinus rhythm with Blocked Premature atrial complexes
  • Low voltage QRS
  • Septal infarct, age undetermined
• 2024-05-30 Patho - soft tissue biopsy / simple excision (non lipoma)
  • Soft tissue, lower periumbilical, right, core needle biopsy — Metastatic mucinous adenocarcinoma
  • The sections show a picture of metastatic mucinous adenocarcinoma, composed of nests and cords of polygonal neoplastic cells suspended in abundant extracellular mucin. Focal tubular formation is present.
• 2024-05-20 CT - abdomen
  • Abdominal and Chest CT with and without IV contrast ehnancement shows:
    • S/p port-A placement with its tip at left brachiocephalic vein.
    • Cardiomegaly is noted.
    • Senile fibrotic change is noted at lung fields.
    • s/p op. over cecum.
    • Soft tissue nodule at periumbilical region is found measuring 1.86cm. In comparison with CT dated on 2024-01-19, the lesion enlarged.
    • The urinary bladder is partially distended without evidence of abnormal soft tissue lesion.
    • One skin nodule at right lateral abdominal wall measuring 1.0cm is found. S9e301 Im86), In comparison with CT dated on 2020-12-29, the lesion is stationary. Meta is less likely.
  • Imp:
    • s/p cecum op.
    • Peri-umbilical soft tissue nodule. 1.86cm, in enlargement. r/o meta.
    • RLQ skin nodule. 1.0cm, stationary. Meta is less likely.
• 2024-01-19 CT - abdomen
  • FINDINGS:
    • There is an enhancing soft tissue nodule 1 cm in the umbilical area (Srs:8 Img:91). Metastasis is highly suspected.
      • In addition, there is another soft tissue nodule 1.6 x 0.7 cm in right upper pelvis wall (Srs:8 Img:90). Metastasis is also suspected.
    • S/P right hemicolectomy.
    • There are several hepatic cysts in both lobes and the largest one is measured about 2.2 cm in size at segment 8.
      • A calcified gallstone 6 mm is noted.
    • There is no focal lesion in both lung and mediastinum.
      • Right lobe thyroid shows enlarged in size and few poor enhancing lesions (up to 2.3 cm). Left lobe and isthmus thyroid show few poor enhancing and few enhancing nodules. Nodular goiter is highly suspected. Please correlate with sonography.
        
  • IMP:
    • There is an enhancing soft tissue nodule 1 cm in the umbilical area (Srs:8 Img:91). Metastasis is highly suspected.
      • In addition, there is another soft tissue nodule 1.6 x 0.7 cm in right upper pelvis wall (Srs:8 Img:90). Metastasis is also suspected.
• 2023-12-21 Patho - soft tissue tumor, extensive resection
  • PATHOLOGIC DIAGNOSIS
    • Ventral hernia sac, repair — Mucinous adenocarcinoma, recurrent
    • Greater omentum, cytoreductive surgery — Mucinous adenocarcinoma, recurrent
    • Tumor, abdominal wall, ditto — Mucinous adenocarcinoma, recurrent
    • Mesenteric tumor, ditto — Mucinous adenocarcinoma, recurrent
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of
      • 1. four small pieces of ventral hernia sac tissue measuring up to 4.2 x 2.7 x 1.1 cm in size. Grossly, few myxoid nodules measured up to 0.7 x 0.4 cm were seen. Representatively embedded for section in cassette A,
      • 2. one piece of greater omentum tissue measuring 15.5 x 6.5 x 3.2 cm in size. Grossly, some myxoid nodules measured up to 1.7 x 1.5 cm were seen. Representatively embedded for section in cassette B1-B2,
      • 3. one small piece of abdominal wall tumor tissue measuring 4 x 3.3 x 2.7 cm in size, Grossly, few myxoid nodules measured up to 3.7 cm were seen. Representatively embedded for section in cassette C1-C2 and
      • 4. one small piece of mesenteric tumor tissue measuring 2.2 x 1.3 x 1.0 cm in size. All embedded for section in cassette D respectively.
  • MICROSCOPIC EXAMINATION
    • Microscopically, the sections pictures as follows:
      • Ventral hernia sac: mucinous adenocarcinoma. According to histopathologic finding and patient’s past history, it is compatible with recurrent
      • Greater omentum: mucinous adenocarcinoma, compatible with recurrent
      • Tumor of abdominal wall: mucinous adenocarcinoma, compatible with recurrent
      • Mesenteric tumor: mucinous adenocarcinoma, compatible with recurrent
• 2023-11-07 ECG
  • Sinus rhythm with 2nd degree A-V block (Mobitz II) with occasional Premature ventricular complexes.
• 2023-11-07 Flow Volume Chart
  • Mild restrictive ventilatory impairment, please correlated with clinical condition
• 2023-11-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (114 - 31.7) / 114 = 72.19%
    • M-mode (Teichholz) = 72.2-77.4
  • Conclusion:
    • Normal AV with mild AR
    • Normal MV with mild MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
• 2023-11-06 Tc-99m MDP bone scan
  • A hot spot in the ant. aspect of the right 5th rib, several faint hot spots in the post. aspect of the right rib cage, and increased radiotracer uptake at several right costovertebral junctions, the nature is to be determined (early bone mets. post-traumatic change or other naure ?), suggesting follow-up with bone scna in 3 months for investigaiton.
  • Suspected benign lesion maxilla, mandible, C-spine, lower L-spine, sacroiliac joints, shoulders, sternoclavicular junctions, hips, and feet.
• 2023-10-03 CT - abdomen
  • History and indication: Colorectal cancer s/p OP and C/T, with recurrence
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Right thyroid nodules (up to 2.6cm).
    • S/P colon operation. Some soft tissues in peritoneal cavity r/o tumor seeding. Ventral hernia with bowel loop herniation.
    • Retroversion of uterus. Some LNs at mediastinum.
    • Liver cysts (up to 2.2cm).
    • Left renal stone (5mm).
    • Normal appearance of spleen, pancreas, adrenals.
    • Gallbladder stone (7mm).
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Some soft tissues in peritoneal cavity (arrows) c/w tumor seeding.
• 2023-07-01, -04-08 CT - abdomen
  • Clinical history: 74 y/o female patient with colon cancer with peritoneal seeding.
  • With and without contrast enhancement CT of abdomen - whole:
    • Post-op at the colon. There are peritoneal soft tissue tumors, r/o peritoneal seeding.
      
    • Presence of ventral herniation.
    • Presence of gallbladder stones.
    • Stationary low density liver tumors (up to 2.2cm).
    • Left renal stone.
  • Impression:
    • Post-op at the colon. Peritoneal soft tissue tumors, r/o peritoneal seeding.
    • Stationary liver nodules.
    • Ventral herniation.
    • Gallbladder stones.
    • Left renal stone.
• 2023-06-21 SONO - thyroid
  • Findings:
    • Left nodules 0.79 cm ; 0.75 cm ; 0.33 cm ; 0.41 cm ; 1.17 cm ; 0.42 cm ; 0.4 cm
    • Right nodules 1.34 cm ; 1.52 cm ; 2.73 cm ; 1.12 cm ; 1.89 cm ; 1.91 cm
    • Isthmus nodule 0.98 cm
  • Diagnosis: multiple thyroid nodules
• 2023-03-07 ECG
  • Sinus rhythm with Premature supraventricular complexes
  • Nonspecific T wave abnormality
• 2022-12-22 CT - abdomen
  • History and indication: Malignant neoplasm of appendix s/p OP and C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Right thyroid nodules (up to 2.6cm).
    • S/P colon operation. Some soft tissues in peritoneal cavity suspected tumor seeding. Ventral hernia with bowel loop herniation.
    • Retroversion of uterus.
    • Liver cysts (up to 2.2cm).
    • Left renal stone (5mm).
    • Normal appearance of spleen, pancreas, adrenals.
    • Gallbladder stone (7mm).
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral lungs.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Some soft tissues in peritoneal cavity suspected tumor seeding.
• 2022-11-24 Clinical Dementia Rating, CDR
  • CDR score = 0.5
  • note: The CDR score ranges from 0 (no cognitive impairment) to 3 (severe dementia). A score of 0.5 indicates very mild dementia, 1 indicates mild dementia, 2 indicates moderate dementia, and 3 indicates severe dementia.
• 2022-11-24 Mini-Mental Status Examination, MMSE
  • MMSE score = 27
  • note: The total score ranges from 0 to 30. A higher score indicates better cognitive function.
• 2022-10-06 Needle Aspiration Cytology - thyroid
  • Negative - Benign follicular nodule
• 2022-09-26 CT - abdomen
  • Indication: Appendiceal cancer s/p OP and C/T, Elalrged thyroid, Elevated CEA
  • Abdominal CT with and without enhancement revealed:
    • Visible chest
      • Cardiomegaly is noted.
      • Lobulated right thyroid lesions are found. Suggest regular sonogrpahy/aspiration if indicated.
      • The lung fields are clear.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
    • Abdomen
      • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thikening.
      • s/p RLQ op.
      • No evidence of recurrent/residual tumor in the study.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
  • Imp: s/p RLQ op.
    • No evidence of recurrent/residual tumor at RLQ.
    • Right thyroid lesions. Suggest regular follow up.
• 2022-09-07 SONO - thyroid
  • Autoimmune thyroid disease, multiple nodules
• 2022-06-29 CT - abdomen
  • History and Indication:
    • 20200823 CT: RLQ tumor with abdominal wall involvement, r/o appendix tumor or appendicitis with tumor formation.
    • 20200827 S/P right hemicolectomy: mucinous adenocarcinoma of the appendix with abscess, pT4N0Mx, stage: IIB. S/P C/T for FU
  • MD CT (Aquilion Prime SP) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images with axial and coronal reformated isotropic images were obtained in non-contrast scan and portal venous phase scan after IV contrast injection.
  • FINDINGS:
    • S/P right hemicolectomy.
      • Ventral hernia in the midline lower pelvis with small bowel herniation.
    • There are several hepatic cysts in both lobes and the largest one is measured about 2.2 cm in size at segment 8.
    • A calcified gallstone 6 mm is noted.
    • Prior CT identified1 a soft tissue nodule 6 mm in the middle mesentery is noted again, mild increasing in size to 8 mm.
    • There is no focal lesion in both lung and mediastinum.
      • Right lobe thyroid shows enlarged in size and few poor enhancing lesions (up to 2.3 cm). Left lobe and isthmus thyroid show few poor enhancing and few enhancing nodules. Nodular goiter is highly suspected. Please correlate with sonography.
        
    • Others
      • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion in the omentum.
  • IMP:
    • S/P right hemicolectomy.
    • There is no evidence of tumor recurrence.
• 2022-04-07 CT - abdomen
  • History and indication: Malignant neoplasm of appendix s/p OP and C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Right thyroid nodules (up to 2.6cm).
    • S/P colon operation. Ventral hernia with bowel loop herniation.
    • Retroversion of uterus.
    • Liver cysts (up to 2.2cm).
    • Left renal stone (5mm).
    • Normal appearance of spleen, pancreas, adrenals.
    • Gallbladder stone (7mm).
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral lungs.
    • S/P Port-A infusion catheter insertion.
  • IMP: No evidence of tumor recurrence.
• 2022-01-21 Needle Aspiration Cytology - thyroid
  • Negative - Smears show colloid and benign follicular cells.
• 2021-12-30 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA grade A
    • Superficial gastritis, antrum, s/p CLO test
    • Gastric erosions, low body and antrum
    • Gastric shallow ulcers, antrum
  • Suggestion
    • Pursue CLO test result
• 2021-12-24 Whole body PET scan
  • A mild glucose hypermetabolic lesion in the lower portion of the esophagus near EG junction. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the right pulmonary hilar region and in the soft tissues around bilateral shoulders and hip. Inflammatory process is more likely.
  • Inhomogenously increased FDG uptake in the right lobe of the thyroid gland. The nature is to be determined (multinodular goiter? other nature?). Please correlate with other clinical findings for further evaluation.
  • Some focal areas of increased FDG accumulation in the colon. Physiological FDG accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2021-11-30 CT - abdomen
  • Indication: Colon cancer, CEA gradually elevated
  • Abdominal and chest CT with and without enhancement revealed:
    • Chest:
      • S/p port-A placement with its tip at Superior vena cava.
      • Tortous aorta with calcification is noted.
      • Cardiomegaly is noted.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • s/p RAR. no evidence of recurrent/residual tumor in the study.
      • Left renal stone is found.
      • Ventral herniation from the mid-abdominal wall is found. No strangulation is found.
      • The spleen, liver, pancreas and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • s/p RAR. no evidence of recurrent/residual tumor in the study.
    • Left renal stone is found.
• 2021-09-13 MRI - liver, spleen
  • History and indication: Hx of appendeceal cancer s/p right hemicolectomy and C/T 2021-08-11 Abd CT mention a suspected cyst or mets in S6 of liver
  • With and without contrast MRI of liver revealed:
    • S/P colon operation.
    • Bil. liver cysts (up to 2.4cm).
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • Gallbladder stones (2-3mm).
    • Patency of portal vein.
    • No ascites, nor enlarged lymph node.
    • No abnormal intensity in bilateral basal lungs.
  • IMP:
    • S/P colon operation.
    • Bil. liver cysts (up to 2.4cm).
    • Gallbladder stones (2-3mm).
• 2021-08-11 CT - abdomen
  • History and Indication:
    • 20200823 CT: RLQ tumor with abdominal wall involvement, suspected appendix tumor or appendicitis with tumor formation.
    • 20200827 S/P right hemicolectomy: mucinous adenocarcinoma of the appendix with abscess, pT4N0Mx, stage: IIB. S/P C/T for FU
  • FINDINGS:
    • There is a poor enhancing lesion 1.1 cm in S6 liver (Srs:3 Img:64) that may be cyst or metastasis. Please correlate with sonography.
    • There are several hepatic cysts in both lobes and the largest one is measured about 2.2 cm in size at segment 8.
    • A calcified gallstone 6 mm is noted.
  • IMP:
    • There is a poor enhancing lesion 1.1 cm in S6 liver (Srs:3 Img:64) that may be cyst or metastasis. Please correlate with sonography.
• 2021-05-03 CT - abdomen
  • Clinical history: 72 y/o female patient with R/O PERITONITIS
  • Impression:
    • S/P right hemicolectomy.
    • Gallbladder stone
    • Stationary of peritoneal nodules, up to 0.7cm.
    • R/O liver cysts.
    • Bilateral perirenal fatty infiltrates.
• 2021-05-03 CT - brain
  • Clinical history: 72 y/o female patient with R/O SDH.
  • Impression:
    • Brain atrophy.
    • R/O chronic sinusitis.
• 2021-05-03 ECG
  • Normal sinus rhythm
  • T wave abnormality, consider anterolateral ischemia
• 2021-04-20 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 33) / 100 = 67.00%
    • M-mode (Teichholz) = 67
  • Preserved LV and RV systolic function with normal wall motion
  • Grade 1 LV diastolic dysfunction
  • Mild AR, TR
• 2021-04-19 ECG
  • Normal sinus rhythm
  • T wave abnormality, consider lateral ischemia
• 2021-04-19 Flow Volume Loop
  • suspected mild restrictive ventilatory defect
• 2021-03-27 CT - abdomen
  • Indication: 72 y/o female patient with Appendiceal mucinous adenocarcinoma with liver metastasis s/p receving right hemicolectomy on 2020-08-26, pT4aN0M1a, Stage IVA s/p chemotherapy.
  • With and without contrast enhancement CT of abdomen–whole:
    • s/p right hemicolectomy.
    • Peritoneal nodules and stranding, mild in regression.
    • Gallbladder stone.
    • Several liver cysts. 2.4cm of the largest one in right lobe.
  • Impression
    • s/p right hemicolectomy
    • Peritoneal carcinomatosis, mild in regression
• 2021-03-04 Gynecologic Ultrasonography
  • EM: 4.8mm
• 2020-12-29 CT - abdomen
  • Post-op at colon with mesentery nodules and lymph nodes, suspected carcinomatosis.
  • Presecne of gallbladder stone.
  • Liver cysts, up to 2.4cm in right lobe.
• 2022-12-29, -11-10 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2020-09-22 MRI - liver, spleen
  • Liver and renal cysts (up to 2.3cm).
  • Prominent accessory p-duct.
• 2020-08-31 Tc-99m MDP whole body bone scan
  • Mildly and non-focally increased radiotracer uptake in C-spine and lower L-spine, degenerative spine diseases may show such a picture.
  • Some areas of mildly increased radiotracer uptake in maxilla and mandible, dental lesions may show such a picture.
  • Probably degenerative joint lesions in shoulders, sternoclavicular junctions, sacroiliac joints, and hips.
  • No definite evidence of osteoblastic skeletal metastasis by this bone scan.
• 2020-08-27 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Appendix, R’t hemicoloectomy — Mucinous adenocarcinoma with abscess
      
    • Resection margins, bilateral cutting end, ditto — Free of tumor invasion
      
    • Lymph node, mesocolic, dissection — Negative for tumor metastasis (0/20)
      
    • Ascending colon, R’t hemicoloectomy — Free of tumor invasion
      
    • AJCC pathologic stage — pT4aN0 (if cM0), stage IIB
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: right hemicolectomy
      
    • Specimen site: ascending colon, terminal ileum and appendix
      
    • Specimen size: (a) A-colon: 22.5 x 5.5 cm; (b) Terminal ileum: 4.5 x 3.0 cm; (c) Appendix: 8.5 x 6.0 x 5.5 cm
      
    • Tumor size: 8.5 x 6.0 x 5.5 cm
      
    • Tumor location: appendix
      
    • Tumor appearance: mucinous tumor
      
    • Depth of invasion grossly: Visceral peritoneum
      
    • Representative sections as follows: A1: proximal A-colon margin, A2-A4: peri-tumor soft tissue, A5-A12 and A16-A20: tumor, A13: distal colon margin, A14-A15 and A21-A22: lymph node
      
  • MICROSCOPIC EXAMINATION
    • Histology: mucinous adenocarcinoma
    • Histology Grade: G1-2: well to moderately differentiated
      
    • Depth of invasion: Visceral peritoneum
      
    • Angiolymphatic invasion: absent
      
    • Perineural invasion: present
      
    • Discontinuous extramural tumor extension: absent
      
    • Circumferential (radial) margin: Involved
      
    • Lymph node metastasis, mesocolic: negative (0/20)
      
    • Lymph node metastasis, IMA / SMA: N/A
      
    • Extranodal involvement: N/A
      
    • Pathological TNM Stage: pT4aN0, stage IIB
      
    • Type of polyp in which invasive carcinoma arose: N/A
      
    • Additional pathologic findings: abscess formation
      
    • TNM descriptors: N/A
      
    • Tumor regression grading S/P CCRT: N/A
      
  • IMMUNOHISTOCHEMISTRY
    • CDX-2(+), MLH1(+), PMS2(+), MSH2(+) and MSH6(+) for tumor cells
• 2020-08-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (77.7 - 15.5) / 77.7 = 80.05%
    • M-mode (Teichholz) = 80.1
  • Septal hypertrophy. Dilated AsAO (40mm)
  • Normal RV & LV systolic function. No regional wall motion abnormalities.
  • Impaired LV relaxation.
  • Moderate tricuspid regurgitation.
  • Mild pulmonic regurgitation.
• 2020-08-24 Bronchodilator Test
  • Normal spirometry, without significant response to bronchodilator
• 2020-08-24 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis and duodenitis
    • Gastric and duodenal erosions
  • Suggestion
    • PPI therapy
    • No evident malignanct in UGI tract
• 2020-08-23 CT - abdomen
  • There is soft tissue tumor, 3.56cm in right lower abdomen with abdominal wall involvement, suspected appendix tumor or appendicitis with tumor formation.
  • There is skin tumor, 1.37cm in right lower abdominal wall.
  • Presence of gallbladder stone.
  • Hypodense lesions, up to 2.3cm in S8 of right liver, suspected liver cysts.
  • Ill-defined hypodensities in S6 liver, suggest further study.
• 2020-08-18 Gynecologic Ultrasonography
  • Bilateral adnexae: free
  • Subcutaneous mass: 59x39mm (no blood flow)

[consultation]

• 2021-03-04 Obstetrics and Gynecology
  • Q
    • This 72-year-old woman patient is a case of Appendiceal mucinous adenocarcinoma with liver metastasis s/p receving right hemicolectomy on 2020-08-26, pT4aN0M1a, Stage IVA s/p chemotherapy with FOLFIRI, refractory with mesentery carcinomatosis, rT0N0M1c, stage IVB s/p chemotherapy with FOLFIRU/Avastin. She was admitted for chemotherapy with Avastin(C5)/FOLFIRI(C6D1).
    • This time, for perineum mild bleeding. Now, for evlauate perineum bleeding dispose and therapy. Thank you.
  • A
    • PV: atrophic cervix, no obvious lesion
      • discharge: scanty
      • Sono: endometrium 4.8 mm.
    • IMP: vaginal spotting, but improved now
    • suggestion:
      • no obvious GYN problem now. Bleeding tendency or coagulopathy may be consider.
• 2021-01-26 Ear Nose Throat
  • Q
    • This 72-year-old woman patinet is a case of Appendiceal mucinous adenocarcinoma with liver metastasis s/p receving right hemicolectomy on 2020-08-26, pT4aN0M1a, Stage IVA s/p chemotherapy with FOLFIRI, refractory with mesentery carcinomatosis, rT0N0M1c, stage IVB s/p chemotherapy with FOLFIRU/Avastin. She was admitted for chemotherapy.
    • Hoarseness developed in 2020/12. Now, for evaluate hoarseness examination and therapy. Thank you.
  • A
    • After evaluated via scope, we found bilateral vocal cord atrophy and bilateral vocal nodules.
    • We suggested our OPD f/U and the disease needed to receive operation (already explained to family)

[surgical operation]

• 2024-07-18
  • Operation
    • Ventral hernia repair
  • Finding
    • s/p lower midline incision
    • An incarcerated ventral hernia with a fascia defect below previous suprapubic incision scar, about 4*3cm in diameter
    • No gangreneous change of incacerated small bowel after reduction
    • Moderate adhesion of small bowel in the pelvic cavity
    • Drain: 15 Fr Blake drain *1 in situ
• 2024-07-10
  • Operation
    • Excision of abdominal soft tissue tumor, malignant
  • Finding
    • Recurrent metastatic abdominal wall malignant appendical tumor s/p biopsy
    • IOUS: subcutaneous tumor in right subumbilical region
    • Drain: 15 Fr Blake drain *1 in situ
• 2023-12-20
  • Operation
    • Cytoreductive surgery
    • HIPEC
    • Repair of ventral hernia
  • Finding
    • S/P lower midline incision with ventral hernia
      • Adhesion of small bowel was encountered.
      • Several scatted recurrent nodules were found in the abdominal wall, bowel loops and greater omentum
    • PCI: total = 3
      • [#] region – score
      • [0] central – 2
      • [1] RU – 0
      • [2] epigastrium – 0
      • [3] LU – 0
      • [4] left flank – 0
      • [5] LL – 0
      • [6] pelvis – 0
      • [7] RL – 0
      • [8] right flank – 0
      • [9] upper jejunum – 1
      • [10] lower jejunum – 0
      • [11] upper ileum – 0
      • [12] lower ileum – 0
    • HIPEC regimen
      • Mitomycin-C 35mg/m^2 as Dutch regimen with 3 fractions (1/2 -> 1/4 -> 1/4 every 30 minutes)
    • Drain: 15 Fr J-VAC x2 in the pelvic cavity and Morrison’s pouch
    • Biobank: tumor
• 2021-04-21
  • Operation
    • Laparoscopy adhesionolysis
    • Pelvic drainage
  • Finding
    • S/P right hemicoletomy with a midline incisional scar
    • Adhesion of greater omentum to abdominal wall
    • No gross peritoneal seedings and minimal ascites. Normal appearance of liver surface and stomach
    • Drain; 10Fr Blake drain *1, in the pelvic cavity.
    • Wound: treated with New Epi Plus, 5cc
• 2020-08-26
  • Operation
    • Laparoscopic right hemicolectomy
  • Finding
    • A tumor mass over appendix with severe adhesion to omentum and right lower abdoinal wall; with localized abscess
    • Several small liver cysts in right lobe
    • Drain: 15Fr Blake x 1 in the pelvic cavity
    • Wound: treated with New Epi Plus (5cc)

[immunochemotherapy]

• 2024-08-12 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 150mg/m2 270mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr (Cyramza + FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-06-18 - ………………………………… irinotecan 150mg/m2 270mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4300mg NS 500mL 48hr (infusor) (Cyramza + FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-06-03 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 150mg/m2 240mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-05-17 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 150mg/m2 240mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-04-23 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-04-08 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI. Due to WBC 2700, ANC 1582, DC bolus 5-FU this time)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-03-25 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-03-07 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-02-15 - ………………………………… irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2023-12-20 - Mitonco (mitomycin-C) 35mg/m2 60mg NS 100mL 90min IP

• 2023-10-17 - (Avastin + FOLFOX)

• 2023-09-26 - (Avastin + FOLFOX)

• 2023-09-12 - (Avastin + FOLFOX)

• 2023-08-29 - (Avastin + FOLFOX)

• 2023-08-15 - (Avastin + FOLFOX)

• 2023-08-02 - (Avastin + FOLFOX)

• 2023-07-18 - (Avastin + FOLFOX)

• 2023-07-04 - (Avastin + FOLFOX)

• 2023-06-21 - (Avastin + FOLFOX)

• 2023-06-06 - (Avastin + FOLFOX)

• 2023-05-23 - (Avastin + FOLFOX)

• 2023-05-09 - (Avastin + FOLFOX)

• 2023-04-25 - (Avastin + FOLFOX)

• 2023-04-07 - (Avastin + FOLFOX)

• 2023-03-21 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (Avastin + FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-03-07 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-02-20 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-01-30 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2022-12-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2021-03-30 - ………………………………….. irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (_______ + FOLFIRI)

• 2021-03-16 - ………………………………….. irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (_______ + FOLFIRI)

• 2021-03-02 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFIRI)

• 2021-02-17

• 2021-01-26

• 2021-01-12

• 2020-12-30

• 2020-12-15

• 2020-11-27

• 2020-11-10

• 2020-10-27

• 2020-10-13

• 2020-09-23

==========

2024-08-26

[rising CEA and CA199 with potential GI bleeding management]

CEA and CA199 levels have doubled since August, and an excision of an abdominal malignant soft tissue tumor was performed on 2024-07-10.

Additionally, HGB levels have been trending downward over the past quarter, possibly due to gastrointestinal bleeding (stool FOB positive on 2024-08-13). A transfusion was administered on 2024-08-25. If evidence of GI bleeding persists, the addition of PPI and/or tranexamic acid may be considered.

• 2024-08-21 CEA 1122.95 ng/mL

• 2024-08-06 CEA 1005.44 ng/mL

• 2024-06-13 CEA 386.22 ng/mL

• 2024-05-02 CEA 418.95 ng/mL

• 2024-04-22 CEA 362.09 ng/mL

• 2024-08-21 CA199 209.91 U/mL

• 2024-08-06 CA199 221.02 U/mL

• 2024-06-13 CA199 92.07 U/mL

• 2024-05-02 CA199 100.40 U/mL

• 2024-04-22 CA199 96.31 U/mL

• 2024-08-25 HGB 8.7 g/dL

• 2024-08-21 HGB 8.3 g/dL

• 2024-08-12 HGB 8.1 g/dL

• 2024-08-06 HGB 9.9 g/dL

• 2024-07-30 HGB 9.7 g/dL

• 2024-07-17 HGB 10.2 g/dL

• 2024-07-02 HGB 10.4 g/dL

• 2024-06-18 HGB 10.2 g/dL

• 2024-06-13 HGB 10.5 g/dL

• 2024-05-28 HGB 10.1 g/dL

• 2024-05-17 HGB 10.2 g/dL

• 2024-05-02 HGB 11.8 g/dL

2024-04-23

[CEA and CA199 trends support continued treatment]

Decreasing levels of the tumor markers CEA and CA199 have been observed.

Lab results from 2024-04-22 were grossly within normal limits, indicating no evidence of contraindications for proceeding with chemotherapy.

• 2024-04-22 CEA 362.09 ng/mL

• 2024-03-26 CEA 456.30 ng/mL

• 2024-04-22 CA199 96.31 U/mL

• 2024-03-26 CA199 117.22 U/mL

2024-04-09

Pathology results from the extensive resection of a soft tissue tumor on 2023-12-21 confirmed recurrent mucinous adenocarcinoma. A subsequent abdominal CT scan on 2024-01-19 suggested metastasis. Due to these findings, the treatment regimen was changed to Cyramza + FOLFIRI, initiated on 2024-02-15. Encouragingly, both CEA and CA199 tumor markers have shown a continuous decline since starting the new regimen, suggesting its effectiveness.

• 2024-03-26 CEA 456.30 ng/mL

• 2024-03-19 CEA 594.94 ng/mL

• 2024-02-26 CEA 942.43 ng/mL

• 2024-03-26 CA199 117.22 U/mL

• 2024-03-19 CA199 141.97 U/mL

• 2024-02-26 CA199 182.41 U/mL

However, while the bolus dose of 5-FU was omitted this time due to an ANC of 1582, please continue to monitor for any signs of infection.

• 2024-04-08 WBC 2.70 x10^3/uL
• 2024-04-08 Neutrophil 58.6 %

2023-03-22

Between 2020-09 and 2021-03, the patient received bevacizumab + FOLFIRI, and her CEA levels remained within the normal range. After completing the FOLFIRI treatment, the CEA levels began to rise slowly, but no imaging evidence was found until a CT scan on 2022-12-22, which revealed soft tissues in the peritoneal cavity suspected to be tumor seeding. A new regimen of bevacizumab + FOLFOX was initiated on 2022-12-26, and a subsequent decrease in CEA levels was observed, suggesting the effectiveness of the new treatment.

• 2023-03-07 CEA 340.09 ng/mL
• 2023-01-11 CEA 397.81 ng/mL
• 2022-12-22 CEA 629.24 ng/mL
• 2022-11-24 CEA 543.06 ng/mL
• 2022-10-28 CEA 396.78 ng/mL
• 2022-09-26 CEA 231.52 ng/mL
• 2022-09-01 CEA 212.17 ng/mL
• 2022-08-04 CEA 142.37 ng/mL
• 2022-07-07 CEA 109.08 ng/mL
• 2022-06-09 CEA 86.83 ng/mL
• 2022-05-12 CEA 67.22 ng/mL
• 2022-04-07 CEA 42.21 ng/mL
• 2022-03-17 CEA 33.96 ng/mL
• 2022-02-18 CEA 24.00 ng/mL
• 2022-01-20 CEA 16.97 ng/mL
• 2021-12-24 CEA 16.37 ng/mL
• 2021-11-25 CEA 12.85 ng/mL
• 2021-10-28 CEA 8.01 ng/mL
• 2021-09-30 CEA 6.43 ng/mL
• 2021-09-03 CEA 5.21 ng/mL
• 2021-08-06 CEA 4.60 ng/mL
• 2021-07-08 CEA 4.52 ng/mL
• 2021-06-10 CEA 3.75 ng/mL
• 2021-03-17 CEA 4.00 ng/mL
• 2021-01-26 CEA 3.47 ng/mL
• 2020-12-29 CEA 2.89 ng/mL
• 2020-11-25 CEA 2.98 ng/mL
• 2020-10-27 CEA 2.87 ng/mL
• 2020-09-30 CEA 3.44 ng/mL

No medication reconciliation issue was identified in the patient.

701509127

240826

[exam findings]

• 2024-08-03 CT - abdomen
  • Indication: pancreatic cancer, ductal adenocarcinoma, poorly differentiated, T4N2M0,stage: III, s/p FOLFIRINOX
  • With and without contrast enhancement CT of abdomen shows:
    • A mass lesion, 3.1cm, in pancreatic body with SMA and portal vein encasement.
    • No definite tumor metastasis of the liver, spleen, and kidneys. Small liver cysts, up to 0.7cm.
    • No ascites, nor extraluminal free air.
    • No evidence of bowel obstruction.
    • No bony destructive lesion on these images.
    • A calcified lesion (4.5cm) in pelvis, r/o calcified myoma.
  • Impression
    • Pancreatic cancer (3.1cm), stationary
• 2024-04-18 CT - abdomen
  • History and indication:
    • pancreatic cancer, ductal adenocarcinoma, poorly differentiated, T4N2M0,stage: III, s/p FOLFIRINOX
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Pancreatic body cancer (3.1cm) with adjacent structures invasion (stable).
    • Liver cysts (up to 9mm).
    • Uterine tumor (4.4cm) with calcifications r/o myoma.
    • Atherosclerosis of aorta, iliac arteries.
• 2024-01-04 MRI - pancreas
  • Abdominal MRI with and without IV contrast enhancement shows:
    • Heterogeneous soft tissue mass at pancreatic body measuring 3.9cm in largest dimension is found. The lesion attached to celiac trunk. Pancreatic cancer is favored.
    • MRCP shows obliteration of the pancreatic duct at distal part is found.
    • Small lymph nodes are found inferior to the main pancreatic mass.
  • Imp:
    • Pancreatic cancer with celiac trunk invasion and regional lymph nodes
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2024-01-04 Patho - pancreas biopsy
  • Pancreas, endoscopic biopsy — Ductal adenocarcinoma, poorly differentiated
  • The specimen submitted consists of multiple small strips of yellow gray soft tissue, labeled pancreas, measuring up to 0.3 x 0.1 x 0.1 cm. All for section.
  • The sections show a picture of ductal adenocarcinoma, composed of nests, cords, and single large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation and mucin secretion are present.
• 2023-12-22 CT - abdomen
  • 20231218 CC: abdominal pain for 2-3 months.
  • History: She ever visited MacKay Memorial Hospital for aid.
  • EGD and sono at Cathay General Hospital was performed 2 months ago showed gastritis. Some drugs were given. But treatment was not effective.
  • Indication: chronic abdominal pain
  • Findings:
    • There is a poor enhancing mass 3.2 cm in the pancreatic body (Srs:301 Img:26) with posterior extension and direct invasion the Celiac trunk (up to 2.2 cm) (Srs:301 Img:21-25).
      • Adenocarcinoma of the pancreatic body with Celiac trunk invasion (T4) is highly suspected. Please correlate with CA199 and EUS-guided biopsy.
    • There are four enlarged nodes in the gastrohepatic ligament and the mesentery root that are c/w metastatic nodes (N2).
    • There is an ill-defined mild poor enhancing area in S8 of the liver (Srs:301 Img:11) that may be pseudo-lesion (flow artifact).
      • The differential diagnosis includes tumor. Please correlate with MRI.
    • There are several hepatic cysts in both lobes (up to 0.7 cm in S4).
    • There is a poor enhancing mass 5 cm in the uterus with multiple calcification component that is c/w myoma with fibroid.
  • Impression:
    • Adenocarcinoma of the pancreatic body with Celiac trunk invasion (T4) is suspected. Please correlate with CA199 and EUS-guided biopsy.
      • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for pancreatic cancer: T4N2M0; stage: III.
• 2023-12-19 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis
    • Gastric subepithelial lesion, antrum, PW.
    • Suspect external compression , upper body, PW.
  • CLO test: not done
  • Suggestion:
    • Further evaluation for gastric subepithelial lesion and external compression

[MedRec]

• 2024-01-21 ~ 2024-01-25 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • pancreatic cancer, ductal adenocarcinoma, poorly differentiated, T4N2M0,stage: III, s/p FOLFIRINOX
    • Chronic viral hepatitis B without delta-agent
    • constipation
  • CC
    • for chemotherapy with FOLFIRINOX Q2W
  • Present illness
    • [omitted] And she complainted lower back pain, so gave OxyNorm for pain control. Anti-Hbc: reactive on 2024/01/11, s/p Vemlidy. The port-a catheter was insertion on 2024/01/18.
    • Under the impression of pancreatic cancer, ductal adenocarcinoma, poorly differentiated, T4N2M0,stage: III, s/p chemotherapy with FOLFIRINOX.
    • This time, she is admitted for C1D1 chemotherapy with FOLFIRINOX on 2024/01/21.
  • Course of inpatient treatment
    • After admission, she received C1D1 chemotherapy with FOLFIRINOX (Irino by self-paid, and the dose decreased 20% due to first chemotherapy) on 1/22-1/24, Vemlidy for Anti-HBc: reactive, Imperam for vomiting. After chemotherapy, smoothly without obvious side effect. She was discharged on 1/25 24 under stable condition, and the OPD will be arranged.
  • Discharge prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • Through (sennoside 12mg) 2# HS
    • Bisadyl supp (bisacolyl 10mg) 2# PRNQD RECT
    • OxyNorm (oxycodone 5mg) 1# Q8H
    • Alpraline (alprazolam 0.5mg) 1# PRNHS
    • Mosapin (mosapride citrate 5mg) 1# TID
• 2024-01-01 ~ 2024-01-05 POMR Gastroenterology Li ZhongXian
  • Discharge diagnosis
    • Malignant neoplasm of body of pancreas
    • Gastro-esophageal reflux disease with esophagitis
    • Functional dyspepsia
  • CC
    • Admitted for pancreatic tumor survey
  • Present illness
    • This 72-year-old woman’s medical history was unremarkable. Since 3 months ago, she has developed abdominal pain that radiates to the back. She went to Cathay General Hospital and MacKay Memorial Hospital to hava examinations and gastritis was diagnosed. Some medications were prescribed but did not releive her symptoms. On 2023/12/18, she came to our OPD. Abdominal CT was performed and revealed suspected adenocarcinoma of the pancreatic body with Celiac trunk invasion (T4N2M0). Her CA199 level was also found to be elevated (1367.28).
    • Under the impression of pancreatic adenocarcinoma, she is admitted for further evaluation and management.
  • Course of inpatient treatment
    • After admission, the patient had a EUS-guide biopsy on 2024/01/03, and MRI of pancreas on 2024/01/04. The MRI results suggested pancreatic cancer with celiac trunk invasion and regional lymph nodes. Pathology results of the biospy revealed ductal adenocarcinoma, poorly differentiated. Adequate pain control was prescribed. She will be discharged today, and will be informed with the further treatment plan at the OPD next week.
  • Discharge prescription
    • none

[chemotherapy]

• 2024-08-24 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 180mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2450mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-08-02 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 180mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2450mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-07-09 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 180mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2450mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-06-18 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 185mg D5W 250mL 1.5hr + leucovorin 400mg/m2 410mg NS 250mL 2hr + fluorouracil 2400mg/m2 2460mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-31 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 185mg D5W 250mL 1.5hr + leucovorin 400mg/m2 410mg NS 250mL 2hr + fluorouracil 2400mg/m2 2470mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-09 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 185mg D5W 250mL 1.5hr + leucovorin 400mg/m2 410mg NS 250mL 2hr + fluorouracil 2400mg/m2 2470mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-15 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 185mg D5W 250mL 1.5hr + leucovorin 400mg/m2 410mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-28 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 180mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2470mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-28 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 180mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-28 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 180mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2445mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-06 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + irinotecan 180mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-02-15 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2400mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-01-22 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2400mg NS 500mL 46hr (FOLFIRINOX 75%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

Chemotherapy regimens for metastatic pancreatic cancer: FOLFIRINOX - 2024-02-16 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

• Cycle length: 14 days.

• Regimen

  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 180 mg/m2 IV
    • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 400 mg/m2 IV bolus
    • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
    • Day 1
  • FU
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2024-02-16 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

• Cycle length: 14 days.

• Regimen

  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 150 mg/m2 IV
    • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

==========

2024-08-26

[stable disease and consistent CA199 levels under FOLFIRINOX]

A CT scan on 2024-08-03, compared to 2024-04-18, showed stable disease. CA-199 levels have remained around 500 U/mL over the past 2 months, and other lab results on 2024-08-24 were generally normal. The patient is tolerating the FOLFIRINOX regimen well, and no medication issues have been identified.

• 2024-08-16 CA-199 (NM) 520.440 U/ml
• 2024-08-09 CA-199 (NM) 455.990 U/ml
• 2024-07-05 CA-199 (NM) 528.090 U/ml
• 2024-06-14 CA-199 (NM) 491.840 U/ml
• 2024-05-29 CA-199 (NM) 705.410 U/ml
• 2024-05-07 CA-199 (NM) 739.420 U/ml

2024-05-10

Abdominal CT scan performed on 2024-04-18, revealed stable pancreatic body cancer without further invasion into adjacent structures. Additionally, lab results showed a continued decline in CA-199 levels. These findings suggest that the current FOLFIRINOX treatment regimen is still effective.

• 2024-05-07 CA-199 (NM) 739.420 U/ml
• 2024-04-16 CA-199 (NM) 918.060 U/ml
• 2024-04-02 CA-199 (NM) 1251.550 U/ml
• 2024-03-19 CA-199 (NM) 1743.600 U/ml
• 2024-03-05 CA-199 (NM) 2685.200 U/ml

No medication discrepancies were identified.

2024-03-29

[clearance for 4th FOLFIRINOX session based on lab results]

Laboratory tests conducted on 2024-03-28 showed all key indicators, including blood counts, electrolytes, and liver and kidney functions, were grossly within normal ranges, allowing for the 4th session of FOLFIRINOX to proceed without medical objections.

A comprehensive examination of the patient’s medication list in both the HIS5 and PharmaCloud databases confirmed consistency and accuracy.

2024-03-07

[reconciliation]

The CA-199 level has declined relative to the previous month’s data. Laboratory results from 2024-03-06 were generally within normal limits, leading to the administration of the third cycle of FOLFIRINOX on the same day.

• 2024-03-05 CA-199 (NM) 2685.200 U/ml
  
• 2024-02-06 CA-199 (NM) 3521.000 U/ml

A thorough review of the HIS5 and PharmaCloud databases revealed no discrepancies in medication.

2024-02-16

[rising CA-199 in newly-started FOLFIRINOX Regimen, further investigation needed. unremarkable labs & no med discrepancies]

This patient initiated FOLFIRINOX treatment in late 2024-01 and the current hospitalization pertains to the second cycle. While other lab findings on 2024-02-15 were unremarkable and no medication discrepancies were identified, ongoing elevation of the tumor marker CA-199 warrants further investigation.

• 2024-02-06 CA-199 (NM) 3521.000 U/ml
• 2024-01-16 CA-199 (NM) 2048.960 U/ml
• 2023-12-26 CA-199 1367.280 U/mL

700685525

240825

[lab data]

Bone marrow cell morphology and cell count

• 2023-10-24 Clinical diagnosis AML
  
• 2023-10-24 Gross: Marrow +
  
• 2023-10-24 Cellularity Hyper-mod.
  
• 2023-10-24 Fat componemt -
  
• 2023-10-24 Megakaryocyte dist absent.
  
• 2023-10-24 M/E ↑
  
• 2023-10-24 M/E(/) 95/5
  
• 2023-10-24 sites lliac. post. R
  
• 2023-10-24 type Aspiration
  
• 2023-10-24 specimen condition adequate
  
• 2023-10-24 smear good
  
• 2023-10-24 Myeloblast 81 %
  
• 2023-10-24 N.Myeloblast 0 %
  
• 2023-10-24 N.Meta 1,5 %
  
• 2023-10-24 N.Band 2.5 %
  
• 2023-10-24 N.Seg. 3.0 %
  
• 2023-10-24 Eo.Myeloblast 0 %
  
• 2023-10-24 Eo.Meta 0 %
  
• 2023-10-24 Eo.Band 0 %
  
• 2023-10-24 Eo.Seg. 0 %
  
• 2023-10-24 Baso 0 %
  
• 2023-10-24 Promyelo. 0 %
  
• 2023-10-24 Mono. 1 %
  
• 2023-10-24 Mo.blast 2 %
  
• 2023-10-24 Mo.promono. 0 %
  
• 2023-10-24 Mo.mature 0 %
  
• 2023-10-24 Lympho 0 %
  
• 2023-10-24 Lym.blast 0 %
  
• 2023-10-24 Lym.promono. 0 %
  
• 2023-10-24 Lym.mature 3 %
  
• 2023-10-24 Plasma Cell 0 %
  
• 2023-10-24 Pro-eyth. B 0 %
  
• 2023-10-24 Normoblast 0 %
  
• 2023-10-24 Nor.Baso 0 %
  
• 2023-10-24 Nor.polych 0 %
  
• 2023-10-24 Nor.ortho. 4 %
  
• 2023-10-24 Peroxidase Positive
  
• 2023-10-24 LAP -
  
• 2023-10-24 CAE Positive
  
• 2023-10-24 ANAE Negative
  
• 2023-10-24 Iron stain -
  
• 2023-10-24 PAS -
  
• 2023-10-24 Other stains -
  
• 2023-10-24 Description AML
  
• 2023-10-24 Comments AML CAE positive

Hepatitis B and C

• 2023-10-23 HBsAg Nonreactive
  
• 2023-10-23 HBsAg (Value) 0.74 S/CO
  
• 2023-10-23 Anti-HBc Reactive
  
• 2023-10-23 Anti-HBc-Value 4.40 S/CO
  
• 2023-10-23 Anti-HBs 356.92 mIU/mL
  
• 2023-10-23 Anti-HCV Nonreactive
  
• 2023-10-23 Anti-HCV Value 0.13 S/CO

[exam findings]

• 2024-08-01 Patho - bone marrow biopsy
  • Bone marrow, iliac, s/p allo-PBSCT, biopsy — marked hypocellularity.
  • Section shows piece(s) of bone marrow with <2 % cellularity and rare lymphoplasmacytoid cells.
  • IHC stains: CD117:(-); CD34:(-); MPO:(-), CD61:(-); CD71:(rare isolated cells).
• 2024-07-26 STR DNA fingerprint
  • 100 % Recipient’s Type
• 2023-10-24 Cardiac Catheterization
  • We perform PICC at cath room.
    • Under the peripheral echo guiding, we successful pucnture left basilic vein successful. Fluroscopy revealed the wire in true lumin. Micro-sheath was advanced. PICC catheter was implanted into SVC under the fluroscopy.
    • Total into 36 cm and fix 14cm at left upper am.
  • SvO2 was also check, it revealed 62. Estimated Fick Cardiac index 2.51 L/min/m2 and cardiac output 4.03 L/min.
• 2023-10-23 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — acute myeloid leukemia.
  • Section shows piece(s) of bone marrow with 90% cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with left shift of leukocytes and many blasts. Megakaryocytes are adequate in number.
  • IHC stains: CD117: 50%; CD34: 50 %; MPO: 60%, CD61: 5 %; CD71: 35% (of the nucleated cells).

[MedRec]

• 2024-06-23 ~ 2024-08-25 POMR Chest Medicine Su WenLin
  • Discharge diagnosis
    • Relapsed/refractory acute myeloblastic leukemia, FLT/ITD mutated type. Induction 7+3 chemotherapy since 2023/10/25-10/31
    • Stenotrophomonas maltophilia and Staphylococcus epidermidis bacteremia
    • Septic shock
    • Postive of anti-HBc
    • Hickman insertion on 2024/06/24
    • Peripherally Inserted Central Catheters insertion on 2024/08/14
    • Antibiotic - induced of Cefim neurological symptoms
  • CC
    • for allo-PBSCT
  • Present illness
    • This is a 43 years-old female, who has myoma /p op in 17 years ago at Cardinal Tien Hospital. According to the patient describe, her physical exam from office showed abnormal blood data, but she not care on 2023/08. She suffered from fever since 2023/10/19, and easy gums bleeding, so she went to Cardinal Tien Hospital for help.
    • At Cardinal Tien Hospital, the lab of CBC/DC showed leucocytosis (WBC: 34800/uL), anemia (Hb: 5.6g/dL), so gave blood transfusion with LPRBC 4U. Due to the personal reason, she was transferred to our ER. Bone marrow pathology showed acute myeloid leukemia. IHC stains: CD117: 50%; CD34: 50 %; MPO: 60%, CD61: 5 %; CD71: 35% (of the nucleated cells) on 2023/10/23. PICC was done by CV man.
    • Induction chemotherapy as 7+3 regimen (Ara-C and Daunorubicin) on 2023/10/25-10/31. Mutation of Flt-3-ITD was detected.
    • Rydapt 2023/11/01-2023/11/14
    • Posaconazole 2023/10/25-2023/11/14.
    • HLABCD data was check on 2023/11/09.
    • Reinduction chemotherapy as C2 7+3 (Ara-C and Daunorubicin) since 10/25-10/31.
    • Posaconazole 3# qd since 11/29-12/19. Rydapt 1# bid since 12/06-12/19.
    • Follow up BM on 2024/01/09, report showed Acute myeloid leukemia also noted.
    • Consolidation chemo as C3 2+5 (Ara-C and Daunorubicin) on 2024/01/10-01/14.
    • Baraclude 0.5mg 1# qdac postive of anti-HBc.
    • Follow up bone marrow on 2024/02/20, report showed acute myelogenous leukemia present.
    • Change newly chemo as C1 HD Ara-C q12h qod on 2024/02/21, 23, 25.
    • Hydrea 1# for refractory AML with higher WBC control, but in vain.
    • Chemo as MEC regimen D1-D4 since 2024/04/16-04/19.
    • BM repeat for follow up on 04/18, report showed acute myelogenous leukemia. IHC stains:  CD117: 50%; CD34: 25 %; MPO: 80%, CD61: 15 %; CD71: < 5% (of the nucleated cells).
    • IPP meeting was done on 2024/04/24, patient agree received allo-PBSCT (her son) and arrange planning on 2024/06/04.
    • She received Gilteritinib 3# qd since 2024/05/06 and blood routine and bone marrow study on 2024-06-18 showed partial response.
    • This time, she was admitted for haploidentical son RD-allo-PBSCT with her FLT-3-ITD muytation refractory AML in partial response and she denied fullness in recently days on 2024/06/23.
  • Course of inpatient treatment
    • After admission, she received hickman insertion at first, ID/OS/CVS/NST were consulted for survey.
    • Dilantin 100mg tid 7 days before Busulfan till 1 day after last dose.
    • Antibiotics and antifungus during hospitalization.
    • Chemotherpay as Fludarabine since 06/28-07/02 and Busulfan since 06/29-07/01.
    • RT with TBI on 07/02-07/03, fever once on 07/02, so we shift oral Cravit to Cefepime current treatment.
    • Halopiridol 0.5# prnbid for severe vomit during TBI.
    • Haploidentical HSCT stem cell infusion on 07/04 (day 0).
    • Chemo as Endozan and Mesna on 07/07-07/08.
    • Tacrlimus and MMF since 07/09.
    • Fentanyl 12mcg 1 patch for severe sore-throat and PPN supplement for poor intake, she received NG tube insertion for nutrition in BMT room.
    • As protocol, antifungus as Mycamine 100mg qd + Flu-D 1# qd, Nystatin 3ml qid, antivirus as Acyclovir 250mg q8h and antibiotics as Mepem and Neomycin combination prophylaxis treatment.
    • Unfortunately, her neutropenia without recovery, so the bone marrow was done on 2024/08/01, pathology showed marked hypocellularity. STR-DNA showed 100% Recipient’s type, so she need do the 2nd haploidentical HSCT later.
    • Thus, her left arm swelling and erythematous, suspect PICC infection. As the same time, SM bacteremia was noted and BP drop on 2024/08/17.
    • Due to left arm suspect compartment syndrome, so we comfirm CVS for remove PICC, the tip culture also showed SM, but Cravit (MIC = R). We comfirm ID man Dr. Peng, who suggested keep Cravit, Zyvox and add Minocycline combination treatment.
    • Frequency blood trasfusion for refractary anemia and thrombocytopenia.
    • PPN supplement and NS hydration for dehydration and oliguia.
    • CVC catheter was insertion over right neck on 2024/08/23.
    • Levophed titration for SBP 75-80mmHg and Oxygen escalated to A/M 50% supplement.
    • Due to critical condition with irritable, so she need transfer to MICU for management therapy on 2024/08/23.
    • After transfer to ICU, O2 therapy and kept antiboltic as Cravit (since 08/19) plus Minocycline (since 08/21) were prescribed for according to PICC tip culture and blood cultutre grewed SM.
    • The blood culture grewed Staphylococcus epidermidis, Zyvox (since 08/19) was prescribed.
    • Adequate fluid supply for hydration, Albumin IV infusion (by payment) and vasopressin agent as Levophed titration were given for shock status.
    • Poor appetite and malnutrition, Albumin IV infusion combine TPN as SmofKalbiven titration.
    • ANC:0, G-CSF 300mcg/qd was given and isolation. Correct imbalance of electrolyte and blood transfusion for correct pancytopenia.
    • Well explain prognosis condistion and treatment programs to patient and her family, they understood and kept on present treatment.
    • Coma status and unstable of blood pressure with air hungar respiratory pattern were also note. Ventialtor full setting and FiO2 100% supply.
    • Oliguria and unstable of blood pressure, the blood gas showed severe metabolic acidosis with hyperkalemia.
    • NPO with adequate fluid supply for hydration and high dose vasopressin agent as Levophed plus Pitressin pump titration.
    • Jusomin total 16 amp iv injection then maintain Jusomin pump titration and D50W + Insulin iv infusion q6h were given.
    • Blood transfusion as LRP, LPRBC and FFP for correct anemia and pancytopenia with shock status.
    • Well explain prognosis condition and highly mortalety rate to patient family, they understood and decide refused cardiomassage/cardioversion.
    • The patient was pronouncement expired at 16:47pm in 2024-08-25.
• 2024-07-15 ProgressNote
  • Objective
    • Oral: mucositis grade 3, very much saliva
    • Chest: no coarse, SpO2 96% under room air
    • Heart: tachycardia
    • Abd: soft, no tenderness, hyperactive bowel sound
    • Limbs: warm, no dry skin
    • PICC over right arm, clear
    • Hickman over right neck, function well
    • BW 57.7kg -> 56.4kg -> 56kg -> 55kg -> 57kg -> 56.5kg
    • I/O +1539g   
  • Problem #1: refractory AML
    • Assessment:
      • Day 12
      • neutropenic fever
    • Plan:
      • Antibiotics as Neomycin 1# qid + Mepem 1g q8h + Add Targocid 600mg q12h * 2 days and qd for 7 days
      • Antifungus as Mycamine 100mg qd + Nystatin 3ml qid
      • Antivirus as Acyclovir 250mg q8h
      • LPBRC 2u + LRP 2u st
      • GCSF 300mcg QD  till WBC > 4000/uL
      • CellCept250 mg/cap (Mycophenolate mofetil) 3.5cap tid
      • Prograf 1mg/cap (Tacrolimus) 1# bid
      • Pain control with Durogesic 12mcg Q3D
      • Add Lidocaine 1 puff EXT prn
      • Monitor painful condition
• 2024-07-14 Weekly Summary
  • This week, she receoved Tacrlimus and MMF since 7/9.
  • Fentanyl 12mcg 1 patch for severe sore-throat.
  • PPN supplement for days, but poor intake also noted, so she received NG tube insertion.
  • Now, keep antifungus as Mycamine 100mg qd + Flu-D 1# qd, Nystatin 3ml qid, antivirus as Acyclovir 250mg q8h and antibiotics as Mepem and Neomycin treatment.
• 2024-07-13 Off Service Note
  • She receoved chemotherapy and stem cell infusion, keep Tacrlimus and MMF since 7/9. Fentanyl 12mcg 1 patch for severe sore-throat. NG feeding now.
• 2024-07-07 Weekly Summary
  • After admission, she received hickman insertion at first, ID/OS/CVS/NST were consulted for survey.
  • Dilantin 100mg tid 7 days before Busulfan till 1 day after last dose.
  • Antibiotics and antifungus during hospitalization.
  • Chemotherpay as Fludarabine since 6/28-7/2 and Busulfan since 6/29-7/1.
  • RT with TBI on 7/2-7/3, fever once on 7/2, so we shift oral Cravit to Cefepime current treatment.
  • Halopiridol 0.5# prnbid for severe vomit during TBI.
  • Stem cell infusion on 7/4 (day0).
  • Chemo as Endozan and Mesna on 7/7-7/8.
  • Now, keep monitor general condition.
• 2024-07-06 Off Service Note
  • Antibiotic as Cefepime 1g q8h + Neomycin 1# qid and antifungus as mycamine 100mg qd
  • Antivirus as Acyclovir 250mg q8h
  • Encourage the patient to get out of bed and move around more often
  • Chemo as Endoxan 35mg/kg qd on 7/7-7/8, Mesna 12mg/kg at 0, 4, 8 hr on 7/7-7/8
  • Arrange Tarcolimus and MMF on 7/9
• 2024-07-04 ProgressNote
  • Day 0
  • stem cell from her son
  • dornor 700943087 A+
  • receptor 700685525 A+
  • stem cell infusion at 10:19 ~ 10:30, 2024/07/04
  • total 8.6x10^6/kg
• 2023-10-21 SOAP MER He YaoCan
  • preliminary impression: C95.90 Leukemia, unspecified not having achieved remission

[consultation]

• 2024-06-25 Infectious Disease
  • Q
    • This is a 43 years-old female and relapsed/refractory acute myeloblastic leukemia, FLT/ITD mutated type.
    • Induction 7+3 chemotherapy since 2023/10.
    • This time. she was admitted for haploidentical son RD-allogenous PBSCT, arrange day 0 in 7/4. We need your help for management.
  • A
    • 43-year-old AML female patient is admitted for allogeneic PBSCT.
    • Please follow up the protocol for bacteremia prophylaxis with Cravit and anti-fungal prophylaxis with Mycamine.
• 2024-06-24 Oral and Maxillofacial Surgery
  • Q
    • This is a 43 years-old female has relapsed/refractory acute myeloblastic leukemia, FLT/ITD mutated type. We need your help for check oral before haploidentical son RD-allogenous PBSCT.
  • A
    • We have examined the patient’s oral cavity via radiographic dental exam and clinical check-up
    • grossly no deep carious tooth or large decay was noticed.
    • plan:
      • explain the findings to the patient
      • oral hygiene instruction
• 2024-06-24 Radiation Oncology
  • Q
    • This is a 43 years-old female and relapsed/refractory acute myeloblastic leukemia, FLT/ITD mutated type. Induction 7+3 chemotherapy since 2023/10. This time. she was admitted for haploidentical son RD-allogenous PBSCT. We need your help for TBI 200cGy/2fr in 7/2-7/3.
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For total body irradiation (TBI) due to AML prepared for bone marrow transplantation
      • PI: The patient suffered from relapsed/refractory acute myeloblastic leukemia, FLT/ITD mutated type. Induction 7+3 chemotherapy since 2023/10. This time. she was admitted for haploidentical son RD-allogenous PBSCT. Consulted for TBI.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
      • Previous RT Hx: (-)
    • O: ECOG: 0
      • Pathology (S2023-20963, 2023-10-25): Bone marrow, iliac, biopsy — acute myeloid leukemia. IHC stains: CD117: 50%; CD34: 50%; MPO: 60%, CD61: 5%; CD71: 35% (of the nucleated cells).
      • Pathology (S2023-23676, 2023-12-01): Bone marrow, iliac, biopsy — acute myeloid leukemia
      • Pathology (S2024-00615, 2024-01-11): Bone marrow, biopsy — Acute myeloid leukemia
      • Pathology (S2024-03134, 2024-02-22): Bone marrow, iliac, clinically: AML s/p CT, biopsy — acute myelogenous leukemia present. IHC stains: CD117: 10-15%; CD34: 10-15%; MPO: 40%, CD61: 5-10%; CD71: 40% (of the nucleated cells).
      • Pathology (S2024-07704, 2024-04-24): Bone marrow, iliac, biopsy — acute myelogenous leukemia. IHC stains: CD117: 50%; CD34: 25%; MPO: 80%, CD61: 15 %; CD71: <5% (of the nucleated cells).
    • A: Acute myelogenous leukemia, s/p chemotherapy, not having achieved remission.
    • P: TBI is indicated for this patient with the following indicators: bone marrow transplantation
      • Goal: curative
      • Treatment target and volume: total body
      • Technique: 2D
      • Preliminary planning dose: 200cGy/2 fractions on 2024-7-2, and 200cGy/2 fractions on 2024-7-3.
      • The treatment modality and the possible effects of total body irradiation were well explained to the patient and her daughter again. The patient understand and agree to receive total body irradiation. The TBI will be scheduled on 2024-7-2 ~ 2024-7-3.
• 2024-06-24 Vascular Surgery
  • Q
    • This is a 43 years-old female and relapsed/refractory acute myeloblastic leukemia, FLT/ITD mutated type. Induction 7+3 chemotherapy since 2023/10. This time. she was admitted for haploidentical son RD-allogenous PBSCT, arrange day 0 in 7/4. We need your help for hickman insertion.
  • A
    • I have had the pleasure of involving with this patient’s care. In brief, She is a 44 year old female seen in consultation for opinion regarding treatment options for permcath insertion for BMT access.
    • The pt’s hx/Dx was noted for Acute myeloblastic leukemia
    • Lab/CXR reviewed.
    • Permcath insertion will be arranged on R’t side on 20240624 under LA
• 2024-01-08 Cardiology
  • Q
    • The 43 y/o woman has AML need your help for one-way PICC today.
  • A
    • This patient is a case of AML, I’m consulted for PICC one way. We will arrange PICC today if patient agree it
    • SvO2 was also check, it revealed 72 %.
      • Estimated Fick Cardiac index 3.49 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
      • Estimated Fick cardiac output 5.41 L/min. (nomral cardiac output range 5~6 L/min)
• 2023-10-24 Cardiology
  • Q
    • The 43 y/o woman has newly diagnosis of AML, so we need your help for PICC one-way insertion.
  • A
    • This patient is a case of AMI. We arrange PICC today
    • SvO2 was also check, it revealed 62. Estimated Fick Cardiac index 2.51 L/min/m2 and cardiac output 4.03 L/min.

[MultiTeam]

• 2024-06-28 Multi-disciplinary Recommendations - Psycho-oncology
  • Consultation Date: 2024-06-23
  • Reason for Consultation: Other: Allogeneic Stem Cell Transplant
  • Conclusion:
    • S
      • Visited on 6/26, accompanied by her daughter, the patient mentioned that currently, her daughter accompanies the patient as she is on summer vocation, allowing her husband to work. Her son, who donated bone marrow just after the Chinese New Year, rested for a few days and then returned to school. Everything timed perfectly, and she expressed to her son that just as she gave her son life, her son has given it back to her.
      • Currently, she feels no discomfort, her cough has improved before finishing the medications from last discharge, and her appetite is good, especially at home where she can cook for herself, enjoying hamburgers with two eggs for breakfast and gaining 4 kg.
      • However, this hospitalization feels more tiring, possibly due to discomfort from the Hickman tube placement the day before, often falling asleep, waking up to walk around, and waking up about three times at night due to noises next door and nurse visits, but she manages to fall back asleep after using the restroom and listens to music and Buddhist scriptures, which help her sleep well.
    • O
      • Acute myelomonocytic leukemia, pre-allogeneic stem cell transplant, donor is her son, family meeting on 4/24; admitted on 6/23.
    • I
      • Supporting the patient’s psychological preparation, encouraging her to maintain his appetite and activity levels.
    • AP
      • The patient remains optimistic about the prognosis, actively cooperating with the treatment, with good support; continued care as needed.
    • Consulted by psychologist Huang XiaoFang.
  • Responder: Huang XiaoFang
  • Response Date: 2024-06-27 09:46
  • Doctor’s response:
    • 06/28 10:45 Gao WeiYao: Proceed as recommended.

[chemotherapy]

• 2024-04-16 - [mitoxantrone 10mg/m2 15mg NS 100mL 10min + etoposide 100mg/m2 158mg NS 400mL 1hr + cytarabine 1000mg/m2 1584mg NS 500mL 2hr] D1-4
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-4
• 2024-02-21 - cytarabine 3000mg/m2 4700mg NS 500mL Q12H D1,3,5 (HD Ara-C)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1,3,5
• 2024-01-10 - daunorubicin 45mg/m2 69mg NS 100mL 10min D1-2 + cytarabine 100mg/m2 154mg NS 500mL 24hr D1-5
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
• 2023-11-29 - idarubicin 10mg/m2 15mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 154mg NS 500mL 24hr D1-7
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-7
• 2023-10-25 - idarubicin 10mg/m2 16mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 163mg NS 500mL 24hr D1-7
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-7

==========

2024-08-16

Lab results

• 2024-08-15 CMV viral load assay 319 IU/mL
  
• 2024-08-15 CMV viral load assay 157 IU/mL

The CMV viral load has tested positive. Several agents are available for systemic CMV therapy, including ganciclovir, valganciclovir, foscarnet, and cidofovir. However, the latter two are not available at this hospital. Below are the two available treatment options for your consideration:

• CGANC01 - Ganciclovir Injection 500mg/vial (ganciclovir)
• KVALC01 - Valcyte F.C 450mg/tab (valganciclovir)

2024-08-14

[ongoing management of pancytopenia post-allo PBSCT]

The patient remains in a state of pancytopenia, with the allo PBSCT blood stem cells not yet fully restoring expected function (2024-07-26 STR DNA fingerprint showed 100% recipient’s type). The patient continues to receive G-CSF, transfusions, and antibiotics. Renal function remains stable, though liver enzyme levels are showing signs of increase. BaoGan (silymarin) might be beneficial. No other issues with the current medication regimen have been identified.

• 2024-08-07 ALT 112 U/L
• 2024-07-30 ALT 54 U/L
• 2024-07-22 ALT 47 U/L
• 2024-07-15 ALT 40 U/L

2024-08-02

[verifying blood draw times for correct trough concentrations - tacrolimus TDM]

According to HIS5 nursing medication records, the first dose on 2024-08-01 was administered at 09:23, with the system showing the blood draw time at 10:12. If the measurement is intended to obtain the trough concentration, the correct blood draw time should be within half an hour before administration. Please verify the accuracy of the blood draw time.

If the system’s recorded time is incorrect but the actual blood draw time was accurate, it is recommended to increase the dose of Prograf (tacrolimus 1mg) to 5# BID to achieve the target concentration range of 5 ng/mL to 20 ng/mL.

[confirming accurate blood draw times in isolation room procedures]

After a phone call with the primary nurse, it was confirmed that the actual blood draw time was accurate. The delay in barcode scanning was due to the inconvenience of leaving the isolation room at the time of the blood draw.

2024-07-29

[evaluating tacrolimus dosage for optimal concentration and monitoring WBC levels]

There is currently no record of diarrhea (diarrhea has resolved). The tacrolimus level increased to 4.4 ng/mL on 2024-07-29, which is closer to the lower limit of the recommended range of 5 ng/mL. According to the nursing medication and TDM records, the blood draw was conducted approximately 4 hours before the medication administration. If the records are accurate, the actual trough concentration might be even lower.

Increasing Prograf (tacrolimus 1mg) to 5# BID could be considered to reach the recommended concentration range. Alternatively, the dosage may remain unchanged, but the patient should be closely monitored for any signs of acute graft-versus-host disease based on clinical status.

WBC levels have dropped again, and filgrastim administration is ongoing.

• 2024-07-29 WBC 0.07 x10^3/uL
• 2024-07-27 WBC 0.11 x10^3/uL
• 2024-07-25 WBC 0.19 x10^3/uL
• 2024-07-23 WBC 0.21 x10^3/uL

2024-07-26

[transfusion update and acute GVHD considerations]

Another transfusion of LPRBC and LRP was conducted on 2024-07-25 to replenish deficient HGB and PLT levels. The WBC count was 0.19 x10^3/uL, still below the target value, so filgrastim 300ug is being administered daily.

According to the progress note, the patient experienced diarrhea 7-8 times yesterday, which might indicate gastrointestinal symptoms of acute GVHD. If confirmed, adjusting tacrolimus to meet the recommended trough level may be considered.

2024-07-23

[Monitoring Post-Transplant WBC Recovery and Tacrolimus Levels]

Today (2024-07-23) marks day 19 since the transplantation. An increase in WBC count is now evident. Liver and kidney function indicators are generally within normal ranges. However, recent tacrolimus levels have not reached the recommended range, and a dosage increase might be considered.

• 2024-07-23 WBC 0.21 x10^3/uL
• 2024-07-22 WBC 0.08 x10^3/uL
• 2024-07-21 WBC 0.05 x10^3/uL
• 2024-07-20 WBC 0.02 x10^3/uL
• 2024-07-19 WBC 0.02 x10^3/uL
• 2024-07-18 WBC 0.02 x10^3/uL
• 2024-07-17 WBC 0.01 x10^3/uL

2024-07-22

[adjusting tacrolimus dosage for optimal levels - TDM]

The patient is currently on Prograf (tacrolimus 1mg) 3# BID. A trough level test on 2024-07-22 showed 2.8 ng/mL, which is below the recommended range of 5-20 ng/mL. The dosage might be increased to 4# BID to reach the target level and reduce the risk of graft-versus-host disease.

2024-07-17

[management of oral ulceration (tongue tie) in this neutropenic patient

]

The patient has developed an ulcer on the tongue tie. Currently, she is still in a neutropenic phase, which makes the use of Nincort Oral Gel (triamcinolone), due to its immunosuppressive effects, not recommended as it could further elevate the risk of infections. An alternative could be Parmason Gargle Solution (chlorhexidine) for oral rinsing and oropharyngeal decontamination.

2024-07-15

[managing suboptimal tacrolimus trough levels in GVHD]

Tacrolimus is used for graft-versus-host disease (GVHD) management.

• for prevention:
  • Oral: Transition from IV to immediate-release oral tacrolimus at a 1:4 ratio. Convert the total daily IV dosage by multiplying by four and administer it in two divided doses every 12 hours.
  • IV: Start with 0.03 mg/kg/day based on lean body weight as a continuous infusion, beginning at least 24 hours before stem cell infusion and continuing until oral medication is feasible.
• for treatment:
  • Oral: Immediate release at 0.06 mg/kg administered twice daily.
  • IV: Maintain the initial dose of 0.03 mg/kg/day as a continuous infusion.

For this patient, the initial oral tacrolimus should have been calculated as 0.12 mg/kg/day times 56 kg, equaling 6.72 mg/day. The actual regimen was 1mg twice daily (2mg total per day), with a trough level on 2024-07-12 of 1.3 ng/mL, which is below the recommended range of 5-20 ng/mL. It is advised to increase the dose to 3# BID and recheck the trough level 3 days after this adjustment.

The findings presented in the article provide evidence to support the aforementioned recommendation. “Early Post-Transplantation Tacrolimus Levels Correlate with Acute Graft-Versus-Host Disease in Allogeneic Hematopoietic Stem Cell Transplantation from Related and Unrelated Donors” - https://ashpublications.org/blood/article/128/22/3429/97989/Early-Post-Transplantation-Tacrolimus-Levels

• Study:
  • This research examined the relationship between early blood levels of tacrolimus (a medication) and the risk of a specific complication (acute Graft-versus-Host Disease, aGVHD) after stem cell transplants (HCT).
• Finding:
  • Low tacrolimus levels (less than 5 ng/ml) during weeks 3-4 after transplant significantly increased the risk of aGVHD in patients receiving transplants from related or matched unrelated donors.
• Confirmation:
  • This study confirms that other factors, like a higher HCT-CI score and donor type, also influence aGVHD risk.
• Impact:
  • These findings help determine appropriate minimum levels for tacrolimus and highlight the importance of close monitoring and dosage adjustments, especially during the transition to outpatient care (weeks 3-4 post-transplant).

2024-04-24

[CMV prevention strategies in allogeneic transplant for AML]

Today at 10:00 in the ward meeting room, the attending physician Dr Gao conducted a family meeting for this patient with AML, detailing the risks of allogeneic transplantation and its significance as a treatment option.

Regarding CMV infection prevention discussed during the meeting, I have gathered the following information, which may be useful for the attending physician and nurse practitioner for reference.

UpToDate suggests that for CMV prevention - initial (induction) pre-emptive therapy, one of the following agents may be used:

• Ganciclovir (available) 5 mg/kg IV every 12 hours

• Valganciclovir (available) 900 mg orally twice daily is an acceptable alternative for patients who can tolerate oral therapy, especially in patients at low risk for CMV disease and who have low viral loads

• Foscarnet (not available in this hospital) 60 mg/kg IV every 8 hours is an alternative for patients who cannot take ganciclovir or valganciclovir

• Letermovir (available, temporary purchase item) is a potential alternative that has considerably less toxicity. It has not been studied for this indication in HCT recipients, but, in a phase IIa study in renal transplant recipients, letermovir pre-emptive therapy was found to be promising.

• Maribavir (not available in this hospital) is a potential alternative to valganciclovir with similar efficacy but has more gastrointestinal toxicity and less myelosuppression.

2023-10-26

[initiating posaconazole treatment]

According to the Sanford Guide, posaconazole should be administered with a loading dose of 300 mg BID for two doses, then switching to a maintenance dose of 300 mg QD.

700761500

240823

[lab data]

2023-06-19 JAK2 single site mutation Undetectable
2023-06-14 HBsAg (NM) Negative
2023-06-14 HBsAg Value (NM) 0.392
2023-06-14 Anti-HCV (NM) Negative
2023-06-14 Anti-HCV Value (NM) 0.047
2023-06-14 Anti-HBc (NM) Positive
2023-06-14 Anti-HBc Value (NM) 0.009
2023-06-14 Anti-HBs (NM) Negative
2023-06-14 Anti-HBs value (NM) 4.930 mIU/mL
2023-03-13 CK 14 U/L
2023-03-03 Zinc,Zn 648 ug/L
2023-02-16 ANA Homogeneous 1:1280; Speckled 1:1280
2023-02-15 Anti-ds DNA Antibody 5.6 IU/ml
2023-02-15 Anti-ENA(Jo-1) EliA U/ml
2023-02-15 Anti Jo-1 antibody 0.3 EliA U/ml
2023-02-15 Anti-ENA (Scl-70) EliA U/ml
2023-02-15 Anti-ENA Scl-70 Ab 2.0 EliA U/ml
2023-02-14 ESR 31 mm/hr
2023-02-09 CK 10 U/L
2021-05-15 ESR 45 mm/hr
2021-03-17 LA1 52.8 sec
2021-03-17 LA2 38.0 sec
2021-03-17 LA1/LA2 ratio 1.1
2021-03-13 ESR 33 mm/hr
2020-07-04 Ferritin 101.9 ng/mL
2020-05-20 ESR 44 mm/hr
2020-05-14 Aspergillus Ag Negative
2020-05-14 Aspergillus Ag Value 0.13 Ratio
2020-05-06 LA1 51.4 sec
2020-05-06 LA2 39.4 sec
2020-05-06 LA1/LA2 ratio 1.1
2020-05-05 Anti-beta2-glycoprotein-I Ab 3.5 U/mL
2020-05-05 Anti-cardiolipin-IgM 3.0 MPL U/mL
2020-05-05 Anti-cardiolipin IgG GPL-U/mL
2020-05-05 Anti-Cardiolopin 8.0 GPL-U/mL
2020-05-05 Anti-ENA Sm 7.0 EliA U/ml
2020-05-05 Anti-ENA RNP 2.4 EliA U/ml
2020-05-05 Anti-ds DNA Antibody 14 IU/ml
2020-05-05 C4 30.4 mg/dL
2020-05-05 C3 102.8 mg/dL
2020-04-20 Aspergillus Ag Positive
2020-04-20 Aspergillus Ag Value 0.5 Ratio
2020-04-20 Anti-ENA SS-A (Ro) >2400 EliA U/ml
2020-04-20 Anti-ENA SS-B (La) >3200 EliA U/ml
2020-04-20 ANA Homogeneous ; 1:1280
2020-04-17 Cryptococcus Ag Negative
2020-04-17 Antibody Identification Anti-M
2020-04-15 Anti-ENA Sm 7.5 EliA U/ml
2020-04-15 Anti-ENA RNP 2.4 EliA U/ml
2020-04-15 Anti-ds DNA Antibody 14 IU/ml

[exam findings]

• 2023-11-06 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — hypercellular marrow.
  • Section shows piece(s) of bone marrow with 65 % cellularity and M:E ratio of approximately 3.5:1. Three cell lineages are present with maturation of leukocytes. Megakaryocytes are adequate in number.
  • IHC stains: CD117: <1%; CD34: <1%; MPO: 70-80%, CD68: 70-80%; CD163: 70-80%; CD61: 5%; CD71: 20-25% (of the nucleated cells).
    • The possibility of chronic myelomonocytic leukemia cannot be excluded. Please correlated with hemogram, bone marrow smear, and, if available, flow cytometry and molecular test findings.
• 2023-06-20 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Hypercellularity, see description
  • Immunohistochemical stains:
    • MPO: positive for myeloid series
    • CD71: positive for erythroid series
    • CD61: positive for megakaryocytes
    • CD117: positive for blast
    • CD34: positive for blast
    • CD138: positive for plasma cell
    • Kappa and lambda: polyclonality
  • Microscopically, the sections show pictures as follows:
    • Hypercellularity for her age, 60%
    • M/E ratio about 4/1, largely normal maturation of myeloid series and erythroid series
    • Adequate megakaryocytes with focal mononucleation and hyposegmentation. No clustering
    • No increase of blast
    • Increased plasma cells, 10% with polyclonality of kappa and lambda light chains
    • Histochemical stain of reticulin shows no myelifibrosis
    • Please correlate with clinical finding and bone marrow smear for conclusive diagnosis.
• 2023-06-09 CXR
  • reticular and hazy areas of increased opacities over Rt and Lt lower lung zones, due to fibrosis
  • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
  • partial atelectasis of inferior lingular segment and RML
  • Minimal dextroscoliosis of the T-spine
    
  • marginal spurs of multiple vertebral bodies
• 2023-06-09 SONO - abdomen
  • Liver cysts
  • Splenomegaly with heterogenous parenchyma.
• 2023-05-08 Spirometry
  • There is mild restrictive lung defect.
  • The bronchodilator test is negative.
• 2023-04-08 CT - chest
  • Bronchiectatic change over right middle lobe and left lingula lobe.
  • The pneumonic patch resolved.
  • Splenomegaly with heterogenous appearance of the splenic parenchyma. Suggest contrast enhanced study.
• 2023-02-08, -01-20, -01-06, 2022-12-26, -12-19 CXR
  • Consolidation and volume reduce over Rt and Lt lower lung zones, further in progression
  • mild enlarged cardiac silhoutte due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad
  • partial atelectasis of inferior lingular segment and RML
• 2023-02-08 SONO - chest
  • Pleural thickening and subpleural consolidation, bilateral
• 2022-12-15 SONO - chest
  • Bilateral lower lobes pneumonia with airbronchogram inside, 3x4 cm in size, bilaterally.
  • Only trivial amounts of plerual effusion, bil.
  • High risk of chest tapping.
• 2022-12-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 35) / 89 = 60.67%
    • M-mode(Teichholz) = 60
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA
    • Mild MR, mild TR and mild PR
    • Mild pulmonary hypertension
    • Preserved RV systolic function
• 2022-12-14 CT - chest
  • consolidation in the lower lobes of the bilateral lung.
• 2022-09-05 CT - Temporal Bone HRCT
  • Noncontrast high resolution CT (HRCT) of bilateral temporal bones in thin axial cut and with coronal reformation shows:
    • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
    • Soft tissue within right middle ear.
    • No obvious bone erosion.
  • IMP: Osteitis media with soft tissue within right middle ear.
• 2022-08-01 ENT Hearing Test
  • Tymp:
    • R’t grommet inserted (ECV 1.0 was noted); L’t type A.
  • ART:
    • R’t ipsi CNT and contra absent.
    • L’t ipsi absent and contra CNT.
  • PTA
    • Reliability FAIR
    • Average RE 65 dB HL; LE 49 dB HL.
    • R’t moderate to profound mixed type HL.
    • L’t mild to profound mixed type HL.
• 2022-02-05 MRI - C-spine
  • herniated disc in the C5/6 disc.
• 2021-10-02 ENT Hearing Test
  • Tymp:
    • R’t type B; L’t type A.
  • ART:
    • Bil absent.
  • PTA
    • Reliability FAIR
    • Average RE 73 dB HL; LE 44 dB HL.
    • R’t moderate to profound mixed type HL.
    • L’t normal to severe SNHL with 15 dB ABG at 4k Hz.
• 2021-04-06 Ga-67 whole body inflammation scan with SPECT
  • The whole-body gallium-67 inflammation scan with SPECT was performed at the 24th and the 48th hour after injecting 6 mCi of Ga-67 to the patient. The images showed relatively increased radiotracer uptake in the liver, spleen, and bilateral shoulders. In addition, there was increased radiotracer accumulation in the colon.
  • IMPRESSION:
    • Relatively increased radiotracer uptake in the liver and spleen, the nature is to be determined. Please correlate with other clinical findings for further evaluation.
    • Mildly increased radiotracer uptake in bilateral shopulders, mild inflammation may show this picture.
    • Increased Ga-67 accumulation in the colon, physiological accumulation of Ga-67 may show this picture.
• 2021-03-17 SONO - chest
  • Pleural effusion, minimal, left
  • Consolidation, LLL, minimal
• 2021-03-15 CT - chest
  • post inflammatory fibrosis in LLL and RLL, stationary.
  • splenomegaly
  • hyperplastic LNs in both axillary region, stationary.
  • new left pleural effusion.
• 2021-03-15 Spirometry
  • mild restrictive ventilatory impairment, FVC 74%, FEV1 75%
• 2020-09-22 CT - chest
  • post inflammatory fibrosis in LLL and RLL.
  • splenomegaly with poorly enhanced foci.
  • regression of hyperplastic LNs in both axillary compared with CT on 2020/04/06
• 2020-07-09 Bronchodilator Test
  • mild restricitve ventilatiory impairemnt
• 2020-04-30 Bronchodilator Test
  • mild restrictive ventilatory impairment, FEV1/FVC = 86%, FVC = 70%, FEV1 = 74%
  • without significant reversibility
• 2020-04-07 SONO - chest
  • Bilateral thorax: minimal amount pleural effusion (thoracocentesis was not performed).
• 2020-04-06 CT - chest
  • nonspecific inflammation r/o infection in lower lungs with pleural effusion. splenomegaly and LAPs in both axillae, hematological disorder?, suggest further correlation with lab. data.
• 2019-12-04 Acoustic Radiation Force Impulse, AFRI
  • CC: For measurement of fibrosis stage
  • Diagnosis: ARFI = F0
  • Suggestion
    • V median = 1.31
    • V IQR/median = 13.4%
• 2019-12-04 SONO - abdomen
  • Liver cysts, three
  • Splenomegaly, mild
• 2018-08-16 Flow Volume Curve
  • Mild restriction
• 2018-08-16 SONO - abdomen
  • Multiple (>20) splenic hemangiomas up to 1.4cm.
• 2017-01-12 SONO - abdomen
  • splenic tumors, C/W hemangioma (by prior study)
  • liver cysts

[MedRec]

• 2024-08-10 SOAP Dermatology Wang ChunHua
  • Prescription
    • Mycomb Cream (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
    • Xyzal (levocetirizine 5mg) 1# QN
    • Limeson (dexamethasone 4mg) 1# QD
    • Betason (betamethasone 2mg, neomycin 5mg; per gram) BID EXT
• 2023-07-23 SOAP Rheumatology and Immunology Chen ZhengHong
  • A/P
    • Sjogren syndrome
    • R/O Fibromyalgia
  • Prescription x3
    • Plaquenil (hydroxychloroquine 200mg) 1# QOD
    • Evoxac (cevimeline 30mg) 1# BID
• 2024-07-13 SOAP Chest Medicine Lin QinJi
  • Prescription x2
    • Compesolon (prednisolone 5mg) 1# QD 28D
    • Mecater (procaterol 25ug) 0.5# BID 2D
    • Actein Effervescent (acetylcysteine 600mg) 1# QD 28D
    • Foster Evohaler (beclomethasone 100ug, formoterol 6ug; per dose) 1# BID INHL 28D
• 2024-06-19 ~ 2024-06-26 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Chronic myelomonocytic leukemia, status post Vidaza(D1-D7 Q1M) on 3/14, 4/16
    • Splenomegaly, not elsewhere classified
  • Present illness
    • C1 VIDAZA D1-D7 Q1M was given on 2024/03/14, C2 on 2024/04/16, C3 on 2024/05/20.
    • This time, she was admitted for C4 Vidaza therapy for CMMoL, (D1-D7 Q1M) on 2024/06/19.
  • Course of inpatient treatment
    • After admission, she received C4 Vidaza therapy on 2024/06/20-06/27.
    • Allegra 1# bid for skin rash over abdomen.
    • Under the stable condition, she can be discharged on 2024/06/26. OPD follow up is arranged.
  • Discharge prescription
    • Allegra (fexofenadine 60mg) 1# BID 5D
• 2024-06-15 SOAP Dermatology Wang ChunHua
  • Prescription
    • Mycomb Cream (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
    • Xyzal (levocetirizine 5mg) 1# QN
    • Limeson (dexamethasone 4mg) 1# QD
• 2023-06-18 ~ 2023-06-20 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Chronic myeloproliferative disease
    • Acute panmyelosis with myelofibrosis not having achieved remission
    • Splenomegaly, not elsewhere classified
    • Pleural effusion, not elsewhere classified
    • Anemia, unspecified
    • Diaphragmatic hernia without obstruction or gangrene
    • Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation
    • Sicca syndrome, unspecified
    • Anemia, unspecified
    • Myelofibrosis
  • CC
    • for bone marrow biopsy
  • Present illness
    • The 61 y/o woman has Sjogren syndrome since 2020, Cervical spondylosis, GU. Due to difficulty defecation 7 days ago, with fullness sensation, so she came to ER on 5/24. 20204/08 ABD CT showed marked splenomegaly: Marked splenomegaly (12.5cm) with heterogeneous parenchyma is found. The abd echo showed splenomegaly on 2023/6/9. Due to 2023/6/9 DC showed Monocyte = 30.7 %, Basophil = 2.0 % and Metamyelocyte = 1.0 %, so she was asdmitted for bone marrow tomorrow. MPN 10 score showed 37 points. 
  • Course of inpatient treatment
    • After admission, Bone marrow biopsy was done on 06/20 smoothly. No bleeding sign was noted. She was discharged on the same day. OPD follow up was arranged for the biopsy report.
• 2023-03-27 SOAP Rheumatology and Immunology Chen ZhengHong
  • Prescription
    • Plaquenil (hydroxychloroquine 200mg) 1# QDCC
    • Celebrex (celecoxib 200mg) 1# QD
    • Evoxac (cevimeline 30mg) 1# BID
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNHS
• 2023-03-13 ~ 2023-03-15 POMR Rheumatology and Immunology Chen ZhengHong
  • Discharge diagnosis
    • Sicca syndrome
    • Chronic obstructive pulmonary disease with acute lower respiratory infection
    • Gastric ulcer
    • Seborrheic dermatitis, unspecified
  • CC
    • admission for AIM survey and steroid pulse therapy
  • Present illness
    • This is a 61y/o woman with PMH of COPD, hemorrhoidectomy, ovary cyst s/p OP, left empyema s/p OP, right eye cataract s/p PCIOL, right middle ear otitis with granulation tissue s/p OP, refractory pneumonia with pleural effusion s/p treatment, Sjogren’s syndrome diagnosed on 2020.04. This time she is admitted for self-paid AIM markers survey and pulse therapy for 3 days.
    • She was in her usual status with good compliance and regular f/u at AIR Dr. Chen’s OPD since 2020. Her initial presentation of the disease course was occasional joints pain, dry mouth and dry eye, laboratory data showed relatievly high ANA 1:1280, Anti-ENA SS-A >2400, anti-ENA SS-B >3200. Sjogren syndrome was comfirmed with Hydroxychloroquine supplied throughout these years. As she was experiencing recurrent pneumonia, tissue invasion was suspected therefore AIM Abs were suggested for testing, and pulse therapy was suggested for management if disease course as well.
    • His time, she was admitted to the ward for pulse therapy with steroid, and AIM screening for possible AIM related pneumonitis.
  • Course of inpatient treatment
    • After admission, laboratories were done and medasone 80mg QD for 3 days was given. AIM exams were done now pending for data and will be explained in OPD. The patient was smooth and able to be discharged with further OPD f/u.
• 2023-02-25 SOAP Dermatology Wang ChunHua
  • S
    • hair loss for months,acute exacer bated
    • enlarged neck (+)
    • malar rash on face for months
  • Prescription
    • Topsym (fluocinonide 0.05%) HS TOPI
    • Zinga (zinc gluconate 78mg) 1# QD
• 2020-05-11 SOAP Hemato-Oncology Gao WeiYao
  • S: She claimed that after medication with her SICCA syndrome, her symptoms improved markedly
• 2020-05-07 SOAP Rheumatology and Immunology
  • A
    • Sjogren syndrome
    • r/o fibromyalgia
  • Prescription
    • Hydroquine (hydroxychloroquine 200mg) 1# QDCC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# HS
    • Bokey (aspirin 100mg) 1# QD
    • LacTam (acetaminophen 500mg) 1# PRNBID
    • Compesolon (prednisolone 5mg) 1# QD
• 2017-01-22 ~ 2017-01-25 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • N83.9 Right ovarian cyst
    • R18.8 Ascites
    • 2017/01/23 Laparoscopic right cystectomy (single port)
  • CC
    • NIL
  • Present illness
    • This 55 year old female, G1P1, had been suffering from lower abdominal pain for one month. She visited some clinics and received some medications but in vain. Due to persisted symptom, she visited our Gyn-OPD for help. Gyn-sonography showed a right ovarian cystic mass with solid component found. Malignancy was suspected, so she was admitted for further evaluation and LSC cyctectomy will be arranged after the complete evaluation.
  • Course of inpatient treatment
    • Patient underwent laparoscopic right cystectomy (single port) on 2017-01-23. Her postop course was uneventful. She remained afebrile and stable and was discharged on POD#2. She was discharged on 2017-01-25. Her followup appointment is scheduled on next week.
• 2016-08-31 ~ 2016-09-08 POMR Chest Medicine Wu ZhiWei
  • Discharge diagnosis
    • J90 compliacted parapneumonic effusion
    • J18.9 Pnaumonia
  • CC
    • Productive cough, short of breath, spiky fever with shaking chills for 2 days.
  • Present illness
    • The 55 years old lady denying any systemic disease has suffered from productive cough, short of breath, spiky fever with shaking chills for 2 days and was transferred from Saint Paul’s Hospital due to left empyema. She reported travel history to Malaysia in recent days. Also she complained of abdominal pain, RUQ > LUQ.
    • At our ED, she present with tachycardia with HR 112 bpm and tachypnea with RR 25/min, and fair BP 123/91 mmHg. Lab data revealed elevated CRP 7.16 mg/dL but normal WBC and lactate level. CXR showed left pleural effusion. The chest CT from Saint Paul’s H. showed left side lobulated pleural effusion suspect empyema and bilateral pneumonia. CS doctor was consulted at ED and suggested conservative treatment. However, low PaO2 66.5 mmHg was noted. NRM was used and she need closely monitor. Under the impression of bilateral pneumonia and left empyema, she was admitted to MICU for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, antibiotics with Tapimycin plus Cravit were used. Tapping of pleural effusion was done and the results reported exudate. We consulted CS Dr. Hsieh. Thoracoscopic decortication of pleura was performed smoothly on 2016/08/25. After the surgery, adequate pain control, chest tube low-pressure suction and O2 support were given. Her respiratory pattern became smooth under N/C support but mild dyspnea was noted on 2016/08/29. The followed CXR on 2016/08/29 disclosed progression of right pneumonia and pleural effusion. Tapping of right pleural effusion was done the the results was also exudate but not empyema. We drained out 650 ml of right pleural effusion and her respiratory pattern became better. Skin rash over back developed and for possible allergy, Tapimycin was discontinued.
    • Under relatively stable condition, the patient was transferred to CM ward for further care on 2016/8/31.
    • At ward, the vital signs was stable with smooth respiratory pattern. On 2016/09/05, the chest tube drainage amount decreased and it was removed. There was mild low grade fever noted before discharge, but she didn`t had other infection signs. Now, under stable condition, she was discharged on 2016/09/08 and further OPD f/u was arranged.

[surgical operation]

• 2017-01-23 Huang SiCheng
  • Operation
    • Laparoscopic partial or complete adnexectomy - single port
  • Finding
    • Uterus: Avfl, grossly normal.
    • LAD: one 9cm solid tumor .
    • RAD: grossly normal.
    • CDS: no adhesion.
  • Estimated blood loss: minimal
  • Blood transfusion: nil
  • Complication: nil
• 2016/08/25 Xie MinXiao
  • Operation
    • Thoracoscopic Decortication of Pleura
    • Closed drainage
  • Findings
    • Massive purulent effusion was noted over left pleural cavity with peel.
    • Estimated blood loss: minimal.
    • One 32 Fr. straight chest tube and another 32 Fr. curved chest tube were inserted via left 8th and 7th ICS.

[chemotherapy]

• 2024-08-22 - Vidaza (azacitidine) 75mg/m2 114mg SC D1-7 (Q1M)
• 2024-06-20 - Vidaza (azacitidine) 75mg/m2 111mg SC D1-7 (Q1M)
• 2024-05-20 - Vidaza (azacitidine) 75mg/m2 111mg SC D1-7 (Q1M)
• 2024-04-16 - Vidaza (azacitidine) 75mg/m2 111mg SC D1-7 (Q1M)
• 2024-03-14 - Vidaza (azacitidine) 75mg/m2 114mg SC D1-7 (Q1M)

==========

2024-08-23

[resumption of Vidaza treatment and skin symptom management, monocyte fluctuations during ongoing treatment]

The planned monthly Vidaza (azacitidine) treatment was skipped in July and restarted on 2024-08-22, with acceptable lab results on the same day.

Medications prescribed by the dermatologist for her skin symptoms have been integrated into the active medication list, with no issues identified.

Monocyte levels have fluctuated significantly throughout the treatment, with a current reading of 20%, 1.3 K/uL during this hospitalization.

Lab Date WBC K/uL Monocyte % Monocyte /uL

• 2024-08-22 6.34 19.9 1262

• 2024-08-10 9.64 39 3760

• 2024-07-30 13.35 40.6 5420

• 2024-07-21 11.92 41.9 4994

• 2024-07-05 3.18 25 795

• 2024-06-25 10.73 37.6 4034

• 2024-06-19 11.72 72.5 8497

• 2024-05-31 4.54 21.2 962

• 2024-05-23 10.56 37.5 3960

• 2024-05-20 10.85 43.7 4741

• 2024-04-29 3.17 10.7 339

• 2024-04-22 7.41 13.3 986

• 2024-04-16 21.2 60.7 12868

• 2024-04-09 4.06 69 2801

• 2024-04-02 0.4 0 0

• 2024-03-28 1.3 4.7 61

• 2024-03-20 5.65 18.6 1051

• 2024-03-18 5.24 9 472

• 2024-03-15 5.75 22.2 1277

• 2024-03-13 6.1 28.9 1763

2024-04-18

[azacitidine skin reactions is managed]

Skin symptoms have developed following the administration of azacitidine during this and the previous hospitalization. Currently, Allegra (fexofenadine) is being used to manage these symptoms, with observation to assess control effectiveness.

Azacitidine may cause various dermatologic issues such as ecchymoses (31%), erythema (7%-17%), pruritus (12%), and rashes (10%-14%). For subcutaneous injections, it is advised to rotate injection sites (upper arms, thighs, or abdomen) to avoid complications. New injection sites should be at least 2.5 cm apart from previous ones, and injections should not be administered into areas that are tender, bruised, red, or hardened.

Recent lab results from 2024-04-16 show a WBC count of 21.2K, a neutrophil percentage of 26.2%, an estimated ANC of 5.55K, and stable temperatures not exceeding 37 degrees Celsius.

Xerostomia is being treated with Evoxac (cevimeline), Plaquenil (hydroxychloroquine), and Celebrex (celecoxib), with no discrepancies in medication found.

2024-03-14

[initiating azacitidine for CMML-MDS, monitoring respiratory risks]

Chronic Myelomonocytic Leukemia-Myelodysplastic Syndrome (CMML-MDS) is likely, given that the dysplastic characteristic (WBC frequently < 13K/uL). Hypomethylating agents such as azacitidine and decitabine have been shown to provide symptomatic relief in patients with CMML, particularly for symptoms related to cytopenia. In this instance, azacitidine treatment was initiated on 2024-03-14 at a standard dosage of 75 mg/m2/day for 7 days within a 28-day treatment cycle. Renal and liver functions were reviewed and, based on the laboratory data from 2024-03-13, are deemed adequate to tolerate this dosage.

Subsequent cycles might planned at 75 mg/m2/day for 7 days every 4 weeks. The dosage might be increased to 100 mg/m2/day if no improvement is observed after 2 cycles and no significant toxicity is noted beyond nausea and vomiting.

A Network Meta-Analysis comparing azacitidine (AZA) and decitabine (DAC) found no statistically significant differences in efficacy, although DAC showed a higher CR rate than AZA in patients with both AML and MDS. There appears to be no clear superiority between the two agents regarding response rates. However, patients receiving DAC experienced more frequent grade 3/4 cytopenias, notably anemia, febrile neutropenia, and leukopenia, compared to those receiving AZA treatment. (Ref: Ma J, Ge Z. Comparison Between Decitabine and Azacitidine for Patients With Acute Myeloid Leukemia and Higher-Risk Myelodysplastic Syndrome: A Systematic Review and Network Meta-Analysis. Front Pharmacol. 2021 Aug 17;12:701690. doi: 10.3389/fphar.2021.701690. Erratum in: Front Pharmacol. 2023 May 05;14:1213053.)

The patient has a history of chronic respiratory symptoms and records of consultations with chest medicine. It is important to closely monitor for respiratory system infections, particularly when chemotherapy leads to a decrease in WBC count.

2023-06-19

Based on the PharmaCloud database, our hospital is the sole medical provider for the patient in the past 3 months. No issues related to medication reconciliation have been identified.

Cyclophosphamide is a potential therapeutic option for severe, refractory cases of dermatomyositis/polymyositis, and it is often administered as an adjunctive treatment. The recommended oral dose typically ranges from 1.5 to 2 mg/kg/day (ref: UpToDate). As of 2023-06-18, the patient’s body weight is 53.3kg, and the current prescription of cyclophosphamide at 50mg QD is below the suggested dosage range. Please continue to monitor the treatment’s effectiveness and consider whether a dose adjustment might be required.

701245701

240823

[lab data]

2020-08-29 PD-L1(22C3) TPS>=50%
2020-08-13 ROS1 not detected
2020-08-12 PD-L1(22C3) TPS >= 50%
2020-08-07 ALK IHC Negative
2020-08-07 EGFR G719X not detected
2020-08-07 EGFR Exon19 del detected
2020-08-07 EGFR S768I not detected
2020-08-07 EGFR T790M not detected
2020-08-07 EGFR Exon20 ins not detected
2020-08-07 EGFR L858R not detected
2020-08-07 EGFR L861Q not detected

[exam findings]

• 2024-08-05 Endoscopic Retrograde Cholangiopancreatography, ERCP

  • Diagnosis:
    • Distal CBD stricture, pancreatic head cancer related, s/p Wallflex 6 cm placement
    • Dilated Bil IHDs
    • GB non-opacification
  • Suggestion:
    • f/u amylase & lipase

• 2024-08-02 CT - abdomen

  • Adenocarcinoma of pancreatic head tumor with liver, left adrenal, bone metastasis, T2N1M1, distal common bile duct obstruction S/P PTCD drainage on 2024/04/09, status post internal stent on 2024/04/22.
  • Findings: Comparison: prior CT dated 2024/04/09.
    • Prior CT identified an ill-defined poor enhancing mass in the pancreatic head, causing marked dilatation of IHDs, CHD, CBD, gallbladder and pancreatic duct, is noted again, stationary.
    • Prior CT identified two regional metastatic nodes in hepatoduodenal ligament are noted again, stationary.
    • Prior CT identified patchy consolidation with air-bronchogram in RLL of the lung, right pleura effusion and thickening is noted again, stationary.
    • There are several renal cysts on both kidney (up to 4.2 cm).
  • Impression:
    • Pancreatic head cancer S/P C/T show stable disease.

• 2024-08-02 SONO - abdomen

  • Diagnosis:
    • Suspected chronic liver parenchyma disease
    • Suspected GB sludge
    • Suspected CBD sludge s/p biliary stent
    • Dilatation of CBD and bilateral IHD
    • Dilatation of P duct
    • Pancreas not shown
  • Suggestion:
    • Please correlate with other image
    • Please correlate with liver function test and follow AFP,CA-199
    • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed

• 2024-06-18, -05-13 CXR erect

  • Enlargement of cardiac silhouette.
  • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
    
  • Right Pleura effusion

• 2024-06-12 CT - chest

  • Indication: Lung cancer, RLL adenocarcinoma, T4N2M1b with bone metastasis,
  • Comparison was made with previous CT dated on 2024/03/06
    • Lungs: extensive consolidation with air-bronchograms and septal thickening at RLL, RML, and posteroinferior region of RUL, in regression of RLL consolidation .
      • a granuloma 4mm in S2 of RUL,stationary.
    • Mediastinum and hila: no enlarged LNs.
      • normal caliber of thoracic aorta and central pulmonary arteries.
    • Heart: normal size
    • Pleura: small Rt-sided pleural effusion with loculation and parietal thickening..
    • Visible abdominal contents: a Lt renal cyst, 2.4 cm.
      • s/p endoscopic biliary stenting
    • focal blastic change in T8 and T9 marginal spurs of vertebrae
  • Impression:
    • extensive parenchymal and interstitial process in Rt lung, treatment related and/or infection?, mildy in regression as compared with chest CT on 2024/03/06. Rt exudative pleural effusion. spinal metastasis, stable.

• 2024-05-09 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 35) / 126 = 72.22%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.

• 2024-04-23 Abdomen - supine (diaphragm)

  • Pneumoperitonum.
  • S/P CBD stenting.
  • Intact bony structure(s).
  • Stool retention in the bowel.
  • Ground glass opacity in bilateral lower lungs.

• 2024-04-22 CXR erect

  • S/P right pig-tail catheter indwelling.
  • Right pleural effusion.
  • Ground glass opacity in RLL.

• 2024-04-22 Endoscopic Retrograde Cholangiopancreatography, ERCP

  • Findings:
    • Common Bile Duct
      • Selective cannulation with C duct is done with precut papillotomy and subsequent cholangiography showed marked dilated biliary tree and constrast medium is accumlulated at the level of cystic duct orifice. There are several susp. filling defects in the distal CBD.
    • Intrahepatic bile duct:
      • The Bil IHDs are dilated.
  • Management:
    • Rendezvous technique with biliary cannulation by the right side PTCD was tried but failed at the distal CBD due to the panceatic head cancer obstruction. Then, standard biliary cannulation succeed and followed by biliary dilatation by Sohehendra (10 Fr. COOK). The biliary stent (Advanix 10Fr. x 7 cm) was placed smoothly.
  • Diagnosis:
    • Distal CBD stricture, pancreatic head tumor obstruction related, s/p 10 Fr 7 cm stent placement
    • Dilated Bil IHDs
    • GB non-opacification
  • Suggestion:
    • f/u amylase & lipase CM

• 2024-04-19 PET

  • Glucose hypermetabolism in the head of the pancreas. Primary pancreatic malignancy may show this picture.
  • Glucose hypermetabolism in some small focal areas in bilateral lungs, in a small focal area in the segment 8 of the liver, in the left adrenal gland and in multipe bones, compatible with multiple lung, liver, left adrenal and bone metastases.
  • Glucose hypermetabolism in a focal area in the left upper abdominal cavity, in a focal area in the right lower abdominal cavity and in multiple focal areas in the soft tissues as as mentioned above, suggesting multiple metastatic lesions.
  • Mild glucose hypermetabolism in the pleura of right posterior lower lung. Inflammation is more likely.

• 2024-04-15 Endoscopic Retrograde Cholangiopancreatography, ERCP

  • Findings

    • Duodenum

      • Several shallow ulcers are found at the bulb.

    • Papilla

      • Normal papilla is found. A clotted stent is found at the orifce of papilla.

    • Pancreatic duct

      • not done

    • Common bile duct

      • Selective cannulation with C duct is done with ordinary catheter and the cholangiography showed dilated biliary tree and a stricture segment 4-5 cm at the distal CBD.

    • Intrahepatic bile duct

      • The Bil IHDs are dilated.

    • Gallbladder

      • GB is not opacified.

    • Others

      • PTCD is noticed.
  • Management
    • A 10 Fr. 7 cm straight stent (Bonton Avanix) is intended to put but too toght to place so procedure failed.
  • Diagnosis:
    • Biliary obstruction s/p EST
    • Dilated Bil IHDs
    • GB non-opacification
    • s/p PTCD
  • Suggestion:
    • f/u amylase & lipase CM

• 2024-04-12 Patho - pancreas biopsy

  • Labeled as “pancreas”, EUS fine needle biopsy biopsy — ductal adenocarcinoma.
  • Specimen submitted in formalin consists of multiple piece(s) of tan, irregular tissue measuring 0.4 x 0.1 x 0.1 cm. All for section(s) in one cassette(s).
  • Section shows many pieces of fibrotic tissue with infiltration of neoplastic ducts.
  • IHC stains: CK19 (+), CK7 (+), CK20 (-), CA19-9 (-), CD56 (-).

• 2024-04-12 Endoscopic ultrasound, EUS

  • EUS findings：
    • Using EUS-UCT 260 showed a 26.3*19.4 mm hypoechoic lesion arising from the head of pancreas.
    • The MPD is dilated up to 5.1 mm in diameter.
  • Diagnosis：
    • Pancreatic head tumor R/O cancer s/p CEH-EUS & EUS/FNB
    • MPD dilatation
  • Suggestion:
    • Pursue the pathology report

• 2024-04-09 Percutaneous Transhepatic Cholangio Drain, PTCD

• 2024-04-09 CT - abdomen

  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T2(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • With and without contrast enhancement CT of abdomen shows:
    • A mass lesion, 2.8cm, in pancreatic head. No definite adjacent structure invasion.
    • Dilatation of CBD, IHDs, gallbladder and P-duct.
    • Two regional lymph nodes noted.
    • A nodular lesion, 1.3cm, in left adrenal gland.
    • Consolidation in RLL and right pleural thickening.
  • Impression
    • r/o pancreatic cancer (2.8cm) with distal CBD obstruction
    • Two regional lymph nodes, r/o lymph node metastasis
    • Left adrenal nodule; DDx: metastasis, adrenal adenoma

• 2024-04-08 CXR erect

  • consolidation with air-bronchograms and reticular opacities at RLL, RML, and RUL subsegmental atelectasis of inferior lingular segment.
  • small Rt pleural effusion with loculation and thickening.

• 2024-04-08 SONO - abdomen

  • Symptoms:
    • Liver
      • Heterogenous liver parenchyma was noted.
    • Bile duct and gallbladder
      • marked dilatation of CBD and bilateral IHD. distention of gallbladder, but not tenderness(no Echo-Murphy sign), echogenic material in the gallbladder:C/W sludge
    • Portal veins and blood vessels
      • Patent portal vein.
    • Kidney
      • No definite stone or hydronephrosis.
    • Pancreas
      • Some parts of pancreas blocked by bowel gas, especially head and tail; dilatation of main pancreatic duct
    • Spleen
      • No splenomegaly
    • Ascites
      • No ascites
  • Diagnosis:
    • Probable liver parenchymal disease
    • marked dilatation of CBD; dilatation of bilateral IHD
    • distention of gallbladder, with sludge
    • dilatation of main pancreatic duct (some parts of pancreas not shown)
  • Suggestion:
    • suggest further image study such as CT scan

• 2024-03-06 CT - chest

  • Indication: Lung cancer, RLL adenocarcinoma, T4N2M1b with bone metastasis
  • Comparison was made with previous CT dated on 2023/11/24
    • Lungs: extensive consolidation with air-bronchograms and septal thickening at RLL, RML, and posteroinferior region of RUL.
      • a granuloma 4mm in S2 of RUL,stationary. subsegmental atelectasis of inferior lingular segment.
      • smooth thickening of Rt interlobar major fissure.
    • Mediastinum and hila: no enlarged LN s.
      • normal caliber of thoracic aorta and central pulmonary arteries.
    • Pleura: small Rt-sided pleural effusion with loculation and nodular parietal thickening. unremarkable.
    • Visible abdominal contents: a Lt renal cyst, 2.4 cm .
      • focal blastic change in T8 and T9 marginal spurs of vertebrae
  • Impression:
    • extensive parenchymal and interstitial process in Rt lung, treatment related and/or infection?

• 2023-11-24 CT - chest

  • Indication: Lung cancer, RLL adenocarcinoma, T4N2M1b with bone metastasis
  • Comparison was made with previous CT dated on 2023/8/31
    • Lungs:
      • no interval change in size of RLL and RML solid nodular opacities with reticular opacities as compared with CT on 2023/08/31.
      • a granuloma 4mm in S2 of RUL, stationary.
      • subsegmental atelectasis of inferior lingular segment.
      • smooth thickening of Rt posterior major fissure.
    • Pleura: small Rt-sided pleural effusion with loculation and nodular parietal thickening.
    • Chest wall: multiple small LNs in axillary regions, stationary.
    • Visible abdominal contents:
      • a Lt renal cyst, 2.4 cm (longest axial diameter)
    • Visualized bones: no lytic or blastic lesion. marginal spurs of vertebrae
  • Impression:
    • stationary of RLL and RML solid nodular lesions and Rt nodular pleural thickening as compared with CT on 2023/08/31

• 2023-10-02 Tc-99m MDP bone scan

  • In comparison with the previous study on 2023/07/18, faint hot spots in the right rib cage and the lesion of increased radiotracer uptake in the T9 spine come to slighly more evident, bone metastasis may be considered. Please correlate with other imaging modalities for further evaluation.
  • Suspected benign lesions in the lower L-spine, bilateral shoulders, hips, and knees.

• 2023-08-31 CT - chest

  • Pleural thickening and nodularity is noted at right middle lobe and right lower lobe pleura and interlobar fissure. In comparison with CT dated on 2023-06-09, the lesion is stationary.

• 2023-07-18 Tc-99m MDP bone scan

  • In comparison with the previous study on 2021/04/13, a new lesion in the lower T-spine. Either degenerative change or bone metastasis may show this picture. Please correlate with other imaging modalities for further evaluation.
  • The lesions in the lower L-spines are slightly less evident. Degenerative spine diseases may show such pictures.
  • Some new faint hot spots in the right rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Probably degenerative joint lesions in bilateral shoulders, hips, and knees.

• 2023-06-09 CT - chest

  • Right middle lobe and right lower lobe pleural thickening and nodularity, stationary

• 2023-03-13 CT - chest

  • stationary in size of RLL and RML solid nodular lesions and Rt parietal pleural thickening as compared with previous CT study on 2022/10/24

• 2022-10-24 CT - chest

  • stationary in size of RLL and RML solid nodular lesions and Rt parietal pleural thickening as compared with previous CT study on 2022/08/01

• 2022-08-01 CT - chest

  • stationary in size of RLL and RML solid nodular lesions as compared with previous CT study on 2022/04/12

• 2022-04-12 CT - chest

  • stationary in size of RLL and RML solid nodular lesions as compared with previous CT study on 2021/12/20
  • mild bronchiolitis at RUL.

• 2021-12-20 CT - chest

  • stationary in size of RLL and RML solid nodular lesions as compared with previous CT study on 2021/09/15

• 2021-08-15 CT - chest

  • stationary in size of RLL and RML solid nodular lesions as compared with previous CT study on 2021/04/13

• 2024-04-13 Tc-99m MDP bone scan

  • Increased radiotracer uptake in the lower L-spine. Degenerative spine diseases may show such pictures. However, please correlate with other imaging modalities for further evaluation.
  • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Probably degenerative joint lesions in bilateral shoulders, sacroiliac joints, hips, and knees.

• 2021-04-13 CT - chest

  • decrease in size of RLL and RML solid nodular lesions as compared with previous CT study on 2020/12/09.

• 2021-01-18 CXR erect

  • minimal Rt pleural effusion and pleural thickening
  • ill-defined nodular lesions in RLL and RML
  • mild enlarged cardiac silhoutte

• 2020-12-09 CT - chest

  • decrease in size of RLL and RML solid nodular lesions and Rt pleural effusion as compared with previous CT study on 2020/10/15.

• 2020-10-15 CT - chest

  • right lower lobe lung cancer with right pleural and right middle lobe meta. In regression.
  • Hepatic low density lesion, r/o simple cyst. Suggest follow up.

• 2020-07-27 Tc-99m MDP bone scan

  • Diffusely increased radiotracer uptake in right lower rib cage, pleural effusion, especially that being malignant in nature, may show such a picture. Please correlate with clinical findings and other work-up studies for further evaluation.
  • Mildly and non-focally increased radiotracer uptake in lower L-spine and sacrum, degenerative spine diseases may show such pictures.
  • Probably degenerative joint lesions in shoulders, sacroiliac joints, hips, and left knee.
  • No definite evidence of osteoblastic skeletal metastasis by this bone scan.

• 2020-07-24 MRI - brain

  • Mild ventriculomegaly. Otherwise, no evidence of intracranial lesion.

• 2020-07-23 CXR

  • mild residual Rt pleural effusion s/p pigtail drainage tube inserted
  • masslike consolidations with reticular opacities in RML and RLL

• 2020-07-23 Patho - lung transbronchial biopsy

  • Lung, ? side, needle biopsy—adenocarcinoma, moderately differentiated
    
  • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma. The immunohistochemiclcal stains are done in N2020-02193.

• 2020-07-23 CT - chest

  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • Chest CT with and without IV contrast enhancement shows:
    • Chest: Mass like lesion at right lower lobe about 3.12cm in largest dimension. (Se304 IM40), Several consolidation patch is found. at right lung.
    • Pleural thickening at right hemithorax with small lymph nodes in the mediastinum is found.
    • No evidence of mass like lesion at left lung.
    • Right pleural effusion s/p pigtail placement.

• 2020-07-22 Bronchodilator Test, BDT

  • Diagnosis: Asthma
  • Conclusion: severe obstructive ventilatory impairment with good BD response

• 2020-07-20 CXR erect

  • massive Rt pleural effusion,
  • Tortousity of thoracic aorta

• 2020-07-20 SONO - chest

  • Right massive pleural effusion post pig-tail insertion.

[MedRec]

• 2024-08-01 ~ 2024-08-09 POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • Adenocarcinoma of pancreatic head tumor with liver, left adrenal, bone metastasis, T2N1M1, distal common bile duct obstruction status post percutaneous transhepatic cholangial drainage on 2024/04/09, status post internal stent on 4/22.
    • Lung cancer,Right lower lung adenocarcinoma, T4N2M1b with bone metastasis, under Tagrisso since 109-10-07
    • Obstruction of bile duct
    • Other postherpetic nervous system involvement
    • Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
    • Constipation
    • Anemia in neoplastic disease
    • Encounter for antineoplastic chemotherapy
  • CC
    • Chills for 2 days.
  • Present illness
    • This 72-year-old female has histories 1. Asthma, 2. Allergic rhinitis, 3. Lung cancer, RLL adenocarcinoma, T4N2M1b with bone metastasis, under Tagrisso since 2020-10-07. She was regular follow up at Chest Medicine OPD.
    • Initial, she suffered from frequent epigastric fullness and depleted was noted for several months. She also told skin yellowish discoloration and tea color urine were noted since last week. She came to GI OPD for help on 2024/04/08 and laboratory elevated hepatobiliary enzyme (AST:200 U/L,ALT: 135 U/L, TBI:5.93mg/dl) was found, where recommend hospitalization. Due to abdominal pain over RUQ area.
    • Abdominal CT on 2024/04/09 revealed 1. r/o pancreatic cancer (2.8cm) with distal CBD obstruction. 2. Two regional lymph nodes, r/o lymph node metastasis. 3. Left adrenal nodule; DDx: metastasis, adrenal adenoma.
    • PTCD was inserted by radiologyist.
    • EUS FNB of pancreas was done on 2024/04/12 and pathology showed ductal adenocarcinoma.
    • ERCP for Biliary obstruction s/p EST was arrange on 2024/04/15.
    • Arrange ERCP for s/p interal stent and removed PTCD on 2024/04/22.
    • Arrange PET on 2024/04/19 for r/o other distant metastasis revealed Glucose hypermetabolism in the multiple lung, liver, left adrenal and bone metastases.
    • She received radiotherapy to L1, L5 for 3000cGy/10 fx is suggested for pain control start since 2024/05/06~5/17.
    • Port-A implantation on 2024/05/13.
    • Follow up 2D echo on 2024/05/09 showed LVEF:71%, 1.Normal LV filling pressure, 2.Normal LV and RV systolic function.
    • She received chemotherapy with FOLFIRINOX (1st all 50%: Oxalip 85mg/m2, Campto 150mg/m2, LV 400mg/m2, 5FU 2400mg/m2) on 2024/05/13 (C1D1), 2024/5/29 (2nd 60%, C1D15), 2024/6/19 (3rd 60%, C2D1), 2024/07/09 (4th 70%, C2D15).
    • This time, she was admitted to the ward for chemotherapy with FOLFIRINOX on 2024/08/01. However, ever since last discharge 3 weeks ago after 4th chemotherapy, the patient suffered from persisted watery diarrhea. The recent 2 days, she also developed left feet edema and chills. There was no fever, no abdominal pain, no cough and throat pain, no burning urinary sensation. Thus, she was admitted for survey first before receiving her next round of chemotherpy.
  • Course of inpatient treatment
    • After admission, the patient was given antibiotics under Meropenem and Cravit.
    • Blood culture on 2024/08/01 showed Pseudomonas aeruginosa.
    • We followup on her total bilirubin and showed continuing elevating of level.
    • We arranged abdomen CT on 2024/08/02 showing ill-defined poor enhancing mass in the pancreatic head, causing marked dilatation of IHDs, CHD, CBD, gallbladder and pancreatic duct. Thus, we consulted GI man for ERCP with stent. Procedure went smoothly without complications.
    • After procedure, we checked her amylase and lypase within normal limits; total bilirubin level also decreased. Her bile culture on 2024/08/06 revealed Enterococcus faecalis Growth:1+ with sensitivity to current antibiotics.
    • We start oral feeding after ERCP and the patient could tolerate well. Thus, under stable condition, the patient is discharged today.
  • Discharge prescription
    • BaoGan (silymarin 150mg) 1# QD
    • MgO 250mg 1# TID
    • Mosapin (mosapride citrate 5mg) 1# BID
• 2020-07-20 ~ 2020-07-28 POMR Chest Medicine Huang JunYao
  • Discharge diagnosis
    • Malignant neoplasm of right main bronchus
    • Pleural effusion in other conditions classified elsewhere
    • Unspecified asthma, uncomplicated
  • CC
    • Cough for three months.
    • Dyspnea on exertion without scanty sputum for a long time.
  • Present illness
    • This 68-years-old female patient with past history of 1) asthma 2) Allergic rhinitis. She was lost followed up.
    • This time, she suffered from cough for three months. Dyspnea on exertion without scanty sputum for a long time. She denied fever and chills. There was also no significant TOCC history. So she visited to our LMD for help than arrange ward.
    • However, she came to our CM ward. Her vital signs were TPR: 36.1/78/20, BP: 220/121mmHg, SpO2: 93%. Respiratory smooth, right breathing sound course, wheezing, crackle and decreased. Lab data: Leukocytosis (WBC: 14740/uL).
    • CXR films on massive Rt pleural effusion, tortousity of thoracic aorta, no abnormal density of visualized bones based on plain image, clear Lt lung field based on plain image. Under the impression of right pleural effusion, she was admitted to CM ward for management.
  • Course of inpatient treatment
    • After admission, empirical antibiotic with Avelox (7/20-7/26), fever was noted on 7/26, than shift to Tapimycin (7/26~7/28) for infection control. Right plueral effusion s/p pigtail on 7/20 and monitor pigtail drainage. Arrange pulmonary function tests on 7/22 and data showed severe obstructive ventilatory impairment with good BD response. Thus, metered-dose inhaler with Spiriva since 7/22.
    • Chest CT guiding biopsy of RLL pleural mass on 7/22 and cell block pathology report displayed it is compatible with metastatic pulmonary adenocarcinoma. After biopsy no pneumothorax, no hemorrhage and no air embolism.
    • MRI of Brain on 7/24 and showed no brain meta.
    • Bone scan on 07/27 and showed no definite evidence of osteoblastic skeletal metastasis by this bone scan.
    • Assist in applying for Lung Cancer Major Injury Card on 7/24.
    • We performed genetic testing (PD-L1, ROS1, EGFR, ALK IHC) on 7/27, data was pending.
    • TKI with Giotrif 30mg/tab stat and 1# QDAC since 7/27.
    • Chemotherapy regimen as C1 Cyramza (2+2) toal 400mg on 07/27.
    • The Chest echo was followed on 7/28 and showed improve plueral effusion then remove pigtail. There were no nausea, vomiting, SOB or chest pain after chemotherapy. Only mild general malaise was mentioned and improved after bed reset and medica treatment. Under the stable condition, she was discharged on 7/28 and will be followed up at OPD on 8/12.
  • Discharge prescription
    • Giotrif (afatinib 30mg) 1# QDAC 14D
    • Ulstop (famotidine 20mg) 1# BID 14D
    • LacTam (acetaminophen 500mg) 1# PRNQ6H if BT > 38’C or pain

[consultation]

• 2024-04-16 General and Gastroenterological Surgery
  • Q
    • Due to pancereas pathology showed: Malignancy, we need further operation assessment, thank you~
  • A
    • primary pancreatic cancer, with regional LN metastasis. left adrenal gland metastasis?
    • PHx; RLL and RML adenocarcinoma, with mediastinum LAP(+), with bone metastasis
    • Suggest:
      • please arrange PET for r/o other distant metastasis
      • we will discuss with the patient and her family about following Tx
• 2024-04-16 Hemato-Oncology
  • Q
    • This 72-year-old female has histories 1. Asthma, 2. Allergic rhinitis, 3. Lung cancer, RLL adenocarcinoma, T4N2M1b with bone metastasis, ECOG 1 under Tagrisso since 2020-10-07. She was regular follow up at Chest Medicine OPD.
    • This time, she suffered from frequent epigastric fullness and depleted was noted for several months. She also told skin yellowish discoloration and tea color urine were noted since last week. She came to GI OPD for help on 4/8 and laboratory elevated hepatobiliary enzyme (AST 200 U/L, ALT 135 U/L, TBI 5.93mg/dl) was found, where recommend hospitalization. Due to abdominal pain over RUQ area. There was no fever, no dizziness, no URI symptoms, no chest tightness, no tarry/bloody/clay stool. She visited ER for help. At ER, TPR showed 35.3 degree/ 88 bpm/ 18 bpm, BP: 145/74 mmHg, consciousness was clear. Blood test showed no leukovytosis (7.71x10^3/uL), but left shift (Seg. 85.4%), elevated CRP level (4.6 mg/dL), anemia (Hb 9.9 g/dL), hypokalemia (3.1 mmol/L).
    • Abdominal CT revealed 1. r/o pancreatic cancer (2.8cm) with distal CBD obstruction. 2. Two regional lymph nodes, r/o lymph node metastasis. 3. Left adrenal nodule; DDx: metastasis, adrenal adenoma. PTCD was inserted by radiologyist. Medicine treatment with 0.298 % KCL and antibiotic treatment with Brosym were administered. Under the impression of suspect pancreatic cancer (2.8cm) with distal CBD obstruction s/p PTCD. She was admitted to the ward for furter evaluation and management.
    • Due to pancereas patrhologic diagnosis showed: Malignancy, we need your evaluation an advice, thank you~
  • A
    • This 72-year-old woman is a case of asthma, lung cancer (RLL adenocarcinoma, T4N2M1b with bone metastasis), ECOG 1, under Tagrisso since 2020-10-07. She was admitted due to epigastric fullness and tea-colored urine.
      • Abdominal CT revealed:
        • Pancreatic cancer (2.8cm) with distal CBD obstruction, with consideration for further evaluation to rule out metastasis.
        • Two regional lymph nodes, with consideration for lymph node metastasis.
        • Left adrenal nodule, with consideration for metastasis or adrenal adenoma.
        • PTCD was inserted by a radiologist. Pancreatic EUS biopsy shows ductal adenocarcinoma (T2N1 at least).
    • Suggestions:
      • Consider arranging a PET/CT scan for further workup. (You may inquire whether this can be covered by insurance through the Nuclear Medicine Department.)
      • Consult General Surgery for operative evaluation.
• 2020-12-22 Dermatology
  • Q
    • For erythmatous skin rash with itchy
    • This 68-years-old female patient with past history of Asthma and allergic rhinitis without out control, Lung cancer, RLL adenocarcinoma, T4N2M1b with bone metastasis, ECOG 1, T4: RLL mass with RML, N2: right mediastinal LAPs ,M1b: bone metasatsis ;EGFRmutation: L858R (-), exon 19 (+), ALK(-) was diagnosed on 109-07-27. The lung cancer treatment regimen as below: =＞ 1st chemotheray with TKI Giotrif combined with C1 Cyramza since 109-07-27, and thenTKI Giotrif shifted Tagrisso since 109-10-07 ( approve by NHIA).
      
    • 5 Days prior to this admission, general multiple erythmatous skin rash with itchy was occured, she was went to LMD for help, but in vain. Because the skin rash condition became worse day by day, she went to our CM OPD for help today. Under the impression of Allergic urticaria ; drug related ?, she was admitted to our CM ward for further management and evaluation .
  • A
    • Skin finding:
      • generalized erythematous macules, patches, and plaque with targetoid-like lesions on face, trunk and 4 limbs, oral mucosal ulcer(+)
    • Imp: r/o Steven-Johnson syndrome/toxic epidermal necrolysis, culprit drug?! r/o Tagrisso related??? or other C/T drugs???
    • Plan:
      • hold suspected drugs as soon as possible
      • vena 1amp IV Q8H
      • systemic steroid is indicated if no contraindication, eg. rinderon 4mg IV Q12H, or hydrocortisone 100mg Q8H, with slowly tappering
      • mycomb cream BID for trunk and 4 limbs
      • nincort gel for oral ulcer
      • watch out sequale of SJS/TEN, eg. eye mucosal or genital mucosal lesion, GI bleeding, etc

[immunochemotherapy]

• 2024-08-22 - oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 130mg D5W 250mL 1.5hr + leucovorin 400mg/m2 340mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2000mg D5W 500mL 46hr (FOLFIRINOX 70%)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-07-09 - oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 130mg D5W 250mL 1.5hr + leucovorin 400mg/m2 350mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2100mg D5W 500mL 46hr (FOLFIRINOX 70%)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-06-19 - (FOLFIRINOX 70%)

• 2024-05-29 - (FOLFIRINOX 70%)

• 2024-05-13 - (FOLFIRINOX 70%)

• 2021-04-15 - ramucirumab 600mg NS 250mL 90min (Cyramza)

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2020-12-09 - durvalumab 240mg NS 250mL 1hr (Imfinzi)

• 2020-12-08 - ramucirumab 600mg NS 250mL 90min (Cyramza)

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2020-11-11 - ramucirumab 600mg NS 250mL 90min (Cyramza)

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2020-10-15 - ramucirumab 600mg NS 250mL 90min (Cyramza)

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2020-09-17 - ramucirumab 400mg NS 250mL 90min (Cyramza)

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2020-08-19 - ramucirumab 400mg NS 250mL 90min (Cyramza)

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2020-07-27 - ramucirumab 400mg NS 250mL 90min (Cyramza)

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

Tagrisso (osimertinib 80mg) - 2020-10-07 ~ Giotrif (afatinib 30mg) - 2020-08 ~ 2020-10

==========

2024-08-23

[favorable tolerability of Tagrisso, effective FOLFIRINOX treatment with elevated CA199 levels]

A CT on 2024-08-02 showed stable disease under ongoing FOLFIRINOX treatment, suggesting the regimen remains effective. However, a CA199 level above 15,000 U/mL was observed on 2024-08-09, warranting further monitoring of disease progression.

Uliden (ursodeoxycholic acid) has been prescribed for elevated bilirubin. The patient has been taking Tagrisso (osimertinib 80mg) 1 tablet QD for lung cancer since 2020-10-07 and is tolerating the treatment well. No medication issues have been identified.

• 2024-08-09 CA199 (NM) 15003.7 U/ml
• 2024-06-07 CA199 25.58 U/mL
• 2024-05-24 CA199 13.13 U/mL
• 2024-05-10 CA199 12.44 U/mL
• 2024-04-11 CA199 54.05 U/mL

2024-08-02

[addressing infection and bilirubin rise in patient care]

Lab results showed elevated PCT and CRP, suggesting a possible infection. The patient is being treated with Cravit (levofloxacin) and Mepem (meropenem). Additionally, bilirubin levels have rapidly increased, primarily due to elevated conjugated bilirubin. Uliden (ursodeoxycholic acid) has been administered. No medication issues have been identified.

• 2024-08-01 CRP 16.1 mg/dL
  

• 2024-08-01 Procalcitonin (PCT) 9.36 ng/mL

• 2024-08-02 Bilirubin total 3.72 mg/dL
  

• 2024-08-01 Bilirubin total 3.37 mg/dL
  

• 2024-07-09 Bilirubin total 0.95 mg/dL
  

• 2024-06-18 Bilirubin total 0.76 mg/dL
  

• 2024-06-07 Bilirubin total 0.47 mg/dL

• 2024-08-02 Bilirubin direct 2.64 mg/dL
  

• 2024-06-18 Bilirubin direct 0.28 mg/dL
  

• 2024-05-29 Bilirubin direct 0.11 mg/dL

701523105

240823

[exam findings]

• 2024-05-17 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Tumor, proximal ascending colon, laparoscopic right hemicolectomy — Adenocarcinoma
    • Resection margins, bilateral, ditto — Free of tumor invasion
    • Lymph node, mesocolic, dissection — Metastatic adenocarcinoma (3/30)
    • Appendix — Free of tumor invasion
    • AJCC pathologic stage — pT4aN1b, stage IIIB, if cM0
  • MACROSCOPIC EXAMINATION
    • Operation procedure: laparoscopic right hemicolectomy
    • Specimen site: ascending colon, terminal ileum and appendix
    • Specimen size: (a) A-colon: 21.3 cm in length, up to 8 cm in circumference, (b) Terminal ileum: 2.8 cm in length, 2.2 cm in diameter and (c) Appendix: 6 cm in length, 0.6 cm in diameter
    • Tumor size: 4.7 cm
    • Tumor location: proximal ascending colon, 3 and 12.5 cm away from bilateral resection margins
    • Tumor appearance: annular ulcerative mass
    • Depth of invasion grossly: visceral peritoneum
    • Representatively embedded for sections as A1: ileum + colonic margin, A2: appendix, A3-A12: tumor + serosa (ink), A13: tumor, A14-A18: lymph nodes
  • MICROSCOPIC EXAMINATION
    • Histology: adenocarcinoma with tumor necrosis
    • Histology Grade: G2, moderately differentiated
      
    • Depth of invasion: visceral peritoneum
    • Angiolymphatic invasion: Present
    • Perineural invasion: Present
    • Discontinuous extramural tumor extension: NOT present
    • Circumferential (radial) margin: involved
    • Lymph node metastasis, mesocolic: metastatic adenocarcinoma (3/30)
    • Lymph node metastasis, IMA / SMA: N/A
    • Extranodal involvement: present (3/3)
    • Pathological TNM Stage: pT4aN1b
    • Type of polyp in which invasive carcinoma arose: N/A
    • Additional pathologic findings: not identified
    • TNM descriptors: N/A
      
    • Tumor regression grading S/P CCRT: N/A
    • Immunohistochemistry: EGFR(+), PMS2(+), MSH2(+), MSH6(+) and MLH1(+) for tumor
• 2024-05-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (94 - 42) / 94 = 55.32%
    • M-mode (Teichholz) = 55
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA
    • Mild MR and trivial TR
    • Preserved RV systolic function
• 2024-05-14 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Left ventricular hypertrophy with repolarization abnormality
• 2024-05-10 CT - chest
  • Indication: A-colon cancer, for pre-op evaluation and staging
  • Impression: no abnormality in the lungs. moderate CAD.
• 2024-05-06 Patho - colon biopsy
  • Tumor, 90 cm from anal verge, biopsy — Compatible with adenocarcinoma
  • Microscopically, the section shows a picture compatible with adenocarcinoma characterized by a few atypical epithelial nests show enlarged hyperchromatic nuclei, embedded within much necrotic debris as well as some benign colon mucosa tissue. According to image (CT shows 5.1 cm tumor, cT4aN1bM0) and scope (4 cm tumor) findings, it is compatible with adenocarcinoma. Clinical correlation is advised.
• 2024-04-29 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Soft tissue mass at right ascending colon with extraluminal extension is found up to 5.1cm in largest dimension. (se701 Im42). Colon cancer with peritoneal seeding is considered.
    • Enlarged left adrenal gland nodularl lesion is found up to 1.7cm is found. r/o adenoma.
    • Tiny hepatic cyst at left lateral segment up to 1.06cm in largest dimension is found.
  • Imp:
    • Colon cancer at ascending colon with peritoneal extension?
• 2024-04-26 SONO - abdomen
  • Symptoms:
    • Liver:
      • moderate increased brightness.
      • one 1.0cm anechoic lesion with PAE at S3.
    • Bile duct and gallbladder:
      • negative
    • Portal veins and blood vessels:
      • negative
    • Kidney:
      • heterogenous echotexture of bilateral kidneys and several anechoic lesions with PAE in bilateral kidneys, size around 1.0~1.4cm.
    • Pancreas:
      • Some parts of pancreas blocked by bowel gas, especially body and tail
    • Spleen:
      • negative
    • Ascites:
      • focal fluid accumulation at RLQ area.
    • Others:
      • one focal wall thickening at RLQ area, at least 4cm in length and some focal ascites nearby.
  • Diagnosis:
    • suspicous, Colon lesion(A-colon) with focal ascites
    • Fatty liver, moderate
    • Liver cyst, S3
    • Parenchymal renal disease and renal cyst, bilateral
    • pancreatic body and tail masked by gas.
  • Suggestion:
    • correlate with other image or CFS.

[MedRec]

• 2024-07-05 SOAP Gastroenterology Zhao YouCheng
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD

[chemotherapy]

• 2024-08-22 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (FOLFOX. Oxa 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-07-23 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (FOLFOX. Oxa 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-06-25 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (FOLFOX. Oxa 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-08-23

[CEA and CA199 doubling: consider updating imaging]

Hyponatremia and hypomagnesemia were observed and appropriately supplemented.

• 2024-08-22 Na (Sodium) 127 mmol/L
• 2024-08-22 Mg (Magnesium) 1.5 mg/dL

The patient has received 3 sessions of FOLFOX (with 80% oxaliplatin dose) at approximately 28-day intervals, with the last session on 2024-08-22. The eGFR has remained around 70 ml/min/1.73m² over the past few months, so no dose adjustment is needed.

Notably, both CEA and CA199 markers have doubled in the past month, suggesting that updating imaging may be necessary to assess disease progression.

• 2024-08-13 CEA (NM) 7.470 ng/ml

• 2024-07-09 CEA (NM) 2.764 ng/ml

• 2024-06-14 CEA (NM) 4.450 ng/ml

• 2024-04-27 CEA 118.16 ng/ml

• 2024-08-13 CA-199 (NM) 53.183 U/ml

• 2024-07-09 CA-199 (NM) 24.645 U/ml

• 2024-06-14 CA-199 (NM) 46.408 U/ml

700882780

240822

[MedRec]

• 2024-08-12 SOAP Hemato-Oncology Gao WeiYao
  • A/P
    • 2024/08/09 Free Light Chain κ/λ; FKLC = 27.37 mg/L
• 2024-08-05 SOAP Hemato-Oncology Gao WeiYao
  • A/P
    • Severe anemia and thrombocytopenia nature to be determined (20240805)
    • Buttock pain
    • Hearing impairment
    • BPH ?
• 2017-01-25 SOAP Neurology Yang FuYi
  • Diagnosis
    • Cerebral atherosclerosis [I67.2]
    • Cervical spondylosis without myelopathy [M47.892]
    • Dizziness and giddiness [R42]
    • Chronic ischemic heart disease, unspecified [I25.9]
  • Prescription x3
    • Celebrex (celecoxib 200mg) 1# PRNQD
    • Euclidan SC (nicametate citrate 50mg) 1# BID
    • diphenidol 25mg 1# PRNQD
    • Pentop (pentoxifylline 400mg) 1# BID
• 2017-01-17 SOAP Urology Lin JiaDa
  • Diagnosis
    • Hypertrophy (benign) of prostate [N40.1]
    • Other inflammatory disorders of penis [N48.29]
  • Prescription x3
    • Mycomb BID TOPI 7D
    • Urief (silodosin 4mg) 1# BID

==========

2024-08-22

[assessing anemia and thrombocytopenia with elevated FKLC]

Anemia, thrombocytopenia, elevated free kappa light chain, and normal levels of serum IgG, IgA, IgM, and IgE were observed. Possible causes include aplastic anemia or multiple myeloma, and a bone marrow biopsy has been arranged.

Underlying conditions are being managed with medications from the active list, and no discrepancies have been identified.

• 2024-08-21 HGB 7.2 g/dL **
  

• 2024-08-19 HGB 6.7 g/dL ***

• 2024-08-12 HGB 8.1 g/dL *
  

• 2024-08-05 HGB 9.3 g/dL
  

• 2024-08-05 HGB 8.8 g/dL *
  

• 2024-08-05 HGB 5.3 g/dL ****

• 2024-06-11 HGB 9.3 g/dL
  

• 2024-03-04 HGB 9.3 g/dL

• 2024-08-21 PLT 101 *10^3/uL
  

• 2024-08-19 PLT 119 *10^3/uL
  

• 2024-08-12 PLT 108 *10^3/uL
  

• 2024-08-05 PLT 98 *10^3/uL
  

• 2024-08-05 PLT 87 *10^3/uL
  

• 2024-08-05 PLT 100 *10^3/uL
  

• 2024-06-11 PLT 134 *10^3/uL
  

• 2024-03-04 PLT 173 *10^3/uL

• 2024-08-09 FKLC 27.37 mg/L *

• 2024-08-09 FLLC 18.28 mg/L
  

• 2024-08-09 FK/FL ratio 1.50 ratio

• 2024-03-13 IgG/A/M Kappa/Lambda No Paraprotein
  

• 2024-03-11 IgG (blood) 953 mg/dL
  

• 2024-03-11 IgA 102 mg/dL
  

• 2024-03-11 IgM 129.0 mg/dL
  

• 2024-03-05 IgE 6.64 IU/mL

701519596

240822

[exam findings]

• 2024-08-22 CT - chest
  • Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck
  • Chest CT with and without IV contrast enhancement shows:
    • Tree in bud appearance of bilateral lung fields is found.
    • S/p port-A placement with its tip at Superior vena cava
    • s/p cholecystectomy.
    • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
  • Imp:
    • No evidence of recurrent/residual lymphadenopathy in the study.
    • Liver cirrhosis.
• 2024-07-22 SONO - neurology
  • Mild atherosclerosis in right ECA and right ICA.
  • Normal extracranial carotid and vertebral arterial flows.
• 2024-07-06 MRA - brain
  • IMP: Mild intracranial atherosclerosis. Mild mucosal thickening at right lateral nasopharyngeal recess.
• 2024-05-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 22) / 87 = 74.71%
    • M-mode (Teichholz) = 75
  • Conclusion:
    • Dilated LA
    • Thickening of IVS and LVPW
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Mild MR,AR, TR and PR
    • No regional wall motion abnormalities
• 2024-05-13 PET
  • Increased FDG uptake in bilateral nasopharyngeal regions (Deauville score 5) and in level V lymph nodes of the left neck region (Deauville score 5), highly suspected lymphoma with involvement of lymph node regions.
    
  • Increased FDG uptake in level V lymph nodes of the right neck region (Deauville score 3-4), probably reactive nodes (priority) or lymphoma with involvement of lymph node region.
  • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, probably reactive nodes, suggesting follow-up.
  • Increased FDG accumulation in bilateral kidneys, ureters, and colon, probably physiological uptake of FDG.
    
  • Lymphoma, c-stage II (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2024-05-10 CT - chest
  • Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck
  • Chest and abdomen without & with contrast enhancement:
    • old calcified LNs in the visceral space, sequela of previous TB infection
    • extensive coronary arterial calcification
    • Thoracic aorta: normal caliber, moderate atherosclerotic change of aortic arch and descending thoracic aorta.
    • mild dilatation of CHD and CBD that may be secondary to S/P cholecystectomy
    • suspect mild liver cirrhsosis, please clinical correlation.
    • Extensive atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
    • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • no LAP or abnormal soft-tissue mass in the chest and abdomen.
    • extensive 3V-CAD.
• 2024-05-09 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with 40 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • IHC stains: CD117: %; CD34: %; MPO: %, CD61: %; CD71: % (of the nucleated cells).
• 2024-04-17 Patho - lymphnode biopsy
  • Labeled as “left neck”, core biopsy — lymphoma present.
  • Section shows monotonous lymphoid cell infiltration.
  • IHC stain: CK (-), CD3 and CD20: a predominant B cell sub-population.
• 2024-04-16 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopharynx, left, biopsy — Follicular lymphoma, predominantly diffuse, grade 3A
  • The sections show a picture of follicular lymphoma with following features:
    • Specimen: Nasopharynx
    • Procedure: Biopsy
    • Tumor site: Nasopharyngeal tissue
    • Histologic type: Follicular lymphoma, predominantly diffuse with subtle follicles
    • Histologic grade: Grade 3A
    • Immunophenotyping: CD3(-), CD20(+), CD23(-/+), CD10(+), MUM1(+), and C-myc(-)
• 2024-07-15 Sinoscopy
  • Sinoscope: bi nasopharyngeal tumor without active oozing, biopsy from left side done
  • Impression: bi nasopharyngeal tumor
• 2024-04-11 MRI - nasopharynx
  • Findings
    • A huge soft tissue mass, about 51 mm at the largest dimension, with T1-hypointensity, T2-hyperintensity, poor enhancement and diffusion restriction involving nasopharynx, more prominent on right side.
    • Multiple enlarged lymph nodes (one with necrotic change) at left levels II and III, with the largest one about 23 mm at long axis.
    • A small retropharyngeal lymph node (7 mm) on left side.
    • Susceptibility artifacts over oral cavity due to dental prosthesis.
    • Mottled T2-hyperintensity in right mastoid air cells, indicating mastoiditis.
    • Mild mucosal thickening in bilateral maxillary and ethmoid sinuses, indicating chronic sinusitis.
    • Diffuse mucosal thickening over bilateral nasal turbinates.
  • IMP:
    • Nasopharyngeal tumor and left neck lymphadenopathy. D/D: lymphoma, nasopharyngeal carcinoma.
• 2024-04-02 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopharynx, right, biopsy — Atypical lymphoid hyperplasia
  • Section shows several pieces of respiratory epithelium lined tissue with infiltration of atypical median-size lymphoid cells.
  • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD56(+), and Cyclin D1(-).
  • The immunohistochemical stains of CD10, BCL2, BCL6, CD43, and CD5 show reserved lymphoid follicles.
  • The Ki-67 is increased. Please correlate with the clinical presentation and image study to exclude lymphoma.
• 2024-04-01 Sinoscopy
  • Description: bi nasopharyngeal tumor without active oozing, biopsy from right side done, surgicel cover on the biopsy wound
  • Impression: Nasopharyngeal lesion s/p biopsy
• 2024-03-25 Nasopharyngoscopy
  • bi nasopharyngeal tumor
  • epistaxis
  • Left nasal cavity tumor, suspect malignancy and causing epistaxis

[MedRec]

• 2024-05-09 ~ 2024-05-16 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck, stage II, status post R-COP
    • Chronic viral hepatitis B without delta-agent - anti-Hbc positive
    • port-A insertion via right cephalic vein on 2024/05/14.
    • Hypomagnesemia
  • CC
    • For bone marrow, PET, chemotherapy.
  • Present illness
    • This is a 81 years old man who has hypertension, Gout, Benign prostatic hyperplasia for 20+ years, regular follow-up at the clinic.
    • He suffered from left painless neck mass for a month, and nasal obstruction for long time, subsided partially after LMD antibiotics, bilateral epistaxis for 2 days, unknown body weight loss, so he was visiting Cardinal Tein Hospital ENT OPD for help first, then mass lesion over NPx told, s/p NPx biopsy twice (not Malignancy).
    • He came to our ENT OPD for help, and followed-up Nasopharynx MRI (2024/04/11) revealed Nasopharyngeal tumor and left neck lymphadenopathy. D/D: lymphoma, nasopharyngeal carcinoma.
    • The nasopharynx (left) biopsy was done on 2024/04/16, the report showed Follicular lymphoma, predominantly diffuse, grade 3A, Immunophenotyping: CD3(-), CD20(+), CD23(-/+), CD10(+), MUM1(+), and C-myc(-).
    • The SONO guide at left lymph node, the biopsy revealed lymphoma present. IHC stain: CK (-), CD3 and CD20: a predominant B cell sub-population on 2024/04/17.
    • Under the imperssion of Follicular lymphoma, predominantly diffuse, grade 3A. So he is admitted for bone marrow, PET, and chemotherapy.
  • Course of inpatient treatment
    • After be admitted, he received bone marrow was done on 2024/05/09, the biopsy report: Negative for malignancy.
    • Continue Compesolon 1tab PO BID for Follicular lymphoma, Baraclude 0.5mg/tab (Entecavir) 1tab PO QDAC for HBsAg reactive.
    • Followed-up chest- abdomen CT (2024/05/10) revealed: no LAP or abnormal soft-tissue mass in the chest and abdomen, extensive 3V-CAD.
    • After bone marrow, no bleeding signs. Consulted GS for port-a insertion evaluation.
    • Whole body PET scan (2024/05/13) showed: 1. Increased FDG uptake in bilateral nasopharyngeal regions (Deauville score 5) and in level V lymph nodes of the left neck region (Deauville score 5), highly suspected lymphoma with involvement of lymph node regions. 2. Increased FDG uptake in level V lymph nodes of the right neck region (Deauville score 3-4), probably reactive nodes (priority) or lymphoma with involvement of lymph node region. 3. Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, probably reactive nodes, suggesting follow-up. 4. Increased FDG accumulation in bilateral kidneys, ureters, and colon, probably physiological uptake of FDG. 5. Lymphoma, c-stage II (AJCC 8th ed.), by this F-18 FDG PET scan.
    • The port-A insertion on 2024/05/14, and the family meeting was done on 05/14 24.
    • He received #1 chemotherapy with R-COP (the dose dreased due to old age) on 2024/05/15. After chemotherapy, he denide having a fever, vomiting, dyspnea or any complaints. He can be discharged on 2024/05/16, the OPD follow-up will be arranged.
  • Discharge prescription
    • MgO 250mg 1# TID 7D
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 7D
    • Alpraline (alprazolam 0.5mg) 1# HS 7D
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Compesolon (prednisolone 5mg) 5# BID 3D
    • Ulstop (famotidine 20mg) 1# QN 7D

[immunochemotherapy]

• 2024-08-21 - (R-COP)
• 2024-07-27 - (R-COP)
• 2024-07-05 - (R-COP)
• 2024-06-14 - (R-COP)
• 2024-05-15 - (R-COP)

==========

2024-08-22

[addressing hypomagnesemia and elevated D-dimer levels]

Hypomagnesemia (1.5 mg/dL on 2024-08-21) is being treated with MgSO4 injections. Elevated D-dimer (2338 ng/mL) may warrant continued monitoring. Other lab results were generally unremarkable, and no medication issues were identified.

701528009

240822

[exam findings]

• 2024-08-20 CXR, Chest supine a-p view
  • Patchy opacity projecting at right upper lung and right hilum with lung volume decrease is noted, which is c/w bronchogenic carcinoma after correlate with CT.
  • Interstitial and alveolar infiltrates involving predominantly the mid-and lower-lung fields are seen. Acute pulmonary edema is suspected.
  • The differential diagnosis includes Bronchopneumonia and lymphangitic carcinomatosis. please correlate with clinical condition and CT.
  • Atherosclerotic change of aortic arch
  • Scoliosis of the T-spine with convex to right side.
• 2024-08-01 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 71) / 116 = 38.79%
    • M-mode (Teichholz) = 38
    • 2D (M-Simpson) = 39
  • Conclusion:
    • Moderately abnormal LV systolic function with global hypokinesia
    • Moderate MR, trivial TR and trivial PR
    • Preserved RV systolic function
    • Mild pulmonary hypertension
    • Tachycardia with HR 142~144 at the exam
• 2024-08-01 ECG
  • Sinus tachycardia
  • Left axis deviation
  • Poor wave progression V1~3
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2024-07-31 ECG
  • Sinus tachycardia
  • ST elevation only V3
• 2024-07-31 ECG
  • Sinus tachycardia
  • ST elevation consider anterior injury or acute infarct
• 2024-07-29, -07-26, -07-04, -06-27 CXR erect
  • Huge Patchy opacity projecting at right upper lung and right hilum with lung volume decrease is noted, which is c/w bronchogenic carcinoma. Please correlate with CT.
  • S/P PICC catheter insertion via right forearm.
  • Atherosclerotic change of aortic arch.
  • Scoliosis of the T-spine with convex to right side.
• 2024-06-28 MRI - brain
  • IMP: No evidence of intracranial lesion. Chronic paranasal sinusitis and nasal polyposis, more severe on right side.
• 2024-06-27 Tc-99m MDP bone scan
  • Increased activity in the L 3 and L5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, elbows, wrists, hips, knees, ankles and feet, compatible with benign joint lesions.
• 2024-06-26 PET
  • Glucose hypermetabolism in the right upper lung with involvement of lymph nodes in the right pulmonary hilar region, bilateral mediastinal spaces, right ICF, and bilateral SCF, highly suspected lung cancer with regional lymph nodes metastases.
    
  • Glucose hypermetabolism in lymph nodes in the right lower neck region, right post. back region, and at the L5 spine, highly suspected lung cancer with distant metastases.
    
  • Right upper lung cancer, cTxN3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2024-06-20 Patho - bronchus biopsy
  • Lung, RUL, bronchoscopic biopsy —- small cell carcinoma
  • Sections show large nests of small hyperchromatic tumor cells with scanty cytoplasm and marked crushing artifact, infiltrating in the bronchial wall.
  • The immunohistochemical stains reveal CK(+), TTF-1(focal +), Napsin A(-), CD56(+), Synaptophysin(+), and MPO(-). The Ki-67 is > 90%.
• 2024-06-20 Bronchoscopy
  • Bronchoscopic diagnosis:
    • RB1+RB2 bronchus total occlusion due to RULtumor with external compression
    • RB3 bronchus severely narrowing due to external compression
    • RUL peribronchial malignancy under EBUS
    • Main carina and right main bronchus mucosa tumor invasion
    • Right nasal mucosal polyp or tumor? easy touch bleeding
    • Chronic sinusitis
  • Bronchoscopic finding:
    • The nasal mucosa was severely hypertrophic.
    • Right nasal mucosal polyp or tumor? easy touch bleeding
    • The nasal lumen was very severely narrowed.
    • The was copious mucoid nasal discharge retained in the nasal cavity.
    • Mucosa of nasopharynx was hypertrophic.
    • Nasopharynx was severely narrowed. Mucosa of pharynx cobble-stone in shape.
    • Movement of the both. vocal cord(s) was normal.
    • Bilateral arytenoid proceww was normal.
    • Trachea whole segment: patent and the mucosa was normal.
    • Main carina: widening and fixed on deep breathing due to subcarina tumor invasion.
    • Bilateral endobronchial trees:
      • RB1+RB2 bronchus total occlusion due to RUL tumor submucosal invasion and the RUL tumor external compression.
        • Under EBUS of RB1+RB2 orifice, parabronchial adjacent homogenous infiltratiing lesion with some interrupted bronchial mucosa was noted, favor malignancy.
        • Under fluoroscent bronchoscopy, the mucosa was normal appearance.
      • RB3 bronchus severely narrowing due to external compression, but the scope can pass through.
        • Under EBUS of RB3, peribronchial within homogenous infiltratiing lesion with terrupted bronchial mucosa was noted, favor malignancy.
        • Under fluoroscent bronchoscopy of RB3, the mucosa was normal appearance.
      • The mocusa of right main bronchus orifice was invaded by submucosal tumors.
    • Special Procedures:
      • TBLB from RB3 and bronchus biopsy from RB1+RB3, for pathology.
    • Complication:
      • Self-limited post-biopsy bronchus bleeding
    • Notes:
      • Please Watch for the possibilties of hemoptysis, fever, or pneumothoraces
• 2024-06-19 Bronchodilator Test
  • moderate obstructive impairment before bronchodilator with significant bronchodilator response.
• 2024-06-12 Patho - bone marrow biopsy
  • Bone marrow, iliac crest, biopsy — Compatible with acute myeloid leukemia with maturation
  • The sections show hypercellular marrow (95%). The marrow space is replaced by a population of medium to large-sized immature cells with oval and slightly irregular nucleus, and small amount cytoplasm.
  • IHC: CD34(-), CD117(focal +), MPO(diffuse +), CD3(-), CD79a(-) and TdT(-). The finding is compatible with acute myeloid leukemia with maturation. Suggest bone marrow smear evaluation and cytogenetic correlation.
• 2024-06-11 CT - chest
  • With and without-contrast CT of chest revealed:
    • Consolidation of RUL. Enlarged LNs at mediastinum. Right pleural effusion. Emphysema of bil. lungs.
    • Small LNs at bil. axillary regions.
    • Liver and renal cysts (up to 1.4cm).
  • IMP:
    • Consolidation of RUL r/o malignancy. Enlarged LNs at mediastinum. Right pleural effusion. Emphysema of bil. lungs.

[MedRec]

[consultation]

• 2024-08-21 Cardiology

• 2024-07-16

• 2024-07-09 Radiation Oncology

  • Q
    • This is 63 year old male with underlying disease of DM, hypertension and thalassemia
    • AML and Lung RUL SCC, cTxN3M1c, stage IVB was diagnosed during this hospitalization period.
    • He received Chemotherapy with Cytarabine (C1D1) since 2024/07/03.
    • We need your expertise to evaluate his RUL SCC for radiotherapy.
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For radiotherapy due to small cell carcinoma.
      • PI: The patient suffered from AML and small cell carcinoma of the lung, RUL, stage cTxN3M1c, stage IVB. He received chemotherapy with Cytarabine (C1D1) since 2024-07-03. Consulted for radiotherapy of the RUL tumor.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
      • Personal Hx: DM (+); HTN (+)
      • Previous RT Hx: (-)
    • O: ECOG: 1
      • PE: neck and bil SCF: multiple nodal lesions over right SCF area.
      • CT scan of lung (2024-06-11): Consolidation of RUL r/o malignancy. Enlarged LNs at mediastinum. Right pleural effusion. Emphysema of bil. lungs.
      • Pathology (S2024-11915, 2024-06-14): Bone marrow, iliac crest, biopsy — Compatible with acute myeloid leukemia with maturation
      • Pathology (S2024-12576, 2024-06-25): Lung, RUL, bronchoscopic biopsy —- small cell carcinoma
      • PET (2024-06-26): 1. Glucose hypermetabolism in the right upper lung with involvement of lymph nodes in the right pulmonary hilar region, bilateral mediastinal spaces, right ICF, and bilateral SCF, highly suspected lung cancer with regional lymph nodes metastases. 2. Glucose hypermetabolism in lymph nodes in the right lower neck region, right post. back region, and at the L5 spine, highly suspected lung cancer with distant metastases. 3. Right upper lung cancer, cTxN3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
      • Bone scan (2024-06-27): no evidence of bone metastasis.
      • MRI (2024-06-28): No evidence of intracranial lesion. Chronic paranasal sinusitis and nasal polyposis, more severe on right side.
      • CXR (2024-07-04): Huge Patchy opacity projecting at right upper lung and right hilum with lung volume decrease is noted, which is c/w bronchogenic carcinoma. Please correlate with CT. S/P PICC catheter insertion via right forearm.
    • A:
      • Small cell carcinoma of the lung. RUL, extensive stage (stage cTxN3M1c).
      • AML
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: small cell carcinoma of the lung, extensive stage
      • Goal: palliation
      • Treatment target and volume: RUL tumor and peripheral involved nodal lesions
        
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 3000cGy/10 fractions of the RUL tumor and peripheral involved nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 0830, 2024-07-11.

• 2024-07-09 Nephrology

  • Q
    • This is 63 year old male with underlying disease of DM, hypertension and thalassemia
    • AML and Lung RUL SCC, cTxN3M1c, stage IVB was diagnosed during this hospitalization period.
    • Since his hypokalemia (K:2.5, 7/03), we prescribed KCL 10ml BID# and const-K 1# BID.
    • Then recheck his potassium level, but still hypokalemia
    • Lab
      • 2024-07-08 K (Potassium) 3.0 mmol/L
      • 2024-07-06 K (Potassium) 2.9 mmol/L
      • 2024-07-04 K (Potassium) 3.1 mmol/L
      • 2024-07-03 K (Potassium) 2.5 mmol/L
    • We need your expertise to evaluate his condition. Thanks!
  • A
    • Lab
      • 2024-07-08 Urine-Creatinine 16.58 mg/dL
        
      • 2024-07-08 K (Random Urine) 19.6 mmol/L
        
      • 2024-07-08 Na (Random Urine) 51 mmol/L
        
      • 2024-07-08 Urine osmolarity 331 mOsm/Kg
        
      • 2024-07-08 Blood Osmolality 276 mOsm/Kg
        
      • 2024-07-08 Na (Sodium) 133 mmol/L
        
      • 2024-07-08 K (Potassium) 2.9 mmol/L
        
      • 2024-07-08 Creatinine 0.67 mg/dL
        
      • 2024-07-08 Blood gas (Vein)
      • 2024-07-08 PH 7.456
        
    • Our impressions are as follows:
      • Severe hypokalemia (at least 200-300mEq K deficit) due to renal potassium wasting (urine K/Cr = 118 mmol/g) (TTKG=6), r/o RTA type I or II
      • Solute (osmotic) diuresis due to glucosuria
    • Our advices are as follows:
      • Record daily I/O and BW
      • Replete K with oral cons-K 2# TID to QID (max 200mEq/day) and follow up on serum K level QD
      • Discontinue SGLT2i and adjust current diabetes medications
      • Check urine analysis, urine phosphorus, urine uric acid
      • Check serum phosphorus, uric acid
      • Screen for possible Sjogren syndrome and autoimmune diseases (ANA, anti-dsDNA, C3, C4, RF, Anti-ENA SSA/SSB, ALT, LDH)
    • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance.
  • A 2024-07-12 17:48:04
    • After lab data reviewed, please consult meta to rule out addison’s disease.
    • Continue to prescribe potassium supplement until corrected.

• 2024-07-03 Family Medicine

  • A
    • Palliative combine care concent was signed, the patient and his wife agreed for combining care. At the moment he will proceed the neccessory treatment.
    • An advance directive has been provided, we suggested that the patient and his wife will do further discussion, and feel free to contact us anytime.
    • Indication: AML
    • plan: hospice combined care

[chemotherapy]

• 2024-07-03 - cytarabine 30mg/m2 48mg BID SC D1-7 (low dose Ara-C)

==========

2024-08-22

[managing hypokalemia and magnesium deficiency in renal potassium wasting]

Historical serum potassium levels indicate that the patient frequently experiences hypokalemia. In fact, urine data from 2024-07-08 showed potassium at 19.6 mmol/L and creatinine at 16.58 mg/dL, resulting in a urine K/Cr ratio as high as 118 mmol/g, which suggests renal potassium wasting.

The patient also has hypomagnesemia. Magnesium deficiency is often linked with hypokalemia, as literature suggests that magnesium deficiency exacerbates potassium wasting by increasing distal potassium secretion. A decrease in intracellular magnesium, due to magnesium deficiency, removes the magnesium-mediated inhibition of ROMK channels, leading to increased potassium secretion. However, magnesium deficiency alone does not necessarily cause hypokalemia; factors such as increased distal sodium delivery or elevated aldosterone levels may be required to worsen potassium wasting in the context of magnesium deficiency. Ref: Journal of the American Society of Nephrology 18(10):p 2649-2652, October 2007. DOI: 10.1681/ASN.2007070792

Increasing magnesium supplementation might help improve his hypokalemia.

• 2024-08-21 K (Potassium) 3.1 mmol/L
  

• 2024-08-08 K (Potassium) 3.3 mmol/L
  

• 2024-08-05 K (Potassium) 3.5 mmol/L
  

• 2024-08-03 K (Potassium) 3.0 mmol/L
  

• 2024-08-01 K (Potassium) 3.3 mmol/L
  

• 2024-08-01 K (Potassium) 3.6 mmol/L
  

• 2024-07-31 K (Potassium) 3.3 mmol/L
  

• 2024-07-30 K (Potassium) 3.4 mmol/L
  

• 2024-07-29 K (Potassium) 2.6 mmol/L

• 2024-08-21 Mg (Magnesium) 1.8 mg/dL
  

• 2024-08-08 Mg (Magnesium) 1.9 mg/dL
  

• 2024-08-05 Mg (Magnesium) 1.6 mg/dL
  

• 2024-08-03 Mg (Magnesium) 1.6 mg/dL

[AML treatment response: significant reduction in blast percentage]

Blast Percentage Trends: On 2024-06-11, the blast percentage was 87.0%, peaking at 93.3% on 2024-06-15, indicating an aggressive phase of AML. However, from 2024-07-16 to 2024-08-03, the blast percentage significantly decreased from 3.8% to 1.0%, suggesting a strong positive response to treatment.

Clinical Implications: The initial high blast percentage highlights active AML, while the subsequent decline indicates effective treatment and potential remission. Continuous monitoring is essential due to the risk of relapse.

[management of suspected acute pulmonary edema and cardiac dysfunction]

A CXR on 2024-08-20 indicated suspected acute pulmonary edema, and a cardiac echo on 2024-08-01 showed abnormal LV systolic function with global hypokinesia and pulmonary hypertension. If diuretics are used to manage this condition, a potassium-sparing diuretic would be a more appropriate choice given the patient’s renal potassium wasting.

2024-07-30

[scheduled transfusions for managing pancytopenia, addressing elevated ALT with BaoGan]

Pancytopenia was noted, and a transfusion with 2 units of LPRBC and 2 units of LRP is scheduled. BaoGan (silymarin) has been prescribed for elevated ALT. No medication discrepancies were identified.

• 2024-07-30 WBC 1.47 x10^3/uL
  

• 2024-07-30 HGB 9.6 g/dL
  

• 2024-07-30 PLT 55 *10^3/uL

• 2024-07-30 ALT 109 U/L
  

• 2024-07-29 ALT 89 U/L

700072177

240821

[exam findings]

[MedRec]

• 2024-07-30 ~ 2024-08-19 POMR Oral and Maxillofacial Surgery Xia YiRan
  • Discharge diagnosis
    • Squamous cell carcinoma of left buccal mucosa T3N0M0 stage III in progress induction chemotherapy
    • Encounter for antineoplastic chemotherapy
    • Inflammatory conditions of jaws
    • Adenocarcinoma of the low rectum just above dentate line, cT4aN2bM0, stage IIIC, status post concurrent chemoradiotherapy with 5-Fu from 2023/02/02 to 2023/03/09, s/p TNT chemotherapy with FOLFOX from 2023/03/24
    • Hypokalemia
    • Urinary tract infection
    • Anemia
    • Bacteremia due to port-A infection (Enterobacter cloacae complex)
    • Fever
    • Chemotherapy related grade III neutropenia
  • CC
    • I am admitted for induction chemotherapy because of a malignant tumor at my left cheek since June 2024.
  • Present illness
    • According to patient`s statement, the present illness should be traced back to more than 7 years ago. This 59-year-old male patient had history of squamous cell carcinoma of left buccal mucosa, upper lip and oral commissure, cT3N1M0 stage III After induction chemotherapy, cancer operations and concurrent chemoradiotherapy from 2017/12/05 to 2018/05/08; second squamous cell carcinoma of left lower lip, cT1N0M0, stage I was confirmed and he had received induction chemotherapy and surgery (ypT0NxM0) during 2020/03/06 to 2020/05/20. Because of a proliferal verrucous leukoplakia lesion at his right ventral tongue, we performed wide excision of the precancerous lesion from his right tongue on 2022/10/19. He was followed up at OPD on the regular basis.
    • In 2023, he suffered from adenocarcinoma of rectum, cT4aN2bM0 stage IIIC and recevied concurrent chemoradiotherapy with 5-Fu from 2023/02/02 to 2023/03/09, s/p TNT chemotherapy with FOLFOX from 2023/03/24-2023/08/22, status post Transanal transabdominal total mesorectal excision (TaTME) with Loop ileostomy on 2023/10/18, ypStage IIA, ypT2N0M0. Because of stenosis of anus and rectum, he had recevied anoplasty and anal dilatation on 2024/01/17.
    • During the OS OPD follow-up, we noted a big area of chronic, red and white patche from the left oral commissure to the retromolar area with higher malignancy potential and delivered several conservative treatments to control this red, ulcerative patch for him FOR more than one year. This erythroplakia at the left buccal mucosa was present wihtout malignant change for a quite long period of time. Unfortunately, when he was in the treatment process of colon cancer, we noted that this big area of erythroplakia patch at his left buccal mucosa started to change in its texture. We continuously delivered several courses of conservative treatment for him but in vain. When this erythroplakia became more ulcerative and protruding growing, we had performed an incisional biopsy for him on 2024/04/30.
    • His pathological reported as squamous cell carcinoma (S2024-09791). We, therefore, had adequately explained the pathological finding and treatment plans to the patient. He took our advice to treat his oral cancer in our OS devision. Because of this squamous cell carcinoma of left buccal mucosa was classified as T3N0M0 stage III, his treatment plans were induction chemotherapy followed by salvage surgeries. He started the modified induction chemotherapy with TPF since June 2024. Chemotherapy-related fatigued and diarrhea were noted after the previous chemotherapy course finished. Urgency to urinate was noted. Because of his general condition was stable after previous chemotherapy finished, he was admitted to ward for the 1st session of the 3rd cycle of modified induction chemotherapy.
  • Course of inpatient treatment
    • After admission, he had arrange physcial examination was done which ANC showed 2990 cell/mm3. He finished modified chemotherapy with #3a 80% TPF (Taxotere 32mg/M2, cisplatin 32mg/M2, 5-fu 800mg/M2 plus Leucovorin 80mg/M2) on 2024/07/31 ~ 08/02. Diet education for hypokalemia for patient. Pay attention chemotherapy-related side effeects and general condition for him. Unfortunately, Fever with chillness were noted. Because of bacteremia due to port-A infection (Enterobacter cloacae complex) and under antibiotic agent with Tapimycin 4.5 gm IVD Q6H on 2024/08/09 ~ 08/16. We consulted CS doctor and removed left port-A by CS doctor on 2024/08/14. Because his general condition was acceptable after the operation. He was discharged on 2024/08/19 and OPD follow up at O.S on 2024/08/27.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# Q4H 7D
    • loperamide 2mg 2# TID 7D
    • Eurodin (estazolam 2mg) 1# HS 7D
• 2024-04-17 ~ 2024-04-21 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Adenocarcinoma of rectum, cT4aN2bM0, stage IIIC status post Transanal transabdominal total mesorectal excision (TaTME) with Loop ileostomy on 2023/10/18, ypStage IIA, ypT2N0M0, with anastomic leakage and lumen stricture post anoplasty and dilatation, status post closure of loop ileostomy on 2024/04/17
    • Oral submucous fibrosis
    • Inflammatory conditions of jaws
  • CC
    • For loop ileostomy closure
  • Present illness
    • This is a 59 years old male with underlying disease of
      • squamous cell carcinoma of left buccal mucosa, upper lip and oral commissure, cT3N1M0 stage III status post induction chemotherapy and concurrent chemoradiotherapy; second squamous cell carcinoma of left lower lip, cT1N0M0, stage I s/p induction chemotherapy and surgery (ypT0NxM0); wide excision of the right tongue squamous cell carcinoma on 2022/10/19.
      • Oral submucous fibrosis
      • Inflammatory conditions of jaws
      • rectum cancer s/p Transanal transabdominal total mesorectal excision (TaTME) with loop ileostomy 2023/10/18. This time he came to our hospital for loop ileostomy closure.
      • Anastomic leakage and lumen stricture s/p anoplasty and dilatation
    • According to patient he has done loop ileostomy since the last surgery on transanal transabdominal total mesorectal excision (TaTME). He has finished all the stoma bag and came to our OPD for further evaluation. After discussion with patient he decided to do loop ileostomy closure as there was no need for it purpose. He has previously wanted to do closure on 2023/10/18 but due to personal problem the schedule was cancelled that time.
    • Under the above impression, he is therefore admitted this time for loop ileostomy closure.
  • Course of inpatient treatment
    • After admission, we immediately survey patient’s lab and condition. Anesthesia survey was done thoroughly. Operation closure of loop ileostomy was done on 2024/04/17. After the surgery we closely monitor patient’s vital sign and condition, wound dressing was ordered daily. Patient has minimal pain of wound and there was no active oozing of surgical wound noted during dressing. Penrose has pinkish red color and no fresh blood was noted. We follow up his feeding condition and there was no nausea vomiting under bread and sports drink. Patient has flatus upon follow up and defecation was noted on 4/20 late night. Under stable vital sign and condition he is ready to be discharged on 4/21 with take home medication and OPD follow up on 4/29 is arranged. Education regarding his post OP condition was given thoroughly.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQID
    • Gasmin (dimethylpolysiloxane 40mg) 1# PRNTID
• 2023-01-12 SOAP Colorectal Surgery Xiao GuangHong
  • Assessment: Suggest neoadjuvant chemotherapy Favor TNT then restaging, Consider observation if cCR or local excision (TAMIS) for sphincter preserving.
• 2023-01-11 SOAP Radiation Oncology Huang JingMin
  • A:
    • Squamous cell carcinoma of the left buccal to lip commissure area, stage T4aN0M0, s/p induction chemotherapy, and s/p CCRT.
    • Adenocarcinoma of the low rectum just above dentate line, stage cT4aN2bM0(IIIC)
  • P:
    • Radiotherapy is indicated for this patient with the following indicators: Adenocarcinoma of the low rectum just above dentate line, stage cT4aN2bM0(IIIC)
      • Goal: curative
      • Treatment target and volume: pelvic including low rectal tumor.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-02-01.
• 2023-01-11 SOAP Hemato-Oncology
  • O
    • 2022/12/19 PATHO - Colon biopsy: Colorectum, low rectum just above dentate line, (3 cm from anal verge), Biopsy. Specimen: B — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • 2023/01/05 CT: ABD: T:T4a(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • P
    • Arrange PET-CT
    • Refer to CRS for surgical evaluation
    • Refer to RTO for CCRT
    • Arrange admisson for CCRT
• 2017-11-29 ~ 2017-12-16 POMR Oral and Maxillofacial Surgery Xia YiRan
  • Discharge diagnosis
    • C06.0 - Squamous cell carcinoma with SKIN INVASION at the left buccal mucosa, upper lip and oral commissure, cT2N1M0 (iT4aNxMx)
    • M27.2 - Inflammatory conditions of upper jaw bone
    • Z51.11 - For induction chemotherapy with #1a TPF
    • Z98.89 - Post of port-A insertion (2017/12/04)
    • Fatty liver, moderate
  • CC
    • I had A protuding malignant tumor on my left cheek and upper lip for 3 weeks.
  • Present illness
    • This 52-year-old male had personal history of smoking 1 PPD/day and drinking wine sometimes for 20+ years. He had quit betel nut chewing for 3~4+ years. He denied of HTN, CAd and DM major disease.
    • He was aware of protuding mass lesion on his left cheek for three months. Denied of body wight loss was note during recentlly half years. Because painful swelling with growth of tumor size developed, he visited to our O.S clinic on 2017/11/21. The local finding showed an ulcerative mass with rough white surface at the left buccal mucosa and upper lip (about 3.5*2.0 cm in lenghth). A palpated lymph node on the left neck was noted. The poor oral hygiene and gingival recession of residual teeth were noted. Swelling of left face was noted. Panoramic film showed periodontal bone loss was noted. No bone destruction by tumor is noted. Apical lesion of #33 and #43 were noted.
    • AN Incisional biopsy on 2016/12/07 and its report (Cellblock No: S2017-19232) was Squamous cell carcinoma. IHC stain: p16 (-). His diagnosis was SCC with inflammation at the left buccal mucosa, upper lip and oral commissure cT2N1M0.
    • The MRI image showed that the skin invasion of left buccal mucosa. Therefore, the clinic stage was IVa. Patient did not want to have operations to destroy his lip, his treatment plans were induction chemotherapy followed by CCRT. He was admitted to ward for more aggressive tumor survey and management.
  • Course of inpatient treatment
    • After admission, we had arrange tumor survery.
    • The naspharynx MRI showed tumor location of left upper lip, gingivobuccal mucosa, at least T4aN0Mx.
    • The abdomen sona and whole body bone scan no evidence of distance metastasis.
    • His treatment plan were induction chemotherapy followed by surgery.
    • The 24 hour CCr was done and showed 116mL/min. Port-A insertion on 2017/12/04.
    • Then we had arrange induction chemotherapy with #1a TPF (Taxotere 40mg/M2, Cisplatin 40mg/M2, 5-FU 1000mg/M2 plus Leucovorin 100mg/M2) were delivered since 2017/12/05 ~ 2017/12/07. #1b induction chemotherapy with TPF since 2017/12/12 ~ 2017/12/14. No obvious of nausea, vomiting, poor intake or other discomfort after chemotherapy.
    • Intraoral wound change dressing qd. Mouth care with Parmason solution q3h.
    • After this cycle of chemotherapy finished, his general condition mintained stable. He was discharged and next admission on 2017/12/26 for further chemotherapy course.
  • Discharge prescription
    • Actein Effervescent 1# QID
    • Tramacet 1# Q6H
    • amoxicillin 250mg 2# Q8H 5D
    • Kentamin 1# TID 5D

[surgical operation]

• 2024-04-17  
  • Op Method:
    • Closure of loop ileostomy         
  • Op Finding:
    • Enterostomy at right abdomen
    • Peristomal adhesion: moderate  
    • Anastomosis: functional end-to-end by GIA * 2        
• 2024-01-17
  • Surgery
    • Anoplasty and anal dilatation
  • Finding
    • Rectal cancer s/p OP, coloanal anastomosis with anastomotic leakage ,
    • Severe anal canal scaring, fibrosis and stricture
    • The anal canal diameter : 11mm (pre-OP, under Anasthesia) –> 23 mm (post-OP)
• 2023-10-18
  • Surgery
    • Transanal transabdominal total mesorectal excision (TaTME)     
    • Loop ileostomy     
  • Finding
    • Low rectal cancer at 3 cm from AV s/p CCRT, partial response Narrow pelvis and fatty mesorectum
    • Anastomosis at dentate line using CDH 33 and reinforced by 3-0 Vicryl suture
• 2022-10-19
  • Surgery
    • Wide excision of the precancerous lesion from the right tongue (71001B * 1)
  • Finding
    • O: A white patch at the ventral surface of the right tongue is noted.
    • A: rule out dysplasia or hyperplasia verrucous leukoplakia of the right tongue
• 2020-05-22
  • Surgery
    • Wide excision of the malignant tumor from the lower lip
    • STSG reconstruction of the lower lip (3 * 3 cm)
    • Complicated tooth extraction of #21, #11, #12, #13, #14, #31, #41, #42, #43 and #44
    • NG feeding tube insertion
  • Finding
    • SCC of the lower lip post induction chemotherapy was reduced about 95% in size. Scar tissue is noted at the lower lip and hardly find ulcerative lesion on his lower lip.
    • Multiple hopeless teeth of #21, #11, #12, #13, #14, #31, #41, #42, #43 and #44 are noted.
    • OSF and trismus are noted.

[radiotherapy]

• 2023-02-02 ~ 2023-03-14 - 4500cGy/25 fractions (15MV photon) of the pelvic, and 5040cGy/28 ractions of the rectal tumor bed area.
• 2018-03-20 ~ 2018-05-08 - 5000cGy/25 ractions (6MV photon) of the bilateral neck, 6000cGy/30 fractions of the left buccal to lip commissure tumor, and 7000cGy/35 fractions of the reduced left buccal to lip commissure tumor bed.

[chemotherapy]

• 2024-08-09 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 800mg/m2 1400mg leucovorin 80mg/m2 140mg NS 500mL 22hr (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2024-07-31 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 800mg/m2 1400mg leucovorin 80mg/m2 140mg NS 500mL 22hr (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2024-07-05 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 800mg/m2 1500mg leucovorin 80mg/m2 150mg NS 500mL 22hr (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2024-06-28 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 800mg/m2 1500mg leucovorin 80mg/m2 150mg NS 500mL 22hr (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2024-06-11 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 800mg/m2 1500mg leucovorin 80mg/m2 150mg NS 500mL 22hr (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2024-06-03 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 800mg/m2 1500mg leucovorin 80mg/m2 150mg NS 500mL 22hr (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-08-22 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-08-03 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-07-07 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-06-29 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-06-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-05-08 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-04-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 400mg/m2 730mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-03-24 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 400mg/m2 730mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-03-03 - fluorouracil 225mg/m2 420mg NS 100mL D1-4 (CCRT)
  • none
• 2023-02-13 - fluorouracil 225mg/m2 420mg NS 100mL D1-4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-02-09 - fluorouracil 225mg/m2 420mg NS 100mL D1-2 (CCRT)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2
• 2020-04-23 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1900mg leucovorin 100mg/m2 190mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-04-16 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1900mg leucovorin 100mg/m2 190mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-04-02 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 1900mg leucovorin 100mg/m2 190mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-03-27 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg leucovorin 100mg/m2 200mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-03-13 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg leucovorin 100mg/m2 200mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-03-06 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg leucovorin 100mg/m2 200mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

==========

2024-08-20

[diarrhea management and temporary neutropenia post-TPF treatment resolved]

The lowest neutrophil count within the past month was 1.82K/uL x 44% = 800/uL (grade 3), which occurred approximately one week after TPF administration (80% of the standard dose) on 2024-07-31. In fact, another session of TPF was given on the same day 2024-08-09. The data indicates that this neutropenia was a temporary condition, resolving to normal levels in days without the use of G-CSF.

Regarding diarrhea, it was not listed in the discharge diagnosis under service number I24072540, although loperamide was appropriately prescribed for this condition. No medication issues were identified.

• 2024-08-20 WBC 6.50 x10^3/uL

• 2024-08-16 WBC 4.70 x10^3/uL

• 2024-08-12 WBC 5.36 x10^3/uL

• 2024-08-09 WBC 1.82 x10^3/uL <-

• 2024-08-07 WBC 5.54 x10^3/uL

• 2024-07-30 WBC 4.24 x10^3/uL

• 2024-07-23 WBC 5.15 x10^3/uL

• 2024-07-20 WBC 3.96 x10^3/uL

• 2024-08-20 Neutrophil 68.6 %

• 2024-08-16 Neutrophil 64.6 %

• 2024-08-12 Neutrophil 67.3 %

• 2024-08-09 Neutrophil 43.9 % <-

• 2024-08-07 Neutrophil 74.8 %

• 2024-07-30 Neutrophil 71.6 %

• 2024-07-23 Neutrophil 71.7 %

• 2024-07-20 Neutrophil 61.9 %

2023-05-09

On 2023-01-12, the PET scan showed no significant abnormal focal FDG uptake elsewhere except in the rectum with two regional lymph nodes and an old lesion in the left buccal region. The patient has been treated with TNT for rectal cancer. CCRT with FU was performed in February and March of 2023. The patient is currently being treated with the FOLFOX regimen.

According to PharmaCloud records, all recent medications were prescribed at our hospital and no medication reconciliation issues were identified.

700176651

240821

[exam findings]

• 2024-06-19 PD-L1 (28.8)
  • Cellblock No. S2024-08256 A5
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS >=1 and <5
    • Combined Positive Score (CPS): 1% (optional)
• 2024-05-31 Tc-99m MDP bone scan
  • Increased activity in the lower C- and lower T-spines and L5 spine. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2024-04-25 Patho - stomach subtotal/total (tumor)
  • Diagnosis
    • Stomach, lesser curvature side of pylorus, radical subtotal gastrectomy —- adenocarcinoma, moderately differentiated
    • Duodenum, radical subtotal gastrectomy —- adenocarcinoma, by direct invasion
    • Omentum, omentectomy —- negative for malignancy
    • Margin:
      • F2024-00166: proximal gastric resection margin: free; distal duodenal resection margin: involved
      • S2024-08256: re-excised distal cut end: free
    • Lymph node, lesser curvature, dissection —- metastatic adenocarcinoma (5/5)
    • Lymph node, greater curvature, dissection —- metastatic adenocarcinoma (9/10)
    • Lymph node, group 5, dissection —- metastatic adenocarcinoma (8/12)
    • Lymph node, group 6, dissection —- metastatic adenocarcinoma (3/4)
    • Lymph node, group 7, dissection —- metastatic adenocarcinoma (4/5)
    • Lymph node, group 8a, dissection —- negative for malignancy (0/5)
    • Lymph node, group 9, dissection —- negative for malignancy (0/2)
    • Soft tissue, group 12a, dissection —- no lymph node is found (0/0) —- metastatic adenocarcinoma is seen in soft tissue
    • Soft tissue, group 13, dissection —- negative for malignancy (0/5)
    • AJCC 8 th edition p T N M Pathology stage: pStage IIIC, pT3N3b(if cM0)
  • Gross Description:
    • Procedure: Partial gastrectomy, distal
      
    • Tumor Site: lesser curvature side of pylorus,
      
    • Specimen size: Greater curvature: 17.5 cm; Lesser curvature: 9.8 cm; Duodenum: 0.9 cm; Omentum: 42 x 15.5 x 1.3 cm; Re-excised distal cut end: 1.5 cm in length
    • Tumor Size : 6.5 x 3.5 cm
    • Gross configuration: For advanced carcinoma (Borrmann classification): Type III: Ulcerated with poorly defined infiltrative margins
    • Sections are taken and labeled as:
      • A1: stomach, non-tumor; A2-3: omentum; A4-7: tumor; A8-9: lymph node, lesser curvature; A10-11: lymph node, greater curvature; B: re-excised distal cut end; C: lymph node, group 5; D1-2: lymph node, group 6; E1-2: lymph node, group 7; F: lymph node, group 8a; G: lymph node, group 9; H: lymph node, group 12a; I: lymph node, group 13.
      • F2024-00166
        • FsA: Specimen submitted in fresh consists of 1 piece of tan, irregular tissue measuring 7.5 x 0.5 x 0.5 cm. All for section in one cassette FsA.
        • FsB: Specimen submitted in fresh consists of 1 piece of tan, irregular tissue measuring 3.5 x 1.0 x 0.5 cm. All for section in one cassette FsB.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
      • Lauren classification of adenocarcinoma: Intestinal type
      • WHO (2019): tubular
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
    • Margins
      • Proximal margin: uninvolved by invasive carcinoma
      • Distal margin:
        • F2024-00166: distal duodenal resection margin: involved; 3.0 cm
        • S2024-08256: re-excised distal cut end: free; 0.5 cm; the immunohistochemical stain of CK reveals no invasive tumor.
      • Radial margin: very close, < 0.1 cm
    • Lymphovascular Invasion: present
      
    • Perineural Invasion: present
      
    • Regional Lymph Nodes: please see diagnosis
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
      • Primary Tumor (pT): pT3: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
      • Regional Lymph Nodes (pN): pN3b: Metastasis in 16 or more regional lymph nodes
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
    • Additional Pathologic Findings: None identified
      • F2024-00166
        • FsA: Section shows gastric tissue without malignancy.
        • FsB: Section shows duodenal tissue with adenocarcinoma.
• 2024-04-23 Patho - stomach biopsy
  • DIAGNOSIS:
    • A: Stomach, upper body, biopsy — Hyperplastic polyp, H pylori NOT present
    • B: Stomach, antrum, biopsy — Adenocarcinoma, moderately differentiated
  • GROSS DESCRIPTION:
    • A: Specimen submitted in formalin consists of 2 pieces of tan, polypoid tissue measuring up to 0.2 x 0.2 x 0.2 cm. All for section in one cassette A.
    • B: Specimen submitted in formalin consists of 6 pieces of tan, irregular tissue measuring up to 0.3 x 0.2 x 0.2 cm. All for section in one cassette B.
  • MICROSCOPIC DESCRIPTION:
    • A: Section shows 2 pieces of polypoid gastric tissue with mild hyperplastic change and chronic inflammation. H. pylori are NOT present.
    • B: Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
      • The immunohistochemical stains reveal CK(+) and Her-2/neu (Ab): Negative (1+).
• 2024-04-23 EGD
  • Diagnosis:
    • Suspect gastric malignancy, from angle to antrum, LC, s/p biopsy(B), Borrmann type III, if tissue prove
    • Suspect external compression, 2nd portion
    • Gastric polyps, upper body, s/p biopsy.(A)
    • Reflux esophagitis LA Classification grade A-
    • Antral deformity
    • Bulb deformity
  • CLO test: Negative
  • Suggestion:
    • Pursue CLO test and pathology report
• 2024-04-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (78.6 - 11.8) / 78.6 = 84.99%
    • M-mode (Teichholz) = 85.0
  • Conclusion:
    • Normal AV with trivial AR
    • Normal MV with no MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, mild TR, normal IVC size
• 2024-04-20 ECG
  • Normal sinus rhythm
  • T wave abnormality, consider anterolateral ischemia
• 2024-04-20 CT - abdomen
  • With and without contrast enhancement CT of abdomen - whole:
    • Wall thickening at gastric antrum, r/o gastric malignancy.
    • There are perigastric lymph nodes, r/o lymph nodes metastasis.
    • Small bilateral renal cysts, up to 1cm in right kidney.
    • Fibrotic infiltrates in right upper lung.
  • Impression:
    • R/O gastric malignancy with perigastric lymph nodes, if proven malignancy, cstage T3N2M0.
    • Bilateral renal cysts.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:III__(Stage_value)
• 2024-04-20 KUB
  • Lumbar spondylosis.
  • Disc space narrowing at L4/5 level.

[surgical operation]

• 2024-04-24
  • Operation
    • Radical subtotal gastrectomy + Billroth II gastrojejunostomy
    • Laparoscopy
  • Finding
    • Laparoscopy: gastric cancer, pylorus, with severe adhesion of omentum and duodenum over RUQ, no gross peritoneal seedings and miminal ascites.
    • An ulcerative tumor (Borrmann type III) was encountered in the lesser curvature side of pylorus. Multiple enlarged lymph nodes were found in the lesser curvature side.
    • Clinical status:
      • Size: 4cm
      • Location: anterior wall of pylorus (D, AW)
      • Remnant stomach: No
      • Macroscopic type: Borrmann type 3
      • Depth of tumor invasion: cT3 (SE)
      • LN: gross enlarged lymph nodes (+), along LCS and #7
      • Liver metastasis: No (H0)
      • Peritoneal metastasis: No (P0)
      • Peritoneal cytology: done (CY0)
      • Other metastasis: No (M0)
      • Clinical status: cT3N2M0, stage IIIB
    • Operative status:
      • Approach: Laparoscopy -> laparotomy
      • Operative procedures: subtotal gastrectomy
      • Combined resection: none
      • Involvement of the resection margins: PM(-), DM(+)
      • LN dissection: D2
      • Curative potential of gastric resection: resection B
      • Drain: 19Fr J-VAC*3, in the Morrison`s pouch, lesser sac, and splenic fossa
      • Feeding jejunostomy: not done
    • Biobank: blood + normal tissue + tumor

[chemotherapy]

• 2024-08-20 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFOX 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-07-26 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-07-06 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-06-19 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-08-21

[improving CINV control with aprepitant addition]

Due to chemotherapy-induced nausea and vomiting (CINV) documented on 2024-08-13, the FOLFOX dose was reduced to 80% during this hospitalization.

Since the initiation of FOLFOX, Aloxi (palonosetron) has been used to prevent CINV, but its effectiveness may be insufficient. It is recommended to add Emend (aprepitant) on days 1-3 (covered by NHI) to extend the prevention of CINV, allowing the full FOLFOX dose to be administered without compromising efficacy.

Additionally, CA-199 levels have shown a noticeable increase over the past month, which might warrant an investigation into possible changes in disease progression.

• 2024-08-15 CA-199 (NM) 755.460 U/ml
• 2024-07-22 CA-199 (NM) 537.250 U/ml
• 2024-07-02 CA-199 (NM) 538.710 U/ml
• 2024-06-14 CA-199 (NM) 579.030 U/ml

[oral akynzeo as an option for persistent CINV]

Oral Akynzeo (netupitant 300mg, palonosetron 0.5mg) is available in this hospital as a patient-paid option. It may be considered if CINV persists despite the addition of aprepitant.

2024-06-19

[EPS treatments]

Acute extrapyramidal syndromes (EPS), such as dystonic reactions and akathisia, can treated with diphenhydramine (25 to 50 mg IV in adults, 30 mg was given as premedication with FOLFOX today). Benztropine (1 to 2 mg IV in adults, not available here) may be used initially, or if diphenhydramine therapy fails. Response is often dramatic and typically occurs within minutes of intravenous drug administration. Although the IV route is preferred, both diphenhydramine and benztropine may be given IM or orally. If initial treatment is successful, therapy is continued orally for two to three days to prevent recurrence.

Alternative treatments for EPS include benzodiazepines (eg, lorazepam 1 to 2 mg IV in adults, 1 mg IV at around 12:00 and 13:20 administered), amantadine (100 mg orally twice or three times daily in adults), or biperiden (2 mg orally in adults). At least two controlled studies have shown amantadine to be as effective as anticholinergic therapy, with fewer side effects. Propranolol (20 to 40 mg initial dose) reduces involuntary movements in akathisia, but does not reduce anxiety. A randomized trial of 13 patients with acute akathisia from antipsychotic medications reported a benefit from trazodone (100 mg/day orally in adults).

Ref: https://www.uptodate.com/contents/first-generation-typical-antipsychotic-medication-poisoning

700872470

240821

[exam findings]

• 2024-07-04 Tc-99m MDP bone scan
  • In comparison with the study on 2024/03/25, the previous faint hot spots in bilateral rib cages and sternum are either stationary or a little less evident, possibly more benign in nature.
  • No prominent change is noted in other bone lesions. Suspected benign lesions in the maxilla, some C-, T- and L-spines, sacrum, right sternoclavicular junction, bilateral shoulders, elbows, S-I joints, hips, knees, and feet.
• 2024-05-03 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (60 - 18) / 60 = 70.00%
    • M-mode (Teichholz) = 70
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild AR, MR, moderate TR
• 2024-04-08 Patho - breast mastectomy with regional lymph nodes
  • Diagnosis
    • Breast, right, partial mastectomy with frozen section for margin (F2024-130FSB) — invasive carcinoma, no special type and adenoid cystic carcinoma.
      • IHC stain: CD117(+).
      • Margin: free, 5 mm from deep margin and 2 mm from 3 o’clock margin of F2024-130FSB specimen.
      • Lymph node, right , axillary sentinel, dissection (S2024-130FSA) — metastatic carcinomna (2/2).
    • Breast, right, 3 o’clock margin, further excision (S2024-6893A) — free (2 pieces: 4.4 x 2.7 x 0.3 cm and 1.3 x 1.0 x 0.5 cm in size).
      • Lymph node, right axillary, dissection (S2024-6893B) — metastatic carcinoma (3 / 4) with extranodal extension.
    • pT2 pN2a (if cM0); anatomic stage: IIIA, pathology prgnostic stage group: IIIB, at least.
  • Gross Description
    • Procedure
      • Partial mastectomy with frozen section for margin (F2024-130FSB): right breast tissue: 8.0 x 6.0 x 2.5 cm; Skin intact: 5.0 x 3.0 cm, no nipple; tumor grossly 2.5 x 2.2 x 1.5 cm (NOTE gross tumor size which may include fibrotci tissue and may not represent true neoplastic tumor size).
      • Breast, right, 3 o’clock margin, further excision (S2024-6893A): 2 pieces: 4.4 x 2.7 x 0.3 cm and 1.3 x 1.0 x 0.5 cm.
    • Lymph node sampling (if lymph nodes are present in the specimen)
      • right sentinel lymph nodes: F2024-130FSA
      • right axillary dissection: S2024-6893B
    • Specimen laterality- right
      • Sections are taken and labeled as:
        • Tissue for frozen section: F2024-130FSA1: right sentinel lymph node; F2024-130FSB1: tumor with deep margin; F2024-130FSB2: tumor with 3 o’clock margin.
        • Tissue for formalin fixation: F2024-130A1-3: 12, 6, 9 o’clock margins; A4-5: tumor; A6: skin. S2024-6893A1-2: futher excison 3 o’clock margin (larger piece); A3: further excision 3 o’clock margin; (smaller piece); S2024-6893B: right axillary lymph node dissection.
  • Microscopic Description
    • For Invasive Carcinoma
      • Histologic type: Invasive carcinoma, NST and adenoid cystic carcinoma, IHC stain: CD117(+).
      • Size of invasive carcinoma (mm): 25 x 22 x 15 mm
      • Histologic grade (Nottingham histologic score): Grade II (score 3-5)
      • Extent of tumor (required only if the structures are present and involved)
      • Skin involvement: Absent
      • Chest wall invasion deeper than pectoralis muscle: no chest wall tissue.
    • For Ductal Carcinoma In Situ - no DCIS
      • Tumor size (mm): no DCIS
        • Nuclear grade: no DCIS
        • Architectural pattern: no DCIS
      • Tumor necrosis: no DCIS
    • Margins:
      • Negative, Closest margin (5 mm from deep margin and 5 mm from 3 o’clock margin)
    • Nodal status: metastatic (if lymph nodes are present in the specimen)
      • No. examined: 6
      • No. macrometastases (>2 mm): 5
      • No. micrometastases (> 0.2 ~ 2 mm and/or > 200 cells): 0
      • No. isolated tumor cells (<= 0.2 mm and <= 200 cells): 0
    • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received) - no presurgical treatment.
    • Immunohistochemical Study- result of core biopsy specimen: S2024-05234
      • ER (-, 0%), PR (-, 0%), Her2/neu: negative (score=0), Ki-67 (70%), p63 (-), CK5/6 (-), E-cadherin (+).
    • perineural invasion is present.
• 2024-04-01 SONO - abdomen
  • Findings
    • Anechoic nodules, 1.06x0.68cm in left lobe, 0.65x0.56cm, 0.53x0.59cm, 1.23x1.15cm in right lobe, r/o liver cysts.
    • Presence of gallbladder stone.
    • Patency of PV, HVs, IVC and aorta in hepatic portion.
    • Anechoic nodules, 1.02x1.29cm in right kidney, 1.06x0.88cm in left kidney, r/o renal cysts.
  • Impression:
    • Liver cysts.
    • GB stone.
    • Bilateral renal cysts.
• 2024-03-25 Tc-99m MDP bone scan
  • Several faint hot spots in both rib cages and sternum, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, some C-, T- and L-spine, sacrum, right sternoclavicular junction, bilateral shoulders, elbows, S-I joints, hips, knees, and feet.
• 2024-03-15 Patho - breast biopsy (no need margin)
  • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • IHC stains: ER (-, 0%), PR (-, 0%), Her2/neu: negative (score=0), Ki-67 (70%), p63 (-), CK5/6 (-), E-cadherin (+).
• 2024-02-29 SONO - breast
  • Diagnosis
    • Bil. fibroadenomas
    • R/O right breast tumor (#2)
  • BI-RADS:
    • 4c. suspicious abnormality, biopsy should be considered (high suspicion for malignancy: 50-95%)

[MedRec]

• 2024-06-24 SOAP Neurology Yang FuYi
  • Prescription x3
    • Uformin (metformin 500mg) 1# QD 28D
    • Madopar (levodopa 200mg, benserazide 50mg) 0.5# TID 28D
    • Caduet (amlodipine 5mg, atorvastatin 20mg) 1# QD 28D
    • Bokey (aspirin 100mg) 1# QD 28D
    • MgO 250mg 1# QD 28D
• 2024-04-03 SOAP Neurology Yang FuYi
  • Prescription x3
    • Ulstop (famotidine 20mg) 1# QD
    • Uformin (metformin 500mg) 1# QD
    • Madopar (levodopa 200mg, benserazide 50mg) 0.5# TID
    • Caduet (amlodipine 5mg, atorvastatin 20mg) 1# QD
    • Bokey (aspirin 100mg) 1# QD
• 2024-03-14 ~ 2024-03-16 POMR General and Gastroenterological Surgery Zhang JianHui
  • Discharge disgnosis
    • Right breast tumor status post core needle biopsy on 2024/03/15.
  • CC
    • Intermittent right breast tenderness and a palpable mass on the right breast was found since 2 years ago
  • Present illness
    • This 77-year-old female patient with underlying diseases of (1). Right breast mass (2). Acute left cerebellum infarction on 2024/02/23 (3). Modified ranking scale 2 (4). Essential (primary) hypertension (5). Parkinson’s disease (6). Bilateral huge thyroid tumors with airway compression status poat bilateral thyroidectomy on 110/06/08 (7). Type 2 diabetes mellitus without complications had suffered intermittent right breast tenderness and a palpable mass on the right breast was found since 2 years ago. Then, she presented to our General Surgery clinic on 2024/03/01 with a right breast tumor (1.36cm, 6”, 1.89cm) found on sonography at our hospital. With the impression of right breast mass, she was admitted to our General Surgery ward on 2024/03/14 for right breast mass biopsy.
    • This patient with recent stroke and under aspirin was admitted due to right breast tumor ceore needle biopsy. Neurological sign and bleeding were monitored.
  • Course of inpatient treatment
    • After admission, right breast biopsy was performed on 2024/03/15. We gave her the medicine she usually takes except for bokey to control underlyong disease. The wound is clean and dry and the wound pain was tolerable. The result of right breast biopsy report is pending. Under the stable condition, she was discharged today and re-follow at OPD. There is no new stroke and bleeding developed during this time biopsy.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

• 2024-04-08
  • Surgery
    • Partial mastectomy + SLNB -> axillary LN dissection
  • Finding
    • Breast tumor: 1.8cm 6 o’clock/4cm,
    • margin: free of tumor as shown by frozen section
    • Sentinel lymh node: frozen section: 2, all positive

[chemotherapy]

• 2024-08-20 - paclitaxel 80mg/m2 130mg NS 250mL 90min (paclitaxel weekly)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2024-07-22 - liposome doxorubicin 30mg/kg 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-06-25 - liposome doxorubicin 30mg/kg 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-05-28 - liposome doxorubicin 30mg/kg 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-05-04 - liposome doxorubicin 30mg/kg 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-08-21

[eGFR assessment and paclitaxel dosing]

Lab results from 2024-08-19 show an eGFR of 75.01 ml/min/1.73m², indicating no need for renal dose adjustment for paclitaxel. No issues with the current active medications were identified.

700904907

240821

[exam findings]

• 2024-08-02 CXR erect
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-07-08 CT - abdomen
  • History and indication:
    • Sigmoid cancer s/p OP and C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation. Increased soft tissues in peritoneal cavity with ascites.
    • Left pleural effusion.
    • Retroversion of uterus.
    • Hyperplasia of left adrenal gland.
    • S/P cholecystectomy.
• 2024-07-08 Colonoscopy
  • Diagnosis: No definite mucosal lesion was seen from rectum to previous anastomosis (90cm AAV).
• 2024-02-01 Bone densitometry - spine + hip
  • Hip BMD performed by DXA revealed:
    • Hip, BMD is 0.414 gms/cm2, about 3.9 SD below the peak bone mass (49%) and 1.8 SD below the mean of age-matched people (72%).
    • IMP: osteoporosis
  • L-spines BMD (AP view) performed by DXA revealed:
    • AP L-spines, BMD of L1-4 0.716 gms/cm2, about 3.0 SD below the peak bone mass (68%) and 0.1 SD below the mean of age-matched people (98%).
    • IMP: osteoporosis
• 2024-02-01 T- L-spine AP + Lat
  • T10-L3 compression fractures
  • Kyphosis of T-L spine
• 2023-12-04 T- L-spine AP + Lat
  • T10, T11, T12, L1 compression fracture.
  • Grade 1 degenerative spondylolisthesis at L4-5 level.
  • Grade 1 spondylolytic spondylolisthesis at L5-S1 level.
  • Degenerative change of the spine with marginal spur formation.
• 2023-11-06 T- L-spine AP + Lat
  • Kyphoscoliosis of thoracolumbar spine.
  • Placement of left subclavian port-A catheter.
  • Multiple spinal compression fractures at thoracolumbar levels.
• 2023-10-03 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation. A nodule (1.1cm)at RLQ.
    • Some LNs at mediastinum.
    • Retroversion of uterus.
    • Hyperplasia of left adrenal gland.
    • S/P cholecystectomy.
    • S/P Port-A infusion catheter insertion.
• 2023-07-10 Colonoscopy
  • Diagnosis: No definite mucosal lesion was seen. Previous anastomosis at S-colon and T-colon are normal.
• 2023-07-07 CT - abdomen
  • Findings:
    • There is a soft tissue nodule 1.1 x 0.5 cm in the omentum at right upper pelvis (Srs:301 Img:41). Tumor seeding is highly suspected.
    • S/P LAR with autosuture retention over the sigmoid colon.
    • S/P cholecystectomy.
• 2023-02-06 All-RAS + BRAF
  • ALL-RAS: Detected (KRAS codon 12 GGT > GAT, p.G12D)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-02-03 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Sigmoid colon, open sigmoidectomy — Adenocarcinoma, moderately differentiated
      
    • Resection margins, open sigmoidectomy — Radial margin is invoved by carcinoma
      
    • Lymph nodes, mesocolic, open sigmoidectomy — Negative for malignancy (0/19)
      
    • Omentum, tumor removal — Metastatic adenocarcinoma
    • Pelvis, tumor removal — Metastatic adenocarcinoma
    • Colostomy, closure T-loop colostomy — Metastatic adenocarcinoma
    • Pathology stage: pT4aN0M1c; Stage IVC
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: Open sigmoidectomy + removal tumor seeding + closure T-loop colostomy
    • Specimen site: Sigmoid colon, omentum, pelvic tissue, and colostomy
      
    • Specimen size: 10.5 cm (sigmoid colon), 18 x 12 x 5 cm (omentum), multiple pieces up to 1.5 x 1.2 x 1.2 cm (pelvic seeding) and 8 x 4 x 3 cm (colostomy)
      
    • Tumor size: 6.5 x 3.5 cm
      
    • Tumor location: 2.5 cm away from the one resection margin
    • Depth of invasion grossly: Pericolic soft tissue
    • Mucosa elsewhere: Unremarkable
    • Representative parts are taken for section and labeled: A1-A5= tumor, A6-A8 and X1-X4= regional lymph nodes, B= proximal end, C= distal end, D1-D2= omentum, E1-E2= pelvic seeding, F1-F2= colostomy
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
      
    • Histology Grade: Moderately differentiated
      
    • Depth of invasion: To serosa
    • Angiolymphatic invasion: Present
      
    • Perineural invasion: Present
      
    • Tumor cell budding: High
      
    • Circumferential (radial) margin: Involved by carcinoma
    • Lymph node metastasis, mesocolic: Negative for malignancy (0/19) (No. Positive / No. Total)
      
    • Extranodal involvement: N/A
      
    • Omentum: Metastatic adenocarcinoma
    • Pelvic seeding: Metastatic adenocarcinoma
    • Colostomy: Metastatic adenocarcinoma
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): pT4a (Tumor invades serosa)
      • Regional Lymph Nodes (pN): pN0 (no regional lymph node metastasis)
      • Distant Metastasis (pM): pM1c (metastatic to the peritoneal surface)
    • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma
    • Additional pathologic findings: None identified
    • Tumor regression grading S/P CCRT: N/A
    • IHC (S2023-00555): EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2023-02-01 ECG
  • Possible Left atrial enlargement
  • Septal infarct, age undetermined
  • Nonspecific ST and T wave abnormality
• 2023-01-09 Patho - colon biopsy
  • Sigmoid colon, 30 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
  • The sections show adenocarcinoma, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction.
  • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
• 2023-01-09 Simoidoscopy
  • One tumor mass was noted in the sigmoid colon with lumen obstruction, Size 4.0 cm. ( 30 cm from anal verge)
• 2023-01-04 KUB
  • S/P operation with retention of surgical clips.
  • Compression fracture of T12.
• 2023-01-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (73.4 - 22.5) / 73.4 = 69.35%
    • M-mode (Teichholz) = 69.3
  • Adequate LV systolic function with no regional wall motion abnormality at resting state
  • Mild MR, trivial TR
  • Impaired LV relaxation
  • Mildly dilated LA, thick IVS
• 2023-01-02 CT - abdomen
  • IMP: Sigmoid colon segmental wall thickening with ascites formation. Sigmoid colon cancer is favored.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T: T2(T_value) N: N0(N_value) M: M0(M_value) STAGE: ____(Stage_value)
• 2022-12-30 Abdomen - standing (diaphragm)
  • S/P operation with retention of surgical clips.
  • Degeneration and spondylosis of L-S spine.
• 2020-12-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (63.1 - 12.7) / 63.1 = 79.87%
    • M-mode (Teichholz) = 79.9
  • Normal heart size.
  • Normal RV & LV systolic function. No regional wall motion abnormalities.
  • Impaired LV relaxation.
  • Mild mitral regurgitation.
  • Mild tricuspid regurgitation.
  • Mild pulmonic regurgitation
• 2020-11-20 Treadmill Exercise Test
  • Resting ECG : non specific ST changes
  • ST changes during TET : 1-mm upslope ST-segment depression at leads II, III, AVF and V4-6 at recovery phases
  • Interpretation : Submaximal heart rate achievement, Non-diagnostic test
• 2017-08-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (87.9 - 19.5) / 87.9 = 77.82%
    • M-mode (Teichholz) = 77.8
  • Adequate LV systolic function with no regional wall motion abnormality at resting state
  • Trivial MR
  • Mildly thicked IVS

[MedRec]

• 2023-07-04 SOAP Hemato-Oncology
  • P
    • During admission, arrange colonscopy but no biopsy due to avastin use.
    • consult CV due to SBP 160
• 2023-04-25 SOAP Hemato-Oncology
  • Prescription
    • Smecta (dioctahedral smectite 3mg) 1# TIDAC
    • Ulstop (famotidine 20mg) 1# BID
    • loperamide 2mg 1# PRNQD
• 2023-03-09 ~ 2023-03-11 POMR Hemato-Oncology
  • Discharge disgnosis
    • Adenocarcinoma of sigmoid colon with obstruction s/p colostomy on 2023/01/05, and s/p Exp.Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings and closure of T-loop colostomy s/p open sigmoidectomy on 2023/02/03, pT4aN0M1c(0/19), LVI(+), PNI(+), CRM(+), stage IVC (metastases of omentum, low abdomen wall and pelvic seedings, carcinomatosis), KRAS codon 12 GGT＞GAT, p.G12D, s/p FOLFOX from 2023/03/09~
    • Hypertensive heart disease without heart failure
    • Type 2 diabetes mellitus with hyperglycemia
    • Mixed hyperlipidemia
• 2023-03-07 SOAP Hemato-Oncology
  • O: Now on FOLFOX +/- bevacizumab
  • P: C/T with FOLFOX +/- bevacizumab
• 2023-03-04 SOAP Colorectal Surgery
  • S: doing well, s/p port-A, suggest CCRT followed by C/T + target
  • P:
    • stage IVc, suggest CCRT (pelvic tumor seedings), then C/T + target therapy
    • refer to oncologist
• 2023-02-20 SOAP Radiation Oncology
  • A/P: CT-simulation will be arranged on 20230306. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the visible residual tumor and preOP S-colon tumor bed to 54 Gy/ 30 fx. RT will start around 20230308.
• 2023-02-14 SOAP Colorectal Surgery
  • A: Adenocarcinoma of sigmoid colon with obstruction s/p colostomy (2023-01-05), and s/p Exp.Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings and closure of T-loop colostomystatus post open sigmoidectomy on 2023/02/03, pT4aN0M1c(0/19), LVI(+), PNI(+), CRM(+), stage IVc (metastases of omentum, low abdomen wall and pelvic seedings, carcinomatosis)
  • P:
    • stage IVc, suggest CCRT, then C/T+ target therapy
    • check RAS status
• 2023-01-20 SOAP Colorectal Surgery
  • S
    • Tumor of sigmoid colon with obstruction status post T-loop colostomy on 2023/01/05
    • doing well, arrange staged surgery
  • A: Adenocarcinoma of S-colon with obstruction s/p colostomy (2023-01-05)
  • P: admission (20230201), ERAS, then laparoscopic sigmoidectomy+ close colostomy (20230202, BUT may laparotomy)
• 2023-01-10 SOAP Metabolism
  • Prescription
    • Zulitor (pitavastatin 4mg 1# QN
    • Canaglu (canagliflozin 100mg) 1# QDAC
    • Kludone (gliclazide 60mg) 1# BID
    • Uformin (metformin 500mg) 1# TIDCC
    • Dibose (acarbose 100mg) 1# TIDAC
• 2023-01-03 SOAP Colorectal Surgery
  • S: Intermittent and progressively abdominal cramping pain with difficult passage of stool in recent 2 weeks and obstipation for 4-5 days
  • O: 2023/01/02 CT: ABD - Imp: Sigmoid colon segmental wall thickening with ascites formation. Sigmoid colon cancer is favored. Dilated loops of colon with wall edema(+)
  • A: Tumor of S-colon with obstruction
  • P: admission, nutritional support (PPN), clear liquid diet, suggest colostomy first (20230105) followed by sigmoidectomy 3-4 weeks later
• 2017-01-18 SOAP Metabolism
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, uncontrolled [E11.65]
    • Gouty arthropathy [M10.00]
    • HCVD, malignant without CHF [I11.9]
    • Mixed hyperlipidemia [E78.2]
    • Other specified acquired hypothyroidism [E01.8]
    • Obesity, unspecified [E66.9]
  • Prescription
    • Jardiance (empagliflozin 25mg) 1# QD
    • Uformin (metformin 500mg) 1# TIDCC
    • Glucobay (acarbose 100mg) 1# TIDAC
    • NovoNorm (repaglinide 1mg) 2# TIDAC
• 2017-01-03 SOAP Cardiology
  • Diagnosis
    • Other and unspecified angina pectoris [I20.9]
    • HCVD, benign without CHF [I11.9]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
  • Prescription
    • Hyzaar (losartan 100mg + hydrochlorothiazide 12.5mg) 0.5# QD
    • Coxine (isosorbide-5-mononitrate 20mg) 1# QD
    • Concor (bisoprolol 5mg) 1# QD

[consultation]

• 2023-07-07 Cardiology
  • Q
    • The patient is an 70-year-old female with a history of DM, HCVD, Adenocarcinoma of sigmoid colon with obstruction s/p colostomy on 2023/01/05, and s/p Exp. Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings and closure of T-loop colostomy s/p open sigmoidectomy on 2023/02/03, pT4aN0M1c(0/19), LVI(+), PNI(+), CRM(+), stage IVC s/p RT 45 Gy/ 25 fractions to the pelvis, visible residual tumor and preOP S-colon tumor bed to 54 Gy/30 fractions from 2023/03/08~2023/04/25, CCRT with FOLFOX from 2023/03/09~, plus Avastin from 2023/05/04.
    • She presented with hypertension was noted at home under Norvasc 5mg/tab 0.5# PO QD, Hyzaar 100mg & 12.5mg/tab 1# PO QD, Coxine 20mg/tab 1# PO QD and Concor 5mg/tab 1# PO QD was treated.
    • For anti-hypertension drug adjust, we need your further evaluation and management.
  • A
    • I was consulted for BP control
    • BP: 150-160 mmHg;
    • Lab
      • 2023-07-04 BUN 26 mg/dL
        
      • 2023-07-04 Creatinine 0.56 mg/dL
        
      • 2023-07-04 Na (Sodium) 132 mmol/L
        
      • 2023-07-04 K (Potassium) 3.7 mmol/L
        
    • Suggestion:
      • Keep Hyzaar 1# QD, Concor 1#, Coxine 1# QD
      • Keep Norvasc 1# QD, if SBP > 150 mmHg still, may uptrate to Norvasc 1# BID PO.
    • Thanks for your consultation and F/U on call.

[surgical operation]

• 2023-02-02
  • Surgery
    • Exp. Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings over omentum, pelvic and abdominal wall and closure of T-loop colostomy        
  • Finding
    • Much adhesions and tumor seedings was found after initial laparoscopic procedure, thus we chenged to open laparotomy method    
    • A locally advanced tumor over S-colon with multiple tumor seedings over pelvic wall, and near bil.overy sites, pelvic floor, low abdominal wall and great omentum. Excisions of the gross seeding tumors was performed except seeding tumors at pelvic floor (densely invasion), some clips was put around pelvic floow and bil.ovary sites for possible further R/T treatment.    
    • Sigmoidectomy was done and anastomosis was achieved using endo-GIA EZ/green 60+ CDH-29+ TISSEEL. Air test is ok.     
    • Closure of T-loop colostomy was also done by segmental resection of T-colon and anastomosis was achiseved using hand-sewn side-to-side anastomosis (endo-GIA EZ/green for both ends, then 4/0 PDS + silk)    
    • The whole procedure was smooth. Blood loss was anout 100ml.  
• 2023-01-05
  • Surgery
    • T-loop colostomy        
  • Finding
    • Dilation of colon due to S-colon tumor obstruction    
    • T-llop colostomy was created at RUQ adbomen

[immunochemotherapy]

• 2024-08-20 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 300mg/m2 400mg NS 100mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-08-02 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 300mg/m2 400mg NS 100mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-12 - (Avastin + FOLFOX)
• 2023-09-15 - (Avastin + FOLFOX)
• 2023-08-31 - (Avastin + FOLFOX)
• 2023-08-11 - (Avastin + FOLFOX)
• 2023-07-28 - (Avastin + FOLFOX)
• 2023-07-10 - (Avastin + FOLFOX)
• 2023-06-20 - bevacizumab 5mg/kg 300mg NS 100mL + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-31 - bevacizumab 5mg/kg 300mg NS 100mL + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-04 - bevacizumab 5mg/kg 300mg NS 100mL + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-14 - …………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-27 - …………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-09 - …………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-08-21

[Stable Vital Signs and Lab Results with Rising Tumor Markers]

Vital signs remained stable during this hospital stay, and lab results on 2024-08-20 were generally acceptable, with no medication discrepancies identified. However, both tumor markers CEA and CA199 have shown an upward trend, FOLFIRI has been initialized since 2024-08-02.

• 2024-08-13 CEA 9.21 ng/mL

• 2024-07-22 CEA (NM) 5.082 ng/mL

• 2024-04-03 CEA (NM) 2.018 ng/mL

• 2023-11-16 CEA 1.99 ng/mL

• 2024-08-13 CA199 54.44 U/mL

• 2023-11-16 CA199 28.03 U/mL

2023-07-07

[reconciliation]

• The patient has two prescriptions that are eligible for refill, one given by our department of metabolism and endocrinology dated 2023-04-11, which includes Canaglu (canagliflozin), Zulitor (pitavastatin), Kludone (gliclazide), Uformin (metformin), and Dibose (acarbose) to address her type 2 diabetes mellitus. The other prescription was provided by the cardiology department on 2023-06-30, encompassing Concor (bisoprolol), Coxine (isosorbide-5-mononitrate), Hyzaar (losartan, hydrochlorothiazide), and Norvasc (amlodipine) for her hypertensive heart disease and angina pectoris. All these medications are accounted for in the present medication list and no discrepancies have been detected during the reconciliation process.
• Be aware that the refillable prescription’s validity is capped at a duration of 3 months. As such, the supply of medication prescribed by the metabolism and endocrinology department should be nearing exhaustion soon. Please ensure to advise the patient about the necessity to schedule another appointment with our endocrinologist for a prescription renewal.

[optionally increase Norvasc to 1# daily]

• If the patient’s SBP persistently remains above 140 in most situations, as observed at 14:22 (163mmHg) and 16:52 (150mmHg) on 2023-07-06, it would be advisable to consider increasing the dosage of Norvasc (amlodipine 5mg) from 0.5# to 1# QD.

2023-06-21

• This patient has two refillable prescriptions, one from our Metabolism and Endocrinology department issued on 2023-04-11 for Canaglu (canagliflozin), Zulitor (pitavastatin), Kludone (gliclazide), Uformin (metformin), and Dibose (acarbose) to manage her type 2 DM. The other prescription was issued on 2023-03-24 by the Cardiology department for Concor (bisoprolol), Coxine (isosorbide-5-mononitrate), Hyzaar (losartan, hydrochlorothiazide), and Norvasc (amlodipine) for her hypertensive heart disease and angina pectoris. All these medications have been integrated into the current formulary with no reconciliation issues found.
• Please note that the maximum validity duration of a refillable prescription is limited to 3 months. Therefore, the medication prescribed by the Cardiology department should soon be depleted. Please remind the patient to revisit our cardiologist to renew her prescription.

2023-06-01

• According to PharmaCloud, this patient visited a local clinic for heartburn on 2023-05-03. However, the prescribed medication for a duration of 3 days is now expired. Currently, no issues with medication reconciliation have been identified.

• Aside from anemia, the laboratory results from 2023-05-31 were largely within normal limits. There appears to be a downward trend in HGB levels in this patient following the initiation of FOLFOX treatments on 2023-03-09, with hemoglobin levels not fully recovering. This trend warrants continued monitoring.

  • 2023-05-31 HGB 9.9 g/dL
    
  • 2023-04-25 HGB 10.5 g/dL
    
  • 2023-03-22 HGB 10.7 g/dL
    
  • 2023-02-03 HGB 11.8 g/dL

2023-05-05

• Although the patient is taking metformin, acarbose, gliclazide, and canagliflozin, all serum glucose measurements during this hospitalization were above 200 mg/dL, suggesting inadequate glycemic control.
• Bevacizumab, part of the patient’s current treatment regimen, has been associated with hyperglycemia (26% of cases). If elevated blood glucose levels continue to be a problem, it may be worthwhile to consider adding insulin to help control the patient’s blood glucose.

2023-03-28

• Despite receiving metformin, acarbose, gliclazide, and canagliflozin, the patient has experienced episodes of serum glucose above 200mg/dL during her current hospital stay, indicating poor glycemic control. It is recommended that the patient be arranged to the metabolism and endocrinology outpatient department to renew her prescription for diabetes medications, as her previous refillable prescription is only valid for a limited time (approximate early Apr 2023).

2023-03-10

• The patient has an underlying condition of type 2 diabetes with blood sugar levels fluctuating between 272, 263, and 159mg/dL in high variability, serum glucose management might be further improved. By the way, the patient’s hypertension is well managed, and their vital signs are stable according to the TPR panel.
• The evidence supports that the patient’s diabetes is showing a worsening trend in the mid-term blood sugar index. It is recommended to measure a new value for HbA1c.
  • 2022-12-30 HbA1c 8.1 %
    
  • 2022-10-07 HbA1c 7.9 %
    
  • 2022-07-15 HbA1c 7.0 %

701162809

240821

[lab data]

2024-03-19 Anti-HBc Reactive
2024-03-19 Anti-HBc Value 7.02 S/CO
2024-03-19 Anti-HCV Nonreactive
2024-03-19 Anti-HCV Value 0.11 S/CO
2024-03-19 Anti-HBs 0.00 mIU/mL
2024-03-19 HBsAg Reactive
2024-03-19 HBsAg (Value) 3979.86 S/CO

[exam findings]

• 2024-08-08 CT - abdomen

  • History and indication:
    • Malignant neoplasm of head of pancreas
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P pancreatectomy and splenectomy. Fat stranding at upper abdomen with adjacent vessels (celiac trunk, SMA, common hepatic artery, bil. proximal hepatic arteries, portal vein) encasement. Small caliber of gastroduodenal artery. Pneumobilia. Mild small bowel ileus. Some soft tissues (up to 1.5cm) at upper abdomen r/o tumor seeding.
    • Hyperplasia of bil. adrenal glands.
    • Some small lymph nodes at retroperitoneum.
    • S/P Port-A infusion catheter insertion.

• 2024-07-27 ECG

  • Normal sinus rhythm with sinus arrhythmia
  • Nonspecific T wave abnormality
  • Abnormal ECG

• 2024-07-05 ECG

  • Normal sinus rhythm
  • Nonspecific ST and T wave abnormality
  • Prolonged QT
  • Abnormal ECG

• 2024-05-22 SONO - abdomen

  • Indication: Jaundice
  • Symptoms: Jaundice
  • Diagnosis:
    • Fatty liver, mild
    • Hepatic leisons R/O focal fatty change or metastasis
    • Post-splenectomy
    • GB invisible
  • Suggestion:
    • pain control first

• 2024-05-21 ECG

  • Normal sinus rhythm
  • Nonspecific ST and T wave abnormality

• 2024-05-05 CXR erect

  • Solitary pulmonary nodule at RUL.
  • Ground glass opacity in LLL.

• 2024-05-05 ECG

  • Normal sinus rhythm
  • Septal infarct, age undetermined
  • Abnormal ECG

• 2024-04-30 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 42.5) / 105 = 59.52%
    • M-mode (Teichholz) = 59.5
  • Conclusion:
    • Thickened AV with mild AR
    • Normal MV with no MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • No PR, mild TR, normal IVC size

• 2024-03-26 CT - abdomen

  • S/P pancreatectomy and splenectomy.
  • Fat stranding at upper abdomen.
  • Pneumobilia.
  • Mild small bowel ileus.

• 2024-03-22 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (151 - 71) / 151 = 52.98%
    • M-mode (Teichholz) = 53
  • Conclusion:
    • Dilated LV with hypokinesia of inferoseptum, inferior wall, posterior wall; borderline LV systolic function.
    • Preserved RV systolic function.
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Aortic valve sclerosis with mild AR; mild MR.
    • Mild aortic root calcification.

• 2024-01-24 T-tube cholangiography

  • Cholangiography via PTCD catheter administration revealed:
    • Patency of the catheter.
    • S/P operation.
    • Filling defects in biliary tree.

• 2024-01-13 ECG

  • Normal sinus rhythm
  • T wave abnormality, consider anterior ischemia
  • Prolonged QT

• 2024-01-11 CTA - chest

  • Indication: D-dimer > 10000, r/o pulmonary embolism IVD s/p PTA in 2023/12 s/p total pancreatectomy on 2023/12/28
  • Chest CT with and without IV contrast ehnancement shows:
    • Consolidation of left lower lobe is found.
    • S/p port-A placement with its tip at left brachiocephalic vein.
    • Minimal bilateral pleural effusion is found.
    • s/p Whipple op, splenectomy and partial gastric resectin with drainage tube placement. Some fluid accumulation at splenic fossa with reactive pleural effusion is found.
    • Loculated effusion at anterior abdominal cavity is found measuring 5.07*3.33cm in largest dimension.
  • Imp:
    • s/p Whipple op, splenectomy and partial gastric resectin with drainage tube placement. Some fluid accumulation at splenic fossa with reactive pleural effusion and Consolidation of left lower lobe is found.

• 2024-01-08 CT - abdomen

  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P pancreatectomy and splenectomy. Some fluid collection in peritoneal cavity.
    • Partial atelectasis at bil. basal lungs.
    • Hyperplasia of bil. adrenal glands.
    • Minimal pericardial effusion.
  • IMP:
    • S/P pancreatectomy and splenectomy. Some fluid collection in peritoneal cavity. Partial atelectasis at bil. basal lungs.

• 2023-12-29 Patho - pancreas total/subtatal resection

  • Diagnosis:
    • Pancreas, distal, pancreatectomy — Necrosis with chronic inflammation — Pancreatic intraductal papillary mucinous neoplasm, low grade dysplasia, s/p Whipple operation
    • Spleen, splenectomy — Congestion
    • Small intestine, jejunum, resection — Congestion with chronic inflammation
    • Lymph node, peri-pancreatic, dissection — Negative for malignancy (0/6)
  • MICROSCOPIC DESCRIPTION:
    • Sections show pancreas with necrosis and chronic inflammation. Low grade dysplastic intraductal papillary mucinous neoplasm with ductal hyperplasis is seen in pancreas. No invasive tumor is found. The jejunum is congested with serosal fibrosis and chronic inflammation. The spleen is congested. Six lymph nodes are dissected without malignancy.

• 2023-12-22 Patho - pancreas total/subtatal resection

  • PATHOLOGIC DIAGNOSIS
    • Tumor, pancreatic head, Whipple operation — Ductal adenocarcinoma, moderately differentiated
    • Resection margins — Free of tumor invasion, but very close (< 0.1 cm) to radial margin
    • SMV, partial resection — Tumor invasion
    • Gallbladder, cholecystectomy — Chronic cholecystitis with cholesterolosis
    • Lymph nodes, peri-gastric area, dissection — Free of tumor metastasis (0/11)
    • Lymph nodes, peri-pancreatic area, ditto — Metastatic carcinoma (1/12) with extracapsular extension (1/1)
      
    • Lymph nodes, peri-duodenal area, ditto — Free of tumor metastasis (0/3)
      
    • Duodenum — Tumor invasion
    • Stomach — Free of tumor invasion
    • AJCC pathologic staging — pT4N1, if cM0, stage III
  • MACROSCOPIC EXAMINATION
    • Specimen Type: Whipple operation with lymph node dissection + cholecystectomy
    • Specimen and size:
      • Pancreas: 7.5 x 6.2 x 4.4 cm
      • Duodenum: 24 cm in length, up to 3.1 cm in diameter
      • Stomach: 9.7 x 3.7 x 1.7 cm with staples
      • Gallbladder: 6 x 3 x 1.1 cm, no stone
    • Tumor Site: pancreatic head
    • Tumor Size: 3 x 3 x 2.5 cm
    • Posterior wall of SMV: 1 x 0.5 cm
    • Representative sections as A1: gastric + duodenal cutting end, A2: bile duct cutting end, A3-A5: posterior wall of SMV + tumor + pancreatic tissue, A6-A11: tumor + duodenal invasion, A12: tumor only, A13: gastric mucosa, A14-A15: peri-gastric LNs, A16-A17: peri-pancreatic LNs, A18: peri-duodenal LNs, A19: duodenal mucosa, A20: tumor + fat and B: gallbladder
  • MICROSCOPIC EXAMINATION
    • Histologic Type: ductal adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Margins: Free, less than 0.1 cm to radial margin of pancreas
    • Lymphovascular invasion: identified
    • Perineural Invasion: identified
    • Tumor Extension
      • Tumor invades duodenal wall
      • Tumor invades peripancreatic fat tissue
      • Tumor invades posterior wall of SMV
    • Pathologic Staging (pTNM): pT4N1
    • Additional Pathologic Findings: mucin production
    • Immunohistochemistry: CK7(+) and DPC4(-) for tumor, CD34 highlights endothelial cell

• 2023-12-04 Cardiac Catheterization

  • Finding Summary
    • Syntax Score = 5
    • In conclusion :
      • Left Main : Patent
      • Left Anterior Descending : atheromatous change with 55% stenosis at mid LAD
      • Left Circumflex : Patent
      • Right Coronary : Patent
  • Intervention Summary
    • Conclusion
      • Coronary artery disease, single vessel disease, atheromatous change with 55% stenosis at mid LAD, patent LCx and RCA.
      • LV angiography showed LVEF: 55% without focal hypokinesia, and no mitral regurgitation.
    • Recommendation
      • Keep medical treatment.

• 2023-11-30 Myocardial perfusion SPECT with persantin

  • Probably mild myocardial ischemia at the septum and inferior wall.
  • Mild reverse redistribution of radioactivity to the posterior wall, either normal variant or myocardial ischemia may show this picture.

• 2023-11-28 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (154 - 112) / 154 = 27.27%
    • 2D (M-Simpson) = 37
  • Conclusion:
    • Dilated LV with global hypokinesis and impaired LV systolic function.
    • Preserved RV sytolic function.
    • Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Mild aortic valve sclerosis with mild AR; trivial MR.

• 2023-11-24 Flow Volume Chart

  • Moderate restrictive ventilatory impairment

• 2023-11-23 MRI - liver, spleen

  • Abdominal MRI with and without IV contrast enhancement shows:
    • Heterogeneous enhnced tumor with compression of distal CBD is found at pancreatic head with ductal appeaance inside the lesion and the tumor size is 1.8cm in largest dimension. (Se4 Im23), pancreatic head tumor is considered. IPMT is most likely.
    • s/p PTCD from right intercostal appraoch.
    • Mild bilateral pleural effusion is found.
  • Imp:
    • Pancreatic head tumor with CBD compression. r/o IPMT.
    • No evidence of metastatic lesion is found in the study.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)

• 2023-11-22 Patho - pancreas biopsy

  • Pancreas, head, biopsy— Mucinous pancreatic tumor, in favor of intraductal papillary mucinous neoplasm
    
  • Microscopically, it shows cystic-like pacreatic tissues lined by single layer of gastric-type neoplastic mucinous epithelial cells with focal papillary architecture. The stroma is fibrotic with some atrophic pancreatic acini.
  • Immunohistochemical stains reveals CK20(+), CK(+), CA19-9(+)CK19(+), CEA(+).

• 2023-11-21 PTCD drainage

• 2023-11-20 CT - abdomen

  • Indication: Jaundice
  • Abdominal CT with and without enhancement revealed:
    • Dilated IHDs and CBD with obliteration at distal CBD is found. Suspected low density lesion at pancreatic head measuring 2.0cm in largest dimension. However, the lesion is hard to characterize and correlation with MRCP/MRI is suggested.
  • Imp:
    • Dilated IHDs and CBD with obliteration at distal CBD is found. Suspected low density lesion at pancreatic head measuring 2.0cm in largest dimension. However, the lesion is hard to characterize and correlation with MRCP/MRI is suggested.

• 2023-11-17 CT - abdomen

  • Findings:
    • There is dilatation of IHDs, CHD, and CBD. The gallbladder also shows distension and sludge. The transition zone in the middle CBD.
      • The differential diagnosis includes cholangiocarcinoma and IgG4-related cholangitis. Please correlate with contrast enhanced dynamic CT or MRI.
    • There are few enlarged nodes in the hepatoduodenal ligament.
      • Please correlate with contrast enhanced dynamic CT or MRI.
    • There is an ill-defined equivocal mild hypodense lesion 2.5 cm in between the pancreatic head and duodenum 2nd portion (Srs:301 Img:32).
      • Pseudo-lesion is highly suspected.
      • The differential diagnosis includes tumor.
    • Hyperplasia of bilateral adrenal gland are noted.
  • IMP:
    • Cholangiocarcinoma and IgG4-related cholangitis in the distal CBD is suspected. Please correlate with contrast enhanced dynamic CT or MRI.

• 2023-11-16 SONO - abdomen

  • Suspected CHD lesion with hilar involvement, Klastin tumor, type 2, with biliary obstruction
  • GB stones and sludge

[MedRec]

• 2024-03-06 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • Admission for adjuvant C/T with modified FOLFIRINOX.
    • Prescribe AntiHBV medication
• 2024-03-05 SOAP Metabolism and Endocrinology Hu YaHui
  • Diagnosis
    • Type 2 diabetes mellitus with diabetic nephropathy [E11.21]
    • Mixed hyperlipidemia [E78.2]
    • Cushing`s syndrome [E24.9]
  • A
    • thyroid nodule 0.67 cm,
    • FNAC: atypia
      
  • Prescription x3
    • Apidra (insulin glulisine) 8U TIDAC
    • Tresiba FlexTouch (insulin degludec) 12U HS
    • Atotin (atorvastatin 20mg) 1# QW1257
    • Folacin (folic acid 5mg) 1# QW1357
    • B-Red (hydroxocobalamin) 1mg Q4W IM
• 2024-03-05 SOAP Cardiology
  • A/P
    • Sinus rhyhthm heard today, improved symptoms of exertional dyspnea
    • Still elevated DBP, change candesartan to diovan for better BP control and cardiac protection
    • Arrange echocardiography to evaluate LV function after heart failure treatment for 6 months
  • Prescription x2
    • Bokey (aspirin 100mg) 1# QD
    • Syntrend (carvedilol 25mg) 0.5# BID
    • Diovan (valsartan 160mg) 1# QD
• 2024-02-15 SOAP Gastroenterology Wang JiaQi
  • Prescription x3
    • Baraclude (entecavir 1mg) 1# QDAC
    • Ulstop (famotidine 20mg) 1# QD
• 2023-12-15 ~ 2024-01-29 POMR General and Gastroenterological Surgery Wu ChaoQun
  • Discharge diagnosis
    • Ductal adenocarcinoma of pancreatic head, pT4N1(cM0), stage III status post pancreatico-duodenectomy with partial gastrectomy and superior mesenteric vein posterior wall partial resection with horizotal repair and lymph node dissection on 2023/12/21. ECOG:1
    • Post operative with pancreatitis and pancreaticojejunal anastomosis leakage status post distal pancreatectomy with splenectomy autospleen implantation on 2023/12/28.
    • Post operative with fluid collection in peritoneal cavity status post pig-tail drainage on 2024/01/08.
    • Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
    • Single vessel coronary artery diseaes, status post Percutaneous coronary intervention on 2023/12/04, which showed atheromatous change with 55% stenosis at mid left anterior descending (LAD), patent left circumflex artery (LCx) and right coronary artery (RCA)
    • Intraabdomen infection with ascites showed Vancomycin- Resistant Enterococci, Klebsiella pneumoniae and Candida
    • Bacteremia with Klebsiella pneumoniae related
    • Chronic kidney disease, stage 3 (moderate)
    • Hypoalbuminemia
    • Type 2 diabetes mellitus with diabetic nephropathy
    • Carrier of viral hepatitis B
• 2023-11-16 ~ 2023-12-05 POMR Gastroenterology Wang JiaQi
  • Discharge diagnosis
    • Suspect intraductal papillary mucinous neoplasm with jaundice status post percutaneus transhepatic cholangiodrainage and endoscopic ultrasonography-guided fine needle biopsy.
    • Single vessel coronary artery diseaes, status post Percutaneous coronary intervention on 2023/12/04, which showed atheromatous change with 55% stenosis at mid left anterior descending (LAD), patent left circumflex artery (LCx) and right coronary artery (RCA)
    • Diabetes mellitus due to underlying condition with unspecified complications
    • Chronic kidney disease, stage 3 (moderate)
    • Type 2 diabetes mellitus with diabetic nephropathy
    • Carrier of viral hepatitis B
• 2019-04-16 SOAP Metabolism and Endocrinology Hu YaHui
  • Diagnosis
    • Type 2 diabetes mellitus with diabetic nephropathy [E11.21]
    • Mixed hyperlipidemia [E78.2]
    • Cushing’s syndrome [E24.9]
    • Goiter, unspecified [E04.9]
  • Prescription x2
    • Victoza (liraglutide) QDAC
    • Uformin (metformin 500mg) 1# BIDCC
    • Tulip (atorvastatin 20mg) 1# QD
• 2019-02-22 SOAP Nephrology Hong SiQun
  • Diagnosis
    • Carrier of viral hepatitis B [Z22.51]
    • Unspecified kidney failure [N19]
    • Obesity, unspecified [E66.09]
    • Essential (primary) hypertension [I10]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E13.9]
  • Prescription x2
    • Uformin (metformin 500mg) 1# QD
    • Januvia (sitagliptin phosphate 100mg) 1# QOD

[consultation]

[surgical operation]

• 2023-12-28
  • Surgery
    • distal pancreatectomy with splenectomy
    • autospleen implantation
    • 3 x 3 x 3 cm
  • Finding
    • post whipple op with pancreatitis and PJ leakage
    • durty ascite+
• 2023-12-21
  • Surgery
    • pancreatico-duodenectomy with LN partial 3&4, 5,6,8,12.14a&v, dissection,
    • en block SMV posterior wall partial resection with horizotal repair with cont. prolene 4-0
    • partial gastrectomy
  • Finding
    • pancreatic head tumor 3 x 3 x 2.5 cm with direct invasion to SMV conflurent posterior wall
    • LN enlarge at 12 and 8 was noted

[chemotherapy]

• 2024-07-26 - oxaliplatin 50mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 150mg D5W 250mL 1.5hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (mFOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-07-05 - oxaliplatin 50mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 150mg D5W 250mL 1.5hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (mFOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-06-06 - oxaliplatin 50mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 150mg D5W 250mL 1.5hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (mFOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-10 - oxaliplatin 50mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 150mg D5W 250mL 1.5hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (mFOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-18 - oxaliplatin 50mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 150mg D5W 250mL 1.5hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (mFOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-18 - oxaliplatin 50mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 150mg D5W 250mL 1.5hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (mFOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-05-22

[poor glycemic control: insulin initiated]

Lab results indicated poorly controlled blood sugar levels. Insulin injections have been newly initiated to address this issue.

If blood glucose levels remain above 200mg/dL for two consecutive days, increasing the insulin dosage or adding oral oral antiglycemic agents may be necessary.

• 2024-05-21 Glucose (serum) 174 mg/dL
• 2024-05-18 HbA1c 9.5 %
• 2024-05-18 Glucose (AC) 208 mg/dL

2024-05-07

[optimizing insulin dosing for high fasting glucose levels]

On 2024-05-05, a chest X-ray revealed a solitary pulmonary nodule in the RUL and ground-glass opacity in the LLL, with a CRP level of 3.9 mg/dL, suggesting an infection, currently managed with Brosym (cefoperazone, sulbactam).

The patient is on basal insulin therapy of 10 units at bedtime and bolus insulin before meals - 4 units for breakfast, 5 units for lunch, and 5 units for dinner. Despite this regimen, fasting serum glucose was recorded at 327 mg/dL on 2024-05-07 at 11:42. If such elevated levels persist, an increase in the insulin dosage should be considered.

2024-03-28

[new-onset diabetes after pancreas surgery, potassium level for insulin user]

Approximately 16.6% of patients may develop diabetes following pancreaticoduodenectomy, with preoperative glycated hemoglobin levels above 5.4% being a predictor of new-onset diabetes. (https://doi.org/10.1016/j.jamcollsurg.2018.12.042)

• 2024-03-25 Glucose ( serum ) 227 mg/dL
  
• 2024-03-25 Blood ketone body (quantitative) 1.7 mmol/L
  
• 2024-03-25 K (Potassium) 3.8 mmol/L

The development of diabetic ketoacidosis (DKA) involves both a deficiency of insulin and an excess of glucagon, with glucagon playing a contributing but not essential role.

Insulin is a potent stimulus for hypokalaemia, sparing body potassium from urinary excretion by transporting it into cells. Given that the patient’s serum potassium was normal three days ago on 2024-03-25 and the patient is currently using insulin, it’s advisable to update the potassium level to determine the need for potassium supplementation.

2024-03-19

[fluctuating hyperglycemia: consider increasing basal insulin]

The patient’s blood sugar levels are elevated and fluctuating, as shown by readings of 217, 181, and 361. If these high levels continue, it is recommended to increase the basal insulin dosage by 2 units.

700055154

240820

[exam findings]

• 2024-08-16 CT - abdomen
  • CC: In the past week, the patient developed a fever between midnight and morning. Two clinic visits with negative flu and COVID-19 tests revealed muscle aches and urinary hesitancy
  • Findings:
    • There are multiple enlarged lymph nodes in the mesentery and para-aortic space (up to 1.6 cm). Mesenteric adenitis is highly suspected.
      • The differential diagnosis includes panniculitis and lymphoma.
    • A renal cyst 1.3 cm in right lower pole is noted.

[MedRec]

• 2024-06-12 SOAP Metabolism and Endocrinology Qiu QuanTai
  • S:

    • The patient frequently complains of urinary tract infections, particularly when their blood sugar control is poor.

    • Allergy: NKA

    • PH: Type 2 DM since 2010, HTN, Dyslipidemia,

    • FH: grandma, grandpa, pa: DM, HTN

  • Prescription x3
    • Toujeo (insulin glargine) 54 units QD SC 28D
    • NovoRapid (insulin aspart) 28 units TIDAC SC 28D
    • Glyxambi (empagliflozin 25mg, linagliptin 5mg) 1# QD 28D
    • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QD 28D
    • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD 28D
    • Stilnox (zolpidem 10mg) 1# HS 28D
• 2021-04-07 SOAP Neurology Liu XiuXun
  • Discharge diagnosis
    • Cerebral infarction, unspecified
    • acute infarct in left paramedial pons, TOAST: 2 small vessel occlusion
    • Other specified diabetes mellitus without complications
    • Essential (primary) hypertension
    • Hyperlipidemia, unspecified
    • Modified ranking scale 1

700337554

240820

[lab data]

2024-08-20 HBsAg Nonreactive
2024-08-20 HBsAg Value 0.34 S/CO

2024-08-20 Anti-HCV Nonreactive
2024-08-20 Anti-HCV Value 0.12 S/CO

2024-08-20 Anti-HBc Reactive
2024-08-20 Anti-HBc Value 5.63 S/CO

[exam findings]

• 2024-08-20 ECG
  • Normal sinus rhythm
  • Left ventricular hypertrophy with repolarization abnormality
• 2024-07-27 CT - abdomen
  • History and indication:
    • pelvic tumor
  • IMP:
    • A heterogeneous tumor (5.6cm, progression) at pelvic cavity with left distal ureter, urinary bladder and prostate invasion.
    • Compression fracture of L1.
• 2024-05-21 MRI - lower abdomen
  • History and indication:
    • a nodular lesion in left pelvic cavity
  • IMP:
    • A soft tissue lesion (3.5cm) at left pelvic cavity with some small cystic component and mass effect to left lower ureter r/o neurogenic tumor. Left hydronephrosis and hydroureter.
• 2024-05-16 SONO - nephrology
  • Interpretation:
    • Mild to moderate hydronephrosis and hydroureter, left kidney.
    • Right parapelvic renal cyst.
    • Parenchymal renal disease.
• 2024-05-15 CT - abdomen
  • Without and with contrast Abdomen CT showed
    • Left hydronephrosis and left hydroureter with a heterogeneous low density nodular lesion, about 48mm, in the left pelvic cavity.
      
    • Wall thickening in the gastric antrum
  • IMP
    • left hydronephrosis and left hydroureter
    • a nodular lesion in he left pelvic cavity. Please correlate with other image modality.
• 2024-05-14 CXR
  • Atherosclerosis of the aorta.
  • S/P vascular stenting.
  • Fracture of right ribs with union.
• 2024-05-14 ECG
  • Sinus rhythm with 1st degree A-V block
  • Moderate voltage criteria for LVH, may be normal variant
  • ST & T wave abnormality, consider lateral ischemia
• 2024-03-28 Bladder Sonography
  • Report: PVR: 33ml
• 2024-03-28 Uroflowmetry
  • Q max : low
  • flow pattern : obstructive
• 2024-03-22 Bladder Sonography
  • Report: PVR: 78.5ml
• 2023-04-21 SONO - neurology
  • Mild atherosclerosis in right CCA and CCA bifurcation.
  • Adequate total VA flow volume (201 ml/min).
  • Smaller caliber with decreased flow in left VA, possible left VA hypoplasia.
  • Increased RI in bilateral ICA, indicating distal stenosis.
  • Poor temporal windows for transcranial insonation.

[MedRec]

• 2024-06-20 SOAP Urology Wu ShuYu
  • Prescription x3
    • Wecoli (bethanechol 25mg) 1# TIDAC 28D
• 2024-06-20 SOAP Neurology Xu BoRen
  • Prescription x3
    • Secorin (oxazolam 10mg) 1# HS
    • Urief (silodosin 8mg) 1# QD
    • Madopar HBS (levodopa 100mg, benserazide 25mg) 2# TID
    • Rakinson (rasagiline 1mg) 0.5# QD
    • Harnalidge (tamsulosin 0.4mg) 1# QDAC
    • Crestor (rosuvastatin 10mg) 1# QD
    • Plavix FC (clopidogrel 75mg) 1# QD
    • Nilasen (betahistine 24mg) 1# PRNBID

[consultation]

• 2024-08-20 Urology
  • Q
    • for TRUS biopsy and DJ insertion
    • This is a 87 y/o male with underlying disease of CVA two times, parkinson disease and BPH. He could walk used cane by himself.
    • He suffered from dysuria and body loss 10 kg for 2 month. The foley tube was insertion since 2024/5, and hematuria noted.
    • Followed-up Renal echo showed 1. Mild to moderate hydronephrosis and hydroureter, left kidney. 2. Right parapelvic renal cyst. 3. Parenchymal renal disease.
    • MRI of abdomen revealed A soft tissue lesion (3.5cm) at left pelvic cavity with some small cystic component and mass effect to left lower ureter r/o neurogenic tumor, and tumor marker showed higher PSA level.
    • We need your help for TRUS biopsy and DJ insertion, thanks a lot!!
  • A
    • Prostate cancer with seminal vesicle involvement and progression of left ureter compression is impressed
    • DBJ insertion with TRUSP biopsy may be carried out on 08/26
    • If ureter tumor or bleeding in UVJ is found, transurethral resection of tumor or biopsy may be carried out at the same time
• 2024-05-16 Integrative Medicine
  • Q
    • for a nodular lesion in left pelvic cavity, thanks
    • This is a 86 y/o male with underlying disease of CVA two times, parkinson disease and BPH. He could walk used cane by himself.
    • This time, he presented to the ER with dizziness and fever this morning. At ER, consciousness clear, vital signs BP:226/97mmHg, PR:97bpm, BT:38.3’C, RR:18bpm, SpO2:96%. Laboratory test revealed hypokalemia and elevated CRP level.
    • CT of abdomen revealed left hydronephrosis and left hydroureter. a nodular lesion in left pelvic cavity. Please correlate with other image modality.
    • GU was consulted and suggested The renal functuion was normal without AKI (CRE 0.93mg/dl). The urine analysis show clear urine without evidence of urinary tract infection. Base on current evidence, there’s no emergent surgical indications now. If AKI occurs, left PCND may be required. I suggest oncology department further survey first.
    • Under the impression of left hydronephrosis and left hydroureter. He was admitted for further management
  • A
    • This 86-year-old man, with a history of CVA, Parkinson’s disease, and BPH, was admitted due to sepsis. We are consulted regarding a left pelvic tumor. A CT scan also shows gastric antrum wall thickening.
    • We may consider arranging a panendoscopy and colonoscopy, as well as a pelvic MRI for further evaluation.
    • We also suggest completing tumor markers: CEA, CA 19-9, AFP, and LDH.
    • If the above studies result in negative findings, may consult General Surgery for a laparoscopic biopsy.
    • Thank you!
• 2024-05-15 Urology
  • Q
    • Triage Level 3: Dizziness/Vertigo > Fever (appears ill). Began feeling dizzy today with no nausea. Felt generally weak in the past few days. Had a urinary tract infection two months ago and took medication. Triage assessment revealed a fever.
    • CC: Dizziness and fever this morning.
    • Denied Headache dyspnea chillness diarrhea
    • Hx of Old CVA, and BPH under regular follow up
    • Allergy: Nil

==========

2024-08-20

[CT and MRI findings with PSA elevation and HBV management]

A CT scan on 2024-07-27 revealed a heterogeneous tumor (5.6 cm, showing progression) in the pelvic cavity with invasion into the left distal ureter, urinary bladder, and prostate. An MRI on 2024-05-21 showed a soft tissue lesion (3.5 cm) in the left pelvic cavity with a small cystic component and mass effect on the left lower ureter, raising suspicion of a neurogenic tumor. Elevated PSA and free PSA levels were also noted.

The Anti-HBc test on 2024-08-20 showed reactive. Antiviral prophylaxis is recommended to prevent hepatitis B reactivation if the patient is scheduled to receive anti-cancer therapy.

Other lab results showed generally acceptable blood counts, electrolytes, and liver and kidney function. No pathology report is available yet, and no medication issues were identified.

• 2024-08-20 PSA 17.702 ng/mL

• 2024-03-22 PSA 23.135 ng/mL

• 2024-08-20 Free PSA 3.780 ng/mL

• 2019-07-26 Free PSA 2.081 ng/mL

• 2018-05-18 Free PSA 1.732 ng/mL

700507343

240820

[lab data]

2024-03-13 HBV-DNA-PCR 110000 IU/mL

2024-03-11 Anti-HBs 5.31 mIU/mL
2024-03-11 Anti-HBc Reactive
2024-03-11 Anti-HBc Value 6.06 S/CO
2024-03-11 Anti-HBe Reactive
2024-03-11 Anti-HBe Ratio 0.26 S/CO
2024-03-11 HBsAg Reactive
2024-03-11 HBsAg Value 348.93 S/CO

2024-03-11 Anti-HCV Nonreactive
2024-03-11 Anti-HCV Value 0.06 S/CO

2024-03-11 HIV Ab-EIA Nonreactive
2024-03-11 Anti-HIV Value 0.04 S/CO

[exam findings]

• 2024-08-12 CT - chest
  • Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck lymphoma with supraclavicular LN and spleen involvement
  • Comparison was made with CT on 2023/09/12
    • Lungs:
      • patchy consolidations and ground-glass opacities with septal thickening with lobular sparing in both lower lobes.
      • patchy ground-glass opacities in both upper lobes and a sublobular consolidation in RUL.
    • Complete resolution of extensive lymphadenopathy in bilateral supraclavicular fossae, posterior triangle of neck, and axillary regions.
    • Mediastinum and hila:
      • small LNs in the visceral space and left anterior prevascular space
      • mild coronary arterial calcification
    • Thoracic aorta: dilated ascending aorta (4cm).
    • Central pulmonary arteries: normal caliber.
    • Heart: dilated LA, midseptal hypertrophy of IVS
    • Pleura: trace effusion
    • Visible abdominal contents:
      • mild splenomegaly.
      • upper pole parenchymal loss of Rt kidney.
      • gall bladder stones up to.
      • many multiple Rt Lt renal cysts
      • unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and Lt kidney.
      • no enlarged lymph node.
        
  • Impression:
    • complete resoluion of lymphoma in neck and axillary regions. bilateral pulmonary inflammation or interstitial lung disease (drug related?)
• 2024-05-14, -05-08, -05-03, -03-29, -03-20 CXR erect
  • S/P port-A implantation.
  • S/P implantation of the pacemaker.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-04-29 CXR erect
  • Port-A catheter inserted into distal SVC or cavo-atrial junction via left subclavian vein.
  • s/p transevenous (Rt subclavian vein route) single-chamber pacemaker inserted with pacing lead in RV
  • marked enlarged cardiac silhoutte due to dilated left atrium and prominent cardiophrenic angle mediastinal fat pad /supine position
  • Crowding of vascular markings over Rt lower lung zone
• 2024-04-29, -03-18 ECG
  • Ventricular-paced rhythm
  • Abnormal ECG
• 2024-04-12 ECG
  • Atrial fibrillation with frequent ventricular-paced complexes
  • Abnormal ECG
• 2024-03-19 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — negative for malignancy.
  • Microscopically, it shows mildy increased cellularity (approximately 40%), 3:1 of M:E ratio. Both myeloid and erythroid lineages demonstrate maturation. Megakaryocytes are present in normal in numbers and demonstate no significant morphologic abnormalities. Blast-like cells are not present. No lymphoma is identified.
  • Immunohisotchemical stain reveals CD34(-), CD20 (focal+, ≤ 1%), CD138 (focal+,1%), MPO(+), CD71(+), CD61(+), CD117(-).
• 2024-03-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (118 - 42) / 118 = 64.41%
    • M-mode (Teichholz) = 64
  • Conclusion:
    • Abnormal septal wall motion due to RV pacing; preserved LV systolic function.
    • Normal RV systolic function.
    • Indeterminated LV filling pressure; severely dilated LA.
    • Mild to moderate MR; mild TR; mild PR; aortic valve sclerosis with trivial AR.
    • S/P dual chamber pacemaker implantation with pacing leads in RA/RV.
• 2024-03-01 Patho - lymph node region resection
  • Lymph node, supraclavicular, right, excision — Diffuse large B-cell lymphoma, non-GCB subtype
  • The specimen submitted consists of multiple pieces of gray-white soft tissue, labeled supraclavicular fossa, right, measuring up to 2.3 x 1.7 x 0.6 cm. All for section in two cassettes.
  • The sections show a picture of diffuse large B-cell lymphoma with following features:
    • Specimen: Supraclavicular fossa, right
    • Procedure: Excision
    • Tumor site: Right supraclavicular fossa
    • Histologic type: Diffuse large B-cell lymphoma, non-germinal center B-cell subtype
    • Immunophenotyping: CD3(-), CD20(+), CD10(-), BCL6(-), MUM1(+), BCL2(+, diffuse), MYC(+40%), and Ki-67=95%
• 2024-02-29 ECG
  • Ventricular-paced rhythm
  • Abnormal ECG
• 2024-02-29 CXR
  • Cardiomegaly and tortuosity of the thoracic aorta.
  • Widening of the mediastinum.
  • Increased lung markings over both lungs.
  • S/P pacemaker implant.
  • Degenerative joint disease of T-spine with marginal osteophytes.
• 2024-02-23 PET scan
  • The FDG PET findings suggest that lymphoma involving multiple lymph nodes on both sides of the diaphragm, spleen and bones or bone marrow (stage IV) should be considered first.
  • Increased FDG uptake in the right lobe of the thyroid gland and in some focal areas in both lobe of the liver. Lymphoma involving these areas should be watched out. Please correlate with other clinical findings for further evaluation.
  • Mildly increased FDG uptake in a focal area in the lower lobe of right lung and inhomogenous FDG uptake in the left ventricle of the heart. The nature is to be determined (lymphoma? other nature?). Please also correlate with other clinical findings for further evaluation.
• 2024-02-07 MRI - larynx
  • Findings
    • small bilateral thyroid nodular lesions.
    • unremarkable change in the nasopharynx, oropharynx and hypopharynx.
    • enlarged lymph nodes in the bilateral axilla, bilateral supraclavicular fossa, bilateral lower neck, right carotid and right posterior cervical spaces. The largest one, about 39mm was noted at the right lower neck.
  • IMP:
    • multiple enlarged lymph nodes in the bilateral neck, bilateral supraclaviccular fossa and bilateral axilla.
• 2024-01-16 SONO - neurology
  • Mild atheromatous lesions in L CCA bifurcation.
  • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • Poor temporal windows for transcranial insonation.
• 2023-12-14 ECG
  • Ventricular-paced rhythm
  • baseline atrial fibrillation
• 2023-09-12 CT - abdomen
  • With and without contrast enhancement CT of abdomen - whole:
    • Diffuse enlarged lymph nodes axillary region(more severe at right side), gastroduodenal region and pelvic cavity, lower neck, r/o lymphoma, suggest biopsy.
    • Left renal cyst, 1.3cm.
    • Minimal ascites.
    • Cystic lesion, 3.6cm in left adnexa, r/o left ovarian cyst.
  • Impression:
    • Diffuse lymph nodes in neck, axillary region, upper abdomen and pelvic cavity, r/o lymphoma, suggest biopsy.
    • Left renal cyst.
    • R/O left ovarian cyst.
• 2023-02-07 SONO - neurology
  • Mild atheromatous lesions in L CCA bifurcation.
  • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • Poor temporal windows for transcranial insonation.
• 2022-03-15 SONO - neurology
  • Normal B-mode findings of bilateral carotid arteries.
  • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • Poor temporal windows for transcranial insonation.

[MedRec]

• 2024-02-29 ~ 2024-03-04 POMR Ear Nose Throat Su WanYu
  • Discharge prescription
    • Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
    • Right neck mass status post excision of deep neck mass, right on 2024/03/01
    • Cerebral infarction
    • Type 2 diabetes mellitus without complications
    • Chronic atrial fibrillation
    • Essential (primary) hypertension
  • CC
    • Right neck mass was noted for one month
  • Present illness
    • This 84 years old female patient with history of diabetes mellitus; hypertention under medication control for many years; atrial flutter-fib under medication control and medtronic SSI on 2007/04/03.
    • The atrial flutter-fib was complicated with left MCA infarction with right hemiparesis. This time, she found incidentally right neck mass for one month ago. Mild tenderness and unmovable. She went to our ENT OPD for survey.
    • In physical examination, 3*3 cm firm mass over right neck level IV - V; 0.5 cm smooth suface bulging over right buccal.
    • Neck sonography arranged in 2024/02/05, and showed right supraclsvicular masses and right thyroid mass. Fine needle aspiration biopsy showed malignant lymphoma or marked reactive hyperplasia.
    • Arranged MRI in 2024/02/07 and showed multiple enlarged lymph nodes in the bilateral neck and bilateral supraclaviccular fossa and bilateral axilla.
    • PET showed lymphoma involving multiple lymph nodes on both sides of the diaphragm, spleen and bones or bone marrow (stage IV).
    • After discussion with the patient and family, we suggested her to receive right neck tumor excision. Operation details and risks were explained.
    • Under the impression of right neck tumor, she was admitted for operation.
  • Course of inpatient treatment
    • After admission, pre-operative evaluation was done. The patient underwent the operation of excision of right neck mass. The patient tolerated the whole procedure well.
    • Post the operation, drainage amount was recorded. Wound CD and ENT local treat were given.
    • Empirical antibiotic with Cephalexin and pain control with Acetal were given. There was no wound infection noted. With decreasing amount and homogenous yellowish content, we removed the drainage tube on post op day-3.
    • Under relative stable condition, the patient was discharge with OPD follow-up.  
  • Discharge prescription
    • cephalexin 500mg 1# QID
    • Acetal (acetaminophen 500mg) 1# QID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 90mg, lysozyme 20mg) 1# QID

[immunochemotherapy]

• 2024-08-19 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 930mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 40mg D5W 250mL 90min D2 + vincristine 1.4mg/m2 2.0mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-07-24 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 930mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 40mg D5W 250mL 90min D2 + vincristine 1.4mg/m2 2.0mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-06-28 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 900mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 40mg D5W 250mL 90min D2 + vincristine 1.4mg/m2 2.0mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-05-31 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 900mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 40mg D5W 250mL 90min D2 + vincristine 1.4mg/m2 2.0mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-04-16 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 900mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 40mg D5W 250mL 90min D2 + vincristine 1.4mg/m2 2.0mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-03-19 - rituximab 375mg/m2 560mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 900mg NS 250mL 30min D2 ……………………………………………… + vincristine 1.4mg/m2 1.6mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-COP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2

==========

2024-08-20

[assessing blood counts post R-CHOP treatment]

Lab results on 2024-08-19 were generally normal. However, records indicate that neutropenia (nadir) was observed approximately two weeks after the first day of R-CHOP administration. Continued monitoring of blood cell counts is recommended to determine if G-CSF is needed.

• 2024-08-09 WBC 1.16 x10^3/uL
• 2024-04-29 WBC 0.72 x10^3/uL

2024-07-23

[not meeting ANC threshold for R-CHOP]

WBC lab data:

• 2024-07-22 Band 1.0 %
• 2024-07-22 Neutrophil 60.2 %
• 2024-07-22 WBC 2.15 x10^3/uL
• 2024-07-22 PLT 118 x10^3/uL

ANC = (60.2% + 1.0%) / 100 * 2.15 x 10K/uL = 1.31 x 10K/uL

The generally accepted minimum ANC threshold for administering the R-CHOP regimen is 1,500 cells/μL. It is recommended to delay the treatment until ANC is > 1500/microL and platelet count is > 100K/uL.

2024-05-31

[regular LVEF monitoring recommended]

This patient frequently visits the cardiology department at our hospital, with records dating back to 2017. Recent diagnoses include:

• Complete atrioventricular block [I44.2]
• Atrial fibrillation [I48.2]
• Atrial flutter [I48.1]
• Other postsurgical states, cardiac device in situ, cardiac pacemaker [Z95.0]
• Unspecified late effect of cerebrovascular disease [I69.398]
• Unspecified cardiac dysrhythmia [I49.9]
• Complete atrioventricular block [I44.2]

On 2024-03-18, a 2D transthoracic echocardiography estimated the LVEF at 64%. Using liposomal doxorubicin instead of conventional doxorubicin can reduce the incidence of cardiomyopathy (though not eliminate all the risk). It is recommended to regularly measure LVEF during treatment to monitor for cardiomyopathy.

700734842

240820

{Prostate cancer, pT3bN1cM0, s/p RARP on 2015-06-30, s/p adjuvant radiotherapy on 2015-09-25 and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV}

[exam findings]

• 2024-07-16 Knee Bilat standing
  • Osteoarthritis change of both knees with joint space narrowing and marginal spur formation.
• 2024-07-05 Tc-99m MDP bone scan
  • The scintigraphic findings suggest multiple bone metastases. In comparison with the previous study on 2024/01/12, the lesions in the lower T-spines and adjacent left costovertebral junctions are slightly more evident. However, other previous metastatic bone lesions are either stationary or a little less evident.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • No prominent change is noted in the faint hot spots in both rib cages.
• 2024-07-06 MRI - L-spine
  • Retrolisthesis of L2 on L3, grade I.
  • Multiple ill-defined mass lesions over lumbar and sacral spine, compatible with metastases.
  • Spondylolisthesis of L4 on L5, grade I.
• 2024-07-03 CT - abdomen
  • Findings: Comparison: prior CT dated 2024/03/21.
    • Prior CT identified some LNs (1.5 cm and 1.3 cm) in left para-aortic space are noted again, mild decreasing in size to 1.3 cm and 1 cm.
    • Prior CT identified bony metastases from L1 to L4 vertebral body. are noted again, stationary.
    • There are several hepatic cysts in both lobes and the largest one 2.5 x 1.5 cm in size at S2.
    • A gallstone 1.2 cm is noted.
    • There is mild pleura effusion in left CP angle.
    • S/P prostatectomy.
• 2024-03-21 CT - abdomen
  • History and indication: Prostate Ca
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P prostate operation.
    • Left liver cyst (2.6cm).
    • Some LNs (up to 1.5cm) at retroperitoneum.
    • Some bony metastases at spine.
    • Gallbladder stones (2-3mm).
    • Minimal ascites. Left pleural effusion.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P prostate operation. Some LNs (up to 1.5cm) at retroperitoneum. Some bony metastases at spine.
• 2024-01-12 Tc-99m MDP bone scan
  • In comparison with the previous study on 2023/08/15, the lesions in the left frontal region of the skull, some T- and L-spines, some bilateral ribs, left iliac bone and right humeral head are slightly more evident. Multiple bone metastases in slight progression may show this picture.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
• 2023-12-20 CT - abodomen
  • History:
    • Prostate cancer, pT3bN1cM0, s/p RARP, s/p adjuvant R/T and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV
    • 20230825 PSA:38.479 ng/mL (＜ 4).
  • Findings: Comparison: prior CT dated 2023/08/25.
    • Prior CT identified some LNs (up to 2 x 1 cm) in para-aortic space are noted again, mild increasing in size to 2 x 1.4 cm that is c/w stable disease.
    • Prior CT identified bony metastases from L1 to L4 vertebral body. are noted again, stationary.
    • There are several hepatic cysts in both lobes and the largest one 2.5 x 1.5 cm in size at S2.
    • A gallstone 1.2 cm is noted.
    • S/P prostatectomy.
  • Impression:
    • Prior CT identified some LNs (up to 2 x 1 cm) in para-aortic space are noted again, marked increasing in size to 2 x 1.4 cm that is c/w stable disease.
• 2023-10-03 Bone densitometry - spine, hip
  • L-spines BMD performed by DXA revealed:
    • AP L-spines, BMD of L1-4 0.842 gms/cm2, about 1.9 SD below the peak bone mass (80%) and 0.5 SD below the mean of age-matched people (90%).
  • Hip BMD performed by DXA revealed:
    • Left hip, BMD is 0.720 gms/cm2, about 1.2 SD below the peak bone mass (85%) and 0.1 SD above the mean of age-matched people (101%).
  • Impression
    • Osteopenia
• 2023-09-15 MRA - brain
  • Post-operation change at left frontal lobe, without evidence of residual or recurrent tumor.
• 2023-08-25 CT - abdomen
  • History: Prostate cancer, pT3bN1cM0, s/p RARP, s/p adjuvant R/T and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV
    • 20230825 PSA:38.479 ng/mL (<4).
  • Findings:
    • Prior CT identified some LNs (up to 1 cm) in para-aortic space are noted again, marked increasing in size to 2 cm that is c/w progressive disease.
    • There is an ill-defined osteoblastic lesion with central osteolytic change at right lateral aspect of L3 vertebral body that is c/w bony metastasis. In addition, there are few small osteoblastic nodules in L1, L2, and L4 vertebral body that are also c/w bony metastases.
    • There are several hepatic cysts in both lobes and the largest one 2.5 x 1.5 cm in size at S2.
    • A gallstone 1.2 cm is noted.
    • S/P prostatectomy.
  • Impression:
    • Prior CT identified some LNs (up to 1 cm) in para-aortic space are noted again, marked increasing in size to 2 cm that is c/w progressive disease.
• 2023-08-22 MRI - L-spine
  • Findings: Multiple ill-defined bony lesions with T1- and T2-hypointensity and faint enhancement involving L1-4 vertebral bodies and S1 vertebral body, most severe at L3 vertebral body. Compatible with metastases.
• 2023-08-15 Tc-99m MDP bone scan
  • In comparison with the previous study on 2023/05/10, the hot spot at the left 9th costovertebral junction is less evident.
  • The lesion in the middle T-spine is slightly more evident. The nature is to be determined (degenerative change in a little more severe status? other nature?). Please follow up bone scan for furhter investigation.
    
  • No prominent change is noted in other bone lesions, suggesting in stable condition.
• 2023-06-08 MRI - L-spine
  • Bony metastases involving L1-4 and S1 vertebral bodies.
  • Mild lumbar spondylosis.
• 2023-06-01 CT - abdomen
  • History and indication: Prostate Ca with L-spine mets
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P prostate operation.
    • Left liver cyst (2.5cm).
    • Some LNs (up to 1.0cm) at retroperitoneum.
    • Some bony metastases at spine.
    • Gallbladder stone (0.9cm).
    • Minimal ascites.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P prostate operation. Some LNs (up to 1.0cm) at retroperitoneum. Some bony metastases at spine.
    • Gallbladder stone (0.9cm).
• 2023-05-10 Tc-99m MDP bone scan
  • In comparison with the previous study on 2023/03/03, the hot spot at the left 9th costovertebral junction is new, and the nature is to be determined (new bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
• 2023-03-03 Tc-99m MDP bone scan
  • In comparison with the previous study on 2022/11/28, the lesion in the left sternoclavicular junction is a little less evident, possibly more benign in nature.
• 2023-03-02 CT - abdomen
  • S/P prostate operation. Some LNs (up to 0.9cm) at retroperitoneum. R/O bony metastases at spine.
  • Gallbladder stone (0.9cm).
• 2022-12-17 MRI - L-spine
  • Known a case of prostate cancer. Multiple enhancing nodular lesions within visible thoracic-lumbar vertebral bodies. Compatible with metastatic lesions.
  • Retrolisthesis of L2 on L3, grade I.
  • Spondylolisthesis of L4 on L5, grade I.
• 2022-11-30 SONO - chest
  • Pleural effusion, minimal, bilateral
  • Atelectasis, LLL and RLL
• 2022-11-28 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 2022/06/30, there is a new lesion of increased activity at the left sternoclavicular junction; probably benign in nature.
  • No prominent change is noted in other bone lesions.
• 2022-11-28 Peripheral Vascular Test - vein, lower limbs
  • Report:
    • Right side:
      • SVC: 23.8 mmHg ; 27.3 mmHg ;
      • MVO/SVC: 98 % ; 92 % ;
      • Average MVO/SVC: 95 %
    • Left side:
      • SVC: 23.1 mmHg ; 27.2 mmHg ;
      • MVO/SVC: 95 % ; 87 % ;
      • Average MVO/SVC: 91 %
    • Thrombus : None
      • Varicose vein at L’t LSV
  • Conclusion:
    • Significant venous reflux at left saphenofemoral junction with varicose change of left LSV from upper to lower leg level.
    • Slow venous return flow at left poplital vein; a large perforator vein draining from left distal PTV to LSV was detected.
    • No evidence of venous thrombosis at bilateral lower limbs venous systems.
    • Tissue edema at bilateral lower legs.
    • The ratios of MVO and SVC of bilateral legs were within normal limits.
• 2022-11-26 CT - abdomen
  • Findings
    • S/P prostate operation.
    • Left liver cyst (2.1cm).
    • Bil. pleural effusions.
    • Some LNs (up to 0.8cm, mild regression) at retroperitoneum.
    • Suspected bony metastases at spine.
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • Gallbladder stone (0.9cm).
    • Patency of portal vein.
    • Minimal ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • S/P prostate operation. Bil. pleural effusions.
    • Some LNs (up to 0.8cm, mild regression) at retroperitoneum.
    • Suspected bony metastases at spine.
    • Gallbladder stone (0.9cm).
• 2022-07-19 Nasopharyngoscopy
  • clear middle meatus, inferior turbinate hypertrophy, smooth NPX
• 2022-06-30 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 20220311, the previous bone lesions in the upper and middle T-spines, L3 spine and left iliac bone are all a little less evident.
  • No prominent change is noted in other bone lesions.
• 2022-06-29 CT - abdomen
  • Findings:
    • Prior CT identified some LNs (up to 1.6cm) in para-aortic space and left external iliac chain are noted again, mild decreasing in size that is c/w partial response.
    • There is an ill-defined osteoblastic lesion with central osteolytic change at right lateral aspect of L3 vertebral body that is c/w bony metastasis.
    • There are several hepatic cysts in both lobes and the largest one 2.5 x 1.5 cm in size at S2.
    • A gallstone 1.2 cm is noted.
    • S/P prostatectomy.
  • Impression:
    • Prior CT identified some LNs (up to 1.6cm) in para-aortic space and left external iliac chain are noted again, mild decreasing in size that is c/w metastatic nodes S/P C/T with partial response.
    • There is an ill-defined osteoblastic lesion with central osteolytic change at right lateral aspect of L3 vertebral body that is c/w bony metastasis.
• 2022-04-19 Water’s view
  • Opacification of right maxillary sinus.
• 2022-03-11 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 20210723, the lesions in the upper and middle T-spines are less evident. However, the lesion in the left iliac bone is a little more evident.
  • The lesions in the right humeral head and L3 spine are new. Bone metastases should be watched out. Please correlate with other clinical findings for further evaluation.
• 2022-03-10 CT - abdomen, pelvis
  • S/P prostate operation.
  • Some LNs (up to 1.6cm, mild regression) at retroperitoneum.
  • Suspected bony metastases at spine.
  • Gallbladder stone (0.9cm).
• 2021-11-16 CT
  • S/P prostatectomy.
  • Progression of metastatic paraaortic lymph nodes and bone metastasis.
  • GB stones.
  • Fatty content liver tumor, 2.6cm in S2 liver.
• 2021-07-23 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 20200715, the lesions in the upper and middle T-spines and left iliac bone are new. Bone metastases should be watched out.
  • No prominent change is noted in the previous two faint hot spots in the left frontal region of the skull and posterior aspect of the left 11th rib, possibly more benign in nature.
  • Increased activity in the left aspect of maxilla. The nature is to be determined (dental problem? other nature?).
  • Mildly increased activity in the lower L-spines. Degenerative change is more likely.
  • Suspected benign jount lesions in the right sternoclavicular junction, bilateral shoulders, hips, knees and boh feet.
• 2021-07-22 MRI
  • S/P prostatectomy.
  • Regression of paraaortic lymph nodes in paraaortic lymph node.
  • Liver cyst.
  • Gallbladder stones.
• 2021-07-13 CT
  • metastatic Lt supraclavicular fossa and left retroperitoneal paraaortic lymphadenopathy.
• 2021-03-24 MRI
  • S/P prostatectomy.
  • Suspected metastatic lymph nodes in paraaortic regions. Regression as compare with MRI study on 2020-11-12.
  • Liver cyst.
  • Gallbladder stones.
• 2021-07-15 Tc-99m MDP whole body bone scan
  • Two faint hot spots in the left frontal region of the skull and post. aspect of the left 11th rib, probably post-traumatic change, suggesting follow-up.
  • Suspected benign lesions in the maxilla, right sternoclavicular junction, bilateral shoulders, and hips.
• 2019-05-19 MRA - Brain
  • A frontal base meningioma. Left exophthalmus.
• 2019-01-15 MRI
  • S/P prostatectomy.
  • Suspected metastatic lymph nodes in left common iliac and paraaortic regions.
  • Liver cyst.
• 2019-01-08 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 20180207, the previous lesions in the maxilla, left 11th rib and the left femoral neck are stationary, indicating more benign in nature.
  • Other bone lesions are also stationary. Probably degenerative change in the upper T-spine, bilateral sternoclavicular junctions and bilateral sacroiliac joints, bilateral shoulders, and bilateral hips.
• 2018-02-07 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 20161103, the lesions in the left 11th rib and the left femoral neck had become very faint, indicating benignity in nature.
  • Probably degenerative change in the upper T-spine, sternoclavicular junctions and sacroiliac joints.
  • Increased radiotracer uptake in the maxilla, local inflammatory change such as sinusitis may show such a picture.
• 2016-04 MRI
  • Prostate cancer with extracapsular extension and seminal vesicle invasion, mainly in left aspect.
  • Metastatic left obturator lymph node. Stage T3N1Mx.
• 2015-06-30 Patho (HuaLien TzuChi)
  • Prostate gland, radical prostatectomy, adenocarcinoma (Glason score: 5+4=9) (pT3bN1).
  • Urethra, prostatic, radical prostatectomy, squamous metaplasia.
  • Seminal vesicle, right, radical prostatectomy, adenocarcinoma, invasion.
  • Seminal vesicle, left, radical prostatectomy, adenocarcinoma, invasion.
  • Lymph node, right, lymphadenectomy, no lymph node retrived.
  • Lymph node, left, lymphadenectomy, adenocarcinoma, metastatic (1/2).
  • Prostate gland, apex, resection, adenocarcinoma. Urinary bladder, neck, resection, negative for malignancy.
  • Extraprostatic Extension: Present.
  • Seminal Vesicle Invasion (invasion of muscular wall required): Present.
  • Lymph-Vascular Invasion: Present.
  • Perineural Invasion: Present.

[MedRec]

• 2024-08-19 SOAP Orthopedics Huang MengRen
  • S: Both knees pain off & on for yrs
  • Prescription
    • Caricalm (carisoprodol 175mg, acetaminophen 350mg, caffeine 32mg) 1# TID 28D
    • Celebrex (celecoxib 200mg) 1# QD 28D
• 2023-09-26 SOAP Hemato-Oncology Xia HeXiong
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Casodex (bicalutamide 50mg) 1# QD
    • Zoladex (goserelin 3.6mg) Q4W SC
    • Xgeva (denosumab 120mg) Q4W SC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
• 2023-08-29 SOAP Hemato-Oncology Xia HeXiong
  • A/P: On 2023-08-29, after discussion with patient, the progression over left para-aortic LAP, he want keep ADT and AR blocker, not R/T, not C/T.

[consultation]

• 2022-12-01 Dermatology
  • Q
    • This 66-year-old man patient is a case of Prostate cancer, pT3bN1cM0, s/p RARP on 2015/06/30, s/p adjuvant radiotherapy on 2015/09/25 and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV s/p chemotherapy with Taxotere from 2021/11/17, partal response.
    • He was admitted cellulitis for left lower swelling with redness with antibiotic therapy. This time, for bilateral toe nails onychomycosis. Now, for evaluate bilateral toe nails onychomycosis therapy. Thank you.
  • A
    • The patient had sufferred from prostate cancer s/p chemotherapy. Dry skin patern was noted over lower legs and thickening nail with deformity
      
    • Under the impression of tinea unguium et pedis, xerotic dermatitis on the lower leg.
    • The following suggestion:
      • Exelderm lotion (sulconazole nitrate) 2 tube topical QN use over nail fold and footbase.
        
      • Sinphraderm cream (urea 100mg/gm) 1 tube topical QN use on the dry skin of lower legs.
• 2021-12-30 Mental Health
  • A
    • This is a 65 y/o male patient with prostate cancer, admission for palliative chemotherapy today. He has no psychiatric history.
    • Upon visit, the patient is sitting on his bed, with wife at bedside.
    • The patient is in euthymic, smiley and inviting. Greeting and appropriate speech. He deny depressed mood, deny suicide thought, able to percieve fair night sleep under current medication, fair appetite.
    • No extra medication is needed.
• 2021-11-15 Hemato-Oncology
  • Q
    • This is a 65 y/o male with underlying hypertension, hypothyroidism and dyslipidemia. He was previous diagnosed prostate cancer, pT3bN1cM0 s/p radical prostatectomy + radiotherapy + hormone therapy with refractory, s/p Zytiga 360# since 2020-02 with poor response, s/p Zoladex and Androcur since 20210109, Pamorelin (Q3M) + Casodex on 20210206. However, follow-up lung CT still showed metastatic lymph nodes in Lt supraclavicular fossa. Bony metastasis of upper, middle T spine and left iliac bone was also noted in bone scan on 20210723. Serial PSA level since 2021 April showed 8.74 -> 12.47 -> 14.19 -> 17.40 -> 28.39. He only complained about back pain in recent few months. There was no decreased appetite or body weight loss. Due to progressed disease, he was admitted for port-A insertion and further systemic chemotherapy.
    • We need your expertise for further systemic chemotherapy regimen suggest after port-A insertion.
  • A
    • A case of castration-resistant prostate cancer is noted.
    • Based on the failure to LHRH + Andreocur and Casodex and further abiraterone, palliative chemotherapy with docetaxel is indicated.

[surgical operation]

• 2015-06-30 at HuaLien TzuChi - radical prostatectomy
  • prostate adhesion to bladder wall, suspicious invasion to bladder neck.
  • tumor invasion in seminal vesicle was also suspected. bilateral neurovascular bundles (NVB) did not preserved.

[radiotherapy]

• 2021-07-28 ~ 2021-08-23: 4560cGy/19 fractions (6 MV photon) to left SCF LAPs.
• 2020-12-10 ~ 2021-01-14: 5000cGy/25 fractions (15 MV photon) to paraaortic LAPs.
• 2015-08-05 ~ 2015-09-25: 4500cGy/25 fractions of the pelvic, 5040cGy/28 fractions of the tumor bed and peripheral, and 6480cGy/36 fractions of the reduced tumor bed area.

[chemotherapy]

• 2024-08-20 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-07-27 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-07-03 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-06-06 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-05-08 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-04-11 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-03-21 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-02-24 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-02-03 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-01-12 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-12-20 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-11-24 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-10-30 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-09-28 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-03-17 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-02-06 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-01-04 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-12-16 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-11-01 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-10-11 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-09-20 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-08-30 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-08-10 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-07-22 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-06-30 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-06-09 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-05-19 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-04-26 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-04-06 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-03-11 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
• 2022-02-15 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
• 2022-01-25 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1
• 2021-12-30 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1
• 2021-12-10 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
• 2021-11-17 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

certain medication

• Xgeva (denosumab) CXGEV01
  • 2023-01-04 120mg ST SC OPD
  • 2022-11-24 120mg ST SC IPD
  • 2022-10-25 120mg Q1M SC OPD
  • 2022-08-31 120mg Q1M SC OPD
  • 2022-08-30 120mg Q1M SC IPD
  • 2022-08-03 120mg Q1M SC OPD
• Zoladex (goserelin) CZOLA01
  • 2024-08-21 3.6mg Q4W SC IPD
  • 2024-07-02 3.6mg Q4W SC IPD
  • 2024-05-23 3.6mg Q4W SC OPD
  • 2024-05-16 3.6mg Q4W SC OPD
  • 2024-04-22 3.6mg Q4W SC OPD
  • 2024-03-20 3.6mg Q4W SC IPD
  • 2024-02-02 3.6mg Q4W SC IPD
  • 2023-12-19 3.6mg Q4W SC IPD
  • 2023-10-31 3.6mg Q4W SC IPD
  • 2023-09-26 3.6mg Q4W SC OPD
  • 2023-08-29 3.6mg Q4W SC OPD
  • 2023-08-01 3.6mg Q4W SC OPD
  • 2023-07-07 3.6mg Q4W SC OPD
  • 2023-06-06 3.6mg Q4W SC OPD
  • 2023-05-09 3.6mg Q4W SC OPD
  • 2023-04-11 3.6mg Q4W SC OPD
  • 2022-10-25 3.6mg Q4W SC OPD
  • 2022-08-31 3.6mg Q4W SC IPD
  • 2022-08-03 3.6mg Q4W SC OPD
  • 2022-06-28 3.6mg Q4W SC OPD
  • 2022-05-31 3.6mg Q4W SC OPD
  • 2022-04-26 3.6mg Q4W SC OPD
  • 2022-03-23 3.6mg Q4W SC OPD
  • 2022-02-08 3.6mg Q4W SC OPD
  • 2021-01-09 3.6mg Q4W SC OPD
• Andreocur (cyproterone) KANDR
  • 2018-02-03 ~ 2022-04-03 50mg TID OPD
  • 2017-02-11 ~ 2018-01-20 50mg QD OPD
• bicalutamide KBICA01
  • 2018-05-12 ~ 2020-01-11 50mg QD OPD
• Casodex (bicalutamide) KCASO01
  • 2021-02-06 ~ 2022-01-07 50mg QD OPD
• Pamorelin (triptorelin) CPAMO02
  • 2021-10-15 11.25mg Q3M IM OPD
  • 2021-07-28 11.25mg Q3M IM OPD
  • 2021-05-08 11.25mg Q3M IM OPD
  • 2021-02-06 11.25mg Q3M IM OPD
• Zytiga (abiraterone) KZYTI01 poor response
  • 2020-02-08 1000mg QDAC PO OPD
• Leuplin Depot (leuprorelin)
  • 2018-12 ~ 2020-08 Q3M
• G-CSF, granulocyte colony-stimulating factor (not completed)
  • 2022-09-01 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-08-30
  • 2022-08-17 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-08-10
  • 2022-07-22 Granocyte (lenograstim 250mg) QD SC 3 days IPD
  • 2022-07-12 Granocyte (lenograstim 250mg) QD SC 3 days OPD
  • 2022-06-15 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-06-08
  • 2022-05-25 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-05-19
  • 2022-05-04 Granocyte (lenograstim 250mg) QD SC 3 days OPD
  • 2022-04-06 Granocyte (lenograstim 250mg) QD SC 3 days IPD
  • 2022-03-16 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-03-09
  • 2022-02-23 Granocyte (lenograstim 250mg) QD SC 3 days OPD
  • 2022-01-04 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2021-12-30
  • 2021-12-15 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2021-12-09
  • 2021-11-24 Granocyte (lenograstim 250mg) QD SC 3 days OPD

==========

2024-08-20

[stable PSA and disease control with ongoing disease control with docetaxel and goserelin]

PSA levels have remained stable at around 70 ng/mL over the past three months. A July CT scan, compared with the previous quarter, indicates that the disease has remained stable, suggesting that the current docetaxel and goserelin regimen is still effective.

• 2024-08-06 PSA 71.722 ng/mL
• 2024-07-16 PSA 68.676 ng/mL
• 2024-06-18 PSA 72.389 ng/mL
• 2024-05-23 PSA 74.124 ng/mL
• 2024-05-16 PSA 69.888 ng/mL

Other lab results from 2024-08-19 were generally normal, and no medication discrepancies were identified.

2024-04-11

[stable PSA levels post-docetaxel therapy; managing HBV reactivation and neutropenia effectively]

Since initiating docetaxel treatment on 2023-09-28 after a six-month interval, there appears to be no trend of PSA doubling as of late December 2023, suggesting a stable response to the therapy.

Lab tests on 2024-04-10 were largely normal. The patient continues to take Baraclude (entecavir) and Granocyte (lenograstim) is used as a preventive measure against HBV reactivation and neutropenia, similar to previous protocols, with no discrepancies in medication identified.

• 2024-04-01 PSA 102.865 ng/mL
• 2024-03-20 PSA 93.927 ng/mL
• 2024-03-06 PSA 104.221 ng/mL
• 2024-02-15 PSA 115.264 ng/mL
• 2024-02-03 PSA 115.663 ng/mL
• 2024-01-25 PSA 100.009 ng/mL
• 2024-01-12 PSA 92.218 ng/mL
• 2023-12-21 PSA (NM) 100.285 ng/mL
• 2023-12-11 PSA (NM) 77.905 ng/mL
• 2023-10-31 PSA 73.173 ng/mL
• 2023-10-11 PSA 82.678 ng/mL
• 2023-09-16 PSA 48.013 ng/mL
• 2023-08-25 PSA 38.479 ng/mL
• 2023-08-01 PSA 21.710 ng/mL
• 2023-06-26 PSA 6.551 ng/mL
• 2023-06-01 PSA 3.338 ng/mL
• 2023-05-09 PSA 2.184 ng/mL

2023-01-05

• 2023-01-04 lab data were generally normal, except for a slight decrease in WBC and HGB levels. The vital signs of the patient are stable during this hospitalization.

• All underlying conditions, including HBV, hypothyroidism, and insomnia, are managed with appropriate medication.

2022-08-31

• The PSA reading has been trending downward during the last half year (2022-08-14 10 <- 2022-02-15 43). Currently, it appears that the disease is under control and is in a relatively stable state.
• In recent months, G-CSF has been used triweekly on three consecutive days to protect the patient against neutropenic complications caused by a previously administered chemotherapy.

2022-06-09

• This patient with an advanced, refractory prostate cancer with paraaortic lymph nodes and bone metastases is being treated with docetaxel palliatively.
• CT (2022-03-10) confirmed that some LNs (up to 1.6cm) had mild regression at the retroperitoneum. PSA floats in the 20s (unit ng/mL) since March 2022. As of now, the disease appears to be still under control.
• Underlying diseases such as HBV, hypothyroidism, hyperlipidemia are currently managed with Baraclude (entecavir), Eltroxin (levothyroxine), Zulitor (pitavastatin), respectively.
• SpO2 has been around 95% these two days, please keep an eye on the reading.
• No issue with active prescription.

2023-05-20

• This patient has advanced prostate cancer that is refractory with progression of paraaortic lymph nodes and bone metastases.
• Docetaxel is being administered to the patient palliatively and is generally well tolerated.
• Lab data reported on 2022-05-16 showed grossly normal results, except for a slight pancytopenia and a high PSA (26.464ng/mL).
• Underlying health condition are managed with corresponding self-carried drugs. No issue with active prescription.

2023-04-27

• After using hormone therapy from 2017-01 to 2021-10 and proving the disease castration-resistant (2021-11-16 CT showed progression), the patient has begun taking docetaxel since 2021-11-17.
• Bone scans on 2022-03-11 revealed new lesions in the right humeral head and L3 spine, and CTs on 2022-03-10 showed LNs up to 1.6 cm in the retroperitoneum.
• Lab results on 2022-04-26 showed that blood cell counts, liver and kidney function, serum electrolytes were grossly normal, however PSA 27 ng/mL remained high.
• Underlying health condition are managed with corresponding drugs
  • postprocedural hypothyroidism - Eltroxin (levothyroxine)
  • chronic viral hepatitis B without delta-agent - Baraclude (entecavir)
  • hyperlipidemia - Zulitor (pitavastatin)
  • duodenal ulcer - Nexium (esomeprazole)
  • insomnia - Anxiedin (lorazepam)

2022-04-07

assessment

• Novel hormone therapies include abiraterone, enzalutamide, darolutamide, or apalutamide received for metastatic castration-naïve disease, M0 CRPC, or previous lines of therapy for M1 CRPC.
• After using hormone therapy from 2017-01 to 2021-10 and proving the disease castration-resistant (2021-11-16 CT showed progression), the patient has begun taking docetaxel since 2021-11-17.
• The bone scan on 2022-03-11 revealed new lesions in the right humeral head and L3 spine, however, the PSA level decreased slightly (26.9ng/mL 2022-03-23 <- 43.2ng/mL 2022-02-15).

suggestion

• Tumor testing for microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) is recommended in patients with metastatic castration-resistant prostate cancer and may be considered in patients with regional or castration-naïve metastatic prostate cancer.
• Tumor mutational burden (TMB) testing may be considered in patients with metastatic castration-resistant prostate cancer.
• Cabazitaxel 20 mg/m2 plus carboplatin AUC 4 mg/mL per min with growth factor support can be considered for fit patients with aggressive variant prostate cancer (visceral metastases, low PSA and bulky disease, high LDH, high CEA, lytic bone metastases, neuroendocrine prostate cancer histology) or unfavorable genomics (defects in at least 2 of PTEN, TP53, and RB1). source: Cabazitaxel plus carboplatin for the treatment of men with metastatic castration-resistant prostate cancers: a randomised, open-label, phase 1-2 trial https://pubmed.ncbi.nlm.nih.gov/31515154/

2022-02-16

assessment

• image findings showed the disease progresive and lab data PSA readings keep elevating from 8.7ng/mL (2021-04-05) to 43.2ng/mL (2022-02-15)
• the patient is undergoing hormone therapy triptorelin since 2021-02 (last dose 2021-10) and receiving chemotherapy docetaxel since 2021-11.
• systemic therapies for metastatic castration-resistant prostate cancer such as abiraterone/prednisone, enzalutamide, Ra-223, docetaxel, cabazitaxel, and mitoxantrone have all been shown to reduce skeletal-related events and improve bone pain.

suggestion

• triptorelin could be continued with another dose if there is no contraindication. -tumor testing for microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) is recommended in patients with metastatic castration-resistant prostate cancer and may be considered in patients with regional or castration-naïve metastatic prostate cancer. -tumor mutational burden (TMB) testing may be considered in patients with metastatic castration-resistant prostate cancer.

700801193

240820

[lab data]

• 2024-05-29 Anti-HBc Reactive
  

• 2024-05-29 Anti-HBc Value 6.30 S/CO
  

• 2024-05-29 Anti-HBs 61.54 mIU/mL
  

• 2024-05-29 HBsAg Nonreactive
  

• 2024-05-29 HBsAg Value 0.41 S/CO
  

• 2024-05-29 Anti-HCV Nonreactive
  

• 2024-05-29 Anti-HCV Value 0.11 S/CO

• 2020-05-22 Urine Culture

  • Escherichia coli
    • Amoxicillin/Clavulanic Acid (R)
    • Ciprofloxacin (S = 0.25)
    • Imipenem (S = 0.25)
    • Cefazolin (S = 4)
    • Piperacillin/tazobactam (S = 4)
    • Amilkacin (S = 2)
    • Flomoxef (S = 2)
    • Gentamicin (S = 1)
    • Ceftriaxone (S = 1)
    • Doripenem (S = 0.12)
    • Levofloxacin (S = 0.12)
    • Trimethoprim/Sulfamethoxazole (S = 20)
    • Ampicillin (R >= 32)
    • Cefoperazone/Sulbactam (S = 8)         

[exam findings]

• 2024-07-04 Colonoscopy
  • Diagnosis:
    • poor exam quality due to poor colon preparation.
    • Colon polyp, ascending colon
    • Internal hemorrhoid
  • Suggestion:
    • Repeat colonoscopy under better colon preparation if clinically indicated
• 2024-07-04 EGD
  • Diagnosis:
    • Suboptimal study due to much residual food noted
    • Enteric ulcers, Forrest classification type IIc
    • Status post subtotal gastrectomy and Billroth II anastamosis
    • Remnant gastritis
    • Enteric erosions
  • CLO test: not done
  • Suggestion:
    • PPI use
• 2024-07-02 Bleeding Scan
  • Following the intravenous injection of cold pyrophosphae, RBC labeling with 20 mCi of Tc-99m pertechnetate was done 15 minutes later. After intravenous injection of the radiotracer, dynamic study and serial scintigraphic imaging of the abdomen were obtained.
  • There was increased radiotracer uptake in the right lower lateral aspect of the abdomen in the image acquired 24 hours after radiotracer injection.
  • IMPRESSION:
    • Because of the delayed appearance (24 hours after radiotracer injection) of increased radiotracer uptake in the right lower lateral aspect of the abdomen, the source of the bleeding can not be definitely sure. The source of the bleeding was possibly from the ascending colon or form more proximal area such as small intestine. Please correlate with other clinical findings for further evaluation.
• 2024-06-17 KUB
  • Marked distension and food in the stomach is highly suspected.
  • Please correlate with contrast enhanced CT.
  • Fecal material store in the colon.
• 2024-05-07 Patho - small intestine resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Tumor, duodenum, Whipple operation with partial gastrectoy — Adenocarcinoma
    • Resection margins, ditto — Free of tumor invasion
    • Pancreas, ditto — Tumor invasion, extends more than 0.5 cm
    • Stomach, ditto — Free of tumor invasion
    • Gallbladder, cholecystectomy — Free of tumor invasion, chronic cholecystitis
    • Lymph nodes, peri-tumor area, dissection — Metastatic carcinoma (4/6) with extracapsular extension (3/4)
    • Lymph nodes, lesser curvature, ditto — Metastatic carcinoma (1/4) with extracapsular extension (1/1)
    • Lymph nodes, greater curvature, ditto — Free of tumor metastasis (0/11)
    • Lymph nodes, peri-pancreatic area, ditto — Free of tumor metastasis (0/3)
    • Lymph nodes, duodenal, ditto — Free of tumor metastasis (0/1)
    • AJCC pathologic staging — pT3bN2, if cM0, stage IIIB
  • MACROSCOPIC EXAMINATION
    • Specimen Type: duodenum + pancreatic head + partial stomach + partial lymph node dissection and gallbladder
    • Specimen and size
      • Pancreatic head: 7 x 4.8 x 4.2 cm
      • Small bowel: 16.5 cm in length, 2.8 cm in diameter
      • Gallbladder: 8 x 3 x 2.5 cm, no stone
      • Partial stomach: greater curvature: 12.5 cm; lesser curvature: 8.5 cm
    • Tumor Site: duodenum
    • Tumor Size: one crater mass measured 4 cm with 2 x 0.8 cm ulcer
    • Representatively embedded for sections as A1: small bowel cutting end, A2: gastric cutting end, A3-A6: tumor with serosa (ink), A7-A8: tumor + pancreas, A9: bile duct cutting end, A10-A11: tumor + normal duodenum + pancreas, A12-A13: tumor + stomach, A14-A15: peritumor vague lesion + tumor + pancreas, A16: LNs of lesser curvature, A17-A18: LNs of greater curvature, A19: LNs of peri-tumor area, A20: LN s of peri-pancreatic area, A21: LNs of duodenum and B: gallbladder
  • MICROSCOPIC EXAMINATION
    • Histologic Type: adenocarcinoma with focal necrosis
    • Histologic Grade: G2, moderately differentiated
    • Margins: free, closest margin < 0.1 cm to serosa of duodenum
    • Lymphovascular invasion: present
    • Perineural Invasion: present
    • Pathologic Staging (pTNM): pT3bN2
    • Gallbladder: chronic cholecystitis
• 2024-05-02 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 26) / 102 = 74.51%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Trivial MR and trivial TR
    • Preserved RV systolic function
• 2024-04-30 CT - abdomen
  • Impression
    • Thickening wall at gastric antrum and pylorus, r/o malignancy.
    • Atrophy of left kidney with stone.
    • Mild dilatation of right pelvicaliceal system and upper ureter. Mild right hydronephrosis.
    • Right subpleural nodule, 0.9cm, suggest follow up.
• 2024-04-29 Flow Volume Chart
  • r/o mild restrictive ventilatory defect
• 2024-04-27 MRI - upper abdomen
  • Wall thickening at the gastric antrum measuring 4.4cm in largest dimension. r/o gastric cancer. Please correlate with CT and other image study.
• 2024-04-16 Patho - doudenum biopsy
  • Duodenum, bulb, biopsy — adenocarcinoma, moderately differentiated
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • Immunohistochemical stain reveals CK(+) at tumor.
• 2024-04-16 EGD
  • Diagnosis:
    • Phlebectasia, upper esophagus
    • Reflux esophagitis LA Classification grade A-
    • Superficial gastritis, s/p CLO test
    • Gastric SEL, antrum, AW
    • Duodenal ulcerative mass with ulcer, r/o malignancy, bulb to SDA, s/p biopsy
  • CLO test: Negative
  • Suggestion:
    • Pursue the CLO test and the pathology report
    • Consider to arrange abdomen CT if no contraindication
    • PPI use
• 2024-04-16 SONO - abdomen
  • Renal cyst, right kidney
  • Renal atrophy, left kidney
• 2024-07-24 Bronchodialtor Test
  • Diagnosis: asthma
  • Conclusion: moderate obstructive ventilatory impairment with significant reversibility, small airway disease
• 2023-05-11 CT - brain
  • Brain atrophy with bilateral periventricular ischemic/aging white matter change.
• 2023-03-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (79.4 - 31.4) / 79.4 = 60.45%
    • M-mode (Teichholz) = 60.5
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mitral valve prolapse (anterior leaflet) with mild mitral regurgitation
    • Trivial TR and PR
    • Impaired LV relaxation
    • Thick IVS and LVPW
• 2022-11-14 Mini-Mental Status Examination, MMSE
  • MMSE score = 26
  • note: The total score ranges from 0 to 30. A higher score indicates better cognitive function.
• 2022-11-24 Clinical Dementia Rating, CDR
  • CDR score = 0.5
  • note: The CDR score ranges from 0 (no cognitive impairment) to 3 (severe dementia). A score of 0.5 indicates very mild dementia, 1 indicates mild dementia, 2 indicates moderate dementia, and 3 indicates severe dementia.

[MedRec]

• 2024-05-28 SOAP Hemato-Oncology Xia HeXiong
  • P:
    • Explain the Strategy C/T with FOLFOX x 6 -> CCRT with short infusion 5-FU -> FOLFOX x 6.
    • Consult RTO when 5th dose of FOLFOX is completed.
    • Already told oxaliplatin will be self-pay.
    • Be aware of 5-FU due to impaired renal function
• 2024-04-25 ~ 2024-05-22 POMR General and Gastroenterological Surgery Wu ChaoQun
  • Discharge diagnosis
    • Duodenal adenocarcinoma, pT3bN2(cM0), stage IIIB status post pancreaticoduodenectomy with partial gastrectoy and cholecystectomy and lymph node dissection and Braun’s anastomosis on 2024/05/06. ECOG:1
    • Bilateral lower lung pneumonia with partial atelectasis (Culture: Candida tropicalis)
    • Type 2 diabetes mellitus without complications
    • Chronic kidney disease, stage 4
    • Asthma
    • Hypocalcemia
    • Hyperkalemia
    • Gout
    • Dementia
  • CC
    • admission for duodenal adenocarcinoma survey
  • Present illness
    • This 74-year-old female had histories of 1) Type 2 diabetes mellitus, 2) Hyperlipidemia, 3) Gout, 4) Chronic kidney disease, stage 4, 5) Dementia, 6) Hypertension, 7) Asthma. She was regular follow up at Nepro/ Meta/ Neuro/ CM OPD.
    • Accord patient and her family statement, she experienced epiagstric pain, abdominal fullness for a week and stool occult blood postive was mentioned at Meta OPD. Thus, she referred to GI OPD, where panendoscopy was performed on 2024/04/16 and revealed duodenal ulcerative mass with ulcer, r/o malignancy, bulb to SDA, s/p biopsy.
    • The duodenum biopsy showed adenocarcinoma, moderately differentiated. There was no weight loss, fever, no dizziness, no URI symptoms, no chest tightness, no epigastric pain, no tarry/bloody stool.
    • Under the impression of duodenal adenocarcinoma, she was admitted to the ward for furter evaluation and management.
  • Course of inpatient treatment
    • After admitted, abdominal MRI on 2024/04/27 showed wall thickening at the gastric antrum measuring 4.4cm in largest dimension, r/o gastric cancer. Therefore, due to CKD 4, abdominal CT without contrast is scheduled on 4/30 for further survey. We also checked CEA and CA199 on 2024/04/29.
    • GS was consulted for operation, and PFT and cardiac echo were arranged for pre-op evaluation. Pre-operation PPN supplement was indicated, so she was transferred to GS ward on 2024/05/02 for pre-op.
    • In GS ward, we keep nutrition support with PPN and blood transfusion support for anemia. She underwent Whipple’s op with LN dissection, then transferred to SICU for post operative intensive care on 2024/05/06.
    • During SICU, empiric antibiotic with Brosym (05/06-05/08) for infection control.
    • Keep PPI for prevention GI bleeding. Control SBP < 160mmHg as Perdipine infusion.
    • NPO with decompression, nutrition with PPN support. Added Albumin with Lasix therapy.
    • Pain control under PCA and Morphine PRN used.
    • Oxygenation with nasal cannula support.
    • Tri-flow for respiratory training.
    • However, bacteremia (WBC, CRP and PCT elevation) was noted, the blood, sputum culture was done. Infectious physician was consulted, who suggestion antibiotic shift to Mepenem (05/09-) and Culim (05/09-) for infection treatment.
    • Chest man was consulted for chest therapy of chest X-ray showed ground glass opacity in bilateral lower lungs and suspect lung collaspe, who suggestion Symbicort, Spiriva, A+B+P using, IPPB/VEST/Tri-flow, and bedside rehabilitation.
    • She started try sip water since 2024/05/11 smoothly. After general condition being stabilized, she was transferred to ordinary ward for further care.
    • In GS ward, we observed patient recovery and keep empiric antibiotic, stool softener, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed. She try to introduced diet with step by step and can tolerate well for semi-liquid diet.
    • After the drainage amount decreased and no evidence of intra-abdominal leakage was noted, the Jackson-Pratt (JP) tube was smoothly removed on 05/17 & 05/20. Her generally well beings and relativley stable. There were no nosocomial infection and other complications and vital signs were stable after the surgery. The bowel function, urinary or pulmonary function were normal and abdomen wound showing satisfactory healing. Sugar with stable in control by current Toujeo and Apidra support. Under improved general condition, she was allowed to discharge today and outpatient department follow up was arranged.
  • Discharge prescription
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Ceficin (cefixime 100mg) 1# BID
    • Toujeo (insulin glargine) 14 unit HS SC
    • Apidra (insulin glulisine) 6 unit TIDAC SC
• 2020-05-22 ~ 2020-05-27 POMR Metabolism and Endocrinology Hu YaHui
  • Discharge diagnosis
    • Type 2 diabetes mellitus with diabetic nephropathy
    • Type 2 diabetes mellitus with hyperglycemia
    • Urinary tract infection (Escherichia coli)
    • Hypo-osmolality and hyponatremia
    • Chronic kidney disease, stage 3 (moderate)
    • Anemia, unspecified
    • Gout, unspecified
    • Essential (primary) hypertension
  • CC
    • blood sugar poor control    
  • Present illness
    • This 70 year-old female had histories of 1. DM; 2. hypertension; 3. gout; 4. dementia; 5. Asthma; 6. Thyroid nodules; 7. Appendectomy; 8. Prolapse of uterus s/p Hysterectomy and Bladder suspension. There no TOCC.
    • This time, she suffered from blood sugar poor control and impairment renal function, blood sugar range 150-350mg/dl at home under insulin, HbA1c: 6.5% (2020/05/05).
    • Urination burning sensation was also noted.
    • Under the impression of diabetes mellitus with blood sugar poor control, impairment renal function, suspcet UTI, she was admitted for further treatment and management.
  • Course of inpatient treatment
    • After admission, monitor finger blood sugar and adjust Apidra + sliding scale plus Toujeo for blood sugar control. Consult diettian for DM dietary education.
    • Urination burning sansation was noted, urine routine and urine culture were performed and empirical antibiotic with Cefazolin for UTI treatment. Urine culture yield Escherichia coli. Due to impairment renal function, Nephro was consulted, Suggestion: OPD follow up and keep CKD program in OPD.
    • Now Apidra 11unit QDAC/ 9unit QLAC/ 11unit QNAC + sliding scale and Toujeo 17unit HS SC for blood sugar control.
    • Under clinical stalbe condtion, she was discharged on 2020/05/27 and OPD follow was arranged.

[consultation]

• 2024-05-17 Infectious Disease
  • Q
    • For anti adjustment
    • This 74 y/o female was a case of duodenal cancer s/p Whipple op with partial gastrectoy and LN dissection and Braun’s anastomosis on 2024/05/06.
    • Post op transfer to SICU for post op care. However, WBC: 24700 CRP:22.3 then Abx with Mempem + Cubicin support by infection suggest.
    • After abx used for 1 week, lab data showed WBC: 15090, CRP:4.4. CXR showed bilateral collapse patch was improving after IPPB treatment. Culture showed Sputum candia was noted. So we need to evaluate whether to step-down antibiotic use. Thanks for your time!!
  • A
    • Consultation for antibiotic de-escalation
      • Serial CXR films showed postoperative pneumonia of both lower lobes, followed by pneumonia regression.
      • Sputum culture grew Candida only, no significant pathogen identified.
      • Patient has received 8-day Mepem and Cubicin till now.
      • Fluconazole is added yesterday for coverage of sputum Candida, which should be not necessary.
    • Suggestion:
      • DC Mepem and Cubicin and Flucon
      • Add Brosym 4g iv q12h as sequential therapy for pneumonia.
      • Follow up CxR, CBC, CRP 4-5 days later.
• 2024-05-09 Chest Medicine
  • Q
    • Consult for chest therapy suggest
    • This 74-year-old female has histories of:
      • Type 2 diabetes mellitus with diabetic nephropathy for years, with hyperglycemia status post admission in 2020, under Insulin control.
      • Hyperlipidemia for years, under medication treatment.
      • Gout.
      • Chronic kidney disease, stage IV.
      • Hypertension.
      • Asthma.
      • Dementia.
        
    • She suffered from epigastric pain, abdominal fullness, stool occult blood showed postive. She was referred to our Gastrointestinal department, where the pandoscopy was performed on Apr 16, 2024, it disclosed duodenal ulcerative mass with ulcer, r/o malignancy, bulb to SDA, status post biopsy. The biopsy report disclosed adenocarcinoma, moderately differentiated. Under the impression of duodenal adenocarcinoma, she was underwent Whipple op with partial gastrectoy, LN partial 3/4, 5, 6, 8, 12, 13, 14v dissection, and Braun’s anastomosis on May 06, 2024. Extubation smoothly and she was transferred to intensive on 05/06.
    • However, breathing sound showed wheezing and crackle was noted and the CXR showed Ground glass opacity in bilateral lower lungs. Now, she under respiratory training with tri-flow and IPPB and inhalation agents with:
      • Symbicort Rapihaler 120 dose/bot (Budesonide & Formoterol) 2024-05-09  2 puff    INHL    BID
      • Spiriva Respimat 2.5mcg/puff, 60puff/bot (Tiotropium) 2024-05-09  1 puff    INHL    BID     
      • Butanyl 2.5mg/mL, 2mL/pill (Terbutaline) 2024-05-08  1 pill    INHL    Q6H    
      • Ipratran 500 mcg/2 ml/pill (Ipratropium Bromide) 2024-05-08  1 pill    INHL    Q6H    
      • Siruta inhalation solution 600mg/3mL/amp (Mesna) 2024-05-08  1 amp     INHL    Q8H  
    • We need your professional assessment for chest therapy suggest!! Thank you a lot !!!
  • A
    • A case of 74-year-old female patient admitted to SICU under the impression of duodenal adenocarcinoma s/p Whipple with partial gastrectoy, LN partial 3/4, 5, 6, 8, 12, 13, 14v dissection, and Braun’s anastomosis
    • PE
      • E3-4V5M6
      • Coarse, no wheezing
      • SpO2 > 95% under O2 support
      • mild fever, (37.3-37.6)
      • I/O 375-971-180
    • Lab
      • WBC 24.7/CRP 22.3/PCT 11.10
      • ABG 7.363/39.4/88/21.9/96.2(FiO2 0.35)
      • Cre 1.72/BUN 31
    • CxR
      • Ground glass opacity in bilateral lower lungs, with partial atelectasis
    • 2D
      • LVEF 74
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy; LV diastolic dysfunction, Gr 1
      • Trivial MR and trivial TR
      • Preserved RV systolic function
    • PFT
      • Obstructive ventilatory impairment with both large and small airway involvement
        • FEV1/FVC 68, FVC 78, FEV1 68, MMEF 44 -> 50
    • IMP
      • Bilateral lower lung pneumonia, with partial atelectasis
      • Suspect IAI
      • Asthma with AE, might due to 2nd infection
    • Suggestion
      • Keep antibiotic treatment as INF suggestion, adjust later according to culture results
      • Keep Symbicort, Spiriva, A+B+P using, IPPB/VEST/Tri-flow, and bedside rehabilitation
      • IV steroid might be considered if dyspnea with wheezing still persistent after treatment
      • I will f/u this case
• 2024-05-08 Infectious Disease
  • A
    • A case of diabetes with CKD. Admitted for whipple op with hemigastrectomy and Braun jejunojejunostomy. After operation, the patient treated with Brosym for 2 days. Low grade fever was noticed.
    • Laboratory:
      • 2024-05-08 Band 0.0 %
        
      • 2024-05-08 Neutrophil 91.9 %
        
      • 2024-05-08 Lymphocyte 2.0 %
        
      • 2024-05-08 Monocyte 5.6 %
        
      • 2024-05-08 Eosinophil 0.5 %
        
      • 2024-05-08 Basophil 0.0 %
        
      • 2024-05-08 Atypical Lymphocyte 0.0 %
        
      • 2024-05-08 BUN 36 mg/dL
        
      • 2024-05-08 Creatinine 1.63 mg/dL
        
      • 2024-05-08 eGFR 32.78 ml/min/1.73m^2
        
      • 2024-05-08 K (Potassium) 4.4 mmol/L
        
      • 2024-05-08 Na (Sodium) 133 mmol/L
        
      • 2024-05-08 Ca (Calcium) 2.00 mmol/L
        
      • 2024-05-08 CRP 15.4 mg/dL
        
      • 2024-05-08 Amylase 342 U/L
        
      • 2024-05-08 Lipase 432 U/L
        
    • Drainage: 273ml
    • Impression: Fever. Cause? suspect IAI
    • Suggestion:
      • Please collect dainage fluid for culture (put in the blood culture bottle). Check drain fluid amylase concentration.
      • Follow up blood culture and sputum culture.
      • Please change antibiotics with Meropenem 1000mg i.v. q8h + Daptomycin 500mg i.v. qod
      • Please inform me the result of asites culture result.
      • Thanks for your consultation. Please feel free to contact me if any question.
• 2024-04-29 Cardiology
  • Q
    • This 74-year-old female had histories of
      • 1. Type 2 diabetes mellitus under apidra 10U TIDAC, toujeo 16U HS
      • 2. Hyperlipidemia under atorvastatin 2# QW1357
      • 3. Gout under febuxistat 0.5# QD
      • 4. Chronic kidney disease, stage 4 ( 4/29: Cre:2.31, EGFR: 21.92)
      • 5. Dementia,
      • 6. Hypertension under diovan 0.5# QD, blopress 1# QD, norvasc 1# QD
      • 7. Asthma under symbicort and spiriva
    • Exam
      • 2023/07/24 PFT: moderate obstructive ventilatory impairment with significant reversibility, small airway disease
      • 2023/3/27 2D echo:
        • LVEF:60.5%
          • Adequate LV systolic function with no regional wall motion abnormality at resting state
          • Mitral valve prolapse (anterior leaflet) with mild mitral regurgitation
          • Trivial TR and PR
          • Impaired LV relaxation
          • Thick IVS and LVPW
      • 2024/04/25 EKG: NSR
    • Under the impression of duodenal adenocarcinoma, the patient is scheduled to perform operation on 2024/05/06.
    • Therefore PFT (4/29 4pm) and cardiac echo (on call) are arranged.
    • Due to above reasons, we need your expertise on pre-op evaluation of cardiac functions for this patient.
  • A
    • This female patient has a history of DM, HTN CKD undergoign medical treatment at OPD. We are consulted for pre-op assessment
    • Past history without MI, HFrEF or stroke, but 2020 Treadmill test showed positive for ischemia, Tl201 mild apex, septum and inferiolateral
    • CT of lung (2019) showed calcified LAD, LCX and RCA
    • revised cardiac risk for surgery: 4 points (intraperitoneal surgery, previous (+) stress test , pre-OP insulin use and CKD)
    • The 30 day risk of death, MI stroke and cardiac arrest 1s around 15% by present guideline suggestion.

[surgical operation]

• 2024-05-06
  • Surgery
    • Whipple op with partial gastrectoy
    • LN partial 3/4, 5, 6, 8, 12, 13, 14v dissection
    • Braun’s anastomosis
  • Finding
    • an 5cm circular ulcerative mass at duodenal 1-2 portion with direct invasion to pancreas head
    • no peritoneal seeding no ascite

[chemotherapy]

• 2024-08-20 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-07-27 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr D1 + leucovorin 300mg/m2 450mg NS 250mL 2hr D3 + fluorouracil 1000mg/m2 1500mg D5W 500mL 24hr D3,6 (FOLFOX)
  • betamethasone 4mg + diphenhydramine 30mg D1,3 + palonosetron 250ug + NS 250mL D1,3 + aprepitant 125mg PO D1-3
• 2024-06-21 - leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg D5W 500mL 24hr D1,4
  • diphenhydramine 30mg + NS 250mL
• 2024-06-14 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-08-20

[renal dosing review and electrolyte supplementation]

eGFR is 33.25, and after reviewing the current active medications, no renal dose adjustment is necessary.

Hypomagnesemia and hypoalbuminemia were also noted; magnesium supplementation (MgSO4 injection) has been administered, and albumin supplementation may be considered.

• 2024-08-19 BUN 27 mg/dL
  
• 2024-08-19 Creatinine 1.61 mg/dL
  
• 2024-08-19 eGFR 33.25 ml/min/1.73m^2
  
• 2024-08-19 Albumin (BCG) 3.0 g/dL
  
• 2024-08-19 Mg (Magnesium) 1.6 mg/dL

2024-07-29

[optimizing Xyzal dosage for this patient with reduced CrCl]

When levocetirizine is used in patients with CrCl between 10 and 30 mL/minute, it is recommended to use 2.5 mg twice weekly (every 3 or 4 days). Please adjust Xyzal (levocetirizine 5mg) to 0.5 tablets every 3 days at bedtime (0.5# Q3D HS).

[frequent transfusions; adjusting treatment for severe anemia]

The patient had grade 3 and grade 2 anemia before receiving initial chemotherapy at our hospital in mid-June this year (HGB 7.8 g/dL on 2024-06-13, 8.0 g/dL on 2024-05-02). Prior to gastric surgery, the patient was prescribed B-Red (hydroxocobalamin).

During FOLFOX treatment at our hospital, the doses were reduced (Oxa 65mg/m², 5FU 2000mg/m²). Recently, the patient developed severe anemia with HGB < 6.5 g/dL (6.2 g/dL on 2024-07-26 and 6.1 g/dL on 2024-06-28), occurring after the 1st session and before the 2nd session (2024-07-27). It cannot be ruled out that the anemia is not exacerbated by chemotherapy.

The patient received blood transfusions on 2024-04-29, 2024-05-03, 2024-05-07, 2024-05-13, 2024-06-13, 2024-06-21, 2024-06-28, and 2024-07-26. If the patient cannot tolerate frequent transfusions and severe anemia occurs after the 2nd session of chemotherapy, adjusting the regimen might be necessary.

A bleeding scan on 2024-07-02 did not definitively identify the source of the bleeding. It is possibly originating from the ascending colon or a more proximal area, such as the small intestine. This suspected bleeding site should be prioritized for treatment.

Furthermore, despite multiple transfusions, the patient’s MCV has decreased from nearly 100 fL at the beginning of 2024 to around 80 fL. Iron deficiency has been ruled out by adequate ferritin levels. However, the patient’s poor renal function (eGFR 24) affects erythropoiesis. It might be advisable considering the use of ESA might help the patient reach an HGB target of at least 8.5.

• 2024-07-26 eGFR 24.34 ml/min/1.73m^2

• 2024-07-08 eGFR 31.23 ml/min/1.73m^2

• 2024-06-30 eGFR 33.01 ml/min/1.73m^2

• 2024-07-01 Ferritin 208.2 ng/mL

• 2024-04-01 Ferritin 27.3 ng/mL

• 2022-03-07 Ferritin 72.1 ng/mL

• 2020-06-03 Ferritin 15.8 ng/mL

• 2024-07-26 MCV 81.4 fL

• 2024-07-08 MCV 85.3 fL

• 2024-07-02 MCV 85.0 fL

• 2024-07-01 MCV 85.6 fL

• 2024-06-30 MCV 83.4 fL

• 2024-06-28 MCV 88.7 fL

• 2024-06-24 MCV 87.9 fL

• 2024-06-21 MCV 87.3 fL

• 2024-06-17 MCV 87.9 fL

• 2024-06-13 MCV 91.1 fL

• 2024-05-28 MCV 92.1 fL

• 2024-05-22 MCV 89.2 fL

• 2024-05-22 MCV 91.1 fL

• 2024-05-20 MCV 89.8 fL

• 2024-05-16 MCV 91.0 fL

• 2024-05-13 MCV 90.2 fL

• 2024-05-11 MCV 90.4 fL

• 2024-05-10 MCV 90.7 fL

• 2024-05-09 MCV 92.4 fL

• 2024-05-08 MCV 91.5 fL

• 2024-05-07 MCV 90.9 fL

• 2024-05-06 MCV 89.0 fL

• 2024-05-04 MCV 90.7 fL

• 2024-05-02 MCV 96.0 fL

• 2024-04-29 MCV 97.6 fL

• 2024-04-25 MCV 97.7 fL

• 2024-04-01 MCV 98.5 fL

• 2024-01-08 MCV 97.5 fL

2024-06-20

[tube-feeding considerations for Pariet and Pentop]

Most proton pump inhibitors (PPIs) are formulated with an enteric coating. This coating protects the medication from the acidic environment of the stomach, ensuring that it does not dissolve until it reaches the more neutral pH of the small intestine, allowing for proper absorption and effectiveness.

Pariet (rabeprazole) is available as enteric-coated tablets. It has been discontinued and replaced with injectable Panzolec (pantoprazole). If tube administration is still preferred, Takepron (lansoprazole) orally disintegrating tablets are a viable option.

Pentop (pentoxifylline) SR is designed as a sustained-release formulation due to its short half-life:

• Half-life elimination: Parent drug: 24 to 48 minutes; Metabolites: 60 to 96 minutes
• Time to peak, serum: 2 to 4 hours

For tube-feeding, the sustained-release form needs to be broken down and administered in multiple doses to mimic the original sustained-release effect.

[h yponatremia & hyperkalemia: adrenal insufficiency might be suspected (Addison’s disease?)]

The patient has developed hyponatremia and hyperkalemia concurrently. It’s important to note that she is are not currently taking any diuretics.

• 2024-06-20 Na (Sodium) 127 mmol/L

• 2024-06-19 Na (Sodium) 126 mmol/L

• 2024-06-18 Na (Sodium) 128 mmol/L

• 2024-06-17 Na (Sodium) 129 mmol/L

• 2024-06-13 Na (Sodium) 139 mmol/L

• 2024-06-20 K (Potassium) 5.4 mmol/L

• 2024-06-19 K (Potassium) 5.7 mmol/L

• 2024-06-18 K (Potassium) 5.5 mmol/L

• 2024-06-17 K (Potassium) 5.7 mmol/L

• 2024-06-13 K (Potassium) 3.0 mmol/L

Glucocorticoid withdrawal unlikely: The single dose of betamethasone 4mg administered on 2024-06-14 as premedication for oxaliplatin is unlikely to cause glucocorticoid withdrawal symptoms.

Serum creatinine levels: While the serum creatinine has been ranging between 1.5 and 2.0 mg/dL recently, there haven’t been any signs of rapid worsening.

Possible cause: One potential explanation for this co-occurrence could be a mineralocorticoid deficiency.

Diagnostic suggestion: Testing cortisol and ACTH levels might be helpful in confirming this suspicion.

2024-06-14

[unnecessary co-administration of 2 ARBs]

The following measures have been appropriately implemented:

• LPRBC transfusion has been administered for anemia (HGB 7.8 g/dL).
• Vemlidy (tenofovir alafenamide) for Anti-HBc (+).
• Calglon (calcium gluconate) for hypocalcemia (1.75 mmol/L) and Const-K (KCl) for hypokalemia (3.0 mmol/L).

However, the co-administration of two ARBs, Blopress (candesartan) and Diovan (valsartan), may not be necessary as they belong to the same therapeutic category and serve the same function.

701509592

240820

[lab data]

2024-01-02 Anti-HBc (NM) Positive
2024-01-02 Anti-HBc Value (NM) 0.012
2024-01-02 Anti-HBs (NM) Positive
2024-01-02 Anti-HBs Value (NM) 12.6 mIU/mL
2024-01-02 HBsAg (NM) Negative
2024-01-02 HBsAg Value (NM) 0.477
2024-01-02 Anti-HCV (NM) Negative
2024-01-02 Anti-HCV Value (NM) 0.035

2023-12-27 Fe (Iron-bound) 36 ug/dL
2023-12-27 TIBC 276 ug/dL
2023-12-27 UIBC 240 ug/dL

[exam findings]

• 2024-05-11 CT - abdomen
  • Clinical history: 68 y/o female patient with Adenocarcinoma of D-colon, pT3N1bM0. stage IIIb post left hemicolectomy on 2023/11/28.
  • With and without contrast enhancement CT of abdomen - whole:
    • S/P left hemicolectomy.
    • Liver cysts, up to 2cm in S7 liver.
  • Impression:
    • S/P left hemicolectomy.
    • Liver cysts.
    • Suggest clinical correlation and follow up.

[MedRec]

• 2024-01-14 ~ 2024-01-18 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Adenocarcinoma of D-colon, pT3N1bM0. stage IIIb post left hemicolectomy on 2023/11/28
    • Postive of anti-HBc
  • CC
    • for adjuvent chemotherapy
  • Present illness
    • The 68 y/o woman has Adenocarcinoma of D-colon, pT3N1bM0. stage IIIb post left hemicolectomy on 2023/11/28 in Cardinal Tien hospital nad HBV under treatment of Baraclude since 2024/01/12. She visited our gastroenterology due to colon cancer treatment, then was transferred to Oncology for arrange treatment. She received Port-A insertion on 2024/01/11.
    • This time, she is admitted for first course of first adjuvent chemotherapy, so she was asdmitted on 2024/01/14.
  • Course of inpatient treatment
    • After admission, she received adjuvent as C1D1 FOLFOX on 2024/01/15-01/17.
    • Keep baraclude 1# qdac for postive of anti-HBc.
    • NS hydration during chemotherapy.
    • Under the stable condition, she can be discharged on 2024/01/18. OPD follow up and re-admission is arranged.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2024-01-12 SOAP Gastroenterology Xiao ZongXian
  • A
    • Resolved HBV
    • Adenocarcinoma of D-colon, pT3M1bM0, stage IIIb
    • post Lt hemicolectomy on 2023-11-28
  • P
    • On HBV prophylaxis for chemotherapy: ETV on 2024/01/12
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2023-12-27 SOAP Gastroenterology Zhao YouCheng
  • S
    • Marked hypoalbuminemia has been found prior to undergoing partial colectomy for colon cancer.
  • O
    • P.E.: No icteric sclera, soft abdomen, no leg pitting edema.
    • 2023-10-31: alb 1.83 (at Cardinal Tien hospital)

[chemotherapy]

• 2024-08-20 - oxaliplatin 85mg/m2 119mg D5W 250mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3940mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-07-18 - oxaliplatin 85mg/m2 118mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-06-27 - oxaliplatin 85mg/m2 118mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3890mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-06-04 - oxaliplatin 85mg/m2 119mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-09 - oxaliplatin 85mg/m2 116mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3840mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-04-11 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3840mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-03-19 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3840mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-02-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3735mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-29 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3750mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-15 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3750mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-08-20

[CEA, CA199, and treatment assessment]

Lab results, including CEA and CA199 from 2024-08-19, were generally normal. Baraclude (entecavir) is being used to manage reactive Anti-HBc, and the patient is well-tolerated to the FOLFOX regimen. After reviewing the HIS5 and PharmaCloud databases, no medication discrepancies were identified.

The most recent CT scan was conducted on 2024-05-11. Given that it is now August, a follow-up CT might be beneficial for clinical management.

701528627

240820

[exam findings]

• 2024-07-28 KUB
  • Lumbar spondylosis
  • s/p double J catheter insertion, Lt
• 2024-07-28 ECG
  • Sinus rhythm with premature ventricular or aberrantly conducted complexes
  • Anterior infarct, age undetermined
  • Abnormal ECG
• 2024-07-15, -07-05 CXR erect
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Patchy consolidation of LLL of the lung is noted.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-07-03 SONO - chest
  • Symptom: dyspnea
  • Indication: r/o pleural effusion
  • Clinical diagnosis: R/O endometrial malignancy with urinary bladder invasion, lymph nodes metastasis, bone metastasis, cstage T4N2aM1, cell type: Large cell neuroendocrine carcinoma,
  • The patient was in: sitting upright posture while th chest echography was performed using: 3.75-mHz convex probe.
  • Findings
    • Left-side of thorax:
      • minimal free and anaechoic effusion
      • LLL atelectasis
    • Right-side of thorax:
      • There was minimal pleural effusion
      • mild pleural thickening, subpleural consolidation in RLL
  • Special Procedure
    • A 16# long catheter was inserted into left 5th ICS along mid-posterior scapular line. 350ml light orange fluid was drained and sent for routine, BCS, bacteria/TB/fungus cultures and cell block and MTB-PCR
  • Echo diagnosis
    • Pleural effusion, moderate, left
    • Atelectasis, LLL
    • Pleural thickening, bilateral
• 2024-07-01 Pure Tone Audiometry, PTA
  • Reliability FAIR to POOR
  • Average RE 66 dB HL; LE 61 dB HL
  • R’t moderately severe to profound SNHL.
  • L’t moderate to profound SNHL.
• 2024-06-29 MRI - brain
  • Findings
    • mild dilated intraventricular and extraventricular CSF spaces
    • punctate white matter gliosis in the bilateral supratentorial brain; mild bilateral periventricular leukoaraiosis; old lacunar infarction in the left basal ganglion
  • IMP:
    • no evidence of brain metastasis.
• 2024-06-28 CT - chest
  • R/O endometrial malignancy with urinary bladder invasion, lymph nodes metastasis, bone metastasis, cstage T4N2aM1, cell type: Large cell neuroendocrine carcinoma, origin to be determine
  • Chest CT with and without IV contrast ehnancement shows:
    • Consolidation of left lower lobe with moderate left pleural effusion is found.
    • Tortous aorta with calcification is noted.
    • Calcified coronary arteries is found.
    • Minimal right pleural effusion is found.
    • Confluent lymphadenopathy at paraaortic region with extension to bilateral iliac fossa is found. The left ureter is oblerated by the soft tissue mass.
    • S/P double J cathter placement from pelvic cavity into renal region over left renal pelvis
    • Soft tissue mass at uterus is found measuring 10.2cm is found. Compatible with endometrial cancer.
    • Minimal ascites formation is found.
  • Imp:
    • Uterine endometrial cancer with pelvic side wall invasion, left ureter obliteration and bilateral paraaortic lymphadenopathy
    • Consolidation of left lower lobe with bilateral pleural effusion but no pulmonary meta is found in the study
• 2024-06-24 Aspiration Cytology - lymph node
  • Lymph node: Positive for malignancy
    
  • The smears show lymphocytes, neutrophils and many hyperchromatic atypical epithelial clusters, compatible with metastatic carcinoma. Clinical correlation is advised.
• 2024-06-21 Patho - urinary bladder TUR
  • DIAGNOSIS:
    • A: Urinary bladder, tumor, TURBT — Large cell neuroendocrine carcinoma
    • B: Urinary bladder, tumor, TURBT — Large cell neuroendocrine carcinoma — Mucularis propria involved by tumor
  • MICROSCOPIC DESCRIPTION:
    • A: Section shows urinary bladder tissue with infiltration of nests of large pleomorphic tumor cells.
      • The immunohistochemical stains reveal CK(focal +), GATA3(-), CK7(-), CK20(-), LCA(-), Vimentin(-), CD56(+), Synaptophysin(+), SMA(-), PAX8(-), and CD10(weak +).
    • B: Section shows urinary bladder tissue with infiltration of nests of large pleomorphic tumor cells. Mucularis propria is involved by invasive carcinoma.
• 2024-06-19 MRI - pelvis
  • With and without contrast enhancement MRI - Pelvis:
    • Diffuse soft tissue tumors in the uterus (from funds to cervical region), r/o endometrial malignancy.
    • Presence of hydrometra.
    • Irregular tumor in the urinary bladder.
    • Left hydronephrosis.
    • There are T2 hypointensity tumors, up to 6.3cm, r/o uterine myomas.
    • Unremarkable change of the liver, spleen, pancreas.
    • Diffuse enlarged lymph nodes in the pelvic cavity and paraaortic regions, could be due to metastatic lymph nodes.
    • No ascites.
    • There are multiple bone lesions, r/o bone metastasis.
    • Urinary bladder tumors and left hydronephrosis.
    • Uterine myomas.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T4(T_value) N: N2a(N_value) M:M1(M_value) STAGE:IVB__(Stage_value)
  • Impression:
    • Diffuse tumors in the uterine (from fundus to cervical region) with hydrometra, urinary bladder tumors and left hydronephrosis.
    • Diffuse lymph nodes enlargement (pelvic cavity and paraaortic region).
    • R/O endometrial malignancy with urinary bladder invasion, lymph nodes metastasis, bone metastasis.
    • cstage T4N2aM1.
• 2024-06-18 SONO - gynecology
  • R/O Uterine mass: 171x75mm (malignancy cannot be ruled out)
• 2024-06-18 SONO - nephrology
  • Normal right kidney
  • Left hydronephrosis, mild to moderate degree
  • r/o mass lesion around the left kidney
  • r/o mass lesion of the uterus

[MedRec]

• 2024-06-18 SOAP Obstetrics and Gynecology Huang SiCheng
  • S
    • leg edema +
    • pelvic pain
    • left hydronephrosis
  • O
    • SONO gynecology
      • Myoma: 60 x 50 mm
      • R/O Uterine mass: 171x75 mm
    • PV:
      • discharge: whitish
      • VP: canceress, enlarged
      • UT: AV flexion hard
      • L’t para: indurated till
      • pelvic wall
      • R/O CC IIIb
• 2024-06-18 SOAP Nephrology Hong SiQun
  • S
    • Left leg edema recently
    • Renal sonogram showed left hydronephrosis, and mass lesion in the pelvic cavity, refer to GYN
• 2024-06-17 SOAP Infectious Disease Peng MingYe
  • S
    • recent cystitis symptom for two weeks, no fever, left lower limb edema also noted, visited local clinic without response, epiasgastralgia and acid regurgitation also noted.
    • Underlying hypertension
  • O
    • BP:110/47; HR:83; BH:158 cm; BW:54 kg; BMI:21.6, BT 36.7’C
    • Hgb 9.0, WBC 5930, CRP 8.8, UA 11.7, Cr 1.4
    • U/A: no UTI picture
  • A:
    • use Ceficin for UTI sequential treatment
  • P:
    • refer to Nephro OPD for possible CKD, renal echo and hyperuricemia.
  • Prescription
    • Ceficin (cefixime 100mg) 1# Q12H 7D
    • Uretropic (furosemide 40mg) 0.5# QD 1D
    • Acetal (acetaminophen 500mg) 1# PRNQ6H

[consultation]

• 2024-07-18 Infectious Disease
  • Q
    • Patient was 79 years old women, history of Hypertension under medication and denied surgical history. This time, newly diagnosis Endometrial large cell neuroendocrine carcinoma with urinary bladder invasion, lymph nodes metastasis, bone metastasis. cStage T4N2aM1, s/p Carboplatin/Etoposide on 2024/07/02.
    • Due to urine culture showed VRE, for antibiotic use suggest for infection c ontrol. We need your consultation for evaluation. Thanks a lot!!!
  • A
    • Zyvox 1# PO q12h for 5~7 days is suggested.
• 2024-06-20 Ear Nose Throat
• 2024-06-18 Urology

[chemotherapy]

• 2024-08-20 - carboplatin AUC 4 400mg D5W 500mL 1hr + etoposide 80mg/m2 100mg NS 500mL 1hr D1-3 {TEMP}
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-07-02 - carboplatin AUC 4 400mg D5W 500mL 1hr + etoposide 80mg/m2 100mg NS 500mL 1hr D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

[adjusting carboplatin and etoposide dosing for renal impairment]

The patient’s kidney function is trending downward.

With an eGFR of 37, if carboplatin is to be used, it is recommended to administer 75% of the usual dose for patients with a CrCl of 15 to 50 mL/minute.

For carboplatin AUC dosing using the Calvert formula, with the following patient details - age 79 years, weight 48.5 kg, creatinine 1.43 mg/dL, target AUC 4 mg/mL/min, and female gender - the calculated total dose is 197.7 mg.

• 2024-08-19 BUN 44 mg/dL
  
• 2024-08-19 eGFR 37.93 ml/min/1.73m^2
  
• 2024-08-19 Creatinine 1.42 mg/dL
  
• 2024-08-08 Creatinine 0.71 mg/dL
  
• 2024-08-05 Creatinine 0.64 mg/dL

Carboplatin AUC Dosing (Calvert) Calculator - 2024-08-20 - https://reference.medscape.com/calculator/169/carboplatin-auc-dosing-calvert

2024-07-17

[tube feeding: options for administering Adapine and Const-K]

The half-life elimination of nifedipine varies among different populations: in healthy adults, it ranges from 2 to 5 hours; in individuals with cirrhosis, it extends to 7 hours; and in the elderly, it also reaches about 7 hours when using extended-release tablets.

Adapine S.R.F.C. (sustained-release film-coated) tablets are designed not to break down within the body, hence it is common to find the intact outer shell in the patient’s feces. The design of these tablets is meant to maintain steady drug levels in the bloodstream. Crushing these tablets will compromise their slow-release properties, making them ineffective at sustaining intended drug concentrations. If there is a need to continue using this medication, it should ideally be administered in divided doses to maintain stable blood levels.

Const-K 750mg is an extended-release tablet that delivers 10 mEq of potassium per tablet and is the only oral potassium supplement available in this hospital. If injectable potassium supplementation is not preferred, Const-K tablets can be crushed into fine particles for easier administration with water.

[evaluating the possibility of fungal infection in unresolved lung consolidation]

Neutropenia has largely resolved, yet CRP levels remain elevated while PCT has returned to normal ranges. Based on the comparison of CXR images from 2024-07-15 and 2024-07-05, patchy consolidation in the lower left lobe of the lung showed no improvement. If respiratory symptoms do not improve, a fungal infection could be suspected.

• 2024-07-17 WBC 3.41 x10^3/uL

• 2024-07-16 WBC 3.37 x10^3/uL

• 2024-07-15 WBC 0.61 x10^3/uL

• 2024-07-11 WBC 0.24 x10^3/uL

• 2024-07-08 WBC 0.26 x10^3/uL

• 2024-07-05 WBC 11.74 x10^3/uL

• 2024-07-01 WBC 3.41 x10^3/uL

• 2024-07-16 CRP 15.8 mg/dL

• 2024-07-15 CRP 15.3 mg/dL

• 2024-07-11 CRP 23.4 mg/dL

• 2024-07-08 CRP 14.3 mg/dL

• 2024-07-05 CRP 34.2 mg/dL

• 2024-07-16 Procalcitonin (PCT) 0.32 ng/mL

• 2024-07-15 Procalcitonin (PCT) 0.42 ng/mL

• 2024-07-11 Procalcitonin (PCT) 1.89 ng/mL

• 2024-07-08 Procalcitonin (PCT) 11.44 ng/mL

• 2024-07-05 Procalcitonin (PCT) 13.06 ng/mL

2024-07-10

[carboplatin and etoposide administration and subsequent neutropenia]

Carboplatin and etoposide were administered on 2024-07-02, and neutropenia was noted on 2024-07-08. Given the elevated CRP and PCT levels, infection cannot be ruled out. Consequently, a 3-day course of Granocyte (lenograstim) was initiated on 2024-07-08. Blood transfusions were also conducted on 2024-07-01, 2024-07-05, and 2024-07-09. These measures are considered appropriate for the condition.

• 2024-07-08 Procalcitonin (PCT) 11.44 ng/mL

• 2024-07-05 Procalcitonin (PCT) 13.06 ng/mL

• 2024-07-08 CRP 14.3 mg/dL

• 2024-07-05 CRP 34.2 mg/dL

• 2024-07-08 WBC 0.26 x10^3/uL *

• 2024-07-05 WBC 11.74 x10^3/uL
  

• 2024-07-01 WBC 3.41 x10^3/uL
  

• 2024-06-30 WBC 3.76 x10^3/uL
  

• 2024-06-18 WBC 5.77 x10^3/uL
  

• 2024-06-17 WBC 5.93 x10^3/uL

• 2024-07-08 HGB 8.9 g/dL
  

• 2024-07-05 HGB 8.0 g/dL
  

• 2024-07-01 HGB 8.2 g/dL
  

• 2024-06-30 HGB 8.7 g/dL
  

• 2024-06-18 HGB 9.6 g/dL

• 2024-07-08 PLT 103 *10^3/uL
  

• 2024-07-05 PLT 227 *10^3/uL
  

• 2024-07-01 PLT 271 *10^3/uL
  

• 2024-06-30 PLT 253 *10^3/uL
  

• 2024-06-18 PLT 326 *10^3/uL

700160767

240819

[exam findings]

• 2024-07-01 CT - abdomen
  • S/P CBD stenting with pneumobilia. Mild progression of pancreatic cancer with adjacent structures invasin and LNs metastases. Distention of gallbladder with stone (1.1cm).
• 2024-06-24, -06-17, -06-12 KUB
  • S/P metalic stent implantation in between CHD and duodenum.
  • Pneumobilia on both lobes IHDs are noted.
  • S/P Foley’s catheter insertion
• 2024-06-07 Abdomen - standing (diaphragm)
  • S/P metalic stent implantation in between CHD and duodenum.
  • Pneumobilia on both lobes IHDs are noted.
  • S/P nasogastric tube insertion
• 2024-06-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (97.1 - 35.2) / 97.1 = 63.75%
    • M-mode (Teichholz) = 63.7
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild AR, MR, TR and PR
    • Dilated aortic root; thick IVS and LVPW
• 2024-06-06 Endoscopic Retrograde Cholangiopancreatography, ERCP
  • Findings
    • Duodenum:
      • No ulcer is found at the bulb.
    • Papilla:
      • Precut major papilla was noted.
    • Pancreatic Duct:
      • P stent was noted and removed with alligator forceps.
    • Common Bile Duct (CBD):
      • The distal CBD was strictured. The CBD stent was noted and removed with alligator forceps via duodenoscopy.
    • Intrahepatic Bile Ducts:
      • Dilated intrahepatic ducts (IHD).
    • Gallbladder:
      • The gallbladder (GB) is visualized after the injection of contrast medium via the PTGBD tube, and there is a drainage tube within the lumen.
    • Other Findings:
      • Some engorged varices were noted in the gastric body.
  • Management:
    • After CBD and MPD stent was removed, the CBD stent was pulled out by duodenoscopye. The pancreatic stent was left at the gastric body. Some blood oozing from the major papilla. Then, biliary stenting is performed with PCSEMS (partially covered self-expandable metal stent), using Wallflex stent (80 mm in length and 10 mm in diameter) smoothly. Some pus like fluid was slowly drained from the mental stent. The previous bloody oozing was stopped spontaneously.
  • Diagnosis:
    • Malignant distal biliary stricture s/p removing plastic CBD and pancreatic stent & PCSEMS
    • Chornic cholangitis with septic shock
    • Major papilla oozing, suspect stent removal related, stop
    • Gastric varices, body
  • Suggestion:
    • f/u amylase & lipase
    • Check X ray and sent bile juice for culture
• 2024-06-03 Endoscopic Retrograde Cholangiopancreatography, ERCP
  • Findings
    • Duodenum:
      • negative
    • Papilla:
      • Normal papilla is found.
    • Pancreatic Duct:
      • P duct cannulatoin is done inaverdently and p stenting is performed.
    • Common Bile Duct (CBD):
      • Selective cannulation with C duct is done with TPS method and the cholangiography showed marked dilatation of proximal biliary tree and the stricture segment measured about 1 cm in diameter. There is no filling defect in the biliary tree.
    • Intrahepatic Bile Ducts:
      • The Bil IHDs are not shown.
    • Gallbladder:
      • GB is not shown but part of cystic duct is opacified.
    • Other Findings:
      • nil
  • Management:
    • Transpancreatic Precut Sphincterotomy is performed due to repeated p duct cannualtion inaverdently. A 8.5 Fr. 7 cm straight stent (Gadileus) is placed for free drainage. Mild oozing is found after EST, therefore local injection at the cutting edge of EST wound and hemostasis is achieved.
  • Diagnosis:
    • Biliary stricture s/p TPS, EST & biliary stenting
      
    • s/p P duct stenting
      
    • GB non-opacification
    • post EST bleeding s/p hemostasis
  • Suggestion:
    • f/u amylase & lipase CM
• 2024-05-25 CT - brain
  • Clinical information:
    • Cranial CT scans from the vertex to the mid-maxillary level were performed without i.v. contrast injection.
  • Impression:
    • The brain shows normal grey and white matter attenuation without evidence of focal lesion. There is no intracranial hemorrhage seen.
    • The size of the lateral and third ventricles appears normal.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal.
• 2024-05-24 CT - abdomen
  • CC: abdominal pain for 2 months
  • History: pancreatic adenocarcinoma with paraaortic lymph node metastasis diagnosed in 2023/12, s/p C/T x4 times in South Africa.
  • Indication: Pancreatic cancer for FU
  • Oral and rectal contrast was not given for bowel opacification. Findings:
    • There is a well-defined lobulated poor enhancing mass in the pancreatic head and body, 5.8 cm in size (the largest dimension), causing marked dilatation of bile duct and pancreatic duct.
      • The portal vein is not visualized that is c/w tumor encasement.
      • The superior mesenteric artery root shows narrowing that is also c/w tumor encasement.
      • Adenocarcinoma of the pancreatic head (T4) is noted.
    • There are four enlarged nodes in the celiac trunk that are c/w regional metastatic nodes (N2).
    • There is a large poor enhancing mass 3 cm in left para-aortic space that is c/w non-regional metastatic node (M1).
    • There is a gallstone 1 cm.
    • The urinary bladder shows small size and S/P Foley’s catheter insertion.
  • Impression:
    • Adenocarcinoma of the pancreatic head and body (T4) is noted.
      
    • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for pancreatic cancer: T4 N2 M1; stage: IV
• 2024-05-23 KUB
  • Calcifications in the pelvic cavity, could be due to phleboliths.
  • Lumbar spondylosis.
• 2024-05-23 CXR erect
  • Intimal calcification of thoracic aorta.

[MedRec]

• 2024-05-23 SOAP Medical Emergency Hu YuHui
  • S
    • Triage: 3 Abdominal pain > Acute central moderate pain (4-7) Abdominal distension and pain, returned from South Africa on 2024/05/22
    • found to have pancrease cancer, stage 4, in 2023/02, diagnosed in South Africa. s/p 4 times C/T.

[consultation]

• 2024-06-27 Family Medicine
  • Q
    • For hospice combine care.
    • This is a 66y/o female with pancreatic adenocarcinoma with paraaortic lymph node metastasis diagnosed in South Africa 2023/12.
    • The patient underwent chemotherapy x4 times in South Africa. Since the patient and her husband are part of Tzi CHi member in South Africa, they decided to come back to Taiwan for further treatment. Therefore, she was admitted to our oncology ward on 2024/05/23.
    • Exam/Lab
      • 2024/05/19 Abodminal CT: Adenocarcinoma of the pancreatic head and body, ycT4N2M1, stage IV with bile duct and pancreatic duct dilatation.
      • 2024/05/24 Lab: CA-199: 2816 U/mL, CEA: 97.0 ng/mL
      • 2024/05/24 ~ 05/27:
        • morphine overdose related consicous change s/p Naloxone
        • aspiration pneumonia
      • 2024/06/03: ERCP with biliary & pancreatic duct stenting
      • 2024/06/06: re-do ERCP due to stent migration s/p re-stenting
      • 2024/06/06 ~ 06/18: septic shock s/p levephed, B/C: CRAB, bile culture: CRAB (2024/06/12: B/C: no growth)
      • 2024/06/18 ~: encourage intake (remove NG on 2024/06/20), hold C/T due to poor PS (ECOG: 2)
      • 2024/06/27
        • Vital sign: E4V5M6, BP: 114/78, HR:101, BT: 37.1^C. RR:16, SPO2: 98% (RA)
        • lab: PCT: 0.05, TBI:0.76, WBC:4k, Hb: 9.6, Plt: 190000
    • Due to previous conscious change status, DNR was signed by the husband.
    • However, today the patient expressed that she no longer wants chemotherapy. (The patient mentioned that her son will be returning from South Africa soon and hopes to take the ashes back then to avoid troubling him with two trips.). We explained to her that her current clinical conditions are relatively stable. Therefore, she signed AD today.
    • We plan to f/u abdominal CT and lab on 7/1.
    • Due to above reasons, we need your expertise on hospice combine care for this patient.
  • A
    • This is a 66y/o woman with pancreatic cancer with para-aortic LNs metastasis s/p 4 times of chemotherapy. She was admitted to ER due to abdominal fullness and pain.
    • As we visited the patient, she had clearly insisted with no further un-neccessary treatments, but her husband wants to continue treatments. (Her husband stated that her life is in the hands of the doctor, and the doctor cannot stop treatment without explicitly stating that treatment is no longer necessary.) After explaining the purpose of palliative care, the patient had agreed and can fully accept with the hospice management.
    • Abdominal fullness and pain sensation was complained, suitable regular pain control is suggested if pain persist. We had also offered herb medical cream for the patient to apply on the abdomen for symptom relief. Hospice combined care was signed by the patient’s husband. We will keep following up of the patient’s condition.
    • Indication: pancreatic cancer
    • Plan: Hospice combined care

==========

2024-08-19

[managing elevated serum bilirubin and post-transfusion HGB monitoring]

Elevated serum bilirubin has been observed. Please ensure that bile flow remains unobstructed and monitor the post-transfusion rise in HGB levels. Additionally, supplementing sodium and albumin might also be considered.

• 2024-08-17 Na (Sodium) 131 mmol/L

• 2024-08-17 Albumin (BCG) 2.0 g/dL

• 2024-08-17 Bilirubin total 3.56 mg/dL

• 2024-07-30 Bilirubin total 0.81 mg/dL

• 2024-08-17 HGB 6.5 g/dL

• 2024-08-08 HGB 8.3 g/dL

2024-06-28

[addressing daytime fatigue by modifying medication schedule]

I visited the patient late this morning. The patient was in bed while her husband rested on a nearby bench. The patient mentioned that her sleep quality has been poor recently due to frequent nighttime trips to the bathroom, which leaves her feeling very tired during the day.

Currently, Dulcolax (bisacodyl) is administered as HS. If the administration time is changed to earlier in the day, such as between lunch and dinner, it might help the patient to have bowel movements earlier before the bedtime. This adjustment could even make it possible to discontinue Zolon (zopiclone) HS, depending on the patient’s condition.

2024-05-27

[elevated conjugated bilirubin: Uliden considered]

The primary contributor to the elevated total bilirubin appears to be conjugated bilirubin. Currently Buscopan (hyoscine-N-butylbromide) is in use since 2024-05-23.

If no contraindications are identified, adding Uliden (ursodeoxycholic acid 100mg) 1# BID or TID may be considered.

Maintaining bile flow throughout treatment is crucial to prevent biliary obstruction.

• 2024-05-27 Bilirubin total 2.23 mg/dL
• 2024-05-27 Bilirubin direct 1.11 mg/dL
• 2024-05-27 DBI/TBI 49.78 %

2024-05-24

[elevated liver function tests and possible pancreatic cancer link]

Multiple liver function tests are elevated. It is unclear if this is related to the underlying pancreatic cancer.

The addition of BaoGan (silymarin) as a potential treatment option can be considered.

• 2024-05-24 AST 121 U/L
  
• 2024-05-24 ALT 187 U/L
  
• 2024-05-24 Bilirubin total 1.32 mg/dL
  
• 2024-05-23 Alkaline phosphatase 1175 U/L
  
• 2024-05-23 r-GT 1473 U/L
  
• 2024-05-23 ALT 231 U/L

700163238

240819

[lab data]

2024-06-25 HBsAg Nonreactive
2024-06-25 HBsAg Value 0.60 S/CO
2024-06-25 Anti-HBs 32.01 mIU/mL
2024-06-25 Anti-HBc Nonreactive
2024-06-25 Anti-HBc Value 0.22 S/CO

2023-02-10 Anti-HBc Nonreactive
2023-02-10 Anti-HBc Value 0.60 S/CO
2023-02-10 Anti-HBs 32.66 mIU/mL
2023-02-10 Anti-HCV Nonreactive
2023-02-10 Anti-HCV Value 0.05 S/CO
2023-02-10 HBsAg Nonreactive
2023-02-10 HBsAg Value 0.40 S/CO

[exam findings]

• 2024-06-27 Patho - lung wedge biopsy
  • Lung, ? side, CT-guide biopsy — consistent with metastatic endometrioid adenocarcinoma
  • Sections show alveolar lung tissue with solid nests and glandular umor cells infiltrating in fibrotic stroma.
  • The immunohistochemical stains reveal PAX8(+), TTF-1(-), and Napsin A(-). The results are consistent with metastatic endometrioid adenocarcinoma.
• 2024-06-06 PET
  • Multiple glucose hypermetabolic lesions in bilateral lungs. Multiple lung metastases should be considered.
  • Multiple glucose hypermetabolic lesions in bilateral parotid glands. The nature is to be determined (some kind of parotid lesions? other nature?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the lower C-spine. Benign nature is more likely.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation may show this picture.
• 2024-05-28 CT - abdomen
  • Nodules (up to 1.0cm) at bil. lungs.
  • S/P hysterectomy.
• 2024-04-09 SONO - gynecology
  • No obvious uterine or ovarian lesion
• 2023-09-13, -06-07 CT - abdomen
  • S/P hysterectomy.
  • There is no evidence of tumor recurrence.
• 2023-02-01 Patho - uterus with or without SO non-neoplastic/prolapse
  • Diagnosis:
    • Uterus, endometrium, total hysterectomy — endometrioid adenocarcinoma, grade 3
    • Uterus, myometrium, total hysterectomy — endometrioid adenocarcinoma invading > 1/2 thickness
    • Uterus, cervix, total hysterectomy — free
    • Ovaries and fallopian tubes, bilateral, BSO — free
    • Lymph node, bilateral pelvic, dissection — free
      
    • pT1b pN0 (if cM0), AJCC 8th edition Pathology stage: IB, at least.
  • Gross description:
    • Procedure (select all that apply)
      • Total hysterectomy and bilateral salpingo-oophorectomy. Uterus: 9 x 5.5 x 3.5 cm.Right ovary: 2.5 x 1.5 x 1.2 cm; right tube: 4.5 x 0.5 x 0.5 cm; left ovary: 2.5 x 1.5 x 1.2 cm; left tube: 4.5 x 0.5 x 0.5 cm.
      • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
    • Tumor Site (select all that apply) - upper and middle uterine segment, 4.5 cm from cervix.
    • Tumor Size:
      • Greatest dimension: 4.5 cm
      • Additional dimensions (centimeters): 3.5 x 3 cm. Uterine surface: free.
    • Sections are taken and labeled as:
      • A: left iliac lymph nodes; B: left obturator lymph nodes; C1-2: right iliac lymph nodes; D: right obturator lymph nodes; E1: left ovary; E2: left tube; E3: right ovary; E4: right tube; E5: cervix; E6-11: uterine corpus (tumor); E12: uterine corpus (non-tumor);
        
  • Microscopic Description:
    • Histologic Type: Endometrioid carcinoma
    • Histologic Grade: (required only if applicable): FIGO grade 3 (high-grade)
    • Myometrial Invasion: present ( >= 1/2 whole thickness)
    • Uterine Serosa Involvement - Not identified
    • Cervical Stromal Involvement - Not identified
    • Other Tissue/ Organ Involvement (select all that apply):
      • Not identified
      • Bilateralt ovary - free
      • Bilateral fallopian tube - free
    • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
      • Ectocervical/Vaginal Cuff Margin: Free
    • Lymphovascular Invasion: Present
    • Regional Lymph Nodes: free (0/21)= A: left iliac lymph nodes (0/4); B: left obturator lymph nodes (0/5); C1-2: right iliac lymph nodes (0/7); D: right obturator lymph nodes (0/5).
      • No lymph nodes submitted or found
      • Right Pelvic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): 0/12
      • Left Pelvic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): 0/9
    • Additional Pathologic Findings - None identified
      
    • Ancillary Studies - S2023-00748
    • Comment(s) - none
• 2023-01-19 MRI - pelvis
  • Findings
    • Infiltrative soft tissue tumor in the uterine fundus and body region, r/o endometrial malignancy.
    • Filling defect in right renal pelvis.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T1b(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ib (Stage_value)
  • Impression:
    • Soft tissue tumor in the uterine cavity, r/o endometrial malignancy, cstage T1bN0M0.
    • Filling defect in right renal pelvis, suggest further study.
• 2023-01-11 Patho - endometrium curretage/biopsy (Y1)
  • Uterus, endometrium, D＆C — endometrioid adenocarcinoma, high-grade
  • Microscopically, sections shows endometrioid adenocarcinoma composed of a proliferation of atypical tumor cells arrange din solid to glandular architectures and foci of necrosis. The tumor cells have larged hyperchromatic nucleu, pleomorphism and mitoses.
  • IHC stain— p53: aberrant type, ER: positive (intermediate, 50%), vimentin(+) at tumor cells.
• 2022-01-03 SONO - gynecology
  • IMP: EM 10.2mm
• 2022-12-26 Papanicolaou Test (Pap Smears)
  • adenocarcinoma
• 2021-11-15 SONO - gynecology
  • IMP: EM 5.3mm

[MedRec]

• 2024-06-26 ~ 2024-06-28 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Endometrioid adenocarcinoma, grade 3 of the uterine endometrium, AJCC 8th edition Pathology stage: IB, status post Laparoscopic gynecologic oncology staging surgery, and CCRT with Cisplatin (weekly)*6 plus radiotherapy (2024/03-2024/04)
    • Postmenopausal atrophic vaginitis
    • Menopausal and female climacteric states
    • Endometrial hyperplasia, unspecified
    • Secondary malignant neoplasm of unspecified lung
    • Hypertension
    • Insomnia
    • Hyperlipidemia
  • CC
    • For lung biopsy, and C1 chemotherapy with Taxol plus Carboplatin Q3W.
  • Present illness
    • This 68 years-old married female, gravida 2, para 2 (cesarean section 2 times), with underlying disease of hypertesion under control, had hematuria, dysuria, urinary frequency and burning sensation since 2022/12/23. urine routine and culture showed no abnormal findings. Vaginal bleeding was noted on 2023/01/03, thus Dilation and Curettage (D&C) was arranged on 2023/01/11 and pathology showed: Uterus, cervix, biopsy — mild dysplasia (CIN 1) with koilocytosis. Uterus, endometrium, D&C — endometrioid adenocarcinoma, high-grade.
    • Pelvis MRI (2023/01/19) showed: 1. Soft tissue tumor in the uterine cavity, r/o endometrial malignancy, cstage T1bN0M0. 2. Filling defect in right renal pelvis, suggest further study. The Laparoscopic gynecologic oncology staging surgery was completed on 2023/02/01, status post CCRT with Cisplatin (40mg/m2, weekly) on 2024/03/01-04/07 (6 times), radiotherapy (2023/3/6-4/20) with 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.
    • Abdomen CT (2023/06/07): S/P hysterectomy. There is no evidence of tumor recurrence.
    • Abdomen CT (2023/09/13): S/P hysterectomy. There is no evidence of tumor recurrence.
    • Gynecologic ultrasonography (2024/01/09): No obvious uterine or ovarian lesion
    • Abdomen CT (2024/05/28): Nodules (up to 1.0cm) at bil. lungs. S/P hysterectomy.
    • Whole bodt PET (2024/06/06): 1.Multiple glucose hypermetabolic lesions in bilateral lungs. Multiple lung metastases should be considered. 2.Multiple glucose hypermetabolic lesions in bilateral parotid glands. The nature is to be determined (some kind of parotid lesions? other nature?). Please correlate with other clinical findings for further evaluation. 3.Mild glucose hypermetabolism in the lower C-spine. Benign nature is more likely. 4.Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation may show this picture. 5.No prominent abnormal focal FDG uptake was noted elsewhere.
    • This time, she is admitted for lung biopsy, and C1 chemotherapy with Taxol plus Carboplatin Q3W on 2024/06/26.
  • Course of inpatient treatment
    • After be admitted, consulted radiation oncology for CT-guide biopsy, and CT-guide was done on 2024/06/28, pending left upper lung biopsy report. After CT-guide biopsy, re followed-up chest x-ray: no pneumothroax, no hemothorax, and the breathing pattern is smooth. She received #1 chemotherapy with Taxol (175mg/m2)/ Carboplatin (AUC: 5) on 2024/06/27, Imperan for vomiting. After chemotherapy, she denide having a fever, chest tightness, vomiting, diarrhea. She can be discharged on 2024/06/28, the OPD follow-up will be arranged.
  • Discharge diagnosis
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 7D

[surgical operation]

• 2023-02-01
  • Surgery
    • Diagnosis:
      • Endometrial cancer
    • Operation:
      • Laparoscopic gynecologic oncology staging surgery        
  • Finding
    • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
    • Bilateral adnexa: grossly normal
    • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • CDS: free
    • Estimated blood loss: 50 mL
    • Blood transfusion: nil
    • Complication: nil    
• 2023-01-11
  • Surgery
    • Dilatation and curettage  
    • Cervical biopsy      
  • Finding
    • Uterus: Anteversion, 7 cm.
    • Some endometrial tissue were curetted out.
    • 2 small pieces of cervical tissue were cut.
    • Estimated blood loss: 5 mL, Blood transfusion: nil, complication: nil.   

[chemotherapy]

• 2024-08-19 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 370mg NS 250mL 2hr (paclitaxel + carboplatin. 90%)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-07-23 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 390mg NS 250mL 2hr (paclitaxel + carboplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-06-27 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr (paclitaxel + carboplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-04-06 - cisplatin 40mg/m2 50mg NS 500mL 2hr + NS 100mL (Y-sited CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3
• 2023-03-30 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 100mL (Y-sited CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3
• 2023-03-23 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 100mL (Y-sited CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3
• 2023-03-16 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 100mL (Y-sited CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3
• 2023-03-09 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 100mL (Y-sited CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3
• 2023-03-02 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 100mL (Y-sited CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3

==========

2024-08-19

[optional G-CSF prophylaxis after reduced paclitaxel and carboplatin dose]

Neutropenia was observed after the administration of paclitaxel and carboplatin. The session initiated on 2024-08-19 used 90% of the original dose. Prophylactic G-CSF might be also prepared in advance after the administration.

• 2024-08-18 WBC 2.39 x10^3/uL *

• 2024-07-22 WBC 4.25 x10^3/uL

• 2024-07-09 WBC 1.23 x10^3/uL **

• 2024-06-26 WBC 3.54 x10^3/uL

• 2024-08-18 Neutrophil 69.1 %

• 2024-07-22 Neutrophil 67.3 %

• 2024-07-09 Neutrophil 9.6 % **

• 2024-06-26 Neutrophil 72.9 %

701113147

240819

[lab data]

2024-07-31 Anti-HBc Nonreactive
2024-07-31 Anti-HBc Value 0.65 S/CO

2024-07-29 HBsAg Nonreactive
2024-07-29 HBsAg Value 0.34 S/CO

2024-07-29 Anti-HBs 16.65 mIU/mL

2024-07-29 Anti-HCV Nonreactive
2024-07-29 Anti-HCV Value 0.16 S/CO

[exam findings]

[MedRec]

[chemotherapy]

• 2024-08-14 - obinutuzumab 100mg NS 150mL 4hr D1 + obinutuzumab 900mg NS 500mL 4hr D2 (Infuse two bags sequentially from a single vial, starting at 50 mL/hour and increasing by 50 mL/hour every hour, with a maximum rate of 400 mL/hour.) (Gazyva + chlorambucil)
  • [dexamethasone 20mg + diphenhydramine 30mg + acetaminophen 500mg 2# PO + NS 250mL] D1-2

Obinutuzumab: Drug information - 2024-08-19 - https://www.uptodate.com/contents/obinutuzumab-drug-information

• Chronic lymphocytic leukemia, previously untreated:
  • In combination with chlorambucil:
    • Cycle 1: IV: 100 mg on day 1, followed by 900 mg on day 2, followed by 1,000 mg weekly for 2 doses (days 8 and 15) of a 28-day treatment cycle.
    • Cycles 2 through 6: IV: 1,000 mg on day 1 of a 28-day treatment cycle for 5 doses.
  • Off-label dosing/combinations:
    • Single-agent obinutuzumab:
      • Cycle 1: IV: 100 mg on day 1, followed by 900 mg on day 2, followed by 1,000 mg weekly for 2 doses (days 8 and 15) of a 21-day treatment cycle.
      • Cycles 2 through 8: IV: 1,000 mg on day 1 of a 21-day treatment cycle for 7 doses.
    • In combination with acalabrutinib:
      • Cycle 2: IV: 100 mg on day 1, followed by 900 mg on day 2, followed by 1,000 mg weekly for 2 doses (days 8 and 15) of a 28-day treatment cycle (cycle 1 is acalabrutinib only; obinutuzumab begins with cycle 2).
      • Cycles 3 through 7: IV: 1,000 mg on day 1 of a 28-day treatment cycle for 5 doses (continue acalabrutinib until disease progression or unacceptable toxicity).
    • In combination with ibrutinib:
      • Cycle 1: IV: 100 mg on day 1, followed by 900 mg on day 2, followed by 1,000 mg weekly for 2 doses (days 8 and 15) of a 28-day treatment cycle.
      • Cycles 2 through 6: IV: 1,000 mg on day 1 of a 28-day treatment cycle for 5 doses (continue ibrutinib until disease progression or unacceptable toxicity).
    • In combination with venetoclax (in patients with coexisting conditions):
      • Cycle 1: IV: 100 mg on day 1, followed by 900 mg on day 2 (or 1,000 mg on day 1), followed by 1,000 mg weekly for 2 doses (days 8 and 15) of a 28-day treatment cycle (venetoclax is initiated on day 22 of cycle 1).
      • Cycles 2 through 6: IV: 1,000 mg on day 1 of a 28-day treatment cycle for 5 doses (continue venetoclax until the end of cycle 12).

Chlorambucil: Drug information - 2024-08-19 - https://www.uptodate.com/contents/chlorambucil-drug-information

• Chronic lymphocytic leukemia:
  • Chronic lymphocytic leukemia in previously untreated patients (off-label dosing):
    • Oral: 0.4 mg/kg day 1 every 2 weeks; if tolerated may increase by 0.1 mg/kg with each treatment course to a maximum dose of 0.8 mg/kg and maximum of 24 cycles
      • or 0.5 mg/kg on days 1 and 15 every 28 days for 6 cycles
      • or 30 mg/m2 day 1 every 2 weeks (in combination with prednisone)
      • or 40 mg/m2 day 1 every 4 weeks until disease progression or complete remission or response plateau for up to a maximum of 12 cycles.
  • Chronic lymphocytic leukemia in previously untreated patients (off-label combinations):
    • Chlorambucil-obinutuzumab:
      • Oral: 0.5 mg/kg on days 1 and 15 every 28 days for 6 cycles.
    • Chlorambucil-ofatumumab:
      • Oral: 10 mg/m2 once daily for 7 days (days 1 to 7) every 28 days for a minimum of 3 cycles and up to 12 cycles or best response (clinical response that did not improve after 3 additional cycles); if necessary, reduce dose to 7.5 mg/m2/day and then to 5 mg/m2/day for hematologic toxicity.
    • Chlorambucil-rituximab:
      • Oral: 10 mg/m2 once daily for 7 days (days 1 to 7) every 28 days for 6 to 12 cycles.
  • Manufacturer’s labeling:
    • Oral: 0.1 mg/kg/day for 3 to 6 weeks or 0.4 mg/kg pulsed doses administered intermittently, biweekly, or monthly (increased by 0.1 mg/kg/dose until response/toxicity observed).
      • Note: Reduce initial dose if full-dose radiation or myelotoxic drugs have been administered within the last 4 weeks. With bone marrow lymphocytic infiltration involvement in chronic lymphocytic leukemia, the manufacturer recommends a maximum dose of 0.1 mg/kg/day; while short treatment courses are preferred, if maintenance therapy is required, the manufacturer recommends a maximum dose of 0.1 mg/kg/day.

==========

2024-08-19

[scheduling obinutuzumab and chlorambucil for CLL treatment; HBV risk assessment]

Gazyva (obinutuzumab) for previously untreated chronic lymphocytic leukemia is administered in combination with chlorambucil. For Cycle 1: IV administration includes 100 mg on day 1, followed by 900 mg on day 2, and 1,000 mg weekly for 2 doses (days 8 and 15) within a 28-day treatment cycle. Since the treatment started on 2024-08-14 (day 1), the next two administrations should be scheduled for 2024-08-21 and 2024-08-28.

Anti-HBs is 16.65 mIU/mL and Anti-HBc is nonreactive, indicating that the patient has been vaccinated for HBV. The risk of HBV reactivation is relatively low, so prophylactic use of Baraclude or Vemlidy might not be necessary.

Leukeran (chlorambucil 2mg/tab, KLEUK) 7# BID was administered on 2024-08-14, totaling 28 mg that day. With a body weight of 55 kg, this dosage equates to approximately 0.5 mg/kg. The schedule for combined use with obinutuzumab should follow administration on day 1 and day 15 of each 28-day cycle, so the next chlorambucil dose is due on 2024-08-28.

Before administering chlorambucil, the patient still had certain WBC, HGB, and PLT counts, indicating no signs of bone marrow failure, so the medication can be administered.

All oral medications currently used are suitable for administration via feeding tube. No medication discrepancies were identified.

• 2024-08-19 WBC 1.10 x10^3/uL

• 2024-08-15 WBC 57.65 x10^3/uL

• 2024-08-15 WBC 30.39 x10^3/uL

• 2024-08-12 WBC 4.70 x10^3/uL

• 2024-08-19 HGB 7.9 g/dL

• 2024-08-15 HGB 7.2 g/dL

• 2024-08-15 HGB 7.8 g/dL

• 2024-08-12 HGB 8.8 g/dL

• 2024-08-19 PLT 8 *10^3/uL

• 2024-08-15 PLT 120 *10^3/uL

• 2024-08-15 PLT 17 *10^3/uL

• 2024-08-12 PLT 22 *10^3/uL

701525971

240819

[exam findings]

• 2024-06-26 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (76 - 18) / 76 = 76.32%
    • M-mode (Teichholz) = 76.7
  • Conclusion:
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
• 2024-06-25 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with chronic lymphocytic leukemia/small lymphocytic lymphoma
  • The sections show normocellular marrow (30%). The M/E ratio= 6:1. The megakaryocytes are normal in number and morphology. Dense intertrabecular and paratrabecular small lymphoid cell aggregates are present.
  • IHC, the aggregates reveal a predominance of CD20+ B cells with scattered CD3+ T cells. The B cells also show: CD5(+), CD23(+) and cyclin D1(-). The finding is compatible with chronic lymphocytic leukemia/small lymphocytic lymphoma. Suggtest bone marrow smear evaluation and clinic correlation.
• 2024-06-25 SONO - abodmen
  • Symptoms:
    • Multiple hypoechoic lesions were noted in the abdomen and around the aorta.
  • Diagnosis:
    • Multple lymph nodes, suspect lymphoma
• 2024-06-04 SONO - neck
  • Sonography of neck revealed multiple cystic lesions in bil. neck.

[MedRec]

• 2024-08-16 ~ 2024-08-17 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Small cell B-cell lymphoma, Lugano stage IV
    • Chronic viral hepatitis B without delta-agent HBsAg/Anti-Hbc positive
  • CC
    • for chemothereapy
  • Present illness
    • The 70 y/o woman has been well in the past. No TOCC history.
    • Her left neck had a mass around 3*2cm around 2 months and BW loss 5kg in 6 months. Surgical intervention for removed mass and pathology showed low grade B cell lymphoma, favor SLL/CLL at Cardinal catholic hospital by Dr O.
    • The PET showed lymphoma with bil pleural seeding, bil neck LNS, bil supraclavicular LNs, bil axillary LNs, retroperitoneal LNs, mesenteric LNS nvolvement, Lugano stage IV.
    • Bone marrow showed compatible with chronic lymphocytic leukemia/small lymphocytic lymphoma on 2024/6/24. Echocardiography was done for chemotherapy survey, but no significant problem. She received port-a insertion on 6/27.
    • C1 R-COP on 2024/06/28-06/29, C2 R-CHOP on 2024/07/21.
    • Under the stable condition, she was admitted for C3 R-CHOP chemotherapy on 2024/08/16.
  • Course of inpatient treatment
    • After admission, she received C3 R-CHOP (epirubicin) on 2024/8/16-17, smoothly without obvious side effect. She was discharged on 8/17 24 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC 7D
    • Mosapin (mosapride citrate 5mg) 1# TID 7D
    • Through (sennoside 12mg) 2# HS 7D
    • Ulstop (famotidine 20mg) 1# BID 5D
    • Compesolon (prednisolone 5mg) 8# BID 5D (8/17-21)

[immunochemotherapy]

• 2024-08-16 - rituximab 375mg/m2 540mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1085mg NS 250mL 30min D2 + epirubicin 70mg/m2 100mg NS 100mL 10min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 40mg BID PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-07-22 - rituximab 375mg/m2 540mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1085mg NS 250mL 30min D2 + epirubicin 70mg/m2 100mg NS 100mL 10min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 40mg BID PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-06-28 - rituximab 375mg/m2 540mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 …………………………………….. + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 40mg BID PO D2-6 (R-COP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2

==========

701526750

240819

[lab data]

2024-06-15 Anti-HBs 312.09 mIU/mL
2024-06-15 Anti-HBc Reactive
2024-06-15 Anti-HBc Value 5.67 S/CO
2024-06-15 Anti-HCV Nonreactive
2024-06-15 Anti-HCV Value 0.11 S/CO
2024-06-15 HBsAg Nonreactive
2024-06-15 HBsAg Value 0.32 S/CO

[exam findings]

• 2024-08-07 Bronchodilator Test, BDT
  • Function Test
    • Basline:
      • FVC: 2.51
      • FEVI: 1.82
    • Cutoef value:
      • FVC: 2.26
      • FEVI: 1.64
    • Bronchodilator
      • FVC: 2.35
      • FEVI: 1.69
      • BORG: 1
  • Result PC20: > 25 mg/ml (Reference Bronchodilator Norman Vaiue PC20 25 mg/ml)
    • Negative provocation
  • Conclusion
    • Moderate obstructive ventilatory impairment with good BD response, small airway disease
• 2024-06-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 29) / 102 = 71.57%
    • M-mode (Teichholz) = 68.1
  • Conclusion:
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild PR, TR
• 2024-06-24 Aspiration Cytology - thyroid
  • Clinical finding: left thyroid tumor
  • Result: suspicious malignancy
  • PATHOLOGIC DIAGNOSIS
    • Scatter atypical pleomorphic cells, suspicious for malignancy
      
  • MICROSCOPIC EXAMINATION
    • Two suboptimal low cellular smears show colloid, blood, lymphocytes, neutrophils and some scatter individual atypical cells show spindled, ovoid or epithelioid shape, suspicious for malignancy, but the origin is uncertain. Please check the site of FNA and confirmatory biopsy is advised for conclusive diagnosis
• 2024-06-11 Patho - lung transbronchial biopsy
  • Lung, left, CT-guide biopsy — pleomorphic malignant spindle cell tumor, compatible with metastatic sarcoma (S2024-11368), please correlate with the clinical presentation
• 2024-06-04 Patho - uterus (with or without SO) neoplastic (Y2)
  • Diagnosis:
    • Uterus, endometrium, staging surgery — High grade endometrial stromal sarcoma
    • Uterus, myometrium, staging surgery — Involved by tumor
      
    • Uterus, cervix, staging surgery — Nabothian cyst
    • Ovary, bilateral, staging surgery — Negative for malignancy
    • Fallopian tube, bilateral, staging surgery — Negative for malignancy
    • Parametrium, left, staging surgery — Involved by tumor
      
    • Omentum, staging surgery — Negative for malignancy
    • Lymph node, left iliac, dissection — Negative for malignancy
      
    • Lymph node, left obturator, dissection — Negative for malignancy
      
    • Lymph node, right iliac, dissection — Negative for malignancy
    • Lymph node, right obturator, dissection — Negative for malignancy
      
    • Lymph node, left paraaortic, dissection — Negative for malignancy
    • Lymph node, right paraaortic, dissection — Negative for malignancy
      
    • AJCC 8th edition pathology stage: pT2bN0M1; FIGO IVB
  • Gross description:
    • Procedure (select all that apply)
      • Staging surgery (total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + infracolic omentectomy)
      • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
    • Specimen size:
      • Uterus: 12x8x8 cm
      • Ovary, right: 2.5x2x1.5 cm
      • Ovary, left: 2.3x2x1.3 cm
      • Fallopian tube, right: 7 cm in length and 0.5 cm in greatest diameter
      • Fallopian tube, left: 8 cm in length and 0.5 cm in greatest diameter
      • Omentum: 10x 5 cm
    • Tumor Site (select all that apply)
      • Endometrium
    • Tumor Size:
      • Greatest dimension: 10 cm
      • Additional dimensions (centimeters): 8 x 5 cm
    • Sections are taken and labeled as: A1:left iliac LN, A2:left obturator LN, A3:right iliac LN, A4:right obturator LN, A5: left paraaortic LN, A6:right paraaortic LN, A7–8:right adnexa, A9-10:left adnexa, A11:right paraovarian tissue, A12:left paraovarian tissue,A13:right parametrial mass, A14:CX, A15-20: endometrial and myometrial tumor, A21:omentum
  • Microscopic Description:
    • Histologic Type:
      • Endometrial stromal sarcoma
    • Histologic Grade: (required only if applicable*)
      • High grade
    • Myometrial Invasion:
      • present
    • Uterine Serosa Involvement
      • Present
    • Cervical Stromal Involvement
      • Not identified
    • Other Tissue/ Organ Involvement (select all that apply):
      • Right parametrium
    • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
      • Ectocervical/Vaginal Cuff Margin: Free (3 cm)
      • Parametrial/Paracervical Margin: Free (0.2 cm)
    • Lymphovascular Invasion: Absent
    • Regional Lymph Nodes:
      • Left iliac — 0/4
      • Left obturator — 0/4
      • Right iliac — 0/7
      • Right obturator — 0/7
      • Left paraaortic — 0/5
      • Right paraaortic — 0/2
    • Additional Pathologic Findings:
      • Leiomyoma
    • Ancillary Studies: immunohistochemical stains: CD10(+), ER(-),CK(-), p53: aberrant (complete negative staining), Ki-67 index: 70%, SMA(+), cyclin D1(+), CD34(-)
    • Comment(s)
• 2024-05-30 MRI - pelvis
  • Findings
    • S/P IUD in the uterine cavity.
    • Irregular soft tissue tumor, 8.9x8.8cm in the uterus, r/o sarcoma.
    • Cysts in the uterine cervical region, suggesting Nabothin cysts.
    • Soft tissue nodules around left aspect of the uterus, r/o regional lymph nodes.
    • Cyst, 1.8cm in left adnexa, r/o left ovarian cyst.
    • There are lung tumors, r/o lung metastasis.
  • Imaging Report Form for corpus uterine leiomyosarcoma and ESS
    • Uterine tumor (high grade sarcoma) with regional lymph nodes, cstage T2N1M1 (if lung metastasis).
    • Bilateral lung tumors, cant rule out primary lung malignancy with metastasis.
• 2024-05-30 CT - chest
  • Referred from ZhongShan Hospital
  • Findings:
    • Multiple nodular and mass lesions are found at bilateral lung fields up to 4.2cm at left lower lobe. Lung meta is considered.
  • Imp:
    • Bilateral lung meta up to 4.2cm at left lower lobe

[MedRec]

• 2024-06-26 ~ 2024-06-29 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Uterine sarcoma status post staging surgery on 2024/60/03 with bilateral lung metastasis, pT2bN0M1, FIGO IVB. 2024/05/30 CT: Bilateral lung metastases, status post first Adriamycin + Ifosfamide
    • Secondary malignant neoplasm of unspecified lung
    • Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
  • CC
    • For first Adriamycin + Ifosfamide
  • Present illness
    • This is a 49-year-old woman with uterine sarcoma, pT2bN0M1; FIGO IVB, status post staging surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy+ bilateral pelvic lymph node dissection + paraaortic lymph node dissection + infracolic omentectomy) on 2024/06/03.
    • According to the patient herself, abnormal uterine bleeding had been noted for months, and hysteroscopic polypectomy was done at ZhongShan Hospital which revealed high grade sarcoma. She then came to our gynecology OPD for further survey on 2024/05/30.
    • Hemogram: elevated CA-125: 92.9 U/ml, normal CA-199: 6.23 U/ml.
    • 2024/5/30 Lung CT: Bilateral lung meta up to 4.2cm at left lower lobe.
    • 2024/5/30 Pelvis MRI: 1. Uterine tumor (high grade sarcoma) with regional lymph nodes, cstage T2N1M1 (if lung metastasis). 2. Bilateral lung tumors, cant rule out primary lung malignancy with metastasis.
    • The patient underwent staging surgery on 2024/06/03, pathology report: High grade endometrial stromal sarcoma, pT2bN0M1; FIGO IVB. Ct-guided lung biopsy was arranged on 6/11, malignant spindle cell tumor, compatible with metastatic sarcoma.
    • Left subclavian Port-A was inserted on 2024/6/14. She visited our GS OPD to remove stiches of Port-A on 2024/6/21.
    • Left neck mass was also noted, so fine needle biopsy of left thyroid was done on 6/24, with pathology report: scatter atypical pleomorphic cells, suspicious for malignancy. Pending reports of TRAb, TSH, free T4.
    • In the past months, there was about 1.5kg of weight loss. Fatigue, exertinal dyspnea, chronic cough with occasional hemoptysis were also noted. No dizziness, no fever nor chills, no dysuria, no abodminal distension, no constipation nor diarrhea, no bloody nor tarry stool.
    • 2024/6/14 CXR: no pleural effusion , bilateral lung tumors.
    • Under the impression of uterine sarcoma, pT2bN0M1; FIGO IVB, the patient was admitted to our concology ward for first Adriamycin + Ifosfamide on 2024/6/26.
  • Course of inpatient treatment
    • After admission, cardiac echo was arranged, with LVEF: 68.1%, Mild PR,TR. Hydration with normal saline 500ml QD + feburic 1# QD were pescribed due to elevated uric acid: 7.8 mg/dL.
    • We followed-up hemogram on 2024/06/28, and uric acid decreased to 3.3 mg/dL. Cough with occasional hemoptysis were noted, so we educated the patient on lung metastasis and prescribed Zcough, cough mixture and oral transamin for symptom control.
    • Adriamycin + Ifosfamide were prescribed on 6/27. Uromitexan was also prescribed to prevent hemorrhagic cystitis.
    • There were no fever, no nuasea, no diarrhea, no hematuria afterwards. Under stable conditions, the patient was discharged on 2024/6/29 with follow-up at our oncology OPD.
  • Discharge Prescription
    • Cough Mixture (platycodon) 5mL TID 4D
    • Trand (tranexamic acid 250mg) 1# BID 4D
    • Feburic (febuxostat 80mg) 1# QD 4D
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 4D
    • Acetal (acetaminophen 500mg) 1# PRNQ6H 4D
    • Zcough (benzonatate 100mg) 1# TID 4D

[chemotherapy]

• 2024-08-16 - doxorubicin 50mg/m2 75mg NS 100mL 20min + mesna 4000mg/m2 6300mg NS 500mL 24hr (Y-sited ifosfamide) + ifosfamide 4000mg/m2 6300mg NS 900mL 24hr (Y-sited mesna) + mesna 2000mg/m2 3150mg NS 500mL 12hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-07-22 - doxorubicin 50mg/m2 70mg NS 100mL 20min + mesna 4000mg/m2 6000mg NS 500mL 24hr (Y-sited ifosfamide) + ifosfamide 4000mg/m2 6000mg NS 900mL 24hr (Y-sited mesna) + mesna 2000mg/m2 3100mg NS 500mL 12hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-06-27 - doxorubicin 50mg/m2 70mg NS 100mL 20min + mesna 4000mg/m2 6000mg NS 500mL 24hr (Y-sited ifosfamide) + ifosfamide 4000mg/m2 6000mg NS 900mL 24hr (Y-sited mesna) + mesna 2000mg/m2 3100mg NS 500mL 12hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-08-19

[effective management post-doxorubicin and ifosfamide session]

Lab results on 2024-08-16 were generally normal, and vital signs have remained stable in recent days, even after this session of doxorubicin and ifosfamide. Baraclude (entecavir) is being used for reactive Anti-HBc (2024-06-15). No medication discrepancies were identified.

701533197

240819

[exam findings]

• 2024-07-30 Cardiac Catheterization
  • SvO2 was also check, it revealed 66 %.
  • Estimated Fick Cardiac index: 3.07 L/min/m2
  • Estimated Fick cardiac output: 5.8 L/min.
• 2024-07-29 Patho - bone marrow biopsy (Y2)
  • Bone marrow, iliac, biopsy — compatible with acute lymphoblastic leukemia.
  • Section shows piece(s) of bone marrow with 99% cellularity and monotonous round blue blasts like cells.
  • IHC stains: CD117: 0%; CD34: 99%; TdT: 99%, MPO: <1%, CD3: <1%; CD20: <1% (of the nucleated cells). The pattern is compatible with acute lymphoblastic leukemia.

[chemotherapy]

• 2024-08-19 - vincristine sulfate 2mg NS 100mL 10min

• 2024-08-15 - cytarabine 40mg IT 3min + methylprednisolone 40mg XX 3min

• 2024-08-14 - methotrexate 15mg IT 3min

• 2024-08-12 - vincristine sulfate 2mg NS 100mL 10min

==========

2024-08-19

[pancytopenia management during combination therapy]

Glivec (imatinib 100mg) 4# BID has been administered in combination with vincristine, cytarabine, and methylprednisolone since 2024-08-12. Pancytopenia has developed since then; however, anemia and thrombocytopenia were observed prior to treatment, so the therapy should not be considered the sole cause of the low blood cell counts.

Blood transfusion was performed on 2024-08-17 and G-CSF (filgrastim) 300mg SC daily was initiated today, and no issues have been identified.

• 2024-08-19 WBC 1.35 x10^3/uL

• 2024-08-17 WBC 3.11 x10^3/uL

• 2024-08-15 WBC 3.36 x10^3/uL

• 2024-08-14 WBC 13.88 x10^3/uL

• 2024-08-12 WBC 147.07 x10^3/uL

• 2024-08-10 WBC 163.98 x10^3/uL

• 2024-08-08 WBC 200.62 x10^3/uL

• 2024-08-19 Blast 7.2 %

• 2024-08-17 Blast 7.2 %

• 2024-08-15 Blast 53.0 %

• 2024-08-14 Blast 81.6 %

• 2024-08-12 Blast 68.0 %

• 2024-08-10 Blast 89.0 %

• 2024-08-08 Blast 98.0 %

• 2024-08-19 HGB 6.4 g/dL

• 2024-08-17 HGB 8.1 g/dL

• 2024-08-15 HGB 8.8 g/dL

• 2024-08-14 HGB 11.0 g/dL

• 2024-08-12 HGB 9.6 g/dL

• 2024-08-10 HGB 9.0 g/dL

• 2024-08-08 HGB 8.3 g/dL

• 2024-08-19 PLT 26 *10^3/uL

• 2024-08-17 PLT 51 *10^3/uL

• 2024-08-15 PLT 59 *10^3/uL

• 2024-08-14 PLT 16 *10^3/uL

• 2024-08-12 PLT 32 *10^3/uL

• 2024-08-10 PLT 44 *10^3/uL

• 2024-08-08 PLT 24 *10^3/uL

700306057

240816

[exam findings]

• 2024-07-29 MRI - pelvis
  • Clinical history: 76 y/o female patient with Cervix biopsy, discharge:bloody, VP: cauliflower mass pus coating
  • With and without contrast enhancement MRI: Pelvis
    • Lobulated tumor(7.4x6.8cm) in posterior cervical region and anterior wall of rectum, progression at cervical part, but regression of rectal region tumor, as compare with MRI study on 2024-1-2.
    • Uterine tumors, up to 2.88cm, r/o uterine myomas.
    • Bulging disc at L5/S1.
    • Non-enhancing nodule, 0.57cm in right kidney, r/o right renal cyst.
• 2024-07-26 Patho - cervix biopsy
  • Uterus, cervix, biopsy — adenocarcinoma.
  • Section shows multiple pieces of cervical tissue with adenocarcinoma.
  • IHC stains: CK7 (-), CK20 (+), CDX-2 (+), WT-1 (-), ER (-). a pattern compatible with colonic origin.
• 2024-04-06 CT - abdomen
  • Findings
    • Mild regression of rectal cancer with adjacent fat stranding, uterus invasion and regional LAP.
    • Tiny renal cysts.
    • A tumor (3.0cm) in uterus r/o myoma.
    • Some LNs (up to 1.4cm) at bil. inguinal regions.
    • Hyperplasia of left adrenal gland.
    • Gallbladder stones (up to 1.0cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Mild regression of rectal cancer with adjacent fat stranding, uterus invasion and regional LAP.
• 2024-01-02 MRI - pelvis
  • History and indication:
    • rectal cancer
  • With and without contrast MRI of pelvis revealed:
    • Wall thickening of rectum with adjacent fat stranding, uterus invasion and regional LAP.
    • Tiny renal cysts.
    • A tumor (2.8cm) and a cyst (1.3cm) in uterus. A cyst (8.7mm) in uterine cervix.
  • IMP:
    • Rectal cancer (T4bN2aM0, stage IIIC).
• 2023-12-28 CT - abdomen
  • History and indication:
    • rectal cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent fat stranding, uterus invasion and regional LAP.
    • Tiny renal cysts.
    • A tumor (2.8cm) in uterus r/o myoma.
    • Some LNs (up to 1.4cm) at bil. inguinal regions.
    • Gallbladder stones (up to 1.0cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2023-12-27 Patho - colon biopsy
  • Colorectum, rectum, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

• 2024-06-03 SOAP Metabolism and Endocrinology Duan WeiLun
  • Prescription x3
    • Uformin (metformin 500mg) 0.5# BIDCC 28D
    • Galvis Met (vildagliptin 50mg, metformin 500mg) 1# BIDCC 28D
    • Dibose (acarbose 100mg) 1# TIDAC 28D
    • Crestor (rosuvastatin 10mg) 0.5# QOD 28D
    • Micardis (telmisartan 80mg) 1# QD 28D
    • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# QD 28D

[chemotherapy]

• ….-..-..

• 2024-03-28 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2024-03-07 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2024-02-22 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2024-02-01 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2024-01-24 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2024-01-16 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2024-08-16

[Managing Possible Infection and Normocytic Anemia]

CRP is elevated at 7.5 mg/dL with an increased WBC count, indicating a possible infection; Cravit (levofloxacin) is currently being used.

Normocytic anemia has also been observed; however, given that MCV has remained over 90 fL for months, iron deficiency is less likely (she is taking Foliromin currently). Recent ferritin and/or transferrin saturation test results are not available and might be considered.

• 2024-08-14 CRP 7.5 mg/dL
  
• 2024-08-14 Neutrophil 92.4 %
  
• 2024-08-14 WBC 14.56 x10^3/uL
  
• 2024-08-14 HGB 8.0 g/dL
• 2024-08-14 MCV 92.1 fL
  
• 2024-08-13 MCV 92.2 fL
  
• 2024-07-26 MCV 93.3 fL
  
• 2024-07-16 MCV 92.4 fL
  
• 2024-06-25 MCV 92.8 fL
  
• 2024-06-04 MCV 93.0 fL
  
• 2024-04-24 MCV 93.1 fL
  
• 2024-04-11 MCV 91.8 fL
  
• 2024-03-27 MCV 92.9 fL
  
• 2024-03-06 MCV 91.4 fL
  
• 2024-02-21 MCV 89.5 fL
  
• 2024-01-31 MCV 89.6 fL
  
• 2024-01-23 MCV 89.4 fL
  
• 2024-01-09 MCV 87.5 fL
  
• 2023-12-26 MCV 89.5 fL

700810506

240816

[exam findings]

• 2024-04-23 Patho - soft tissue tumor, extensive resection
  • Diagnosis:
    • Ovary, right, oophorectomy —- mucinous carcinoma; AJCC 8th edition: pStage IIB, pT2bN0(if cM0); 2015 FIGO Stage: IIB
    • Ovary, left, oophorectomy —- not found
    • Fallopian tube, bilateral, salpingectomy —- Negative for malignancy
    • Uterus, corpus, total hysterectomy —- Negative for malignancy
    • Uterus, cervix, total hysterectomy —- Negative for malignancy
    • Omentum, omentectomy —- Negative for malignancy
    • Peritoneum, left pelvic, excision —- metastatic carcinoma
    • Lymph node, para-aortic, dissection —- Negative for malignancy (0/2)
    • Lymph node, left iliac, dissection —- Negative for malignancy (0/7)
    • Lymph node, left obturator, dissection —- Negative for malignancy (0/2)
    • Lymph node, right iliac, dissection —- Negative for malignancy (0/9)
    • Lymph node, right obturator, dissection —- Negative for malignancy (0/4)
  • Gross description:
    • Procedure (select all that apply): debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + para-aortic lymph node dissection + pelvic lymph node dissection + left pelvic tumor excision)
      
    • Specimen size:
      • F2024-00162
        • right ovary: 21.5 x 15.0 x 8.5 cm, 1.8 kg;
        • right tube: 6.5 cm in length and 0.3 cm in diameter;
          
      • S2024-08116
        • uterus: 7.5 x 5.5 x 3.5 cm, 90.8 g; cervix: 2.8 x 2.5 x 2.5 cm; endometrial cavity: 4.3 x 2.4 x 0.1 cm
        • left ovary: not found
        • left tube: 8.0 cm in length and 0.4 cm in diameter;
        • omentum: 27.7 x 9.2 x 12.0 cm
        • left pelvic peritoneum mass: 1.3 x 0.5 x 0.4 cm
      • Specimen Integrity
        • Specimen Integrity of Right Ovary (if applicable): Capsule intact (手術中未破裂 ,完整取出體外後再切開)
        • Specimen Integrity of Left Ovary (if applicable): not found
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact (手術中未破裂 ,完整取出體外後再切開)
        • Specimen Integrity of Left Fallopian Tube (if applicable) Serosa intact
    • Tumor Site: Right ovary
    • Ovarian Surface Involvement (required only if applicable): Absent
    • Fallopian Tube Surface Involvement (required only if applicable): Absent
    • Tumor Size: Greatest dimension (centimeters): 21.5 cm
    • Additional dimensions (centimeters): 15.0 x 8.5 cm
    • Sections are taken and labeled as:
      • F2024-00162: Representative sections are taken and labeled as: FsA1-3: right ovary tumor, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: tube; X2: adnexal soft tissue; X3-10: tumor.
      • S2024-08116: Representative sections are taken and labeled as: A1: cervix; A2: endometrium; A3: myometrium; A4: left fallopian tube; A5: left adnexal soft tissue; A6: right adnexal soft tissue; B1-2: omentum; C: left pelvic peritoneum mass; D: lymph node, para-aortic; E1-2: lymph node, left iliac; F: lymph node, left obturator; G1-3: lymph node, right iliac; H1-2: lymph node, right obturator.
        
  • Microscopic Description:
    • Histologic Type: Mucinous carcinoma; The immunohistochemical stains reveal CK7(+), CK20(+), PAX8(focal +), WT-1(-), Napsin A(-), p53(Overexpression), and PR(-).
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors) Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.
      • WHO Grading System: G2: Moderately differentiated
    • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
    • Other Tissue/ Organ Involvement (select all that apply): left pelvic peritoneum: The immunohistochemical stains reveal CK7(+), CK20(+), PAX8(focal +), p53(Overexpression), and Calretinin(-).
      
    • Largest Extrapelvic Peritoneal Focus (required only if applicable): absent
      
    • Peritoneal/Ascitic Fluid: N2024-01479: Negative for malignancy (normal/benign)
      
    • Regional Lymph Nodes:
      • Negative for metastasis: para-aortic: 0/2; left iliac: 0/7; left obturator: 0/2; right iliac: 0/9; right obturator: 0/4
    • Additional Pathologic Findings: None identified
• 2024-03-25 CT - abdomen
  • Clinical history: 18 y/o female patient with huge LOV cystic tumor, post LSC left oophorcystectomy 3/21 large pelvic tumor, mixed solid and cystic component, cannot exclude malignancy (central , near right side)
  • With and without contrast enhancement CT of abdomen–whole:
    • Large heteregeneous soft tissue tumor, 11.8cm in the pelvic cavity, r/o ovarian malignancy.
    • Irregular soft tissue with enhancement in left abdominal wall around scar region, r/o recurrent tumor.
    • Enlarged lymph node in the aortocaval region, r/o metastatic lymph node.
    • Presence of ascites.
  • Impression:
    • Large tumor, r/o ovarian malignancy.
    • Left abdominal wall irregular tumor around scar region, r/o recurrent tumor.
    • Ascites.
    • R/O metastatic lymph node in aortocaval region.
• 2023-04-06 Sonography - gynecology
  • IMP: R/O Mucinous mass:214x138mm

[chemotherapy]

• 2024-08-16 - paclitaxel 175mg/m2 340mg NS 300mL 3hr + carboplatin AUC 5 780mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-07-22 - paclitaxel 175mg/m2 340mg NS 300mL 3hr + carboplatin AUC 5 780mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-07-01 - paclitaxel 175mg/m2 337mg NS 300mL 3hr + carboplatin AUC 5 780mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-06-11 - paclitaxel 175mg/m2 330mg NS 300mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-05-20 - paclitaxel 175mg/m2 320mg NS 300mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

700957375

240816

[lab data]

2024-03-06 HLA A-high 02:03
2024-03-06 HLA A-high 33:03
2024-03-06 HLA B-high 51:01
2024-03-06 HLA B-high 58:01
2024-03-06 HLA C-high 03:02
2024-03-06 HLA C-high 14:02
2024-03-06 HLA DR-high 11:06
2024-03-06 HLA DR-high 13:02
2024-03-06 HLA DQ-high 03:01
2024-03-06 HLA DQ-high 06:09

2024-02-22 HBsAg Nonreactive
2024-02-22 HBsAg Value 0.50 S/CO
2024-02-22 Anti-HBc Nonreactive
2024-02-22 Anti-HBc Value 0.35 S/CO
2024-02-22 Anti-HCV Nonreactive
2024-02-22 Anti-HCV Value 0.06 S/CO

[exam findings]

• 2024-08-12 Patho - bone marrow biopsy
  • Bone marrow, ilium, biopsy — Compatible with myelodysplastic syndrome with excess blasts, progress to acute myeloid leukemia
  • The sections show hypercellular marrow (60%). M/E ratio = 4:1. The megakaryocytes are normal in number and occasional micromegakaryocytes are present. Scattered CD34+ and/or CD117+ blasts, account for 20% of nucleated cells can be identified. The finding is compatible with myelodysplastic syndrome with excess blasts and progress to acute myeloid leukemia. Suggest bone marrow smear evaluation and clinical correlation.
• 2024-07-29 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A-
    • Chronic superficial gastritis
    • Gastric erosions, lower body, LC
    • Suspected gastric ulcer scar, prepyloric antrum. LC
  • CLO test: not done
• 2024-07-11 SONO - abdomen
  • IMP: Left renal cysts (1.29x1.48cm, 1.69x2.33cm).
• 2024-06-30 ECG
  • Sinus tachycardia
  • Abnormal QRS-T angle, consider primary T wave abnormality
• 2024-06-13 Patho - bone marrow biopsy
  • Bone marrow, iliac crest, biopsy — Compatible with myelodysplastic syndrome with acute myeloid leukemia transformation
  • The sections show hypercellular marrow (70%). M/E ratio = 3:1 in CD71 stains. The erythoid precursors are dispersed and scattered. The megakaryocytes are slightly increased and occasional micromegakaryocytes are present. Increased CD34+ and/or CD117+ blasts, account for 20-25% of nucleated cells. The finding is compatible with myelodysplastic syndrome with acute myeloid leukemia transformation. Suggest further bone marrow smear evaluation and clinic correlation.
• 2024-03-20 SONO - abdomen
  • A cyst 2 cm in left kidney is suspected. Follow up is indicated.
• 2024-03-13 SONO - soft tissue
  • Subcutaneous and muscular edema of both lower legs, r/o inflammatory or infectious process.
• 2024-02-05 CT - abdomen
  • History and indication: suspected CML
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Focal low attenuation at right kidney. Left renal cyst (2.2cm).
    • Minimal ascites.
    • Retroversion of uterus.
• 2024-02-05 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — myelodysplastic syndrome (RAEB-II).
  • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 3.3 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
  • Section shows piece(s) of bone marrow with 90% cellularity and M:E ratio of approximately 3:2. Three cell lineages are present with left shift of leukocytes. Megakaryocytes are adequate in number with micromegakaryocytes.
  • IHC stains: CD117: 10-15 %; CD34: 10-15 %; MPO: 10%, CD163: 40%, CD3: 5%; CD20: 2%; CD61: 5 %; CD71: 40 % (of the nucleated cells).
• 2024-02-05 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (84.4 - 21.1) / 84.4 = 75.00%
    • M-mode (Teichholz) = 71.4
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild to moderate TR
    • Mitral valve prolapse (anterior leaflet) with mild MR
• 2024-01-30 Patho - stomach biopsy
  • Stomach, antrum, biopsy — Gastric erosion, Helicobacter pylori (+)
  • The sections show gastric erosion, composed of gastric mucosal tissue with superficial necrosis, fibrinous exudate, moderate incomplete intestinal metaplasia, and moderate acute and chronic inflammatory cells infiltration. Colonies of Helicobacter pylori are found.
• 2024-01-30 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Gastric ulcer, prepyloric antrum, AW, s/p biopsy
  • CLO test: Positive
  • Suggestion:
    • Pursue CLO and biopsy results
    • OPD follow up
• 2023-12-27 Mammography
  • Digital mammography of left breast with MLO and CC views:
    • S/P right mastectomy.
    • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
  • Impression:
    • Dense breast. S/P right mastectomy.
    • No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
  • BI-RADS: Category 1: negative. - annual screening.
• 2023-12-27, -10-04 SONO - abdomen
  • A cyst measuring 2 cm in left kidney is suspected.
• 2023-07-26 Gynecologic Ultrasonography
  • Findings
    • CUL-DE-SAC: with fluid
      
  • IMP:
    • R/O mild Adenomyosis
    • R/O RT Ovarian cyst
• 2023-07-12 SONO - abdomen
  • Left renal cyst (1.58 x 1.68cm)
• 2023-07-12 SONO - breast
  • Diagnosis
    • Left fibroadenomas as described
    • s/p right breast operation
  • BI-RADS: 2. benign finding
• 2023-04-19 SONO - abdomen
  • A cyst measuring 2.7 cm in left kidney is suspected.
• 2022-07-05 Patho - breast mastectomy with regional lymph nodes
  • PATHOLOGIC DIAGNOSIS
    • Breast tumor, right, simple mastectomy
      • — Invasive carcinoma of no special type with extensive intraductal component, intermediate grade, 50-60%
      • — Benign Phyllodes tumor
        
    • Resection margins, ditto — Free of tumor invasion, less than 0.1 cm at closest base margin
    • Skin and nipple, R’t breast, ditto — Free of tumor invasion
    • Lymph nodes, R’t axillary sentinel area, frozen section — Free of tumor metastasis (0/3)
    • AJCC Pathologic Anatomic Stage — pT1cN0, if cM0, stage IA and Prognostic Stage: stage IA
  • MACROSCOPIC EXAMINATION
    • Breast: 16.8 x 10.2 x 1.3 cm
    • Skin: 13.9 x 3.8 cm
    • Nipple: 1.6 x 1.1 cm, not retracted
    • Tumor: two nodules, 1.3 x 1.1 and 1.3 x 0.8 cm
    • Resection margins: Free, less than 0.1 cm away from base, at least 1.1 cm away from peripheral margins
    • Lymph node: right axillary sentinel lymph node
    • Representative sections as A1: four peripheral margins, A2-A10: tumor (1.3 x 1.1 cm) + base (ink), A11: tumor (1.3 x 0.8 cm), A12: breast, random, A13: nipple and skin [Reference: F2022-00312 R’t axillar sentinel lymph nodes]
  • MICROSCOPIC EXAMINATION
    • Histologic type: Invasive carcinoma of no special type with extensive intraductal component, intermediate grade (50-60%) arranged in cribriform pattern with focal necrosis
    • Size of invasive carcinoma: 1.3 x 1.1 cm
    • Histologic grade (Nottingham histologic score): Grade 2 (score 6) characterized by (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
    • Margins: Free, < 0.1 cm away from closest base, at least 1.1 cm away from unlabelled peripheral margins
    • Nodal status: free of tumor metastasis (0/3)
    • Treatment Effect: N/A
    • Lymphovascular space invasion: not identified
    • Perienural invasion: not identified
    • Immunohistochemical study: p63 and myosin highlight invasive component
    • Non-tumor breast: benign phyllodes tumor measures 1.3 x 0.8 cm as well as fibrocystic change with adenosis, apocrine metaplasia, flat epithelial atypia, microcalcification and fibroadenomatous feature (0.3 cm)
• 2022-06-30 Tc-99m MDP bone scan
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, elbows, wrists, hips, knees, ankles and feet, compatible with benign joint lesions.
  • No prominent bone abnormality was noted elsewhere.
• 2022-06-24 Her-2/neu DISH
  • HER2 Dual ISH Report
  • Results (according to 2018 ASCO/ CAP HER2 testing guideline in breast cancer):
    • Negative (Non-amplified)
    • Average number of HER2 gene copy signal per cell: 2.7
    • Average number of CEP17 gene copy signal per cell: 1.6
    • Ratio of avergae HER2/CEP17: 1.68
  • Specimen adequacy:
    • The specimen contains enough invasive tumor cells adquate for evaluation
  • Method:
    • VENTANA HER2 Dual ISH DNA Probe Cocktail
  • Tissue source:
    • Breast cancer
  • Immunohistochemistry HER2/Neu result:
    • Equivocal: IHC 2+ (S2022-101338)
  • Interpretation criteria:
    • Positive (Amplified):
      • Dual probe HER2/CEP17 ratio ≥ 2.0 with an average HER2 gene copy number ≥4.0.
      • HER2/CEP17 < 2.0 with an average HER2 gene copy number ≥ 6.0 signals / cell.
    • Negaitive (Non-amplified):
      • HER2/CEP17 ratio < 2.0 with an average HER2 gene copy number < 4.0 signals/cell.
      • HER2/CEP17 ratio > 2.0 with an average HER2 gene copy number ≥ 4.0 signals/cell and < 6.0 signals/cell.
      • HER2/CEP17 ratio ≥ 2.0 with an average HER2 gene copy number < 4.0 signals/cell.
• 2022-06-24 Patho - breast biopsy
  • DIAGNOSIS:
    • Breast, right, core needle biopsy
      • — invasive carcinoma of no special type
        
      • — ductal carcinoma in situ, intermediate-grade
        
  • Gross description:
    • The specimen submitted consists of 4 pieces of tissue cores measuring up to 1.5x 0.1x 0.1 cm in size, fixed in formalin. Grossly, they are tan and elastic.
    • All for section is taken.
  • Microscopically, the breast shows invasive carcinoma composed of irregular tumor nests with ductal differentiation, invasive growth pattern and stromal fibrosis. The tumor shows hyperchromatic nuclei, plemorphism, hisgh N/C ratio and mitoses. Ductal carcinoma in situ is also seen.
    • Immunohistochemical stain stain (for invasive carcinoma) reveals ER (+, strong intensity, >95%), PR (+, moderate intensity, 95%), Her2/Neu: equivocal (2+), Ki-67 index: 5%, CK5/6 (-), p63 (-).
    • Immunohistochemical stain stain (for DCIS) reveals ER (+, strong intensity, >95%), PR (+, moderate intensity, 95%), Her2/Neu: positive (3+), Ki-67 index: 5%, CK5/6 (-), p63 (+).

[MedRec]

• 2024-02-01 ~ 2024-02-06 POMR General and Gastroenterological Surgery Zhang YaoRen
  • Discharge diagnosis
    • macrocystic severe anemia
    • Malignant neoplasm of unspecified site of right female breast
    • Reticulocytosis
    • lymphocytosis
    • bilateral lower limb edema
  • CC
    • 2024/01/31 Lab data showed a severe macrocytic anemia, refer to hematology for further evaluation
  • Present illness
    • This 51-year-old female patient had the history of Right breast invasive carcinoma status post simple mastectomy + Sentinel Lymph Node Biopsy on 2022/07/05. cT1cN0M0, stage IA. ER (>95%), PR(95%), Her2/Neu: equivocal (2+), Ki-67 index: 5%, ECOG:0, on hormone therapy.
    • According to her statement, she suffered from abdominal distension, heartburn over chest region constantly for 2 years since she got COVID-19 infection and more during fasting or after having some food. Her pitting edema over lower extremities for one year. She felt general malaise, short of breath, dizziness and headache in recent half year. There are no nausea, no vomiting, no fever, no cold sweating, diarrhea or constipation accompanied.
    • She came to our GI OPD and EGD was arranged on 2024/01/30 and showed chronic gastritis with small GU and HP infection.
    • Lab data revealed macrocytic anemia HGB:7.0 g/dL; MCV : 118.0 fL and normal folate and B12.
    • She was admitted for diagnosing her severe anemia with grade 2 pitting edema over lower extremities.
    • Due to the above reasons, the patient was admitted to our ward for further management.
  • Course of inpatient treatment
    • After admission, given her history of right breast invasive carcinoma post-mastectomy and hormone therapy, as well as her persistent symptoms post-COVID-19 infection.
    • Since her admission to the oncology ward on 2024-02-01 due to severe macrocytic anemia and grade 2 pitting edema, she has been under continuous observation, and a series of diagnostic and therapeutic measures have been taken.
    • The laboratory findings have consistently indicated macrocytic anemia, with her latest hemoglobin showing a slight improvement to 7.5 g/dL from 7.0 g/dL at the time of admission, suggesting, albeit limited, a positive response to our interventions.
    • The consistent low platelet count is concerning, with the most recent count critically low at 40 x 10^3/uL, prompting us to administer two units of apheresis platelets.
    • Moreover, an elevated D-dimer suggests a hypercoagulable state, necessitating close monitoring for thrombotic events. We’ve conducted a bone marrow biopsy to further elucidate the etiology of her hematological abnormalities. Our patient’s vital signs have remained stable throughout her stay, without any indicators of an acute infectious or severe exacerbation of her chronic conditions.
    • For an in-depth assessment, we have arranged for Doppler echocardiography and CT scans of the abdomen and pelvis. Due to the relative stable condition, the patient was able to be discharged today.
• 2024-01-03, 2023-10-11, -07-19, -04-26, -02-01, 2022-11-02, -08-10, -07-13 SOAP General and Gastroenterological Surgery Zhang YaoRen
  • Prescription x3
    • Nolvadex (tamoxifen citrate 10mg) 1# BID
• 2022-07-04 ~ 2022-07-06 POMR General and Gastroenterological Surgery Zhang YaoRen
  • Discharge diagnosis
    • Right breast invasive carcinoma status post simple mastectomy + Sentinel Lymph Node Biopsy on 2022/07/05. cT1cN0M0, stage IA. ER (>95%), PR (95%), Her2/Neu: equivocal (2+), Ki-67 index: 5%, ECOG:0
  • CC
    • noted a palpable mass at right breast since last month.
  • Present illness
    • This 49-year-old female patient denied any past history including HTN, DM, HBV or heart disease. She had COVID 19 infection on 2022/04/22.
    • She noted a palpable mass at right breast since last month. She came to our OPD for help. Breast sono showed a lesion, Right 10/2.94 cm , size: 1.68x1.05 cm, r/o malignancy suggest biopsy.
    • Core needle biopsy revealed invasive carcinoma, ER (>95%), PR (95%), Her2/Neu: equivocal (2+), Ki-67 index: 5%. CA-153：7.294 U/ml, CEA：0.85 ng/ml.
    • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis.
    • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
    • PE: a hard, nontender, movable mass and irregular margin at right breast around 2x2 cm without discharge. The nipple was dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
    • Under the impression of right breast invasive carcinoma, she was admitted for surgery of simple mastectomy + SLNB. 
  • Course of inpatient treatment
    • After admission, right breast simple mastectomy + SLNB was performed on 2022/07/05. The wound is clean and dry. Under the stable condition, she was discharged today, wound will be follow up in OPD.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID

[consultation]

• 2024-03-26 Infectious Disease
  • Q
    • for neutropneia & R/O fungus infection
  • A
    • This is a case of
      • myelodysplastic syndrome (RAEB-II)
      • Refractory anemia with excess of blasts 2
      • invasive carcinoma of no special type ductal carcinoma in situ, intermediate-grade Immunohistochemical stain stain (for invasive carcinoma) reveals ER (+, strong intensity, > 95%), PR (+, moderate intensity, 95%), Her2/Neu: equivocal (2+), Ki-67 index: 5%, CK5/6 (-), p63 (-). Immunohistochemical stain stain (for DCIS) reveals ER (+, strong intensity, > 95%), PR (+, moderate intensity, 95%), Her2/Neu: positive (3+), Ki-67 index: 5%, CK5/6 (-), p63 (+).
      • Anemia
    • She was admitted because of low-grade fever and dyspnea.
    • Lab
      • 2024-03-22 WBC 13.70 x10^3/uL
        
      • 2024-03-22 Neutrophil 5.9 %
        
    • ANC 808. Agree with your use with mycamine and cefim for the neutropenic fever.
    • Please collect B/C, arrange abd sono and CV-echo.
• 2024-03-11 Dermatology
  • Q
    • for multiple tender masses
    • This 51-year-old woman, a paitnet of myelodysplastic syndrome (RAEB-II) S/P C/T with 3+7 since 2/23-2/29 24. She complained of right knee swelling, pain & local heat on 3/8 24 and antibiotic with Ciproxine was given but progression of right knee swelling, pain & local heat was also noted. R/O knee fluid or pus discharge. We need expertise to evaluate her condition thanks!
  • A
    • This patient suffered from multiple erythematous patches - nodules on 4 limbs for days.
    • Painful (+)
    • Imp: Erythematous indurasum
    • Suggestion:
      • Doxyclin 1 / Bid
      • Predinisolon 1 / Bid
      • Topsym cream * 2 tubes/bid

[surgical operation]

• 2022-07-05
  • Operation
    • Simple mastectomy and sentinel lymph node biopsy         
  • Finding
    • a 2x1.5x1 cm slight firm mass in rt breast
    • SLN 0/3      

[chemotherapy]

• 2024-08-15 - (FLAG)

• 2024-06-13

• 2024-04-16

• 2024-02-23 - daunorubicin 45mg/m2 60mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 137mg NS 500mL 24hr D1-7

  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-7

==========

2024-08-16

[Initiation of FLAG Regimen and Neutrophil Count Trends]

The FLAG regimen was initiated on 2024-08-15, and lab results showed an ANC of 966/uL with an upward trend in neutrophil count. The patient’s WBC has been consistently low for months, suggesting that this condition may not be entirely due to chemotherapy.

• 2024-08-16 Neutrophil 64.0 %

• 2024-08-10 Neutrophil 19.6 %

• 2024-07-18 Neutrophil 22.1 %

• 2024-08-16 WBC 1.51 x10^3/uL

• 2024-08-10 WBC 1.59 x10^3/uL

• 2024-07-18 WBC 3.35 x10^3/uL

• 2024-07-10 WBC 2.54 x10^3/uL

• 2024-07-08 WBC 1.75 x10^3/uL

• 2024-07-06 WBC 1.01 x10^3/uL

• 2024-07-03 WBC 0.89 x10^3/uL

• 2024-06-30 WBC 0.83 x10^3/uL

• 2024-06-27 WBC 1.02 x10^3/uL

• 2024-06-26 WBC 0.83 x10^3/uL

• 2024-06-24 WBC 1.00 x10^3/uL

• 2024-06-23 WBC 0.77 x10^3/uL

• 2024-06-21 WBC 0.67 x10^3/uL

• 2024-06-17 WBC 0.85 x10^3/uL

• 2024-06-10 WBC 2.24 x10^3/uL

• 2024-05-21 WBC 6.29 x10^3/uL

• 2024-05-13 WBC 2.24 x10^3/uL

• 2024-05-10 WBC 1.55 x10^3/uL

• 2024-05-08 WBC 0.93 x10^3/uL

• 2024-05-06 WBC 0.71 x10^3/uL

• 2024-05-04 WBC 0.84 x10^3/uL

• 2024-05-02 WBC 0.78 x10^3/uL

2024-03-13

[bedside visit: patient reports improvement in leg swelling and redness]

I visited this patient around 13:40 today, who reported feeling an improvement in the redness and swelling of her legs. She relayed what our dermatologist had said, mentioning that the swollen areas would crust over. However, the patient expressed suspect about the extensive crusting, likening it to her legs undergoing a skin replacement.

The patient had no issues with other medications but remained curious about whether a specific drug could be causing these symptoms.

2024-03-11

[ciprofloxacin: short use followed by knee pain & treatment change]

Ciprofloxacin may cause tendinopathy or rupture of tendon; Achilles is most commonly cited, but inflammation/rupture of many other tendons (including hand, rotator cuff, biceps, and thumb) has been reported.

• Mechanism: Dose- and time-related; upregulation of matrix metalloproteinase (MMP) enzymes capable of damaging components of the extracellular matrix, including collagen and elastin. Direct effect on the viability of chondrocytes and tenocytes responsible for collagen synthesis, due to generation of reactive oxygen species, caspase activation and apoptosis.
• Onset: Varied; per the manufacturer’s labeling, tendinopathy or tendon rupture may occur within hours or days of initiation or may be delayed for several months after discontinuation.

In addition, arthropathy, or joint disease, has been observed in both animal and pediatric human studies following treatment with fluoroquinolone antibiotics, including ciprofloxacin. In an international, multicenter, randomized trial of ~700 pediatric patients (ciprofloxacin versus comparator), more patients in the ciprofloxacin group experienced musculoskeletal events both within 6 weeks and 1 year of follow-up. Arthropathy and arthralgias appear to resolve after discontinuation of treatment with no long-term sequelae. Though the true incidence is unknown, arthropathy and arthralgia are considered to be infrequent, but potentially serious adverse reactions.

• Mechanism: Unknown; several hypotheses have been proposed including inhibition of mitochondria DNA synthesis in immature chondrocytes, direct toxic effect of fluoride on cartilage, magnesium chelation and subsequent deficiency in cartilage, and defective proteoglycan and procollagen synthesis with decreased incorporation of tritiated thymidine by chondrocytes.
• Onset: Varied; may occur within first day of treatment initiation or months following discontinuation.

Cinolone (ciprofloxacin) was used from 2024-03-07 to 2024-03-09.

On 2024-03-08, the patient reported right knee swelling, pain, and localized heat. After antibiotic therapy with ciprofloxacin. Progression of these symptoms (right knee swelling, pain, and localized heat) was observed.

On 2024-03-09, the cinolone was discontinued. Our dermatologist recommended a regimen consisting of doxycycline, prednisolone, and Topsym Cream (fluocinonide) to address these symptoms.

[bedsite visit]

Upon arrival at 11:30 on 2024-03-11, the patient had just returned to the ward from the dermatology OPD.

I saw the patient had tenderness and swelling near her right knee. There are about five red bumps, each about the size of a coin, near the right knee skin. There is also a slightly red area on her left calf skin, about 7 x 15 cm in size.

I advised her to apply the medications prescribed by our dermatologist and monitor for symptom improvement. If symptoms persist or worsen in these 2 days, further evaluation will be necessary.

[derm suspects erythematous induratum (EI) - workup for underlying cause - evaluation for tuberculosis]

During a visit to dermatology earlier today (2024-03-11), the patient was suspected to have erythematous induratum (EI).

EI is an uncommon form of panniculitis that may occur in association with tuberculosis (most common), other diseases or drugs, or as an idiopathic condition. EI is regarded as an immune-mediated hypersensitivity reaction. EI most frequently occurs in adult females. The most common clinical presentation of EI is single or multiple erythematous nodules on the posterior or lateral lower legs. Thigh and upper extremity involvement occurs occasionally. Truncal, facial, or disseminated EI is rare. Ulceration of nodules is common.

The diagnosis of EI is made based upon the presence of consistent clinical and histologic findings. Skin biopsies demonstrate a predominantly lobular panniculitis with a mixed and granulomatous inflammatory infiltrate with vasculitis. Multiple sections or multiple specimens may be required to identify vasculitis. Given the strong association of EI with tuberculosis, all patients with EI should be evaluated for tuberculosis. (Ref: https://www.uptodate.com/contents/erythema-induratum-nodular-vasculitis)

First-line treatment for nonidiopathic EI is treatment of the underlying associated disease. Nonsteroidal anti-inflammatory drugs, rest, elevation, and compression may aid with symptomatic improvement. When an underlying disease cannot be identified and treated, treatment may be challenging. Data on therapeutic options are limited. It is suggested a trial of oral potassium iodide for these patients (Grade 2C). Other treatments that may be beneficial include systemic glucocorticoids, clofazimine, colchicine, gold salts, and mycophenolate mofetil. Additional immunosuppression may not be optimal for this patients undergoing chemotherapy.

701060062

240816

[exam findings]

• 2024-08-16 CT - abdomen

  • Findings:
    • S/P right hemicolectomy
    • There is fatty stranding in right side mesentery that may be post-operative change. Follow up is indicated.
    • Left ovarian cyst 4.5 cm is highly suspected. Please correlate with GYN. sonography.
  • Impression:
    • S/P right hemicolectomy.
    • There is no evidence of tumor recurrence.

• 2024-06-05 Bladder Sonography

  • PVR: 96.3ml

• 2024-05-16 RAS + BRAF V600

  • Cellblock No. S2024-05631 A1
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: Detected (BRAF codon 600 GTG > GAG, p.V600E)

• 2024-05-06 MRI - lower abdomen

  • History and indication:
    • Malignant neoplasm of ascending colon
  • IMP:
    • S/P operation. Stranding of peritoneal fat and abdominal wall fat.
    • Left ovary cyst (4.5cm).
    • Some LNs (up to 1.2cm) at bil. inguinal regions.
    • Gallbladder stone (0.8cm).

• 2024-04-03 Bladder Sonography

  • PVR: 74.87ml

• 2024-04-03 Uroflowmetry

  • Q max : low
  • flow pattern : obstructive

• 2024-03-20 Patho - colon segmental resection for tumor

  • Diagnosis
    • Large intestine, ascending colon laparoscopic right hemicolectomy —- Adenocarcinoma, poorly differentiated.
      • IHC stains: CK7 (-), CK20 (focal weak +), CD56 (-), chromogranin-A ), hepatocyte (-).
    • Resection margins: bilateral cut ends free; radial margin involved
      
    • Lymph node, mesocolic, dissection —- metastatic carcinoma (3/21) no extranodal extension
    • Tissue labeled as “peritoneum”, excision —- Adenocarcinoma, poorly differentiated.
    • Tissue labeled as “subcutaneous mass, right” , excision —- Adenocarcinoma, poorly differentiated.
    • Tissue labeled as “subcutaneous mass, left” , excision —- Adenocarcinoma, poorly differentiated.
    • pT4a pN1b pM1c; Pathology stage: IVC
      
  • Gross Description:
    • Procedure - Right hemicolectomy: colon: 19 x 6 x 6 cm; terminal ileum: 6 cmm in length; tumor excision. Omentum: 16 x 6 x 2 cm; Tissue labeled as “peritoneum”: 3.0 x 2.0 x 2.0 cm; Tissue labeled as “subcutaneous mass, right”: 0.9 x 0.9 x 0.9 cm; Tissue labeled as “subcutaneous mass, left”: 1.8 x 1.7 x 1.6 cm.
    • Tumor Site: ascending colon, 6 cm from closer cut end, proximal cut end..
    • Tumor Size: 8 x 7 x 7 cm.
      
    • Macroscopic Tumor Perforation: Present
      
    • Macroscopic Intactness of Mesorectum - Incomplete
    • Sections are taken and labeled as:
      • A1-5: tumor; A6-7: ileocecal valve; A8: omentum; A9-12: lymph nodes; A13: Tissue labeled as “peritoneum”; A14: Tissue labeled as “subcutaneous mass, right”; A15: Tissue labeled as “subcutaneous mass, left”.
  • Microscopic Description:
    • Histologic Type - Adenocarcinoma
    • Histologic Grade - G3: Poorly differentiated
    • Tumor Extension - Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Involved
      • Distance of tumor from margin: 0 mm
        
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Present
    • Tumor Budding
      • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2) - Intermediate score (5-9)
    • Type of Polyp in Which Invasive Carcinoma Arose:none.
    • Tumor Deposits: Present
      • Specify number of deposits: 3
    • Regional Lymph Nodes
      • Number of Lymph Nodes Involved/Examined: 3/21. no extranodal extension
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition) : IVC
      • TNM Descriptors - not applicable.
      • Primary Tumor (pT) - pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
      • Regional Lymph Nodes (pN)
      • pM1c: Metastasis to the peritoneal surface is identified alone or with other site or organ metastases
    • Additional Pathologic Findings (select all that apply) - None identified
    • Ancillary Studies - IHC stains: CK7 (-), CK20 (focal weak +), CD56 (-), chromogranin-A ), hepatocyte (-).
    • Comment(s) - none.

• 2024-03-19

• 2024-03-13 CT - abdomen

  • CC:
    • BW loss 7 Kg in one year. Appetite: well
    • A-colon cancer with partial obstruction s/p biopsy
  • Findings:
    • There is lobulated segmental circumferential asymmetrical wall thickening and irregular contour at the terminal ileum, ileocecal valve, ascending colon, and cecum, measuring 9 cm in size (the largest dimension), causing dilatation of the terminal ileum.
      • Adenocarcinoma of the cecum (T4a) and proximal ascending colon with ileo-cecal valve and terminal ileum invasion causing partial obstruction is highly suspected.
    • There are seven enlarged nodes in the adjacent mesocolon that are c/w regional metastatic nodes (N2b).
    • There are two soft tissue nodules in the subcutaneous fat layer of the upper pelvis, 1.7 cm and 0.7 cm.
      • Metastases (M1a) is suspected. Biopsy is indicated.
    • There is no focal lesion in both lung and mediastinum.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)

[immunochemotherapy]

• 2024-08-15 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 160mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 80mg D5W 250mL 2hr + leucovorin 200mg/m2 250mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3090mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 60%, Oxalip 60%, LV 80%, 5FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.3mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-07-26 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 150mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 68mg D5W 250mL 2hr + leucovorin 200mg/m2 250mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3075mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 60%, Oxalip 60%, LV 80%, 5FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.3mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-07-09 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 100mg D5W 250mL 1.5hr + oxaliplatin 50mg/m2 68mg D5W 250mL 2hr + leucovorin 200mg/m2 240mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3000mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 40%, Oxalip 40%, LV 80%, 5FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.3mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-19 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 130mg/m2 100mg D5W 250mL 1.5hr + oxaliplatin 50mg/m2 67mg D5W 250mL 2hr + leucovorin 200mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.3mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-31 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 600mg D5W 250mL 2hr + fluorouracil 400mg/m2 600mg D5W 10min + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino 60%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.3mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-15 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 170mg D5W 250mL 1.5hr + leucovorin 400mg/m2 600mg D5W 250mL 2hr + fluorouracil 400mg/m2 600mg D5W 10min + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino 60%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.3mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-25 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 140mg D5W 250mL 1.5hr + leucovorin 400mg/m2 310mg NS 250mL 2hr + fluorouracil 400mg/m2 310mg NS 10min + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino ?off)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.3mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-11 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 140mg D5W 250mL 1.5hr + leucovorin 400mg/m2 310mg NS 250mL 2hr + fluorouracil 400mg/m2 310mg NS 10min + fluorouracil 2400mg/m2 1900mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino ?off)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.3mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

701080996

240815

[exam findings]

[MedRec]

• 2024-04-12 ~ 2024-06-15 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Malignant (primary) neoplasm, Metastatic Adenocarcinoma, T4N3M1C,stage IVB, breast cancer immunohistochemical stains reveal ER (Ab): Positive(> 90%, strong), PR (Ab): Positive (1%, weak), and Her-2/neu (Ab): Positive (3+), GATA3 (+).
    • Interstitial change of bilateral lungs status post uniportal video-assisted thoracoscopic surgery right lower lobe lung wedge resection on 2024/04/17
    • Metastasis carcinoma of unknow primary site
    • Pneumonia of bilateral lower lobes, sputum culture still pending
    • Reflux esophagitis LA Classification grade A-(minimal)
    • Superficial gastritis, prepyloric antrum
    • Chronic viral hepatitis B without delta-agent anti-Hbc positive
  • CC
    • right lower chest patient with radiation to back for one week
  • Present illness
    • This 70-year-old woman who had denied any systemic past history before, operation history of Cataract status post operation.
    • According to the statement of the patient’s families and ER medical record. This time the patient suffered from right lower chest pain with radiation to back, Intermittent cough for one year. However dyspnea progression in this week. She deniey fever, nausea, vomitting or chest tightness before. Therefore she was sent to our ER.
    • At MER, physical exam showed bilateral coarse BS. The TPR showed BP:139/80mmHg; HR:109 rate/min; BT:36.5’C; RR:18 rate/min; Con’s:E4V5M6; saturation:97%. The laboratory studies disclosed normal WBC count and CRP level; Elevated of liver function and glucoce.
    • The chest film disclosed cardiomegaly, faint aveolar opacity over right lower lobe and left lower lobe is found.
    • Chest CT report extensive interstitial change at bilateral lungs with mild bilateral pleural effusion more on right hemithorax is noted. Rule out lymphangitis carcinomatosis, pulmonary congestion or others. r/o bone meta.
    • Under impression of favor Interstitial lung disease. She was admitted for further evaluation and management
  • Course of inpatient treatment
    • After admission, antuissive and mucolytic agents were prescribed for symtom relief.
    • Diuretic agent was used for pulmonary congestion.
    • Sputum, TB culture and atypical pneumonia profile were checked.
    • Pulmonary function test was conducted and reported mild restrictive lung defect.
    • Ultibro Breezhaler was prescribed.
    • Chest echogram revealed bilateral trivial amount of pleural effusion, and no thoracentesis was done due to high risk.
    • Chest CT was done and disclosed extensive interstitial change at bilateral lungs with mild bilateral pleural effusion, more on right hemithorax, r/o lymphangitis carcinomatosis, pulmonary congestion, r/o bone metastatis.
    • Surgical biopsy was considered. After discussing with the patient and her family about pros and cons of VATS RLL wedge biopsy, they agreed with surgical intervention.
    • The patient received uniportal VATS RLL wedge resection on 2024/04/17. After the surgery, she was transferred to CS service.
    • At CS ward, pain was controlled by Deflam-K and Dynastat. Pigtail catheter was connected with LPS -15cmH2O.
    • We removed Foley catheter on 2024/04/18. Follow chest film on 2024/04/19 showed no hemopneumothorax. Pigtail catheter was removed on the same day.
    • With relatively stable condition, she was transfer to chest ward service on 2024-04-19.
    • After transfer to chest ward, endoscopy was conduct due to decrease appetite and intake, whick report reflux esophagitis LA Classification grade A-(minimal)
    • Superficial gastritis, prepyloric antrum, s/p CLO test was negative finding and biopsy disclose chronic gastritis with intestinal metaplasia, H pylori not present. Right lower lobe lung wedge resection show metastatic carcinoma, unknow primary site.
    • Whole body PET was conduct that reveal there was increased FDG uptake in multiple focal areas in bilateral lungs (SUVmax early: 6.61, delay: 8.26), more evident in the left lung, in the right paratracheal and bilateral pulmonary hilar lymph nodes (SUVmax early: 5.03, delay: 7.81), in the right lateral chest wall (SUVmax early: 3.72, delay: 3.84) and in multiple bones (SUVmax early: 7.17, delay: 7.99) including multiple C-, T- and L-spines, sternum, ribs and bilateral pelvic bones. Besides, there was increased FDG accumulation in the colon and both kidneys.
    • Brain MRI was done which show cerebral small vessel disease, mild.
    • Due to metastasis carcinoma of unknown primary site, renal echo was conduct that report bilateral chronic change with small sized kidney.
    • Consult Gastroenterologist that suggest check tunor marker and arrange colonscopy is indicate. Painless colonscopy was arrange on 2024-04-29 that reveal internal hemorroid.
    • We also consult obstetrics and gynecology that GYN echo showed no obvious uterine or ovarian lesion, no ascites was noted.
    • Follow laboratory data include tumor marker pending data and chest film show s/p RLL wedge resection. reticular opacities over both lungs and patchy consolidations in RLL and LLL due to lymphangitic carcinomatosis. small Rt and Lt pleural effusions.
    • For metastasis carcinoma unknow primary site, Mammography was arranged on 4/30, it revealed dense breast. Benign coarse calcifications in bilateral breasts.
    • We consulted GS Dr for metastasis carcinoma unknow primaryn site, who was impression suscipious occult breast cancer; and suggestion of 1. Breast image work-up: Breast sonogarphy is considered at first. If no obvious tumor is found, breast MRI (+contrast) is advised to localized the occult breast tumor. 2. If positive image finding, tissue biopsy is candidated for further treament. The breast echo arranged on 5/6, it revealed Bilateral breast cysts and fibroadenomas. However, fever and dyspnea with desaturation was occured on 5/5.
    • Fever worke up was performed and showed leukocytosis and CXR showed bilateral pneumonia. Empiric antibiotic with Brosym IV was prescried for pneumonia control. Steroid with solu-mederal IV and bronchodilator with Atrovent, butanyl and pulmicort inhalation were given for dyspnea. NIPPV support also use for respiratory failure. We well explained the present condition to her familes (sister and son), they totaly understood and critical consition was annourced.
    • FMH Dr was consulted for further hospice care and combined care was suggestion. After treatment, her general condition got improved gradually and less dyspnea noted. The steroid was tapperred to oral form Prednisolone use and started try weaning NIPPV step by step since 5/13.
    • Due to highly suspect breast cancer with lung metastasis. She was transfferred to our ward for chemotherapy on 5/20 24.
    • Clexance 60mg sc q12h was given on 5/21-5/25 24 then shifted to Eliquis 1# po qd for D-dimer > 10000 and R/O thrombolism related.
    • Chemotherapy with Herceptin 600mg /Perjeta 420mg self-paid was given on 5/20 & Taxotere 75mg/m2 (60mg, D1 & D8) was given on 5/21 & 6/11 24, smoothly without obvious side effect.
    • The chemotherapy with Taxotere 75mg/m2 (60mg, D1 & D8) was given next given time on 5/28.
    • Empiric antibiotic with Brosym was administered for aspiration pneumonia & infection control.
    • On NIPPV support/Codeine PO and codeine IM prn used for productive cough.
    • Entecavir was added due to anti-Hbc positive.
    • Ultracet 1# po q8h was given for pain control.
    • Eliquis 1# po qd was given and recheck D-dimer showed 1932 on 5/27 24.
    • Hold D8 chemotherapy with Taxotere due to neutropenia. G-CSF 300mcg sc qd was given for neutropenia treatment.
    • O2 from BIPAP tappered to ventuil mask 40% 8L overnight on 5/30 24.
    • Codeine 1# po q6h was added for severe dry cough.
    • Mekei 0.5# po bid (self-paid) & Alginos 10cc po qid (self-paid) were added for cachexia and epigastric discomfort.
    • Dyspnea was noted and CXR(6/3 24) showed progression pneumonia over both upper lungs and we consulted chest man for evaluation and advisted to empirically use broad spectrum antibiotics, work up opportusnic infection TB, crypto, aspergillus, CMV, PJP, other fungus viral infection etc, stop RX breast CA for a while until lung condition had inproved, may try iv steroid methyl prednisolone 20mg g8h withh antacid after R/O opportusnic infection and gradual taper steroid. Intravenous steroid was given for symptom relief. keep steroid treatment was given for 3 days.
    • Dyspnea improved gradually post treatment and she was discharged on 6/15 24 under stable condition and will follow-up at OPD on 6/18 24.
  • Discharge prescription
    • Alginos Susp (sod alginate, NaHCO3, CaCO3) 10mL QID 5D
    • Baraclude (entecavir 0.5mg) 1# QDAC 5D
    • Eliquis (apixaban 5mg) 1# QD 5D
    • Megejohn (megestrol acetate 160mg) 0.5# BID 5D
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q8H
    • Actein Effervescent (acetylcysteine 600mg) 1# BID 5D
    • Alpraline (alprazolam 0.5mg) 1# QD 5D
    • codeine phosphate 15mg 1# Q6H 5D
    • Eurodin (estazolam 2mg) 0.5# HS 5D
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Through (sennoside 12mg) 2# HS

[immunochemotherapy]

• 2024-08-15 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 60mg NS 250mL 1hr (DHP Q3W, docetaxel D1,8)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL (post mab, pre taxol)
• 2024-07-30 - ………………………………………………….. docetaxel 75mg/m2 60mg NS 250mL 1hr (DHP Q3W, docetaxel D1,8)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-07-22 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 60mg NS 250mL 1hr (DHP Q3W, docetaxel D1,8)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL (post mab, pre taxol)
• 2024-07-02 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 60mg NS 250mL 1hr (DHP Q3W, docetaxel D1,8)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL (post mab, pre taxol)
• 2024-06-18 - ………………………………………………….. docetaxel 75mg/m2 60mg NS 250mL 1hr (DHP Q3W, docetaxel D1,8)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-06-11 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 60mg NS 250mL 1hr (DHP Q3W, docetaxel D1,8)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL (post mab, pre taxol)
• 2024-05-20 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 60mg NS 250mL 1hr (DHP Q3W, docetaxel D1,8)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL (post mab, pre taxol)

Systemic treatment for HER2-positive metastatic breast cancer - https://www.uptodate.com/contents/systemic-treatment-for-her2-positive-metastatic-breast-cancer

Pertuzumab, trastuzumab, and docetaxel for HER2-positive metastatic breast cancer - 2024-08-15 - https://www.uptodate.com/contents/image?imageKey=ONC%2F96342

• Cycle length: Every 21 days.
• Duration of therapy: Until disease progression or unacceptable toxicity.
• Regimen
  • Pertuzumab (loading dose)
    • 840 mg IV
    • Dilute in 250 mL NS and administer over 60 minutes. DO NOT mix with D5W and DO NOT infuse as an IV push or bolus.
    • Cycle 1: Day 1
  • Pertuzumab
    • 420 mg IV
    • Dilute in 250 mL NS and administer over 30 to 60 minutes. DO NOT mix with D5W and DO NOT infuse as an IV push or bolus.
    • Cycle 2 and after: Day 1
  • Trastuzumab (loading dose)
    • 8 mg/kg IV
    • Dilute in 250 mL NS and administer over 90 minutes for the loading dose. DO NOT mix with D5W and DO NOT infuse as an IV push or bolus.
    • Cycle 1: Day 1
  • Trastuzumab
    • 6 mg/kg IV
    • Dilute in 250 mL NS◊ and administer over 30 to 90 minutes. DO NOT mix with D5W and DO NOT infuse as an IV push or bolus.
    • Cycle 2 and after: Day 1
  • Docetaxel
    • 75 mg/m2 IV
    • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
    • Day 1

==========

2024-08-15

[clearance for DHP treatment without dose adjustment]

The patient is scheduled to receive DHP (docetaxel, trastuzumab, pertuzumab) treatment. Based on the blood cell count, electrolytes, liver, and renal function lab results from 2024-08-14, there are no contraindications, and no dose adjustments are necessary.

(pertuzumab loading was missed)

701275896

240815

[lab data]

2024-08-09 Anti-HBc Nonreactive
2024-08-09 Anti-HBc Value 0.12 S/CO

2024-08-09 HBsAg Nonreactive
2024-08-09 HBsAg Value 0.74 S/CO

2024-08-09 Anti-HCV Nonreactive
2024-08-09 Anti-HCV Value 0.15 S/CO

2024-07-26 CA125 251.2 U/mL
2024-06-27 CA-125 (NM) 190.110 U/ml
2024-06-21 D-dimer 3206.00 ng/mL (FEU)
2023-10-25 ANA Centromere 1:1280

2023-10-23 Anti ENA (Ro,La) 2023-10-23 Anti-ENA SS-A (Ro) 24 EliA U/ml
2023-10-23 Anti-ENA SS-B (La) <0.3 EliA U/ml

2023-10-23 ANCA 2023-10-23 PR3 Negative IU/ml
2023-10-23 PR3 Value <0.6 IU/ml
2023-10-23 MPO Negative
2023-10-23 MPO Value 2.5 IU/ml

2021-09-13 ANA Centromere; Cytoplasmic; 1:640
2021-05-24 ANA Centromere; Cytoplasmic; 1:640

[exam findings]

• 2024-08-07 PET
  • Glucose hypermetabolism in lymph nodes in the left cervical region, bilateral SCF, right ICF, left mediastinal space, left axillary region, bilateral para-aortic spaces, pelvic cavity, left inguinal region, and left upper thigh region, highly suspected diffuse large B-cell lymphoma, suggesting biopsy (nodules in the left upper thigh region) for investigation.
    
  • A focal lesion of mild glucose hypermetabolism in the right inguinal region, probably s/p surgical reaction.
  • Glucose hypermetabolism in both lobes of the thyroid gland, the nature is to be determined (benign or even malignant tumor, or other nature ?), suggesting neck sonogram for investigation.
    
  • No focal or nodular lesion of significantly increased FDG uptake in the right inguinal region, highly suspected lymphoma involvement of lymph node regions on both sides of the diaphragm, by this F-18 FDG PET scan.
• 2024-07-26 SONO - gynecology
  • IMP: Bilateral inguinal mass noted, r/o inguinal lymph nodes.
• 2024-07-18 Patho - lymphnode biopsy
  • Lymph node, right groin, excision — metastatic adenocarcinoma
    • NOTE: Please check genital organ (ovary and uterus) for tumor origin first.
  • Microscopically, it shows adenocarcinoma composed of solid to glandular patterns with tumor necrosis and stromal fibrosis.
  • Immunohistochemical stains reveals PAX-8(+), CK7(+), TTF-1(-), CK20(-), GATA3(-).
• 2024-07-08 CT - abdomen
  • IMP:
    • Some LNs (up to 2.3cm) at retroperitoneum, pelvic cavity and bil. inguinal regions. Emphysema of bilateral lungs.
• 2024-06-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (90 - 19) / 90 = 78.89%
    • LVEF (%) = 79
    • M-mode (Teichholz) = 79
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Dilated LA; intermediate LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR.
• 2024-06-21 Sonography - vein
  • Findings
    • Report: Thrombus at L’t CFV
      
    • Varicose vein : None
      
  • Right side:
    • SVC: 11.7 mmHg ; 13.5 mmHg ;
    • MVO/SVC: 90 % ; 96 % ;
    • Average MVO/SVC: 93.00 %
  • Left side:
    • SVC: 12.8 mmHg ; 14.8 mmHg ;
    • MVO/SVC: 76 % ; 72 % ;
    • Average MVO/SVC: 74.00 %
  • Conclusion:
    • Partial venous thrombosis at left CFV with adequate proximal augementation and parital venous thrombosis at left proximal LSV at upper thigh level.
    • No evidence of venous thrombosis at other venis of left lower limb venous systems and right lower limb venous sytems.
    • The perforator vein draining from right distal SFV to LSV and from right middle PTV to LSV were detected.
    • No significant venous reflux at bilateral lower limbs venous systems.
    • The ratios of MVO and SVC of bilateral legs were within normal limits.
• 2023-10-17 Spirometry
  • Normal spirometry, without response to bronchodilator
  • Low TLC, low IC, no hyperinflation, but air-trapping
  • Impaired diffusion capacity and normal airway resistance
  • favor DPLD with small airway dysfunction
• 2023-10-17 Exercise pulmonary function test, ePFT
  • Parenchymal lung disease with rapid and prolong desaturation during walking (time to desaturation at 40s, time to SaO2 nadir at 165s), with slowly recovery after take resting 80s.
  • No evidence of obstructive airway or small airway dysfunction.
  • Compared with previous study at 2022.10.04, the present study showed disease in progression.
• 2023-10-09 CT - chest
  • Impression:
    • combined paraseptal emphysema/bullae and interstitial pneumonia (fibrotic NSIP or atypical UIP) associated small airways disease), stationary as compared with CT on 2022/9/19.
    • pumonary hypertension.
• 2022-10-04 Exercise pulmonary function test
  • ePFT showed late but prolonged desaturation after exercise at 113s, with SaO2 nadir at 235s, with delay recovery after resting 173s. No inspiratory or expiratory flow limiation. Favor parenchymal lung disease related.
• 2022-09-19 CT - chest
  • Impression:
    • combined paraseptal emphysema/bullae and interstitial pneumonia (fibrotic NSIP or atypical UIP) associated small airways disease), seem stationary as compared with previous CT on 2021/9/9. mild pulmonary hypertension.
• 2022-09-19 Bronchodilator Test, BDT
  • Bronchodilator
    • FVC: 2.27
    • FEVI: 1.89
    • BORG: 0
  • Result PC20: > 25 mg/ml (Reference Bronchodilator Norman Vaiue PC20 25 mg/ml)
  • Conclusion
    • Normal spirometry
    • MCT test with PC20 > 25
    • without significant response to bronchodilator
• 2021-09-09 CT - chest
  • Imp:
    • Interistial change at bilateral basal lungs is found. UIP is favored.
    • Paraseptal Emphysematous change over both lungs.
    • Calcified coronary arteries is found.
• 2021-06-16 Sialoscintigraphy
  • IMPRESSION:
    • Mildly to moderately impaired uptake function of bilateral parotid and submandibular glands.
    • The tracer excretion after acid stimulation is fair from both parotid glands and right submandibular gland, and mildly delayed from the left submandibular gland.
      
  • COMMENT:
    • Salivery gland uptake: normal > 0.25%, 0.2%–0.25% (mild), 0.15% - 0.2% (moderate), 0.1%-0.15% (marked), and <0.1% (severe).
• 2021-05-17 CT - chest
  • combined paraseptal emphysema/bullae and interstitial pneumonia (fibrotic NSIP? or atypical UIP?) associated small airways disease. please correlate with history, any autoimmune diease or connective tissue disorder.
• 2021-05-06 CXR
  • Tortousity of thoracic aorta, mild
• 2021-04-29 Bruce ECG
  • Resting ECG:
    • Incomplete RBBB
  • ST Segment Abnormalities:
    • No significant ST-T change during exercise and recovery phases.
  • Arrhythmia:
    • Isolated PACs from 5’‘R to 7’’R
  • Conclusion
    • Negative for myocardial ischemia
• 2021-04-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 41) / 102 = 59.80%
    • M-mode (Teichholz) = 59
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • LV diastolic dsyfunction, Gr 1
    • Preserved RV systolic function
• 2021-04-09 ECG
  • Normal sinus rhythm
  • Incomplete right bundle branch block
  • Borderline ECG

[MedRec]

• 2024-07-05 SOAP Hemato-Oncology Li QiCheng
  • S
    • 69 y female, PH: NP, non-smoking
    • left leg swelling for 1 more months
    • 2024-06-21: proved left leg DVT
    • PC/PS: WNL Amti-thrombin III: WNL, lupus Ab: (-)
    • CA 125: 190, D dimer: 3206
    • starting anti-coagulant: Rivaroxaban 15 mg QD
    • PE: Abd: MP
    • Plan: CXR and abdominal/pelvic CT
  • O
    • PE: left leg: DVT
    • Abd: NP
  • A/P
    • Deep venous thrombosis, left leg, cause?
    • 2024/06/27 CA-125 (NM) = 190.110 U/ml; cause?
• 2024-07-05 SOAP Cardiology Duan DeMin
  • S
    • 20240621 lef leg swelling and edema for a month
    • 20240705 BP: 90-100+/55-60+; HR: 70+ bpm; no discomfort; left leg swelling still;
  • Prescription x3
    • Xarelto (rivaroxaban 15mg) 1# QDCC 28D

==========

2024-08-15

[taxol and carboplatin treatment cleared by lab results]

The patient is scheduled for treatment with Taxol and Carboplatin. Based on the blood cell count, electrolytes, liver, and renal function lab results from 2024-08-14, there is no evidence of contraindications.

700366810

240814

[exam findings]

• 2024-07-12 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — No evidence of Hodgkin lymphoma involvement
  • The sections show normocellular marrow (40%). M/E ratio = 6:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. No lymphoid aggregates. Scattered small CD3+ T-cell and CD20+ B lymphocyte in interstitium. No Hodgkin/Reed-Sterburg cells can be identified in PAX5, CD30 and CD15 immunostins. There is no evidence of Hodgkin lymphoma with bone marrow involvement in the sections examined.
• 2024-07-12 Bronchodilator Test, BDT
  • Normal ventilatory function
  • Not significant bronchodilator reversibility
• 2024-07-11 MRI - pelvis
  • History and indication:
    • suspected Lymphoma
  • With and without contrast MRI of pelvis revealed:
    • Enlarged LNs (up to 3.9cm) at retroperitoneum (mainly along aorta and IVC), pelvic cavity and bil. inguinal regions with bil. psoas muscles invasion.
    • Mild liver cirrhosis with splenomegaly.
    • Enlargement of prostate.
• 2024-07-10 Tc-99m MDP bone scan with SPECT
  • Faint hot spots in both rib cages and increased activity in the sternum, some C-, T- and L-spine, and bilateral S-I joints, the nature is to be determined ( (lymphoma involving bone/bone marrow, anemia or other nature ?), suggesting biopsy (S-I joints) and follow-up with PET scan for further evaluation.
  • Suspected benign lesions at bilateral shoulders.
• 2024-07-09 PET
  • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm as mentioned above (at least stage III).
  • Increased FDG uptake in the left transverse process of T7 spine and mildly and diffusely increased FDG uptake in the bone marow of the skeleton. The nature is to be determined (lymphoma involving the bone/bone marrow? other nature?). Please correlate with other clinical findings for further evaluation.
• 2024-07-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 23) / 122 = 81.15%
    • M-mode (Teichholz) = 81
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR.
    • Dilated aortic root.
• 2024-07-08 Patho - lymphnode biopsy
  • Lymph node, intraabdominal, biopsy — lymphoma, in favor of classic Hodgkin lymphoma
  • Microscopically, it shows lymphoma composed of Reed-Sternberg-like cells containing large sized, bilobated to multilobated nucleus, prominent eosinophilic nucleolus, ample amphophilic cytoplasm. The background show mixed inflammatory infiltrate of lymphoplasmacytes and neutrophils.
  • Immunohistochemical stain reveals CD30(+ at R-S cells), CD15(+), CD10(+), cyclin D1(-), CD3(+ at T cells), CD20(+ at B cells).
  • ADDENDUM: IHC stain — EBER: negative
• 2024-07-05 CT - abdomen
  • history: early cirrhosis of liver with splenomegaly
  • Findings:
    • There are multiple enlarged lymph nodes in para-aortic space, para-cava space, bilateral common iliac chain, and bilateral external iliac chain.
      • Lymphoma is highly suspected.
      • The differential diagnosis includes metastatic nodes.
      • Please correlate with PET scan, AFP, CEA, PSA, and CA199.
    • Ill-defined lobulated poor enhancing lesions in left seminal vesicle are highly suspected. Please correlate with MRI.
    • The liver shows irregular contour and atrophy of segment 4 that is consistent with cirrhosis.
    • There is splenomegaly (the greatest cranial-caudal dimension: 14.6 cm).
    • Equivocal osteoblastic change of T8 and T9 vertebral body are suspected. Please correlate with bone scan.
• 2024-06-26 MRI - L-spine
  • Impression:
    • Degenerative spinal and disc disease.
    • Confluent lymphadenopathy at bilateral paraaortic region, suggest further malignancy workup.
• 2024-06-04 Nonenhanced ECG-gated CT for calcium scoring and enhanced spiral CT of heart and coronary arteries

[MedRec]

• 2024-07-06 ~ 2024-07-18 POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • Hodgkin lymphoma involving multiple lymph node regions on both sides of the diaphragm, left transverse process of T7 spine and FDG uptake in the bone marrow of the skeleton, stage IV, IPS:6, high risk
    • Carrier of viral hepatitis B
    • Unspecified cirrhosis of liver
    • Primary insomnia
    • Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation
    • Fever
    • Anemia
    • Constipation
  • CC
    • Low back pain that lasts for at least two months
  • Present illness
    • This 51-year-old man, with history of hypertension and CAD for 3 years, without regular control with Antihypertensives (drug: unknown).
      • Operation history of 1) right lower lung tumor s/p VATS on 2021/10/08; 2) Chronic sinusitis and snoring s/p left multiple sinusectomy and adenoidectomy on 2022/01/12; 3) OSAS s/p drug induced sleep endoscopy, uvulopalatopharyngoplasty and partial epiglottidectomy on 2022/04/01; 4) Radiofrequency-assistd uvulopalatoplasty, Coblation-assisted tongue base reduction on 2023/08/22.
    • According the describe, he suffered from lower back pain for two months (left buttock and posterior thigh pain, radiating to calf. Worsened by forward bending or prolonged sitting/standing. Relieved by bed rest), and chillness with low grade fever noted at the every evening recently, but he denied having weight loss.
    • He came to our neurosurgery OPD for help. L-spine MRI (6/26 24): Degenerative spinal and disc disease. Confluent lymphadenopathy at bilateral paraaortic region, suggest further malignancy workup. He was coming to Oncology OPD first, then he was transferred to ER for help.
    • Abdomen CT on 2024/07/05: 1. Lymphoma is highly suspected. 2. Ill-defined lobulated poor enhancing lesions in left seminal vesicle are highly suspected. 3. Equivocal osteoblastic change of T8 and T9 vertebral body are suspected. He is admitted for cancer survey due to suspect lyphoma, and pain control.
  • Course of inpatient treatment
    • After admission, fever was noted, Sintrix 1gm/vial 2000mg IVD QD for infection control from 2024/07/06~7/13.
    • Arranged malignancy workup: CT guide biopsy, Pelvis MRI, PET, Bone scan, 2D echo.
    • Pain control with Morphine 15mg/tab 1# PO Q8H, Morphine 10mg/mL/amp 5mg IVD PRNQ6H.
    • CT guide biopsy of retroperitoneal LNs was done on 2024/07/08, pathology showed Lymph node, intraabdominal, biopsy — lymphoma, in favor of classic Hodgkin lymphoma, Immunohistochemical stain reveals CD30(+ at R-S cells), CD15(+), CD10(+), cyclin D1(-), CD3(+ at T cells), CD20(+ at B cells).
    • PET on 2024/07/09 showed Compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm as mentioned above (at least stage III). Left transverse process of T7 spine and mildly and diffusely increased FDG uptake in the bone marow of the skeleton.
    • 2D echo on 2024/07/09 showed LVEF:81%, Mild MR; mild TR. Dilated aortic root.
    • Bone scan on 2024/07/10 showed faint hot spots in both rib cages and increased activity in the sternum, some C-, T- and L-spine, and bilateral S-I joints, Suspected benign lesions at bilateral shoulders.
    • Pelvis MRI on 2024/07/11 showed enlarged LNs (up to 3.9cm) at retroperitoneum (mainly along aorta and IVC), pelvic cavity and bil. inguinal regions with bil. psoas muscles invasion. Mild liver cirrhosis with splenomegaly.
    • Consult Reh for low back soreness, provide health education.
    • Consult GS for Port-A implantation, arrange on 2024/07/15.
    • Bone marrow was done on 2024/07/12, pathology showed no evidence of Hodgkin lymphoma involvement.
    • Arrange PFT for survey on 2024/07/15 showed normal ventilatory function, not significant bronchodilator reversibility.
    • Insomnia with Effexor XR 75mg/cap 1# PO HS, Eurodin 2mg/tab 1.5# PO HS and Mesyrel 50mg/tab 2# PO HS.
    • Gastric ulcer with Dexilant 60mg/cap 1# PO QD.
    • Consult GI for follow up, suggest EGD and abdominal echo for further evaluation.
    • Wait for pathology, add Vemlidy. Carrier of viral hepatitis B with Vemlidy 25 mg/tab 1# PO QD.
    • Constipation with Through 12mg/tab 2# PO HS, Dulcolax 5mg/enteric-coated tab 1# PO QN, MgO 250mg/tab 2# PO TID.
    • He received chemotherapy with BV-AVD (Adriamycin 25mg/m2, Vinblastine 6mg/m2, Dacarbazine 375mg/m2) on 2024/07/16~07/17(C1).
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2024/07/18 and OPD followed up later.
  • Discharge prescription
    • Dexilant (dexlansoprazole 60mg) 1# QD 5D
    • Dulcolax (bisacodyl 5mg) 1# QN 5D
    • Effexor XR (venlafaxine 75mg) 1# HS 5D
    • Eurodin (estazolam 2mg) 1.5# HS 5D
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID 5D
    • MgO 250mg 2# TID 5D
    • Mesyrel (trazodone 50mg) 2# HS 5D
    • Mosapin (mosapride citrate 5mg) 1# TID 5D
    • Through (sennoside 12mg) 2# HS 5D
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD 5D
    • Uretropic (furosemide 40mg) 1# BID 3D
    • morphine 15mg 1# Q8H 5D
    • morphine 15mg 1# PRNQ12H if VAS > 3 4D

[chemotherapy]

• 2024-07-27 - doxorubicin 25mg/m2 53mg NS 50mL 10min + vinblastine 6mg/m2 12.8mg NS 50mL 10min + dacarbazine 375mg/m2 800mg D5W 250mL 3hr (BV-AVD)
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-07-16 - doxorubicin 25mg/m2 53mg NS 50mL 10min + vinblastine 6mg/m2 12.8mg NS 50mL 10min + dacarbazine 375mg/m2 800mg D5W 250mL 3hr D2 (BV-AVD)
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-08-14

[proceeding with chemotherapy despite mild neutropenia and normocytic anemia]

Mild neutropenia and normocytic anemia were observed; however, since the ANC is > 1500/uL, this does not preclude proceeding with chemotherapy. Other lab results were generally normal, and no medication discrepancies were identified.

• 2024-08-13 WBC 3.03 x10^3/uL

• 2024-08-13 Neutrophil 61.3 %

• 2024-08-13 HGB 9.8 g/dL
  

• 2024-08-13 MCV 90.9 fL

701492366

240814

[exam findings]

• 2024-08-13 CXR supine
  • Multiple ndules of variable sizes in both lungs due to metastasis.
  • Elevation of both hemidiaphragms may be due to expiratory phase.
  • Normal heart size
  • Increased density and enlargement of Lt hilum
  • Port-A catheter inserted terminates in right atrium
• 2024-07-26 SONO - abdomen
  • Diagnosis:
    • Liver tumor, both lobe
    • Liver cysts, S5
    • Post cholecystectomy
    • Abdominal tumor, RLQ and LLQ
    • Suboptimal study of pancreas, masked by bowel gas
  • Suggestion:
    • Please correlate with other image study
    • Please correlate with AFP and LFT
• 2024-07-19 CT - abdomen
  • Findings:
    • There are multiple soft tissue masses in both lungs that are c/w lung metastases.
    • There is a lobulated mild hypodense mass in right lobe and S4 of the liver, 10 cm in size (the largest dimension) and another hypodense mass in S2-3 of the liver, 7 cm in size.
      • Please correlate with contrast enhanced dynamic CT or MRI.
    • There is a lobulated heterogeneous mass in between the midline pelvic wall muscle layer and the urinary bladder, 9 cm in size (the largest dimension).
    • There are three mass-like lesions at the RMQ, RLQ, and LLQ abdomen.
      • Please correlate with contrast enhanced dynamic CT.
    • There is mild left hydroureteronephrosis.
      • Please correlate with retrograde pyelography.
    • S/P right hemicolectomy? please correlate with clinical history.
      
    • The normal gallbladder is not identified in the gallbladder fossa.
      • please correlate with clinical history.

[MedRec]

• 2024-08-07 SOAP Hemato-Oncology He JingLiang
  • leiomyosarcoma s with lung mets s/p several chemotherapy and target therapy
  • he came for hospice care
• 2024-07-31 SOAP Gastroenterology Zheng KuenLin
  • For admission certificate (07/20-07/27)
  • He will continue further palliative treatment at NTUH.
  • pt no show
• 2024-07-20 ~ 2024-07-27 POMR Gastroenterology Zheng KuenLin
  • Discharge diagnosis
    • Leiomyosarcoma with multiple metastases, stage IV, status post operation and concomitant chemo-radio-therapy (at NTUH treatment)
    • Fever, cause to be determined
    • Anemia status post blood transfusion
    • Deep and complicated anal fistula with hemorrhoids status post fistulotomy and loose Seton placement with hemorrhoidectomy in our hospital on 113/03/20
  • CC
    • RLQ, LLQ abdominal pain and anal wound pain for days
  • Present illness
    • This is a 56 year-old male patient with past history of the following diagnoses, presents with intermittent low grade fever for 1 week.
      • leiomyosarcoma of abdomen, lung ; ongoing C/T in NTUH
      • anemia, unknown cause with frequent blood transfusion
      • anal fistula and hemorrhoids s/p fistulotomy with partial hemorrhoidectomy in our hospital on 2023/11/28
      • deep and complicated anal fistula with hemorrhoids s/p fistulotomy and loose Seton placement with hemorrhoidectomy in our hospital on 2024/03/20
    • The patient also suffered from RLQ, LLQ abdominal pain and anal wound pain. However, there were no sore throat, dyspnea, chest tightness, nausea, vomiting, or dysuria noted. He was then brought to our ER for help on 2024/07/19.
    • At our ER, body temperature showed 37.8’C. PE showed pale conjunctiva and local tenderness over RLQ, LLQ area. Left lower leg pitting edema 2+ was also noted. Lab showed normal value of WBC count (6530/uL) but elevated CRP level (10.7mg/dL). Hb showed 3.5g/dL. Other lab showed ALT: 8U/L and CRE: 0.63mg/dL. COVID-19 rapid test and Influenza A/B Ag were all negative.
    • CXR showed mass like lesion at left hilar region and nodular lesion at right lower lobe on 2024/07/19 while abdominal CT showed (1) multiple lung metastases, (2) two soft tissue masses in both hepatic lobes, (3) a lobulated heterogeneous mass in between the midline pelvic wall muscle layer and the urinary bladder, 9 cm in size (the largest dimension), and (4) three mass-like lesions at the RMQ, RLQ, and LLQ abdomen on the same day. Blood transfusion with LPRBC 4U was conducted. Blood culture was still pending, and Abx with Tapimycin 4.5g IVD Q6H was given.
    • Under the impression of intermittent low grade fever, the patient was admitted on 2024/07/20 for further evaluation and management.
  • Course of inpatient treatment
    • After admission, adequate IV fluid supplement and IV transamin were administered. Blood transfusion with LPRBC was administered for the correction of anemia. Pain control with Fentanyl, OxyNorm and Morphine PRN were prescribed.
    • We consulted hospice and patient wants to keep treatment at current ward, we will follow up under share care were suggested.
    • Oncologist was consulted and 1.Best supportive care, maintain Hb levels between 7-8. 2.Adequate pain control, PRN every 4 hours with painkyl as needed with follow-up oncology outpatient department were suggested.
    • Abdominal sonography was performed and revealed 1) Liver tumor, both lobe; 2) Liver cysts, S5; 3) Post cholecystectomy; 4) Abdominal tumor, RLQ and LLQ; 5) Suboptimal study of pancreas, masked by bowel gas. Blood culture didn’t yield any bacteria.
    • Under stable condition, he was discharged on 2024/07/27 and Oncology OPD follow-up would was arranged later.
  • Discharge prescription
    • OxyNorm (oxycodone 5mg) 1# QID 6D
    • Uretropic (furosemide 40mg) 0.5# QD 6D
    • Painkyl buccal soluble films (fentanyl 200ug) 1# PRNBID STICK 6D
• 2023-11-28 ~ 2023-11-29 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Anal fistula status post fistulotomy on 2023/11/28
    • Mixed hemorrhoid status post hemorrhoidectomy on 2023/11/28
    • Leiomyosarcoma of abdomen
  • CC
    • Anal pain, swelling and discharge for about 1 year, symptoms worsen developed recently.
  • Present illness
    • This 56-year-old male had history of
      • Leiomyosarcoma status post tumor excision, cholecystectomy about 2 years ago, under chemotherapy
    • This time, he sufferred from anal pain, swelling and discharge for about 1 year, symptoms worsen developed recently. Then he came to our OPD for help. At OPD, digital rectal examination showed left lateral fistula and abscess 5*5cm, posterior chronic anal fissure with anal stricture. After discussing with the patient, fistulotomy and partial hemorrhoidectomy was arranged. The surgical risks, such as post operative hemorrhage and wound infection were explained to the patient and he understood the risks. He was admitted after operation for post-op care and further management. 
  • Course of inpatient treatment
    • After admission, pre-op and anesthesia assessment was done. Fistulotomy and partial hemorrhoidectomy was performed smoothly on 2023/11/28. After operation, no specific complain except for mild wound pain. Wound was clean and no ozzing. Under relative stable condition, we arranged his discharge on 2023/11/29 and OPD follow up.     
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H 7D
    • Meitifen (diclofenac 75mg) 1# PRNQ12H 12D
    • Ulstop (famotidine 20mg) 1# PRNQ12H 12D
    • Biomycin Ointment (neomycin, tyrothricin) BID TOPI 7D

[surgical operation]

• 2023-11-28 - Op Method:    
  • Fistulotomy + Hemorrhoidectomy                
  • Finding:
    • Anal fistula at 3 o’clock
    • Mixed hemorrhoids

==========

2024-08-14

[review of pain management and symptom relief medications]

According to the PharmaCloud prescription records, this patient has primarily been treated at NTUH, with medications including fentanyl, oxycodone, naproxen, diphenhydramine, and hydrocortisone for pain management and symptom relief.

On 2024-08-13, the CRP was 12.4 mg/dL, and a urine exam showed bacteria 1+. The patient is currently using Soonmelt (amoxicillin, clavulanic acid) and morphine. No issues with the current medication regimen were identified.

701343649

240813

[lab data]

2024-03-30 Anti-HBc Nonreactive
2024-03-30 Anti-HBc Value 0.10 S/CO
2024-03-30 Anti-HBs 6.47 mIU/mL
2024-03-30 Anti-HCV Nonreactive
2024-03-30 Anti-HCV Value 0.08 S/CO
2024-03-30 HBsAg Nonreactive
2024-03-30 HBsAg Value 0.54 S/CO

[exam findings]

• 2024-08-12 Nasopharyngoscopy
  • Smooth nasopharynx, oropharynx and hypopharynx; left vocal palsy; bil. vocal cord edema; patent airway
• 2024-05-24 Tc-99m MDP bone scan
  • Increased activity in the lower L-spines and bilateral S-I joints. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2024-05-23 MRI - brain
  • Imaging finding:
    • Known a case of Sigmoid colon cancer with liver and lung metastases, pT4aN1bcM1a, stage IVA. At least two mass lesions (3.4cm and 2.7cm) over left frontal lobe, shwoing thin peripheral enhancement and central necrosis. Favor metastatic lesions.
    • The size of the cerebral ventricles is normal.
    • Peritumoral edema.
    • The intracranial vessels are normally signal-void.
    • The paranasal sinuses and mastoid air cells are aerated.
    • The globes, optic nerve and extraoccular muscles are sketchyily intact in the non-FatSat images.
  • Impression:
    • Known a case of Sigmoid colon cancer with liver and lung metastases, pT4aN1bcM1a, stage IVA. At least two mass lesions (3.4cm and 2.7cm) over left frontal lobe, shwoing thin peripheral enhancement and central necrosis. Favor metastatic lesions.
• 2024-05-22 CT - chest
  • without & with contrast enhancement, coronal and sagittal reconstructed images shows: comparisonL prior CT dated on 2024/02/17
    • massive Lt pleural effusion with parietal pleural thickening and loculation, in progression.
    • huge tumor lesion in left hemithorax involving hilum, adjacent mediastinum, numerous randomly distributed pulmonary nodules of varying sizes, and RUL-S3 tumor with atelectasis, in progression.
    • extensive metastatic LAP in the mediastinum.
    • Heart: normal size of cardiac chambers.
    • S/P LAR with autosuture retention and soft-tissue mass over the sigmoid colon. Lt adrenal tumor 20mm.
    • a small cystic mass at pancreatic tail with dilated P-duct and atrophic change in distal porion.
    • unremarkable of the liver, GB, spleen, Rt adrenal gland, and both kidneys. no enlarged lymph node.
  • Impression:
    • sigmoid colon cancer with lung, mediastinal LNs, pleural , and adrenal gland metastases, in progression as compared with the previous CT on 2024/02/17. local recurrent sigmoid tumor is noted.
• 2024-05-22 SONO - gynecology
  • EM:8.0mm
• 2024-03-20, -03-07 CXR erect
  • S/P port-A implantation.
  • There are few patchy and nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
    
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-02-23 MRI - brain
  • Findings
    • Two intra-axial enhancing tumors with necrotic change in left paramedial frontal lobes, about 39 mm and 37 mm at their largest dimensions, associating with extensive perifocal edema and causing midline shift to right side for 16 mm and left uncal herniation.
    • A small similar lesion, about 8 mm, in right anterior frontal lobe.
    • No intracranial hemorrhage, nor acute/subacute infarct.
    • No remarkable finding of skull base and bony structures.
  • IMP:
    • Multiple brain metastases with mass effect.
• 2024-02-17 CT - chest
  • S/p port-A placement with its tip at Superior vena cava.
  • Numerous nodular lesions over both lungs, compatible with metastases.
  • Huge mass lesions over left apical lung and lower lung. Invasion of the mediastinum by left apical lung lesion.
  • Collapse of right apical lung.
  • One nodular mass lesion over the pancreatic body. Suggest tissue proof.
• 2024-02-17 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • ST & T wave abnormality, consider inferolateral ischemia
  • Abnormal ECG
• 2023-05-18 CT - chest
  • Findings
    • Nodular lesion at left upper lobe measuring 3.59cm is found. Another nodule at left lower lobe is also found measuring 1.85cm. In comparison with CT dated on 2023-02-01, the lesions enlarged.
  • Imp
    • Recurrent/residual left lung meta, in progression.
• 2023-02-01 CT - chest
  • Findings: Comparison was made with previous CT dated on 2022/11/01
    • Lungs:
      • interval increase in size three solid nodules at left lung up to 18m at medial LUL as compared with CT on 2022/11/01
      • staple lines and coarse reticular fibrotic change at Rt lung and LLL due to post op change.
  • Impression:
    • left lung metastatic tumors, increase in size as compared with CT on 2022/11/01
• 2022-12-26 Patho - lung wedge biopsy
  • Lung, right, upper lobe, wedge resection —- Metastatic adenocarcinoma, moderately differentiated, consistent with colorectal origin
  • Lung, right, middle lobe, wedge resection —- Metastatic adenocarcinoma, moderately differentiated, consistent with colorectal origin
  • Lung, right, lower lobe, wedge resection —- Metastatic adenocarcinoma, moderately differentiated, consistent with colorectal origin
  • Lymph node, right, group No.7, lymphadenectomy —- Negative for malignancy (0/3)
  • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
  • Lymph node, right, group No.11, lymphadenectomy —- Negative for malignancy (0/5)
• 2022-11-01 CT - abdomen, pelvis
  • Colon cancer s/p operation.
  • S/P partial lung resection. Nodules (up to 7mm) at bil. lungs.
• 2022-05-04 CT - abdomen, pelvis
  • Post-operative change at LLL of the lung is suspected.
  • The differential diagnosis include residual metastasis.
• 2022-03-16 Patho - lung total/lobe/segmental
  • Pathologic Diagnosis
    • Lung, left, upper lobe, lingula, segmentectomy — Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
    • Lung, left, lower lobe, wedge resection — Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
  • Microscopic Description
    • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobe
    • Histologic Type (select all that apply): Adenocarcinoma
    • IHC stains reveal CDX2(+) and TTF-1(-)
    • The morphology and immunohistochemical stains are consistent with metastatic colonic tumor.
      
    • Histologic Grade: G2: Moderately differentiated
    • Visceral Pleura Invasion: PL1
    • Lymphovascular Invasion (select all that apply): present
• 2022-02-14 PET
  • Glucose hypermetabolism in the lower third of esophagus and soft tissue of RUQ of abdomen, probably s/p radiotherapy change.
    
  • Glucose hypermetabolism in the gastro-hepatic space, the nature is to be determined (metastatic lymph nodes or other nature?). Please correlate with other clinical findings for further evaluation.
    
  • Glucose hypermetabolism in the left upper and left lower lungs, compatible with cancer with lung metastases.
  • Increased FDG uptake in the uterus, probably physiological uptake of FDG or benign in nature. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    
  • S-colon cancer s/p treatment, ycTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2022-01-28 CT - abdomen, pelvis
  • Lung metastases S/P C/T show partial response.
  • Liver metastasis S/P C/T shows complete response.
• 2021-10-26 Abdominal Ultrasonography
  • Liver:
    • Suboptimal examination, the area near the diaphragm couldn’t be seen well. Smooth liver surface. No definite lesion could be seen.
  • Biliary system:
    • No gallbladder stone. No CBD dilatation.
• 2021-10-25 Patho - colon segmental resection for tumor
  • Pathologic Diagnosis
    • Tumor, sigmoid colon, laparoscopic AR — Adenocarcinoma
      
    • Bilateral cutting ends, ditto — Free from tumor
      
    • Lymph nodes, mesocolic, dissection — Tumor metastasis (3/17), with extracapsular extension (2/3)
      
    • AJCC pathologic stage — pT4aN1bcM1a, stage IVA
      
  • Microscopic Examination
    • Histology: Adenocarcinoma
      
    • Histology Grade: G2, moderately differentiated
      
    • Depth of invasion: visceral peritoneum
      
    • Angiolymphatic invasion: present
      
    • Perineural invasion: present
      
    • Circumferential (radial) margin of rectosigmoid: Involved
      
    • Lymph node metastasis, mesocolic: positive (3/17)
      
    • Extranodal involvement: present (2/3)
      
    • Pathological TNM Stage: pT4aN1bcM1b, stage IVB
      
    • Additional pathologic findings: focal tumor necrosis
      
  • Immunohistochemistry
    • CDX-2(+), MLH1(+), PMS2(+), MSH2(+) and MSH6(+) for tumor
  • Addendum
    • Admission and OP note recorded a case of sigmoid cancer with liver and lung metastasis (cT3N0M1) according to serial examinations in Fu Jen Catholic University Hospital, but after examination and team discussion in our hospital, no definite lesion was seen in liver, so clinical M stage is modified from M1b (stage IVB) to M1a (stage IVA)

[MedRec]

• 2024-03-05 Multidisciplinary Team Recommendations - Psycho-Oncology
  • Consultation Date: 2024-02-22
  • Consultation Reason:
    • Disease-related stress events:
      • Psychosocial stress reactions and emotional distress arising from physical illness or decisions regarding treatment options.
      • Emotional distress: Anxiety, fear, depression, anger, shyness, shock, and other emotions.
      • Social/interpersonal/communication difficulties: Conflicts or communication difficulties with family, colleagues, friends, healthcare providers, and other patients.
  • Conclusion:
    • S
      • Visit on 2024/02/27: The patient’s older sister and a male relative visited. The patient’s sister mentioned that the positioning for radiation therapy was finalized yesterday, and the first session could start today at the earliest. The patient responded that she does not have headaches, is doing okay, and is not undergoing chemotherapy yet. She also mentioned that she would sleep when she felt nauseous before. The patient’s sister expressed that if the patient could use a wheelchair, she would like to take a walk in the garden (visited both the 8th and 5th floors).
    • O
      • Medical history:
        • 2021-10 colon cancer with liver and lung metastases
        • Postoperative chemotherapy
        • Previous history of psychosocial support for chemotherapy-induced nausea
        • Lung tumor surgery in Mar and Dec 2021
        • No follow-up visits since May 2022 (due to anxiety)
        • Admitted on 2024/02/17 for dizziness and dyspnea; diagnosed with pneumonia and brain metastasis on 2024/02/23
        • Family meeting recommended radiation therapy and palliative care
        • Specialist consultation required to assess psychosocial needs
    • I
      • Assess the family’s expectations regarding care.
    • AP
      • The patient refused psychiatric medication at the time of diagnosis; they are highly self-disciplined and actively cooperate with treatment. The family remains positive about treatment and avoids discussing prognosis. The team should continue to provide support.
  • Psychologist: Huang XiaoFang
  • Responder: Huang Xiaofang
  • Response Date: 2024-03-04 17:56
  • Physician Response:
    • 2024/03/05 08:57 Xia HeXiong: Acknowledged. Will follow the recommendations.
• 2024-02-23 Progress Note - Family Meeting Record
  • Main Issue:
    • Physiological - Sigmoid colon cancer with lung and liver metastases, disease progressing.
  • Meeting Purpose:
    • Discuss stage IV sigmoid colon cancer, with lung metastasis recurrence discovered on 2023-02-01 after lung surgery, lung tumor enlargement observed on 2023-05-18 CT scan, and right lung collapse indicated on 2024-02-17 CT scan.
  • Discussion:
    • Explained to the patient’s father, mother, sister, and younger sister that post-admission on 2024-02-17, a bronchoscopy was arranged, but both lungs were invaded, making it impossible to clear the obstructions. Showed the family CT scans from the start of treatment in 2021 to present. No follow-ups since the last visit to the hemato-oncology department on 2023-05-10, after the 2023-05-18 CT scan. Brain MRI on 2024-02-23 showed multiple brain metastases, indicating the disease is nearly unmanageable, posing an immediate risk to the patient’s life. Consulted on 2024-02-23 for urgent radiation therapy intervention by the oncology department, followed by chemotherapy. The family understood and accepted, agreeing to hospice combined care. The patient expressed a wish against resuscitation, leading to the signing of an advance directive for hospice palliative care and life-sustaining treatment choices.
• 2024-02-23 Multi-Team Recommendation - Hospice Care
  • Date of Consultation: 2024-02-22
  • Response Content:
    • During Dr. Xia from Family Medicine’s visit, the patient appeared weak. The patient’s father expressed a desire for aggressive treatment and declined the hospice team’s involvement.
  • Conclusion and Recommendation:
    • The patient’s father refused collaborative hospice care.
  • Responder: Chen Hui
  • Response Date: 2024-02-22 17:05
  • Doctor’s Response:
    • 2024/02/23 08:43 Xia HeXiong replied: Acknowledged

[consultation]

• 2024-02-23 Radiation Oncology
  • Q
    • for Brain meta, arrange R/T !
  • A
    • This 35 year-old woman due to S-colon ca with lung and liver metastasis, s/p LAR, palliative C/T, and lung mets resection. She suffered from limbs weakness recently. Brain MRI today showed multiple mets.
    • Palliative RT is indicated. CT-simulation will be arranged on 2/26. Plan to deliver 18 Gy/ 6 fx to the whole brain. Then boost the gross brain mets tumors to 36 Gy/ 12 fx. RT will start around 2/27.
• 2024-02-22 Family Medicine
  • A
    • This is a 35 y/o female has history of S-colon cander with lung and liver metastasis.
    • Cons: E4V5M6. ECOG4, DNR (-).
    • Hospice team explained hospice care, but they do not agree with it, even when it’s shared care.
  • A 2024-02-23 17:16:06
    • We will arrange hospice combined care.
    • Indication: colon cancer
    • Plan: Hospice Combined Care

[surgical operation]

• 2022-03-16
  • Surgery
    • VATS, lingular segementectomy + LLL wedge resections + RLND
  • Finding
    • Metastatic nodule about 1.2cm in diameter, at lingula segement and LLL x2 s/p lingula segmentectomy + LLL wedge resections x 2
    • No malignant pleural effusion noted
    • Lymph nodes dissection over para-aortic, AP window, hilar and interlobar.
• 2021-10-22
  • Surgery
    • Laparoscopic LAR        
  • Finding
    • Tumor at sigmoid colon cancer with liver, lung metastasis and obstruction, cT4N0M1b
    • Anastomosis is done

[immunochemotherapy]

• 2024-08-12 - oxaliplatin 65mg/m2 82mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + lorazapam 1mg Q12H D1-3 + NS 250mL D1-3
• 2024-07-24 - oxaliplatin 65mg/m2 82mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + lorazapam 1mg Q12H D1-3 + NS 250mL D1-3
• 2024-07-06 - oxaliplatin 65mg/m2 82mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + lorazapam 1mg Q12H D1-3 + NS 250mL D1-3
• 2024-06-07 - oxaliplatin 65mg/m2 82mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + lorazapam 1mg Q12H D1-3 + NS 250mL D1-3
• 2024-05-24 - oxaliplatin 65mg/m2 82mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + lorazapam 1mg Q12H D1-3 + NS 250mL D1-3
• 2024-04-30 - ………………………………… irinotecan 100mg/m2 120mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2000mg/m2 2500mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + lorazepam 1mg Q12H D1-3 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
• 2024-04-12 - bevacizumab 5mg/kg 100mg NS 70mL 90min + irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + lorazepam 1mg Q12H D1-3 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
• 2024-03-29 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 60mg/m2 75mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + lorazepam 1mg Q12H D1-3 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
• 2024-03-15 - bevacizumab 5mg/kg 200mg NS 100mL 90min ………………………………….. + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg ………………. + palonosetron 250ug + lorazepam 1mg ……… + aprepitant 125mg PO D1-3 + NS 250mL D1
• 2023-01-10 - FOLFIRI + bevacizumab
• 2021-12-15 ~ 2022-07-06 - FOLFIRI + bevacizumab
• 2021-11-09 ~ 2021-12-03 - FOLFIRI

==========

2024-08-13

[managing hypomagnesemia, weight loss, and anemia]

Hypomagnesemia (Mg 1.6 mg/dL on 2024-08-12) is currently being treated with injectable MgSO4.

The patient’s body weight decreased from 37.9 kg on 2024-04-12 to 31 kg on 2024-08-12, a nearly 20% loss in 4 months. Megest (megestrol) has been added, but if weight loss continues, additional nutritional interventions may be necessary.

Lab results from 2024-08-12 also showed HGB 10.0 g/dL and MCV 79.5 fL, indicating microcytic anemia, suggesting that some iron supplementation could be beneficial.

2024-07-26

[effectiveness of FOLFOX regimen under scrutiny]

The treatment regimen was shifted from FOLFIRI to FOLFOX following CT and MRI scans in late May that showed disease progression. No new CT or MRI scans have been conducted since then. However, both CEA and CA199 levels have shown a significant upward trend, suggesting that the new regimen may be less effective than expected.

• 2024-07-16 CEA 38.49 ng/mL

• 2024-06-04 CEA 18.95 ng/mL

• 2024-05-22 CEA 20.73 ng/mL

• 2024-04-25 CEA 14.20 ng/mL

• 2024-07-16 CA199 294.03 U/mL

• 2024-06-04 CA199 201.21 U/mL

• 2024-05-22 CA199 183.95 U/mL

• 2024-04-25 CA199 129.01 U/mL

2024-04-01

[elevated tumor markers amidst normal lab results; Avastin + FOLFIRI administration deemed appropriate]

With the exception of elevated tumor markers CEA at 27 ng/mL and CA199 at 224 U/mL, lab results from 2024-03-27 were largely within normal parameters. Given these findings, the administration of Avastin + FOLFIRI on 2024-03-29 appears to be medically appropriate without contraindications based on the lab data. Additionally, a review of the medication records revealed no discrepancies.

2022-06-21

• On the basis of the lab results reported on 2022-06-14, the patient is expected to be able to tolerate the current regimen as in the past.
• The TPR, BP, and SpO2 have remained stable since being hospitalized.

2022-06-02

• This patient was diagnosed with sigmoid cancer with lung mets following surgical operations on the colon (2021-10-22) and lung (2022-03-16). He is currently receiving Folfiri since 2021-11-09 (plus bevacizumab since 2021-12-15).
• CT on 2022-01-28 showed a partial response to lung mets, however, CT on 2022-05-04 showed possibly residual lung mets.
• The results of lab tests on 2022-05-26 indicated that liver and kidney function, electrolytes, and blood cell counts were grossly normal, which were considered acceptable to receive the regimen.
• No issue with active prescription.

2022-05-17

• This patient was diagnosed with sigmoid cancer with lung mets s/p surgical operations on the colon (on 2021-10-22) and lung (on 2022-03-16) and has been receiving FOLFIRI since 2021-11-09 (plus bevacizumab since 2021-12-15).
• CT on 2022-01-28 showed a partial response to lung mets, however CT on 2022-05-04 revealed a possible residural metastasis in the lungs.
• Lab data on 2022-05-10 showed that liver and kidney function, electrolytes, CBC and biomarkers were generally normal.
• No issue with active prescription.

700379772

240812

[MedRec]

• 2024-02-22 ~ 2024-02-27 POMR Thoracic Surgery Xie MinXiao
  • Discharge diagnosis
    • Esophageal cancer, middle esophagus, cT4N2M0, stage IVA
    • Essential (primary) hypertension
    • Type 2 diabetes mellitus without complications
  • CC
    • Progressive difficult swallowing with intermittent vomiting for about 3 months.
  • Present illness
    • A 66-year-old male with a past medical history of hypertension, diabetes mellitus, left putaminal hemorrhage with right side hemiparesis in 2019-02, esophageal varices, peptic ulcer, alcoholic liver cirrhosis, liver abscess, gall stones, renal stones, hypertrophy of prostate and paralysis of unilateral vocal cords and larynx regular follow up on our GI, ENT OPD. His surgical history were anal fistula s/p surgery at ShuangHe Hospital about 10 years ago and liver abscess s/p laparoscopic drainage on 2005-10-14.
    • According to his and his son statement, he felt progressive dysphagia for about 3 months. He couldn’t take solid food a month ago with symptoms of nausea and vomiting, thus aspiration occurred and he admitted to pulmological ward on 2024-01-30. During last admisson, Esophagogastroduodenoscopy found a 5cm fungating lesion at lower esophagus and pathology was Squamous Cell Carcinoma. The chest CT staging was cT3N2M0 on 2024-02-06.
    • The times, he took liquid diet for a month and body weight lost 10kg in a month was noticed, there was vomitng sometimes. He was admitted for esophageal cancer staging and further management.
  • Course of inpatient treatment
    • After admission, a series of esophageal cancer staging was arranged, whole body PET scan on 2/23, Brain MRI on 2/24, EUS and bronchoscopy on 2/26 and whole body bone scan on 2/27. after complete of these studies, according to bronchoscopy found tracheal lesion which suspected tumor invasion and chest CT, his clinical stage was cT4N2M0 stage IVA. He could only take liquid diet. During admission, no vomitting occurred under liquit diet. Because of completing of cancer staging studies, he was discharged and arranged next admission for port-a and jejunostomy next week.
• 2024-01-30 ~ 2024-02-07 POMR Integrative Medicine Rao LunYu
  • Discharge diagnosis
    • Bronchopneumonia (mixed normal flora)
    • Malignant neoplasm of lower third of esophagus (squamous cell carcinoma )
    • Dysphagia
    • Essential (primary) hypertension
    • Type 2 diabetes mellitus without complications
    • Hyperlipidemia, unspecified
  • CC
    • Vomit with sputum and food content after drink or eat since 2024/01/22.
  • Present illness
    • A 65-year-old male with a past medical history of hypertension, diabetes mellitus, old cerebrovascular accident with right side hemiparesis, esophageal varices, peptic ulcer, alcoholic liver cirrhosis, liver abscess, gall stones, renal stones, hypertrophy of prostate and paralysis of unilateral vocal cords and larynx regular follow up on our GI, ENT OPD.
    • The patient reported nausea and vomiting persisting for five days, along with an aspiration episode four days ago and Fever was noticed, accompanied by cough with sputum, rhinorrhea. The patient was cames our ED for help on 2024/01/22, CXR showed Bochopneumonia. refused admission with take Oral antibiotic Cravit back home. However, symptoms worsened in the last 2-3 days, experiencing vomiting with sputum and food content after eating or drinking, he brought to our ED for help on 2024/01/29. Umremarkable TOCC.
    • At ED, the vital sign showed Blood Pressure: 107/55; Pulse: 66 beats per minute; Body Temperature: 36.9’C; Respiratory Rate: 18 breaths per minute, the laboratory data showed leukocytosis (WBC 13.00 x10^3/uL), elevation of CRP 6.6mg/dl, hypoglycemia (Glu 60mg/dl), hypokalemia (K 3.1mmol/L), and abnormal Renal function (Cre 1.97, BUN 17), the CXR showed bilateral pneumonia, the kub revelaed Non-specific small bowel and colon gas pattern. The physical examination showed rales breathing sound.he was admittion to our ward for further management.
  • Course of inpatient treatment
    • After admission, empirical antibiotic with Curam since 2024/01/30 to control the infection. We recommended placement of a nasogastric tube, but the patient refused.
    • Collect blood cultures and await culture results. We recommend that due to a history of unilateral vocal cord and laryngeal paralysis, consult an otolaryngology department and respond to right vocal cord paralysis and continue recovery. If suffocation persists, consider NG insertion.
    • The rehabilitation department was also consulted and they arranged a bedside ST (swallowing) rehabilitation program.
    • Esophagogastroduodenoscopy (EGD) dysphagia investigation was performed on 2024-02-01, and post-biopsy and pathology result showed squamous cell carcinoma, moderately differentiated. The CS was consulted and he will arrange admission on 2024-02-18 for cancer evaluation and thrapy.
    • No fever and smooth respiration, check laboratory data showed normal WBC and CRP level, and CXR was improved of lung infiltration on 2024-02-05. Antibiotic was discontinue on 2024-02-06 for complete treatment. He can be discharged on 2024-02-07.
  • Discharge prescription
    • Norvasc (amlodipine 5mg) 1# QD

[consultation]

• 2024-03-19 Rehabilitation

• 2024-03-15 Nephrology

  • Q
    • for hyperammonemia, acidosis and AKI
    • A 65-year-old male with a past medical history of hypertension, diabetes mellitus, old cerebrovascular accident with right side hemiparesis, esophageal varices, peptic ulcer, alcoholic liver cirrhosis, liver abscess, gall stones, renal stones, hypertrophy of prostate and paralysis of unilateral vocal cords and larynx regular follow up on our GI, ENT OPD. He was discharged on 2024/02/07 under the diagnosis of esophageal squamous cell carcinoma. He reported nausea and vomiting persisting during last admission, along with an aspiration episode four days ago and fever was noticed, accompanied by cough with sputum, rhinorrhea.
    • Esophagogastroduodenoscopy dysphagia investigation was performed on 2024-02-01, and post-biopsy and pathology result showed Squamous cell carcinoma, moderately differentiated. Clinical staging has been done last month and reported cT4N2M0 stage IVA. For jejunostomy and portA insertion, he was admitted to our ward. After admission, port-A was inserted and jejunostomy was performed. After operation, we kept NPO for 1 day with TPN given. Then we tried feeding from jejunostomy and it was smooth. For his esophageal malignancy, we consulted oncologist and he suggested follow up serum data for chemotherapy.
    • He was transferred to oncology ward for chemotherapy on 2024/03/07. After oncology ward, Neoadjuvant CCRT is indicated. CT-simulation was arranged on 2024/03/06. Plan to deliver 45 Gy/ 25 fx to the whole esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumors and LAPs to 50.4 Gy/ 28 fx. RT was start since 2024/03/07~. Chemotherapy with C1 PF4 on 2024/03/08~2024/03/12.
      
  • A
    • We visited the patient at the bedside and evaluated his condition. His consciousness was poor, unresponsive to sound and his eyes were merely staring off into the distance. He showed no signs of respiratory distress and all four of his limbs were not edematous. According to his family members, his consciousness deteriorated rapidly and had diarrhea since undergoing chemotherapy on 2024/03/13.
    • Lab
      • 2024-03-15 Procalcitonin (PCT) 3.73 ng/mL
        
      • 2024-03-15 Blood ammonia 116 umol/L
        
      • 2024-03-15 BUN 125 mg/dL
        
      • 2024-03-15 Creatinine 3.93 mg/dL
        
      • 2023-07-04 Creatinine 1.54 mg/dL
        
    • Our impressions are as follows:
      • Acute kidney injury (stage 2) due to dehydration and Cisplatin nephrotoxicity
      • Chronic kidney disease (stage 3)
      • Altered state of consciousness due to hepatic/uremic encephalopathy and ongoing sepsis
    • Our advices are as follows:
      • Record daily I/O and BW
      • Discontinue Exforge (contains ARB) and avoid all nephrotoxic agents until AKI resolves
      • Arrange renal sonogram for assessment of chronic kidney changes and to rule out post renal obstructions
      • Check stool OB to rule out possible GI bleeding
      • Administer adequate IV fluid hydration 500-1000mL/day, but be wary of fluid overload
    • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance.

• 2024-03-14

• 2024-03-05

• 2024-03-04

• 2024-02-22

• 2024-02-07 Thoracic Surgery

  • Q
    • Esophagus cancer, SCC
    • This 65 years old man had a history with DM, hypertension, Liver cirrhosis
    • admission due to vomit and pneumonia
    • vocal paresis by ENT impression, we arranged PES and R/I cancer s/p Biopsy,
    • the pathology report showed:
      • Esophagus, lower, 30 cm to 35 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
      • Section shows pieces of squamous mucosa with infiltration of nests of neoplastic squamous cells.
      • The immunohistochemical stains reveal CK5/6(+) and p40(+).
    • so we need your consult for evaluation and suggest, thank a lot.
  • A
    • Please arrange staging and arrange next admission on my service.

• 2024-01-31 Rehabilitation

  • Q: swallowing training.
  • A
    • Assessment
      • Dysphagia
      • Aspiration pneumonia
    • Plan
      • Rehabilitation programs: arrange bedside ST (swallowing) rehabilitation programs.
      • Goal: improve swallowing ability.
      • Suggest tracking the food and water intake for 2-3 days. If there are issues with inadequate food or water intake or frequent choking, NG tube insertion is suggested.
      • Caregiver and the patient were educated about oral hygiene and safe eating for the patient, including proper positioning (must be seated upright), consuming small amounts at a time, ensuring no wet voice before taking the next bite, and verifying patient’s wakefulness during meals, not in a drowsy state.

• 2024-01-30 Ear Nose Throat

  • Q
    • paralysis of unilateral vocal cords .
    • this is 65 years-old men, he has a history of vocal palsy, DM , HTN, Liver chirrosis, BPH. he was brought to our ED for help. At ED, the laboratory showed leukocytosis, and elevation of CRP, the CXR revealed pneumonia. he was admission due to aspiration pneumonia treamtment.
    • this time, due to history of Dysphagia for 3 months and paralysis of unilateral vocal cords and larynx diagnosed by ENT, and patient suffered difficult to swallowing, we need your consulted and suggestion for paralysis of unilateral vocal cords and the patient expresses a desire to be cared for by ENT instead.
  • A
    • S:
      • easily choking for months
      • admission due to aspiration pneumonia
      • we’re consulted for right vocal palsy
      • sore throat-, odynophagia-
      • History of stroke (right side weakness at that time)
      • history of hypertension, diabetes mellitus, old cerebrovascular accident with right side hemiparesis, esophageal varices, peptic ulcer, alcoholic liver cirrhosis, liver abscess, gall stones, renal stones, hypertrophy of prostate
    • O:
      • Scope: smooth NPx, oropharynx, hypopharynx
      • right vocal palsy, adequate upper airway currently
      • not much saliva pooling, clear pyriform sinus
      • complete white out when swallowing, but delayed swallowing movement
      • sono in 2023-09: no mass compression
    • A:
      • right vocal palsy
    • Plan:
      • dysphagia and chocking not only resulted from right vocal palsy
      • well explained about airway isuue, including the risk of bil. vocal palsy and the possibility of intubation/tracheostomy, if dyspnea, stridor, back to hospital soon
      • keep rehabilitation
      • if still choking, consider NG insertion
      • keep ENT OPD f/u

[chemotherapy]

• 2024-06-12 - cisplatin 75mg/m2 60mg NS 500mL 24hr + MgSO4 10% 20mL NS 250mL 1hr + furosemide 20mg 10min + fluorouracil 800mg/m2 1250mg NS 500mL D1 (Y-sited CDDP D1) (PF CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-09 - cisplatin 75mg/m2 60mg NS 500mL 24hr + MgSO4 10% 20mL NS 250mL 1hr + furosemide 20mg 10min + fluorouracil 800mg/m2 1250mg NS 500mL D1-3 (Y-sited CDDP D1) (PF CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-08 - cisplatin 75mg/m2 90mg NS 500mL 24hr + MgSO4 10% 20mL NS 250mL 1hr + furosemide 20mg 10min + fluorouracil 1000mg/m2 1250mg NS 500mL D1-5 (Y-sited CDDP D1) (PF CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-08-12

[PLT count stabilized after LRP transfusion]

After transfusion of 2 units of LRP, the platelet count has risen to nearly 100K/uL, significantly reducing the immediate risk of severe bleeding.

• 2024-08-12 PLT 92 *10^3/uL
• 2024-08-09 PLT 36 *10^3/uL

2024-06-13

The elevated bilirubin levels are trending closer to the normal range. A CT-guided biopsy of the right lung mass is scheduled for tomorrow 2024-06-14. No medication-related issues have been identified at this time.

• 2024-06-12 Bilirubin total 1.26 mg/dL

• 2024-05-24 Bilirubin total 1.48 mg/dL

• 2024-05-06 Bilirubin total 1.84 mg/dL

• 2024-04-18 Bilirubin total 2.46 mg/dL

• 2024-06-12 Bilirubin direct 0.43 mg/dL

• 2024-05-24 Bilirubin direct 0.48 mg/dL

• 2024-05-06 Bilirubin direct 0.59 mg/dL

• 2024-04-18 Bilirubin direct 0.72 mg/dL

2024-03-15

[cisplatin & AKI: slow rise in creatinine after 5-7 Days, urinary concentration defect]

Acute kidney injury (AKI) from cisplatin exposure typically manifests with a slow rise in serum creatinine after five to seven days of therapy. The timing of AKI may be earlier (within three to five days of therapy) in patients with comorbid risk factors, such as preexisting chronic kidney disease (CKD), older age, hypoalbuminemia, or concomitant nephrotoxic drugs.

• 2024-03-15 Creatinine 3.93 mg/dL
  

• 2024-03-14 Creatinine 2.65 mg/dL
  

• 2024-03-11 Creatinine 0.99 mg/dL
  

• 2024-03-08 Creatinine 0.87 mg/dL
  

• 2024-03-06 Creatinine 0.83 mg/dL

• 2024-03-15 eGFR 16.43 ml/min/1.73m^2
  

• 2024-03-14 eGFR 25.89 ml/min/1.73m^2
  

• 2024-03-11 eGFR 80.64 ml/min/1.73m^2
  

• 2024-03-08 eGFR 93.60 ml/min/1.73m^2
  

• 2024-03-06 eGFR 98.83 ml/min/1.73m^2

• 2024-03-15 BUN 125 mg/dL
  

• 2024-03-14 BUN 89 mg/dL
  

• 2024-03-11 BUN 36 mg/dL
  

• 2024-03-08 BUN 21 mg/dL

Most patients will experience a mild to moderate increase in serum creatinine (ie, 1.5 to 2.9 times baseline), while some may progress to more severe AKI (serum creatinine > 3 times baseline) or require kidney replacement therapy. Severe AKI is uncommon in the absence of preexisting CKD and/or other comorbid risk factors.

Unless the kidney injury is severe, the urine output in patients with cisplatin nephrotoxicity typically remains above 1000 mL per day due to the induction of a concentrating defect. This defect may reflect platinum-induced damage to the loop of Henle, where the countercurrent gradient required for urinary concentration is established, or to the collecting tubules, the site of action of antidiuretic hormone.

[sepsis concern: left shift, elevated markers & BUN/Cr, AKI]

Lab findings consistent with sepsis include left-shifted WBC DC, elevated PCT and CRP, and elevated BUN/Creatinine (>31).

• 2024-03-15 Band 11.5 %
  

• 2024-03-15 Neutrophil 56.7 %
  

• 2024-03-15 Lymphocyte 12.5 %
  

• 2024-03-15 Metamyelocyte 8.7 %
  

• 2024-03-15 Myelocyte 1.9 %

• 2024-03-15 CRP 13.6 mg/dL
  

• 2024-03-15 Procalcitonin (PCT) 3.73 ng/mL

This presentation raises concern for sepsis-associated AKI with possible vasodilation.

2024-03-14

[loperamide treatment for 5-FU-induced diarrhea]

Treatment with CDDP and 5-FU was initiated on 2024-03-08. It is subsequently reported diarrhea. While the TPR panel recorded bowel movements of 0 to 2 times per day between 2024-03-07 to 2024-03-13, a progress note documented > 10 bowel movements on 2024-03-13.

UpToDate Drug Information indicates that cisplatin is associated with a less than 1% incidence of diarrhea, whereas fluorouracil is known to cause severe diarrhea. Based on this information, it is more likely that fluorouracil is the primary cause of the diarrhea.

Loperamide has been initiated as the appropriate treatment for this type of diarrhea.

700824591

240812

[exam findings]

• 2024-06-04, -05-23, -05-09 KUB
  • S/P Percutaneous nephrostomy of right and left kidney
  • Spondylosis with scoliosis of the L-spine with convex to left side.
  • Fecal material store in the colon.
  • Ascites is highly suspected. Please correlate with sonography.
  • S/P total hip arthroplasty, right and left hip
  • S/P Foley’s catheter insertion
• 2024-05-10 ECG
  • Sinus rhythm with Premature atrial complexes
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2024-04-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (54.4 - 14.8) / 54.4 = 72.79%
    • M-mode (Teichholz) = 82
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with trivial MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • No PR, no TR, normal IVC size
• 2024-04-03 PET
  • Glucose hypermetabolic lesions in bilateral axillary regions, in the spleen, and in soft tissue of abdomen and plevis, highly suspected lymphnoma with involvement of lymph node regions.
    
  • Increased FDG uptake in the left iliac bone and left ischium, compatible with lymphoma with involvement of bone marrow.
  • Diffuse large B-cell lymphoma, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2024-04-02 CXR
  • S/P Port-A infusion catheter insertion.
  • S/P bil. pig-tail catheters indwelling.
  • Bilateral pleural effusion.
  • Ground glass opacities in bil. lungs.
• 2024-04-01 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — positive for diffuse large B cell lymphoma
    
  • Microscopically, the bone marrow shows presence of diffuse large B cell lymphoma.
    
  • Immunohisotchemical stain reveals CD34 (-), CD20 (diffuse+), CD138 (focal+,1~2%), MPO (focal+), CD71 (focal+), CD117 (-).
• 2024-03-26 Patho - peritoneum biopsy
  • PATHOLOGIC DIAGNOSIS
    • Tissue, retroperitoneum, CT guide biopsy — Diffuse large B-cell lymphoma, non-GCB
  • MACROSCOPIC DESCRIPTION
    • Operation procedure: CT guide biopsy
    • Topology: retroperitoneum
      
    • Specimen size and number: several pieces, ≤ 0.1 cm
  • MICROSCOPIC EXAMINATION
    • Histology type: B-cell neoplasms - Diffuse large B-cell lymphoma
    • Immunohistochemical stain profiles: CD20(diffuse +), CD3(+ at background T cells), PAX-8(+), CK(-), CK20(-), CK7(-), p53:wild-type, WT-1(-), CD56(-), vimentin(+), Ki-67 index: 80%, MUM1(+), c-myc: negative (＜ 40%), CD10(-), Bcl-6(+), Bcl-2(+), cyclin D1(-)
• 2024-03-26 CT - abdomen
  • History and indication: Intra-abdominal mass, cause? wating for tissue proof
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Extensive enlarged LAP at retroperitoneum and pelvic cavity with vascular encasement.
    • Some poor enhancing nodules (up to 4.3cm) in liver and spleen.
    • Bil. pleural effusion with adjacent lung collapse.
    • S/P bil. PCN.
    • Large amount ascites. General subcutaneous edema.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P bilateral THR without evidenced prothesis loosening. S/P foley catheter indwelling.
  • IMP:
    • Extensive enlarged LAP at retroperitoneum and pelvic cavity with vascular encasement r/o lymphoma.
    • Some poor enhancing nodules (up to 4.3cm) in liver and spleen r/o metastases.
    • Bil. pleural effusion with adjacent lung collapse.
    • S/P bil. PCN.
    • Large amount ascites. General subcutaneous edema.
• 2024-03-22 Vein Sonography
  • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
    • Spontaneous signal:
      • Right:
        • CFV: N
        • SFV: N
        • PV: N
        • PTV: N
        • SV: N
      • Left:
        • CFV: N
        • SFV: N
        • PV: N
        • PTV: N
        • SV: N
    • Respiratory changes:
      • Right:
        • CFV: N
        • SFV: N
        • PV: N
        • PTV: N
        • SV: N
      • Left:
        • CFV: N
        • SFV: N
        • PV: N
        • PTV: N
        • SV: N
    • Cough response:
      • Right:
        • CFV: N
        • SFV: N
        • PV: N
        • PTV: N
        • SV: N
      • Left:
        • CFV: N
        • SFV: N
        • PV: N
        • PTV: N
        • SV: N
    • Compression study:
      • Right:
        • CFV: N
        • SFV: N
        • PV: N
        • PTV: N
        • SV: N
      • Left:
        • CFV: N
        • SFV: N
        • PV: N
        • PTV: N
        • SV: N
    • Report: Thrombus : None
      • Right side:
        • SVC: 7.8 mmHg ; 6.0 mmHg ;
        • MVO/SVC: 77 % ; 88 % ;
        • Average MVO/SVC: 82 %
      • Left side:
        • SVC: 10.0 mmHg ; 10.8 mmHg ;
        • MVO/SVC: 69 % ; 73 % ;
        • Average MVO/SVC: 71 %
  • Conclusion:
    • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
    • Bilateral long saphneous vein mild engorgement
    • Bilateral posterior tibial vein engorged, with perforator veins connecting PTVs to superficial veins
• 2024-03-08 Patho - stomach biopsy
  • Stomach, body, biopsy — Hyperplastic polyp. H pylori present.
• 2024-03-07 CT - abdomen
  • Without contrast enhancement CT of abdomen shows:
    • Infiltrating retroperitoneal mass.
    • Bilateral hydronephroureter due to uteral obstruction.
    • Suspect a mass lesion, 3.2cm, spleen. A cystic lesion in perigastric region.
    • Small amount of ascites in pelvis.
  • Impression
    • Retroperitoneal mass; DDx: lymphoma, retroperitoneal fibrosis
    • Bilateral hydronephroureter
• 2024-03-07 Pelvis - THR:
  • s/p bilateral total hip replacements
  • Good alignment without prosthesis loosening
• 2024-03-07 L spine Lat. - only (including sacrum)
  • Maintained bony alignment
  • Disc space narrowing at L1-2-3-4-5
  • Facet degeneration of lumbar spine
• 2024-03-07 Knee
  • Knee BIL standing AP and Lat views:
    • Mild to moderate osteoarthritis of both knees
    • Ahlback calcification: grade 2, 2
• 2024-3-07 Abdomen - standing (diaphragm)
  • S/P bilateral THR without evidenced prothesis loosening.
  • Presence of scoliosis of the lumbar spine.
• 2024-03-07 EGD
  • Reflux esophagitis LA Classification grade C
  • Superficial gastritis
  • Gastric polyps, fundus and body, s/p biopsy

[MedRec]

• 2024-05-09 SOAP Hemato-Oncology Xia HeXiong
  • O
    • Cancer Multi-Specialty Team Meeting Conclusions, Meeting Date: 2024-04-08
      • Diffuse large B-cell lymphoma, non-GCB, Stage Ⅳ
      • 2.Regimen R-COP (1st course split R-COP to different days).
• 2024-05-09 SOAP Metabolism and Endocrinology Qiu QuanTai
  • S
    • CC/PI: T2DM diagnosed after 70 Y/O
    • PH: T2DM, Diffuse large B-cell lymphoma, stage IV, retroperitoneum and bone marrow invasion, chemotherapy with R-COP from 2024/04/08~
  • A/P
    • Repaglinide keep 0.5 tab TIDAC
    • Trajenta to Galvus met BID
    • Toujeo 4 => 6 HS
    • No need to receive prandial RI (rescue dose)
    • RTC 2 M later
  • Prescription x2
    • Through (sennoside 12mg) 1# HS
    • Relinide (repaglinide 1mg) 0.5# TIDAC15
    • Toujeo (insulin glargine) 6 unit HS
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID

[consultation]

• 2024-05-15 Ophthalmology
  • Q
    • for urine culture was KP, combine hx of DM
    • This 75-year-old woman, a patinet of diffuse large B-cell lymphoma, stage IV, retroperitoneum and bone marrow invasion, chemotherapy with R-COP from 2024/04/08~. She lives in a nursing home (KangYuan). She Return for OPD on 5/9 24 and laboratory showed WBC:770, seg:58.6, band:1.0, ANC: 458 and Lenograstim 250mcg sc qd x 3 days for back home. However, fever (37.9 degree C) without chills and deep color of urine via foley cather were developed on 5/10 24 and she came to our ER for aid. At ER, the laboratory showed WBC:1080, seg:9.8, band:1.5 ANC:122, urinalysis:leucocyte Ester:3+, pro:3+, OB:2+, RBC:20-29, WBC:20-29, bacteria:3+. Under the impression of neutropenia fever and UTI due to related to long-term urinary catheter indwelling. She was admitted for further evaluation and treatment.
  • A
    • S: for DR check up
      • PH: DM+(HbA1c: 7.7%), diffuse large B-cell lymphoma
      • NKA
    • O:
      • nVA 20/200 (as baseline)
      • IOP 17/16 mmHg
      • Pupil: 3+/3+, no RAPD, round ou
      • Conj: not injected ou
      • K: clear ou
      • AC: d&cl ou
      • lens: NS+ ou
      • fundus: C/D ratio: 0.2, no DR ou
    • A:
      • Cataract ou
    • P:
      • control blood sugar
      • come back asap if s/s worsen
• 2024-04-24 Metabolism and Endocrinology
  • Q
    • for blood sugar control (Prednisone 60mg/m2 for 5days since 2024/04/11 to 2024/04/15 in chemotherapy regimen)
    • The AKI subside, arrange CT image abdominal to pelvic with contrast on , tissue proof of retroperitonem mass on 3/26, Tissue of retroperitoneum, CT guide biopsy was Diffuse large B-cell lymphoma, non-GCB. Hypoalbuminemia with albumin 50ml/bot QD for 3days(3/18~3/30) by self-payment. Consult GS for port-a insertion. First-line for diffuse large B-cell lymphoma chemotherapy with R-COP(Mabthera 375mg/m2 on 2024/04/08, vincristine 1.4mg/m2 on 2024/04/09, cyclophosphamide 750mg/m2 on 2024/04/10, Prednisone 60mg/m2 for 5days since 2024/04/11 to 2024/04/15). Due to old age with poor renal function thus we challenge chemotherapy step by step. Hyperglycermia with insulin SC as sliding scale. Dirutic with furosemide 40mg iv bid since 4/16, furosemide 20mg iv bid since 4/18.
    • We sincerely need your professional assistance!!
  • A
    • This 75 year old female with hypertension, diffsuse large B cell lymphoma and DM was admitted for chemotherapy. We were consulted for blood sugar control.
    • S:
      • The patient was hospitalized for chemotherapy. She has been able to eat better recently.
    • O:
      • BH: 152 cm, BW:69.3 kg
        
      • Diet: normal diet
      • Medication in OPD: Metformin 1# BID
      • Medication during hospitalization: 4u RI TIDACPRN if bs > 250, 5U
      • BUN/Crea(eGFR): 26/0.95/60.95
      • Na/K 140/3.4
      • ALT/AST:25/18
      • HbA1c:4/10 6.4%
      • F/S:

        •    4/21        4/22       4/23           4/44

        • 0600 219 238 178 208
          
        • 1100 309+5 332+6 254+5 233
        • 1700 177 165 150
        • 2100 198 255 261
    • A:
      • Type 2 DM
      • Diffuse large B cell lymphoma, s/p R-COP(Mabthera 375mg/m2 on 2024/04/08, vincristine 1.4mg/m2 on 2024/04/09, cyclophosphamide 750mg/m2 on 2024/04/10, Prednisone 60mg/m2 for 5days since 2024/04/11) step by step.
      • AKI, s/p left PCN insertion on 3/11
      • History of hypercalcemia, DLBCL related
      • Hypertension
    • P:
      • Toujeo 6u HS
      • RI 3U TIDAC with correction scale (It has been explained to the patient that because the condition changes a lot during hospitalization, insulin should be administered first and then taken orally after discharge) (please contact us 2 days before discharge)
      • Check lipid profile when blood drawing next time
      • Feel free to concact us, and arrange META OPD follow up after discharge (If the patient is willing to be followed up in the outpatient clinic of our hospital, the department can add registration at any time, but we apologize for the long wait due to the large number of outpatients.)
      • Thanks for your consultation.
  • A 2024-04-29 13:53:21
    • Swtich RI to rescue dose
    • Add on trajenta 5 mg QD and repaglinide 0.5 mg TIDAC
• 2024-04-15 Rehabiliation
  • A
    • Impression
      • Diffuse large B-cell lymphoma, stage IV, retroperitoneum and bone marrow invasion
      • Hypercalcemia
      • Acute kidney failure
      • Anemia, unspecified
    • Plan
      • Rehabilitation programs: arrange bedside PT rehabilitation programs; caregiver training.
      • Goal: recondition; improve endurance and muscle strength; improve sitting balance and transfer skill; maintain ROM.
• 2024-03-11 Cardiology
  • Q
    • for HTN intermittent
    • This is a 75y/o female, Hx of DM, HTN, Hyperlipidemia. She was regular follow at LMD for medical control.
      
    • This time, she suffer from low abdominal pain and body weight loss 5 Kg in recent 6 months, acompany with vomiting after meal for 2-3 days. Constipation also was noted. She visited our GS OPD. GI OPD found Hypercalcemia then takeover to our ER. At MER, the vital sign: blood pressure 246/109; pulse 91; temperature 35.9’C; respiratory rate 20; Con’s E4V5M6; saturation 98%.
    • The laboratory data disclosed WBC 8.69*10^3/uL, CRP 7.5mg/dl, Ca 4.73, Mg 3, LDH 401, HB 9.1, PLT 271000/uL.
    • The CXR shows No active lung lesion. EKG shows Normal sinus rhythm.
    • Abdominal CT(c-) shows Retroperitoneal mass DD: lymphoma, retroperitoneal fibrosis, Bilateral hydronephroureter.
    • For Bilateral hydronephroureter, s/p r’t PCN, PCN Lt was Failure, Arrange L’t PCN insertion done on 2024/03/08 morning.
    • For Hypercalcemia with hydration + Lasix + Calcitonin.
    • Under the impression of Hypercalcemia, Retroperitoneal mass favor lymphoma, she was admitted to Hematology and Oncology ward for management.
    • We sincerely need your professional assistance!!
  • A
    • This 75 y/o female is a case of DM, HTN, and Hyperlipidemia. This time, she admitted due to Retroperitoneal mass favor lymphoma, complicated with obstruction nephropathy s/p PCN. However. poor BP control. I’m consulted for it.
      • CxR no cardiomegaly
      • EKG: NSR
      • BP 220/102 HR 114
      • conscious oriented
      • Chest: clear BS
      • Heart: RHB without
      • Cr 4.14
      • K 2.9
    • impression
      • HTN poor control
      • Retroperitoneal mass favor lymphoma, complicated with obstruction nephropathy s/p PCN.
      • Acute on chronic renal failure,
      • Hypokalemia
    • Suggestion
      • Maybe using labetolol 1# po BID + norvasc 1# po BID.
      • add hydralazine 1# po Q8H PRN if SBP > 160 mmHg.
      • K 2.9, maybe support K to keep K 3.5~5.1.
      • maybe follow up Mg, because CKD, MgO is not suitable.
• 2024-03-08 Nephrology
  • Q
    • for AKI, indication of H/D?
    • This is a 75y/o female, Hx of DM, HTN. She suffer from low abdominal pain and body weight loss 5 Kg in recent 6 months, acompany with vomiting after meal for 2-3 days. Constipation. She visited our GS OPD. GI OPD found Hypercalcemia then takeover to our ER.
    • Abdominal CT(c-) shows Retroperitoneal mass DD: lymphoma, retroperitoneal fibrosis, Bilateral hydronephroureter.
    • For Bilateral hydronephroureter, s/p r’t PCN, PCN Lt was Failure, Arrange L’t PCN insertion done on 2024/03/08 morning.
    • For Hypercalcemia with hydration + Lasix + Calcitonin.
    • Under the impression of Hypercalcemia, Retroperitoneal mass favor lymphoma, she was admitted to Hematology and Oncology ward for management.
  • A
    • We visited the patient at the bedside and evaluated her condition. Her consciousness was clear, speech was coherent and not in respiratory distress. She complained of generalized weakness and lethargy. A urinary catheter was inserted this afternoon.
      • 2024-03-08 Ca (Calcium) 4.22 mmol/L
        
      • 2024-03-07 Creatinine 3.16 mg/dL
        
      • 2024-03-07 BUN 57 mg/dL
        
    • Our impressions are as follows:
      • Hypercalcemia of malignancy, either due to elevated PTHrp (humoral hypercalcemia) or elevated 1,25-dihydroxyvitamin D (lymphoma)
    • Our advices are as follows:
      • IV isotonic 0.9% saline 100-200mL/h, in the absence of edema, keep urinary output 100-150 mL/h
      • IV Furosemide in conjunction with IV fluid hydration to promote urinary Ca excretion
      • IV Zoledronic acid ST, slowly infuse (4mg over 1 hour) in renal impairment, and look out for jaw osteonecrosis
    • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance. Thank you.
• 2024-03-07 Urology
  • A
    • CT (A+P) showed huge mass lesion in retroperitoneal space with bilateral obstructive uropathy. We are consulted for bilateral hydronephrosis
    • Impression: Huge retroperitoneal mass (suspect lymphoma) with bilateral obstructive uropathy
    • Suggestion:
      • consult radiologist for bilateral PCN drainage
      • correct anemia and hypercalcemia as your expertise
      • consult oncology for further tumor survey

[immunochemotherapy]

• 2024-07-23 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 60mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 100mg PO QD D1-5 (R-CHOP)
  • dexamethasone 8mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2024-06-17 - rituximab 375mg/m2 610mg NS 500mL 8hr + vincristine 1.4mg/m2 2mg NS 50mL 15min + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + prednisolone 60mg/m2 100mg PO QD D1-5 (R-COP)
  • dexamethasone 8mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2024-05-24 - rituximab 375mg/m2 610mg NS 500mL 8hr + vincristine 1.4mg/m2 2mg NS 50mL 15min + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + prednisolone 60mg/m2 100mg PO QD D1-5 (R-COP)
  • dexamethasone 8mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2024-04-29 - rituximab 375mg/m2 650mg NS 500mL 8hr + vincristine 1.4mg/m2 2mg NS 50mL 15min + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min + prednisolone 60mg/m2 105mg PO QD D1-5 (R-COP)
  • dexamethasone 8mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2024-04-08 - rituximab 375mg/m2 650mg NS 500mL 8hr D1 + vincristine 1.4mg/m2 2mg NS 50mL 15min D2 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D3 + prednisolone 60mg/m2 55mg QD 50mg QN D1-5 (R-COP)
  • acetaminophen 500mg PO D1 + dexamethasone 8mg D1-3 + diphenhydramine 30mg D1-3 + NS 250mL D1-3 + palonosetron 250ug D3 + aprepitant 125mg PO D3-5

==========

2024-08-12

[Monitoring WBC Levels Post R-CHOP Regimen]

The final session of the R-CHOP regimen was administered on 2024-07-23, with the WBC nadir observed on 2024-08-02, approximately 10 days later. Granocyte (lenograstim 250ug) was administered from 2024-07-31 to 2024-08-08. Currently, there is no evidence of neutropenia.

• 2024-08-12 WBC 11.19 x10^3/uL
• 2024-08-09 WBC 12.74 x10^3/uL
• 2024-08-07 WBC 3.35 x10^3/uL
• 2024-08-05 WBC 0.32 x10^3/uL **
• 2024-08-02 WBC 0.04 x10^3/uL ***
• 2024-07-31 WBC 0.05 x10^3/uL **
• 2024-07-28 WBC 3.17 x10^3/uL
• 2024-07-22 WBC 7.72 x10^3/uL

2024-06-17

[hyperuricemia managed with febuxostat, preventing HBV activation with tenofovir]

Beta-2 microglobulin levels remain elevated. Hyperuricemia is currently managed with Feburic (febuxostat), and Vemlidy (tenofovir alafenamide) is used to prevent HBV reactivation. Blood sugar control is acceptable. No medication discrepancies were identified.

• 2024-06-15 Uric Acid 7.8 mg/dL

• 2024-06-12 B2-Microglobulin 7071 ng/mL

• 2024-05-10 B2-Microglobulin 6101 ng/mL

• 2024-04-08 B2-Microglobulin 7052 ng/mL

2024-05-17

The neutropenia that developed following the administration of the R-COP regimen has now resolved.

• 2024-05-17 WBC 11.57 x10^3/uL
• 2024-05-13 WBC 15.72 x10^3/uL
• 2024-05-11 WBC 1.08 x10^3/uL **
• 2024-05-09 WBC 0.77 x10^3/uL ***
• 2024-04-30 WBC 11.24 x10^3/uL <- 04/29 R-COP
• 2024-04-25 WBC 10.11 x10^3/uL
• 2024-04-22 WBC 0.64 x10^3/uL ***
• 2024-04-17 WBC 4.71 x10^3/uL
• 2024-04-15 WBC 9.28 x10^3/uL
• 2024-04-12 WBC 9.95 x10^3/uL
• 2024-04-08 WBC 7.35 x10^3/uL <- 04/08 R-COP

2024-03-12

[hypercalcemia resolved: Miacalcic - discontinuation option]

The serum calcium level has already decreased to within the normal range (albumin also in normal range). If the cause of the hypercalcemia is no longer present, Miacalcic (calcitonin) can be discontinued.

• 2024-03-12 Albumin (BCG) 3.6 g/dL
• 2024-03-12 Ca (Calcium) 2.47 mmol/L
• 2024-03-11 Ca (Calcium) 2.87 mmol/L
• 2024-03-10 Ca (Calcium) 3.45 mmol/L
• 2024-03-09 Ca (Calcium) 3.62 mmol/L
• 2024-03-08 Ca (Calcium) 4.22 mmol/L
• 2024-03-08 Ca (Calcium) 4.33 mmol/L
• 2024-03-07 Ca (Calcium) 4.73 mmol/L

[improving kidney function & low K]

Based on the data, the patient’s kidney function is improving.

• 2024-03-12 Creatinine 3.88 mg/dL
  

• 2024-03-11 Creatinine 4.14 mg/dL
  

• 2024-03-09 Creatinine 4.28 mg/dL

• 2024-03-12 BUN 64 mg/dL
  

• 2024-03-11 BUN 67 mg/dL
  

• 2024-03-09 BUN 71 mg/dL

Serum potassium levels have fallen below the reference range, possibly due to the use of furosemide. Const-K is currently used for potassium supplementation.

• 2024-03-12 K (Potassium) 3.1 mmol/L
  
• 2024-03-11 K (Potassium) 2.9 mmol/L
  
• 2024-03-10 K (Potassium) 3.0 mmol/L
  
• 2024-03-09 K (Potassium) 3.7 mmol/L
  
• 2024-03-07 K (Potassium) 4.0 mmol/L

Once kidney function (eGFR) has recovered to above 30 and is expected to continue improving, spironolactone can be added as an aldosterone antagonist to partially replace furosemide to maintain serum potassium levels within a reasonable range. One of the methods that is used is spironolactone 50 mg and furosemide 20 mg 2 doses daily..

2024-03-08

[dosing strategies for calcitonin in hypercalcemic emergencies]

Calcitonin can be utilized as an adjunctive treatment for severe hypercalcemia:

It is recommended for use in conjunction with other suitable agents (such as IV hydration and bisphosphonates) for patients experiencing severe hypercalcemia (for example, symptomatic cases with an albumin-corrected serum calcium level exceeding 14 mg/dL [>3.5 mmol/L]). This is to promptly decrease serum calcium levels, while bisphosphonate therapy achieves a sustained effect.

For IM or SUBQ administration: The initial dose is 4 units/kg every 12 hours. Should the reduction in calcium prove insufficient after 6 to 12 hours, the dosage may be escalated to 8 units/kg every 6 to 12 hours. It is advisable to limit the total duration of therapy to between 24 to 48 hours due to the risk of tachyphylaxis.

[weighing denosumab for hypercalcemia with renal considerations]

Isotonic saline hydration and loop diuretics are currently being used to treat hypercalcemia.

Renal lab results:

• 2024-03-07 Creatinine 3.16 mg/dL
  
• 2024-03-07 eGFR 15.23 ml/min/1.73m^2
  
• 2024-03-07 BUN 57 mg/dL

Given the patient’s compromised renal function, the use of bisphosphonates, which have an onset of action ranging from 24 to 72 hours and a duration of action between 2 to 4 weeks, is not feasible.

Denosumab, with an onset of action between 4 to 10 days and a duration of action extending from 4 to 15 weeks, may be a viable alternative considering the risk of tachyphylaxis associated with calcitonin. If there are no clinical contraindications, denosumab at a dosage of 120 mg once weekly for up to three doses could be contemplated.

[Regpara for hypercalcemia]

Regpara (cinacalcet 25mg/tab, available in this hospital now; onset of action 2-3 days) belongs to a drug class called calcimimetics. It works by mimicking the effect of calcium on calcium-sensing receptors. This action helps to lower parathyroid hormone (PTH) levels. Regpara is used to treat hypercalcemia caused by conditions like parathyroid carcinoma or secondary hyperparathyroidism in patients with CKD.

Initial 25 mg twice daily; may increase dose incrementally (to 50 mg twice daily, 75 mg twice daily, and 100 mg 3 to 4 times daily) every 2 to 4 weeks as necessary to normalize serum calcium levels.

701179854

240812

[exam findings] (not completed)

• 2024-08-08 CT - abdomen
  • History and indication:
    • Very distended small bowel loops with fluid inside was noted at whole abdomen.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation. Some soft tissues in abdominal cavity. A soft tissue lesion (7.5cm) at right kidney. Thickening of left lateral abdominal wall. S/P right side double J catheter insertion. Ileus of small and large bowel.
    • Ascites and pleural effusion.
    • Liver cysts (up to 2.1cm). S/P splenectomy.
    • Enlargement of prostate.
    • Distention of gallbladder.
    • Degeneration and spondylosis of L-S spine.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • S/P operation. Some soft tissues in abdominal cavity. A soft tissue lesion (7.5cm) at right kidney. Thickening of left lateral abdominal wall. S/P right side double J catheter insertion. Ileus of small and large bowel.
    • Ascites and pleural effusion.
• 2024-08-08 Sonography - abdomen
  • Diagnosis:
    • r/o Small bowel obstruction
    • Hepatic cyst, S2/3
    • Hepatic lesion, S2/3 tip, suspicious tumor
    • Perirenal tumor, RK
    • Ascites, small
    • Pleural effusion, right
• 2024-07-20 MRI - brain
  • Findings:
    • Severe periventricular small vessel disease. NO acute ischemic infarct.
    • A few old lacuna infarcts over both corona radiata.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • MR angiography of the brain shows normal intracranial vessel including circle of willis.
  • Impression:
    • No evidence of brain metastasis.
• 2024-07-19 CT - abdomen
  • Findings: Comparison: prior CT dated 2024/06/05.
    • Prior CT identified a soft tissue lesion 6.7 cm in right kidney is noted again, increasing in size to 8 cm.
    • Prior CT identified a soft tissue lesion 3.4 cm in left para-aortic space is noted again, mild decreasing in size to 3 cm.
    • Prior CT identified a soft tissue tumor at LLQ abdomen 9 cm with direct invasion adjacent internal oblique muscle is noted again, increasing in size to 18 cm. However, most part of this tumor shows cystic change. please correlate with clinical condition.
    • There is a newly developed cystic mass in RLQ abdomen, 5 cm in size (the largest dimension). Recurrent tumor is highly suspected.
      
    • S/P total gastrectomy, distal pancreatectomy and splenectomy.
    • There are several hepatic cysts in both lobes and the largest one 2 cm in size at S6/7.
    • S/P double J catheter insertion, right side urinary tract.
  • IMP:
    • Prior CT identified a soft tissue lesion 6.7 cm in right kidney is noted again, increasing in size to 8 cm.
    • Prior CT identified a soft tissue lesion 3.4 cm in left para-aortic space is noted again, mild decreasing in size to 3 cm.
    • Prior CT identified a soft tissue tumor at LLQ abdomen 9 cm with direct invasion adjacent internal oblique muscle is noted again, increasing in size to 18 cm. However, most part of this tumor shows cystic change. please correlate with clinical condition.
    • There is a newly developed cystic mass in RLQ abdomen, 5 cm in size (the largest dimension). Recurrent tumor is highly suspected.
• 2024-06-18 Sonography - nephrology
  • Interpretation:
    • Right renal tumor.
    • Left mild hydronephrosis.
• 2024-06-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (68 - 29) / 68 = 57.35%
    • M-mode (Teichholz) = 57
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH; normal LV diastolic function.
    • Normal RV systolic function.
    • Aortic valve sclerosis with mild AR; mild MR; mild TR.
    • Dilated aortic root.
• 2024-06-05 CT - abdomen
  • Findings: Comparison: prior MRI dated 2024/01/30.
    • Prior CT identified a soft tissue lesion 3.4 cm in right kidney is noted again, increasing in size to 6.7 cm.
    • Prior CT identified a soft tissue lesion 3.4 cm in left para-aortic space is noted again, stable in size.
    • Prior CT identified a soft tissue tumor at LLQ abdomen 5.5 cm with direct invasion adjacent internal oblique muscle is noted again, increasing in size to 9 cm. However, most part of this tumor shows cystic change. please correlate with clinical condition.
    • S/P total gastrectomy, distal pancreatectomy and splenectomy.
    • There are several hepatic cysts in both lobes and the largest one 2 cm in size at S6/7.
    • S/P double J catheter insertion, right side urinary tract.
• 2024-01-31 Patho - soft tissue lipoma
  • Soft tissue, LLQ, intra-abdomen, CT-guide biopsy — Consistent with recurrent inflammatory variant of dedifferentiated liposarcoma
  • Sections show pleomorphic spindle cells infiltration in fibrous stroma with neutrophils, eosiniphils and lymphocytes.
  • The immunohistochemical stains reveal CDK4(+) and MDM2(+). The results are consistent with recurrent inflammatory variant of dedifferentiated liposarcoma.

[chemotherapy]

• 2024-08-05 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-07-10 - trabectedin 1.1mg/m2 1.7mg NS 500mL 24hr
  • dexamethasone 20mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-07-09 - liposome doxorubicin 40mg/m2 47mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-06-18 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

trabectedin - 2024-08-12 - https://www.uptodate.com/contents/trabectedin-drug-information

• Soft tissue sarcoma, unresectable/metastatic liposarcoma or leiomyosarcoma:
  • Previously treated unresectable/metastatic liposarcoma or leiomyosarcoma:
    • IV: 1.5 mg/m2 as a continuous infusion over 24 hours once every 3 weeks; continue until disease progression or unacceptable toxicity (Demetri 2016).
  • Previously untreated unresectable/metastatic leiomyosarcoma (off-label use/combination):
    • IV: 1.1 mg/m2 over 3 hours once every 3 weeks (in combination with doxorubicin and pegfilgrastim) for a maximum of 6 combination cycles, followed by single-agent trabectedin maintenance therapy of 1.1 mg/m2 over 3 hours once every 3 weeks until disease progression or unacceptable toxicity for up to a maximum of 17 maintenance cycles (Pautier 2022).

701530661

240812

[exam findings]

• 2024-08-01 Patho - Omentum, laparoscopic biopsy
  • Omentum, laparoscopic biopsy— adenocarcinoma, seeding
  • Microscopically, sections shows adenocarcinoma composed of invasive neoplastic glands and stromal fibrosis. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • IHC stain — CA19-9 (focal+), CK20(-), CK7(+), PAX-8(-), CDX-2(focal weak+)
• 2024-08-01 Patho - peritoneum biopsy
  • Peritoneum, laparoscopic biopsy — adenocarcinoma, seeding
  • Microscopically, section show shows adenocarcinoma composed of invasive neoplastic glands and stromal fibrosis. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • IHC stain — CA19-9 (focal+), CK20(-), CK7(+), PAX-8(-), CDX-2(focal weak+)
• 2024-07-15 Cell block cytology - ascites (Y1)
  • Smears and cell block show atypical tumor cells with increased N/C ratio and prominent nucleoli. Metastatic adenocarcinoma is favored. Please correlate with the clinical presentation.
  • The immunohistochmeical stains reveal CK7(+), CK20(-), CDX2(focal +), DPC4(focal +), ER(-), PAX8(-), and Calretinin(-). The results are consistent with S2024-14314. Metastatic ovarian carcinoma is less likely.
• 2024-07-13 MR cholangiography, MRCP
  • History and indication: pancrea tail tumor and massive ascites
  • With and without contrast MRI of abdomen with MRCP reconstruction revealed:
    • A poor enhancing tumor (4.0cm) at pancreatic tail with stomach and spleen invasion. Some LNs at LUQ.
    • Increased soft tissues in peritoneal cavity with ascites.
    • Multiple liver tumors.
    • Bil. pleural effusion.
    • Normal appearance of adrenals and kidneys.
    • Some nodules in bilateral basal lungs.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T2(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)
• 2024-07-12 Aspiration cytology
  • CT (2024-06-26) at the SKMH showed massive ascites and panc tail tumor
  • Cytological diagnosis
    • Malignancy - adenocarcinoma
    • Smears show clustes of adenocarcinomatous cells with nuclear hyperchromasia, irregular nuclear contours and conspicuous nucleoli.
• 2024-07-12 Surgical pathology Level IV
  • PATHOLOGIC DIAGNOSIS
    • Liver, EUS-FNB — Adenocarcinoma, moderatly differentiated, compatible with metastatic pancreatic ductal adenocarcinoma
  • MICROSCOPIC EXAMINATION
    • The sections show a picture of adenocarcinoma, composed of nests, cords, and single large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation is present. The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
• 2024-07-12 Surgical pathology Level IV (Y1)
  • PATHOLOGIC DIAGNOSIS
    • Pancreatic tail, EUS-FNB — Ductal adenocarcinoma, moderatly differentiated
  • MICROSCOPIC EXAMINATION
    • The sections show a picture of ductal adenocarcinoma, composed of nests, cords, and single large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation and tumor necrosis are present.
    • IHC: PAX8 (-), ER (-) and PDC4 (no expression)
    • Comment: Metastatic ovarian carcinoma is less likely
• 2024-07-08 Ascites Tapping
  • Procedure: Ascites tapping
  • Indication: For paracentesis
  • Symptoms: Ascites
  • Course：
    • After echo localization, paracentesis was performed at RLQ and 1500ml straw-colored ascites was drained out with 18Fr catheter.
• 2024-07-08 SONO - abdomen
  • Diagnosis:
    • Pancreatic tail tumor, suspicious
    • Hepatic tumors, bilateral lobes, favor metastases
    • Hepatic cyst, right lobe
    • GB sludge
    • Ascites, massive

[chemotherapy]

• 2024-07-19 - oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + irinotecan 180mg/m2 140mg D5W 1.5hr + leucovorin 400mg/m2 300mg NS 250mL 2hr + fluorouracil 2400mg/m2 2000mg NS 500mL 46hr (FOLFIRINOX 50%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.3mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

700526571

240802

==========

2024-08-02

[carbapenem safety in penicillin-allergic patients: Tapimycin (piperacillin, tazobactam) and Mepem (meropenem) cross-reactivity]

Studies have shown that the risk of cross-reactivity between penicillins and carbapenems is relatively low. According to a systematic review and meta-analysis published in the Journal of Allergy and Clinical Immunology: In Practice, the risk of cross-reactivity to any carbapenem in penicillin-allergic patients is around 0.87% (95% CI, 0.32-2.32%)​ (https://pubmed.ncbi.nlm.nih.gov/31170539/)​. This suggests that many patients with a penicillin allergy can safely use carbapenems like meropenem, although careful consideration and possible consultation with an allergist are recommended.

Another study demonstrates that bedside meropenem allergy testing for hospitalized patients with reported penicillin allergies is safe and effective, with 96.4% of patients tolerating the procedure and only two experiencing non-severe reactions. This approach allows for the appropriate use of meropenem, avoiding less effective second-line antibiotics. Overall, the procedure enhances patient care and helps mitigate antibiotic resistance. (https://doi.org/10.1016/j.alit.2023.02.008)

700551627

240801

[lab data]

2024-02-07 Cryoglobulin Positive
2023-10-23 Cryoglobulin Positive

2023-06-02 HBsAg (NM) Negative
2023-06-02 HBsAg Value (NM) 0.438
2023-06-02 Anti-HCV (NM) Negative
2023-06-02 Anti-HCV Value (NM) 0.040
2023-06-02 Anti-HBc (NM) Positive
2023-06-02 Anti-HBc Value (NM) 0.009
2023-06-02 Anti-HBs (NM) Positive
2023-06-02 Anti-HBs value (NM) 18.200 mIU/mL

2022-02-04 Anti-HBc Reactive
2022-02-04 Anti-HBc-Value 7.63 S/CO
2022-02-04 Anti-HBs 31.17 mIU/mL
2022-02-04 HBsAg Nonreactive
2022-02-04 HBsAg Value 0.00 IU/mL
2022-02-04 Anti-HCV Nonreactive
2022-02-04 Anti-HCV Value 0.07 S/CO

[exam findings]

• 2024-07-02 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. A recurrent tumor at vaginal stump with urinary bladder invasion.
    • Some LNs (up to 1.5cm) in mediastinum.
    • A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma. Grade 4 fatty liver.
    • Mild splenomegaly. S/P Port-A infusion catheter insertion.
    • Some nodules at RLL and LLL.
  • IMP:
    • S/P hysterectomy. A recurrent tumor at vaginal stump with urinary bladder invasion.
    • Some LNs (up to 1.5cm) in mediastinum.
    • Some nodules at RLL and LLL.
• 2024-04-11 CT - chest
  • Chest CT without IV contrast ehnancement shows:
    • s/p op. over bilateral lower lungs.
    • Enlarged lymph nodes are found at both sides of the mediastinum. In comparison with CT dated on 2023-05-03, the lesion is stationary.
    • S/p port-A placement with its tip at Superior vena cava.
  • Imp:
    • Post op. change at bilateral lung fields.
    • Stationary mediastinal lymph nodes
• 2024-04-08 CT - abdomen
  • Indication:
    • Adenocarcinoma, HPV-associated, of the vgaina, pT1aNx, stage IA (if cMo); FIGO stage I status post Exision of vaginal lesion on 2021/12/20
  • Abdominal CT with and without enhancement revealed:
    • s/p hysterectomy. Suspected cystic tumor formation at viginal stump measuring 1.7cm in largest dimension. In comparison with CT dated on 2023-12-28, the lesion is stationary.
    • One hepatic tumor at S4/8 of liver measuring 1.5cm in largest dimension is found. Hemangioma is suspected. Stationary
    • s/p bilateral lower lung op.
  • Imp:
    • s/p hysterectomy.
    • Suspected cystic tumor at viginal stump, 1.7cm, stable.
    • Hepatic hemangioma.
• 2024-01-17 PET
  • Increased FDG uptake in the lower pelvis, compatible with the recurrent tumor.
    
  • Increased FDG uptake in a right inguinal lymph node, probably reactive node.
    
  • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, and in several nodular lesions in the right lower lung, cancer with distant metastases shoulde be considered, suggesting biopsy for investigation.
    
  • Increased FDG accumulation in bilateral kidneys, ureters, and colon, probably physiological uptake of FDG.
  • Recurrent vaginal cancer, rcTxN0M1c (AJCC 9th ed.), by this F-18 FDG PET scan.
• 2023-12-28 CT - abdomen
  • History and indication: vigina ca s/p OP s/p C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. A recurrent tumor (1.9cm) at vaginal stump with urinary bladder invasion.
    • Some LNs (up to 1.5cm) in mediastinum.
    • A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma. Grade 4 fatty liver.
    • Mild splenomegaly.
    • Some nodules at RLL.
  • IMP:
    • S/P hysterectomy. A recurrent tumor (1.9cm) at vaginal stump with urinary bladder invasion. Some LNs (up to 1.5cm) in mediastinum. Some nodules at RLL.
• 2023-11-22 Pap’s Smear
  • Atypical glandular cells favor neoplasm
• 2023-09-22 CT - abdomen
  • history: 52 y/o female patient with Vaginal cancer s/p OP
    • 20220914 lung nodule in RLL and LLL, favor metastases?
    • 20220921 Lung, RLL, VATS wedge: Non-necrotizing granulomatous inflammation
      
    • 20221116 Lung, LLL, VATS wedge: adenocarcinoma in situ.
  • Findings: Comparison: prior chest CT dated 2023/05/03.
    • Prior CT identified several enlarged lymph nodes in the paratracheal space are noted again, mild increasing in size.
      • Follow up is indicated.
    • Prior CT identified two poor enhancing mass 1.5 cm in S8 and 0.4 cm in S5/6 of the liver are noted again, stationary that are c/w hemangiomas after correlate with prior MRI.
    • There are soft tissue lesion with curvelinear calcification in RLL and LLL of the lung that are c/w prior VATS procedure.
      • In addition, there is no focal lesion in both lung and mediastinum.
  • Impression:
    • Prior CT identified several enlarged lymph nodes in the paratracheal space are noted again, mild increasing in size. Follow up is indicated.
• 2023-08-11 All-RAS + BRAF gene mutation analysis
  • Tissue Block No: S2023-10045
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-06-23 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • R’t : 31 dB HL, normal to moderate SNHL
  • L’t : 35 dB HL, mild to moderate SNHL.
• 2023-06-05 Bladder Sonography
  • PVR: 26 mL
• 2023-06-22 CXR
  • Interstitial pattern at LLL.
• 2023-05-23 Patho - vaginal biopsy
  • Vagina, vaginectomy — Adenocarcinoma, recurrent
  • The secvtions show a picture of adenocarcinoma (tumor size: 0.3 x 0.3 cm), composed of low columnar to cuboidal neoplastic cells, arranged in glandular and papillary patterns, floating in mucin pool. The surgical margin is free of carcinoma. The distance of tumor from closest margin about 3 mm.
• 2023-05-03 CT - chest
  • Indication: AIS of lung Vagina adenocarcinoma s/p OP and R/T. R/O recurrence
  • Comparison was made with previous CT dated on 2022
    • Lungs: surgical staple lines and coarse reticular and subsegmental opacities at both lower lobes, s/p wedge-resection.
      • a 11mm lung cyst at RLL too.
      • normal appearance of both upper lobes and RML.
    • Mediastinum and hila: no enlarged LN or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion.
    • Vessels: normal appearance of thoracic aorta.
    • Central pulmonary arteries: dilated trunk (3.4cm in caliber)
    • Heart: normal in size of cardiac chambers.
    • Pleura: minimal effusion and thickening, both sides.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: a poor enhancing nodule (1.5cm) at liver dome, S8, r/o a hemangioma
      • normal appearance of gall bladder. unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
    • Visualized bones: compression fracture of L1 vertebral body
  • Impression:
    • post op change in both lower lobes of the lungs.
    • no new lung nodule (s). pulmonary hypertension, cause?
• 2023-05-02 CT - abdomen
  • History and indication: Malignant neoplasm of vagina
  • IMP:
    • S/P hysterectomy. R/O recurrent tumor (2.3cm) at vaginal stump with urinary bladder invasion.
    • A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma.
• 2023-04-12 Pap Smear
  • Atypical glandular cells favor neoplasm
• 2023-03-07 CT - abdomen
  • Clinical history: 53 y/o female patient with liver lesion and pathological report and follow up the deisease condition and report. LMP 8/3/20 HPV : + (type 18) pap : abnormal (2020). LEEP in 2016 NTUH, LSC LAVH+BSO (SlLS) on 20200907.
    • post laparotomy operation visit. for checking wound. Vaginal Ca s/p OP.
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P hysterectomy. There is rim enhanced lesion, 1.6cm in the vaginal stump, with urinary bladder involvement, r/o recurrent tumor.
    • Liver tumor, 1.5cm in S8, prior MRI study showed hemangioma. Suggest follow up.
    • Ventral herniation (lower abdomen).
  • Impression:
    • S/P hysterectomy. Rim enhanced lesion in the vaginal stump, with urinary bladder involvement, r/o recurrent tumor.
    • Liver tumor, r/o hemangioma.
    • Post-op at bilateral lower lungs.
• 2023-01-09 CXR
  • Cardiomegaly is noted.
  • Some fibrotic change at left lower lobe is found.
  • Osteopenia of the bony structure is noted.
• 2022-12-09 CT - abdomen
  • history: 52 y/o female patient with Vaginal cancer s/p OP
    • 20220914 lung nodule in RLL and LLL, favor metastases?
    • 20220921 Lung, RLL, VATS wedge: Non-necrotizing granulomatous inflammation
      
    • 20221116 Lung, LLL, VATS wedge: adenocarcinoma in situ.
  • Findings:
    • Prior CT identified two poor enhancing mass 1.5 cm in S8 and 0.4 cm in S5/6 of the liver are noted again, stationary that are c/w hemangiomas after correlate with prior MRI.
    • There are soft tissue lesion with curvelinear calcification in RLL and LLL of the lung that are c/w prior VATS procedure.
  • Impression:
    • Two hemangioma in S8 and S5/8 show stationary.
• 2022-11-16 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, left, lower lobe, wedge resection —- Adenocarcinoma in situ
    • Lymph node, left, group No.9, lymphadenectomy —- Negative for malignancy (0/2) —- Non-necrotizing granulomatous inflammation
      
    • AJCC 8th edition pTNM Pathology stage: pTisN0
  • MACROSCOPIC EXAMINATION:
    • Specimen:
      • F2022-00544: Lung, size: 5.7 x 4.2 x 1.1 cm
      • S2022-20247: Lymph nodes, a bottle, group 9, maximal size: 0.5 x 0.2 cm
    • Tumor Site: Periphery
    • Tumor Size: Solitary: 0.2 x 0.2 x 0.2 cm
    • Gross tumor patterns: Well defined
    • A granuloma measuring 0.3 x 0.2 x 0.2 cm is seen.
    • Tissue for sections:
      • F2022-00544: Representative sections are taken and labeled as: FsA1: granuloma; FsA2: tumor, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: resection margin; X2: lung; X3-4: lung, near tumor.
      • S2022-20247: All for section in a cassette.
        
  • Microscopic Description
    • Tumor Focality: Single tumor
    • Histologic Type (select all that apply): Adenocarcinoma in situ (AIS), nonmucinous; The immunohistochemical stain of TTF-1 is positive.
      
    • Histologic Grade: Not applicable
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Not identified
    • Lymphovascular Invasion (select all that apply): Not identified
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.5 cm
      • Specify closest margin: wedge resection margin
    • Treatment Effect: No known presurgical therapy
    • Regional Lymph Nodes: group 9: 0/2
    • Extranodal Extension: Not identified
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pTis (AIS): Adenocarcinoma in situ (AIS): adenocarcinoma with pure lepidic pattern, ≤3 cm in greatest dimension
        • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
    • Additional Pathologic Findings (select all that apply)
      • Non-necrotizing granulomatous is seen in the lung parenchyma and lymph nodes. The PAS and AFB special stains are negative.
• 2022-11-01 Patho - cervix biopsy
  • Uterus, cervix, biopsy — high-grade glandular dysplasia
  • Microscopically,it shows high-grade glandular dysplasia characterized by papillary hyperplasia of atypical glands lined by high-grade atypical cells with nuclear hyperchromaisa and pleomorphism, coarse chromatin and occasional mitotic figures.
  • Immunohistochemical stain reveals ap16(+) and Ki-67 (+) at dysplastic cells.
• 2022-09-22 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right lower lobe, VATS wedge — Non-necrotizing granulomatous inflammation
      
    • Lymph node, LN 7, right, LND — Non-necrotizing granulomatous inflammation
      
  • MICROSCOPIC EXAMINATION:
    • The section of both “RLL nodule” and “LN7” show a picture of non-necrotizing granulomatous inflammation, composed of granulomas with aggregates of tightly clustered epitheloid histiocytes with giant cells. Necrosis is not present. Neither T.B. bacilli nor fungi can be identified in the acid fast and PAS stains.
• 2022-08-10 Pap Smear
  • Atypical glandular cells favor neoplasm
• 2022-05-16 CT - abdomen
  • S/P hysterectomy.
  • A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma.
• 2022-02-14 MRI - liver, spleen
  • R/O hemangiomas (up to 1.3cm) at S6-8 of liver. Right liver cyst (0.3cm).
• 2022-01-04 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Moderate fatty change, compatible with non-alcoholic fatty liver disease (NAFLD)
    
  • The sections show liver tissue with mild portal inflammation, subtle piecemeal necrosis, mild lobular inflammation, few hepatic ballooning, a poorly formed granuloma, and moderate steatosis (50%). Periportal fibrosis and bridging fibrosis can be identified. There is no evidence of malignancy in the sections examined.
    
  • The grading and staging for NAFLD as follows:
    • Grading: Score = 4 (steatosis = 2/3, ballooning = 1/2, lobular inflammation = 1/3)
      
    • Staging: 3 (Bridging fibrosis)
• 2021-12-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (65 - 17) / 65 = 73.85%
    • M-mode (Teichholz) = 73.8
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Concentric LVH, grade 1 LV diastolic dysfunction
    • Trivial MR, mild TR and PR
• 2021-12-27 Cystography
  • The bladder capacity is about 200cc.
  • No evidence of contrast medium leakage.
• 2021-12-21 Patho - vaginal biopsy
  • PATHOLOGIC DIAGNOSIS
    • Vagina, resection — Adenocarcinoma, HPV-associated
      
    • Pathologic Stage (AJCC 8th ed.): pT1aNx, stage IA if cMo; FIGO stage I
      
  • MICROSCOPIC EXAMINATION
    • Procedure: Vaginal resection
      
    • Tumor Site: Vagina, not otherwise specified
      
    • Tumor Size: 0.8 x 0.6 cm
      
    • Histologic Type: Adenocarcinoma, HPV-associated
      
    • Histologic Grade: G2, moderately differentiated
      
    • Tumor Extension: Involves muscular wall (pT1a)
      
    • Lymphovascular Invasion: Not identified
      
    • Margins: All margins negative for invasive carcinoma
      • Distance of closest margin at least 4 mm
        
    • Regional Lymph Nodes: No lymph nodes submitted (pNx)
      
    • Distant Metastasis: Not applicable
    • Additional Findings: Adenocarcinoma in situ
      
    • IHC: CK7(+), CK20(-), CDX2(focal+), and p16(+)

[MedRec]

• 2024-02-20 SOAP Rheumatology and Immunology Chen ZhengHong
  • S: recheck cryoglobulin level
  • A: Cryoglobulinemia
  • Prescription x3
    • Plaquenil (hydroxychloroquine 200mg) 1# QDCC
• 2023-11-21 SOAP Rheumatology and Immunology Chen ZhengHong
  • S: check immune report
    • Multiple skin rash over four limbs for years. Itchy sensation was also noted.
    • PH: Vagina Ca, DM
    • NKA
  • A
    • Skin rash, cause?
    • Cryoglobulinemia
• 2023-06-21 ~ 2023-06-24 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Adenocarcinoma, HPV-associated, of the vgaina, pT1aNx, stage IA( if cMo); FIGO stage I status post Exision of vaginal lesion on 2021/12/20, recurrent tumor (2.3cm) at vaginal stump with urinary bladder invasion, s/p vaginal stump mass + partial vaginectomy on 2023/05/22, s/p chemotherapy with Paclitaxel plus carboplatin from 2023/06/23
    • Malignant neoplasm of vagina
    • Type 2 diabetes mellitus without complications
    • Chronic viral hepatitis B without delta-agent
  • CC
    • for prepare chemotherapy
  • Present illness
    • This is a 53-year-old, G6P2AA4 (C/S X 2) woman with underlying medical history of:
      • Cervix biopsy with report CIN3 and Condyloma at right vagina-s/p Loop electrosurgical excision procedure (LEEP) at NTUH on 2005.
      • s/p tracheletomy with report CIN2 recurrence and right side vgina biopsy report VAIN1 at NTUH on 2006.
      • Uterus, cervix, biopsy report LSIL at NTUH on 2009.
      • Recurrent abnormal findings of pap smear; HPV 18 (+) - Cervix biopsy with report: moderate glandular dysplasia, s/p Laparoscopic assisted vaginal hysterectomy + bilateral salpingo-oophorectomy on 2020/09/07 - 2021/10 Vaginal cuff smear: atypical glandular cells, favor neoplasm, s/p vaginal cuff biopsy: high grade glandular dysplasia, s/p Exision of vaginal lesion on 2021/12/20, with pathology report:(Cervical cancer), Adenocarcinoma, HPV-associated, pT1aNxcM0; FIGO stage I, s/p radiotherapy (2022/1/21~3/22); with recurrence.
      • Hemangiomas (up to 1.3cm) at S6-8 of liver.
      • Carcinoma in situ of lung over left lower lobe, s/p video-assisted thoracoscopic surgery left lower lobe lung wedge resection and lymph node sampling on 2022-11-16, under OPD followup.
      • Non necrotizing granulomas in the lungs, under OPD followup.
      • Type II diabetes mellitus, on oral hypoglycemic agent.
    • She has had regular follow-ups at Taipei Tzu Chi Hospital after LAVH + BSO since 2020, and for the above diseases. Abdomen + pelvis CT was performed as needed, in which liver dome and lund nodule were noticed and metastases of cervical cancer had been ruled out via examinations and pathology test. She reported no vaginal bleeding. Occasional vaginal discharge and palpitations were noted.
    • During the recent GYN OPD followup on 2023/03/24, elevated tumor marker CEA level (CEA = 5.23 ng/mL) was detected. Cystoscopy was performed for cancer surverys, and no urethra or bladder invasion was noted. Abdomen + pelvis CT was arranged on 2023/05/02 with impression of 1) S/P hysterectomy.R/O recurrent tumor (2.3cm) at vaginal stump with urinary bladder invasion; 2) A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma. Under the impression of cervical cancer with recurrence, excision of vaginal stump mass + partial vaginectomy, which were performed on 2023/05/22. Severe adhesion between vagina and posterior bladder wall was noted during the operation and bladder ruptured intraoperatively during adhesiolysis, received bladder repair. This time, she was admitted for the prepare chemotherapy and further management.
  • Course of inpatient treatment
    • After admission, collect 24hrs CCr. on 2023/04/04 showed 66.4mL/min, and arranged audiometry on 2023/06/23 showed R’t : 31 dB HL, normal to moderate SNHL、L’t : 35 dB HL, mild to moderate SNHL. Dorison 5#(20mg) po and Cimetidine 1# po before chemotherapy with Taxol 12 hrs on 2023/06/22 at 23:00 and before chemotherapy with Taxol 6 hrs on 2023/06/23 at 05:00, she received chemotherapy with paclitaxel (175mg/m2, self paid) plus carboplatin (AUC:6, sflf paid) on 2023/06/23 (C1) smoothly. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. Type 2 diabetes mellitus was treated with Kludone MR 60mg/tab 1# PO QDAC and Forxiga 10mg/tab 1# PO QDAC control. For chemotherapy, Vemlidy 25 mg/tab 1# PO QD was given for Anti-HBc reactive. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/06/24 and OPD followed up later.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-05-20 ~ 2023-05-25 POMR Obstetrics and Gynecology Huang SiCheng
  • Course of inpatient treatment
    • She was arranged to admit for excision of vaginal stump mass + partial vaginectomy, which were performed on 20230522. Severe adhesion between vagina and posterior bladder wall was noted during the operation and bladder ruptured intraoperatively during adhesiolysis. We consulted urologist for bladder repair.The perforation lesion was repaired with 3-0 vicryl with watertight closure technique. There was no leak after normal saline leak test for 200 ml. Cystoscopy showed intact trigone and bilateral DBJ in situ. We were suggested to keep her foley 1 week after the operation for further observation. Her postoperative course was uneventful. Abdominal wound was clear without discharge and healing was well. Under patient’s requirement, she was discharged on 2023/05/25 with foley and double-J catheterization. Her OPD follow-up appointment is scheduled on 2023/05/30. Cystoscopy will be arranged then.
• 2023-05-04 SOAP Obstetrics and Gynecology Huang SiCheng
  • Plan
    • 2022/11/08 ~ 2023/01/10 Aldara Cream (imiquimod 5% w/w)
    • 2023/04/27 1st Aldara
    • 2023/05/02 2nd Aldara
    • 2023/05/04 Pause the use of Aldara for now and supplement with female hormones.
• 2021-12-30 SOAP Hemato-Oncology Xia HeXiong
  • Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 2021-12-30
    • Liver biopsy (2021/12/9 Abd CT: r/o liver meta)
    • Postoperative Radiotherapy.

[consultation]

• 2023-05-21 Urology
  • A:
    • The cystoscopy on 05/03 showed tip of trigone being elevated.
    • The mucosa was healthy at that time but the tumor is very near trigone.

[surgical operation]

• 2023-05-22 Cystorrhaphy + cystoscopic exam
  • Finding:
    • A 3 cm laceration wound at posterior wall, just near the previous vaginal wall
    • No N/S leak after 200 ml infusion to bladder
  • Procedure:
    • We took over from GYN doctor. Identify the perforation site of urinary bladder. Repair with 3-o vicryl with watertight closure technique. There was no leak after normal saline leak test for 200 ml. Cystoscopy showed intact trigone and bilateral DBJ in situ. The GYN doctor took over for the further surgery.
• 2023-05-22 Excision of vaginal stump mass + partial vaginectomy
  • Finding:
    • Moderate adhesion of pelvic wall and sigmoid colon. Little ascites s/p washing cytology.
    • Vaginal lesion with papillary tissue at 9 ~12 oclock direction, 2x1cm, s/p excision
    • Severe adhesion between vagina and posterior bladder wall, bladder rupture intraoperatively, s/p repair by urologist.
    • Estimated blood loss: 300ml
    • Blood transfusion: nil
    • Complication: nil
  • Procedure:
    • Put patient on the lithotomy position.
    • Skin disinfection with betadine.
    • Supraumbilical midline vertical skin incision was done
    • Open the abdominal wall layer by layer.
    • Apply auto-retractor and pack up the intestine to expose the pelvic cavity.
    • Pelvic adhesiolysis was done.
    • Severe adhesion between vagina and posterior bladder wall, bladder rupture intraoperatively, s/p repair by urologist.
    • Excision of vaginal lesion and partial vaginectomy were performed smoothly to remove the lesion with safe margin.
    • Close the wound with 2-0 Vicryl.
    • Severe adhesion between vagina and posterior bladder wall, bladder rupture with a 3x2 cm hole intraoperatively, s/p repair by urologist.
    • Checking bleeding and hemostasis.
    • Two 15fr J-VAC were placed in the bilateral CDS
    • Reperitonealization and close the abdominal wall layer by layer.
    • Approximation of skin with 4-0 Vicryl.
• 2023-05-22 cystoscopy examination and bilateral double J stenting   - Finding:
  • mass compression of bladder neck from external side
  • No gross tumor noted in bladder
  • Procedure:
    • Under endotracheal general general anesthesia, the patient was in lithotomy position. Disinfection and draping the operation field were done as usual methods. Cystoscopy was performed to examinate bladder and identify bil UO. After retrograde insertion of guidewire, 6 Fr 24 cm double-J catheters were inserted at each side.
    • A 14 Fr Foley catheter was indwelled. The patient stood the procedures 

[chemotherapy]

• 2024-08-01 - bevacizumab 900mg NS 250mL 1.5hr + paclitaxel 120mg/m2 180mg NS 250mL 3hr + carboplatin AUC 3 300mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-07-03 - bevacizumab 900mg NS 250mL 1.5hr + paclitaxel 140mg/m2 210mg NS 250mL 3hr + carboplatin AUC 4 360mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-06-04 - bevacizumab 900mg NS 250mL 1.5hr + paclitaxel 140mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 540mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-04 - bevacizumab 900mg NS 250mL 1.5hr + paclitaxel 140mg/m2 210mg NS 250mL 3hr + carboplatin AUC 4 360mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-11 - bevacizumab 900mg NS 250mL 1.5hr + paclitaxel 140mg/m2 270mg NS 250mL 3hr + carboplatin AUC 6 540mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-22 - bevacizumab 900mg NS 250mL 1.5hr + paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-27 - bevacizumab 900mg NS 250mL 1.5hr + paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-03 - bevacizumab 900mg NS 250mL 1.5hr + paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-27 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-05 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-10 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-18 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-21 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-08-01

[Granocyte and blood glucose monitoring recommendations]

Granocyte (lenograstim) is scheduled for 3 consecutive days to treat the patient’s neutropenia (WBC 2.33 x10^3/uL on 2024-07-31).

Serum glucose levels were recorded at 236 mg/dL on the morning of 2024-04-11 on the TPR panel. However, there are no recent HbA1c or serum glucose (AC) data available in the HIS5 lab panel. It is recommended that these tests be conducted routinely for better blood glucose monitoring and control.

2024-04-11

[considering hypoglycemic adjustment for elevated glucose; normal liver enzymes and potential cessation of baogan]

A CT scan conducted on 2024-04-08 revealed a suspected cystic tumor at the vaginal stump and hepatic tumors appeared unchanged. Subsequent lab tests on 2024-04-10 showed no significant abnormalities.

However, serum glucose levels, recorded at 293 mg/dL on the morning of 2024-04-11, were elevated despite current treatment with Forxiga (dapagliflozin) and Kludone (gliclazide). Should these high glucose levels persist, there may be a need to consider additional hypoglycemic agents to manage the patient’s condition.

Given the AST and ALT levels have remained within the normal range for several weeks, discontinuation of BaoGan (silymarin) might be considered.

2023-08-11

[reconciliation]

A refill for a 28-day quantity of Omeprotect (omeprazole) and Dulcolax (bisacodyl) was recently completed on 2023-08-05, but these medications are currently not listed in the active medication records. Kindly assess whether these drugs are no longer required for the patient.

2023-07-19

[reconciliation]

On 2023-07-08, the patient just refilled a 28-day supply of Omeprotect (omeprazole) and Dulcolax (bisacodyl), and on 2023-07-10 refilled a 30-day supply of Anxoken (metformin), Kludone (gliclazide), and Forxiga (dapagliflozin). However, metformin is currently absent from the active medication list, and a serum glucose level of 341mg/dL was recorded on 2023-07-19 at 16:16. It is advisable to determine if the omission of metformin is deliberate or due to the scheduling of a CT scan.

700832253

240801

[lab data]

• 2024-01-09 HBsAg (NM) Positive
  
• 2024-01-09 HBsAg Value (NM) 1403.000
  
• 2024-01-09 Anti-HBc (NM) Positive
  
• 2024-01-09 Anti-HBc Value (NM) 0.007
  
• 2024-01-09 Anti-HCV (NM) Negative
  
• 2024-01-09 Anti-HCV Value (NM) 0.035

[exam findings] (not completed)

• 2024-01-05 Patho - colorectal polyp
  • Colorectum, rectum, 3 cm above anal verge, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (focal weak +), MSH6 (+), MSH2(+), MLH1 (+).

[chemotherapy]

• 2024-07-31 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-07-13 - (FOLFOX)
• 2024-06-29 - (FOLFOX)
• 2024-06-06 - (FOLFOX)
• 2024-05-23 - (FOLFOX)
• 2024-04-29 - (FOLFOX)
• 2024-04-09 - (FOLFOX)
• 2024-03-04 - fluorouracil 225mg/m2 340mg NS 500mL 20hr D1-5 (5-FU CCRT)
• 2024-02-26 - fluorouracil 225mg/m2 340mg NS 500mL 20hr D1-5 (5-FU CCRT)
• 2024-02-19 - fluorouracil 225mg/m2 340mg NS 500mL 20hr D1-5 (5-FU CCRT)
• 2024-01-29 - fluorouracil 225mg/m2 340mg NS 500mL 20hr D1-5 (5-FU CCRT)
• 2024-01-25 - fluorouracil 225mg/m2 340mg NS 500mL 20hr D1-2 (5-FU CCRT)

==========

2024-08-01

[patient tolerates FOLFOX regimen well with grossly normal lab results]

Lab data on 2024-07-30 were generally normal, and the patient is well tolerated with the FOLFOX regimen. Baraclude (entecavir) has been properly administered for positive Anti-HBc (2024-01-09). No medication issues were found.

700884718

240801

[exam findings]

• 2024-07-03 SONO - abdomen
  • Symptoms
    • Liver
      • Smooth liver surface; homogeneous echotexture.
      • One hypoechoic tumor with hyperechoic rim sized 1.28 cm in S6
      • Poor echo window of left lobe due to bowel gas mask
    • Bile duct and gallbladder
      • Hyperechoic calculi in GB up to 0.66 cm. No IHD dilatation. CHD/CBD masked
    • Kidney
      • Increased echogenicity and thinning cortex of both kidneys.
      • Cysts noted in both kidneys: up to 2.95 cm
      • Hyperechoic lesions (some with PAS) in both kidneys
  • Diagnosis
    • Liver tumor, S6, probable hemangioma (stationary in size)
    • GB stones; CHD/CBD masked
    • Chronic kidney disease with renal cysts and calcifications/stones
    • Suboptimal echo window; left lobe not seen
• 2024-05-15 Patho - bone marrow biospy
  • Bone marrow, biopsy — No evidence of lymphoma involvement
  • The sections show normocellular marrow (35%). M/E ratio = 5:1. The myeloid cells show good maturation. The megakaryocytes are slightly increased in number and normal morphology. No lymphoid aggregates can be identified. Scattered small CD3+ T-cells and CD20+ B lymphocytes in in terstitium. There is no evidence of lymphoma involvement in the sections examined. Suggest further bone marrow smear evaluation and clinic correlation.
• 2024-05-14 PET
  • Increased FDG uptake in bilateral pulmonary hilar lymph nodes and in some focal areas in the abdominal left paraaortic region. Lymphoma involving the lymph nodes in these regions should be watched out.
  • Increased FDG uptake in some focal areas in the anterior mediastinum. The nature is to be determined (lymphoma? other nature?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG uptake in the midline lower anterior abdominal wall. The nature is to be determined (post-operative inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Mildly increased FDG uptake in a small focal area in the upper lobe of left lung, possibly more benign in nature. However, please follow up chest CT scan for further evaluation.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation may show this picture.
• 2024-05-14 KUB
  • Spondylosis of the L-spine is noted.
  • Compression fracture of T12 vertebral body.
  • Fecal material store in the colon.
• 2024-05-10 CT - abdomen
  • Findings
    • There are few free gas bubbles in the peritoneal cavity that may be post-operative change.
    • There is mild dilatation of the small intestine that may be functional ileus. please correlate with clinical condition.
    • There is soft tissue lesion and surrounding fatty stranding in the umbilical aera. please correlate with clinical condition.
    • There are few gallstones.
    • There are several renal cysts on both kidney (up to 2.2 cm).
    • Abdominal aorta shows atherosclerosis and ectasia 2.2 cm.
    • Prior CT identified a homogeneous enhancing lesion 1.3 cm in S6/7 of the liver is noted again, stationary that may be hemangioma.
• 2024-05-03 Patho - small intestine resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Small intestine, distal jejunum, laparoscopic segmental small bowel resection with anastomosis —- Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue tumor (MALT lymphoma)
    • Lymph node, mesentery, small bowel — positive for MALT lymphoma (3/20)
      
  • MACROSCOPIC DESCRIPTION
    • Operation procedure: laparoscopic segmental small bowel resection with anastomosis
    • Topology: small, distal jejunum
      
    • Specimen size and number: 10 cm in length and 4.5 cm in greatest diameter
    • Tumor size: 5 cm in greatest dimesion
    • Sections are taken and labeled as: A1:bil cut ends, A2-6:tumor, A7-9:LNs,
  • MICROSCOPIC EXAMINATION
    • Histology type:
      • B-cell neoplasms
        • Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue tumor (MALT lymphoma)
    • Immunohistochemical stain profiles:
      • SOX-11(-), lambda light chain(-), kappa light chain(-), CD43(+ at background T cells), MUM1(-), Bcl-2(+), CD3(+ at background T cells), Ki-67 index: <= 5%, CD23(focal patchy +, < 10%), CD5(+ at background T cells), CD20(+), cyclin D1(-), CD10(-), Bcl-6(focal+), CD138(-).
• 2024-05-02, 2024-08-28 ECG
  • Atrial-sensed ventricular-paced rhythm
  • Abnormal ECG
• 2024-04-29 Flow volume chart
  • mild obstructive ventilatory defect
• 2024-04-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (179 - 67.1) / 179 = 62.51%
    • M-mode (Teichholz) = 62.5-61.9
  • Conclusion:
    • s/p AVR with bio-prosthesis, no AR, normal pressure gradient (AVA 2.16, Vmax 2.75 , MPG 15)
    • Bileaflet MV prolapse, severe focal prolapse of A3, 2 MR jet, severe MR at A3 (EROA 0.57), mild MR at A1-P1
    • Concentric LVH, dilated LV
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
    • Dilated LA, PPM leads in RA/RV (tip at RV apex)
• 2024-03-23 ECG
  • Left ventricular hypertrophy with QRS widening and repolarization abnormality
  • Functional pacemaker rhythm
• 2024-03-18 Colonoscopy
  • Findings
    • Colon
      • The scope had been inserted up to cecum. Much liquid and semiliquid stool in colon. Some diverticulum were noted at ascending colon
  • Diagnosis
    • Colon diverticulumn, ascending colon
    • Internal hemorrhoid
    • Poor colon preparation
• 2024-03-05 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Periampullary diverticulum, 2nd portion
  • CLO test: Negative
• 2024-02-20 Flow volume chart
  • moderate airway obstruction
• 2024-02-19 Small Intestine
  • Duodenal diverticulum.
  • No abnormal bowel loop displacement.
  • The passage time is about 60 minutes.
  • S/P pace-maker implantation.
• 2024-02-19 SONO - abdomen
  • Symptoms
    • Liver
      • Smooth surface and fine echotexture of liver was noted.
    • Bile duct and gallbladder
      • Several hyperechoic lesions with PAS up to 1.5cm were noted in GB.
      • CBD and bilateral IHD were not dilated.
    • Kidney
      • Several anechoic lesions up to 2.4cm were noted at both kidneys.
    • Pancreas
      • Some parts of pancreas blocked by bowel gas, especially head and tail.
    • Others
      • Increased bowel gas was noted. Focal SB wall thickening was noted at LLQ, up to 0.8cm in thickness
  • Diagnosis:
    • Enteropathy, LLQ
    • GB stones
    • Renal cysts, both
• 2024-02-06 CT - abdomen
  • Findings
    • Dilatation of small bowel with collapse of distal ileum and colon, c/w obstruction. Presence of transitional zone.
    • Gallstones.
    • Bilateral renal cysts, up to 1.3cm.
    • Diverticulosis of proximal A-colon.
    • Disc space narrowing of L4/5 and L5/S1.
  • Impression
    • Small bowel obstruction
• 2024-02-06 KUB
  • increased air in distended loops of small bowel over LUQ, RUQ, LLQ and visible Lt colonic segments air, could be paralytic ileus.
  • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, L-spine.
• 2023-10-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (200 - 94) / 200 = 63.00%
    • 2D (M-Simpson) = 53
  • Conclusion:
    • Dilated LV with hypokinesia of lateral wall, posterior wall; borderline LV systolic function.
    • Normal RV systolic function.
    • Biventricular hypertrophy with Gr II LV diastolic dysfunction; severely dilated LA.
    • S/P aortic vavle replacement (bioprosthesis) with adequate prosthetic valve function and residual mild aortic stenosis (AVA = 1.62 cm2 by Doppler method; Mean aortic pressure gradient = 13 mmHg).
    • Degenerative changes of mitral valve and redundant chordae with anterior mitral leaflet prolapse (A3) and moderate to severe eccentric MR (2 jets); mild PR.
    • S/P intracardiac device implantation with leads in RA/RV.
    • Mild aortic root calcification.

[MedRec]

• 2024-03-23 ~ 2024-03-26 POMR General and Gastrointestinal Surgery Chen YenZhi
  • Discharge diagnosis
    • Ileus, unspecified
  • CC
    • abdominal pain for 2 days
• 2024-03-04 SOAP Hemato-Oncology Yang MuJun
  • S: refill
    • Recurrent small bowel obstruction (2022 and 2024), s/p conservative Tx during 2/16-2/24
    • Focal small bowel wall thickening, enteritis or malignancy could be not rale out.
  • Prescription
    • Foliromin (ferrous sodium citrate 50mg) 1# QD 28D
• 2024-02-16 ~ 2024-02-24 POMR Gastroenterology Xiao ZongXian
  • Discharge diagnosis
    • Recurrent small bowel obstruction
    • Focal small bowel wall thickening, rule out enteritis or malignancy
    • Anemia, unspecified
    • Sepsis, unspecified organism
    • Chronic kidney disease, stage 3 (moderate)
    • Paroxysmal atrial fibrillation, with pacemaker in placement
    • Heart failure, unspecified
  • CC
    • Severe abdominal pain at epigastric region without nausea or vomiting in the wee hours (2am, 4am) this morning.
• 2024-02-07 ~ 2024-02-11 POMR Gastroenterology Xiao ZongXian
  • Discharge diagnosis
    • Small bowel obstruction, r/o enteritis or other nature, improved
  • CC
    • Sudden right upper abdominal pain with nausea and watery vomiting 3 times since wee hours.
• 2024-02-05 SOAP Hemato-Oncology Yang MuJun
  • S:
    • IDA, cause? pending panendoscopy and colonoscopy result (2/22), add foliromin
  • Prescription
    • Foliromin (ferrous sodium citrate 50mg) 1# QD 28D
• 2024-01-24 SOAP Hemato-Oncology Yang MuJun
  • S:
    • refer for anemia, panendoscopy and colonoscopy (2/22) arranged by GI doctor, check ferritin, ANA, protein EP, Folic acid, vit B12

[consultation]

• 2024-05-02 Cardiology
  • Q
    • This 76 year old patient (1) recurrent small bowel obstruction, (2) CKD stage 3, (3) Paroxysmal atrial fibrilation, with pacemaker in placement, (4) heart failure (5) severe MR, s/p AVP with bio-prosthesis, no AR (6) BPH s/p
    • According to the patient, yesterday (5/1), he climbed stairs and felt dizzy, then slowly fell down onto his hip, without initially losing consciousness or hit the head.
    • His had IDA under Fe supplament. Hgb today was 10.9 g/dL (9.8 g/dL).
    • Lab
      • 2024-05-02 CRP <0.1 mg/dL
        
      • 2024-05-02 PT 10.8 sec
        
      • 2024-05-02 INR 1.03
        
      • 2024-05-02 HGB 10.9 g/dL (2024-04-01 HGB 9.8 g/dL)
        
      • 2024-05-02 MCV 87.2 fL
        
    • 2024-04-29 2D transthoracic echocardiography
      • Report:
        • AO(mm) = 29
        • LA(mm) = 50
        • IVS(mm) = 11.8
        • LVPW(mm) = 11.4
        • LVEDD(mm) = 59.8
        • LVESD(mm) = 39.3
        • LVEDV(ml) = 179
        • LVESV(ml) = 67.1
        • LV mass(gm) = 298
        • RVEDD(mm)(mid-cavity) =
        • TAPSE(mm) = 24.8
        • LVEF(%) =
        • M-mode(Teichholz) = 62.5-61.9
        • 2D(M-Simpson) =
      • Diagnosis:
        • Heart size: Dilated LA,LV ;
        • Thickening: IVS,LVPW
        • Pericardial effusion: None
        • LV systolic function: Normal
        • RV systolic function: Normal
        • LV wall motion: Normal
        • MR: severe ; PISA radius 14 mm , Effective regurgitant orifice area 0.57 cm²; TR: mild ; Max pressure gradient = 29 mmHg ; PR: mild ;
        • Mitral E/A = 111 / 137 cm/s (E/A ratio = 0.8) ; Dec.time = 296 ms ;
        • Septal MA e’/a’ = 7.74 / 10.5 cm/s ; Septal E/e’ = 14.3; Lateral MA e’/a’ = 7.16 / 9.38 cm/s ; Lateral E/e’ = 15.5 ;
        • Intracardiac thrombus : None
        • Vegetation : None
          
        • Congential lesion : None
        • Calcified lestions : None
        • IVC size 16.9 mm with inspiratory collapse > 50%
      • Conclusion:
        • s/p AVR with bio-prosthesis, no AR, normal pressure gradient (AVA 2.16, Vmax 2.75 , MPG 15)
        • Bileaflet MV prolapse, severe focal prolapse of A3; 2 MR jet, severe MR at A3 (EROA 0.57), mild MR at A1-P1
        • Concentric LVH, dilated LV
        • Preserved LV and RV systolic function
        • Mild PR, mild TR, normal IVC size
        • Dilated LA, PPM leads in RA/RV (tip at RV apex)
    • We need your expertise examine this patient. Thank you
  • A
    • I was consulted for his chronic heart condition and acute repeated ileus with scheduled operation.
    • EKG: A-sensed and V-paced.
    • CXR: normal heart size, no pulmonary congestion.
    • Cardiac echo:
      • s/p AVR with bio-prosthesis, no AR, normal pressure gradient (AVA 2.16, Vmax 2.75 , MPG 15)
      • Bileaflet MV prolapse, severe focal prolapse of A3; 2 MR jet, severe MR at A3 (EROA 0.57), mild MR at A1-P1
      • Concentric LVH, dilated LV
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
      • Dilated LA, PPM leads in RA/RV (tip at RV apex)
    • Lab
      • 2024-05-02 Creatinine 1.44 mg/dL
        
      • HGB 10.9 g/dL
        
    • Suggestion:
      • This patient is in his chronic heart conditon with no acute problem, keep CV OPD medication as possible. May resume NOAC as soon as possible if no risk of bleeding.
      • Avoid fluid overload and keep adequate BP control.
• 2024-02-06 General and Gastroenterological Surgery

[immunochemotherapy]

• 2024-07-15 - rituximab 375mg/m2 625mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1250mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 100mg QD PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + acetaminophen 500mg PO + NS 250mL
• 2024-06-24 - rituximab 375mg/m2 625mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1250mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 100mg QD PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + acetaminophen 500mg PO + NS 250mL

==========

701527442

240801

[exam findings]

• 2024-06-14 Patho - ovary biopsy/wedge resection
  • Ovary, left, laparoscopic exploration biopsy — Serous carcinoma, high-grade
  • The sections show a picture of high-grade serous carcinoma, composed of polygonal neoplastic cells arranged in solid and papillary patterns. Marked nuclear atypia is present.
  • IHC, the tumor cells reveal: WT1(+), PR(rare +), Napsin A(-), p53(+, mutant-pattern), and p16(diffusely +).
• 2024-06-06 Ascites Tapping
  • Procedure: Ascites tapping
  • Indication: Ascites
  • Symptoms: Abdominal fullness
  • Course: 18G needle was inserted at RLQ under echo guided insertion. 2000ml yellowish ascites was drainaged and sent to exam.

[MedRec]

[chemotherapy]

• 2024-07-31 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2024-07-06 - paclitaxel 175mg/m2 265mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2024-06-17 - paclitaxel 175mg/m2 265mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL

==========

2024-08-01

[successful reduction of ca125 with paclitaxel and carboplatin]

The tumor marker CA125 readings have continued to decrease after initiating the paclitaxel and carboplatin regimen on 2024-06-17. Lab data on 2024-07-30 were generally acceptable. No medication discrepancies were identified.

• 2024-07-22 CA-125 (NM) 117.708 U/ml
• 2024-07-08 CA-125 (NM) 1227.000 U/ml
• 2024-07-01 CA-125 (NM) 3489.920 U/ml
• 2024-06-06 CA-125 4346.7 U/mL

700521108

240730

[exam findings]

[MedRec]

• 2024-04-22 ~ 2024-04-25 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Recurrent melanoma of skin status post operationt with tumor recurrence and distant metastasis, rcTxNxM1, stage IV
    • Unspecified viral hepatitis B without hepatic coma
  • CC
    • for chemotherapy
  • Present illness
    • This 66 years old female patient has histpry of hypertension.
    • She first visited Jing-Mei hospital on 2022/07/11 because of a granuloma swelling pain at her left heel /p debridement and excision. However a amelotic melanoma was noted on the pathology report at the JingMei hospital. She was later admitted to Taipei Tzu-Chi hospital Oncology department on 2022/7/29 for furthur consultation and was diagnosed with cutaneous abscess of left foot and neoplasm of her sole. She then visited PS OPD on 2022/08/09 and surgical excision to remove melanoma and graft implantation for the wound on 2022/08/18.
    • PET on 2022/8, report showed 1. A glucose hypermetabolism lesion in the left foot, probably an inflammation/infection process and 2. Increased FDG uptake in bilateral shoulders, knees, and right hip, probably benign in nature.
    • She regular ONC OPD follow up, repeat PET on 2024/02/26, report showed recurrent tumor with lymph node metastasis, suggesting biopsy for investigation, several new lesions of markedly increased FDG uptake in soft tissue near the left knee, in a left pelvic lymph node, and at the L4 spine compared with the previous study on 2022-08-03, highly suspected recurrent tumor with regional lymph nodes and distant metastasis. Malignant melanoma of skin s/p treatment with tumor recurrence and distant metastasis, rcTxNxM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2024/03/15 “lymph node”, excision biopsy — malignant melanoma, (1/1), with extracapsular extension. IHC stains: HMB-45 (+), S-100 (+), vimentin (+), CK7 (-), CK20 (equivocal).
    • Postive of HBsAg, GI OPD take Tenofovir control.
    • This time, she was admitted for chemotherapy on 2024/04/22.
  • Course of inpatient treatment
    • After admission, she received self paid of Taxotere on 2024/04/25. Dorison 2# bid * 3 days since 4/24-4/26. Under the stable condition, he can be discharged on 2024/04/25. OPD follow up is arranged.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 5D
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 90mg, lysozyme 20mg) 1# TID 5D
    • Limeson (dexamethasone 4mg) 2# BID 2D
    • Ulstop (famotidine 20mg) 1# BID 2D
    • Metifen SR (diclofenac 75mg) 1# PRNQD if joint pain
• 2024-03-29 SOAP Gastroenterology Chen HongDa
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD 28D

[chemotherapy]

• 2024-07-30 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-07-06 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-06-11 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-20 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-04-25 - docetaxel 75mg/m2 118mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

700653785

240730

[exam findings]

• 2024-06-08 CXR
  • Right catheterization to SVC in position.
  • S/P Port-A infusion catheter insertion.
  • Left pleural effusion.
  • Ground glass opacities in bil. lungs.
• 2024-06-03 Patho - peritoneum biopsy
  • Labeled as “greater omentum”, “peritoneal tumor excision” — adenocarcinoma.
  • Sections show omental tissue with focal of adenocarcinoma. Many intra-vascular tumor thrombi are present.
  • IHC stains: CDX2 (+), CK20 (+), compatible with gastric origin.
• 2024-05-30 PET
  • Glucose hypermetabolism in the lower body and antrum of the stomach with possible invasion to pancreas and in some regional lymph nodes, compatible with primary gastric malignancy with possible invasion to pancreas and some regional lymph node metastases.
  • Glucose hypermetabolism in the left supraclavicular, bilateral pulmonary hilar, mediastinal and parasternal lymph nodes and in multiple mesenteric, bilateral paraaortic and common iliac lymph nodes, compatible with metastatic lymph nodes.
  • Glucose hypermetabolism in multiple bones as mentioned above, suggesting multiple bone metastases.
  • Glucose hypermetabolism in a focal area in the soft tissue of right buttock. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
• 2024-05-24 SONO - abdomen
  • Indication: Abdominal pain
  • Symptoms:
    • Liver
      • Heterogenous echotexture of liver parenchyma
    • Bile duct and gallbladder
      • Echogenic substance in GB.
      • No CBD dilatation.
    • Portal veins and blood vessels
      • Patent portal vein.
    • Kidney
      • No definite stone or hydronephrosis.
    • Pancreas
      • Some parts of pancreas blocked by bowel gas, especially head and tail. No obvious P-duct dilatation was noted. One 1.5cm hypoechoic lesion was noted at pancreatic head. Prominent pancreatic head
    • Spleen
      • No splenomegaly
    • Ascites
      • Moderate ascites
    • Others
      • Gastric wall thickening was noted. Bilateral pleural effusion was noted
  • Diagnosis:
    • Prominent pancreatic head, without P-duct dilatation
    • Suspicious lymph node, pancreatic head
    • Parenchymal liver disease
    • Suspicious gallbladder sludge
    • Moderate ascites
    • Gastric wall thickening
    • Bilateral pleural effusion
  • Suggestion:
    • Please correlate with CT scan
    • Consider arrange ascites survey if clinical condition needed
• 2024-05-23 Patho - stomach biopsy
  • Stomach, lower body, biopsy — poorly differentiated adenocarcinoma with signet-ring cell differentiation.
  • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of malignant tumor cells arranged in solid architecture, and signet-ring cell diffferentiation. H.pylori are present.
  • Immunostain — Her2/neu: negative (1+), CK: positive
• 2024-05-22 CT - abdomen
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:4b(T_value) N:3b(N_value) M:1(M_value) STAGE:IV B(Stage_value)
• 2024-05-22 KUB
  • Calcification over right upper abdomen overlaping with renal shadow, could be due to right renal stone.
  • Calcifications in the pelvic cavity, could be due to phleboliths.
  • Non-specific bowel gas pattern.
  • Lumbar spondylosis.
• 2024-05-22 ECG
  • Sinus tachycardia
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2024-05-22 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Gastric mucosal lesion, favor fungating tumor, suspect adenocarcinoma (Bormann type 3) or lymphoma, lower body to antrum/pylorus, and duodenal bulb with stricture, s/p biopsy
  • CLO test: Positive
  • Suggestion:
    • pursue pathology and CLO test
    • Arrange CT scan

[MedRec]

• 2024-06-25 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • Arrange admission for FLOT +/- Nivo (docetaxel -> self-pay, and Nivo self pay first before NHI)
• 2024-03-18 SOAP Psychosomatic Medicine Lin JingEn
  • Diagnosis
    • Depressive disorder, not elsewhere classified [F32.9]
    • Generalized anxiety disorder [F41.1]
  • Prescription x3
    • Lexapro (escitalopram 10mg) 1# HS
    • Eurodin (estazolam 2mg) 0.5# HS
• 2017-01-24 SOAP Psychosomatic Medicine Wang HuiYi
  • Diagnosis
    • Depressive disorder, not elsewhere classified [F32.9]
    • Generalized anxiety disorder [F41.1]
  • Prescription x3
    • Leeyo (escitalopram 10mg) 1# HS

[consultation]

• 2024-06-04 Gastroenterology
  • Q
    • Weight loss 5kgw in one month was mentioned. Under impressed of gastric cancer, she underwent GJ bypass on 2024/06/03.
    • We need your help for nutrition support with TPN after operation. Thank you!!
  • A
    • A case of gastric cancer who request post-op nutrition support.
      • General appearance: ill looking
      • GI tract: GJ bypass on 2024/06/03
        
      • Feeding: NPO
      • Allergy: NKA
      • Nutrition assessment:
        • BH 156.6cm BW 52kg
        • IBW 53.9kg 97%IBW BMI 21.2
          
        • BEE 1166kcal TEE 1819kcal
      • Lab data: Alb 2.3 K 4.2 GOT 58 BS 141
        
    • According to the patient’s present conditions, parenteral nutrition will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
    • PN Use Recommendation:
      • DC SMOFkabiven peri 1440ml QD
      • SMOFkabiven central 1477ml QD, 61.5ml/hr
      • Lyo-Povigent 4ml/QD (add in TPN) (if not availabe, then swift to B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
      • Addaven 10ml/QD（add in TPN）
    • Items to be monitored when PN use:
      • TPN is for single route, do not mix with other drugs except TPN drugs.
      • Check BW QW5 and record I/O Q8H
      • Check one touch Q6H x2 days, if stable QD check
      • Please control BS < 200 mg/dl with RI sliding scale
      • QW1 check CBC/DC
      • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
      • When TPN is insufficient, replace with YF5 or D10W.
• 2024-05-29 General and Gastrointestinal Surgery
  • Q
    • Stomach, lower body, biopsy— poorly differentiated adenocarcinoma with signet-ring cell differentiation.
    • We need your expertise for further advise Thaks~
  • A
    • impression
      • gastric cancer, with pancreas invasion, suspicious peritoneal carcinomatosis
    • suggest
      • please arrange PET first for r/o other distant metastasis
      • PN support after PET due to BW loss (56 -> 51kg)
      • we will f/u this case
• 2024-05-28 Hemato-Oncology
  • Q
    • This 59-year-old female has the history of Depressive disorder and Generalized anxiety disorder under medication control at our PSY OPD.
    • She suffered from epigastric pain for a long time symptom accompany with nausea vomit, she ever visted LMD for help but invain then was refered here for further survay. At ER, physical examination revealed pale conjunctiva, abdomen distended and epigastric tenderness.
    • Lab data showed anemia (7.0 g/dL) elevated serum CRP (3.3 mg/dL), hypokalaemia (3.3 mmol/L), Lipase (576 IU/L). Blood transfusion with LPRBC 2units was given to correct anemia.
    • EGD was schedued for anemia survay which reported Reflux esophagitis LA Classification grade A,Gastric mucosal lesion, favor fungating tumor, suspect adenocarcinoma (Bormann type 3) or lymphoma, lower body to antrum/pylorus, and duodenal bulb with stricture, s/p biopsy. Suggestion: pursue pathology and CLO test Arrange CT scan.
    • The Abdomen CT reported: 1. segmental wall thickening in the gastric antrium; 2. prominent pancreatic head with enlarged lymph nodes in the adjacent region; 3. moderate ascites in the pelvic cavity.
    • She denied nasal bleeding, nausea, tarry stool or bloody stool passage but weight loss 5kgw in one month was mentioned. No TOCC history was mentioned. Under the impression of Gastric mucosal lesion, favor fungating tumor, suspect adenocarcinoma, she was admitted to our GI ward for further evaluation and management.     
    • EGD pathology report Stomach, lower body, biopsy — poorly differentiated adenocarcinoma with signet-ring cell differentiation.
    • we need your further advise Thanks~  
  • A
    • This 59-year-old woman has a history of depressive disorder and generalized anxiety disorder. We are consulted regarding her case of gastric poorly differentiated adenocarcinoma with signet-ring cell differentiation.
    • Please send the ascites cell block and consult GS for further evaluation. Patient want arrange sely pay PET/CT scan.
    • If the tumor is unresectable, arrange for port A implantation and check HBsAg, Anti-HBc, Anti-HBs, and Anti-HCV.

[chemotherapy]

• 2024-07-04 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 70mg NS 250mL 1hr + oxaliplatin 85mg/m2 125mg D5W 250mL 2hr (Y-sited Covorin) + leucovorin 200mg/m2 300mg D5W 250mL 2hr (Y-sited Oxalip) + fluorouracil 2600mg/m2 3800mg D5W 500mL 24hr (Opdivo + FLOT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-04 - fluorouracil 750mg NS 500mL 1hr IP D1-5 + leucovorin 20mg/m2 30mg NS 250mL 2hr + mitomycin-C 20mg/m2 30mg NS 500mL 2hr (IPEC)
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-07-30

[Nexium (esomeprazole) tube feeding]

To prepare Nexium (esomeprazole) for administration through a feeding tube, use the Simple Suspension Method (SSM). The SSM involves administering tablets or capsules by disintegrating and suspending them in warm water without crushing or opening the capsule. This method allows the medication to be converted into a liquid form suitable for feeding tube administration.

2024-07-02

[considering silimarin for (Brosym-induced?) hepatic enzyme elevation]

General urine examination:

• 2024-07-01 App Turbid
• 2024-07-01 PRO 3+
• 2024-07-01 OB 2+
• 2024-07-01 Sediment-RBC 10-19 /HPF
• 2024-07-01 Casts Hyaline:1-2 /LPF
• 2024-07-01 Bacteria 3+ /HPF
• 2024-07-01 Crystal CaOX:1+ /HPF

The urine exam indicated a suspected infection. After Brosym (cefoperazone, sulbactam) was initiated on 2024-07-01, the patient’s body temperature has begun to decrease. Records show the patient has tachycardia, while respiratory rate and blood pressure remain stable, with an SpO2 of 95%.

Possible adverse reactions to Brosym include increased serum alanine aminotransferase and increased serum aspartate aminotransferase. It is unclear whether the elevation in hepatic enzymes occurred after starting Brosym, so continued monitoring is necessary. The addition of BaoGan (silymarin) might be beneficial.

• 2024-07-01 AST 91 U/L

• 2024-06-20 AST 35 U/L

• 2024-07-01 ALT 69 U/L

• 2024-06-20 ALT 18 U/L

[managing calcium oxalate crystals in urine]

The urine exam (2024-07-01) revealed calcium oxalate crystals. If this result is expected to cause problems, the medical management can aim to reduce urinary calcium oxalate saturation and oxalate production to minimize kidney oxalate deposition and delay the progression of kidney injury.

• Increased fluid intake
  • A high fluid intake, resulting in a urinary output of more than 3 L/day per 1.73 m2, is the most effective therapy to decrease tubular fluid oxalate concentration and reduce intratubular oxalate deposition.
• Inhibition of calcium oxalate precipitation
  • Alkalinizing urine with potassium citrate can reduce urinary calcium oxalate saturation by forming complexes with calcium, thereby decreasing stone formation. Oral potassium citrate at a dose of 0.15 g/kg divided into two or three doses per day is recommended. If kidney function is impaired and plasma potassium is increased, sodium citrate can replace potassium citrate.
  • Other inhibitors of calcium oxalate crystallization, used selectively, include neutral phosphate (20 to 30 mg/kg) or magnesium oxide (500 mg/day per m2), administered orally in two or three doses per day. Phosphate supplements should be discontinued in patients with impaired kidney function who develop hyperphosphatemia. A serum phosphate level should be obtained if a patient’s eGFR decreases. If hyperphosphatemia is present, phosphate supplementation should be stopped to prevent phosphate accumulation and secondary hyperparathyroidism exacerbation.
• Dietary oxalate restriction
  • Although intestinal oxalate absorption is lower in patients with primary hyperoxaluria compared to healthy subjects, foods high in oxalate (such as tea, chocolate, spinach, and rhubarb) should be restricted from their diet. However, since most oxalate is of endogenous origin, these dietary measures have a minor impact in most patients.

701080267

240730

[MedRec]

• 2023-11-29 ~ 2023-12-06 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Malignant neoplasm of rectum, status post laparoscpic abdominoperineal resection (APR) on 2023-11-30, ypT3N1aM1a(1/5), G3, LVI(+), PNI(+), stage IV1 (left inguinal lymph node metastasis)
  • CC
    • Bloody stool since 2023-03, colonscopy / computer tomgraphy / pathology report proved adenocarcinoma of rectum cT3N1aM1a, stage IVa status post concurent chemoradiotherapy, admitted for laparascopic abdominoperineal rescetion.
  • Present illness
    • This 67-year-old woman has a history of diabetes mellitus type 2, hyperlipidemia, and hypertension, all of which are well controlled with medication. She denies any prior surgeries to her chest, abdomen, or anus.
    • She has been experiencing perianal bleeding after defecation and constipation since 2023-03.
    • She underwent colonoscopy, which revealed a colon polyp that was pathologically confirmed to be adenocarcinoma.
    • Computer tomography (CT) and pelvic magnetic resonance imaging (MRI) in 2023-05 indicated stage IVa adenocarcinoma of the low rectum with cT3N1aM1a classification, with positive left inguinal lymph nodes.
    • She was then referred to the colorectal surgery department for further management.
    • She received concurrent chemoradiotherapy, which included pelvic radiotherapy to a total dose of 45 Gy in 25 fractions and radiotherapy to the rectal tumor and lymphadenopathy to a total dose of 50.4 Gy in 28 fractions.
    • Restaging with CT in 2023-09 revealed: Partial response of adenocarcinoma of the rectum after chemoradiotherapy (CCRT) Persistence of a non-regional metastatic node measuring 1.4 cm in the left inguinal area, with a slight decrease in size from 1.6 cm.
    • Sigmoidoscopy in 2023-11 showed progression of the disease, with a low rectal cancer lesion involving the anus that was easily friable and prone to bleeding. There was no bloody stool, body weight loss, and bowel habit change ever since CCRT.
    • Preoperative assessment was performed, including echocardiogram, which revealed: Left ventricular ejection fraction of 64%; Preserved left ventricular (LV) and right ventricular (RV) systolic function with normal wall motion; Grade 1 LV diastolic dysfunction.
    • Lung function tests showed mild restrictive ventilatory impairment.
    • The patient was informed of the risks and benefits of surgical intervention and agreed to the procedure. She signed the necessary operation permits.
    • Under the impression of adenocarcinoma of the low rectum involving the anus, cT3N1aM1a, stage IVa (revised by MRI), with positive left inguinal lymph nodes after CCRT, the patient is now admitted for laparoscopic abdominoperineal resection scheduled for tomorrow.
  • Course of inpatient treatment
    • After admission, preoperative assessment was done and no contraindication was found against operation.
    • Laparoscopic abdominal peritoneal resection was performed on 2023/11/30. The operation went uneventfully and the patient was brought back to ward afterwards.
    • After operation, the patient had mild operation wound pain. Flatus and stool passage was noted at enterostomy site, and no abdominal discomfort was noted after low-residual diet intake.
    • Foley was removed on 2023/12/02 and smooth urination was noted afterwards. JP drain was removed on 2023/12/04 and no discomfort or discharge was noted after removal.
    • Under stable condition, she was discharged today and OPD follow up was arranged.
  • Discharge prescription
    • cephalexin 500mg 1# QID
    • MgO 250mg 2# BID
    • Through (sennoside 12mg) 1# HS
    • biomycin Ointment (neomycin, tyrothricin) BID TOPI
    • Meififen SR (diclofenac 75mg) 1# BID
    • Ulstop (famotidine 20mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# PRNQ6H if pain

[chemotherapy]

• 2024-07-30 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 466mg NS 250mL 2hr + fluorouracil 2800mg/m2 3264mg NS 500mL 46hr (FOLFIRI 30% off)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

701117401

240730

[MedRec]

• 2024-04-19 ~ 2024-04-29 POMR Integrative Medicine Hong BoBin
  • Discharge diagnosis
    • Mantle cell lymphoma, stage IVB, status post chemotherapy with R-CHOP regimens and underwent autologous peripheral blood stem cell harvest on 2015/10/26-28
    • Normocytic anemia
  • CC
    • She wants to be an organ donor.
  • Present illness
    • This is a 76-year-old female with a medical history including:
      • Mantle cell lymphoma, stage IVB, treated with R-CHOP regimens for 8 cycles, followed by relapse and treated with RB for 4 cycles (on 20150520, 20150615, 20150707, 20150730) achieving a second complete remission. She underwent autologous peripheral blood stem cell harvest on 2015/10/26-28, followed by high-dose chemotherapy with BEAM regimens and autologous peripheral stem cell transplantation on 2016-03-02. She has been on oral target therapy with Ibrutinib 140 mg twice daily since 2019-12-18, and VENCLEXTA FC TAB 100 MG three times daily since 2022-10-12. She underwent salvage therapy with the addition of Rituximab on 2023/10/03, 11/03, 12/04 2024/01/02.
      • Spinal high-grade B-cell lymphoma, intra-dural, intra-medullary at T12-L1 with spinal stenosis, treated with surgical intervention (total laminectomies, T12-L1, and tumor removal) on 2019-11-20, currently in a stable condition.
      • Hypertension. 　 - She has been regularly followed up at Tri-Service General Hospital. Presently, she experienced general fatigue for several days and sought help at the emergency department of NeiHu Tri-Service General Hospital on 2024-04-18. Due to her wish to donate her body, she was referred by her senior relative (a patient’s cousin) to our hospital’s emergency department on 2024-04-19. 　 - At the time of admission to the emergency room, her vital signs were as follows: blood pressure 185/105 mmHg, pulse rate 92 beats/min, temperature 36.5 ℃, respiratory rate 18 breaths/min, consciousness level: E4V5M6, oxygen saturation 96%. Laboratory results showed WBC= 2.98*10^3/uL, N.seg= 28.8%, Na= 131 mmol/L, K= 5.1 mmol/L, BUN= 56 mg/dL, Cr= 2.8 mg/dL.
    • Given the impression of lymphoma with cachexia status, she was admitted to the Hematology and Oncology ward for further management.
  • Course of inpatient treatment
    • After admission, she was received of a series of exams including HIV, RPR, Hepatitis B & C profile for donation related tests. After receiving the best supportive care and mental support, her condition improved. Blood transfusion with PRBC to correct anemia. Under the relatively stable condition, the patient can be discharged on 2024/04/29 and further OPD follow-up.
  • Discharge prescription
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID 8D
    • Norvasc (amlodipine 5mg) 1# QD

==========

2024-07-30

[managing pancytopenia with frequent blood transfusions]

Pancytopenia and a right-shifted WBC differential count were observed. Elevated CRP levels and normal PCT levels might suggest a viral infection or non-infectious inflammatory conditions.

The patient frequently receives blood products, so checking iron levels might be advisable.

• 2024-07-29 Procalcitonin (PCT) 0.09 ng/mL

• 2024-07-29 CRP 5.6 mg/dL

• 2024-07-29 Band 0.0 %

• 2024-07-29 Neutrophil 39.2 %

• 2024-07-29 Lymphocyte 41.2 %

• 2024-07-29 Monocyte 4.9 %

• 2024-07-29 Eosinophil 4.9 %

• 2024-07-29 Basophil 1.0 %

• 2024-07-29 Metamyelocyte 7.8 %

• 2024-07-29 Blast 1.0 %

• 2024-07-29 Atypical Lymphocyte 0.0 %

• 2024-07-29 Reticulocyte Ratio 2.250 %

• 2024-07-29 WBC 2.49 x10^3/uL

• 2024-07-29 HGB 7.5 g/dL

• 2024-07-29 PLT 22 *10^3/uL

701450638

240730

[exam findings]

• 2024-02-21 CT - abdomen
  • Findings: Comparison: prior CT dated 2023/11/10.
    • Prior CT identified multiple metastases on both hepatic lobes are noted again, decreasing in size.
      • It is c/w multiple liver metastases S/P C/T with partial response.
    • S/P LAR with autosuture retention over the rectosigmoid junction.
      • S/P colostomy at left upper pelvis and para-stromal hernia.
    • Prior CT identified metastatic lymph node in hepatoduodenal ligament is noted again, decreasing in size.
    • Prior CT identified few small metastatic nodes in para-aortic space and para-cava space are noted again, stationary that is c/w few metastatic nodes S/P C/T show stable disease.
    • Prior CT identified a lung metastasis in LLL is noted again, stable in size.
  • Impression:
    • Multiple liver metastases S/P C/T show partial response.
• 2023-11-10 CT - abdomen
  • Findings: Comparison: prior CT dated 2023/08/18.
    • S/P LAR with autosuture retention over the rectosigmoid junction.
    • S/P colostomy at left upper pelvis and para-stromal hernia.
    • Prior CT identified multiple metastases on both hepatic lobes are noted again, mild increasing in size.
      • It is c/w multiple liver metastases S/P C/T with progressive disease.
    • Prior CT identified metastatic lymph node in hepatoduodenal ligament is noted again, stationary.
    • Prior CT identified few small metastatic nodes in para-aortic space and para-cava space are noted again, stationary that is c/w few metastatic nodes S/P C/T show stable disease.
    • Prior CT identified a lung metastasis in LLL is noted again, stable in size.
  • Impression:
    • Multiple liver metastases S/P C/T show progressive disease.
• 2023-08-18 CT - abdomen
  • 20220906 CT: Sigmoid colon cancer with micro-perforation and attachment to bladder region and liver, lung with distant lymph nodes metastasis, cT4N2M1b, stage: IVB status post Hartmann’s operation on 2022/09/06
  • History: hepatitis B anti-Hbc: positive
  • Findings: Comparison prior chest CT dated 2023/02/21.
    • S/P LAR with autosuture retention over the rectosigmoid junction.
    • S/P colostomy at left upper pelvis.
    • Prior CT identified multiple metastases on both hepatic lobes are noted again, increasing in size.
      • Multiple liver metastases S/P C/T show progressive disease.
    • Prior CT identified metastatic lymph node in hepatoduodenal ligament is noted again, stationary.
    • Prior CT identified few small metastatic nodes in para-aortic space and para-cava space are noted again, stationary that is c/w few metastatic nodes S/P C/T show stable disease.
    • Prior CT identified a lung metastasis in LLL is noted again, mild decreasing in size.
  • Impression:
    • Multiple liver metastases S/P C/T show progressive disease.
• 2023-05-30 Tc-99m MDP bone scan
  • Increased activity in the lower C-spine and lower L-spines. Degenerative change is more likely. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone sacn for further evaluation.
  • Increased activity in the right shoulder, right sternoclavicular junction, bilateral hips and knees, compatible with benign joint lesions.
• 2023-05-19 CT - abdomen
  • 20220906 CT: Sigmoid colon cancer with micro-perforation and attachment to bladder region and liver, lung with distant lymph nodes metastasis, cT4N2M1b, stage: IVB status post Hartmann’s operation on 2022/09/06
  • History: hepatitis B anti-Hbc: positive
  • Findings: Comparison: prior chest CT dated 2023/02/21.
    • S/P LAR with autosuture retention over the rectosigmoid junction.
      • S/P colostomy at left upper pelvis.
    • Prior CT identified several metastases on both hepatic lobes are noted again, mild decreasing in size.
      • However, three liver metastases in S4, S5, and S6/7 are noted again, mild increasing in size.
      • Multiple liver metastases S/P C/T show stable disease.
    • Prior CT identified metastatic lymph node in hepatoduodenal ligament is noted again, stationary.
    • Prior CT identified multiple metastatic nodes in para-aortic space and para-cava space are not noted again that is c/w multiple metastatic nodes S/P C/T show complete response.
    • Prior CT identified a lung metastasis in LLL (Srs:7 Img:5) is noted again, mild decreasing in size.
  • Impression:
    • Multiple liver metastases S/P C/T show stable disease.
• 2023-05-17 Shoulder Rt
  • AP internal and external rotation views of left shoulder show:
    • Rt osteoarthritis of A-C joint
• 2023-04-10 SONO - abdomen
  • Liver parenchymal disease
  • liver tumors, favor metastatic tumors
  • fatty infiltration of pancres(incomplete exam of pancreas)
• 2023-02-21 CT - chest
  • Impression: sigmoid colon cancer with lung, liver, and distant LNs metastases, in regression as compared previous CT on 2022/09/13.
• 2022-09-13 CT - chest
  • Impression: sigmoid colon cancer with lung, liver, and distant LNs metastases, with pleural effusion.
• 2022-09-08 All-RAS + BRAF mutation
  • All-RAS: There was no variant detected in the KRAS/NRAS gene
  • BRAF: There was no variant detected in the BRAF gene
• 2022-09-07 Patho - colon segmental resection for tumor (Y1)
  • Diagnosis:
    • Intestine, large, sigmoid colon, Hartmann procedure - moderately differentiated adenocarcinoma
      • perforation with acute peritonitis
    • Lymph node, regional, dissection
      • metastatic adenocarcinoma (9/13)
    • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
    • AJCC 8th edition pathology stage: pT4aN2b(cM1c); AJCC stage IVC
  • Gross Description:
    • Procedure: Hartmann procedure    - Tumor Site: Sigmoid colon
    • Tumor Size: 6 x 4 cm.
      
    • Macroscopic Tumor Perforation: Present
      
    • Macroscopic Intactness of Mesorectum (if applicable): Complete
    • Sections are taken and labeled as: A1: bil cut-ends, A2-4: LNs, A5-10: tumor
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension
      • Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Involved
        
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Present
    • Tumor Budding
      • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2):
      • Intermediate score (5-9)
    • Type of Polyp in Which Invasive Carcinoma Arose: Absent
    • Tumor Deposits: Not identified
      • Specify number of deposits: N/A
    • Regional Lymph Nodes
      • Number of Lymph Nodes Involved/Examined: 9/13
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
      • Primary Tumor (pT)
        • pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
      • Regional Lymph Nodes (pN):
        • pN2b: Seven or more regional lymph nodes are positive
      • Distant Metastasis (pM)
        • N/A
    • Additional Pathologic Findings (select all that apply):
      • perforation with acute peritonitis
    • Ancillary Studies: Pending (IHC stain of MSI will be followed.)
      
    • Comment(s)
      • NOTE: There is no peritoneal tissue, adjacent organs or structures for proof of tumor invasion or metastasis.
• 2022-09-06 CT - abdomen
  • Clinical history: 72 y/o male patient with fever for 1 day and abd pain for 1 wk, diarrhea+ for 3 months.
  • With and without contrast enhancement CT of abdomen - whole:
    • Focal thickening wall at the sigmoid colon with ulceration, r/o sigmoid colon cancer.
    • Focal air bubbles around sigmoid colon, proximal to the sigmoid tumor, r/o perforation.
    • There are poor enhancing tumors, up to 6.5cm in S4 liver, r/o liver metastasis.
    • There are multiple enlarged lymph nodes in pericolonic, common iliac and paraaortic regions.
    • Presence of ascites.
    • Left lower lung nodules, r/o lung metastasis.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • Impression:
    • Sigmoid cancer with lymph nodes metastasis, liver and lung metastasis, cstage T4N2M1.
    • Focal air bubbles around sigmoid colon, proximal to the sigmoid tumor, r/o perforation.

[MedRec]

• 2022-09-23 Gastroenterology
  • S
    • Come for NUC prophylaxis for C/T
    • First C/T scheduled on 20221003
  • O
    • PH:
      • OBI (ChatGPT: In a medical context, OBI stands for “Occult Hepatitis B Infection”. Occult Hepatitis B infection is characterized by the presence of hepatitis B virus (HBV) DNA in the liver (with detectable or undetectable HBV DNA in the serum) of individuals testing hepatitis B surface antigen (HBsAg) negative in routine assays.)
      • S-colon cancer with liver mets, s/p operation, under C/T
    • Start NUC prophylaxis. Check HBV DNA/antiHBs in advance
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2022-09-20 SOAP Hemato-Oncology
  • S: explain to pt & his wife & son about the indication & risk / benefit of palliative C/T wt FOLFIRI / Avastin IV Q2W x 12. (9/20 22).
    • 2022/09/14 HBsAg (NM) = Negative;
    • 2022/09/14 Anti-HBc (NM) = Positive;
    • 2022/09/14 Anti-HCV (NM) = Negative;
    • will consult Dr Xiao ZongXian for anti-HBV Tx for C/T (9/20 22).
    • will consult Dr Chen YanZhi for Port-A installation (9/20 22)
    • will do HBsAg, anti-HBc, anti-HCV
    • will give palliative C/T wt FOLFIRI / Avastin IV Q2W x 12. (9/20 22).
    • Adm on 10/3 22 for #1 palliative C/T wt FOLFIRI / Avastin IV Q2W x 12.
• 2022-09-06 ~ 2022-09-14 POMR Colorectal Surgery
  • Discharge diagnosis
    • Adenocarcinoma of sigmoid colon with microperforation and attachment to bladder region and liver, lung with distant lymph nodes metastasis, cT4N2M1c, stage: IVC status post Hartmann’s operation on 2022/09/06 with lung, liver, and distant LNs metastases, with pleural effusion
    • Malignant neoplasm of sigmoid colon
  • CC
    • abdominal fullness over lower abdomen for a long time this year, assciated requent bowel movement up to 7-8 times per day, acute onset of severe abdominal cramps this morning.
  • Present illness
    • This 72-year-old man denied major systemic disease. This time, he has abdominal fullness over lower abdomen for a long time this year, assciated requent bowel movement up to 7-8 times per day, acute onset of severe abdominal cramps this morning. He was vist our GI OPD for help. Physical Exam show abdomen soft, mass like distention over lower abdomen, tympanic on percussion, dullness on percussion over pelvic region, but marked rebound tenderness over lower abdomen. KUB was performed and revaled stool retention in the bowel. Then,refer to ER for PE signs of peritonitis. At ER, the con’s clear,Vital sign TPR:38.2/110/18 BP:131/79mmHg. Abdomen CT was performed and revealed 1. Sigmoid cancer with lymph nodes metastasis, liver and lung metastasis, cstage T4N2M1, 2. Focal air bubbles around sigmoid colon, proximal to the sigmoid tumor, r/o perforation. CRS was consulted and he underwent oepration of Hartmann’s procedure. Postoperation, he was admission to SICU for further management.
  • Course of inpatient treatment
    • He underwent oepration of Hartmann’s procedure on 2022/09-06. Op finding: 1) micro perforation over sigmoid colon region and attachment to bladder region. 2) much turbid pus intra abdomen. Following the operation, he was transferred to the surgical intensive care unit for further monitoring. At SICU, he was given nothing by mouth with adequate IV fluid supplement and empirical antibiotic treatment with Brosym were prescribed. After well weaning parancter, extubation smoothly on 2022/09/07. She had passed stool with normal bowel movement. Oral intake with clear liquid diet is encouraged. Since the general condition became more stabalized, he was transferrd to ordinary ward for further care on 2022/09/08.
    • We keep antibiotic treatment with Brosym. No fever or chills, leukocytosis improved much. Early activity is encouraged. The wound healing well and no erythema change. He had flatus passage and abdominal wound pain subsided. Drain is clear ascites and removal of JP drain on 2022/09/10. Oral intake program was adjusted and there was no abdominal discomfort after trying oral intake, IV fluid supplement was tapered and discontinued later. Chest CT was done for cancer survey and showed sigmoid colon cancer with lung, liver, and distant LNs metastases, with pleural effusion. His abdominal wound pain had got much better. In stable condition, he was discharged on 2022/09/14 and will receive OPD follow up next week.
  • Prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# Q12H
    • Acetal (acetaminophen 500mg) 1# PRNQ6H

[consultation]

• 2024-01-02 Dermatology
  • Q
    • for acne at face, and skin itchy around whole body evaluation
    • This 73-year-old male, a patient of S-colon cancer, pT4N2M1b, stage: IVB, with microperforation and attachment to bladder region and liver, lung mets with distant LNs mets.
    • Abdomen CT (2023/11/10) revealed Multiple liver metastases S/P C/T show progressive disease. And the tumor marker level is increased, so shift to Cetuximab plus FOLFOX.
    • He complaints acne at face noted since receive targeted therapy with Erbitux, and skin itchy around whole body. So we need your help for acne evaluation, thanks a lot!!
  • A
    • The patient had sufferred from pusutlar lesions on the face and nape (the back of the neck). Besides, xerotic dermatitis was noted on the trunk.
      
    • Under the impression of acniform eruption and follculitis on the nape, xerotic dermatitis on the trunk.
    • The following sugeetion:
      • for face, Kolincin Gel 1 tube topical bid use over face and Zalaine cream 1 tube topical bid use over nape.
      • for trunk, agree with Mycomb and Sinphraderm use and consider add C.B Strong 2 tube topical PRN use for pruritus control.

[immunochemotherapy]

• 2024-07-29 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. Yang MuJun)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-25 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-04 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 520mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-14 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 520mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-15 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 520mg NS 250mL 2hr + fluorouracil 2800mg/m2 3750mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-20 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 520mg NS 250mL 2hr + fluorouracil 2800mg/m2 3750mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-19 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-01-30 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-01-02 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-08 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-10 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg 500mL 46hr (Avastin + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-10-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4030mg 500mL 46hr (Avastin + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-09-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg 500mL 46hr (Avastin + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-09-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg 500mL 46hr (Avastin + FOLFOX. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-08-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg 500mL 46hr (Avastin + FOLFIRI. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-07-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg 500mL 46hr (Avastin + FOLFIRI. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-07-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg 500mL 46hr (Avastin + FOLFIRI. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-06-26 - Avastin + FOLFIRI. He JingLiang
• 2023-04-14 - Avastin + FOLFIRI. Wan XiongLin
• 2023-03-27 - Avastin + FOLFIRI. Wan XiongLin
• 2023-03-10 - Avastin + FOLFIRI. Wan XiongLin
• 2023-02-21 - Avastin + FOLFIRI. Zhang ShouYi
• 2023-02-03 - Avastin + FOLFIRI. Zhang ShouYi
• 2023-01-06 - Avastin + FOLFIRI. Zhang ShouYi
• 2022-12-19 - Avastin + FOLFIRI. Zhang ShouYi
• 2022-12-05 - Avastin + FOLFIRI. Zhang ShouYi
• 2022-11-21 - Avastin + FOLFIRI. Zhang ShouYi
• 2022-11-07 - Avastin + FOLFIRI. Zhang ShouYi
• 2022-10-20 - FOLFIRI. Zhang ShouYi
• 2022-10-03 - FOLFIRI. Zhang ShouYi

==========

2024-07-30

[managing high alt, ast, and bilirubin levels]

ALT, AST, and bilirubin levels remain elevated. BaoGan (silymarin) and Uliden (ursodeoxycholic acid) are being used, and no medication discrepancies have been identified.

• 2024-07-29 ALT 122 U/L

• 2024-07-10 ALT 126 U/L

• 2024-06-25 ALT 154 U/L

• 2024-07-29 AST 129 U/L

• 2024-07-10 AST 108 U/L

• 2024-06-25 AST 132 U/L

• 2024-07-29 Bilirubin direct 0.60 mg/dL

• 2024-06-25 Bilirubin direct 0.44 mg/dL

• 2024-06-04 Bilirubin direct 0.50 mg/dL

2024-06-04

[the current treatment regimen is not suspected to be the primary contributor to the patient’s established liver impairment]

The patient’s liver function tests have shown persistent abnormalities for several months, characterized by elevated levels of AST, ALT, and bilirubin. Notably, these abnormalities predate the initiation of the current Erbitux (cetuximab) plus FOLFOX regimen in Dec 2023. Therefore, a causal relationship between the treatment and the current liver impairment is not absolute likely.

2024-05-15

[liver impairment history might not be current regimen related]

The patient’s liver function has remained abnormal for the past months, as indicated by consistently elevated AST, ALT, and bilirubin levels. The current regimen of Erbitux (cetuximab) plus FOLFOX was initiated in Dec 2023, while the elevated liver function test results occurred well before the regimen started. Therefore, it cannot be directly concluded that the regimen is the primary cause of the recent liver impairment.

• 2024-05-14 AST 125 U/L

• 2024-04-15 AST 110 U/L

• 2024-04-03 AST 113 U/L

• 2024-03-20 AST 131 U/L

• 2024-03-06 AST 138 U/L

• 2024-02-19 AST 138 U/L

• 2024-02-07 AST 155 U/L

• 2024-01-30 AST 134 U/L

• 2024-01-10 AST 148 U/L

• 2024-01-02 AST 104 U/L

• 2024-05-14 ALT 126 U/L

• 2024-04-15 ALT 111 U/L

• 2024-04-03 ALT 146 U/L

• 2024-03-20 ALT 148 U/L

• 2024-03-06 ALT 173 U/L

• 2024-02-19 ALT 174 U/L

• 2024-02-07 ALT 222 U/L

• 2024-01-30 ALT 172 U/L

• 2024-01-28 ALT 192 U/L

• 2024-01-10 ALT 208 U/L

• 2024-01-02 ALT 155 U/L

• 2024-05-14 Bilirubin direct 0.45 mg/dL

• 2024-04-15 Bilirubin direct 0.53 mg/dL

• 2024-03-20 Bilirubin direct 0.54 mg/dL

• 2024-02-19 Bilirubin direct 0.39 mg/dL

• 2024-01-30 Bilirubin direct 0.64 mg/dL

• 2024-01-02 Bilirubin direct 0.69 mg/dL

[updated imaging and further tests advised due to rising tumor markers]

The most recent imaging study was performed on 2024-02-21. Tumor markers CEA and CA199 showed signs of rising from their lowest levels. It might be advisable to update the medical imaging and/or obtain new marker readings through a blood draw.

• 2024-04-12 CEA (NM) 24.598 ng/ml

• 2024-03-12 CEA (NM) 23.991 ng/ml

• 2024-02-16 CEA (NM) 85.185 ng/ml

• 2024-04-12 CA-199 (NM) 1971.020 U/ml

• 2024-03-12 CA-199 (NM) 1451.260 U/ml

• 2024-02-16 CA-199 (NM) 7879.800 U/ml

[considering Uliden for bilirubin management and potential Baraclude dosage adjustment]

Given that the increase in bilirubin is primarily due to direct bilirubin, and considering the persistently high total bilirubin, adding Uliden (ursodeoxycholic acid 100 mg) at a dose of 1# QD might be an optional treatment to improve this condition.

Should HBV DNA PCR and HBeAb also be tested to determine if Baraclude (entecavir) should be increased from 0.5 mg to 1 mg?

• 2024-05-14 DBI/TBI 33.58 %
• 2024-04-15 DBI/TBI 41.41 %
• 2024-03-20 DBI/TBI 45.00 %
• 2024-02-19 DBI/TBI 41.49 %
• 2024-01-30 DBI/TBI 46.38 %
• 2024-01-02 DBI/TBI 54.33 %

2024-03-21

[Avastin to Erbitux + FOLFOX: markers change support CT’s partial response]

The patient’s treatment regimen transitioned from Avastin + FOLFOX (last used in Nov 2023) to Erbitux + FOLFOX in Dec 2023. A CT scan comparison on 2024-02-21, showed findings consistent with the partial response observed on the prior CT scan from 2023-11-10.

Furthermore, these imaging results correlate well with the ongoing decline in CEA and CA199 tumor markers over the past 3 months. No medication issues found.

• 2024-03-12 CEA (NM) 23.991 ng/ml

• 2024-02-16 CEA (NM) 85.185 ng/ml

• 2024-01-16 CEA (NM) 211.760 ng/ml

• 2023-12-26 CEA (NM) 433.020 ng/ml

• 2023-11-28 CEA (NM) 737.500 ng/ml

• 2024-03-12 CA-199 (NM) 1451.260 U/ml

• 2024-02-16 CA-199 (NM) 7879.800 U/ml

• 2024-01-16 CA-199 (NM) 12838.000 U/ml

• 2023-12-26 CA-199 (NM) 19957.500 U/ml

• 2023-11-28 CA-199 (NM) 17565.000 U/ml

2024-02-20

LFTs remained elevated, BaoGan is currently being used. Other labs were largely unremarkable.

• 2024-02-19 AST 138 U/L
• 2024-02-19 ALT 174 U/L
• 2024-02-19 Bilirubin direct 0.39 mg/dL

No medication discrepancy found.

2024-01-31

[high direct-to-total bilirubin ratio]

Lab data:

• 2024-01-30 DBI/TBI 46.38 %
  
• 2024-01-02 DBI/TBI 54.33 %
  
• 2023-12-08 DBI/TBI 50.86 %
  
• 2023-11-10 DBI/TBI 50.74 %
  
• 2023-11-09 DBI/TBI 48.39 %
  
• 2023-10-19 DBI/TBI 22.39 %
  
• 2023-09-27 DBI/TBI 22.22 %
  
• 2023-09-08 DBI/TBI 26.32 %
  
• 2023-08-17 DBI/TBI 20.37 %
  
• 2023-07-13 DBI/TBI 31.71 %
  
• 2023-06-09 DBI/TBI 17.65 %
  
• 2023-03-27 DBI/TBI 4.44 %

The ratio of direct bilirubin to total bilirubin showed an upward trend in the serial lab data. Normally, the ratio is less than 20%. A high ratio suggests a problem with the conjugation or excretion of bilirubin. Possible causes of a high ratio:

• Intrahepatic causes:
  • Liver diseases like hepatitis, cirrhosis, or alcoholic liver disease can affect the conjugation of bilirubin.
  • Liver inflammation or damage can block the bile ducts within the liver, preventing bilirubin excretion.
• Extrahepatic causes:
  • Gallstones blocking the common bile duct or other biliary ducts.
  • Tumors of the liver, bile ducts, or pancreas.
  • Pancreatitis causing inflammation and blockage of the bile duct.

If primary biliary cholangitis is identified, the addition of Ursodiol (ursodeoxycholic acid) might be a treatment option.

2024-01-03

[cetuximab toxicity: dose adjustment strategies]

Following the CT scan on 2023-11-10, which revealed multiple liver metastases indicating progressive disease, the treatment plan was altered from Avastin + FOLFOX to Erbitux + FOLFOX. The patient was admitted to receive the second session of the Erbitux + FOLFOX regimen.

Due to elevated levels of DBI, TBI, AST, ALT, and alkaline phosphatase, a reduced dose of the regimen was administered. Tumor markers CEA and CA199 continue to be elevated, and a significant downward trend has not been observed.

Our dermatologist has been consulted regarding the management of dermatologic toxicity and infectious sequelae associated with cetuximab, such as acneiform rash and mucocutaneous disease. The recommended approach for managing these side effects is as follows:

• For the first occurrence of grade 3 or 4 toxicity: Delay cetuximab infusion by 1 to 2 weeks. If there is improvement, resume cetuximab at a dose of 250 mg/m2. If there is no improvement, discontinue cetuximab.
• For the second occurrence of grade 3 or 4 toxicity: Delay cetuximab infusion by 1 to 2 weeks. If there is improvement, continue cetuximab at 200 mg/m2. If there is no improvement, discontinue cetuximab.
• For the third occurrence of grade 3 or 4 toxicity: Delay cetuximab infusion by 1 to 2 weeks. If there is improvement, continue cetuximab at 150 mg/m2. If there is no improvement, discontinue cetuximab.
• For the fourth occurrence of grade 3 or 4 toxicity: Permanently discontinue cetuximab.

2023-09-28

The refill of Baraclude (entecavir) prescribed by our gastroenterologist is included in the list of active medications with no discrepancy found.

2023-08-18

A 28-day supply of Baraclude (entecavir) refilled on 2023-07-25 has been added as a current use item and no medication reconciliation issues found.

2023-07-28

[liver function follow-up]

Observation shows a spike in liver enzymes, which exceeded 200 U/L in early June. Despite a visible decrease, the levels have not yet returned to the normal range. The patient is currently prescribed BaoGan (silymarin). At this time, there does not appear to be a need to change the treatment plan. Please continue to monitor the changes closely.

2023-07-26 S-GPT/ALT 97 U/L 2023-07-13 S-GPT/ALT 155 U/L 2023-07-07 S-GPT/ALT 101 U/L 2023-06-25 S-GPT/ALT 140 U/L 2023-06-21 S-GPT/ALT 156 U/L 2023-06-14 S-GPT/ALT 179 U/L 2023-06-10 S-GPT/ALT 235 U/L 2023-06-09 S-GPT/ALT 217 U/L 2023-04-26 S-GPT/ALT 27 U/L 2023-04-14 S-GPT/ALT 25 U/L

701177943

240729

[exam findings]

[MedRec]

• 2024-07-01 ~ 2024-07-04 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Relapse follicular lymphoma, stage III
    • Small cell B-cell lymphoma, intra-abdominal lymph nodes
    • Chronic peptic ulcer, site unspecified, without hemorrhage or perforation
  • CC
    • for bone marrow and chemotherapy
  • Present illness
    • This 74-year-old man patient with small bowel pathology showed involved by follicular lymphoma stage II at least s/p chemotherapy with R-CHOP on 2019/06/11-09/26.
    • Chest CT (2022/12/5) showed progression intra-abdominal B-cell lymphoma in mesentery and para-aortic region compared with CT on 2022/06/24. mild centrilobular emphysema and substantial subpleural paraseptal emphysema in both upper lobes.
    • Finally, follow up abdominal CT (2024/03/30) showed Lymphadenopathy at abdominal cavity, in enlargement. CT-guide biopsy of peritoneum was performed on 2024/05/17, pathology showed consistent with follicular lymphoma, grade 2.
    • PET on 2024/06/03, report showed 1. Increased FDG uptake in bilateral mediastinal lymph nodes, in the celiac and left intra-abdominal lymph nodes, in bilateral para-aortic lymph nodes, and in a right internal iliac lymph node, highly suspected follicular lymphoma with involvement of lymph node regions. 2. Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG. 3. Follicular lymphoma (recurrent tumor or the other primary malignancy ?), c-stage III.
    • This time, he denied fever or night sweat in 1+ months. He was admitted for relapse follicular lymphoma stage III, so he was admitted for bone marrow and C1 chemotherapy on 2024/07/02.
  • Course of inpatient treatment
    • After admission, he received C1 R-COP on 7/2-7/3 and pending bone marrow condition. No tumor lysis syndrome after chemotherapy. Under the stable condition, he can be discharged on 2024/07/04. OPD follow up is arranged.
  • Discharge prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD 14D
    • Mosapin (mosapride citrate 5mg) 1# TID 4D
    • Ulstop (famotidine 20mg) 1# QD 4D
    • Compesolon (prednisolone 5mg) 9# BID 4D

[immunochemotherapy]

• 2024-07-26 - rituximab 375mg/m2 585mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1055mg NS 250mL 30min D2 + epirubicin 70mg/m2 NS 100mg 10min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mb BID PO D2-6 (R-CHOP, Endoxan & Epicin 10% off)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2
• 2024-07-02 - rituximab 375mg/m2 530mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1070mg NS 250mL 30min D2 ……………………………….. + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mb BID PO D2-6 (R-COP, Endoxan 10% off)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2

==========

701428029

240729

[exam findings]

• 2024-06-05 CT - abdomen
  • Findings:
    • There is a small ground-glass opacity in RUL of the lung, 5 mm in size at lung window setting (Srs:301 Img:33). Follow up is indicated.
    • S/P LAR with autosuture retention over the sigmoid colon.
    • S/P partial resection of S6-7 of the liver.
    • Prior CT identified two non-enhancing lesions in S7 and S8 of the liver are noted again, stationary. Liver metastases S/P treatment with complete response is highly suspected. Follow up is indicated.
    • S/P LAR with autosuture retention over the sigmoid colon.
    • There is splenomegaly (the greatest anterior-posterior dimension: 14 cm).
    • There are several renal cysts on both kidney (up to 2.4 cm).
  • Impression:
    • There is a small ground-glass opacity in RUL of the lung, 5 mm in size at lung window setting (Srs:301 Img:33). Follow up is indicated.
• 2024-03-13 CT - abdomen
  • Findings:
    • S/P LAR with autosuture retention over the sigmoid colon.
    • S/P partial resection of S6-7 of the liver.
    • Prior CT identified two non-enhancing lesions in S7 and S8 of the liver are noted again, stationary. Liver metastases S/P treatment with complete response is highly suspected. Follow up is indicated.
    • S/P LAR with autosuture retention over the sigmoid colon.
    • There is splenomegaly (the greatest anterior-posterior dimension: 13.9 cm).
    • There are several renal cysts on both kidney (up to 2.4 cm).
  • Impression:
    • S/P LAR with autosuture retention over the sigmoid colon.
    • S/P partial resection of S6-7 of the liver.
    • There is no evidence of tumor recurrence.
• 2023-11-14 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Post-op at right lobe liver and colon.
    • Hypodense lesion, 1.5cm in S8, stationary.
    • Heteregeneous hypodense lesion(1cm) in periphery of left lateral segment, mild regression.
    • Bilateral renal cysts, up to 1.7cm in right kidney.
  • Impression:
    • Post-op at right lobe liver and colon.
    • Hypodense lesion, 1.5cm in S8, r/o liver cyst, stationary.
    • Left lateral segment 1cm heteregeneous nodule, mild regression.
    • Renal cysts.
• 2023-08-28 CXR erect
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
• 2023-07-27 PET
  • A glucose hypermetabolic lesion in the segment 6 of the liver and two small glucose hypermetabolic lesions in the segment 8 of the liver respectively. Liver metastases may show this picture.
    
  • Mild increased FDG uptake in bilateral pulmonary hilar regions, in bilateral shoulders and in the soft tissues around bilateral hips. Inflammation is more likely.
• 2023-07-20 CT - abdomen
  • History and indication: Malignant neoplasm of sigmoid colon
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon operation.
    • Low attenuations (up to 3.9cm) in liver.
    • Renal cysts (up to 2.1cm).
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P colon operation.
    • Low attenuations (up to 3.9cm) in liver.
• 2023-05-12 CT - abdomen
  • Findings:
    • There is a poor enhancing lesion 2.5 x 1.8 cm in S8 of the liver that is c/w metastasis S/P alcohol injection with complete response.
    • There is a cystic lesion with gas component in S7 of the liver that may be biloma S/P surgical resection for metastasis.
      • In addition, there is a poor enhancing lesion 2.4 cm in S6 of the liver that also may be biloma S/P surgical resection for metastasis.
    • Prior MRI identified five metastases on both hepatic lobes S/P surgical resection are not noted again.
    • S/P partial resection of right and left lobe liver.
    • There is right side Pleura effusion.
    • S/P LAR with autosuture retention over the sigmoid colon.
    • There is splenomegaly and the greatest anterior-posterior dimension measuring about 13.9 cm.
  • Impression:
    • There is no evidence of tumor recurrence in the liver.
    • Follow up is indicated.
• 2023-04-07 Patho - liver partial resection
  • DIAGNOSIS:
    • Liver, S2, segmentectomy —- moderately differentiated adenocarcinoma, metastatic, compatible with colorectal origin —- Mild fatty change (20-30%)
    • Liver, S5, partial hepatectomy —- moderately differentiated adenocarcinoma, metastatic, compatible with colorectal origin —- Mild fatty change (20-30%)
    • Liver, S4b, partial hepatectomy —- moderately differentiated adenocarcinoma, metastatic, compatible with colorectal origin —- Mild fatty change (20-30%)
    • Liver, S7, medial, partial hepatectomy —- moderately differentiated adenocarcinoma, metastatic, compatible with colorectal origin —- Mild fatty change (20-30%)
    • Liver, S7, lateral, partial hepatectomy —- moderately differentiated adenocarcinoma, metastatic, compatible with colorectal origin —- Mild fatty change (20-30%)
    • Liver, S8, segmentectomy —- moderately differentiated adenocarcinoma, metastatic, compatible with colorectal origin —- Mild fatty change (20-30%)
    • Soft tissue, round ligament, excision —- negative for malignancy
  • MICROSCOPIC DESCRIPTION:
    • Sections of specimens A, B, C, D, E, F show moderately differentiated adenocarcinoma with abundant extravasated mucin.
      • The immunohistochemical stains reveal CK7(-), CK20(+), and CDX2(+). The results are typical for metastatic colorectal cancer. The tumors have not invasion through the capsule. The resection margins are free of tumor.
      • The adjacent liver is non-cirrhotic. The portal tracts reveal mild chronic inflammation cell infiltration and mild fibrous expansion. Mild fatty change (20-30%) is also noted.
        
    • Sections of specimen G show fibroadipose tissue without malignancy.
• 2023-04-07 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, sigmoid colon, sigmoidectomy —- Adenocarcinoma, moderately differentiated, s/p palliative C/T
      
    • Large intestine, T-loop colostomy, excision —- Negative for malignancy
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection —- Negative for malignancy (0/22)
    • Lymph node, IMA / SMA, dissection —- Not received
      
    • AJCC 8th edition Pathology stage: ypStage IVB, ypT3N0M1b
    • F2023-00150 - Omentum, excision — fibrotic nodules
  • Gross Description:
    • Operation procedure: sigmoidectomy and closure of loop-colostomy
    • Specimen site: sigmoid colon
      
    • Specimen size: Colon: 12.5 cm in length; loop-colostomy: 5.0 x 4.7 x 3.0 cm
    • Tumor size: 4.0 x 3.0 x 1.5 cm
    • Tumor location: 6.7 cm and 2.5 cm away from the two resection margins, respectively.
    • Depth of invasion grossly: mesocolic soft tissue
    • Mucosa elsewhere: congestion
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as:
      • A1: colon, non-tumor; A2-5: tumor; A6-8: lymph node, mesocolic; B: distal resection margin; C: proximal resection margin; D1-2: T-loop colostomy.
      • F2023-00150: The specimen submitted in fresh consists of 2 pieces of omentum, measuring up to 6.5 x 4.3 x 0.5 cm. Multiple fibrotic nodules, measuring up to 0.8 x 0.5 x 0.3 cm, are seen. Representative section is taken in a cassette, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1-2.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma, s/p palliative C/T; The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
      
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved, Distance of tumor from margin: 2 mm
        
    • Lymphovascular Invasion: Not identified
    • Perineural Invasion: Not identified
    • Tumor Budding: Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes: 0/22
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): y (posttreatment)
      • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
      • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        
      • Distant Metastasis (pM): pM1b: Metastasis to two or more sites or organs is identified without peritoneal metastasis (S2023-6447)
    • Additional Pathologic Findings (select all that apply): None identified
    • Tumor regression grading S/P CCRT: Tumor regression grading S/P CCRT: Modified Ryan scheme: Tumor regression score: 2, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response).
    • F2023-00150: Sections show fibroadipose tissue with fibrotic nodules and chronic inflammation. No malignancy is seen. The immunohistochemical stains reveal CD34(-), CD117(-), DOG-1(-), and SMA(-).
• 2023-02-22 PET
  • No previous study for comparison.
  • Glucose-hypermetabolism in the S-colon, highly suspected recurrent tumor.
    
  • Increased FDG uptake in nodular lesions in both lobes of the liver, highly suspected colon cancer with distant metastases.
    
  • Increased FDG accumulation in bilateral kidneys and ureters, probably physiological uptake of FDG.
    
  • S-colon cancer s/p treatment with tumor recurrence and liver metastases, rcTxNxM1a, stage IVA (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-01-02 MRI - liver, spleen
  • S/P colostomy. Cystic lesions (up to 3.1cm) in liver without interval change.
  • Bil. renal cysts (up to 2.1cm).
• 2022-12-20 CT - abdomen
  • S/P colostomy.
  • S-colon cancer s/p treatment with regression as compare with CT study on 2022-09-22.
  • Liver low density tumors, up to 3.1 cm in S8. Stationary.
  • Right renal cyst, up to 2.3cm.
• 2022-09-22 CT - abdomen
  • History and indication: Malignant neoplasm of sigmoid colon
  • Findings
    • Mild regression of S-colon cancer with liver metastases. S/P colostomy.
    • Renal cysts (up to 2.1cm).
  • IMP: -Mild regression of S-colon cancer with liver metastases.
• 2022-06-29 CT - chest
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1b(M_value) STAGE:____(Stage_value)
• 2022-06-29 Patho - colon biopsy
  • Sigmoid colon, 20 cm AAV, biopsy — Adenocarcinoma
  • The sections show a picture of adenocarcinoma, composed of moderately differentiated columnar to cuboidal neoplastic cells, arranged in glandular and cribriform patterns with subtle desmoplastic stromal reaction.
• 2022-06-28 Sigmoidoscopy
  • Findings
    • The scope reach the 20cm AAV
    • One tumor with luminal narrowing was noted at S-colon (20cm AAV), s/p biopsy
  • Diagnosis
    • Highly suspect colon cancer with luminal narrowing, S-colon (20cm AAV), s/p biopsy
  • Suggestion
    • F/U pathology report
  • Complication
    • No immediate complication

[consultation]

• 2023-03-14 Colorectal Surgery
  • Q
    • for perpare operation evaluation
    • This 56-year-old man, a patient of S-colon adenocarcinoma with reginal and distant lymph nodes and hepatic metastasis, T4N2M1a, stage IV s/p T-colostomy S/P C/T.
    • He was admitted for chemotherapy. We need expertise to evaluate his condition thanks!
  • A
    • O
      • 2022-12-20: CT:
        • S/P colostomy.
        • S-colon cancer s/p treatment with regression as compare with CT study on 2022-09-22.
        • Liver low density tumors, up to 3.1 cm in S8. Stationary.
      • 2023-01-02: MRI:
        • S/P colostomy. Cystic lesions (up to 3.1cm) in liver without interval change.
        • Bil. renal cysts (up to 2.1cm).
      • 2023-02-22: PET scan:
        • There was increased FDG uptake in the S-colon (SUVmax early: 35.81, delay: 53.03), in a nodular lesion in the left lobe of the liver (SUVmax early: 5.44, delay: 8.58), and in a nodular lesion in the right lobe of the liver (SUVmax early: 4.90, delay: 5.85). In addition, increased FDG accumulation in bilateral kidneys and ureters was also noted.
    • A
      • S-colon adenocarcinoma with obstruction and hepatic metastases, cT4N2M1a, stage IV s/p T-colostomy and chemotherapy+ Avastin with partial regression
    • P:
      • We had arranged his admission on 4/5, and the operation of sigmoidectomy + closure of colostomy as well as combined hepatic surgery (GS) will be performed on 2023/04/06
      • Surgical detail and risk had been informed
      • Please inform us if any problems
• 2022-07-07 Hemato-Oncology
  • Q
    • This is a 55y/o man with PMH of DM under diet control. This time he was admitted due to S colon tumor with reginonal lymphadnopathy and several hepatic metastasis. Due to poor intake and prominent obstructive symptoms, after discussing with the patient, he underwent T-loop colostomy and port A insertion. Now that the patient is relatively stable with much improved of the previous symptoms, OP wound and colostomy site with no infection signs, we would like to consult you for further treatment.
  • A
    • Impression:
      • Sigmoid colon cancer with regional and distant LNs and hepatic metastases T4N2M1a s/p T-loop colostomy and port A insertion
      • COVID-19 infection
      • DM
    • Suggestion:
      • We will discuss with patient about further chemotherapy. We may take over this case
      • Pending AntiHbc, HbsAg, Anti-HCV, CEA data
      • Pening colon patholgy for MMR IHC stain (MLH1、MSH2、MSH6、PMS2) and All RAS mutation survey
      • Thanks for your consultation. If there is any problem, please feel free to let us known.

[surgical operation]

• 2022-06-30 T-loop colostomy

[chemotherapy]

• 2024-07-29 - oxaliplatin 85mg/m2 175mg D5W 250mL 2hr + leucovorin 400mg/m2 830mg NS 250mL 2hr + fluorouracil 2800mg/m2 5870mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
• 2024-07-15 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX 20% off, due to ANC 1751 & WBC 3280)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
• 2024-06-24 - oxaliplatin 85mg/m2 175mg D5W 250mL 2hr + leucovorin 400mg/m2 840mg NS 250mL 2hr + fluorouracil 2800mg/m2 5900mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
• 2024-06-03 - oxaliplatin 85mg/m2 175mg D5W 250mL 2hr + leucovorin 400mg/m2 840mg NS 250mL 2hr + fluorouracil 2800mg/m2 5850mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
• 2024-04-29 - oxaliplatin 85mg/m2 180mg D5W 250mL 2hr + leucovorin 400mg/m2 830mg NS 250mL 2hr + fluorouracil 2800mg/m2 5900mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
• 2024-04-15 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 175mg D5W 250mL 2hr + leucovorin 400mg/m2 830mg NS 250mL 2hr + fluorouracil 2800mg/m2 5850mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2024-01-29 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 175mg D5W 250mL 2hr + leucovorin 400mg/m2 825mg NS 250mL 2hr + fluorouracil 2800mg/m2 5750mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
• 2023-12-11 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 175mg D5W 250mL 2hr + leucovorin 400mg/m2 825mg NS 250mL 2hr + fluorouracil 2800mg/m2 5750mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
• 2023-11-13 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5700mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-10-16 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-09-25 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 165mg D5W 250mL 2hr + leucovorin 400mg/m2 790mg NS 250mL 2hr + fluorouracil 2800mg/m2 5500mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
• 2023-08-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + leucovorin 400mg/m2 810mg NS 250mL 2hr + fluorouracil 2800mg/m2 5500mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
• 2023-03-13 - irinotecan 180mg/m2 370mg D5W 250mL 90min + leucovorin 400mg/m2 830mg NS 250mL 2hr + fluorouracil 2800mg/m2 5800mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 3mg + NS 250mL
• 2023-02-21 - irinotecan 180mg/m2 370mg D5W 250mL 90min + leucovorin 400mg/m2 830mg NS 250mL 2hr + fluorouracil 2800mg/m2 5860mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 3mg + NS 250mL + aprepitant 125mg PO
• 2023-01-30 - irinotecan 180mg/m2 370mg D5W 250mL 90min + leucovorin 400mg/m2 830mg NS 250mL 2hr + fluorouracil 2800mg/m2 5810mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 3mg + NS 250mL + aprepitant 125mg PO
• 2022-12-19 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 820mg NS 250mL 2hr + fluorouracil 2800mg/m2 5740mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
• 2022-11-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5650mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
• 2022-11-14 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2800mg/m2 5650mg 46hr (Avastin + FOLFIRI)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
• 2022-10-31 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2800mg/m2 5600mg 46hr (Avastin + FOLFIRI)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
• 2022-10-17 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 370mg 90min + leucovorin 400mg/m2 820mg 2hr + fluorouracil 2800mg/m2 5700mg 46hr (Avastin + FOLFIRI)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
• 2022-09-26 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (Avastin + FOLFIRI)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
• 2022-09-12 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (Avastin + FOLFIRI)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
• 2022-08-29 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 340mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5320mg 46hr (Avastin + FOLFIRI)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
• 2022-08-16 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 340mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5320mg 46hr (Avastin + FOLFIRI)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
• 2022-08-03 - irinotecan 180mg/m2 330mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5275mg 46hr (FOLFIRI)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg + atropine 1mg + aprepitant 125mg PO
• 2022-07-20 - irinotecan 180mg/m2 330mg 90min + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr (FOLFIRI)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg + atropine 1mg + aprepitant 125mg PO
• 2022-07-05 - irinotecan 160mg/m2 290mg 90min + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr (FOLFIRI)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg + atropine 1mg + aprepitant 125mg PO

==========

2024-07-29

[liver function remains abnormal]

Liver function tests continue to show elevated levels, indicating that the liver is still under stress, even with silymarin treatment. Regular monitoring is necessary.

• 2024-07-28 ALT 92 U/L
• 2024-07-14 ALT 94 U/L
• 2024-06-24 ALT 80 U/L
• 2024-06-03 ALT 85 U/L
• 2024-04-28 ALT 52 U/L

2024-06-25

[rising cea levels since august 2023, elevated liver enzymes in june 2024]

It appears that CEA levels reached their lowest point in Aug 2023 and have since been gradually rising. Additionally, liver enzymes ALT and AST have shown a noticeable increase compared to the previous month. BaoGan has been prescribed and will also be provided upon discharge. No medication discrepancies were identified.

• 2024-04-30 CEA (NM) 7.236 ng/ml

• 2024-03-15 CEA (NM) 6.671 ng/ml

• 2024-02-02 CEA (NM) 6.639 ng/ml

• 2023-08-29 CEA (NM) 4.708 ng/ml

• 2023-07-04 CEA (NM) 7.161 ng/ml

• 2022-12-29 CEA (NM) 31.350 ng/ml

• 2022-09-23 CEA (NM) 34.242 ng/ml

• 2022-07-05 CEA (NM) 360.500 ng/ml

• 2024-06-24 ALT 80 U/L

• 2024-06-03 ALT 85 U/L

• 2024-04-28 ALT 52 U/L

• 2024-04-15 ALT 53 U/L

• 2024-03-13 ALT 58 U/L

• 2024-01-29 ALT 59 U/L

• 2023-12-10 ALT 43 U/L

• 2023-11-13 ALT 34 U/L

• 2024-06-24 AST 51 U/L

• 2024-06-03 AST 49 U/L

• 2024-04-28 AST 30 U/L

• 2024-04-15 AST 36 U/L

• 2024-03-13 AST 36 U/L

• 2024-01-29 AST 37 U/L

• 2023-12-10 AST 35 U/L

• 2023-11-13 AST 31 U/L

701488243

240729

[exam findings]

• 2024-07-05 MRI - breast
  • With and without enhancement MRI of breast:
    • S/P bilateral breast augmentation.
    • R/O diffuse siliconomas in bilateral breasts.
    • Moderate regression of left breast malignancy with residual spiculated tumor (0.7cm).
      
    • Regression of left axillary lymph node.
    • R/O bone metastasis.
  • Impression:
    • S/P bilateral breast mammoplasty and diffuse siliconomas.
    • S/P neoadjuvant C/T with moderate regression of left breast malignancy and axillary lymph node.
  • BI-RADS:
    • Category 6-proven malignancy
• 2024-06-06 SONO - breast
  • Diagnosis
    • Bil. fibroadenomas
    • s/p bil. breast operation
    • Bil. breast calcifications
  • BI-RADS: 2. benign finding
• 2024-04-08 CT - chest
  • Indication: left breast cancer with LN and bone metastasis, suspect lung metastaaais
  • Comparison was made with CT on 2023/12/27
    • Lungs: miliary lesions bilateral lungs still visible, stable.
    • Chest wall and visible lower neck: interval stationary in size of left breast tumor and left axillary LAP. s/p breasts augmentation.
    • Visible abdominal contents: many hepatic cysts measuring up to 35mm. unremarkable of the GB, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node.
    • Visualized bones: diffuse blastic change in the spine and bones of thoracic cage.
  • Impression:
    • left breast cancer, axillary LNs, lung meta and diffuse bone metastases, stationary as compared with CT on 2023/12/27
• 2024-04-08 SONO - abdomen
  • Findings
    • Anechoic nodules, 3.94x2.55cm and 3.69x2.21cm in left lobe, 0.84x0.61cm and 0.56x0.36cm in right lobe, r/o liver cysts.
      
    • Presence of gallbladder polyp, 0.42cm.
    • Patency of PV, HVs, IVC and aorta in hepatic portion.
  • Impression:
    • Liver cysts.
    • GB polyp.
• 2024-02-20 Tc-99m MDP bone scan
  • IMPRESSION: In comparison with the previous study on 2023/06/26, most of the previous bone lesions are a little less evident, suggesting multiple bone metastases with some resolution.
• 2024-01-08 PET
  • The lesions of increased FDG uptake in the left breast and in the left axillary lymph nodes are old and show much less evident, and no new lesion of increased FDG uptake is noted compared with the previous study on 2023-07-05.
    
  • Increased FDG uptake in bilateral pulmonary hilar lymph nodes, probably reactive nodes.
    
  • All of above-mentioned bone lesions of increased FDG uptake are old and come to much less evident or even disappear compared with the previous study on 2023-07-05.
    
  • Left breast cancer with suspected bone mets s/p treatment, partial metabolic response to current therapy by this F-18 FDG PET scan.
• 2023-12-28 SONO - abdomen
  • Bil. liver cysts (up to 3.35cm).
• 2023-12-28 SONO - breast
  • Diagnosis
    • Bil. fibroadenomas as described
    • S/P bil. mammoplasty
    • Bil. breast calcifications
  • BI-RADS: 3. probably benign finding, intitial short-interval follow-up suggested (suspicion for malignancy: <= 2%)
• 2023-12-27 CT - chest
  • Indication: left breast cancer
  • Comparison was made with CT on 2023/6/29
    • Lungs: miliary lesions bilateral lungs still visible.
    • Mediastinum and hila: no enlarged LN or mass.
    • Chest wall and visible lower neck: interval decreased size of left breast tumor and left axillary LAP. s/p breasts augmentation.
    • Visible abdominal contents: many hepatic cysts measuring up to 35mm.
    • Visualized bones: diffuse blastic change in spine and bones of thoracic cage.
  • Impression:
    • left breast cancer, axillary LNs, lung meta and diffuse bone metastases, in regression as compared with CT on 2023/6/29
• 2023-10-04 SONO - abdomen
  • Real-time sonographic evaluation of the abdomen was performed - Findings:
    • The liver shows normal in size and echogenicity.
      • There are several hepatic cysts in both lobes (the largest one in S2 shows septum formation and 3.73 x 2.42 cm in size).
        
      • Portal vein flow: patent.
      • Bile ducts: not dilated.
    • The gallbladder appears normal in wall thickness and size.
      • There is no evidence of stone, polyp or sludge.
        
    • The pancreatic head and body shows normal in size and texture.
      • The pancreatic tail is obscured by overlying bowel gas.
    • The spleen shows normal in size and echogenicity without focal lesion.
    • Right side Pleura effusion.
  • Impression:
    • There are several hepatic cysts in both lobes (the largest one in S2 shows septum formation and 3.73 x 2.42 cm in size).
      
    • Right side Pleura effusion.
• 2023-07-10 Patho - breast biopsy (no need margin)
  • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (+, 100%, strong intensity), PR(+, 10%, intermediate intensity), Her2/neu: negative(score= 1+), Ki-67(<10 %), E-cadherin (+). An addendum report of the result of Her2/neu DISH will be followed.
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2023-07-08 MRI - breast
  • Clinical history: 61 y/o female patient with malignancy with bone mets.
  • With and without enhancement MRI of breast (axial T1, T1FS, sagittal T2, T2FS, axial and sagittal T1FS contrast, dynamic study):
    • S/P bilateral breast augmentation.
    • R/O diffuse siliconomas in bilateral breasts.
    • There are irregular tumors (6.7x3.1cm) with enhancemant in left breast, with skin involvement, r/o malignancy.
    • Left axillary lymph nodes, r/o lymph nodes metastasis.
    • Right pleural effusion.
    • R/O bone metastasis.
  • Impression:
    • S/P bilateral breast mammoplasty.
    • Left breast malignancy with skin invasion and axillary lymph nodes metastasis, bone metastasis.
    • Right pleural effusion.
      
  • BI-RADS:
    • Category 6 - proven malignancy
• 2023-07-05 PET
  • Increased FDG uptake in the left breast and left axillary lymph nodes, highly suspected left breast cancer with regional lymph nodes metastases.
    
  • Increased FDG uptake in the left pulmonary hilar lymph nodes, in the right lower lung, and in the right cervical lymph nodes, the nature is to be determined, suggesting investigation.
    
  • Increased FDG uptake in skeleton including the skull, spines, sacrum, bilateral pelvic bones, sternum, both rib cages, clavicles, scapulae, humeri, and femurs, highly suspected multiple bone metastases.
  • Left breast cancer, cTxN2aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-06-29 CT - chest
  • Indication: suspected left breast cancer with lung and ribs mets
  • Chest CT with and without IV contrast ehnancement shows:
    • s/p breast augmentation.
    • Minimal soft tissue mass enhancement at left breast is found. The possiblity of neoplasm should be suspected.
    • Very tiny nodular lesion are found at both lung fields.
    • Diffuse blastic change at whole bony structure is found. Breast cancer with bone meta is considered.
    • Patent airway is found.
    • Enarged lymph node at left hilar region and left axillary lymphadenopathy is found.
    • Mild right pleural effusion is found.
    • Hepatic cysts at both lobes of liver up to 3.67cm in largest dimension. Simple cysts are considered.
  • Imp:
    • s/p breast augmentation with left breast cancer, axillary lymphadenopathy, lung meta and diffuse bone meta.
• 2023-06-26 Tc-99m MDP bone scan SPECT
  • Highly suspected malignancy (lung, breast, or other site ?) with multiple bone metastases, suggesting chest CT and breast sono for further investigation.

[MedRec]

• 2023-12-06 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • Prescription
    • Ibrance (palbociclib 75mg) 1# QDCC 21D
    • Femara (letrozole 2.5mg) 1# QD 28D
    • Zobonic (zoledronic acid 4mg) ST IVD
    • NS 100mL ST IVD
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
• 2023-10-11 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • Prescription
    • Ibrance (palbociclib 75mg) 1# QDCC 21D
    • Femara (letrozole 2.5mg) 1# QD 28D
    • Stilnox (zolpidem 10mg) 1# HS 7D
    • BioCal chewable tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# BID 28D
• 2023-09-13 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • Prescription
    • Ibrance (palbociclib 75mg) 1# QDCC 21D
    • Ibrance (palbociclib 75mg) 1# QDCC 21D (freebie)
    • Femara (letrozole 2.5mg) 1# QD 28D
    • Stilnox (zolpidem 10mg) 1# HS
    • Zobonic (zoledronic acid 4mg) ST IVD
    • NS 100mL ST IVD
• 2023-08-16 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • Prescription
    • Zobonic (zoledronic acid 4mg) ST IVD
    • NS 100mL ST IVD
    • NS 500mL QD IVD 1D
    • Femara (letrozole 2.5mg) 1# QD 28D
• 2023-08-07 ~ 2023-08-12 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Left breast invasive carcinoma with lymph nodes and bone metastasis, cT4bN1M1, stage IV. ECOG:2
    • Agranulocytosis secondary to cancer chemotherapy
    • Anemia, unspecified
  • Course of inpatient treatment
    • After admission, general weakness was noted after car accident since last month.
    • Thrombocytopenia, anemia and neutropenia fever. Hold Ibrance and Cefa was given. PRNC, PLT transfusion. GCSF x2 days.
    • After stable condition, she was discharge today. OPD will be arrange.
  • Discharge prescription
    • Ibrance (palbociclib 75mg) 1# QDCC 5D
    • Femara (letrozole 2.5mg) 1# QD 7D
    • BioCal chewable tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# BID 30D
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Megejohn (megestrol acetate 160mg) 1# QD
    • cephalexin 500mg) 1# QID
    • Celebrex (celecoxib 200mg) 1# QD
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
• 2023-07-20 ~ 2023-07-21 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Left breast invasive carcinoma with lymph nodes and bone metastasis, cT4bN1M1, stage IV. ECOG:0
  • CC
    • noted left shoulder pain over 5 months.
  • Present illness
    • This 61-year-old female patient denied any past history including hypertension, diabetes mellitus or heart disease. HBV was noted from 2023/07. She denied any TOCC histories in recent 3 months.
    • She noted left shoulder pain over 5 months. Suspected malignancy with bone mets by shoulder MRI at JingMei Hospital. She came to our hospital for help.
    • Bone scan was arranged revealed highly suspected malignancy (lung, breast, or other site ?) with multiple bone metastases. She refer to GS OPD for survey.
    • Breast sono showed diffuse subcutaneous tissue thickening of left breast r/o malignancy.
    • Core needle biopsy revealed invasive carcinoma, ER(100%), PR(10%), Her2/neu( 1+), Ki-67: <10%. CA-153：234.040 U/ml, CEA：36.463 ng/ml.
    • Lung CT was arranged very tiny nodular lesion are found at both lung fields.
    • PET showed multiple lymph nodes and bone metastasis.
    • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
    • PE: siliconomas in bilateral breasts. A hard, nontender, movable mass and irregular margin at left breast around 11x13x7 cm without discharge. The nipple was retraction. The left breast skin has multiple scar wounds.
    • Palliative CDK4/6 inhibitor and Zometa was suggest.
    • Under the impression of left breast invasive carcinoma with multiple lymph nodes and bone metastasis, she was admitted for CDK4/6 inhibitor.
  • Course of inpatient treatment
    • After admission, consulted Radiation Oncology Dr Chang YouKang due to left shoulder pain. R/T to right humerus for 3000cGy/10 fx is suggested for pain control. CT simulation is arranged on 2023-07-24.
    • Consulted GI due to HBV carrier. CDK4/6 inhibitor was given. Under stable condition, she was discharged today. Arrange next admitted after 15 days.
  • Discharge prescription
    • Ibrance (palbociclib 125mg) 1# QDCC 16D
    • Stilnox (zolpidem 10mg) 1# HS 7D
    • BioCal chewable tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# BID 30D
• 2023-07-17 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • O
    • 2023/07/10 PATHO-breast biopsy
      • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains: ER (+, 100%, strong intensity), PR(+, 10%, intermediate intensity), Her2/neu: negative(score= 1+), Ki-67(<10 %), E-cadherin (+).
      • An addendum report of the result of Her2/neu DISH will be followed.
    • 2023/07/10 PATHO-lymphnode biopsy
      • Labeled as “right lateral neck lymph node”, core needle biopsy — benign lymph node.
      • IHC stain: E-cadherin (-).
    • 2023/07/08 MRI: Breast
      • S/P bilateral breast mammoplasty.
      • Left breast malignancy with skin invasion and axillary lymph nodes metastasis, bone metastasis.
      • Right pleural effusion.
        
    • 2023/07/05 PET scan
      • Increased FDG uptake in the left breast and left axillary lymph nodes, highly suspected left breast cancer with regional lymph nodes metastases.
        
      • Increased FDG uptake in the left pulmonary hilar lymph nodes, in the right lower lung, and in the right cervical lymph nodes
      • Increased FDG uptake in skeleton including the skull, spines, sacrum, bilateral pelvic bones, sternum, both rib cages, clavicles, scapulae, humeri, and femurs, highly suspected multiple bone metastases.
      • Left breast cancer, cTxN2aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2023-06-26 BONE SCAN
      • Highly suspected malignancy (lung, breast, or other site ?) with multiple bone metastases, suggesting chest CT and breast sono for further investigation.
  • Prescription
    • Zobonic (zoledronic acid 4mg) ST IVD
    • NS 100mL ST IVD
    • BioCal chewable tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# BID 7D
    • Femara (letrozole 2.5mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H

==========

2024-07-29

[ongoing treatment and monitoring for Ibrance and Femara regimen for managing neutropenia]

The patient has been taking Ibrance (palbociclib 75mg) and Femara (letrozole 2.5mg) daily for several months. While the latter is at the recommended dose, the standard dose for Ibrance is 125mg once daily for 21 days followed by 7 days off, repeated every 28 days. However, the actual palbociclib administration has been 75mg once daily for 14 or even 7 days, followed by 7 days off.

The patient has experienced neutropenia multiple times, with WBC counts not exceeding 3K/uL in recent months. Despite this, further dose reduction or interval increase for palbociclib is not recommended as it is already at the minimum recommended dose and administered less frequently.

Another reason for not adjusting the Ibrance dose or frequency is that tumor markers CA153 and CEA continue to decline, and imaging (MRI on 2024-07-05 and CT on 2024-04-08) showed that the disease remains controlled, indicating the current regimen is still effective.

If there is concern about the prolonged low WBC count leading to infection, the use of G-CSF might be considered.

• 2024-07-12 CA-153 66.283 U/ml

• 2024-04-12 CA-153 112.348 U/ml

• 2024-01-03 CA-153 107.046 U/ml

• 2023-10-09 CA-153 158.890 U/ml

• 2023-07-07 CA-153 234.040 U/ml

• 2024-07-12 CEA 4.785 ng/ml

• 2024-04-12 CEA 7.688 ng/ml

• 2024-01-03 CEA 10.442 ng/ml

• 2023-10-09 CEA 12.856 ng/ml

• 2023-07-07 CEA 36.463 ng/ml

• 2024-07-26 WBC 1.78 x10^3/uL **

• 2024-07-05 WBC 1.86 x10^3/uL **

• 2024-06-06 WBC 2.17 x10^3/uL *

• 2024-05-22 WBC 1.69 x10^3/uL **

• 2024-05-15 WBC 1.63 x10^3/uL **

• 2024-04-26 WBC 2.65 x10^3/uL *

• 2024-04-08 WBC 2.25 x10^3/uL *

• 2024-03-19 WBC 2.93 x10^3/uL *

• 2024-02-19 WBC 3.20 x10^3/uL

• 2024-01-22 WBC 2.91 x10^3/uL *

• 2023-12-27 WBC 1.86 x10^3/uL **

• 2023-12-06 WBC 3.08 x10^3/uL

• 2023-11-08 WBC 2.62 x10^3/uL *

• 2023-10-04 WBC 1.90 x10^3/uL **

• 2023-09-13 WBC 2.48 x10^3/uL *

• 2023-08-16 WBC 4.59 x10^3/uL

• 2023-08-12 WBC 3.08 x10^3/uL

• 2023-08-11 WBC 2.53 x10^3/uL *

• 2023-08-09 WBC 1.36 x10^3/uL **

• 2023-08-07 WBC 1.83 x10^3/uL **

• 2023-07-31 WBC 2.33 x10^3/uL *

• 2023-07-03 WBC 6.85 x10^3/uL

2023-12-28

[leukopenia]

The patient’s primary medications include the cyclin-dependent kinase inhibitor palbociclib and the aromatase inhibitor letrozole. Palbociclib was initially prescribed at a daily dose of 125mg starting from late July this year, which was then reduced to 75mg daily from early August. Letrozole has been consistently administered at a daily dose of 2.5mg. The bone mineral density loss associated with the use of AI letrozole and bone metastases are being managed with zoledronic acid and calcium supplements.

Neutropenia, including grades 3 and 4, is a common observation in patients taking palbociclib. The median duration of neutropenia of grade >=3 is approximately 7 days. Cases of febrile neutropenia and neutropenic sepsis have also been reported. Neutropenia caused by palbociclib is rapidly reversible upon stopping the medication.

• Mechanism: The neutropenia is dose-related and occurs due to the inhibition of CDK6, a crucial regulator of hematopoietic precursor proliferation. Inhibiting CDK6 leads to cytostatic effects on the cell cycle of neutrophils.
• Onset: The median onset for any grade of neutropenia is around 15 days, with the median onset for grade ≥3 neutropenia being about 28 days.

Our hospital currently stocks Ibrance (palbociclib) in 125mg, 100mg, and 75mg dosages. However, the patient is already on the lowest recommended dose of 75mg. Other CDK4/6 inhibitors like abemaciclib and ribociclib also have similar adverse effects of leukopenia.

According to the latest NCCN guidelines, for postmenopausal patients with ER (+), PR (+), Her2 (-) stage IV breast cancer, the recommended treatments include:

• Aromatase inhibitor + CDK4/6 inhibitor
• Fulvestrant + CDK4/6 inhibitor

Both options involve the use of a CDK4/6 inhibitor. Given that the CT scan on 2023-12-27 showed disease regression, indicating that the current regimen is still effective in controlling the disease.

While some research suggests that G-CSF isn’t always necessary for managing neutropenia in CDK4/6 inhibitor-based treatments, it’s important to consider the differences between this and chemotherapy-induced neutropenia. Ref: Management of adverse events during cyclin-dependent kinase 4/6 (CDK4/6) inhibitor-based treatment in breast cancer. Ther Adv Med Oncol. 2018 Sep 3;10:1758835918793326.

Key Points: - CDK4/6 inhibitor-induced neutropenia (usually with palbociclib and fulvestrant) is typically less severe: - Grade 3/4 neutropenia usually resolves within 7 days. - Missing pancytopenia and lower infection rates compared to chemotherapy. - G-CSF may not be necessary. - Chemotherapy-induced neutropenia is more severe and frequent: - Grade 4 neutropenia in over 30% of patients within the first 4 cycles. - Up to 23% experience febrile neutropenia. - Mortality rate of around 5%. - CDK4/6 inhibitor-induced neutropenia shows a favorable profile: - Lower rates of both grade 4 neutropenia and febrile neutropenia compared to chemotherapy. - Neutropenia often decreases with each treatment cycle, suggesting no cumulative toxicity. - Aligns with the targeted mechanism of CDK4/6 inhibitors.

If the patient does not object, it may be possible to add testing for PIK3CA or AKT1/PTEN-activating mutations for reference in the future selection of drugs.

701510940

240729

[exam findings]

• 2024-03-21 CT - brain
  • No evidence of ICH, SAH or SDH.
  • No evidence of space occupying lesion in the brain parenchyma is found.
  • Right maxillary sinusitis, chronic.
• 2024-01-15 SONO - abdomen
  • Renal tumor, LK, nature unknown
  • Hepatic cyst, right lobe
• 2024-01-08 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — hypercellularity, compatible with myelodysplastic syndrome with excessive blasts.
  • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 1.3 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
  • Section shows piece(s) of bone marrow with 80 % cellularity and M:E ratio of approximately 6:1. Three cell lineages are present with left shift of leukocytes. Megakaryocytes are adequate in number.
  • IHC stains: CD117: <1 %; CD34: <1 %; MPO: 70-80 %, CD61: 10-15 %; CD71: 10-15 % (of the nucleated cells). The findings in conjunction with blast count of 17% in the peripheral blood is compatible with myelodysplastic syndrome with excessive blasts.
• 2024-01-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (96.3 - 22.8) / 96.3 = 76.32%
    • M-mode (Teichholz) = 76.3-71.8
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with milf MR
    • Normal LV chamber size and borderline wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
    • Dilated LA
• 2024-01-03 CT - abdomen
  • Wedge shaped perfusion defect at left kidney is found. APN is considered.
  • Engorged pulmonary trunk is found.

[MedRec]

• 2024-01-04 ~ 2024-01-24 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Refractory anemia with excess of blasts 2
    • Acute myeloblastic leukemia, not having achieved remission, IHC stains: CD117: <1 %; CD34: <1 %; MPO: 70-80 %, CD61: 10-15 %; CD71: 10-15 % (of the nucleated cells), s/p low-dose Ara-C
    • Left Acute Pyelonephritis, Urine culture: After 48 hours 1000 CFU/mL
    • Bronchopneumonia at right lower lung, sputum culturte: Mixed normal flora Growth 3+
    • hypertension
    • type II diabetes mellitus
    • hyperlipidemia
    • hyperuricemia
    • Hypocalcemia
    • Chronic viral hepatitis B without delta-agent, Anti-HBc: reactive on 2024/1/5
    • hypokalemia
    • hypomagnesemia
    • mucositis, grade II
  • CC
    • for suspect acute myeloid leukemia, Blast 17.5%.
  • Present illness
    • This is a 73 year-old female who has the history of hypertension with Sevikar control for 10+ years, hyperlipidemia with ZoloTIN for 10+ years, and Type II diabetes mellitus with Metformin control for 10+ years, and regular follow-up at the Clinic.
    • According the family describe, the patient suffered from cough with sputum, mild headache noted for 3 days, then fever up to 38C at morning on 2023/1/3. Due to the severe symptoms, so she was brought to our ER for help. the patient’s body weight loss unknown, and denide fatigue, weakness, appetite change, TOCC history.
    • At ER, the lab of CBC/DC shower leucocytosis (WBC: 27000/uL), anemia (Hb: 6.7g/dL), thrombocytopenia (Plt: 40000/uL), and Blast: 17.5%.
    • The chest x-ray revealed bilateral increased infiltrations, abdomen CT was done on 2023/01/03, the report showed Left renal APN. So gave empiric antibiotic with Soonmelt, hydration, Acetal for fever control, the blood transfusion with LRP 2U, LPRBC 4U first.
    • Under the impression of 1). suspect acute myeloid leukemia, Blast 17.5%, 2). Left Acute Pyelonephritis, 3). Bronchopneumonia at right lower lung, so she is admitted for future evaluation.
  • Course of inpatient treatment
    • After be admitted, she received hydration, empiric antibiotic with Cefim for infection control, and on critical.
    • Hydrea 1tab BID was given on 2024/01/04~01/08 for leucocytosis, Zcough plus Actein for cough with sputum treatment, and nasal cannula support.
    • After treatment, the symptom of leucocytosis, fever, and cough with sputum improved.
    • The lab showed hyperuricemia (Uric acid: 7.1mg/dL), so gave Rolikan for alkalize urine, Feburic by self-paid for hyperuricemia, Famotidine for stool OB:1+.
    • The bone marrow will done on 2024/01/08, the report revealed hypercellularity, compatible with myelodysplastic syndrome with excessive blasts. IHC stains:  CD117: <1 %; CD34: <1 %; MPO: 70-80 %, CD61: 10-15 %; CD71: 10-15 % (of the nucleated cells).
    • The sputum culture growth mixed normal flora 3+, urine culture: After 48 hours 1000 CFU/mL, blood cuture no growth for 5 days aerobically, anaerobically.
    • She suffered from severe cough noted on 2024/01/07, followed-up chest x-ray revealed infiltration over right and left lower lung zone is noted, blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion, so gave Albumin plus Lasix for pleural effusion.
    • After treatment, the symptom of leucocytosis, hyperuricemia, and cough improved.
    • The lab results showed electrolyte imbalance, gave MgO, Const-K to correct electrolyte imbalance. However, the symptom of electrolyte imbalance was corrected.
    • The condition became smooth, so she received #1 chemotherapy with low-dose Ara-C 30mg Q12H, D1-D7 on 2024/01/15-01/21, Vemlidy 1tab QD for Anti-HBc: reactive, blood transfusion for anemia, thrombocytopenia.
    • After chemotherapy, she denide having a fever, vomiting, chest tightness, or any complaints.
    • Under the room air, the respiratory pattern is smooth.
    • She suffered from mucositis grade II, and an ulcer, painful at the tongue, so gave Nystatin for mucositis, Nincort Oral Gel, Scrat 2pk plus Lido Jelly 1 tube (self-paid) were mixed for oral ulcer, and pain control.
    • After treatment, the symptom of mucositis, oral ulcer improved.
    • Under the condition become smooth, so she can be discharged on 2024/01/24, the OPD follow-up will be arranged.
  • Discharge prescription
    • MgO 250mg 1# TID
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Alpraline (alprazolam 0.5mg) 0.5# HS
    • Mycostatin Oral Suspension 0.1MU/mL 3mL QID - Rinse mouth for three minutes and then swallow
    • Through (sennoside 12mg) 2# HS
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
    • Uformin (metformin 500mg) 1# BID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# PRNTID - Use when coughing

[chemotherapy]

• 2024-07-18 - cytarabine 30mg/m2 20mg NS 100mL Q12H 30min D1-7 (low dose Ara-C)

• 2024-06-11 - cytarabine 30mg/m2 20mg NS 100mL Q12H 30min D1-7 (low dose Ara-C)

• 2024-05-28 - azacitidine 100mg SC D1-3 (Vidaza)

  • acetaminophen 500mg PO D1-3

• 2024-03-29 - cytarabine 30mg/m2 20mg NS 100mL Q12H 30min D1-7 (low dose Ara-C)

• 2024-03-19 - azacitidine 100mg SC D1-3 (Vidaza)

  • acetaminophen 500mg PO D1-3

• 2024-03-05 - azacitidine 100mg SC D1-3 (Vidaza)

  • acetaminophen 500mg PO D1-3

• 2024-02-20 - azacitidine 100mg SC D1-3 (Vidaza)

  • acetaminophen 500mg PO D1-3

• 2024-02-06 - azacitidine 100mg SC D1-3 (Vidaza)

  • acetaminophen 500mg PO D1-3

• 2024-01-15 - cytarabine 30mg/m2 30mg NS 100mL Q12H 30min D1-7 (low dose Ara-C)

==========

2024-07-26

[alternate day dosing of Targocid for renal adjustment]

This patient has been prescribed Targocid (teicoplanin 800mg) QD, and her eGFR was 43.06 ml/min/1.73m² on 2024-07-26.

According to the Sanford Guide, the renal adjustment for this medication should be 6-12 mg/kg every other day. For this patient, with a body weight of 70 kg, it is recommended to adjust the dosage interval to alternate days.

2024-07-22

[managing unstable AML with cytarabine and venetoclax]

Lab data:

• 2024-07-22 Blast 71.0 %
• 2024-07-19 Blast 74.4 %
• 2024-07-18 Blast 80.3 %
• 2024-07-17 Blast 77.1 %
• 2024-07-15 Blast 61.7 %
• 2024-07-09 Blast 17.6 %
• 2024-07-01 Blast 4.6 %
• 2024-06-28 Blast 2.5 %
• 2024-06-26 Blast 12.4 %
• 2024-06-24 Blast 4.0 %
• 2024-06-20 Blast 18.4 %
• 2024-06-19 Blast 21.7 %
• 2024-06-17 Blast 25.8 %
• 2024-06-13 Blast 64.6 %
• 2024-06-09 Blast 62.5 %
• 2024-06-04 Blast 63.6 %
• 2024-05-28 Blast 46.2 %
• 2024-04-17 Blast 1.0 %
• 2024-04-04 Blast 5.1 %
• 2024-04-01 Blast 4.5 %

The patient’s AML control is unstable. The blast percentage reduction with Vidaza (azacitidine) is less effective than with cytarabine, but the effect of cytarabine (maintaining blasts < 20%) lasts only about two weeks. According to our hospital’s chemotherapy protocol (version 2023-02-20), the administration method from the reference “Cancer. 2007 Mar 15;109(6):1114-24” for low dose Ara-C is 20 mg twice daily for 10 days, whereas the patient received it for only 7 days.

Given the patient’s ECOG PS is 2, low dose cytarabine combination therapy might be considered. The oral BCL2 inhibitor venetoclax is covered by NHI, with the reimbursement rule requiring it to be used with low-dose cytarabine for newly diagnosed AML patients who cannot undergo high-intensity chemotherapy:

• The patient must meet one of the following conditions:
  • Over 75 years old.
  • 18-75 years old with ECOG performance status of 2 or 3, and one of the following:
    • History of heart failure with left ventricle ejection fraction (LVEF) < 50%.
    • History of chronic lung disease with DLCO < 65%.
    • Abnormal liver function: Bilirubin level between 1.5-3.0 times the normal value.
• The patient must not have previously received azacitidine for myelodysplastic syndrome (MDS).
• Prior approval is required, and reapplication every two cycles is necessary with effectiveness evaluation. Treatment should be stopped if the condition worsens.
• Up to 6 pills per day, with a maximum of 4 cycles covered.

2024-06-12

[pre-existing anemia and thrombocytopenia complicate chemotherapy assessment]

The patient was diagnosed with AML at the beginning of this year. Throughout the HIS5 lab data, her HGB and PLT levels have never reached the lower limit of the normal range, even with 18 blood transfusions. The persistent anemia and thrombocytopenia developed even before the initialization of chemotherapy (2024-01-15).

Both azacitidine and cytarabine are known to be associated with anemia and thrombocytopenia, so the contribution of chemotherapy cannot be ruled out. However, given the patient’s pre-existing anemia and thrombocytopenia, it is difficult to determine the extent to which chemotherapy has contributed.

• 2024-04-20 HGB 7.8 g/dL

• 2024-04-17 HGB 7.3 g/dL

• 2024-04-11 HGB 7.6 g/dL

• 2024-04-04 HGB 6.8 g/dL

• 2024-04-01 HGB 6.5 g/dL

• 2024-03-28 HGB 7.8 g/dL

• 2024-03-26 HGB 7.5 g/dL

• 2024-03-21 HGB 7.9 g/dL

• 2024-03-19 HGB 8.3 g/dL

• 2024-03-12 HGB 7.8 g/dL

• 2024-03-05 HGB 7.1 g/dL

• 2024-02-20 HGB 7.2 g/dL

• 2024-02-06 HGB 7.5 g/dL

• 2024-01-31 HGB 8.6 g/dL

• 2024-01-24 HGB 8.5 g/dL

• 2024-01-22 HGB 7.9 g/dL

• 2024-01-18 HGB 8.2 g/dL

• 2024-01-15 HGB 7.8 g/dL

• 2024-01-11 HGB 7.9 g/dL

• 2024-01-08 HGB 6.8 g/dL

• 2024-01-05 HGB 8.2 g/dL

• 2024-01-04 HGB 6.7 g/dL

• 2024-01-03 HGB 6.9 g/dL

• 2024-06-09 PLT 29 *10^3/uL

• 2024-06-04 PLT 24 *10^3/uL

• 2024-05-28 PLT 16 *10^3/uL

• 2024-05-14 PLT 24 *10^3/uL

• 2024-04-30 PLT 30 *10^3/uL

• 2024-04-22 PLT 94 *10^3/uL

• 2024-04-20 PLT 30 *10^3/uL

• 2024-04-17 PLT 35 *10^3/uL

• 2024-04-11 PLT 3 *10^3/uL

• 2024-04-04 PLT 55 *10^3/uL

• 2024-04-01 PLT 36 *10^3/uL

• 2024-03-28 PLT 103 *10^3/uL

• 2024-03-26 PLT 25 *10^3/uL

• 2024-03-21 PLT 94 *10^3/uL

• 2024-03-19 PLT 33 *10^3/uL

• 2024-03-12 PLT 23 *10^3/uL

• 2024-03-05 PLT 39 *10^3/uL

• 2024-02-20 PLT 44 *10^3/uL

• 2024-02-06 PLT 63 *10^3/uL

• 2024-01-31 PLT 8 *10^3/uL

• 2024-01-24 PLT 65 *10^3/uL

• 2024-01-22 PLT 17 *10^3/uL

• 2024-01-18 PLT 83 *10^3/uL

• 2024-01-15 PLT 22 *10^3/uL

• 2024-01-11 PLT 33 *10^3/uL

• 2024-01-08 PLT 11 *10^3/uL

• 2024-01-05 PLT 64 *10^3/uL

• 2024-01-04 PLT 134 *10^3/uL

• 2024-01-03 PLT 40 *10^3/uL

2024-04-08

A low dose of Ara-C was administered (again) on 2024-03-29, resulting in a reduction of peripheral blast percentage to around 5%. Concurrently, grade 3 anemia has developed, suggesting the need for LPRBC transfusion.

• 2024-04-04 Blast 5.1 %

• 2024-04-01 Blast 4.5 %

• 2024-03-28 Blast 19.2 %

• 2024-04-04 HGB 6.8 g/dL

• 2024-04-01 HGB 6.5 g/dL

2024-02-28

[persistent blast percentage despite chemotherapy, considering LPRBC transfusion]

The patient underwent a 7-day low-dose Ara-C treatment starting on 2024-01-15, followed by four biweekly 3-day sessions of 100mg azacitidine, concluding on 2024-03-21.

Despite these treatments, the blast percentage in the peripheral blood rose from a nadir of 1.1% on 2024-01-22 to approximately 20%, indicating that remission was not achieved. With hemoglobin levels below 8 g/dL, a leukapheresis red blood cell (LPRBC) transfusion may be necessary if symptoms persist.

• 2024-03-28 Blast 19.2 %

• 2024-03-26 Blast 21.6 %

• 2024-03-21 Blast 22.2 %

• 2024-03-19 Blast 21.0 %

• 2024-03-12 Blast 13.5 %

• 2024-03-05 Blast 12.8 %

• 2024-01-22 Blast 1.1 %

• 2024-01-18 Blast 3.2 %

• 2024-01-15 Blast 7.7 %

• 2024-01-11 Blast 7.2 %

• 2024-01-08 Blast 6.1 %

• 2024-03-28 HGB 7.8 g/dL

• 2024-03-26 HGB 7.5 g/dL

• 2024-03-21 HGB 7.9 g/dL

2024-01-10

After 5 days of hydroxyurea treatment (500mg BID from 2024-01-04 to 2024-01-08), the blast percentage in peripheral blood significantly reduced from nearly 20% to below 10%.

• 2024-01-08 Blast 6.1 %
• 2024-01-05 Blast 2.5 %
• 2024-01-04 Blast 17.5 %
• 2024-01-03 Blast 19.1 %

Hydroxyurea can be used off-label for cytoreduction in AML, effectively normalized the WBC count to 4.1K/uL by 2024-01-08. Consequently, further administration of hydroxyurea is currently unnecessary.

700549625

240726

==========

2024-07-26

[Proper Storage and Usage of Flumarin (Flomoxef Sodium)]

According to the Flumarin (flomoxef sodium) package insert, the medication should be used as soon as possible after preparation. If it must be prepared in advance, it should be used within 6 hours when stored at room temperature or within 24 hours when refrigerated.

701314187

240726

[exam findings]

• 2024-07-23 KUB
  • KUB shows: Bilateral clear psoas shadows. Unremarkable bowel gas pattern. Intrauterine device in the pelvic cavity.
• 2024-07-04 CT - abdomen
  • History and indication: Gastric cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of gastric body (stable) with adjacent LAP. Increased soft tissues in peritoneal cavity.
    • Multiple bony metastases.
    • Cystic lesions (up to 4.6cm) in bil. adnexa.
    • An IUD in the pelvic cavity.
  • IMP:
    • Wall thickening of gastric body (stable) with adjacent LAP. Increased soft tissues in peritoneal cavity r/o tumor seeding.
    • Multiple bony metastases.
    • Cystic lesions (up to 4.6cm) in bil. adnexa.
• 2024-06-17 SONO - gynecology
  • IMP:
    • IUD in situ
    • Uterine myoma
    • R/O RT Ovarian cyst (47x40mm)
    • R/O RT Ovarian mass (113x62mm), Malignancy cannot be ruled out
• 2024-06-14 Colonoscopy
  • Diagnosis:
    • Colon polyp, Paris classification 0-Is, sigmoid colon, about 33cm AAV.
    • Proctitis, rectum.
    • Internal hemorrhoid
    • Biopsy was not performed, due to thrombocytopenia.
  • Suggestion:
    • Biopsy removal would be suggested, after condition relative stable
  • Complication:
    • No immediate complication
• 2024-06-12 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the sternum, multiple T- and L-spine, bilateral multiple ribs, bilateral multiple pelvic bones, femurs, shoulders, and knees.
  • IMPRESSION:
    • Highly suspected malignancy with multiple bone metastases.
    • Suspected benign lesions at bilateral shoulders and knees.
• 2024-06-11 Patho - stomach biopsy
  • Stomach, lower body, GC, biopsy — Adenocarcinoma.
  • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
  • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
• 2024-06-11 EGD
  • Diagnosis:
    • R/o gastric cancer, lower body, s/p biopsy
    • Reflux esophagitis LA Classification grade A-
    • Superficial gastritis
    • Duodenitis, bulb
  • CLO test: not done
  • Suggestion:
    • Pursue pathology report
• 2024-06-06 SONO - abdomen
  • Diagnosis:
    • Fatty liver, mild
    • Bilateral renal stones
• 2024-06-05 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Metastatic adenocarcinoma and see description
  • The sections show a picture of metastatic adenocarcinoma, composed of low columnar to cuboidal pleomorphic neoplastic cells, arragned in solid, cribriform and glandular patterns with desmoplastic stromal reaction. The hematopoietic component is marked decreased.
  • IHC, the tumor cells show: CK7(+), CK20(rare +), CDX2(+), TTF1(-), and PAX8(-). Suggest check upper GI tract or pancreatobiliary tract.
• 2024-06-04 CTA - chest
  • Findings
    • Lungs: dependent subsegmental atelectasis at RLL. normal appearance of RUL, RML, and left lung.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
    • Heart: normal size of cardiac chambers.
    • Pleura: small Rt-sided effusion.
    • Chest wall and visible lower neck: mild enlarged thyroid gland with cystic nodule 24mm.
    • abdomena and pelvic: a left adrenal low attenuated mass (34mm).
    • contents: a well circumscribed, ovoid soft-tissue mas (51x59mm)
      • with inferior ascites at Rt lower quadrant of abdoemn. enlarged uterus with intrauterine device inserted.
    • unremarkable of the liver, GB, spleen, pancreas, and both kidneys. no focal wall thickening of GI tract.
    • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • thyroid goiter. small Rt transudative effusion.
    • RLQ tumor, may be exophytic uterine myoma. Lt adrenal tumor.
• 2024-06-04 L-spine AP + Lat. (including sacrum)
  • Suspect mild L2 compression fracture. Degenerative change of the spine with marginal spur formation.
• 2024-06-04 SONO - gynecology
  • IMP:
    • IUD in situ
    • Uterine myoma
    • R/O Adenomyosis
    • R/O LT Ovarian cyst

[MedRec]

• 2024-07-14 ~ 2024-07-18 POMR Hemato-Oncology Gao WeiYao
  • Present illness
    • She had undewent 2nd chemotherapy on 07/01 and nausea with vomiting and abdominal distension was noted and improved 2 days later. This time she was admission for 3rd chemotherapy.
  • Course of inpatient treatment
    • After admission, hydration and lab data exam was arranged, WBC:2110, HB:9.6,PLT:64000 was noticed.
    • We correct her HB and PLT and FOLFOX C3 was started on 7/16.
    • Transfusion 2U with LPRBC was supplied to keep her HB > 10 for radiotherapy.
    • FOLFOX C3 finsihed on 7/18 afternoon. Since her stable condtion, she discharged with OPD f/u. The next admission will be arranged on 8/06.
  • Discharge prescription
    • Nebilet (nebivolol 5mg) 1# QD
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Norvasc (amlodipine 5mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
• 2024-06-29 ~ 2024-07-04 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Adenocarcinoma of stomach with pelvic bone and other bone and marrow metastases, stage IV
    • Thrombocytopenia, unspecified
    • Anemia, unspecified
  • Course of inpatient treatment
    • After admission, we recheck her lab data and HB:8.6g/dL, PLT62000/uL was noticed. Transfusion with LPRBC 2U was prescribed.
    • Then FOLFOX C2D1 from 2024/07/01-03.
    • Mild dizziness and nausea sensation was complained, vena and dexamethasone was supplied.
    • We recheck her lab data on 7/4 and transfusion with LRP 2U.
    • She discharged on 7/4 with OPD follow up. She will be re-admitted on 2024/7/14 for next round C/T.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# HS
    • Nebilet (nebivolol 5mg) 1# QD
    • Norvasc (amlodipine 5mg) 1# QD
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Trand (tranexamic acid 250mg) 1# TID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
• 2024-06-04 ~ 2024-06-22 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Gastric adenocarcinoma with Rt overy (Krunkeberg tumor),bone and bone marrow metastases
    • Thrombocytopenia, unspecified
    • Anemia, unspecified
  • CC
    • Diffuse ecchymosis noted for one week
  • Present illness
    • A 52 years-old female who has
      • Hypertension with Norvasc, Nebilet control for 5 years,
      • Hyperlipidemia with Pitarty control for 3 months,
      • Hyperthyroidism with Carbizo control for 10years.
    • This time she was admitted due to diffuse ecchymosis noted for one week.
    • According to the patient statement, she suffered from back pain for two weeks and stated difficult bending. Thus she went to LMD and had taken pain killer of Tonful (Carisoprodol + Paracetamol) and Celebrex. However, she started to had diffuse ecchymosis after pain killers. She also stated that her mense was irregular and large amount. She denied fever, URI symptoms, chest pain, chest tightness, abdominal pain, dysuria, tarry stool or hematuria. Due to above symptoms, she came to other hospital (YiLan YangMing Univ.) for help first, the lab showed abnormal coagulation function (PT/aPTT 21.3/51.1, INR 1.69), thrombocytopenia, then she was transerred to our hospital for personal reason (Her son is a nurse practioner in the internal medicine department of our hospital).
    • At ER, the vital signs: BT:36.7’C; HR:79 bpm; RR:17 bpm; BP: 144/78 mmHg, SpO2: 96%, Con’s: E4V5M6, the lab of CBC/DC revealed thrombocytopenia (Plt: 9000/uL), gave blood transfusion with LRP 2U, and re-checked the platelets level up to 34000/uL. Abnormal coagulation function (PT/aPTT 15.6/33.5, INR 1.55), and poor liver function (GOT 107U/L), D-dimer > 10000 ng/mL.
    • The chest x-ray showed Ground glass opacity in RLL. L-spine x-ray showed suspect mild L2 compression fracture. Degenerative change of the spine with marginal spur formation. Ultrasound showed no obvious liver leision, no splenomegaly, and had uterine myoma around 4.5 cm in diameter. Gynecologic ultrasonography showed 1.IUD in situ, 2.Uterine myoma, 3.R/O Adenomyosis, 4.R/O LT Ovarian cyst. CTA was done on 2024/06/04, the report showed thyroid goiter, small Rt transudative effusion, RLQ tumor,may be exophytic uterine myoma, and Left adrenal tumor. Indirect Coomb Test/ Direct Coomb Test showed negative. Under the impression of suspect ITP, so she is admitted for future management.
  • Course of inpatient treatment
    • After admission, we arranged bone marrow biopsy and report showed metastatic adenocarcinoma.
    • Due to elevated ALP 179, we arranged abdomen ultrasound showed fatty liver, mild and bilateral renal stones. And we added silymarin 1# TID since 6/4.
    • Port A insertion was done on 06/07. For thrombocytopenia, LRP had been given as lab data report.
    • Tumor marker showed elevated CEA 59, CA199 465, CA125 88. We had arrange upper GI endoscopy on 6/11, and report showed r/o gastric cancer, lower body.
    • Pathology showed adenocarcinoma. Bone scan showed highly suspected malignancy with multiple bone metastases.
    • We cancelled pitavastatin use due to abnormal liver enzyme.
    • FOLFOX was given on 6/15.
    • Due to heavy mentrual flow on 06/17, we consulted Gynecologist and they stated that there was a Right ovarian tumor, highly suspected Krukenberg tumor, but other ovarian malignancy still cannot be ruled out. And transamin was given as they suggested.
    • Under relative stable condition, she will discharge on 06/22 with OPD follow up.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ7H if headache
    • Trand (tranexamic acid 250mg) 1# TID
    • Nincord Oral Gel (triamcinolone 1mg/gm) BID TOPI
    • Ulstop (famotidine 20mg) 1# BID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
    • Norvasc (amlodipine 5mg) 1# QD
    • Nebilet (nebivolol 5mg) 1# QD
    • Mosapin (mosapride citrate 5mg) 1# TID
    • BaoGan (silymarin 150mg) 1# TID
    • Baraclude (entecavir 0.5mg) 1# HS

[chemotherapy]

• 2024-07-16 - oxaliplatin 85mg/m2 144mg D5W 250mg 2hr + leucovorin 400mg/m2 678mg NS 250mL 2hr + fluorouracil 2800mg/m2 4748mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-07-01 - oxaliplatin 85mg/m2 145mg D5W 250mg 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-06-15 - oxaliplatin 85mg/m2 147mg D5W 250mg 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2866mg/m2 4800mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-07-26

[delaying folfox treatment due to low ANC levels]

Recent lab results from 2024-07-24 show a WBC count of 1.35K, a neutrophil percentage of 46.2%, thus an estimated ANC of 624/uL. The planned FOLFOX treatment is recommended to be delayed until the ANC rises above 1500/uL. In urgent cases, the ANC should be above 1000/uL before administration.

• 2024-07-24 WBC 1.35 x10^3/uL
• 2024-07-24 Neutrophil 46.2 %

701528056

240726

[lab data]

2024-07-23 HBsAg Nonreactive
2024-07-23 HBsAg Value 0.26 S/CO
2024-07-23 Anti-HBc Reactive
2024-07-23 Anti-HBc Value 1.63 S/CO
2024-07-23 Anti-HCV Nonreactive
2024-07-23 Anti-HCV Value 0.06 S/CO

[exam findings]

• 2024-07-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (94 - 27) / 94 = 71.28%
    • M-mode(Teichholz) = 71
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild TR
• 2024-07-09 PET
  • Mildly increased FDG uptake in the stomach, compatible with lymphoma of low FDG uptake.
  • Mildly increased FDG uptake in bilateral submandibular glands and bilateral pulmonary hilar lymph nodes and faintly increased FDG uptake in some bilateral inguinal lymph nodes. Inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
• 2024-07-05 Patho - bone marrow biopsy
  • Bone marrow, iliac crest, biopsy — No evidence of lymphoma involvement
  • The sections show normocellular marrow (20%). M/E ratio = 5:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. No focal lymphoid aggregation. Scattered small CD3+ T-cells and CD20+ B lymphocytes can be found. There is no evidence of lymphoma involvement in the sections examined. Suggest further bone marrow smear evaluation and clinical correlation.
• 2024-06-29 CT - abdomen
  • History and indication:
    • Newly diagnosis gastric diffuse large B cell lymphoma
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of stomach.
    • Colonic diverticula.
    • Some LNs at mesentery and bil. inguinal regions.
    • Tiny renal cysts.
    • Retroversion of uterus.
    • Atherosclerosis of aorta, iliac arteries.
    • Compression fracture of L2.
  • IMP:
    • Wall thickening of stomach.
    • Colonic diverticula.
    • Some LNs at mesentery and bil. inguinal regions.
• 2024-06-19 Patho - stomach biopsy
  • DIAGNOSIS:
    • Stomach, lower body, GC/PW site, s/p biopsy (A) — lymphoprofetation, feature suggestive of diffuse large B cell lymphoma. Non-germinal center type. Please correlate with scope and, if available, abdominal CT scan finding. H pylori NOT present.
    • Stomach, middle body, GC/PW site, s/p biopsy (B) — lymphoprofetation, feature suggestive of diffuse large B cell lymphoma. Non-germinal center type. Please correlate with scope and, if available, abdominal CT scan finding. H pylori NOT present.
  • MICROSCOPIC DESCRIPTION:
    • Section shows gastric mucosal tissue with lymphoprofetation, feature suggestive of diffuse large B cell lymphoma. Non-germinal center type. Please correlate with scope and, if available, abdominal CT scan finding. H pylori NOT present.
    • Section shows gastric mucosal tissue with lymphoprofetation, feature suggestive of diffuse large B cell lymphoma. Non-germinal center type. Please correlate with scope and, if available, abdominal CT scan finding. H pylori NOT present.
    • IHC stains: CD3 and CD20: a higher B cell / T cell subpopulation ratio; bcl-2 (+), bcl-6 (-), CD10 (-), c-myc (-), MUM-1 (-), CD23 (-), Ki67: 10%.
• 2024-06-18 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis, s/p CLO test
    • Gastric mucosal lesion, lower body, GC/PW site, s/p biopsy (A)
    • Gastric fungating lesion, r/o Borrmann type II, middle body, GC/PW site, s/p biopsy (B)
  • CLO test: Negative
  • Suggestion:
    • Pursue CLO test and pathology report
• 2024-06-18 SONO - abdomen
  • Gallbladder polyp

[immunochemotherapy]

• 2024-07-23 - rituximab 375mg/m2 550mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 85mg QD PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramiine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL

701532825

240726

[exam findings]

• 2024-07-23 CT - abdomen
  • Clinical history: 57 y/o male patient with dyspnea for 4 days
  • Past history: DM, HBV W/O Rx
  • A-/B-/C+: smoking over 30 years, now quit.
  • Productive cough (yellow and blood streak), dyspnea, no cold sweating, Fatigue
  • With and without contrast enhancement CT of abdomen:
    • Diffuse right lung tumor with loculated right pleural effusion.
    • Multiple liver tumors, up to 10cm in right lobe liver, could be due to malignancy, primary or metastasis. suggest further study.
    • Enlarged lymph nodes in hepatic hilar region, r/o lymph nodes metastasis.
    • Bilateral pleural effusion.
    • Presence of ascites.
    • Presence of pericardial effusion.
  • Impression:
    • Multiple liver tumors and massive right pleural effusion, diffuse right lung tumor. Suggest tissue study.
    • R/O lymph nodes metastasis in hepatic hilar region.
    • Pleural effusion and ascites, pericardial effusion.
• 2024-07-23 CXR
  • Chest image in sitting position shows:
  • Opacification of Rt hemithorax with ipsilateral tracheal deviation, may be due to pleural effusion and atelectatic lung
  • Bullous emphysema in LUL

700155232

240723

[lab data]

2024-07-17 Anti HTLV I/II Nonreactive
2024-07-17 Anti HTLV I/II Value 0.05 S/CO
2024-07-17 Anti-HBc Reactive
2024-07-17 Anti-HBc Value 5.13 S/CO
2024-07-17 Anti-HBs 38.56 mIU/mL
2024-07-17 HBsAg Nonreactive
2024-07-17 HBsAg Value 0.28 S/CO
2024-07-17 Anti-HCV Nonreactive
2024-07-17 Anti-HCV Value 0.07 S/CO

[exam findings]

• 2024-07-04 Patho - skin cyst/tag/debridement
  • Labeled as “right posterior thigh”, biopsy — peripheral T cell lymphoma, in favor of mycosis fungoides.
  • Section shows one piece of skin with dermal and perivascular infiltration of atypical lymphoid cells demonstrating cerebriform nuclei, and many mitoses. Epidermotropism is present.
  • IHC stains: CD3 and CD20 show a predominant T cell sub-population. CD4 and CD8 show a predominant CD4 subpopulation. CD25 (+), CD30 (70%), CD56 (rare), Granzyme B (-).
• 2024-03-28 CT - abdomen
  • Hyperplasia of bil. adrenal glands.
  • Grade 4 fatty liver.
  • Right renal cyst (1.7cm).
  • Gallbladder and CBD stones (2-3mm).
• 2024-03-26 SONO - nephrology
  • Parenchymal change of bilateral kidneys
  • Single renal cyst, right kidney
• 2023-11-28 SONO - neurology
  • Mild to moderate atherosclerosis in following arteries:
    • Lt External carotid artery (ECA)
  • Elevated pulsatility index (PI) in following arteries, indicating distal stenosis:
    • Bilateral Vertebral artery & Basilar artery
  • Inadequate total blood flow volume of bilateral Vertebral artery (84.5 ml/min), indicating Vertebrobasilar insufficiency (VBI).
  • Incomplete study due to poor temporal windows for transcranial insonation.

[MedRec]

• 2024-05-21 SOAP Neurology Zou ChuYin
  • Diagnosis
    • Unspecified late effect of cerebrovascular disease [I69.80]
    • Essential hypertention, unspecified [I10]
    • Other insomnia [G47.00]
    • Dyslipidemia ; other and unspecified hyperlipidemia [E78.5]
    • Peptic ulcer, site unspecified Unspecified as acute or chronic, without haemorrhage or perforation [K27.9]
  • Prescription x3
    • Toricam (piroxicam 10mg/gm) PRNBID TOPI
    • Norvasc (amlodipine 5mg) 1# BID
    • Eurodin (estazolam 2mg) 0.5# PRNHS
    • Plavix (clopidogrel 75mg) 1# QD
    • Alpraline (alprazolam 0.5mg) 1# PRNHS
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 0.5# BID
    • Linicor (niacin 500mg, lovastatin 20mg) 1# QOD
    • Forxiga (dapagliflozin 10mg) 1# QOD
    • Const-K (potassium chloride 750mg 10mEq) 1# QD

==========

(not posted yet)

Testing for human T-cell lymphotropic virus (HTLV) can sometimes be helpful for people who appear to have peripheral T-cell lymphoma. In rare cases, HTLV can cause adult T-cell leukemia/lymphoma. This type of T-cell lymphoma can look very similar to peripheral T-cell lymphoma, but is treated differently. The anti HTLV I/II showed nonreactive and the value was 0.05 S/CO on 2024-07-17.

People with human immunodeficiency virus (HIV) tend to have a weakened immune system. So if the patient has peripheral T-cell lymphoma, it might be beneficial to know whether she also has HIV

700373217

240723

[MedRec]

• 2024-07-19 ~ 2024-07-21 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Sigmoid colon adenocarcinoma with impending obstruction and metastases of liver and para-aortic lymph nodes, cT4aN2bM1b, stage IVb, post laparoscopic sigmoidectomy on 2023-12-14, pT3N1bM1b, stage IVb for tenth Avastin and eleventh FOLFIRI palliative chemotherapy
    • Grade 3 diarrhea
    • Type 2 diabetes mellitus
    • Hepatitis B carrier
  • CC
    • Admission for palliative chemotherapy for sigmoid colon adenocarcinoma with impending obstruction and metastases of liver and para-aortic lymph nodes, cT4aN2bM1b, post laparoscopic sigmoidectomy on 2023-12-14, pT3N1bM1b, stage IVb.
    • epigastric cramping pain, watery diarrhea more than 10 times a day for 2 weeks, general weakness, poor appetite for a weeks.
  • Present illness
    • This 61-year-old male patient was a case of sigmoid colon adenocarcinoma with impending obstruction and metastases of liver and para-aortic lymph nodes, cT4aN2bM1b, stage IVb, was diagnosed on 2023/11.
    • He underwent laproscopic sigmoidectomy on 2023/12/14. Pathologic stage: pT3N1bM1b, stage IVb (liver and para-aortic lymph nodes metastases). Postoperative course was rather smooth.
    • Palliative chemotherapy with FOLFIRI was started on 2024/01/24 and Avastin was added on 2024/02/15. The patient was quite well without nausea, vomiting, diarrhea or general malaise.
    • However, he got epigastric cramping pain, watery diarrhea more than 10 times a day for 2 weeks, general weakness, poor appetite for a weeks. He ever visited ER and GI OPD for further management, anti-diarrhea medications were given.
    • After medical treatment, his diarrhea improved gradually. Now he admitted to our ward for palliative chemotherapy.
  • Course of inpatient treatment
    • After admission, he received FOLFIRI and Avastin palliative chemotherapy. All the dose were reduced by 20% due to grade 3 diarrhea.
    • Hospital course was smooth. Nausea or vomiting did not occurr. Fever or infection signs wasn`t noted. In stable condition, he was discharged on 2024/07/21.
  • Discharge prescription
    • Stogamet (cimetidine 300mg) 1# TID

[immunochemotherapy]

• 2024-07-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 1000mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL
• 2024-06-21 - bevacizumab 5mg/kg 391mg NS 100mL 90min + irinotecan 180mg/m2 346mg D5W 250mL 90min + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 5395mg NS 1000mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 8mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL
• 2024-06-07 - bevacizumab 5mg/kg 388mg NS 100mL 90min + irinotecan 180mg/m2 346mg D5W 250mL 90min + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 5395mg NS 1000mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 8mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL
• 2024-05-24 - bevacizumab 5mg/kg 385mg NS 100mL 90min + irinotecan 180mg/m2 345mg D5W 250mL 90min + leucovorin 400mg/m2 765mg NS 250mL 2hr + fluorouracil 2800mg/m2 5359mg NS 1000mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 8mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL
• 2024-05-10 - bevacizumab 5mg/kg 385mg NS 100mL 90min + irinotecan 180mg/m2 345mg D5W 250mL 90min + leucovorin 400mg/m2 765mg NS 250mL 2hr + fluorouracil 2800mg/m2 5359mg NS 1000mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 8mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL
• 2024-04-26 - (Avastin + FOLFIRI)
• 2024-04-11 - (Avastin + FOLFIRI)
• 2024-03-21 - (Avastin + FOLFIRI)
• 2024-03-01 - (Avastin + FOLFIRI)
• 2024-02-15 - (FOLFIRI)
• 2024-01-24 - (FOLFIRI)

==========

2024-07-23

[monitoring diarrhea occurrence after chemotherapy dosage adjustment]

Palliative chemotherapy with FOLFIRI was started on 2024-01-24, and Avastin was added on 2024-02-15. This regimen has been in use for approximately six months. Although both irinotecan and fluorouracil can cause diarrhea, the patient has tolerated them well in the past. This raises the question of whether the patient’s condition or physiology has changed, warranting further investigation.

The most recent administration of Avastin + FOLFIRI was on 2024-07-19, with the dosage adjusted to 80% of the previous amount. This is a reasonable measure, and further observation is needed to determine if diarrhea still occurs.

700567233

240723

[exam findings]

• 2024-06-24, -06-18 CXR supine
  • S/P port-A implantation.
  • S/P pigtail catheter implantation at right CP angle.
  • Patchy opacity projecting at right lower lung is noted. Please correlate with CT.
  • Enlargement of cardiac silhouette.
  • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
• 2024-06-14 Bronchoscopy
  • Symptom: dyspnea​, cough
  • Clinical diagnosis: Lung tumor, for tissue prove, Chronic cough, r/o endobronchial lesion
  • Bronchoscopic diagnosis:
    • Narrowing of bronchus intermedius due to external compression, r/o malignancy
    • Partial obstruction at bronchus intermedius, r/o endo-bronchial tumor
  • Bronchoscopic finding:
    • The nasal mucosa was hypertrophic.
    • The nasal lumen was severely narrowed.
    • Mucosa of nasopharynx was swelling .
    • Nasopharynx was severely narrowed.
    • Mucosa of pharynx cobble-stone in shape.
    • Bilateral arytenoid proceww was swelling .
    • Main carina: sharp and movable on deep breathing.
    • bilateral bronchial trees
      • Narrowing of bronchus intermedius due to external compression, r/o malignancy
      • Partial obstruction at bronchus intermedius, r/o endo-bronchial tumor
• 2024-06-14 EEG
  • Continuous lateralized rhythmic delta activity plus fast activity were noted, highly suscepted related to non-convulsive stattus epilepticus.
  • Further image study, anti seizure mediciube use and f/u EEG study was suggested.
• 2024-06-13 MRI - brain
  • Still presence of one well-defined intra-axial tumor, about 28 mm, with heterogeneous enhancement involving left pons, compressing the aqueduct and associating with extensive perifocal edema.
  • Presence of hydrocephalus.
• 2024-06-13 SONO - chest
  • Special Procedure
    • echo-assisted - Insertion of pig-tail catheter Right side 14 fr. through the 6 ICS
  • Echo diagnosis
    • pleural effusion and pneumothorax, right.
• 2024-06-12 CT - chest
  • lung cancer with brain metastasis s/p RML and RLL lobectomy, post op follow up
  • Comparison was made with CT on 2023 2024
    • moderate Rt hydropneumothorax with thickening of parietal pleura.
    • lungs: a subsegmental consolidation in posteroinferior aspect of Rt remnant lung parenchyma. mild patchy ground glass opacities over basal segments of LLL.
    • subcutaneous emphysema in the right chest wall.
    • Mediastinum and hila: no enlarged LN.
    • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal size of cardiac chambers.
    • Visible abdominal contents: a left hepatic cyst, 8mm in S4 and a few Left renal cysts, 9mm.
  • Impression:
    • moderate Rt hydropneumothorax, cause? broncho-pleural fistula?
    • subsegmental infection or inflammation in Rt remnant lung.
• 2024-06-10, -06-05 CXR supine
  • S/P port-A implantation.
  • Gas content in right axillary area is noted. Please correlate with CT.
  • Patchy opacity projecting at RLL or right lower chest wall is suspected. Please correlate with CT.
• 2024-06-03 CXR
  • s/p right chest tube in place, its tip directed superiorly , projecting over Rt 2nd intercostal space
  • focal increased opacity over Rt lower lung in progression, and s/p RML wedge and RLL lobectomy
• 2024-06-03 ALK IHC
  • Cellblock No. S2024-09781 A3
  • RESULT: Negative
• 2024-05-27 PD-L1 (28.8)
  • Cellblock No. S2022-19870
  • RESULTS：
    • Tumor cell (TC) staining assessment: TC: >= 1% and < 5%
    • Percentage of PD-L1 expressing tumor cells (%TC): 1%
• 2024-05-22 ROSI IHC
  • Cellblock No. S2024-09781 A3
  • RESULT: Negative
• 2024-05-22 PD-L1 (22C3)
  • Cellblock No. S2024-09781 A3
  • RESULTS：
    • Tumor Proportion Score (TPS) assessment: TPS >= 1% and < 50%
    • Tumor Proportion Score (TPS): 5%
• 2024-05-22 EGFR gene mutation test
  • Cellblock No. S2024-09781 A3
  • Result:
    • No mutation was detected at exons 18,19,20,21 of EGFR gene in this specimen.
• 2024-05-15 Patho - lung total/lobe/segmental
  • Diagnosis
    • Lung, specimen 01 right, lower lobe, VATS lobectomy (S2024-9781 specimen 01) — adenocarcinoma. With lymph node metastasis (4/9 in this specimen).
      • IHC stains: Napsin-A (+), TTF-1 (+), CK7 (+), CK20 (-), CD56 (-).
    • Lung, labeled as “RML and RLL, right”, biopsy and frozen section (F2024-193FS) — necrotic tissue only.
    • Lymph node, (or groupNo. LN10; LN11; LN12), lymphadenectomy (S2024-9781s pecimens 02, 03, 04) —Free (0/6)
    • pT1c pN1 (if cM0) Pathology stage: IIB, at least.
    • PT1c pN1 (if cM1b); Pathology stage: IVA, at least.
  • Gross Description
    • Specimen received:
      • Lung, size: frozen section biopsy specimen (F2024-193): 0.6 x 0.5x 0.3cm; RLL lobectomy specimen (S2024-9781 specimen 01): 13 x 7 x 4 cm.     - Lymph nodes, 3 bottles, maximal size: 0.5x 0.2x 0.2 cm
    • Tumor Site: Peribronchial
    • Gross Tumor Size:     - Solitary : 2.2x 1.5x 1.5cm
    • Gross tumor patterns: poorly defined
    • Representative sections are taken and labeled as:
      • Tissue for frozen section: F2024-193FS: Lung, labeled as “RML and RLL, right”.
      • Tissue for formalin fixation: S2024-9781: A1-5: right, lower lobe, VATS lobectomy (S2024-9781 specimen 01): A1-4: tumor; A5: non-tumor; A6: LN10; A7: LN11; A8: LN12.
  • Microscopic Description
    • Tumor Size
      • Greatest dimension (centimeters): 2.2 cm
      • Additional dimensions (centimeters): 1.5 x 1.5 cm
    • Tumor Focality - Single tumor
      • Note: Required elements that differ among the tumor nodules (eg, tumor size, histologic type) should be reported for each tumor nodule.
    • Histologic Type (select all that apply) - Invasive adenocarcinoma, acinar predominant (100%)
    • Histologic Grade (according to the main histological type) - G2: Moderately differentiated
    • Spread Through Air Spaces (STAS) - Not identified
    • Visceral Pleura Invasion - Not identified
    • Lymphovascular Invasion (select all that apply) - Present
      • Lymphatic
    • Direct Invasion of Adjacent Structures (select all that apply) - No adjacent structures present
    • Margins (select all that apply)
      • Note: Use this section only if all margins are uninvolved and all margins can be assessed.
      • All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.5 cm
      • Specify closest margin: bronchial margin.
    • Treatment Effect - No known presurgical therapy
    • Regional Lymph Nodes - 4/15 with extrnodal extension
      • lymph node metastasis (4/9 in 01 right, lower lobe, VATS lobectomy); 02 LN10 (0/1); 03 LN11 (0/1); 04 LN12 (0/4)
    • Extranodal Extension - Present
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Note: Reporting of pT, pN, and (when applicable) pM categories is based on information available to the pathologist at the time the report is issued. Only the applicable T, N, or M category is required for reporting; their definitions need not be included in the report. The categories (with modifiers when applicable) can be listed on 1 line or more than 1 line.
      • TNM Descriptors (required only if applicable) (select all that apply) - not applicable
        • Primary Tumor (pT) - pT1c: Tumor > 2 cm but <= 3 cm in greatest dimension
          • Note: Tumors with these features are classified as T2a if <= 4 cm or if the size cannot be determined and T2b if > 4 cm but <= 5 cm.
        • Regional Lymph Nodes (pN) - pN1: Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes, including involvement by direct extension
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case)
          • (if cM0) Pathology stage: IIB, at least.
          • (if cM1b) Pathology stage: IVA, at least.
    • Specify site(s) (if applicable): pontine tumor mass effect.
      • Note: Most pleural (pericardial) effusions with lung cancer are a result of the tumor. In a few patients, however, multiple microscopic examinations of pleural (pericardial) fluid are negative for tumor, and the fluid is nonbloody and not an exudate. If these elements and clinical judgment dictate that the effusion is not related to the tumor, the effusion should be excluded as a staging descriptor.
    • Additional Pathologic Findings (select all that apply) - None identified
    • Ancillary Studies - IHC stains: Napsin-A (+), TTF-1 (+), CK7 (+), CK20 (-), CD56 (-).
      • Note: For reporting cancer biomarker testing results, the CAP Lung Biomarker Template should be used. Pending biomarker studies should be listed in the Comments section of this report.
    • Comment(s) - none
• 2024-05-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (84 - 24) / 84 = 71.43%
    • M-mode (Teichholz) = 70
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
• 2024-05-09 Flow Volume Chart
  • Mild vital capacity reduced.
• 2024-05-02 PET
  • Glucose hypermetabolism in a focal area near the right pulmonary hilar region. Primary lung malignancy may show this picture.
  • Glucose hypermetabolism in a focal area in the left aspect of the pons. A metastatic lesion should be considered first. Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
• 2024-05-02 CXR erect
  • There is a nodular opacity projecting in RLL of the lung that is c/w lung cancer after correlate with CT.
• 2024-04-30 Tc-99m MDP bone scan with SPECT
  • Mildly increased activity in the lower L-spines. Degenerative change may show this picture.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • Mildly increased activity in the left parietotemporal area of the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips, knees and right ankle, compatible with benign joint lesions.
• 2024-04-30 SONO - breast
  • Right breast cysts. Suggest follow up.
  • BI-RADS category 2, Benign finding.
• 2024-04-30 Patho - colon biopsy
  • Colon, sigmoid, biopsy — tubular adenoma with low grade dysplasia
  • Colon, transverse, biopsy — tubular adenoma with low grade dysplasia
  • Section shows a fragment of polypoid colonic mucosal tissue with proliferative mucinous glands lined by cells containing hyperchromatic and elongated nuclei.
• 2024-04-23 CT - abdomen
  • With and without contrast enhancement CT of abdomen - whole:
    • S/P cholecystectomy.
    • Liver cyst, 0.79cm in S4 liver.
    • Left renal cysts, up to 0.9 cm.
    • Thyroid nodule, 2cm in right lobe thyroid.
    • Soft tissue density in right hilar region, 2.1cm, r/o malignancy.
• 2024-04-23 CXR supine
  • A poorly defined nodule over medial Rt lower lobe-superior segment, a high possibly of a malignant lesion
• 2024-04-23 ECG
  • Normal sinus rhythm
  • ST & T wave abnormality, consider anterior ischemia
• 2024-04-19 MRA - brain
  • Findings
    • A well-defined intra-axial tumor, about 28 mm, with heterogeneous enhancement involving left pons, compressing the aqueduct and associating with extensive perifocal edema.
    • Presence of hydrocephalus.
    • Diffuse luminal irregularity with mild segmental stenosis of major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
    • Fetal origin of left PCA.
  • IMP:
    • Pontine tumor with mass effect. D/D: primary malignancy, metastasis.

[MedRec]

• 2024-06-26 ProgressNote Chen ShuHua
  • Problem #1:
    • Adenocarcinoma of right lower lobe lung, pT1cN1M1c stage IVA; presenting with pontine metastasis, mass effects, and signs of increased intracranial pressure status post Video-Assisted Thoracoscopic Surgery with right middle lobe wedge resection, right lower lobe lobectomy and radical lymph node dissection on 2024/05/14
    • Assessment: ECOG:3
    • Radiotherapy to pontine metastasis for 3600cGy/12Fx, CT simulation on 4/29, start since 2024/05/10 to 05/14, re-start since 05/20 to 05/24, 05/27 to 05/30, Limeson 4mg/tab 0.5# PO QD for avoid IICP.
    • Plan:
      • Epidermal growth factor receptor (EGFR) testing, anaplastic lymphoma kinase (ALK) and ROS1 showed wild-type without mutations. Testing for programmed death-ligand 1 (PD-L1)(22C3) show Tumor Proportion Score(TPS) : 5 %. We also send NGS study for further evaluation on 2024/06/05 showed KRAS G12C, and explain to family for 2nd line of medication(Sotorasib).
      • ** before Alimta, FOLACIN 5mg/tab 1# PO QD、 Kentamin (B1 50mg & B6 50mg & B12 500mcg) 1# PO QD ** for prophylactic measure to reduce treatment-related toxicity since 2024/06/01.
      • she received chemotherapy with Pembrolizumab 100mg(self paid)/ Alimta(500mg/m2)/ Cisplatin(75mg/m2) on 2024/06/06, Mgso 1amp + KCl 5ml in N/S 500ml run 2hrs was given for against cisplatin-induced nephrotoxicity.
      • arrange Chest CT and Brain MRI for survey, Chest CT on 2024/06/12 showed moderate Right hydropneumothorax, cause? broncho-pleural fistula?、subsegmental infection or inflammation in Rt remnant lung.
      • empirical antibiotic with Cravit 250mg/50mL/bot 750mg IVD QD from 2024/06/12~6/17 for cover bornchopneumonia, change to Mepem 250mg/vial 1000mg IVD Q8H from 2024/06/17~6/20, shift to Sintum 1g/vial 2g IVD Q8H from 2024/06/20~
      • Brain MRI on 2024/06/13 showed 1. Still presence of one well-defined intra-axial tumor, about 28 mm, with heterogeneous enhancement involving left pons, compressing the aqueduct and associating with extensive perifocal edema、2. Presence of hydrocephalus. add Limeson 4mg/tab 1# PO BID for extensive perifocal edema.
      • EEG on 2024/06/14 showed Continuous lateralized rhythmic delta activity plus fast activity were noted, highly suscepted related to non-convulsive stattus epilepticus. Further image study, anti seizure mediciube use and f/u EEG study was suggested. Add Keppra 500mg/5mL/vial 500mg IVD QD for relief. 
      • consult NS for brain edema relief, VP shunt is suggest, but her’s brother refuse surgery. After family discussion, they decided to undergo surgery, VP-shunt will be arranged on 2024/06/25 PM.
      • Chest echo was done on 2024/06/13 showed pleural effusion and pneumothorax, right. Insertion of pig-tail catheter Right side 14fr. through the 6th ICS, use connector to drain air and fluid into chest bottle with under water sealed.
      • Bronchoscopy was done on 2024/06/13 showed Narrowing of bronchus intermedius due to external compression, r/o malignancy、Partial obstruction at bronchus intermedius, r/o endo-bronchial tumor.
  • Problem #5:
    • Chronic viral hepatitis B without delta-agent, Anti-HBc reactive
    • Assessment: stable
    • Plan:
      • Baraclude 0.5mg/tab 1# PO QDAC.
  • Problem #9:
    • Candidal stomatitis
    • Assessment: oral candida, improving
    • Plan:
      • Mycamine injection 50mg/vial 100mg IVD QD from 2024/06/13~6/19.
      • stop Limeson 4mg/tab 0.5# PO use (6/13)
      • Fungus Culture (Bronchial wash) showed Candida albicans Growth: 1+, add Mycamine injection 50mg/vial 100mg IVD QD from 2024/06/21~
  • Problem #10:
    • Tinea cruris
    • Assessment: Skin lesions over gluteal cleft
    • Plan:
      • consult for Red rash on both buttocks, Imp: Tinea cruris, suggest Topical Exelderm cream BID for gluteal cleft lesions and Keep diaper area dry and clean as possible.
• 2024-04-25 SOAP Medical Emergency He YaoCan
  • Prescription
    • diphenhydramine
    • MgO
    • Through (sennoside)
    • Acetal (acetaminophen)
    • Famoster (famotidine)
    • Decan (dexamethasone)
    • NS 500mL
    • Decan (dexamethasone)
    • Famoster (famotidine)
• 2024-04-24 SOAP Radiation Oncology Chang YouKang
  • S
    • went to RenAi Hospital, brain CT: ICH was told
    • however, 2024/04/19 MRA: Brain showed Pontine tumor with mass effect. D/D: primary malignancy, metastasis.
    • Allergy: none
    • PHx: none; no cancer history.
    • Divorced, 1 daughter; coming with her brother.
    • CC: right side weakness progressing after fell down in Japan on 2024/02/20; nausea and poor intake.
  • O
    • CT, 2024/04/20: Soft tissue density in right hilar region, 2.1cm, r/o malignancy.
    • PE, 2024/04/24: No SCF LNs; weakness of right limbs.
  • A
    • Imp; Rt lung cancer, right hilum, with pontine metastasis, mass effects and IICP sign, weakness of right limbs (30% muscle power now).
  • P
    • Plan: Admission (Dr. Yang MuJun) for tissue proof, IICP medication & brain RT as soon as possible.
    • RT to pontine mets for 3960cGy/12 fx is suggested for tumor control. CT simulation on 2024/04/29 15:30. Possible toxicity is told.
    • Dexametathsone for IICP first.
    • The patient and her family have declined to wait for a bed in the emergency department. They have been advised that if her condition worsens and affects her breathing, they should return to the emergency department immediately for a bed and treatment with antihypertensive medication.
• 2024-04-23 SOAP Medical Emergency Lin BoZhen
  • P: The patient politely declined hospitalization despite being informed about her current medical condition, potential risks involved, and the possibility of her condition changing. We explained the benefits of staying for observation and arranged for potential hospitalization, but the patient and/or her family member(s) refused. Currently, they are waiting in the emergency room for a bed, however, they have expressed a strong desire to leave the hospital at this time.
  • Prescription
    • Decan (dexamethasone) 4mg ST IVD
    • NS 500mL ST IVD for drug
• 2024-04-22 SOAP Hemato-Oncology Yang MuJun
  • O: 2024/04/19 MRA: Brain (with and without contrast)
    • Findings
      • A well-defined intra-axial tumor, about 28 mm, with heterogeneous enhancement involving left pons, compressing the aqueduct and associating with extensive perifocal edema.
      • Presence of hydrocephalus.
      • Diffuse luminal irregularity with mild segmental stenosis of major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
      • Fetal origin of left PCA.
    • IMP: Pontine tumor with mass effect. D/D: primary malignancy, metastasis.
• 2024-04-19 SOAP Medical Emergency He YaoCan
  • A: Preliminary Impression: I61.9 Nontraumatic intracerebral hemorrhage, unspecified
  • Prescription
    • MgO 250mg 1# TID
    • NS 500mL ST IVD
• 2024-04-19 SOAP Neurology Lin XinGuang
  • S:
    • fell down in Japan on 2024/02/20 with R hemiparesis, visited RenAi Hospital when back to Taiwan, denied of HT, but PH of HL, under Rehab at FengRong Hospital, was noted weaker on R limbs recent 2 weeks,
    • head injury: -, nasuea seanstion p taking meal after ICH,
    • CT on 2024/03/07: L pons round hyperdens lesion with diffuse low density at pons and L thalamus
  • O: on wheel chair, speech: grossly OK,
    • MP upper: 4+/5, lower: 4/5, R artificial eye
    • abnormal pontine hyperdense leision, may arrange MRA for further evaluation (C+), but MRA is scheduled on 2024/05/02, refer to ER for MRA (C+) to R/O L pontine lesion

[consultation]

• 2024-06-18 Dermatology
  • Q
    • This 58-year-old woman is a case of right lung cancer, specifically adenocarcinoma located at the right hilum, with a single pontine metastasis, classified as pT1c pN1c M1b, stage IVA.
    • She presents with mass effects and signs of increased intracranial pressure (IICP), along with weakness in the right limbs and right central facial palsy.
    • She underwent video-assisted thoracoscopic surgery (VATS) lobectomy and lymph node dissection (LND) of the right lower lobe (RLL) on 2024/05/14.
    • Her Eastern Cooperative Oncology Group (ECOG) performance status is 4.
    • Post-operatively, she received radiation therapy (RT) for the pontine tumor.
    • Epidermal growth factor receptor (EGFR) testing showed wild-type without mutations. Testing for anaplastic lymphoma kinase (ALK) is pending.
    • She received Cycle 1 systemic therapy with alimta + CDDP + pembrolizumab on 2024/06/06.
    • For Red rash on both buttocks, we need your consultation for evaluation. Thanks a lot!!
  • A
    • C.C:
      • Skin lesions over gluteal cleft
    • Skin finding:
      • Erythematous plaques with scaling over gluteal cleft
    • Imp:
      • Tinea cruris
    • Plan:
      • Topical Exelderm cream BID for gluteal cleft lesions
      • Keep diaper area dry and clean as possible
• 2024-06-18 Neurosurgery
  • Q
    • Due to Glasgow Coma Scale drop, follow up Brain MRI on 2024/06/13 showed
      • Still presence of one well-defined intra-axial tumor, about 28 mm, with heterogeneous enhancement involving left pons, compressing the aqueduct and associating with extensive perifocal edema.
      • Presence of hydrocephalus.
    • We need your consultation for evaluation. Thanks a lot!!
  • A
    • A case of 58 y/o female;right lung cancer, stage IVA
    • Right chest tube for hemopneumothorax.
    • Brain MRI showed obstructive hydrocephalus due to a large left mid brain metastastic lesion.
    • NS is consulted for VP shunt;
    • P: I will elucidate and discuss her condition to her family soon.
• 2024-05-20 Rehabilitation
  • Q
    • This 58 year-old-female has histories of:
      • Gallbladder stone with cholecystitis status post laparoscopic cholecystectomy in 2009.
      • Constipation for years.
      • Post OD prosthetic eye.
      • Intracerebral hemorrhage with right hemiparesis diagnosed in Feb, 2024.
        
    • She was admitted under the impression of right lung cancer located at the right hilum, presenting with pontine metastasis, mass effects, and signs of increased intracranial pressure. She was admitted to our ward on 2024/04/26.
    • For tumor tissue proof, she underwent operation of Video-Assisted Thoracoscopic Surgery with right middle lobe wedge resection, right lower lobe lobectomy and radical lymph node dissection on 2024/05/14. After the surgery, she was transferred to SICU for intensive care. Extubation under respiratory pattern smooth on 2024/05/19. Under hemodynamic stable and respiraotry pattern smooth, she was transferred to ordinary ward for further care on 2024/05/20.
    • Due to right side weakness, she need rehabilitation training. Thus, we need your professional knowledge and management. Thank you very much.
  • A
    • ICH in 2024/02 + lung cancer with brain meta (receive radiotherapy during this admission)
      • Due to right side weakness, we were consulted for further rehabilitation.
    • Premorbid status
      • ICH in 2024/02 with right hemiparesis
        • Before 2024/02 - Walk ID; BADL ID
        • After 2024/02 - walk under modA; BADL ID/modA
    • Physical examination
      • 2024/05/20 16:38 T/P/R: 35.6’C / 93bpm / 17bpm BP:115/61mmHg Body weight: 57.1
        • Consciousness: clear
        • Cognition: fair but slow response
        • Speech: fair
        • Swallowing: NG(+)
        • Sphincter: Foley(+); stool continence with diaper
        • Brunnstrom’s stage: RUE P/D: V/V, RLE: V
        • Muscle power:
          • RUE/RLE 4/4-
          • LUE/LLE 4+/4+
        • Mobility: bed rest
        • BADL: maxA
        • MRS: 4 (need follow-up)
        • O2: N/C 3L
    • Assessment
      • Right lung cancer located at the right hilum, presenting with pontine metastasis, mass effects, and signs of increased intracranial pressure status post Video-Assisted Thoracoscopic Surgery with right middle lobe wedge resection, right lower lobe lobectomy and radical lymph node dissection on 2024/05/14
      • Intracerebral hemorrhage in 2024/02 with right hemiparesis
      • Internal hemorrhoid, transverse colon and sigmoid colon polyp biopsy by colon scopy on 2024/4/29
      • Reflux esophagitis, lower esophagus, Los Angeles classification, grade A with superficial antral gastritis by panendoscopy on 2024/4/29
    • Plan
      • Rehabilitation programs: arrange bedside ST(swallowing), PT and OT rehabilitation programs.
      • Goal: Ambulation with device smoothly indoor; BADL partially ID; improve swallowing therapy.
• 2024-05-10 Ophthalmology
• 2024-05-07 Thoracic Surgery
• 2024-04-26 Radiation Oncology
• 2024-04-19 Neurosurgery

[immunochemotherapy]

• 2024-07-23 - pembrolizumab 100mg NS 100mL 30min + pemetrexed 500mg/m2 740mg NS 100mL 10min + cisplatin 75mg/m2 110mg NS 500mL 3hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr (after CDDP) (Keytruda + Alimta + Kemoplat)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-07-02 - pembrolizumab 100mg NS 100mL 30min + pemetrexed 500mg/m2 770mg NS 100mL 10min + cisplatin 75mg/m2 110mg NS 500mL 3hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr (after CDDP) (Keytruda + Alimta + Kemoplat)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-06 - pembrolizumab 100mg NS 100mL 30min + pemetrexed 500mg/m2 770mg NS 100mL 10min + cisplatin 75mg/m2 110mg NS 500mL 3hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr (after CDDP) (Keytruda + Alimta + Kemoplat)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-07-23

[LPRBC transfusion for chemotherapy-induced anemia]

Blood transfusion of 2 units LPRBC administered on 2024-07-23, due to anemia (hemoglobin 8.5 g/dL) secondary to chemotherapy. No medication-related issues identified.

2024-06-26

[Sevatrim Dose Adjustment for Pneumocystis Pneumonia]

P. jiroveci DNA PCR test returned positive on 2024-06-20. Subsequently, treatment with TMP-SMX Sevatrim (sulfamethoxazole 400mg, trimethoprim 80mg; 5mL/vial) 10mL Q6H was initiated on 2024-06-23. This translates to a daily TMP dose of 640mg.

For the treatment of Pneumocystis jirovecii pneumonia (PJP), the recommended dosage range for TMP is 15 to 20 mg/kg/day. Based on the patient’s weight of 51.6 kg as of 2024-06-25, the ideal daily TMP dose would be between 774mg and 1032mg. To achieve this target dose, Sevatrim administration can be adjusted to:

• 15mL Q8H, resulting in a daily TMP dose of 720mg.
• Alternatively, 15mL Q6H, providing a daily TMP dose of 960mg.

This may switch to oral after clinical improvement; treat for a total of 21 days.

701020753

240723

[exam findings]

• 2024-07-22 KUB

  • Dilatation of small bowel and collapse of colon, r/o obstruction
  • s/p sigmoid colon stent

• 2024-07-22 CXR erect

  • Increased infiltration in both lower lung fields
  • Dilatation of small bowel

• 2024-07-22 ECG

  • Sinus tachycardia
  • T wave abnormality, consider anterolateral ischemia

• 2024-07-17, -07-11 KUB

  • S/P nasogastric tube insertion
  • Bowel obstruction is still noted.
  • S/P metalic stenting at the sigmoid colon.

• 2024-07-17 CXR erect

  • Increased lung markings on both lower lungs are noted.

• 2024-07-12 Tc-99m MDP bone scan

  • In comparison with the previous study on 2024/03/28, the lesions in the middle T-spines and sacrum are a little less evident. Degenerative change is more likely.
  • No prominent change is noted in other bone lesions, possibly more benign in nature.

• 2024-07-04 EGD

  • Diagnosis:
    • No active bleeders noted in this study
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric subepithelial lesion, fundus
  • CLO test: not done
  • Suggestion:
    • Consider arranging miniprobe EUS at OPD for further evaluation of the gastric subepithelial lesion

• 2024-07-03 CT - abdomen

  • Findings:
    • S/P metalic stent implantation at the sigmoid colon cancer area.
      • There is marked dilatation of the colon and small intestine, and the transition zone locates beyond metalic stent in the sigmoid colon.
      • Mechanical colonic obstruction secondary to metalic stent occlusion is highly suspected. please correlate with colonoscopy.
      • Prior CT identified segmental circumferential wall thickening at the sigmoid colon is noted again, stationary.
      • S/P left hemicolectomy.
    • Prior CT identified several metastases in both hepatic lobes (up to 3.7 cm in S2) are noted again, increasing in size that is c/w liver metastases S/P C/T with progressive disease.
    • Prior CT identified one lung metastasis in RLL of the lung, 1 cm in size, is noted again, increasing in size and number.
      • It is c/w lung metastases with progressive disease.
    • Prior CT identified several metastatic nodes in paratracheal space and para-aortic space are noted again, mild increasing in size.
    • Prior CT identified multiple lymph nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space, para-cava space, mesentery, and bilateral inguinal area are noted again, stable in size.
      • Metastatic nodes S/P C/T show stable disease.
        
    • Right middle abdominal wall herniation.
    • A renal stone 5 mm in left upper pole.
  • Impression:
    • Mechanical colonic obstruction secondary to metalic stent occlusion is highly suspected. please correlate with colonoscopy.
    • Liver metastases S/P C/T show progressive disease.
    • Lung metastases S/P C/T show progressive disease.
    • Several metastatic nodes in the paratracheal space and para-aortic space S/P C/T show mild increasing in size.

• 2024-07-03 ECG

  • Sinus tachycardia
  • Left atrial enlargement
  • ST & T wave abnormality, consider anterolateral ischemia
  • Abnormal ECG

• 2024-04-22 CT - abdomen

  • History and indication: Malignant neoplasm of descending colon
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operaiton and internal stenting. Enlarged LNs (up to 2.2cm) at mediastinum, mesentery and retroperitoneum.
    • Multiple liver metastases (up to 2.8cm).
    • Left renal stone (5mm).
    • Interstitial pattern at bilateral basal lungs. A nodule (1.8cm) at RLL.
  • IMP:
    • S/P operaiton. Liver and lung metastases.
    • Enlarged LNs (up to 2.2cm) at mediastinum, mesentery and retroperitoneum.

• 2024-03-28 Tc-99m MDP bone scan with SPECT

  • In comparison with the previous study on 2021/06/28, the lesions in the middle T-spines and sacrum are slightly more evident. Degenerative change in a little more severe status is more likely. However, please follow up bone scan for further evaluation and to rule out other possibilities.

• 2024-01-18 CT - abdomen

  • History and indication: Malignant neoplasm of descending colon
  • With and without contrast CT of abdomen-pelvis revealed:
    • S/P operaiton and internal stenting. Enlarged LNs (up to 1.0cm) at mesentery and retroperitoneum.
    • Multiple liver metastases.
    • Right abdominal wall herniation.
    • Left renal stone (5mm).
    • Interstitial pattern at bilateral basal lungs. A nodule (1.5cm) at RLL.
  • IMP:
    • S/P operaiton. Liver and lung metastases.

• 2023-11-03 All-RAS + BRAF mutation

  • Cellblock No. F2022-00282 FsA4
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.

• 2023-10-04 CT - abdomen

  • History: D-colon CA wt obstruction, pT3N1c cM0, pStage IIIB, s/p Op on 2/17 21 by Dr Lv ZongRu
    • 20220520 CT: two kissing lesions with soft tissue and cystic component in right adnexa, measuring 4.8 cm and 2.8 cm in size. The differential diagnosis includes cystic adenocarcinoma of right ovary or tumor seeding of the colon cancer.
      
    • 20220617 Rt, oophorectomy: adenocarcinoma, metastatic, colon origin.
    • 20230531 CT: Recurrent adenocarcinoma of the sigmoid colon.
    • 20230627 sigmoidoscopy: sigmoid colon cancer with obstruction S/P stent implantation.
  • Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There are three newly developed poor enhancing lesions 1.6 cm in S7 and S2, and 1.1 cm in S6 of the liver that are c/w metastases.
    • There is a newly developed soft tissue nodule in RLL of the lung, 1 cm in size, that is c/w lung metastasis.
    • Prior CT identified multiple lymph nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space, para-cava space, mesentery, and bilateral inguinal area are noted again, stable in size.
      • Metastatic nodes S/P C/T show stable disease.
        
    • S/P metalic stent implantation at the sigmoid colon cancer area.
    • Prior CT identified segmental circumferential wall thickening at the sigmoid colon is noted again, stationary.
    • S/P left hemicolectomy.
    • Right middle abdominal wall herniation.
    • A renal stone 5 mm in left upper pole.
  • Impression:
    • Three newly developed metastases in S7, S2, and S6 of the liver.
    • One newly developed metastasis 1 cm at RLL of the lung.
    • Multiple metastatic nodes S/P C/T show stable disease.

• 2023-06-26 CT - abdomen

  • Findings
    • Enhanced, thickening mucosa at sigmoid colon is found. In comparison with CT dated on 2023-05-31, thelesion is stationray.
    • Severe dilated intestines is found. There is right abdominal wall herniation. No strangulation at the herniated sac is found but narrowing of the intestinal lumen at sigmoid colon wall thickning region is found.
  • Imp
    • Wall thickneing at sigmoid colon with proximal intestinal dilatation. r/o recurrent/residual tumor with intestinal obstruction.

• 2023-06-26 CXR

  • Cardiomegaly is noted.
  • S/p port-A placement with its tip at left brachiocephalic vein.
  • Faint aveolar opacity over right lower lobe and ll is found.
  • Osteopenia of the bony structure is noted.
  • Increased intestinal gas is found.

• 2023-06-26 ECG

  • Sinus tachycardia
  • ST & T wave abnormality, consider anterior ischemia

• 2023-05-31 CT - abdomen

  • History: D-colon CA wt obstruction, pT3N1c cM0, pStage IIIB, s/p Op on 2021/02/17
    • 20220520 CT: two kissing lesions with soft tissue and cystic component in right adnexa, measuring 4.8 cm and 2.8 cm in size.
      • The differential diagnosis includes cystic adenocarcinoma of right ovary or tumor seeding of the colon cancer.
        
    • 20220617 Rt, oophorectomy: adenocarcinoma, metastatic, colon origin.
  • Findings:
    • There is segmental circumferential wall thickening at the sigmoid colon, 5 cm in size, causing marked dilatation of the proximal colon.
      • Recurrent adenocarcinoma of the sigmoid colon is highly suspected.
      • Please correlate with colonoscopy and CEA.
    • S/P left hemicolectomy
    • Prior CT identified multiple lymph nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space, para-cava space, mesentery, and right supra-diaphragm cardiac-phrenic space are noted again.
      • Some of them show enlarged in size.
      • Metastatic nodes are highly suspected.
        
    • Right middle abdominal wall herniation.
    • Mild fatty liver.
    • A renal stone 5 mm in left upper pole.
    • Prior CT identified multiple small poor enhancing lesions in the spleen are noted again, stationary.
  • Impression:
    • Recurrent adenocarcinoma of the sigmoid colon is highly suspected.
      • Please correlate with colonoscopy and CEA.
    • Metastatic nodes in para-aortic space and para-cava space.

• 2023-05-24 Peripheral Echography

  • Report:
    • Right side:
      • SVC: 14.1 mmHg ; 15.7 mmHg ;
      • MVO/SVC: 89 % ; 87 % ;
      • Average MVO/SVC: 88 %
    • Left side:
      • SVC: 11.9 mmHg ; 14.4 mmHg ;
      • MVO/SVC: 84 % ; 80 % ;
      • Average MVO/SVC: 82 %
    • Thrombus : None
      
    • Varicose vein : None
      
  • Conclusion
    • No evidence of DVT, bilateral lower legs
    • Right CFV trivial reflux
    • Left CFV trivial reflux

• 2023-05-24 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (123 - 31) / 123 = 74.80%
    • M-mode (Teichholz) = 75

• 2023-04-07, -02-23 CXR

  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.

• 2023-02-23 CT - abdomen

  • History and indication:
    • Malignant neoplasm of descending colon
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operaiton. Enlarged LNs (up to 2.0cm) at mesentery and retroperitoneum.
    • Right abdominal wall herniation.
    • Left ovary cyst (2.0cm).
    • Left renal stone (5mm).
    • Grade 4 fatty liver.
    • Interstitial pattern at bilateral basal lungs.
  • Imp
    • S/P operaiton. Enlarged LNs (up to 2.0cm) at mesentery and retroperitoneum.

• 2023-01-27 Colonoscopy

  • The scope only reach the D-colon (40cm AAV, previous anastomosis) under good colon preparation. No mucosal lesion was found. The scope can not be advanced more.

• 2023-01-27 Esophagogastroduodenoscopy, EGD

  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
  • Gastric polyp, fundus, favor fundic gland polyp
  • Suspect gastric subepithelial lesion, fundus

• 2022-11-14 CT - abdomen

  • Abdominal CT with and without enhancement revealed:
    • Left renal tiny stone about 0.2cm is found.
    • The spleen, liver, pancreas and adrenals are intact.
    • The GB is well distended without soft tissue lesion
    • Abdominal wall herniation is found at RLQ.
    • s/p LAR.
    • Mininmal interstitial change at bilateral basal lungs. previous viral infection is favored.
  • Imp:
    • s/p LAR.
    • No evidence of recurrent/residual tumor in the study.
    • Left renal stone.

• 2022-10-12 Carotid angiography bilat. Vertebral angiography

  • Diagnostic intraarterial angiography of brain vasculature by way of bilateral internal carotid and left vertebral arteries was performed. The related benefit and risk of this procedure was explained to patient and patient family member with written consent being obtained in advance.
  • Imaging findings:
    • Fenetration of V-B junction. Suggest follow up by MRA annually.
    • The whole procedure was smoothly done without apparent immediate complication and the patient stood it well under local anesthesia.

• 2022-10-12 Aortography - thoracic

  • Diagnostic aortography was performed. The related benefit and risk of this procedure was explained to patient and patient family member with written consent being obtained in advance.
  • Imaging findings:
    • Type I aortic arch.
    • No critical stenosis of bilateral proximal carotid and vertebral arteries.
    • The whole procedure was smoothly done without apparent immediate complication and the patient stood it well under local anesthesia.

• 2022-10-11 ECG

  • Normal sinus rhythm
  • T wave abnormality, consider anterior ischemia

• 2022-09-20 MRA - brain

  • Findings:
    • Known a case of colon cancer. No abnormal signal lesion within brain parenchyma.
    • Mild periventricular small vessel disease. NO acute ischemic infarct.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • MR angiography of the brain shows possible one fusiform aneurysm (8.5mm in length) over V-B junction. Suggest check CTA or refer to my OPD (W3/No.209).
  • Impression:
    • Possible one fusiform aneurysm (8.5mm in length) over V-B junction. Suggest check CTA or refer to my OPD (W3/No.209).

• 2022-07-25 CT - chest

  • Indication: submassive PE s/p EKOS throbmolysis post-op f/u
  • Findings:
    • pulmonary arteries: complete resolution of filling defects at Rt distal pulmonaty artery and RUL pulmonary artery compared with CTPA on 2022/6/21. well opacification of other pulmonary arteries. dilated right main artery (2.5cm).
    • Pleura: trace bilateral effusions.
    • Lungs: multiple small solid nodules in both lungs, with minimal centrilobular nodular and branching opacities at RUL.
      • mosaic attenuation at RLL and LLL.
    • Visible abdomen:
      • right middle abdominal wall herniation and a 4mm left renal stone.
  • Impression:
    • resolution of pulmonary embolism as compared with CTPA on 2022/06/21.
    • multiple small solid nodules in both lungs due to metastases, with minimal inflammatory bronchiolitis at RUL.

• 2022-06-27 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 27) / 106 = 74.53%
    • LVEF(%) = 74
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 1.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR.
    • Possible mild pulmonary hypertension, estimated PASP: 38 mmHg.
    • No RA/RV dilatation; no RV pressure overload sign.

• 2022-06-21 CTA - chest

  • Findings
    • Vessels:
      • pulmonary arteries: filling defects at Rt distal pulmonaty artery and RUL pulmonary artery consistent with acute pulmonary embolism. dilated trunk (3.5cm in caliber) and left and right main arteries.
        • well opacified proximal and middle segments of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal appearance of thoracic aorta.
      • Heart: dilated LA.
    • Pleura: small bilateral effusions.
    • Lungs: dependent partial atelectasis of both lower lobes. mosaic attenuation at LUL.
    • Visible abdomen: right middle abdominal wall herniation and mild ascites. increased air in nondistended loops of small bowel and colonic segments. a tiny left renal stone 5mm.
  • Impression:
    • Rt pulmonary artery and RUL pulmonary artery acute pulmonary embolism.
    • pulmonary hypertension and small pleural effusion.
    • dependent atelectasis of both lower lobes of lungs and suspect LUL small airways disease.

• 2022-06-21 Vein Sonography

  • Conclusion:
    • No venous thrombosis at bilateral deep and superficial venous system
    • No varicose veins at both GSV/SSV area
    • delay venous return at both popliteal and PTV due to prolonged bed rest
    • The MVO/SVC ratio didnot favor the proximal iliac vein or IVC obstruction

• 2022-06-21 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (137 - 54) / 137 = 60.58%
    • M-mode (Teichholz) = 60
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA and LV, grade 1 LV diastolic dysfunction
    • Mild MR, TR and PHTN

• 2022-06-17 Patho - soft tissue tumor, extensive resection

  • PATHOLOGIC DIAGNOSIS
    • Ovary, right, salpingo-oophorectomy with frozen section (F2022-283) —- adenocarcinoma, metastatic. IHC stains: CK7 (-), CK20 (+), CDX-2 (+), PAX-8 (-), WT(-): a pattern of colon origin.
    • Ovary, left, salpingo-oophorectomy —- Free
    • Fallopian tube, left, salpingo-oophorectomy —- free.
    • Fallopian tube, right, salpingo-oophorectomy —-adenocatcinoma, metastatic
    • Uterus, corpus, total hysterectomy (S2022-9791A) — free; Endometrium: benign atrophic
    • Uterus, cervix, total hysterectomy — free
    • Abdominal tumor, excision (S2022-9791B) — one tumor nodule and one of two lymph node with tumor metastasis (½).
    • Abdominal tumor, excision (S2022-9791C) — calcified fibrotic nodes and one benign lymph node (0/1)
    • Lymph node, Bilateral pelvic iliac and obturator, dissection (S2022-9791D-G) — Free.
  • MACROSCOPIC EXAMINATION
    • Procedure
      • Debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymphnode dissection + abdominal tumor excision) + enterolysis
      • Peritoneal washing
    • Specimen size:
      • right ovary: 8 x 6 x 4 cm (opened by surgeon) with multiple solid component inside and on the serosal surface of the ovary, the largest tumor focus 3 x 2.2 x 2.2 cm.
      • left ovary: 2 x 1.5 x 1 cm;
      • right tube: 4.5 x 0.5 x 0.5 cm;
      • left tube: 4 x 0.5 x 0.5 cm;
      • uterus: 8 x 5 x 3 cm
      • 2. abdominal tumor: 3 pieces, up to 0.8 x 0.4 x 0.4 cm.
      • 3. abdominal tumor”: 3 pieces, up to 1.2 x 0.8 x 0.8 cm.
    • Specimen Integrity
      • Specimen Integrity of Right Ovary
        • Capsule – opened by the surgeon
      • Specimen Integrity of Left Ovary
        • Capsule intact
      • Specimen Integrity of Right Fallopian Tube – tumor seeding
      • Specimen Integrity of Left Fallopian Tube-Serosa intact
    • Tumor Site: Right ovary
    • Ovarian Surface Involvement- Present (Right)
    • Fallopian Tube Surface Involvement -Present (Right)
    • Tumor Size -multiple solid component inside and on the serosal surface of the ovary, the largest tumor focus 3 x 2.2 x 2.2 cm.
      • Greatest dimension (centimeters): 3 cm
      • Additional dimensions (centimeters): 2.2 x 2.2 cm
    • Sections are taken and labeled as:
      • Tissue for frozen section: F2022-282FSA1-4: right ovarian tumor.
      • Tissue for formalin fixation: F2022-282X1: right Fallopian tube; X1-8: additional sampling of tumor in and on the right ovary.
      • S20229791A1: left Fallopian tube; A2: left ovary; A3-4: endometrium and uterine corpus; A5-6: uterine cervix; B: “02. abdominal tumor”; C: “03. abdominal tumor”; D: “04 right iliac lymph nodes”; E: “05. right obturator lymph nodes”; F: “ 06. left iliac lymph nodes”; G: “07. left obturator lymph nodes”.
  • MICROSCOPIC EXAMINATION:
    • Histologic type: adenocarcinoma.
    • Contralateral ovary involvement: absent
    • Tumor side ovarian surface involvement: present
    • Contralateral ovary surface involvement: absent
    • Right tube involvement: absent
      
    • Left tube involvement: present
    • In situ adenocarcinoma in right ＆/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: present
    • Left adnexa soft tissue involvement: absent
    • Pelvic soft tissue involvement: present (tissue labeled as “02. abdominal tumor”)
    • Uterine serosa involvement: absent
    • Omentum involvement: no tissue submitted.
    • Uterine Cervix involvement: absent
    • Endometrium involvement: absent
    • Myometrium involvement: absent
    • Appendix involvement: not received
    • Peritoneal/Ascitic Fluid- Negative for malignancy (normal/benign)
    • Regional Lymph Nodes: Negative for metastasis: describe locations - 0/29= D: “04 right iliac lymph nodes” 0/9; E: “05. right obturator lymph nodes” 0/7; F: “06. left iliac lymph nodes” 0/7; G: “07. left obturator lymph nodes” 0/6.
    • Other organs or specimens involvement: absent.

• ……

• 2021-02-18 Patho - colon segmental resection for tumor

  • PATHOLOGIC DIAGNOSIS
    • Large intestine, descending colon, extensive left hemicolectomy
      • Adenocarcinoma, moderately differentiated
        
      • A tumor deposit is seen
        
      • A colostomy is present
        
    • Small intestine, ileum, extensive left hemicolectomy —- Negative for malignancy
      
    • Omentum, extensive left hemicolectomy —- Negative for malignancy
      
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection —- Negative for malignancy (0/70)
      
    • Lymph node, IMA / SMA, dissection —- Not received
      
    • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1c(if cM0)
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: extensive left hemicolectomy
      
    • Specimen site: descending colon
      
    • Specimen size: colon: 57 cm in length, ileum: 7 cm, omentum: 28 x 6 x 2 cm, appendix is not found; with a colostomy
      
    • Tumor size: 3.5 x 3.0 cm, annularly ulcerated
      
    • Tumor location: 3.0 cm and 55 cm away from the two resection margins, respectively
      
    • Depth of invasion grossly: mesocolic soft tissue
      
    • Mucosa elsewhere: congestion
      
    • Representative sections are taken and labeled as: A1-2: bilateral resection margins; A3: colon, non-tumor; A4: colostomy; A5:omentum; A6-9: tumor; A10-15: lymph node, mesocolic.
  • MICROSCOPIC EXAMINATION
    • Histology: adenocarcinoma
      
    • Histology Grade: moderately differentiated
      
    • Depth of invasion: mesocolic soft tissue
      
    • Angiolymphatic invasion: Present.
      
    • Perineural invasion: Present.
      
    • Discontinuous extramural tumor extension: Not identified.
      
    • Serosal margin status of colon: Uninvolved, 2 mm in distance.
      
    • Lymph node metastasis, mesocolic: 0/70
      
    • Lymph node metastasis, IMA / SMA: Not received
      
    • Extranodal involvement: Not identified.
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        
      • Regional Lymph Nodes (pN): pN1c: No regional lymph nodes are positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/mesorectal tissues.
        
      • Distant Metastasis (pM): if cM0
        
    • Type of polyp in which invasive carcinoma arose: Tubular adenoma.
      
    • Additional pathologic findings:
      • A tumor deposit is seen.
        
      • A colostomy is present.
        
      • The immunohistochemical stains reveal EGFR(-), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
        
      • Tumor Budding: Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2): Low score (0-4)
        
      14. TNM descriptors: unknown
          
    • Tumor regression grading S/P CCRT: patient not received

[consultation]

• 2023-06-26 Colorectal Surgery
  • Q
    • Abdominal pain > Acute moderate central pain (4-7), self-reported abdominal pain for 4-5 days and feeling like vomiting
    • fever, no diarrhea, no bloody stool, deny URI S/S
    • PH: colon cancer s/p op and C/T; s/p appendectomy; Rt ovary tumor; Arrhythmia
    • KNA
  • A
    • this is a 66- year old woman with intestinal obstruction
    • CT : R/I sidmoid colon cancer with obstruction
    • A/P: admission and suggest NPO and NG free drainage
    • suggest exp lap or stent decompression
• 2022-06-23 Anesthesia
  • Q
    • We have current evidence for acute submassive Pulmonary embolism at RPA.
    • She will be received surgical intervention (EKOS) on 6/23.
    • We need your help for pre-op (surgical intervention (EKOS)) anesthesia evaluation. Thanks a lot.
  • A
    • Dx: Acute submassive Pulmonary embolism at RPA
    • Op: EKOS
    • Hx: 6/17 ATH
    • Condition: Cons. clear, previous walking ok, no dyspnea, chest tightness or leg edema
    • CXR: Cardiomegaly, Tortous aorta with calcification, Osteopenia, Senile fibrotic change
    • EKG: Left atrial enlargement
    • AS A4 due to Acute submassive Pulmonary embolism at RPA (ASA 4: A patient with a severe systemic disease that is a constant threat to life.)
    • Airway: Mouth open ok, previous ETT ok
    • Plan:
      • High risk of stroke, shock, MI, AKI…
      • Anes. plan and risk was told to her at bedside at 0830 and son at door of SICU at 0850
      • Resucitation will be procedured if emergence condition.
      • We will arrange ETGA
      • Correct underly dx as your expertise.
      • Follow one-touch q6h when nil per os if DM or high risk of hypoglycemia
• 2022-06-21 Cardiac Surgery
  • Q
    • for surgical intervension
    • The 65 years old female patient, a case of pelvic tumor, right ovarian cancer s/p debulking surgery on 20220617, Hx of colon cancer s/p OP and arrhythmia
    • She sufferred from sudden onset of dyspnea and elvated D-dimer
    • Chest CT showed right pulmonary embolism
    • We need expertise to evaluate her condition thanks
  • A
    • I have had the pleasure of involving with the patient’s care. In brief, She is a 65 year old female seen in consultation for opinion regarding treatment options for acute submassive Pulmonary embolism at RPA
    • Her underlying dz was noted for:
      • right ovarian adenocarcinoma -> debulking surgery on 2022-06-17
      • Right pulmonary artery and RUL pulmonary artery embolism was noted by CT
      • 2D echo and lower extremities ultrasound done and reviewed. no DVT, no RV strain.
    • upon my visit, her con’s clear. O2: mask. HR 76 NSR. hemodynamics stable.
    • SUGGESTION & PLAN:
      • We have current evidence for acute submassive Pulmonary embolism at RPA
      • I think we have reached a point where there is prudence in considering surgical intervention (EKOS)
      • Explain to family. The patient and family are agreeable with my surgical consultation.
• 2022-06-21 Cardiology
  • Q
    • Chest CTA -> Right pulmonary embolism
    • Shortness of breath (SOB) was noted at 01:59 this day on 2022/06/21. She had shortness of breath before but SOB could relived by its own. This time, her SOB persisted with respiratory rate up to 36/min.
    • Portable Chest X ray was done and no hemothorax, pleural effusion, or pneumonia match was noted. Breathing sound showed negative wheezing or rhonchi.
    • Blood gas was done and mild respiratory alkalosis was noted with PH:7.403, HCO3:20.5mmol/L, PCO2:33.7mmHg, PO2:101.6mmHg. D-dimer was 9434.35 and NT-proBNP was 166pg/ml.
    • Foster was given as empirical medicine for SOB. Mask oxygenation was used to replace O2 cannula.
    • Her SOB subsided in the morning, and further differential diagnosis was suggested. We need your expertise to evaluate this patient. Thank you very much.
  • A
    • The 65 years old female patient, a case of pelvic tumor, right ovarian cancer s/p debulking surgery on 20220617, Hx of colon cancer s/p OP and Hx of arrhythmia.
    • She sufferred from sudden onset of dyspnea and elvated D-dimer.
      • Chest CT showed right pulmonary embolism
      • O2 sat 95 %, BP 135/63 mmHg, HR 87 BPM
      • CXR showed normal heart size, left platelet lesion
    • Impression
      • acute pulmonary embolism
      • Pelvic tumor and right ovarin cancer s/p debulking surgery
    • Suggest
      • monitor hemodynamics and O2 saturation
      • to arrange echocardiography and venous duplex of lower extremity
        
      • to check protein C and S, antithrombin III, ANA, lupus anticoagulant
      • clexane 60 mg H q12h if no bleeding tendency or contraindication
      • Blood transfusion to correct anemia
• 2021-01-17 Colerectal Surgery
  • Q
    • Abdominal pain > Acute central moderate pain (4-7), self-reported abdominal distension and abdominal pain. Vomiting this morning. This patient has been diagnosed with irritable bowel syndrome, she still has abdominal pain after taking medication. TOCC-
    • abdominal fullness and intermittent cramping pain for three days, no radiation to back
    • nausea and vomiting for three times
    • no diarrhea
    • denied fever
    • bilateral pelvic pain for long time, took Ibuprofen rencently
    • PH: arrythmias under Inderal, bil. renal stones s/p ESWL; s/p appendectomy
    • Allergy: nil
  • A
    • suspect D colon lesion with obstruction
    • please NPO with hydration 2500ml QD + antibiotics treatment
    • T loop colostomy if still obstruction
    • NG tube free drain is suggested

[surgical operation]

• 2022-06-23
  • Surgery
    • Right pulmonary artery EKOS (EkoSonic endovascular system) catheter implantation (12cm) under fluoroscopy
  • Finding
    • Intra-op fluoroscopy confirmed submassive emboli at RPA superior trunk and inter-lobar branch
    • EKOS catheters were inserted at desired target positions.
• 2022-06-17
  • Surgery
    • Debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymphnode dissection + abdominal tumor excision) + enterolysis
  • Finding
    • Uterus: 8x5x3 cm, normal looking
    • cervix – seemed free of cancer invasion
    • right ovary and tube: ROV 8x8cm solid, necrotic mass, spontaneous ruptured with bloody ascites 600c.c (whole part cut, for frozen pathology)
      • origin? may be primary ovarian cancer or metastitic colon cancer (previous colon cancer stage III, s/p subtotal colectomy + colostomy)
      • frozen pathology of right ovary – adenocarcinoma, origin to be deterimined
    • left ovary and tube: normal-looking
    • bowels and liver – seemed free of cancer invasion
    • omentum and appendix – not found due to previous resection?
    • abdominal tumor (located on bladder surface) – cancer invasion?
    • abdominal tumor (located on right pelvis) – cancer invasion?
    • Bilateral pelvic iliac and obturator LNs was removed
    • CDS: bloody ascites 600c.c (cytology was sent), amnd severe bowel adhesion (due to previous s/p subtotal colectomy + colostomy and appendectomy?) was noted between ant peritoneum, bladder, bil pelvis and bowels s/p enterolysis
    • After the operation, optimal debulking surgery was achieved; no residue tumor
    • A 7mm JP drain was placed in CDS
• 2021-02-17
  • Surgery
    • Subtotal colectomy + Closure of loop colostomy      
  • Finding
    • Anastomosis : Functional end-to-end anastomosis by GIA * 2    
    • One JV at pelvic area  
• 2021-01-18
  • Surgery
    • T loop colostomy        
  • Finding
    • Dilation of T colon    

[chemotherapy]

• 2024-06-15 - cetuximab 400mg/m2 300mg 2hr + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4250mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2024-05-29 - cetuximab 400mg/m2 600mg 2hr + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 4350mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2024-04-22 - cetuximab 400mg/m2 600mg 2hr + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 4350mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2024-04-08 - cetuximab 400mg/m2 600mg 2hr + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 4350mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2024-03-25 - cetuximab 400mg/m2 600mg 2hr + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 4350mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2024-03-11 - cetuximab 400mg/m2 600mg 2hr + irinotecan 180mg/m2 285mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4490mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2024-02-15 - cetuximab 400mg/m2 600mg 2hr + irinotecan 180mg/m2 285mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4490mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2024-01-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2024-01-05 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2023-12-06 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2023-11-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2023-11-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
• 2023-10-11 - irinotecan 160mg/m2 240mg D5W 250mL 90min (FOLFIRI. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 0.25mg
• 2023-09-20 - irinotecan 160mg/m2 240mg D5W 250mL 90min (FOLFIRI. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 0.25mg
• 2023-08-30 - irinotecan 160mg/m2 240mg D5W 250mL 90min (FOLFIRI. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 0.25mg
• 2023-08-09 - irinotecan 160mg/m2 240mg D5W 250mL 90min (FOLFIRI. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 0.5mg
• 2023-07-19 - irinotecan 160mg/m2 260mg D5W 250mL 90min (FOLFIRI. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 0.5mg
• 2023-06-20 - irinotecan 160mg/m2 260mg D5W 250mL 90min (FOLFIRI. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg SC
• 2023-05-12 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr (FOLFOX. Wan XiangLin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-07 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr (FOLFOX. Wan XiangLin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-17 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr (FOLFOX. Wan XiangLin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-21 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr (FOLFOX. Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-31 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-13 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-22 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-01 - oxaliplatin 80mg/m2 130mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-04 - oxaliplatin 80mg/m2 130mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-09-13 - bevacizumab 5mg/kg 300mg NS 150mL 90min + oxaliplatin 80mg/m2 130mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-08-23 - oxaliplatin 70mg/m2 110mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-08-08 - irinotecan 160mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2022-07-22 - irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4590mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2021-05-14 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4530mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-04-30 - oxaliplatin 85mg/m2 137mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-04-16 - oxaliplatin 60mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-08-23 ~ undergoing - Xeloda (capecitabine 500mg) 3# BID
• 2021-06-25 ~ 2021-11-29 - Xeloda (capecitabine 500mg) 2# BID

==========

2024-07-23

[evaluating treatment resistance: 4-fold increase in tumor markers and disease progression]

Lab results showed a fourfold increase in both CEA and CA199 tumor markers in July. Early July CT scans revealed suspected mechanical colonic obstruction secondary to metallic stent occlusion, progressive liver and lung metastases, and enlarged metastatic nodes in the paratracheal and para-aortic spaces. These indicate that the disease has developed resistance to the Erbitux + FOLFIRI regimen. Next-line therapy might need to be considered.

• 2024-07-22 CEA (NM) 27.397 ng/ml

• 2024-07-02 CEA (NM) 7.355 ng/ml

• 2024-05-10 CEA (NM) 6.076 ng/ml

• 2024-04-17 CEA (NM) 4.699 ng/ml

• 2024-04-09 CEA (NM) 4.572 ng/ml

• 2024-03-22 CEA (NM) 4.149 ng/ml

• 2024-02-27 CEA (NM) 2.899 ng/ml

• 2024-07-22 CA-199 (NM) 25.661 U/ml

• 2024-07-02 CA-199 (NM) 6.732 U/ml

• 2024-05-10 CA-199 (NM) 7.109 U/ml

• 2024-04-17 CA-199 (NM) 6.103 U/ml

2024-01-30

[propranolol dosage consideration following new BP data]

Lab data from 2024-01-29 and vital signs from the TPR panel appear largely within normal limits. However, the BP reading on the morning of 2024-01-30 was 98/51 mmHg, which is not considered high. Based on the clinical context, it might be feasible to slightly reduce the dosage of Propranolol (Propranolol) if deemed appropriate.

2023-07-05

[leukopenia]

• The temporal changes in the WBC count are summarized in the following table, where records marked with an asterisk represent WBC counts < 3K/uL.

  • 2023-07-03 WBC 2.81 x10^3/uL *
  • 2023-07-01 WBC 3.68 x10^3/uL
  • 2023-06-29 WBC 4.66 x10^3/uL
  • 2023-06-28 WBC 3.10 x10^3/uL
  • 2023-06-27 WBC 2.23 x10^3/uL * filgrastim
  • 2023-06-26 WBC 2.48 x10^3/uL *
    
  • 2023-06-20 WBC 9.57 x10^3/uL irinotecan - can be associated with leukopenia (63% to 96%, grades 3/4: 14% to 28%)
  • 2023-06-14 WBC 5.16 x10^3/uL
  • 2023-06-07 WBC 5.72 x10^3/uL
  • 2023-05-12 WBC 5.62 x10^3/uL oxaliplatin
  • 2023-04-28 WBC 4.95 x10^3/uL
  • 2023-04-07 WBC 6.58 x10^3/uL oxaliplatin
  • 2023-03-17 WBC 7.04 x10^3/uL oxaliplatin

• The dosage of irinotecan used on 2023-06-20 was adjusted down from the standard 180mg/m2 to 160mg/m2.

• On 2023-07-03, the ANC was 2.81K/uL x 41.9% = 1177/uL, which is a grade 2 neutropenia (1000~1499/uL). If this value occurs during a therapy cycle, a further decrease of 20mg/m2 to 140mg/m2 could be considered.

700033317

240722

[MedRec]

• 2024-06-20 ~ 2024-07-01 POMR Hemato-Oncology Xia HeXiong
  • Course of inpatient treatment
    • After admission, preparing for chemotherapy, collect 24hr Ccr and arrange PTA for survey. 24hrs CCr. on 2024/06/21 showed 150mL/min, PTA on 2024/06/25 showed Reliability FAIR, Average RE 38 dB HL; LE 21 dB HL. RE normal to severe mixed type HL; LE normal to moderately severe SNHL.
    • Tramacet 37.5 & 325mg/tab 0.5# PO Q6H for pain control.
    • Megest 40mg/mL,120mL/bot 10ml PO QD and IVF for poor appetite.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for Anti-HBc reactive.
    • He receive chemotherapy with PF (Cisplatin 60mg/m2 D1, 5-Fu 1000mg D1-D4, (MgSO4 1amp and Lasix 1amp after Cisplatin))(C1) on 2024/06/25~06/28.
    • Hypothyroidism was treated with Eltroxin 50mcg/tab 1# PO QDAC.
    • Anemia was noted, BT LRBC 2unit on 2024/06/20.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2024/07/01 and OPD followed up later.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • MgO 250mg 1# QID
    • Through (sennoside 12mg) 1# HS
    • Megest (megestrol 40mg/mL) 10mL QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# PRNQ6H if VAS > 3
    • Eltroxin (levothyroxine 50ug) 1# QDAC
• 2024-06-13 SOAP Hemato-Oncology Xia HeXiong
  • P: Amission for BT with pRBC and IV nutrition support
• 2024-05-21 ~ 2024-05-23 POMR Ear Nose Throat Huang TongCun
  • Discharge diagnosis
    • Right oropharyngeal lesion status post right oropharyngeal tumor incisional biopsy on 2024-05-22.
    • Right oropharyngeal cancer, HPV+, cT4N1M0, stage III s/p CCRT 2022-04-28 to 2022-06-20.
    • Malignant neoplasm of esophagus, unspecified
    • Other specified hypothyroidism
  • CC
    • Sore throat sometimes, right mandible and right upper neck pain off and on over 2 years, trismus aggravated grandually in recent one month.
  • Present illness
    • This 71-year-old man has history of right oropharyngeal cancer, HPV+, cT4N1M0, stage III, status post CCRT since 2022-04-28 to 2022-06-20. Due to persistent sore throat, right neck pain and right tonsillar fossa lesion, the patient received several times of lesion biopsy on 2022-07-28, 2022-11-10 and 2024-03-21. However, all the pathology result showed no malignancy.
    • Since the MRI revealed suspected residual tumor, the patient received Ufur treatment since 2022-09-01 since 2023-02, 2023-03-23 until now.
    • The patient complained of right neck pain and swelling progression in recent one month. He came to our ENT OPD for help. Physical examination revealed trismus and right neck stiffness and swelling.
    • Nasopharyngeal MRI on 2024-05-01 showed progressive change of right oropharyngeal tumor as compared with MRI on 2023-12-26.
    • Under the impression of right tonsillar lesion suspected malignancy, tissue proof was suggested. After well explanation about the surgical details, he was admitted for biopsy of right oropharyngeal lesion.
  • Course of inpatient treatment
    • After admission, pre-operative evaluation was done. The patient underwent the operation of right oropharyngeal tumor incisional biopsy. The whole procedure was performed smoothly, and the patient tolerated it well. Post the operation, cool liquid diet, Prophylatic antibiotic with cephalexin 1# po q6h, pain control with Ultracet 1# po q6h and Difflam spray were given. There was no active oropharyngeal wound bleeding or infection signs. Under relative stable condition, the patient was discharged and continue OPD follow up.  
  • Discharge prescription
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# QID 7D
    • cephalexin 500mg 1# QID 7D
    • MgO 250mg 1# QID 7D
• 2024-04-25 SOAP Hemato-Oncology Xia HeXiong
  • A:
    • Squamous cell carcinoma of the M/3 esophagus, stage cT3N2M0, s/p CCRT.
    • Basal cell carcinoma of the nasal skin, s/p excision.
    • Squamous cell carcinoma, moderately differentiated, of the right oropharynx, P16(+), stage cT4N1M0 (stage III), s/p CCRT.
  • P:
    • Arrange MRI, if obvious tumor and biopsy is feasible -> biopsy again and check PD-L1 in new tissue; if biopsy is not feasible, check PD-L1 using old tissue
• 2017-08-07 SOAP Hemato-Oncology Zhang ShouYi
  • S: 65 y/o male, a pt of esophageal CA, SCC, cT3N2M0, cSatge III, Dx in 2010-12 by Dr Chen HongDa, s/p CCRT wt PF IV QW plus R/T over Eso tumor finishing in 2011-03 by Dr Huang JingMin, s/p post-CCRT for PF wkly x 2 Q3W x 4 finishing in 2011-05.

[surgical operation]

• 2024-05-22
  • Op Method:
    • Right oropharyngeal tumor incisional biopsy
  • Finding:
    • Right tonsillar fossa focal cavity formation with whitish exudate coating and focal necrotic tissue (2024/03/21 biopsy at outpatient department: necrosis with focal moderate dysplasia), with posterior mouth floor involvement

[immunochemotherapy]

• 2024-07-20 - cetuximab 500mg/m2 800mg 90min + cisplatin 60mg/m2 85mg NS 500mL 24hr (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1200mg NS 500mL (D1-4) (PF)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-25 - cetuximab 500mg/m2 800mg 90min + cisplatin 60mg/m2 85mg NS 500mL 24hr (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1200mg NS 500mL (D1-4) (PF)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-06-20 - cisplatin 40mg/m2 60mg NS 500mL (cisplatin CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + NS 500mL 1hr (pre-CDDP)
• 2022-06-13 - cisplatin 40mg/m2 60mg NS 500mL (cisplatin CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + NS 500mL 1hr (pre-CDDP)
• 2022-06-06 - cisplatin 40mg/m2 60mg NS 500mL (cisplatin CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + NS 500mL 1hr (pre-CDDP)
• 2022-05-30 - cisplatin 40mg/m2 60mg NS 500mL (cisplatin CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + NS 500mL 1hr (pre-CDDP)
• 2022-05-23 - cisplatin 40mg/m2 60mg NS 500mL (cisplatin CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + NS 500mL 1hr (pre-CDDP)
• 2022-05-16 - cisplatin 40mg/m2 60mg NS 500mL (cisplatin CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + NS 500mL 1hr (pre-CDDP)
• 2022-05-09 - cisplatin 40mg/m2 60mg NS 500mL (cisplatin CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + NS 500mL 1hr (pre-CDDP)
• 2022-05-02 - cisplatin 40mg/m2 60mg NS 500mL (cisplatin CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + NS 500mL 1hr (pre-CDDP)

700629294

240722

[exam findings]

• 2024-05-13 SONO - breast
  • Post-op scar in bilateral breasts.
  • Left breast subcutaneous nodule, 0.63x0.24cm, suggest follow up.
  • BI-RADS 2. benign finding
• 2024-04-26 CT - chest
  • Indication: Left breast cancer, ER(+), PR(-), Her2(+), HER2(-), cT1N1M0, stage IIA
  • Chest CT with and without IV contrast ehnancement shows:
    • S/P mastectomy at left and right breast. Subcutaneous infiltration at previous op. region over left axillary region is found. (Se301 Im30). In comparison with CT dated on 2023-11-09, the lesion is more pronounced.
    • Low density lesion at S2 of liver measuring 2.6cm in largest dimension is found. Simple cyst is considered.
    • There is stone at dependent portion of GB. GB stone(s) are noted.
  • Imp:
    • Breast cancer s/p MRM at bilateral breast
    • Suspected newly fibrosis or soft tissue at left breast. Please correlate with other study.
• 2024-04-22 SONO - abdomen
  • Moderate fatty liver
  • Liver hypoechoic lesion: favor cyst
  • Gallbladder stones
  • Fatty infiltration of pancreas
• 2024-04-12 T-L spine AP + Lat
  • mild spondylolisthesis at L4-5
  • mild decreased disc space in the L4/5 disc.
• 2024-04-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (64 - 16) / 64 = 75.00%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Trivial MR, mild AR. trivial TR and trivial PR
    • Preserved RV systolic function
• 2024-03-11 Pure Tone Audiometry
  • PTA: Reliability FAIR
  • Average RE 15 dB HL; LE 19 dB HL.
  • Bil WNL.
• 2024-03-08 Joint soft tissue sonography
  • Finding:
    • Increased vascular signal under power Doppler over the left FPL tendon at the MCPj with snapping pain.
  • Impression And Suggestions:
    • Left FPL tenosynovitis s/p USG inj. with shincort 5mg and lidocaine 10mg.
• 2024-01-29 Patho - breast simple/partial mastectomy
  • Diagnosis
    • Breast, left, simple mastectomy — invasive carcinom of no special type, grade 2
    • Skin, left breast, simple mastectomy — negative for malignancy
    • AJCC 8th edition pathology stage: rpT1cNx (if cM0); AJCC prognostic stage IA
  • Gross Description
    • Procedure: simple mastectomy
    • Specimen size: Breast: 3 pieces, up to 18x 9x 4 cm; Skin: 14x 5 cm
    • Lymph node sampling (if lymph nodes are present in the specimen): Not included
    • Specimen laterality: Left. Sections are taken and labeled as: A1-5:tumor with skin and margin
  • Microscopic Description
    • For Invasive Carcinoma
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 1.1 cm
      • Histologic grade (Nottingham histologic score): grade II (score 6)
      • Extent of tumor (required only if the structures are present and involved)
      • Skin involvement: Absent
      • Chest wall invasion deeper than pectoralis muscle: Absent
    • For Ductal Carcinoma In Situ: not identified
      • Tumor size (mm): not applicable
      • Nuclear grade: not applicable
      • Architectural pattern: not applicable
      • Tumor necrosis: not applicable
    • Margins:
      • Negative, Closest margin ( 10 mm from deep margin)
    • Nodal status: not included
      • No. examined: not applicable
      • No. macrometastases (> 2 mm): not applicable
      • No. micrometastases (> 0.2 ~ 2 mm and/or > 200 cells): not applicable
      • No. isolated tumor cells (<= 0.2 mm and <= 200 cells): not applicable
    • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
      • In the Breast: probable or definite response to presurgical therapy in the invasive carcinoma
      • In the Lymph nodes: not applicable
        
    • Immunohistochemical Study: Reference: S2023-25373
• 2024-01-11 PET scan
  • A mild glucose hypermetabolic lesion in the anterolateral aspect of left anterior chest region, compatible with recurrent breast malignancy of low FDG uptake.
  • Mild glucose hypermetabolism in bilateral shoulders and hips. Inflammatory process may show this picture.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
• 2023-12-29 Patho - breast biopsy (no need margin)
  • Breast, left, 2/3, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (-, 0%), PR (-, 0%), Her2/neu: positive (score = 3+), Ki-67 (70%), E-cadherin (+).
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2023-12-19 SONO - breast
  • Diagnosis
    • s/p bil. breast operation
    • R/O left breast tumor
  • BI-RADS:
    • 4a. suspicious abnormality, biopsy should be considered (low suspicion for malignancy: 2-10%)
• 2023-11-09 CT - chest
  • left breast cancer s/p left mastectomy and C/T.
  • non-specific lymph nodes at left breast region. Stationary.
• 2023-11-02 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 21) / 106 = 80.19%
    • M-mode (Teichholz) = 79
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
• 2023-07-31 SONO - breast
  • Hx: Breast cancer s/p Op and C/T
  • Findings:
    • Parenchymal pattern: Homogeneously sonodense.
    • Post-op scar in bilateral breasts. No significant focal sonographic lesion.
      
    • Non-specific axillary lymph node.
  • Suggestion:
    • Post-op scar in bilateral breasts, suggest clinical correlation and follow up.
  • BI-RADS: Category 1: negative.
• 2023-07-31 Mammography
  • BI-RADS category 2, Benign finding.
• 2023-07-31 CT - chest
  • No evidence of recurrent tumor in the study.
• 2023-06-05 SONO - abdomen
  • Mild fatty liver.
  • A hepatic cyst 1.87 cm in S2.
  • Multiple small stones or sludges in the gallbladder are noted.
• 2023-05-11 CT - chest
  • S/p port-A placement with its tip at Superior vena cava.
  • S/P mastectomy at left side.
  • No evidence of recurrent/residual tumor in the study.
• 2023-03-17 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (71.7 - 31.4) / 71.7 = 56.21%
    • M-mode (Teichholz) = 56.2
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild AR and PR, trivial TR
    • Thick IVS, mildly dilatation of LA and aortic root
• 2022-10-22 CT - chest
  • No evidence of recurrent/residual tumor in the study
• 2022-10-06 Gynecologic ultrasonography
  • Bilateral adnexae: free
  • EM: 4.7mm.
• 2022-07-22 Patho - breast simple/partial mastectomy
  • DIAGNOSIS:
    • A. Breast, right partial mastectomy with frozen section (F2022-337SA) — atypical ductal hyperplasia (ADH) with microcalcifciation.
      • IHC stains: CK5/6 (+, focal rim staining) p63 (rim staining).
    • B. Lymph node, sentinel, right, sentinel LN, s/p neoadjuvant chemotherapy (F2022-337FSC) — negative for malignancy. Two focus of fibrosis probably involuted lymph node after chemotherapy.
    • C. Breast, right, total mastectomy total mastectomy (S2022-11852) — scleroscing adenosis, fibrocystic disease, and adenosis.
  • MICROSCOPIC DESCRIPTION:
    • A. Sections F2022-337FSA1-2 show breast tissue with atypica ductal hyperplasia with microaclcification.
      • IHC stains: CK5/6 (+, focal rim staining) p63 (rim staining). Foci of scleroscing adenosis, fibrocystic disease, and adenosis are present.
    • B. Sections F2022-337FSC1-2 show fibroadipose tissue with moderate fibrosis.
    • C. Sections S2022-11852 show breast tissue with scleroscing adenosis, fibrocystic disease, and adenosis are present.
• 2022-07-22 Patho - breast simple/partial mastectomy
  • Diagnosis
    • Breast, left, s/p neoadjuvant chemotherapy followed by total mastectomy (S2022-11851) — no residual malignancy
    • Resection margin: free:
    • Lymph node, left, sentinel lymph node biopsy with frozen section (F2022-337FSB) — free
    • yp T0 ypN0(sn) (if cM0)
  • Gross Description
    • Procedure - mtotal mastectomy with senteinel lymph nodes.
    • Lymph node sampling - sentinel lymph node(s)
    • Specimen laterality - Left
      • Sections are taken and labeled as:
        • Tissue for frozen sections: F2022-337FSB: left sentinel lymph nodes.
        • Tissue for formalifixation: S2022-11851A1-12: left breast.
  • Microscopic Description
    • For Invasive Carcinoma: no residual malignancy.
    • For Ductal Carcinoma In Situ: no DCIS
    • Margins: no residual malignancy
    • Nodal status: Negative (if lymph nodes are present in the specimen)
      • No. examined: 2
      • No. macrometastases (>2 mm): 0
      • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
      • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
    • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
      • In the Breast
        • No residual invasive carcinoma is present in the breast after presurgical therapy
      • In the Lymph nodes
        • No lymph node metastases and no prominent fibrous scarring in the nodes
    • Immunohistochemical Study: result of biopsy specimen: S2021-19572
      • IHC stains (using blockS2021-19572): ER(+ , 100%, strongintensity), PR(-), Her2/neu: positive(score=3+), Ki-67(70 %), p53(50%).
• 2022-07-21 Frozen section
  • Preliminary diagnosis:
    • FSA1-2: right breast: irrregular duct. The possibility of malignancy cannot be excluded. Will need IHC stain to determine the nature of these ducts.
    • FSB: left sentinel LN s/p neoadjuvant therapy: free (0/2).
  • ADDENDUM:
    • FSC1-2: right sentinel LN, s/p neoadjuvant chemotherapy: negative for malignancy. Two focus of fibrosis probably involuted lymph node after chemotherapy.
• 2022-07-21 Lymphoscintigraphy
  • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential dynamic and static images over the chest revealed at least one focal area of increased accumulation of radioactivity at the left axilla.
  • IMPRESSION: Probably at least one sentinel lymph node at the left axillary region.
• 2022-07-07 Mammography
  • Impression:
    • Regression of left breast tumor (LIQ) and axillary lymph node.
    • Focal asymmetry in UOQ of right breast (posterior portion), stationary.
  • BIRADS 6
• 2022-07-07 SONO - breast
  • Diagnosis
    • Bil. fibroadenomas as described
    • Left breast cancer
  • BI-RADS:
    • 6 - known biopsy-proven malignancy
• 2022-06-11 CT - lung/mediastinum/pleura
  • IMP: No evidence of lung metastases based on this CT study.
• 2022-01-25 2D transthoracic echocardiography
  • LVEF(%) = 72
• 2022-01-14 CT - abdomen, pelvis
  • Left breast cancer with left axillary lymph node metastasis is highly suspected. please correlate with clinical condition.
  • The gallbladder shows mild irregular wall thickening and few stones that may be chronic inflammation. The differential diagnosis include gallbladder cancer.
• 2021-12-28 Patho - breast biopsy
  • Breast, left, 5/2, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains (using blockS2021-19572): ER (+, 100%, strongintensity), PR(-), Her2/neu: positive (score=3+), Ki-67(70 %), p53 (50%).
• 2021-12-28 Patho - lymphnode biopsy
  • Lymph node, left, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains (using blockS2021-19571): ER (+, 100%, strongintensity), PR(+, 30%, strong intensity), Her2/neu: positive (score=3+), Ki-67(90 %), p53 (60%).
• 2021-12-28 SONO - breast
  • Bilateral breast irregular tumors, suspected malignancy, suggest biopsy.
  • Enlarged left axillary lymph node, suspected lymph node metastasis.
  • Suggest biopsy.
    
  • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.
• 2021-12-18 Mammography
  • BI-RADS category 0, Need additional imaging evaluation.
  • Suggest ultrasound correlation for developing left breast nodules and enlarged left axillary lymph node.
• 2019-05-03 Mammography
  • Impression: No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
  • BI-RADS: Category 1: negative.-annual screening.

[MedRec]

• 2024-05-13 SOAP Ophthalmology

[consultation]

• 2022-03-31 ENT
  • Q
    • for right ear pain and headache
    • This 58 year-old woman panient suffered from left breast mass in 2021/11. Breast SONO on 2021/12/28 showed bilateral breast irregular tumors, suspected malignancy, suggest biopsy, enlarged left axillary lymph node, suspected lymph node metastasis and suggest biopsy. Left lymph node core biopsy showed invasive carcinoma, no special type, NST. IHC stains (using block S2021-19571): ER (+ , 100%, strongintensity), PR(+, 30%, strong intensity), Her2/neu: positive(score=3+), Ki-67(90 %), p53 (60%). Left 5/2 breast core biopsy showed Invasive carcinoma, no special type, NST. IHC stains (using block S2021-19572): ER (+ , 100%, strongintensity), PR(-), Her2/neu: positive(score=3+), Ki-67(70 %), p53 (50%).
    • This time, she was admitted to ward for chemotherapy with AC(C4) on 2022/03/31, then she complaints right ear pain and headache for 3-4 days, so we need your help for survey evulation, thanks a lot.
  • A
    • Eating on side(+, L) R otalgia with bil temple pain for 3 days.
    • PE:
      • Ear drum: bil intact
      • EAC: clean
      • TMJ: right TMJ tenderness when compression
    • Imp: TMJ syndrome
    • Plan: Pain control

[surigcal operation]

• 2024-01-29
  • Surgery
    • partial mastectomy
  • Finding
    • left 2/3 recurrent breast cancer, < 1cm in diameter
• 2022-07-21
  • Surgery
    • bilateral simple mastectomy and SLNB
  • Finding
    • left breast cancer, HER-2 type, s/p neoadjuvant chemotherapy and target therapy, tumor regression, SLNB: negative of malignancy
    • right breast tumor, excision for frozen pathology: irrregular duct. The possibility of malignancy cannot be excluded. Will need IHC stain to determine the nature of these ducts –> do simple mastectomy and SLN sampling
• 2018-07-05 PCS code 87003C
  • Benign neoplasm of skin of eyelid, including canthus
  • lid tumor, os

[immunochemotherapy]

• 2024-07-20 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-06-21 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-05-25 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-04-26 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-04-02 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-03-11 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-05 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2023-05-10 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2023-04-12 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2023-03-16 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2023-02-22 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2023-01-30 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2022-12-30 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2022-12-08 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2022-11-18 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2022-10-18 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2022-09-27 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2022-09-06 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2022-08-16 - Herceptin (trastuzumab) 600mg SC (adjuvant)
• 2022-06-29 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
• 2022-06-10 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
• 2022-05-16 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
• 2022-04-22 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
• 2022-04-01 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
• 2022-03-11 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
• 2022-02-15 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
• 2022-01-25 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr

[medication]

• 2023-06-29 ~ Femara (letrozole)

==========

2024-05-27

Lab results on 2024-05-24 were grossly normal and TPR readings during this hospitalization appear to be stable. No medication discrepancies were identified after review of HIS5 and PharmaCloud database.

2024-04-26

[monitoring elevated glucose and lipid levels]

The patient exhibited elevated levels of blood lipids and serum glucose. Regular monitoring is advised to determine if any intervention is necessary.

• 2024-04-16 Cholesterol total 207 mg/dL
  
• 2024-04-16 LDL-C 139 mg/dL
  
• 2024-04-16 Triglyceride (TG) 165 mg/dL
  
• 2024-04-16 Glucose (serum) 114 mg/dL

2022-10-22

• Trastuzumab administration (2022-04-22 ~ undergoing) might result in subclinical and clinical cardiac failure. The incidence and severity might be higher for patients received anthracycline-containing chemotherapy regimens (doxorubicin 2022-01 ~ 2022-04). An update of 2D transthoracic echocardiography is recommended (the most recent was performed on 2022-01-25 prior to the introduction of doxorubicin).

2022-05-17

• The patient was diagnosed with breast cancer (ER+, PR (-, + lymph nodes) Her2/neu 3+) and has been treated with doxorubicin/cyclophosphamide followed by docetaxel/trastuzumab.
• The last CT performed on 2022-01-14 showed a thickening of the gallbladder wall. Since gallbladder mets from breast cancer are rare, it might be sufficient to follow the gallbladder on an annual basis.
• Lab data on 2022-05-10 showed that liver and kidney function, electrolytes and CBC were generally normal.
• TPR readings remain stable during this hospital stay, no issues with active prescription.

701008526

240722

[diagnosis]

• recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020-07-02, RFA on 2020-12-11, rcTxN0M1a, stage IVA

[exam findings]

• 2024-06-28 Patho - skin non-cyst/tag/debridement/plastic
  • PATHOLOGIC DIAGNOSIS
    • Skin, right forearm, wide excision — Keratoacanthoma
    • Lymph node, ___ (site), dissection — Not received
    • Pathology stage: No AJCC 8th edition staging system.
  • MACROSCOPIC EXAMINATION
    • Operation procedure: wide excision
    • Specimen site: right forearm
    • Specimen size: 1.6 x 1.1 x 0.5 cm
    • Tumor size: 0.9 x 0.8 cm
    • Tumor description: hyperkeratosis
    • All for section in a cassette.
  • MICROSCOPIC EXAMINATION
    • Histology Type: Keratoacanthoma; The immunohistochemical stains reveal EMA(focal +) and p40(+).
      
    • Histology Grade: I (well differentiated)
      
    • Depth of invasion: Tumor invades the dermis
      
    • Resection Margins: Peripheral and deep margins are free of tumor; peripheral: 0.4 cm; deep: 0.2 cm
      
    • Lymphovascular Invasion: Absent
      
    • Perineural Invasion: Absent
      
    • Tumor Necrosis: Absent
      
    • Mitotic count / 5 hpf : 9/ 5 hpf
    • Lymph Node metastasis: not received
      
    • Maximum size of metastasis: not applicable
• 2024-06-03 CXR erect
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Patchy consolidation projecting at RLL of the lung is noted. Please correlate with clinical condition to rule out Bronchopneumonia.
    
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-04-24 CT - abdomen
  • History: Recurrent rectal cancer with liver metastasis
    
  • Findings:
    • There are few Patchy consolidation with air-bronchogram at RML, RLL, and LUL of the lung. Bronchopneumonia is highly suspected. Please correlate with clinical condition.
    • S/P LAR with autosuture retention over the rectum. There is no evidence of tumor recurrence.
    • There is a non-enhancing lesion 2.1 x 1.5 cm in S5 of the liver that is c/w metastasis s/p RFA with complete response.
      • In addition, Prior CT identified a poor enhancing lesion 8 mm in S8 of the liver is noted again, stationary. Follow up is indicated.
      • Prior CT identified few hepatic cysts on left lobe liver, the largest one 1 cm in S4, are noted again, stationary.
    • Bil. renal cysts (up to 2.9cm).
    • S/P posterior instrumentation fixation from L4 To L5.
  • Impression:
    • There are few Patchy consolidation with air-bronchogram at RML, RLL, and LUL of the lung. Bronchopneumonia is highly suspected. Please correlate with clinical condition.
    • S/P LAR with autosuture retention over the rectum. There is no evidence of tumor recurrence.
• 2024-04-23 Tc-99m MDP bone scan
  • In comparison with the previous study on 2023/04/27, the lesions in the L-spines are slightly more evident. The nature is to be determined (degenerative change in a little more severe status? other nature?). Please correlate with other imaging modalities for further evaluation.
    
  • Some new hot and faint hot spots in the anterior aspect of bilateral rib cages and in some left costovertebral junctions. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • No prominent change is noted in other bone lesions, possibly more benign in nature.
• 2024-03-13 Patho - colon biopsy
  • Intestine, large, rectum, biopsy — adenocarcinoma
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern.
  • The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
• 2024-03-12 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A (minimal)
    • Atrophic gastritis, s/p CLO test
    • suboptimal study due to some food debris
  • CLO test: Negative
  • Suggestion:
    • suboptimal study due to some food debris
    • arrange other image for GI bleeding survey
    • repeat EGD after sufficient NPO duration if clinical indicated
• 2024-03-12 Sigmoidoscopy
  • Diagnosis:
    • highly suspect rectal cancer
  • Suggestion:
    • medication with transamine
    • further assessment.
• 2023-12-15 Nasopharyngoscopy
  • foregn body stuck at throat, mild pain, intentional cough to expectorate in vain, no vocal palsy
• 2023-11-07 CT - abdomen
  • History and indication: Recurrent rectal cancer with liver metastasis
    
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Rectal cancer s/p operation without interval change.
    • Liver tumor s/p RFA.
    • Bil. renal cysts (up to 3.4cm).
    • No ascites. Some small lymph nodes at mediastinum. Bronchiectasis at RML. A nodule (1.1cm) at RUL.
    • S/P posterior longitudinal transpedicular screws and rods fixation.
  • IMP:
    • Rectal cancer s/p operation without interval change.
    • Liver tumor s/p RFA without viable tumor.
• 2023-09-26 EGD
  • Reflux esophagitis LA Classification grade A
• 2023-09-20, -09-11 ECG
  • Sinus rhythm with 1st degree A-V block
• 2023-08-30 SONO - abdomen
  • Diagnosis:
    • Post cholecystectomy
    • Hepatic tumor C/W single metastasis s/p RFA
    • Liver cyst
    • Hepatic tumor R/O hemangioma
    • Renal cyst, left
• 2023-07-03 Swallowing video fluoroscopy
  • Mild hocking during swallowing.
• 2023-06-30 CT - abdomen
  • History: Recurrent rectal cancer with liver metastasis
    
  • Findings:
    • S/P LAR with autosuture retention over the rectum.
      • There is no evidence of tumor recurrence.
    • There is a non-enhancing lesion 2.1 x 1.5 cm in S5 of the liver that is c/w metastasis s/p RFA with complete response.
      • In addition, Prior CT identified a poor enhancing lesion 8 mm in S8 of the liver is noted again, stationary. Follow up is indicated.
      • Prior CT identified few hepatic cysts on left lobe liver, the largest one 1 cm in S4, are noted again, stationary.
    • Bil. renal cysts (up to 2.9cm).
    • S/P posterior instrumentation fixation from L4 To L5.
  • Impression:
    • S/P LAR with autosuture retention over the rectum.
    • There is no evidence of tumor recurrence.
• 2023-06-23 Anoscopy
  • Stool color : normal
  • Rectal mucosa : normal
  • Anal canal : abnormal
  • Impression : DRE/anoscopy: no palpable mass, no blood, mild hemorrhoids
• 2023-06-21 Nasopharyngoscopy
  • Findings
    • vocal cords movement well and symmetric.
    • much whitish sputum in hypopharynx and larynx.
  • Diagnosis/conclusion
    • Swallowing disorder
• 2023-04-28 Nasopharyngoscopy
  • Findings
    • No tumor noted in nasopharynx, oropharynx, hypopharynx and larynx.
    • Injected arytneoids.
  • Diagnosis/conclusion
    • Reflux laryngitis
• 2023-04-27 Tc-99m MDP bone scan
  • In comparison with the previous study on 2021/04/20, the lesions in the L-spines are a little more evident. Degenerative change in a little more severe status may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • No prominent change is noted in other bone lesions.
• 2023-04-07 Anoscopy
  • Stool color : normal
  • Rectal mucosa : normal
  • Anal canal : abnormal
  • Impression : 2022-01-18: DRE: mild blood in finger, no tumor obstruction, mild hemorrhoids
• 2023-03-31 Bladder sonography
  • Report: PVR: 67 ml
• 2023-03-31 Uroflowmetry
  • Q max : low
  • flow pattern : obstructive
• 2023-03-27 CT - abdomen
  • History and indication: Recurrent rectal cancer with liver metastasis
    
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Rectal cancer s/p operation without interval change.
    • Liver tumor s/p RFA.
    • Bil. renal cysts (up to 2.9cm).
    • S/P posterior longitudinal transpedicular screws and rods fixation.
  • IMP:
    • Rectal cancer s/p operation without interval change.
    • Liver tumor s/p RFA without viable tumor.
• 2023-02-19 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-02-16 CT - brain
  • Clinical history: 86 y/o male patient with contusion of scalp, initial encounter: Malignant neoplasm of rectum, Essential (primary) hypertension
    • preliminary impression: Contusion of scalp, initial encounter.
  • Without enhancement CT of brain:
    • Low density lesions in bilateral basal ganglia regions, could be due to infarcts.
    • Widening cerebral sulci, fissure and cisterns due to cerebral atrophy.
    • No intracranial hemorrhage.
    • No midline structure deviation.
    • Normal pneumotization of paranasal sinuses and bilateral mastoid air cells.
    • Calcification of bilateral supraclinoid ICAs and VAs.
  • Impression:
    • Suspected infarcts in bilateral basal ganglia region.
    • Brain atrophy.
• 2022-12-05 CT - abdomen
  • Indication: Recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, (kras 12/13mutated), rcTxN0M1a, stage IVA
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness) Abdominal CT with and without enhancement revealed:
    • s/p RFA at right lobe liver. Several hepatic cysts at both lobes of liver is found. Simple cysts are favored.
    • s/p LAR. Minimal infiltration at presacral space is found. In comparison with CT dated on 2022-08-25, the lesion is stationary.
    • Swelling of the cecum is found. In comparison with CT dated on 2022-08-25, the change is stationary. Suggest correlate with tumor marker.
  • Imp:
    • s/p LAR with residual infiltration at presacral space. Statinary.
    • s/p RFA at right lobe liver. No recurrent/residual tumor in the liver is found.
    • Swelling of cecum. Suggest correlate with tumor marker and follow up.
• 2022-10-18 KUB
  • S/P posterior longitudinal transpedicular screws and rods fixation.
  • Presence of ileus.
  • S/P operation.
  • Compression fracture of L1-3.
• 2022-09-30 Nasopharyngoscopy
  • no obvious bleeder or erosion wound noticed over bilateral nasal cavity, Npx
• 2022-09-06 CT - brain
  • Brain atrophy with bilateral periventricular ischemic/aging white matter change. Atherosclerosis.
• 2022-08-25 CT - abdomen
  • Rectal cancer s/p operation without interval change.
  • Liver tumor s/p RFA without viable tumor.
• 2022-05-20 Colonoscopy
  • Local recurrent cancer at low rectum
  • Colon polyps, A-colon and S-colon
• 2022-05-17 CT - abdomen, pelvis
  • Post-op at the colon, with prominent soft tissue around anastomosis, suggest colonoscopy study.
  • S/P RFA for liver tumor.
  • Duodenal diverticulum.
  • Stationary of right upper pole kidney low density lesion, 1.4cm, suggest follow up.
  • Fibrotic infiltrate in bilateral upper lungs.
• 2022-02-16 Chest PA erect view
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2022-02-14 Chest PA erect view
  • Ground glass opacity in bilateral lower lungs.
• 2022-01-04 CT - whole abdomen, pelvis
  • S/P RFA for liver tumor.
  • Duodenal diverticulum.
  • Stationary of right upper pole kidney low density lesion, 1.4cm, suggest follow up.
  • Fibrotic infiltrate in bilateral upper lungs.
• 2021-10-01 Sigmoidoscopy
  • Diagnosis: local recurrent cancer at low rectum
  • Suggestion: possible R/T or transanal debulking excision
• 2021-09-23 CT - whole abdomen, pelvis
  • Rectal cancer s/p operation without interval change.
  • Liver tumor s/p RFA without viable tumor.
• 2021-04-20 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 20190725, the lesions in the upper L-spines are a little less evident. Compression fracture or severe degenerative change with some resolution may show this picture.
  • The previous hot spots in some right costovertebral junctions are also a litlte less evident. However, please correlate with other imaging modalities for further evaluation.
  • No prominent change is noted in the lesions in the lower L-spines. Post-operative change may show this picture.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and wrists, compatible with benign joint lesions.
• 2021-04-06 CT - whole abdomen, pelvis
  • Post-op at the colon with preirectal fatty infiltrates, stationary.
  • S/P RFA for liver tumor.
  • Suspected complicated right renal cyst.
  • Fibrotic infiltrates in bilateral lung apex and RML.
  • Osteoblastic lesions in the ribs, spine and pelvis, suspected bone metastasis.
• 2021-02-26 Colonoscopy
  • Recurrent rectal tumor found 6cm AAV.
• 2021-01-07 CT - liver, spleen, biliary duct, pancreas
  • Rectal cancer s/p operation without interval change.
  • Liver tumor s/p RFA without viable tumor.
• 2020-11-10 PET scan
  • In comparison with the previous study on 20200622, the previous glucose hypermetabolic lesion in the segment 5 of the liver is less evident. However, the previous glucose hypermetabolic lesion on the rectal wall disappeared and no prominent FDG uptake was noted in the previous glucose hypermetabolic lesion in the segment 4 of the liver.
  • Two mild and small glucose hypermetabolic lesions in the right lower lung field. The nature is to be determined (inflammation? early metastases? other nature?).
  • Glucose hypermetabolism in bilateral pulmonary hilar regions and some mediastinal lymph nodes. Inflammation may show this picture.
  • Increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.
• 2020-10-30 Sigmoidoscopy
  • Previous anastomosis site was no evidence disease (NED).
• 2020-10-07 CT - abdomen, pelvis
  • Metastasis 1.6 x 1.1 cm in S5 of the liver is suspected and it shows stable in size. Please correlate with MRI.
  • Renal cyst with hemorrhage 2 cm at right upper pole shows stable in size.
• 2020-07-03 Patho - colorectal polyp
  • Rectum, transanal excision - Adenocarcinoma, recurrent
• 2020-06-22 PET scan
  • A glucose-hypermetabolic lesion on rectal wall, compatible with the lesion of recurrent rectal cancer as diagnosed histopathologically.
  • Glucose hypermetabolism in the lesion in segment 5 of liver revealed in the previous CT scan, hepatic metastasis may show such a picture.
  • Another glucose-hypermetabolic lesion in segment 4 of liver, nature to be determined (inflammatory lesion, malignancy, or other nature).
  • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change resulting from locoregional inflammation may show such a picture.
  • Rectal cancer with recurrence, rcTxN0M1a, stage IVA (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2020-06-17 CT - abdomen, pelvis
  • Metastasis 1.6 x 1.1 cm in S5 of the liver is suspected.
  • Renal cyst with old hemorrhage 2 cm at right upper pole is suspected.
• 2020-06-15 Patho - colon biopsy
  • Large intestine, rectum, biopsy - Adenocarcinoma, moderately differentiated
• 2020-06-12 Sigmoidoscopy
  • one 2.5cm tumor mass was noted in the low rectum (previous anastomosis, posterior site)
• 2020-01-03 Patho - colon segmental resction for tumor
  • Recto-Sigmoid colon, LAR - Adenocarcinoma
  • Bilateral cutting ends, ditto - Free of tumor invasion
  • Lymph node, dissection - Positive for tumor metastasis (2/12) without extracapsular extension (0/2)
  • AJCC pathologic stage - ypT3N1b(if cM0), stage IIIB
  • IHC: CDX-2(+), MLH1(+), PMS2(+), MSH2(+) and MSH6(+)
• 2019-07-01 CT - liver, spleen, biliary duct
  • Rectal cancer s/p CCRT with regional LAP (T3N2Mx).
  • Segmental wall edema of terminal ileum with adjacent fat stranding and ascites. A poor enhancing lesion (2.4cm) in right kidney.
• 2019-06-08 CT - abdomen
  • Imaging Report Form for Colorectal Carcinoma: T3N2Mx

[MedRec]

• 2024-03-11 SOAP Neurology Xu BoRen
  • A: chemotherapy related polyneuropathy + L spine radiculopathy
  • Prescription x3
    • Muaction (tramadol 100mg) 1# PRNBID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
    • Trynol (amitriptyline 25mg) 1# HS
    • Neurontin (gabapentin 100mg) 1# BID
    • calcium carbonate 500mg 1# QD
    • U-Ca (calcitriol 0.25mg) 1# QD
    • Madopar (levodopa 200mg, benserazide 50mg) 0.5# TID
• 2024-03-11, 2023-12-15, -09-08, -06-23, -03-31 SOAP Urology Luo QiWen
  • Prescription x3
    • Urief (silodosin 8mg) 1# QN
    • Betmiga (mirabegron 50mg) 1# QN
• 2024-02-02, 2023-11-15 SOAP Psychosomatic Medicine Chen YiQian
  • A/P
    • Dx:
      • Insomnia
      • R/O MCI
    • Tx:
      • Psychoeducation
      • Family counseling
      • Provide emotional support
  • Prescription x3
    • Alpraline (alprazolam 0.5mg) 1# HS
• 2023-12-30 SOAP Gastroenterology Wang JiaQi
  • Prescription x3
    • Ulstop (famotidine 20mg) 1# BID
    • Gasmin (dimethylpolysiloxane 40mg) 1# BID
    • Mosapin (mosapride citrate 5mg) 1# BID
• 2023-12-28 SOAP Cardiology Xie JianAn
  • Prescription x3
    • Januvia (sitagliptin 100mg) 0.5# QD
    • Eliquis (apixaban 5mg) 0.5# BID
    • Zandip (lercanidipine 10mg) 1# QD
• 2023-12-15 SOAP Neurology Xu BoRen
  • A: chemotherapy related polyneuropathy + L spine radiculopathy
  • Prescription x3
    • Muaction (tramadol 100mg) 1# PRNBID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
    • Trynol (amitriptyline 25mg) 1# HS
    • Neurontin (gabapentin 100mg) 1# BID
    • calcium carbonate 500mg 1# QD
    • U-Ca (calcitriol 0.25mg) 1# QD
• 2023-03-03, 2022-12-12, -09-05 SOAP Urology Luo QiWen
  • Prescription x3
    • Vesicare (solifenacin 5mg) 1# HS
    • Harnalidge (tamsulosin 0.4mg) 1# HS

[consultation]

• 2022-05-19 Colorectal Surgery
  • Q
    • The 85y/o male recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, rcTxN0M1a, stage IVA
      
    • 2022/05/17 f/u CT Impression: Post-op at the colon, with prominent soft tissue around anastomosis, suggest colonoscopy study, so we need ypor help. Thank you.
  • A
    • The 85y/o male recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, rcTxN0M1a, stage IVA, with C/T + target therapy.
    • Impression:
      • Post-op at the colon, with prominent soft tissue around anastomosis, suggest colonoscopy study.
      • S/P RFA for liver tumor.
      • Duodenal diverticulum.
      • Stationary of right upper pole kidney low density lesion, 1.4cm, suggest follow up.
      • Fibrotic infiltrate in bilateral upper lungs.
    • A: Recurrent rectal cancer with liver metastases s/p CCRT and RFA, with disease progression
    • P:
      • Colonoscopy will be performed on this Friday afternoon
      • We would like to follow this patient
• 2022-01-08 Infectious Disease
  • Q
    • The 85 y/o man has recurrent rectum cancer under chemotherapy. Due to fever with chills, we gave Cefepime for infection control at first. The Sphingomonas paucimobilis bacteremia from port-a was noted, but Port-a was removed in 20220106. We need your help for antibiotic assassment. Thanks!
  • A
    • Infections of Sphingomonas paucimobilis include bacteraemia/septicaemia caused by contaminated solutions, e.g. distilled water, and sterile drug solutions.
    • Infections due to S. paucimobilis have not been associated with mortality.
    • The drug of choice may be a fluoroquinolone because of the susceptibility patterns and ease of administration.
    • Levofloxacin in a dose of 500 mg per day, or Finibax in the dose of 500 mg every 8 hours may be used.
• 2021-11-08 Urology
  • Q
    • The 82 y/o man has recurrent rectum cancer stage IV with urinary incontinence, so we need your help for management. Thanks!
  • A
    • This 84yo male has underlying diseases of recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, (kras 12/13mutated), rcTxN0M1a, stage IVA.
    • CC: urinary incontinence was noted for 3 months
    • PI: urgency+, frequency+, IPSS: 22
    • Suggestion:
      • acquire U/A, PSA fisrt
      • arrange UFM, PVR and TURSP
      • may add solifenacin if PVR < 100 ml
• 2021-09-28 Colorectal Surgery
  • Q
    • The 84 y/o man has adenocarcinoma of rectum, cT3N2bM0, IIIC, s/p CCRT with partial response, s/p laparoscopic- LAR and protective ileostomy (2020-01-02), pT3N1bM0(2/12), LVI(+), PNI(-), stage IIIB. Due to few bloody after stool passage for 1-2 weeks, no hemorrhoid or fistula noted, so we need your help for management. Thanks!
  • A
    • The patient was consulted for bloody stool passage in recent 1-2 weeks.
    • 2021-09-23 CT:
      • Rectal cancer s/p operation without interval change.
      • Liver tumor s/p RFA without viable tumor.
    • A:
      • Local recurrent rectal adenocarcinoma with S5 liver metastasis, stage IVa s/p transanal local excision (2020-07-02) and s/p palliative R/T + chemotherapy + target therapy and RFA for liver metastasis
      • Adenocarcinoma of rectum, cT3N2bM0, IIIC, s/p CCRT with partial response, s/p laparoscopic- LAR and protective ileostomy(109-01-02), pT3N1bM0(2/12), LVI(+), PNI(-), stage IIIB, s/p close ileostomy (2020-04-20)
    • P
      • Suggest sigmoidoscopy this Friday afternoon
      • We would like to follow this case
• 2021-08-10 Psychosomatic Medicine, Mental Health
  • Q
    • The 84 y/o man has recurrent rectal cancer stage IVA, is admitted for deep drowsy. In hospital, we hold his sedation as Eurodin, Revotril and Imipramine. Due to delirium at night for days, so we need your help for management.
  • A
    • Psychiatirc impression:
      • acute delirium
    • Psychiatric history:
      • This 84 year-old male patient with history of rectal cancer stage IVA under chemotherapy. He suffered form diarrhea after chemotherapy since last discharge (20210629~20210716). He present weakness, bedridden and persistent diarrhea during late July 2021. This time we was brought to this ER on 20210801 due to general weakness and drowsiness.
      • According to his son, he display consciousness flactuation and disorientation since late July and progressed after this admission. Sleep cycle disturbance. Sundowning syndrome. Self talking and suspect visual hallucination. Upon visit, sleepiness, poor attention lasting, hearing impairment, incoherent and irrelevent speech, disoriented to time and place.
      • 20210809 Given 0.5# Rivotril due to poor sleep, still cannot fall asleep; given 0.5# again, can fall asleep, but becomes drowsy during the day
      • currently hold eurodin, rivotril and imipramine
    • Suggesting:
      • please correct his underlying condition
      • encorage daily activities and prevnet daytime sleep, reorientation to time, person and place
      • DC rivotril and neurontin and avoid BZD use
      • give risperidol 0.5# hs
      • please contact us if any psychiatric problem
• 2021-08-09 Urology
  • Q
    • The 84 y/o man has Adenocarcinoma of rectum, cT3N2bM0, stage IIIC, post operation with CCRT and chemotherapy. Due to frequency urine noted, we gave Harnalige for control since 20210805, but his son complainted of condition without control. The patient urinates every 2-3 hours during the day and every 1-2 hours at night, so we need your help for management. Thanks!
  • A
    • S/O
      • The 84 y/o man
      • Adenocarcinoma of rectum, cT3N2bM0, stage IIIC, post operation with CCRT and chemotherapy
      • Admitted for weakness
      • Due to frequency urine noted,
      • Harnalige for control since 20210805, but his son complainted of condition without control
      • UA: clear
    • P
      • arrange random PVR, if PVR <300 ml, administer Vesicare 1 tab QD
• 2020-11-13 Gastroenterology
  • A
    • 83M
    • PH:
      • Adenocarcinoma of rectum, cT3N2bM0, stage IIIC status post laparoscopic low anterior resection and protective loop-ileostomy on Jan. 02, 2020 status post CCRT, rcTxN0M1a, stage IVA
      • DVT with left IVC filter status post removal IVC filter on Apr. 7, 2020
      • Gallbladder stones with acute cholecystitis post cholecystectomy on Jan. 19, 2020
      • Hypertension for 10+ years under medical treatment
      • Type 2 diabetes mellituss for 10+ years under medical treatment
      • HIVD s/p L3-L5 spine surgery on 2017-12 at Cathay General Hospital
    • CC:
      • Followed up CT on 2020/06/17 and 10/07 revealed “metastasis 1.6 x 1.1 cm in S5 of the liver is suspected” –> adm for solitary liver lesion
    • Due to liver tumor, we are consulted for RFA.
    • S+O
      • No disconfort
      • Conscious: E4V5M6
      • Abdomen: Soft and flat, no tenderness, no rebound tenderness
      • Lab
        • 2020-11-09 AST:17, ALT:37, BUN:24, Cr:0397, T-bil:0.56
        • WBC:4.97, Hb:11.8, PLT:248
    • Impression
      • Liver tumor, S5
    • Suggestion
      • arrange abdominal echo
      • arrnage GI OPD after discharge. We will discuss with the patient about RFA in GI OPD
• 2020-11-12 General and Gastrointestinal Surgery
  • Q
    • This time,he was admitted for clarifying the nature of solitary liver lesion. PET done on 20201110 which revealed In comparison with the previous study on 20200622, the previous glucose hypermetabolic lesion in the segment 5 of the liver is less evident. However, the previous glucose hypermetabolic lesion on the rectal wall disappeared and no prominent FDG uptake was noted in the previous glucose hypermetabolic lesion in the segment 4 of the liver.
    • We need your expertise for op evaluation, thanks
  • A
    • S: a case of rectal cancer with recurrence, rcTxN0M1a, stage IVA. PET found suspected liver METs over S4 & S5, further evaluation is consulted.
    • O: vital signs: stable, no fever
      • abdomen: soft, ovoid, decrease bowel sound, no tenderness, no rebounding pain
      • lab data: see chart
      • CT & PET: suspected liver & lung METS
    • A: rectal cancer with recurrence, rcTxN0M1a, stage IVA.
    • P: Please arrange biopsy of suspected liver tumors for tissue prove
      • If rectal Ca with liver METS diagnosed, surgical intervention is not suitable for him due to high surgical risk (old age, previous DVT, and terminal stage).
      • RFA and RT, or target and immunotherapy is better and suggested.
• 2020-01-18 General and Gastrointestinal Surgery
  • Q
    • PH: adenocarcinoma of rectum, cT3N2bM0, III s/p L-LAR with protective ileostomy (2020-01-02), decreased appetite, abdomen fullness and discomfort and feels weakness
  • A
    • A case of acute RUQ pain for days
    • PE
      • soft abdomen, no muscle guarding
      • positive murphy signs and knocking pain, right
    • lab disclosed neutrophilia over 80%, CRP over 28
    • CT: gall stones with acute cholecystitis
    • Emergency op or drainage is indicated
• 2020-01-18 Colorectal Surgery
  • Q
    • PH: adenocarcinoma of rectum, cT3N2bM0, III s/p L-LAR with protective ileostomy (2020-01-02), decreased appetite, abdomen fullness and discomfort and feels weakness
  • A
    • This 83-year-old with a known history of adenocarcinoma of rectum, cT3N2bM0, III s/p L-LAR with protective ileostomy (2020-01-02) This time, he had decreased appetite, abdomen fullness and discomfort and feels weakness. His laboratory data showed leucocytosis and elevated CRP level. After evaluation, please arrange abdominal CT.
    • PE:
      • Rebounding pain (+) especial right side and RUQ.
      • knocking tederness (-)
      • ileostomy: gas + watery yellowish diarrhea
    • Suggest:
      • please check abdominal CT
      • please consult GS

[surgical operation]

• 2020-12-11 Colon cancer with single liver metastasis s/p RFA (2 sessions) using RVS

• 2020-01-19

  • Surgery: Exp lap with cholecystectomy and drainage
  • Finding
    • black stones with GB wall thickening and pericholecystal abscesses and adhesions
    • one impaction over orifice of cystic duct
    • no liver tumor or cirrhotic change

• 2019-10-22

  • Diagnosis: L3-S1 spondylosis, radiculopathy
  • PCS code: 96005C
  • Finding
    • bilateral L3-4 HIVD, ASD, spinal stenosis, radiculopathy
    • L5-S1 HIVD
    • intraoperative fluoroscopy confirmed needle localization

[radiotherapy]

• 2019-04-18 ~ 2019-05-31: 4500cGy/25fx of the pelvic and 5040cGy/28fx of the rectal tumor area

[chemotherapy]

• 2024-07-22 - oxaliplatin 85mg/m2 103mg D5W 250mL 2hr + leucovirin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-07-05 - oxaliplatin 85mg/m2 105mg D5W 250mL 2hr + leucovirin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-06-13 - oxaliplatin 85mg/m2 105mg D5W 250mL 2hr + leucovirin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-24 - oxaliplatin 85mg/m2 105mg D5W 250mL 2hr + leucovirin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3400mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-04-24 - oxaliplatin 85mg/m2 105mg D5W 250mL 2hr + leucovirin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3480mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-04-01 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 510mg NS 250mL 2hr + fluorouracil 2800mg/m2 3610mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-03-13 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3660mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-30 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3660mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3660mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-07 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3580mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-09 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3580mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-11 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3610mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-14 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3610mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-07-17 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 3630mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-06-13
• 2023-05-22
• 2023-04-24
• 2023-03-28
• 2023-02-20 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 3770mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-01-09 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-12-02 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-11-16 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-10-27 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-10-14 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-08-22 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-08-01 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-07-18 - oxaliplatin 85mg/m2 115mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-06-16 - oxaliplatin 85mg/m2 115mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3790mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-05-23 - oxaliplatin 85mg/m2 115mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3790mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-03-09 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3750mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2021-12-15 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3615mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2021-11-24 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3615mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2021-11-04 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3690mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2021-10-19 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3625mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2021-09-24 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 3675mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-06-29 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-06-02 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-04-21 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-04-07 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-03-22 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 235mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3650mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-03-08 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 235mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3650mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-10-06 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 235mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3650mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-09-21 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3720mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-09-07 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3720mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-08-18 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3730mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-08-03 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 535mg 2hr + fluorouracil 2800mg/m2 3750mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-07-20 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 535mg 2hr + fluorouracil 2800mg/m2 3750mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD

==========

2024-07-22

[monitoring tumor markers and assessing disease progression]

LPRBC transfusion is planned for HGB at 8.9 g/dL. Tumor markers CEA and CA199 are still on an upward trend, with CA199 tripling in less than one month. The last abdominal CT was conducted 3 months ago on 2024-04-24. It is recommended to update medical imaging to check for disease progression and determine if the treatment regimen needs adjustment.

• 2024-07-16 CEA (NM) 70.622 ng/ml

• 2024-06-28 CEA (NM) 75.866 ng/ml

• 2024-05-07 CEA (NM) 56.994 ng/ml

• 2024-04-12 CEA (NM) 57.916 ng/ml

• 2024-03-26 CEA (NM) 47.810 ng/ml

• 2024-02-16 CEA (NM) 37.327 ng/ml

• 2024-01-03 CEA (NM) 33.875 ng/ml

• 2024-07-16 CA-199 (NM) 672.340 U/ml

• 2024-06-28 CA-199 (NM) 194.991 U/ml

• 2024-05-07 CA-199 (NM) 164.319 U/ml

• 2024-04-12 CA-199 (NM) 167.790 U/ml

• 2024-03-26 CA-199 (NM) 173.605 U/ml

• 2024-02-16 CA-199 (NM) 133.240 U/ml

• 2024-01-03 CA-199 (NM) 107.208 U/ml

2024-06-11

[flomoxef for Escherichia coli infection]

A chest X-ray on 2024-06-03 showed patchy consolidation in the RLL of the lung, might be suggestive of bronchopneumonia. There was also blunting of the right costophrenic angle, likely due to pleural effusion. Despite normal CRP and PCT readings, the patient’s cough sputum culture revealed Escherichia coli 4+, which is sensitive to Flumarin (flomoxef sodium, MIC ≤ 2). Flumarin was initiated on 2024-06-07. No fever over 37°C has been observed since then.

• 2024-06-07 Procalcitonin (PCT) 0.07 ng/mL
• 2024-06-03 CRP 0.8 mg/dL

2024-04-23

[monitoring progression: bone scans, CT, and tumor markers]

Bone scans and CT imaging are scheduled to monitor the progression, as tumor markers CEA and CA199 have shown an increasing trend over the past 6 months.

Laboratory results from 2024-04-22 indicate there are no contraindications to proceeding with a new session of FOLFOX chemotherapy for the treatment of the patient’s condition.

• 2024-04-12 CEA (NM) 57.916 ng/ml

• 2024-03-26 CEA (NM) 47.810 ng/ml

• 2024-02-16 CEA (NM) 37.327 ng/ml

• 2024-01-03 CEA (NM) 33.875 ng/ml

• 2023-11-21 CEA (NM) 33.072 ng/ml

• 2024-04-12 CA-199 (NM) 167.790 U/ml

• 2024-03-26 CA-199 (NM) 173.605 U/ml

• 2024-02-16 CA-199 (NM) 133.240 U/ml

• 2024-01-03 CA-199 (NM) 107.208 U/ml

• 2023-11-21 CA-199 (NM) 106.235 U/ml

2024-03-13

[assessing bloody stools: tranexamic acid use in ongoing GI bleeding management]

The patient reported experiencing bloody stools for a week and underwent an EGD and sigmoidoscopy on 2024-02-12 (HGB 9.9 g/dL).

The presence of bloody stools suggests the possibility of GI bleeding. However, the EGD did not provide a definitive diagnosis due to the presence of food debris. While atrophic gastritis could be associated with the bleeding, further examination is required for a conclusive determination. The suspected rectal cancer, identified separately, demands prompt and focused attention due to its severity.

HR has been stable at 70 to 80, with no signs of resting tachycardia observed.

Hemoclot (tranexamic acid) was administered starting the night of 2024-02-12. Should the bleeding continue, it is often possible to manage the condition with therapeutic interventions during colonoscopy or angiography.

2024-01-31

Lab results from 2024-01-30 did not reveal any significant findings that would contraindicate proceeding with a new session of the FOLFOX regimen.

The active medication list has been updated to include repeat prescriptions from our gastroenterologist (2023-12-30), cardiologist (2023-12-28), neurologist, urologist (2023-12-15), and psychosomatic physician (2023-11-15), with no discrepancies noted.

2023-12-22

Lab results obtained on 2023-12-21 were largely unremarkable with the exception of mild anemia (HGB 9.5 g/dL). Due to this finding, the new session FOLFOX regimen has been continued on 2023-12-21.

Medications from repeat prescriptions issued by our neurologist, urologist (2023-12-15), and psychosomatic physician (2023-11-15) have been successfully integrated into the active medication list. No discrepancies were identified.

2023-11-06

After checking the PharmaCloud database and the patient’s current medication list, it is confirmed that all medications from the refill order have been taken. No discrepancies are found.

2023-10-09

[reconciliation]

The patient has attended multiple departments in our hospital and has been issued several repeat prescriptions that remain valid to date:

• 2023-09-19 Gastroenterology: Ulstop (famotidine), Gaslan (dimethylpolysiloxane), Mopride (mosapride citrate)

• 2023-09-15 Cardiology: Januvia (sitagliptin), Eliquis (apixaban), Zandip (lercanidipine)

• 2023-09-08 Urology: Urief (silodosin), Betmiga (mirabegron)

• 2023-09-01 Neurology: Muaction (tramadol), Kentamin (Vit B1, B6, B12), Trynol (amitriptyline), Neurontin (gabapentin), CaCO3, U-Ca (calcitriol)

• 2023-08-30 Psychosomatic Medicine: Alpraline (alprazolam)

All these medications are actively being used by the patient, and no inconsistencies have been identified.

[tumor markers]

The most recent CT scan of the abdomen dated 2023-06-30 shows no evidence of tumor recurrence in the rectum following LAR surgery. While a lesion in S5 of the liver post-RFA indicates complete recovery, a previously detected lesion in S8 and some liver cysts in the left lobe remain stable, suggesting the need for continued surveillance. However, given the increasing trend of the tumor markers CEA and CA199 in recent months, further imaging or testing may be required to obtain an updated status of the disease.

• 2023-09-28 CEA (NM) 41.773 ng/ml

• 2023-08-29 CEA (NM) 41.022 ng/ml

• 2023-08-01 CEA (NM) 28.657 ng/ml

• 2023-06-27 CEA (NM) 32.370 ng/ml

• 2023-06-06 CEA (NM) 38.089 ng/ml

• 2023-05-09 CEA (NM) 29.020 ng/ml

• 2023-04-11 CEA (NM) 29.090 ng/ml

• 2023-03-07 CEA (NM) 30.892 ng/ml

• 2023-02-22 CEA (NM) 22.304 ng/ml

• 2023-01-20 CEA (NM) 29.331 ng/ml

• 2023-09-28 CA-199 (NM) 128.119 U/ml

• 2023-08-29 CA-199 (NM) 124.920 U/ml

• 2023-08-01 CA-199 (NM) 100.17 U/ml

• 2023-06-27 CA-199 (NM) 102.499 U/ml

• 2023-06-06 CA-199 (NM) 108.696 U/ml

• 2023-05-09 CA-199 (NM) 99.780 U/ml

• 2023-04-11 CA-199 (NM) 94.910 U/ml

• 2023-03-07 CA-199 (NM) 91.315 U/ml

• 2023-02-22 CA-199 (NM) 66.824 U/ml

• 2023-01-20 CA-199 (NM) 70.223 U/ml

2023-08-14

On 2023-06-23, our cardiologist prescribed Januvia (sitagliptin), Eliquis (apixaban), and Zandip (lercanidipine) for the patient, while on 2023-07-01, our gastroenterologist prescribed Ulstop (famotidine), Gaslan (dimethylpolysiloxane), and Mopride (mosapride citrate). All medications, with the exception of Mopride, are currently on the active medication list. Please determine if the use of Mopride is still necessary.

2023-07-17

This patient just refilled his prescription for Januvia (sitagliptin), Eliquis (apixaban), Zanidip (lercanidipine), Betmiga (mirabegron), Urief (silodosin) on 2023-07-11 at a local pharmacy and these drugs are now added to the active medication list with no reconciliation issues found.

2023-06-12

According to the PharmaCloud database, the patient has solely been using our hospital for both outpatient and inpatient services over the past three months.

The patient visited our Neurology and Psychosomatic Medicine OPD on 2023-06-09 for chemotherapy-related polyneuropathy, L spine radiculopathy, suspected mild cognitive impairment, and insomnia. Refillable prescriptions were given for Muaction (tramadol), Kentamin (B1, B6, B12), Trynol (amitriptyline), Neurontin (gabapentin), calcium carbonate, U-Ca (calcitriol), and Alpraline (alprazolam). These drugs are appropriately reflected on the current active medication list. No issues were identified in the medication reconciliation process.

2023-05-22

A review of PharmaCloud records did not identify any medication reconciliation issues.

This patient’s chemotherapy-induced polyneuropathy may be more likely due to the oxaliplatin component of the FOLFOX regimen, which was started in Oct 2021. Appropriate measures have been taken, including the addition of Kentamin (B1, B6, B12) and Neurontin (gabapentin) to the patient’s active medication regimen as prescribed by our neurologist.

The patient’s CEA and CA199 levels have shown similar upward trends in recent months, which may indicate that the disease is becoming more resistant to current treatment. This may require further evaluation and possible adjustments to the future treatment plan.

• 2023-05-09 CEA (NM) 29.020 ng/ml

• 2023-04-11 CEA (NM) 29.090 ng/ml

• 2023-03-07 CEA (NM) 30.892 ng/ml

• 2023-02-22 CEA (NM) 22.304 ng/ml

• 2023-05-09 CA-199 (NM) 99.780 U/ml

• 2023-04-11 CA-199 (NM) 94.910 U/ml

• 2023-03-07 CA-199 (NM) 91.315 U/ml

• 2023-02-22 CA-199 (NM) 66.824 U/ml

2023-03-27

CEA and CA199 levels have been consistently above the normal range since Oct 2022.

The patient is being treated for bilateral L5 and bilateral below wrist numbness caused by chemotherapy-related polyneuropathy and L spine radiculopathy. The treatment plan, including the use of Kentamine (B1 50mg + B6 50mg + B12 500ug), Neurontin (gabapentin), Trynol (amitriptyline), and Muaction (tramadol), has been properly prescribed by our neurologist on 2023-03-24.

As of now, the patient has had one bowel movement on 2023-03-26 and there are no signs of constipation. Loperamide 2mg PRNQ4H has been prepared in advance if needed.

Based on the TPR panel, the patient’s underlying conditions of hypertension and diabetes are well controlled.

There were no medication reconciliation issues identified and there are no issues with the current active prescription.

2023-02-20

As of now, the patient’s TPR, blood pressure, and blood sugar level remain stable. The lab data 2023-02-19 showed grossly normal readings, except for slightly high BUN and slightly low levels of albumin and calcium.

The recently prescribed drugs that were disclosed in the NHI PharmaCloud System have been appropriately prescribed during this hospital stay. No medication reconciliation issues have been found in the patient.

2023-01-09

2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Loprinzi CL, Lacchetti C, Bleeker J, et al. Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325.

Duloxetine for adult patients with chemotherapy-induced peripheral neuropathy: Oral initial 30 mg once daily for 1 week, then 60 mg once daily. Ref: Smith EM, Pang H, Cirrincione C, et al; Alliance for Clinical Trials in Oncology. Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013;309(13):1359-67. doi:10.1001/jama.2013.2813

There is Cymbalta (duloxetine 30mg/cap) available in the stock.

2022-12-02

In this case, the patient had chemotherapy related polyneuropathy and L spine radiculopathy, which was evaluated by our neurologist on 2022-11-14. Neurontin (gabapentin 100mg/cap) 1# BID has been prescribed.

At this time, vital signs appear to be stable. According to the lab data on 2022-12-01, there was a slight pancytopenia, but overall the results were normal.

There is no issue with the active prescription.

2022-10-14

Duloxetine is recommended for the mitigation of chemotherapy-related sensorimotor polyneuropathy (Type of recommendation: evidence based, benefits equal harms; Evidence quality: intermediate; Strength of recommendation: moderate. Ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. Journal of Clinical Oncology 2020 38:28, 3325-3348)

Duloxetine for chemotherapy-induced peripheral neuropathy (off-label use): Oral initial: 30 mg once daily for 1 week, then 60 mg once daily.

2022-07-18

Colonoscopy (2022-05-20) showed local recurrent cancer at low rectum.

CEA levels continue to rise in recent months:

• 2022-06-24 23.795 ng/mL
• 2022-06-10 17.995 ng/mL
• 2022-05-17 14.022 ng/mL
• 2022-03-18 13.494 ng/mL
• 2022-01-20 8.210 ng/mL
• 2021-12-14 6.908 ng/mL

CA199 exhibits a similar trend to CEA

Lab data on 2022-07-18 showed generally normal readings except for slight anemia.

2022-05-17

Lab data on 2022-05-16 showed that liver and kidney function, electrolytes and CBC were generally normal.

Biomarkers

• CEA 2022-03-18 13.494 ng/ml <- 2022-01-20 8.210 ng/ml <- 2021-12-14 6.908 ng/ml, increasing
• CA199 2022-03-18 73.781 U/ml <- 2022-01-20 49.528 U/ml <- 2021-12-14 40.779 U/ml, increasing

The last CT scan was performed on 2022-01-04, so the image may need to be updated.

2022-01-04

According to in-hospital database, the patient had mild drug allergy with: Sketa, Warfarin, Dipyridamole, Valaciclovir, Solaxin (chlorzoxazone).

2021-04-28

• O
  • stool Clostridium difficile GDH positive reported on 4/27
• A
  • Clostridioides difficile infection (CDI) is one of the most common nosocomial infections and is an increasingly frequent cause of morbidity and mortality among older adult hospitalized patients.
  • vancomycin, fidaxomicin, metronidazole might work on CDI.
  • according to lab data reported on 4/19, the patient has normal liver and kidney functions, no need to adjust dose for the above antimicrobials.
• Suggestion
  • discontinuation of the inciting antibiotic agent as soon as possible at least in the patient’s room.
  • vancomycin 125mg PO QID for 10 days or fidaxomicin 200mg PO BID for 10 days could be considered.
  • if vancomycin is prescribed, therapeutic drug monitoring for its trough level at 30 minites just before the 5th dose administration is highly recommended.
  • monitor clinical signs for CDI and recheck stool GDH after having administrating of the above antimicrobials for 5 days to evaluate the effect.

701528673

240722

[lab data]

• 2024-07-20 HBsAg Reactive
  
• 2024-07-20 HBsAg Value 38.94 S/CO
  
• 2024-07-20 Anti-HBc Reactive
  
• 2024-07-20 Anti-HBc Value 7.45 S/CO
  
• 2024-07-20 Anti-HCV Nonreactive
  
• 2024-07-20 Anti-HCV Value 0.08 S/CO

[exam findings]

• 2024-07-08 CXR erect
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
• 2024-07-03 CT - abdomen
  • A case of adenocarcinoma of rectum diagnosed in March 2024 at Post Hospital. suspected from imaging but no tissue proof yet (20240625), cT3N0M1c
    • 20240627 colonoscopy: An ulcerative tumor at upper rectum, 30 cm AAV. Biopsy was done. Pathology: Adenocarcinoma in tubulovillous adenoma
    • 20240702 CEA:3302 ng/mL (<5), CA199:462750 U/mL (<35).
  • History: Alcoholic cirrhosis liver but she quitted it now (20240620)
  • Findings:
    • There is a poor enhancing mass 4.5 cm in the sigmoid colon with irregular contour.
      • Adenocarcinoma of the sigmoid colon (T4a) with suggestive mucinous type is highly suspected. Please correlate with colonoscopy.
    • There are four kissing enlarged nodes in the sigmoid mesocolon that are c/w regional metastatic nodes (N2a).
    • There is massive ascites, mild hyperdense fluid-like lesions in the mesentery, and suggestive omentum cake.
      • Carcinomatosis (pseudomyxoma peritonei) (M1c) is highly suspected.
      • Please correlate with ascites cytology.
    • There are few soft tissue nodules in RLL, RML and LLL of the lung (up to 1 cm) that may be lung metastases.
      • Please correlate with chest CT.
    • There is a cystic lesion in left adnexa, 5.4 x 3.8 cm in size.
      • Please correlate with GYN. sonography and CA125.
    • The liver shows mild irregular contour that may be early cirrhosis.
      • The differential diagnosis includes passive indentation by the pseudomyxoma peritonei.
    • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
  • Impression:
    • Adenocarcinoma of the sigmoid colon (T4a) with suggestive mucinous type is highly suspected. Please correlate with colonoscopy.
    • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4a N2a M1c; stage: IVC
• 2024-06-27 Patho - colon biopsy
  • Rectum, upper, biopsy — Adenocarcinoma in tubulovillous adenoma
  • The sections show adenocarcinoma in tubulovillous adenoma, composed of columnar neoplastic cells, arranged in glandular and papillary patterns with nests of tumor cells floating in mucinous pool.
  • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
• 2024-06-27 SONO - abdomen
  • Intra-abdominal tumor, huge, perhaps GYN origin
  • Ascites, moderate amout
    
  • parenchymal liver disease

[chemotherapy]

• 2024-07-20 - irinotecan 180mg/m2 192mg D5W 250mL 90min + leucovorin 400mg/m2 428mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

==========

2024-07-22

[initiate ETV or TAF before or with cancer therapy]

Lab data:

• 2024-07-20 HBsAg Reactive
  
• 2024-07-20 HBsAg Value 38.94 S/CO
  
• 2024-07-20 Anti-HBc Reactive
  
• 2024-07-20 Anti-HBc Value 7.45

Interpretation:

• The positive HBsAg test suggests the presence of the HBV virus.
• The positive Anti-HBc test indicates an immune response to the virus, further supporting an HBV infection.

However, this limited data cannot definitively differentiate between:

• Acute HBV infection: In this case, additional tests like HBeAg (Hepatitis B e antigen) and Anti-HBe would be needed for confirmation.
• Chronic HBV infection: Chronic infection is characterized by the persistent presence of HBsAg.

Next Steps:

• HBeAg and Anti-HBe: These tests can help differentiate between acute and chronic infection.
• HBV DNA (viral load): This test measures the amount of HBV virus in the blood, which can be helpful for monitoring treatment in chronic infection.

Entecavir or tenofovir is recommended to be initiated as soon as possible relative to the start of anticancer therapy in this patient.

701022064

240719

[MedRec]

• 2024-07-09 CT - brain
  • The brain shows normal grey and white matter attenuation without evidence of focal lesion. There is no intracranial hemorrhage seen.
  • The size of the lateral and third ventricles appears normal.
  • The posterior structures including the brain stem, cerebellum and CP angles look normal.
  • Soft tissue swelling over right parietal scalp with subgaleal hematoma.
• 2024-07-02 ECG
  • Sinus rhythm with Premature atrial complexes with Aberrant conduction
  • Right bundle branch block
• 2024-06-27 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Peri-rectal tumor, Hartmann’s operation — Dedifferentiated endometrioid carcinoma, ovary primary
    • Resection margins, ditto — Free of tumor invasion
    • Lymph nodes, mesocolic, dissection — Free of tumor metastasis (0/12)
  • MACROSCOPIC EXAMINATION
    • Operation procedure: Hartmann’s operation
    • Specimen site: rectum
    • Specimen size: two segments, up to 15 cm in length, 4 cm in diameter
    • Tumor size: 7.5 cm
    • Tumor location: peri-rectal region
    • Tumor appearance: solid mass
    • Depth of invasion grossly: from rectal wall invasion to mucosa layer
    • Representatively embedded for sections as A1: bilateral resection margins, A2-A5: peri-rectal tumor + rectal mucosa, A6-A8: lymph nodes
  • MICROSCOPIC EXAMINATION
    • Histology: dedifferentiated endometrioid carcinoma, ovary primary
    • Depth of invasion: tumor invasion from rectal wall to mucosa layer
    • Lymph node metastasis, mesocolic: free of tumor metastasis (0/12)
• 2024-06-27 Patho - uterus (with or without SO) neoplastic
  • PATHOLOGIC DIAGNOSIS
    • Ovarian mass, left, debulking surgery (s/p neoadjuvant chemotherapy) — Dedifferentiated endometrioid carcinoma, residual
      • Fallopain tube, left, ditto — Tumor invasion
    • Ovary, right, LSO — Tumor invasion
      • Fallopain tube, right, LSO — Tumor invasion
    • Cervix, uterus, total hysterectomy — Atrophy, free of tumor invasion
    • Endometrium, uterus — Atrophy, free of tumor invasion
    • Myometrium, uterus — Leiomyomas, free of tumor invasion
    • Uterine serosa — Tumor invasion
    • Lymph node, left iliac, dissection — Free of tumor metastasis (0/6)
    • Lymph node, left obturator, ditto — Free of tumor metastasis (0/13)
    • Lymph node, right iliac, ditto — Free of tumor metastasis (0/8)
    • Lymph node, right obturator, ditto — Free of tumor metastasis (0/8)
    • AJCC Pathologic staging — ypT3cN0, compatible with stage IVB, if cM1b
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: debulking surgery (total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + Hartmann’s procedure + colostomy)
    • Specimen type: uterus+ R’t adnexa, left ovarian mass and pelvic LNs
    • Specimen size:
      • Left ruptured ovarian tumor: total 1020 gm, multiple fragments measured up to 16 x 15 x 8.5 cm with hemorrhage and extensive necrosis
      • Left fallopian tube: 5.5 cm in length, up to 0.7 cm in diameter
      • Right ovary: 2.5 x 1.3 cm
      • Right fallopian tube: 4.5 cm in length, up to 0.7 cm in diameter
      • Uterus: 14.5 x 9.2 x 5.2 cm and 414 gm
        • Endometrium: 0.2 cm in thickness
        • Myometrium: three myomas measured up to 8 x 6 x 4 cm
        • Cervix: no remarkable change
      • Omentum: not received
    • Tumor site: left ovary
      
    • Tumor size: multiple fragments measured up to 16 x 15 x 8.5 cm
    • Tumor appearance: solid tumor with rupture, hemorrhage and massive necrosis
    • Specimen integrity: ruptured left ovarian tumor
    • Lymph node: left iliac, left obturator, right iliac and right obturator areas
    • Representatively embedded for sections as A: left iliac LNs, B: left obturator LNs, C: right iliac LNs, D1-D2: right obturator LNs, E1-E2: left fallopian tube, E3: left tubo-ovarian soft tissue, E4-E14: left ovarian mass, F1: uterine cervix, F2: endometrium, F3-F4: leiomyomas, F5: right fallopian tube, F6-F7: right ovary + uterine serosa, F8-F9: tumor+ uterine serosa
  • MICROSCOPIC EXAMINATION
    • Histologic type: dedifferentiated endometrioid carcinoma, residual
    • Histologic grade: dedifferentiated
    • Contralateral ovary involvement: identified
    • Tumor side ovarian surface involvement: identified
    • Contralateral ovary surface involvement: absent
    • Right tube involvement: identified
    • Left tube involvement: identified
    • In situ adenocarcinoma in right and/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: absent
    • Left adnexa soft tissue involvement: identified
    • Pelvic soft tissue involvement: not received
    • Uterine serosa involvement: identified
    • Omentum involvement: not received
    • Uterine Cervix involvement: absent
    • Endometrium involvement: absent
    • Myometrium involvement: absent, leiomyomas with calcification
    • Lymph nodes metastasis: Free of tumor metastasis (0/35) in total number
    • Other organs or specimens involvement: rectum invasion, see S2024-13100
    • Immunohistochemistry: PAX-8(+), P53(+, wild type), WT-1(-), ER(+) and Napsin-A(-) for tumor
    • Lymphovascular space invasion: identified
    • Ascites cytology: atypia
• 2024-06-27 Body fluid cytology - ascites
  • 50 cc red cloudy ascites - Atypia
    
  • The smears show lymphocytes, neutrophils, reactive mesothelial cells and few atypical hyperchromatic clusters with degenerative quality
• 2024-06-24 ECG
  • Sinus tachycardia
  • Right bundle branch block
• 2024-06-17 Patho - colon biopsy
  • Labeled as “One large external compression was noted at sigmoid colon with friable mucosal change, 25-30cm AAV”, biopsy — benign colonic mucosal tissue with one separated tissue domnstrating crush artifact and round blue cell infiltration.
  • Section shows benign colonic mucosal tissue with one separated tissue domnstrating crush artifact and round blue cell infiltration.
  • IHC stains: LCA (-), CD3 (-), CD20 (-), CK (-), vimentin (+), CD56 (-), CD117 (-), CD34 (+), dog-1 (-), CD99 (-). The pattern suggestive of gastrointestinal stromal tumor. Please correlate with scope and image findings.

[chemotherapy]

• 2024-05-23 - paclitaxel 140mg/m2 210mg NS 250mL 3hr + carboplatin AUC 4 520mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + hydrocortisone 100mg (due to skin rash after 1st C/T)
• 2024-04-25 - paclitaxel 140mg/m2 210mg NS 250mL 3hr + carboplatin AUC 4 520mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + hydrocortisone 100mg (due to skin rash after 1st C/T)
• 2024-04-03 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 4 520mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-07-19

[trends in blood potassium and supplementation]

Tracking the patient’s blood potassium changes over the past three months reveals a significant downward trend. Since 2024-06, there have been more instances of levels falling below 3 mmol/L, with a drop to less than 2 mmol/L on 2024-07-18. Potassium supplementation is currently being administered as an appropriate treatment.

• 2024-07-18 K (Potassium) 1.9 mmol/L
• 2024-07-12 K (Potassium) 3.1 mmol/L
• 2024-07-06 K (Potassium) 5.0 mmol/L
• 2024-07-03 K (Potassium) 3.0 mmol/L
• 2024-07-03 K (Potassium) 2.7 mmol/L
• 2024-07-02 K (Potassium) 2.2 mmol/L
• 2024-07-01 K (Potassium) 3.9 mmol/L
• 2024-06-30 K (Potassium) 2.3 mmol/L
• 2024-06-29 K (Potassium) 2.5 mmol/L
• 2024-06-28 K (Potassium) 2.6 mmol/L
• 2024-06-27 K (Potassium) 2.9 mmol/L
• 2024-06-26 K (Potassium) 3.3 mmol/L
• 2024-06-23 K (Potassium) 2.8 mmol/L
• 2024-06-20 K (Potassium) 3.0 mmol/L
• 2024-06-14 K (Potassium) 3.7 mmol/L
• 2024-06-13 K (Potassium) 2.9 mmol/L
• 2024-06-11 K (Potassium) 2.7 mmol/L
• 2024-06-08 K (Potassium) 2.5 mmol/L
• 2024-06-07 K (Potassium) 3.3 mmol/L
• 2024-06-05 K (Potassium) 3.7 mmol/L
• 2024-05-22 K (Potassium) 4.0 mmol/L
• 2024-05-08 K (Potassium) 3.6 mmol/L
• 2024-04-25 K (Potassium) 3.8 mmol/L
• 2024-04-18 K (Potassium) 4.0 mmol/L
• 2024-04-11 K (Potassium) 3.8 mmol/L

[managing elevated CRP, rising PCT, and ALT levels]

Lab results show that CRP has been persistently elevated, making it less sensitive for detecting infections. In contrast, PCT and ALT levels have rapidly increased, indicating a potential new infection and liver damage. Flumarin (flomoxef) is currently being administered, and the addition of BaoGan (silymarin) might be considered.

• 2024-07-18 ALT 110 U/L

• 2024-06-27 ALT 18 U/L

• 2024-06-07 ALT 17 U/L

• 2024-07-18 Procalcitonin (PCT) 1.78 ng/mL

• 2024-06-24 Procalcitonin (PCT) 0.15 ng/mL

• 2024-06-20 Procalcitonin (PCT) 0.11 ng/mL

• 2024-06-11 Procalcitonin (PCT) 0.20 ng/mL

• 2024-07-18 CRP 22.2 mg/dL

• 2024-07-12 CRP 27.3 mg/dL

• 2024-07-06 CRP 18.2 mg/dL

• 2024-07-02 CRP 21.3 mg/dL

• 2024-06-28 CRP 26.3 mg/dL

• 2024-06-27 CRP 23.7 mg/dL

• 2024-06-23 CRP 20.4 mg/dL

• 2024-06-20 CRP 14.1 mg/dL

• 2024-06-11 CRP 13.8 mg/dL

• 2024-06-07 CRP 26.1 mg/dL

700516869

240718

[MedRec]

• 2024-06-18 Lower leg Rt
  • vertical fracture of patella
• 2024-05-15 PD-L1 28.8
  • Cellblock No. S2024-07716 A8
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS < 1
    • Combined Positive Score (CPS): 0.5
• 2024-04-18 Patho - stomach subtotal/total (tumor)
  • Diagnosis
    • Stomach, total gastrectomy — Adenocarcinoma, poorly differentiated, pStage IIIC, pT3N3b(if cMx)
    • Margins, proximal, esophagus, total gastrectomy — Adenocarcinoma, by direct invasion
    • Margins, distal, duodenum, total gastrectomy — Adenocarcinoma, by direct invasion
    • Omentum, omentectomy — Negative for malignancy
    • Lymph node, division 1, dissection — Metastatic carcinoma (3/14)
    • Lymph node, division 2, dissection — Metastatic carcinoma (9/17)
    • Lymph node, division 3, dissection — Metastatic carcinoma (5/10)
    • Lymph node, division 4, dissection — Metastatic carcinoma (5/30)
    • Lymph node, division 5, dissection — Negative for malignancy (0/1)
    • Lymph node, division 6, dissection — Negative for malignancy (0/8)
    • Lymph node, division 7, 8, 9, 11, 12, dissection — Metastatic carcinoma (1/9)
    • Lymph node, division 10, dissection — Negative for malignancy (0/0)
  • Gross Description:
    • Procedure:Partial gastrectomy, other (specify): lesser curvature: 13.3 cm; greater curvature: 19.5; esophagus: 0.4 cm in length; duodenum: 1.8 cm in length; omentum: 47 x 25 x 1.0 cm
    • Tumor Site: The whole stomach, esophagus and duodenum are diffusely involved.
    • Tumor Size: 20 x 11 cm
    • Gross configuration
      • For advanced carcinoma (Borrmann classification): Type IV: Infiltrative, predominantly intramural lesion, poorly demarcated
    • Sections are taken and labeled as:
      • A1: proximal resection margin (shaving from the stapled cutend); A2: distal resection margin (shaving from the stapled cutend); A3: tumor, ink serosa; A4: tumor with esophagus; A5: tumor with duodenum; A6-8: tumor; B1-2: omentum; C: lymph node, division 1; D: lymph node, division 2; E: lymph node, division 3; F1-4: lymph node, division 4; G: lymph node, division 5; H: lymph node, division 6; I1-2: lymph node, division 7, 8, 9, 11, 12; J: lymph node, division 10.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma, Lauren classification of adenocarcinoma: Diffuse type; WHO (2019): poorly cohesive, other cell type
      
    • Histologic Grade: G3: Poorly differentiated, undifferentiated
    • Tumor Extension: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
    • Margins
      • Proximal margin: involved by invasive carcinoma; The immunohistochemical stain is positive.
      • Distal margin: involved by invasive carcinoma; The immunohistochemical stain is positive.
      • Radial margin: very close, < 0.1 cm
    • Lymphovascular Invasion: present
      
    • Perineural Invasion: present
      
    • Regional Lymph Nodes: please see diagnosis
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        
      • Primary Tumor (pT): pT3: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
      • Regional Lymph Nodes (pN): pN3b: Metastasis in 16 or more regional lymph nodes
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
    • Additional Pathologic Findings: None identified
• 2024-04-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (135 - 37) / 135 = 72.59%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA and LV
    • Trivial MR and trivial TR
    • Preserved RV systolic function
    • Some isolated VPCs at the exam.
• 2024-04-16 PET
  • Mild glucose hypermetabolism involving the body of the stomach and in some regional lymph nodes. Primary gastric malignancy with some regional lymph node metastases of low FDG uptake may show this picture.
  • Glucose hypermetabolism in bilateral pulmonary hilar and some mediastinal lymph nodes. Inflammatory process is more likely. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Increased FDG uptake in the left axillary lymph nodes, probably due to physiologic FDG uptake because of lymphatic drainage from the site of FDG extravasation in the left upper limb.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
• 2024-04-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 24) / 87 = 72.41%
    • M-mode (Teichholz) = 73
  • Conclusion:
    • Septal hypertrophy with Gr II LV diastolic dysfunction and impaired RV relaxation; mildly dilated LA.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis and mild posterior mitral annulus calcification with trivial mitral regurgitation; mild tricuspid regurgitation.
    • Frequent VPCs.
• 2024-04-12 Patho - stomach biopsy
  • Stomach, middle body, AW/LC, biopsy (A) — Adenocarcinoma.
  • IHC stains: Her2/neu: negative (score=1+), PMS2 (+, intact), MSH6 (+, intact), MSH2(+, intact), MLH1 (+, intact).
• 2024-04-12 Flow volume chart
  • r/o mild restrictive ventilatory defect
• 2024-04-11 EGD
  • Diagnosis:
    • Diffuse infiltrative gastric mucosa lesion with ulcerative mucosa and ulcers, body to fundus, suspect malignancy, Borrmann classification type IV, s/p biopsy (“A” was labelled for the biopsy at middle body, AW/LC ; “B” was for the biopsy at body, GC/PW)
      
    • Reflux esophagitis LA Classification grade A(minimal)
    • Hiatal hernia
    • Duodenal polyp, bulb
  • CLO test: not done
• 2024-04-10 CT - abdomen
  • History: gastric cancer
  • Findings:
    • There is wall thickening at the gastric body, 3 cm in size, that is c/w adenocarcinoma (T3).
    • There are four enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament that may be regional metastatic nodes (N2).
    • A renal cyst 1.3 cm in right middle pole is noted.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3(T_value)    N:N2(N_value)    M:M0(M_value)    STAGE:III(Stage_value)

[MedRec]

• 2024-07-11 SOAPMetabolism and Endocrinology Liao YuHuang
  • Prescription x3
    • Uformin (metformin 500mg) 1# BID 28D
• 2024-06-18 SOAP Cardiology Liu GuanLiang
  • Prescription x3
    • Blopress (candesartan 8mg) 1# QD 28D
• 2024-05-15 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • B12 supplement Q1-3M
    • B12 and Iron profile Q3M
    • Check 28-8 PD-L1 for the possibility of Nivo + FOLFOX (or CapOx)
    • Refer to GS for Port-A insertion
    • Tx plan: Sandwish (C/T -> CCRT -> C/T)
• 2024-05-07 SOAP General and Gastroenterological Surgery Wu ChaoQun
  • O
    • refer to Oncologist for C/T - R/T - C/T
• 2024-04-10 ~ 2024-05-01 POMR General and Gastroenterological Surgery Wu ChaoQun
  • Discharge diagnosis
    • Adenocarcinoma of gastric, pT3N3b(cM0) stage IIIC status post total gastrectomy with D2 lymph nodes dissection and Roux-en-Y esophagojejunal anastomosis and feeding jejunostomy on 2024/04/17. ECOG:2
    • Essential (primary) hypertension
  • CC
    • epigastric discomfort for over 1 month
  • Present illness
    • This 82 year old female case with past history of HTN and type 2 diabetes with regular medications control. This time, she sufferred from poor intake and easy abdomen fullness with pain and vomit were noted for 1 month. She also noted for body weight loss for 10Kg in recent 2 months. She visited to other hospital for help which diagnosis of poorly differentiate cohesive gastric cancer. She referred to our hospital for further operation. Abdomen CT was performed and showed wall thickening at the gastric body, 3 cm in size. cT3N2M0 stage III. This time, she was admitted for nutrition support with TPN first and preoperative evaluation.
  • Course of inpatient treatment
    • After admitted, pre-operation survey was done and no abnormality. Repet UGI scope on 4/11 which showed diffuse infiltrative gastric mucosa lesion with ulcerative mucosa and ulcers, body to fundus, suspect malignancy, Borrmann classification type IV, s/p biopsy. Pathology revealed adenocarcinoma. Whole body pet was performed and showed hypermetabolism involving the body of the stomach and in some regional lymph nodes. Primary gastric malignancy with some regional lymph node metastases. On the resulted, she underwent total gastrectomy with D2+ LN dissection and Roux-en-Y EJ anastomosis and feeding jejunostomy on 4/17. After weaned from ventilator in the operating room , patient was transferred to SICU for post-op intensive care.
    • During her stay in SICU, we closely monitor her vital sign and neurologic status. We held enteral feedind in the mean while provided adequated nutrition suuport with crystalloid and albumin, adequate pain control with PCA and intravenous analgesics, infection control with Cefoxitin. We consulted cardiologist due to VPC finding on EKG monitor and Concor 1.25mg QD was suggested. Due to stable hemodynamics and neurologic status, she was transfered to ordniary ward on 4/19.
    • In GS ward, we observed the patient’s recovery and administered empiric antibiotics, stool softeners, albumin with lasix therapy, and analgesic agents. Wound management was also performed. UGI series was performed and no evidence of intraabdomen leakage was found. Then she attempted to introduce diet with step by step to liquid diet and combine with jejunostomy feedig was tolerated well. Her general well being was relatively stable. There were no nosocomial infections or other complications, and vital signs remained stable after surgery. Bowel, urinary, and pulmonary functions were normal, and wound pain was tolerable. The abdominal wound was clear, and the JP tube was smoothly removed on 4/26 and 4/27. With improved general condition with stable jejunostomy feeding, she was discharged today, and an outpatient department (OPD) follow-up was arranged.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQID 7D
    • MgO 250mg 1# PRNQID 7D

[surgical operation]

• 2024-04-17 - Op Method:
  • total gastrectomy with D2+ LN dissection and Roux-en-Y EJ anastomosis
  • feeding jejunostomy
  • Finding:
    • scirrhous type gastric ca involved from fundus to antrum
    • LN enalarge at station 3,4,8,9

[chemotherapy]

• 2024-07-17 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 480mg NS 250mL 2hr + fluorouracil 300mg/m2 480mg NS 250mL 10min + fluorouracil 2200mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-26 - oxaliplatin 50mg/m2 75mg D5W 250mL 2hr + leucovorin 300mg/m2 480mg NS 250mL 2hr + fluorouracil 300mg/m2 480mg NS 250mL 10min + fluorouracil 2200mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-03 - ………………………………….. leucovorin 300mg/m2 480mg NS 250mL 2hr + fluorouracil 300mg/m2 480mg NS 250mL 10min + fluorouracil 2200mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-07-18

[monitoring renal function in FOLFOX treatment]

The patient’s renal function is showing a declining trend. Despite the dose reduction of oxaliplatin in the FOLFOX regimen, if the renal function continues to deteriorate, it may be necessary to reassess the treatment regimen.

• 2024-07-17 Creatinine 1.30 mg/dL
  

• 2024-07-09 Creatinine 0.96 mg/dL
  

• 2024-06-26 Creatinine 0.74 mg/dL

• 2024-07-17 eGFR 41.58 ml/min/1.73m^2
  

• 2024-07-09 eGFR 58.99 ml/min/1.73m^2
  

• 2024-06-26 eGFR 79.66 ml/min/1.73m^2

[evaluation of iron and vit B12 status following total gastrectomy]

Lab data:

• 2024-07-17 Vitamin B12 4682 pg/mL
  
• 2024-07-17 Ferritin 217.8 ng/mL
  
• 2024-07-17 Fe (Iron-bound) 67 ug/dL
  
• 2024-07-17 TIBC 237 ug/dL
  
• 2024-07-17 UIBC 170 ug/dL

The above lab results suggested that the patient has adequate vitamin B12 and iron levels, which is particularly important following total gastrectomy due to the risk of deficiencies associated with reduced absorption capacities. The elevated vitamin B12 may be due to supplementation, and while not typically harmful, should be monitored to ensure dosages are appropriate. Regular follow-up is crucial to monitor these levels, adjust supplementation as necessary, and check for any signs of micronutrient deficiencies that might not yet be apparent.

700893323

240718

[lab data]

2023-07-24 Anti-HCV Nonreactive
2023-07-24 Anti-HCV Value 0.25 S/CO
2023-07-24 Anti-HBc Reactive
2023-07-24 Anti-HBc-Value 6.92 S/CO
2023-07-24 Anti-HBs 7.37 mIU/mL
2023-07-24 HBsAg Nonreactive
2023-07-24 HBsAg (Value) 0.27 S/CO

[exam findings]

• 2024-06-19 PD-L1 28.8
  • Cellblock No. S2024-14775
  • RESULTS：
    • Tumor Proportion Score (TPS): >= 50%
    • Combined Positive Score (CPS): 73
• 2024-05-20 MRI - nasopharynx
  • Indication: SCC of Lt buccal mucosa with lip invasion, cT2N2bM0, stage IVA on 2023/07/25, s/p induction with disease progression. Now ycT4aN1M0 according to MRI on 2023/12/26. status during CCRT
  • Findings:
    • Diffuse thickening and enhancement of upper and lower buccal mucosa, upper lip and soft tissue of left cheek, progressive as compared with MRI on 20231226.
    • Swelling and striation appearance of subcutaneous tissue at anterior lower neck.
    • Mucosal thickening and fluid accumulation in left maxillary sinus.
  • IMP:
    • C/W left buccal cancer s/p CCRT, progressive change as compared with MRI on 20231226.
• 2024-05-16 EGD
  • Diagnosis:
    • Duodenal ulcers, bulb and SDA
    • Esophageal mucosal lesion, about 25-30cm, s/p biopsy.
    • Esophageal diverticulum, 30cm and 40cm below incisors.
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis, antrum, s/p CLO test
  • CLO test: Negative
• 2024-05-12 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Severe wall edema of gastric antrum and duodenum with adjacent fatty infiltrates and regional lymph nodes enlargement. Nature?
    • R/O distal esophageal diverticulum.
    • Fibrotic infitrates in right upper lung.
    • Tree-in-bud infiltrates in right upper lung.
• 2024-05-12 KUB + L-spine Lat
  • L2 compression fracture.
  • Disc space narrowing at L5-1.
  • S/P hip arthroplasty, bilateral.
• 2024-05-03 PD-L1 22C3
  • Cellblock No. S2023-14775
  • RESULTS：
    • Tumor Proportion Score (TPS): 40%
    • Combined Positive Score (CPS): 45
• 2023-12-29 PET
  • A glucose hypermetabolic lesion involving the left lower lip, left lower gingivobuccal mucosa and adjacent mandible, compatible with primary malignancy of the oral cavity.
  • Glucose hypermetabolism in a left neck level IIa lymph node. A metastic lymph node may show this picture.
  • Glucose hypermetabolism in some left neck level I lymph nodes. The nature is to be determined (inflammation? metastases?). Please correlate with other imaging modalities for further evaluation.
  • Mild glucose hypermetabolism in some right neck level I lymph nodes. Inflammatory process may show this picture.
  • Glucose hypermetabolism around bilateral hip prostheses. Post-operative change may show this picture.
  • Increased FDG uptake/accumulation in bilateral masticatory muscles and colon. Physiological FDG uptake/accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2023-12-26 MRI - nasopharynx
  • Oralcavity
    • Impression (Imaging stage) : T:4a N:1 M:0 STAGE:____
• 2023-07-26 Tc-99m MDP bone scan
  • A hot spot in the left 5th rib, and increased activity in bilateral femurs, tibiae, and left ankle, the nature is to be determined (post-traumatic change or other nature ?), suggesting folllow-up with bone scan in 3 months of rinvestigation.
  • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, L-S junction, bilateral shoulders, and hips.
• 2023-07-26 Patho - gingival/oral mucosa biopsy
  • Lower lip, left, incisional biopsy — Squamous cell carcinoma, moderately differentiated
  • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident. Tumor necrosis with bacterial colonies can be found also.
• 2023-07-25 MRI - nasopharynx
  • Findings
    • Tumor mass in left low lip and left buccal region, up to 33 mm.
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • Multiple enlarged LNs in left level I-II space, some of them clustered.
    • No evident bony destructive lesion.
  • IMP:
    • Left buccal and low lip CA, T2N2bMx stage IVA.
• 2023-07-14 Ribs Bilat
  • fractures at left 2nd and 5th ribs
• 2023-07-14 SONO - abdomen
  • Liver cirrhosis, with splenomegaly
• 2023-04-14 SONO - abdomen
  • Diagnosis:
    • Liver cirrhosis, with splenomegaly
  • Suggestion:
    • patient told he has HBV and loss f/u
    • suggest f/u q3m
• 2023-03-17 Nerve Conduction Velocity, NCV
  • Findings
    • The NCV study showed (1) Prolonged distal motor latency in most sampled nerves. (2) Decreased CMAP amplitude in bilateral median and bilateral peroneal nerves. (3) Slowing motor and sensory conduction velocity in most sampled nerves.
    • The F wave study showed prolonged latency in most sampled nerves.
    • The H reflex study showed both prolonged.
    • The QST study showed abnormal heat and cold sensation in lower limb.
  • Conclusion
    • The above findings suggest sensorimotor polyneuropathy and small fiber disease. Advise clinical correlation.
• 2022-11-23 Nerve Conduction Velocity, NCV
  • Findings
    • Slowing of motor conduction velocities diffusely. Prolonged distal motor latency in left median nerve. Reduce CMAP amplitude in left median and left peroneal nerves. No pick-up in left peroneal nerve.
    • Slowing of motor conduction velocities in left median and left sural nerves
    • The F wave was prolonged in keft median and left ulnar nerve. No pick-up in left peroneal nerve
    • H refelx: prolonged bilaterally
    • The QST study showed abnormal cold threshold test in right lower limbs
  • The abnormal NCS study may suggest mixed sensorimotor polyneuropathyand severe left peroneal nerve neuropathy. The QST study may suggest small fiber disease. Advice clinical correlation
• 2022-11-21 CT - abdomen
  • Abdoeminal and chest CT with and without IV contrast ehnancement shows:
  • Findings:
    • Calcified coronary arteries is found.
    • Dilated esophagus with out-poutching at lower third esophagus is found. Diverticulum or othere is considered.
    • Swelling of the cecum, ascending colon is found. Colitis is consideed.
• 2022-11-21 CXR
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • A mass-like lesion in the left retrocardiac region, abutting the hemidiaphgram due to hiatal hernia or L/3 esophageal diverticulum
  • old fracture of many ribs
• 2022-11-21 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A-
    • Large esophageal diverticulum, lower esophagus, with focal erosive mucosa
    • Superficial gastritis
    • Deformed prepyloric antrum
    • Suspected Duodenal ulcer scar, bulb, AW
  • CLO test: not done
  • Suggestion:
    • Neither active bleeder nor bloody substance was identified in this exam
    • Correlate with the clinical data. Survey other bleeding source, such as LGI bleeding.

[MedRec]

• 2024-06-18 ~ 2024-07-02 POMR Hemato-Oncology Xia HeXiong
  • Course of inpatient treatment
    • After admission, plan to receive Q2W chemotherapy with 5-FU/oral Hydroxyurea (11 dose), but hyperkalemia was noted, adequate N/S IVF was given and Kalimate 5gm/pk 1pk PO QD for correction.
    • After electrolyte correction, he receive Q2W chemotherapy with 5-FU (800mg/m2 for 5 days)/oral Hydroxyurea (total 11 dose) on 2024/06/26~7/1.
    • Sent PD-L1 28-8, pending.
    • Pain control shift to Morphine 15mg/tab 1# PO Q8H, Morphine 10mg/mL/amp 5mg IVD PRNQ6H for pain control.
    • Due to difficulty in oral administration, Duregiges 12mcg/h, 2.1mg/2 patches was used to control pain.
    • Acute kidney injury with N/S hydration was given.
    • For chemotherapy, Vemlidy 25 mg/tab 1# PO QD was given for Anti-HBc reactive.
    • Hypertension with Cardiolol 10mg/tab 1# PO BID and Norvasc 5mg/tab 1# PO QD.
    • Cirrhosis of liver with alcohol withdrawal syndrome, was treated with Anxiedin 0.5mg/tab 1# PO TID, Kentamin 1# PO QD was given.
    • Gout with Feburic F.C 80mg/tab 1# PO QD.
    • Pariet F.C 20mg/tab 1# PO QDAC for Duodenal ulcer.
    • Wound care with Lido Jelly 2%, 30mL/tube use. Consulted dentistry for evaluation, suggest oral wound care with wet dressing impregnated with metronidazole.
    • Imperan 10mg/2mL/amp 1amp IVD Q8H, Bisadyl supp 10mg/pill 2pill RECT QD and LACTUL 666mg/mL, 60mL/bot 15ml PO TID for constipation relief.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2024/07/02 and OPD followed up later.       
  • Discharge prescription
    • MgO 250mg 2# BID
    • morphine 15mg 1# PRNQ6H if VAS > 3
    • Norvasc (amlodipine 5mg) 1# QD
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Durogesic (fentanyl 12ug/h, 2.1mg/patch) 2# Q3D EXT
    • Parmason Gargle Soln (chlorhexidine) BID GAR
    • Lido Jelly (lidocaine 2%) QD EXT
• 2024-06-13 SOAP Hemato-Oncology Xia HeXiong
  • P
    • schedule admission for C/T with HDFL +/- hydroxyurea
    • Port-A flush Q3M, next in 2024-08
• 2023-08-16 SOAP Oral and Maxillofacial Surgery He ChengHan
  • P: The subsequent chemotherapy was arranged by Dr. Xia HeXiong from the Hematology-Oncology department. Oral UFUR
  • Prescription
    • UFT (tegafur 100mg, uracil 224mg) 2# BID
• 2023-08-08 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • 24 hours CCr, audiometry, 5-FU in D5W
    • Refer to CS Chief Hsieh for Port-A implantation
• 2023-07-24 ~ 2023-08-01 POMR Oral and Maxillofacial Surgery He ChengHan
  • Discharge diagnosis
    • Squamous cell carcinoma of left lower gingiva and lower lip, cT2N2bM0, cstage IVA
    • Inflammatory conditions of jaws
    • Hyperkalemia
    • Cirrhosis of liver
    • Splenomegaly
    • Gout, unspecified
    • Essential (primary) hypertension
    • Functional dyspepsia
    • Functional intestinal disorder
  • CC
    • I had PROTRUDING mass lesion of my left lower lip for 1+ months.
  • Present illness
    • According to his statement, the present illness should be traced back to 1+ moths. This 54 year-old male patient, he felt an unhealed and protruding mass lesion of his left lower lip. He did not pay attention to it it in the beginning. Until he FOUND OUT THE MASS on his left lower lip KEPT GROWING and it because much more painful and swelling than it was. He visited to our oral & Maxillary clinic on 2023/07/17, which mouth finding showed protruding, ulcerative mass of left lower lip with induration, more than 2.5cm large. No palpable neck mass was palpated. Suspected malignancy of left lower gingiva and lower lip was impressed. After we had adequately explained the finding and treatment plans to the patient. He was admitted to ward for tumor survery and further management.
  • Course of inpatient treatment
    • After admission, we had arrange physcial examination was done and hyperkalemia (K+ 6.6 mmol/L) was found. RI infusion, hydration and Kalimate were prescribed. Incisional biopsy of left mandibular gingiva under local anesthesia on 2023/07/25. The pathology report showed squamous cell carcinoma. Then we had arrange tumor survey for him. The nasopharynx MRI showed tumor mass in left low lip and left buccal region, up to 33 mm, cT2N2bM0, cstage IVA. Abdomen sona showed liver cirrhosis, with splenomegaly. Whole body bone scan no evidence of distance metastasis. Another, his Anti-HBc(+) with cirrhosis. Due to the result of tumor work-up, we had consulted GI men and oncologist. We had well explained patient`s treatment plans in the future to patient and his family.
    • Complicated extraction of tooth 37, 38 and sent for pathological examination under local anesthesia on 2023/08/01. kept antibiotic agent and analegsic agent were prescribed. Ice packing and cool soft diet was educated.
    • Because of his general condition were stable, he was discharged and OPD follow up.
  • Discharge Prescription
    • UFT (tegafur 100mg, uracil 224mg) 2# BID
    • Acetal (acetaminophen 500mg) 1# Q4H
    • amoxicillin 250mg 2# Q8H
    • Parmason Gargle Solution (chlorhexidine) QD GAR
• 2023-07-17 SOAP Oral and Maxillofacial Surgery He ChengHan
  • S
    • The patient mentioned that the swelling of the lower left lip only started in the last two weeks.
    • betel nut chweing: more than 20 years, on and off
    • PH: anemia under iron Tx; left ribs fx
    • Allergy: keto
  • O
    • Protruding, ulcerative mass of left lower lip with induration, more than 2.5cm large
    • no palpable neck mass was palpated
    • tooth 36 severe attrition, dentinal hypersensitivity was noted.
    • Panoramic findings:
      • Missing: 13
      • Impaction: nil
      • Crown and Bridge: 14
      • Caries: nil
      • Periodontal condition: chronic periodontitis
    • extensive bony destruction of left posterior mandible
  • Assessment:
    • suspected malignancy of left lower gingiva extenidng to left lower lip
  • Plan:
    • explain the current condition to the patient
    • arrange incisional biopsy
• 2023-06-10 SOAP Neurology Xu BoRen
  • S
    • Alcholism
    • Slow progressive four limb weakness or four since 2022/10
    • arthritis
    • sphincter problem (+)
    • 2023/03/11
      • marked improved of limb weakness, no sphincter problem now
      • need cane to walk
      • The patient doesn’t see the original infectious disease specialist and wants me to prescribe the medication from there.
    • 2023/03/24
      • stable, no further weakness
    • 2023/06/10
      • stable
  • O
    • 2023/03/11 Suggest GI OPD for gall bladder or liver disease
  • A/P
    • General weakness, hypo Mg related
    • may taper PPI and Fe next time
  • Prescription x3
    • Anxiedin (lorazepam 0.5mg) 1# TID
    • Cardilol (propranolol 10mg) 1# BID
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Feburic (febuxostat 80mg) 1# QD
    • Rich (lansoprazole 30mg) 1# QDAC 20221121 EGD GERD LA-A doudenal ulcer scar
    • Through (sennoside 12mg) 2# HS
    • Utapine (quetiapine 25mg) 0.5# HS
    • MgO 250mg 1# TID
    • Acetal (acetaminophen 500mg) 1# PRNBID
    • Kentamin (B1 50mg, B6 50mg B12 500ug) 1# QD
• 2023-01-14 SOAP Infectious Disease
  • S
    • Visit for refill medicine as usual.
    • History: alcoholism.
  • P
    • Symptomatic treatment as needed.
  • Prescription
    • Anxiedin (lorazepam 0.5mg) 1# QID
    • Cardiolol (propranolol 10mg) 1# BID
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Feburic (febuxostat 80mg) 1# QD
    • Takepron (lansoprazole 30mg) 1# QDAC 20221121 EGD GERD LA-A doudenal ulcer scar
    • Through (sennoside 12mg) 2# HS
    • Utapine (quetiapine 25mg) 0.5# HS
    • Acetal (acetaminophen 500mg) 1# PRNQD
• 2018-01-11 SOAP Rheumatology and Immunology
  • Diagnosis
    • Gout, unspecified [M10.9]
    • Carpal tunnel syndrome [G56.00]
    • Peptic ulcer, site unspecified, unspecified as acute or chronic, without haemorrhage or perforation [K27.9]
    • Essential hypertention, unspecified [I10]
    • Unspecified inflammatory polyarthropathy [M06.4]
  • Prescription
    • colchicine 0.5mg 1# QD
    • Feburic (febuxostat 80mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQD
• 2017-11-04 SOAP Rheumatology and Immunology
  • S
    • acute urticaria after medication from ER (for SOB)
    • HBV told(?)
    • Crea:1.5->1.2->1.4
    • UA:5.8
    • ANA(-)RF(-)CCP(-)B27(-)
    • alcoholism
    • susp. drug allergy
    • steroid contraindicated due to possible HBV carrier
    • suggest hold current medication
    • suggest ER visit if necessary
    • suggest avoid alcohol
  • O
    • Drug allergy: NSAID, PCN
    • PH: gout? RA? (erosion?)
  • Diagnosis
    • Allergic urticaria [L50.0]
  • Prescription
    • Sinbaby Lotion (zinc oxide, diphenhydramine, dibucaine hydrochloride, dl-camphor) BID TOPI
    • Welizen (famotidine 20mg) 1# BID
    • Kefen KFT112 (ketotifen 1mg) 1# HS
    • Estimin (ebastine 5mg) 1# BID

[consultation]

• 2023-09-13 Family Medicine
  • Q
    • This 54 year-old male patient had gout, GERD, HTN, liver cirrhosis, probably due to hepatitis B and hyperkalemia due to possible acute kidney injury. He had suffered from squamous cell carcinoma of left cT2N2bM0, cstage IVA. He had consulted for hospice combined care. Thanks !!
  • A
    • A 54 year-old male, case of terminal stage of squamous cell carcinoma of left mandibular gingiva (cT2N2bM0, cstage IVA), liver cirrhosis, hepatitis B and hyperkalemia due to possible acute kidney injury.
    • IPP held on 9/13 and had discussed about further treatment plan with patient and his family.
    • Patient decided try agressive treatment.
    • We will arrange hospice combine care and follow up his condition.
    • Indication: left mandibular gingiva squamous cell carcinoma
    • Plan: hospice combined care
• 2023-08-23 Nephrology
  • Q
    • This 54 year-old male patient, diagnosis was Squamous cell carcinoma of left lower gingiva extenidng to left lower lip, cT2N2bM0, Stage IVA.
    • PH:
      • Liver cirrhosis, with splenomegaly and irregular follow up GI clinic.
      • Hypertension
      • Gout
      • Peptic ulcer and acute cholecystitis
      • Bilateral carpel tunnel syndrome, status post relased over left side on 2015/09/08
      • Right THR on 2007/11/15, status post closed reduction on 2009/10/04, 2010/06/11, 2010/06/26, 2010/07/20, 2010/11/29, 2012/01/30, 2012/03/14 and 2012/04/10 due to dislocation
    • For poor renal function and hyperkalemia was noted, we need your consultation for evaluation. Thanks a lot!!
  • A
    • Based on our medical record, he developed acute kidney injury when he was found to have hyperkalemia during his previous visit on 7/14. Over the course of hospitalization recently (7/24-8/1), his blood tests showed elevated levels of creatinine and potassium.
    • This time, blood test showed hyperkalemia and slightly elevated creatinine and BUN levels (not obtained on the same day)
      • 2023-08-23 Creatinine 1.29 mg/dL
        
      • 2023-08-23 K(Potassium) 4.6 mmol/L
        
      • 2023-08-23 K(Potassium) 4.3 mmol/L
        
      • 2023-08-22 K(Potassium) 5.0 mmol/L
        
      • 2023-08-22 K(Potassium) 5.9 mmol/L
        
      • 2023-08-22 K(Potassium) 5.0 mmol/L
        
      • 2023-08-21 K(Potassium) 6.2 mmol/L
        
      • 2023-08-21 BUN 29 mg/dL
        
    • Our impressions are as follows:
      • Hyperkalemia due to possible acute kidney injury
    • Our advices are as follows:
      • Record daily I/O and BW
      • Review current medications, avoid nephrotoxic agents (e.g. NSAID) and medications that cause hyperkalemia (e.g. Spironolactone)
      • Follow up serum potassium levels closely at least QD, and monitor for typical EKG changes of hyperkalemia
      • If follow up serum K remains elevated, perform the following survey:
        • Urine K, Osm, Cre, Na (to evaluate urine K excretion and distal Na delivery)
        • Serum K, Osm, Cre (to evaluate TTKG)
      • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance. Thank you.
• 2023-07-28 Hemato-Oncology
  • Q
    • For neoadjuvant chemotherapy.
    • This is a 55-year-old male patient suffering from malignant tumor of left lower lip and was admitted to our ward for further managment on 2023/07/24.
    • After admitted, biopsy was done and showed moderately-differentiated squamous cell carcinoma.
    • Nasopharynx MRI revealed left buccal and low lip CA, T2N2bMx stage IVA.
    • However, based on our clinical examination, mandibular bone invasion was highly suspected, thus the staging might be cT4aN2bM0, stage IVA.
    • After discussing with the patient and his family, neoadjuvant chemotherapy before surgery is preferred.
    • Thus, we need your expertise for further management of neoadjuvant chemotherapy for the patient. Thanks for your time
  • A
    • This 55 year old man is a case Squamous cell carcinoma, moderately differentiated of left lower lip, cT2N2bM0, stage IVA, Liver cirrhosis, with splenomegaly, Hypertension, Gout, Peptic ulcer, ACKD, and anti HBc positive. We are consulted for neoadjuvant chemotherapy.
    • Pathology show
      • Lower lip, left, incisional biopsy — Squamous cell carcinoma, moderately differentiated
      • The specimen submitted consists of three pieces of gray-tan soft tissue, measuring up to 1.0 x 0.4 x 0.1 cm. All for section.
      • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident. Tumor necrosis with bacterial colonies can be found also.
    • Suggestion:
      • Adequate hydration for AKI with hyperkalemia
      • Antibiotic for bacterial colonies found at pathology
      • Arrange our OPD after discharge. We had well explaint to patient about high risk of chemotherapy due to cirrhosis underline and renal insuffiency.
• 2023-07-28 Gastroenterology
  • Q
    • This 54 year-old male patient, had suffered from unhealed and protruding mass lesion of his left lower lip for 1+ months ago. Suspected malignancy of left lower gingiva and lower lip was impressed, he was admitted to ward for further management. However, his abdomen sona showed liver cirrhosis, with splenomegaly. Anti-Hbc reactive, value 6.92, Anti-Hbs (-) and HbsAg (-). We need your further evaluation and suggestion.
  • A
    • S: 54 years old man was admitted for oral cancer and preoperation survey. However, due to Anti-HBc(+) under cirrhosis, we are consulted.
    • O
      • conscious: clear
      • chest: smooth breath pattern
      • abdomen: soft and flat
      • Lab
        • 2023-07-24 Anti-HCV Nonreactive
          
        • 2023-07-24 Anti-HBs 7.37 mIU/mL
          
        • 2023-07-24 Anti-HBc Reactive
        • 2023-07-24 HBsAg Nonreactive
          
        • 2023-07-24 PT 10.4 sec
          
        • 2023-07-24 S-GOT/AST 27 U/L
          
        • 2023-07-24 S-GPT/ALT 9 U/L
          
        • 2023-07-24 Bilirubin total 0.52 mg/dL
          
      • 2023-07-14 abdominal echo Diagnosis: Liver cirrhosis, with splenomegaly
    • impression
      • Occult HBV infection
      • Liver cirrhosis, probably due to hepatitis B
      • Left buccal and low lip CA, T2N2bMx stage IVA, pending pathology
    • suggestion
      • The prophylactive antiviral treatment of HBV is indicated during the chemotherapy
      • GI OPD follow-up is indicated for the condition of liver cirrhosis
      • Contact us to prescribe the antiviral agent when the chemotherapy is to be launched
• 2023-07-14 Oral and Maxillofacial Surgery
  • Q
    • no fever
    • no vomiting
    • left chest pain after contusion accidentally (when moving things) noted in recent one week
    • left toothache and lip swelling noted for 2~3 weeks
    • PH: anemia under iron supplement Tx; left ribs fx
    • Allergy: keto
  • A
    • This 54-year-old-man took blood test today, and was sent to ER due to hyperkalemia. The ER found that the patient has a protruding mass on his lower lip.
      • General codition: HTN, HBV??
      • Alcholism, Betal nut and cigarette history for 20~30 years, have quitted for 6 months.
    • S: I have swelling over lower lip for 3~4 weeks, there’s no pain at all. I have pain over my lower left tooth.
    • O:
      • Protruding, ulcerative mass of left lower lip with induration
      • tooth 36 severe attrition, dentinal hypersensitivity was noted.
      • lab data:
        • CRP 2.8 mg/dL
          
        • K(Potassium) 6.8 mmol/L
          
        • WBC 8.51 x10^3/uL
          
    • A:
      • Unspecified soft tissue tumor of lower left lip, highly sespect oral cancer
      • Pulpitits of tooth 36 due to attrition
    • P:
      • Physical examination. Explain the findings to the patient and his wife.
      • Please contact us after the patient’s general condition is stable.
• 2022-11-25 Psychosomatic Medicine
  • Q
    • This is a 50-year-old man with previous history of gout, GERD, HTN, and right ulnar styloid fracture.
    • The patient developed general weakness for one month, and the weakness got even worse in the past two weeks.
    • He is a alcoholism, generalized tremor was found, we consulted Neurologist for alcoholic tremor, they suggested check TSH, Free T4, CK and arrange NCV.
    • We added Cardiolol PO and Ativan po for irritable and tremor. He also has visual hallucination for recent days. We need your expertise and evaluation! Thanks a lot!
  • A
    • Psychiatric impression:
      • Acute agitated state
      • r/o Acute delirium
      • r/o Alcohol dependence with withdrawal
    • Symptoms and course:

      • This is a 50 y/o male patient with underlying alcoholism, gout, GERD. He was admitted this time under the impression of: UGI bleeding, cellulitis of foot, and colitis of ascending colon and cecum, the patient was admitted for further evaluation and management. We were consulted for the irritable mood and suspect visual hallucination at night.

      • According to the patient and his wife: A 50-year-old male, living with his wife and son, was a logistics driver for over 10 years and has no history of psychiatric treatment. He left his job a month ago, stating that he resigned due to disagreements with his supervisor. He began social drinking in high school, and over time, the amount and strength of alcohol consumed gradually increased. He now drinks 350ml bottles of sorghum liquor, 1-2 bottles daily. When not drinking, he experiences cravings and withdrawal symptoms, and when drunk, he talks nonsense and reports seeing strange things.

      • The patient and his family indicate that about three weeks ago, after leaving his job, he resolved to stop drinking. He claims that he has not touched alcohol since that day (though his account is somewhat inconsistent). He has been staying at home feeling gloomy, depressed, and irritable, but denies having suicidal thoughts. His wife notes that he was mentally clear during this period but started feeling general weakness before admission to the hospital. After admission, he exhibited irritability, restlessness, incoherent speech, and possible visual hallucinations.

      • Upon visit, he showed mild muddy spirit, limited orientation to time, people and place, rather stable mood. Coherant but sometimes irrelevant speech. Currently denied suicide ideation, denied hallucination. Poor memory function for years. Confabulation(+/-), nystagmus(+), unsteady gait, withdrawal symptom(+): tremor, palpitation.

    • Suggestion:
      • Check and correct underlying cause for the delirium: Infectin, anemia, electrolyte imbalance, blood gas, ammonia, pain, urine retention…
      • Utapine (25mg) 1# HS for the agitation and VH at night; Anxicam 0.5amp IM PRNQ6H if noted still irritable
      • Adequate IVF support, add B-complex IV 1amp QD , can gradually switch to thiamine PO 2# QD
      • Anxiedin 1# QID to reduce the withdrawal symptoms, gradually tapper anxiedin if showed improved autonomic hyperarousal signs (hypertension and tachycardia)
      • Arrange brain CT for evaluation
      • Maintain daylight exposure and activity during the day, reduce noise and light at night, and reposition frequently.
      • Arrange PSY OPD follow up
• 2022-11-22 Neurology
  • Q
    • This is a 50-year-old man with previous history of gout, GERD, HTN, alcoholism and right ulnar styloid fracture.
    • The patient developed general weakness for one month, and the weakness got even worse in the past two weeks. Generalized limbs tremor was found. Erythenatous change with mild tenderness over left ankle and foot was note. Laboratory data showed leukocytosis, normocytic anemia, and stool OB 3+. Gastrscopy showed suspected duodenal ulcer and large esophageal diverticulum. Abdominal CT revealed esophageal diverticulum colitis of ascending colon and cecum.
    • Due to generalized limbs tremor and weakness, we need your expertise and evaluation! Thanks a lot!
  • A
    • O
      • CN: intact
      • MP: RU:4+ RL:4- LU:4+ LL:4-
      • Bil action tremor was noted for more then one year
    • Imp:
      • general weakness, cause to be determined
      • bil hand action tremor, r/o alcoholic tremor, r/o essential tremor
    • Suggestion:
      • Check CK, TSH and free T4
      • Arrange NCV (upper and lower limbs, both sensory and motor, F wave, H refelx, QST)
      • may try propranolol #1 BID for action tremor if no contraindication such as asthma or bradycardia

[chemotherapy]

• 2024-06-26 - fluorouracil 800mg/m2 1200mg NS 500mL 24hr D1-5 + hydroxyurea 1000mg PO Q12H D1-5

• 2024-02-22 - carboplatin AUC 2 170mg D5W 250mL 1hr + MgSO4 10% 20mL NS 100mL (CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-02-08 - carboplatin AUC 2 170mg D5W 250mL 1hr (CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-02-01 - carboplatin AUC 2 170mg D5W 250mL 1hr (CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-01-25 - carboplatin AUC 2 170mg D5W 250mL 1hr (CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-01-18 - carboplatin AUC 2 170mg D5W 250mL 1hr (CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-01-10 - carboplatin AUC 2 170mg D5W 250mL 1hr (CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-12-22 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-11-18 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-11-16 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-11-11 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-10-14 - docetaxel 30mg/m2 45mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-09-22 - ………………………………. carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. no taxel; Carbo AUC 1.5)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-09-15 - ………………………………. carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr (TPF Q3W. no taxel; CrCl 47 Carbo AUC 1.5; 5FU C1 24hr)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-08-22 - docetaxel 40mg/m2 0mg NS 250mL 1hr + cisplatin 40mg/m2 0mg NS 500mL + fluorouracil 2000mg/m2 0mg NS 500mL 46hr (TPF Q3W) [TEMP] (not conducted)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2

==========

2023-11-20

[hyperkalemia episodes]

Episodes of hyperkalemia have occurred several times in the past 5 months. During this period, the highest recorded serum creatinine level was 1.8mg/dL, and the eGFR consistently remained above 40 mL/min/1.73m^2, suggesting that the kidneys should still have the capacity to excrete excess potassium.

• 2023-11-20 K(Potassium) 4.7 mmol/L
• 2023-11-16 K(Potassium) 4.1 mmol/L
• 2023-11-13 K(Potassium) 4.2 mmol/L
• 2023-11-10 K(Potassium) 4.9 mmol/L
• 2023-11-07 K(Potassium) 5.9 mmol/L *
• 2023-10-13 K(Potassium) 4.8 mmol/L
• 2023-10-11 K(Potassium) 5.9 mmol/L *
• 2023-10-03 K(Potassium) 6.6 mmol/L ***
• 2023-09-20 K(Potassium) 3.4 mmol/L
• 2023-09-13 K(Potassium) 3.9 mmol/L
• 2023-09-12 K(Potassium) 6.0 mmol/L **
• 2023-09-11 K(Potassium) 5.9 mmol/L *
• 2023-09-06 K(Potassium) 5.6 mmol/L *
• 2023-08-25 K(Potassium) 4.2 mmol/L
• 2023-08-24 K(Potassium) 4.3 mmol/L
• 2023-08-23 K(Potassium) 4.5 mmol/L
• 2023-08-23 K(Potassium) 4.6 mmol/L
• 2023-08-23 K(Potassium) 4.3 mmol/L
• 2023-08-22 K(Potassium) 5.0 mmol/L
• 2023-08-22 K(Potassium) 5.9 mmol/L *
• 2023-08-22 K(Potassium) 5.0 mmol/L
• 2023-08-21 K(Potassium) 6.2 mmol/L **
• 2023-07-25 K(Potassium) 5.0 mmol/L
• 2023-07-24 K(Potassium) 6.0 mmol/L **
• 2023-07-24 K(Potassium) 6.6 mmol/L ***
• 2023-07-14 K(Potassium) 4.5 mmol/L
• 2023-07-14 K(Potassium) 5.3 mmol/L
• 2023-07-14 K(Potassium) 6.8 mmol/L ***

Upon reviewing the patient’s recent medication history, it was found that olmesartan, a component of Sevikar, could be a potential cause of hyperkalemia, especially considering the patient’s risk factors such as renal dysfunction, diabetes mellitus, concurrent use of potassium-sparing diuretics, potassium supplements, and/or potassium-containing salts. Sevikar has already been discontinued. Additionally, propranolol, which is currently being used, has been sporadically reported in post-marketing studies to be associated with hyperkalemia, although it is considered a less likely cause.

Could hypoaldosteronism be a potential cause in this case?

2023-11-09

[reconciliation]

On 2023-10-18, this patient just refilled his repeat prescription for a 28-day supply of MgO, lansoprazole, sennoside, Kentamin, sodium ferrous citrate, propranolol, febuxostat, quetiapine fumarate, lorazepam. No discrepancies have been found with these medications currently in use.

[alcohol abstinence]

Abstaining from alcohol is the foundation of managing alcohol-associated cirrhosis. This abstinence has been linked to improvements in fibrosis, as well as lower hepatic venous pressure gradients.

Lab tests (2023-11-07) revealed normal AST, ALT, and total bilirubin levels. If the cirrhosis worsens and becomes decompensated, Baraclude (entecavir 1mg) may be a viable treatment option.

2023-08-22

[reconciliation]

Recent MCV and MCH levels have consistently been on the upper end of their normal range, suggesting that iron deficiency anemia is less probable. The ongoing use of the iron supplement Foliromin (ferrous sodium citrate) may be reduced.

• 2023-08-21 MCV 92.3 fL

• 2023-07-24 MCV 93.0 fL

• 2023-07-14 MCV 92.6 fL

• 2023-06-10 MCV 92.3 fL

• 2023-08-21 MCH 31.0 pg

• 2023-07-24 MCH 30.6 pg

• 2023-07-14 MCH 30.2 pg

• 2023-06-10 MCH 30.6 pg

701394474

240718

[exam findings]

[MedRec]

• 2023-07-22 ~ 2023-07-28 POMR Chest Medicine Huang JunYao
  • Discharge diagnosis
    • Adenocarcinoma of right upper lobe lung with multiple brain metastasis pStage IVB, pT2aN1M1c, ECOG:1.
    • Viral hepatitis B without hepatic coma, with prescribed Vemlidy since 2023/07/27.
    • Hypertension.
    • Malignant neoplasm of unspecified part of right bronchus or lung
    • Malignant neoplasm of upper lobe, right bronchus or lung
    • Secondary malignant neoplasm of brain
    • Chronic Obstruction Pulmonary Disease
    • Pyogenic granuloma
  • CC
    • admisison for Dabrafenib + Trametinib, may add VEGF inhibitor, CEA
  • Present illness
    • BRAF V600E ==> Dabrafenib + Trametinib.
    • Under the diagnosis of Adenocarcinoma of right upper lobe lung with multiple brain metastasis ypStage IVB, ypT2aN1M1c, She was admitted for Dabrafenib + Trametinib, may add VEGF inhibitor, CEA further evaluation and management.
  • Course of inpatient treatment
    • After admission, MDI with Symbicort and Spiriva for lung function. Mycomb plus Fusidic for pyogenic granuloma on bil toenails. Follow laboratory data include CEA and chest film was performed.
    • TKI with Trametinib 30# by self-paid on 07/24, start Trametinib 1# QDAC on 07/25.
    • Start chemotherapy with C1 Cyramza 300mg (charge) on 07/26.
    • GI was consulted for HBV(+) and added Vemlidy as suggestion since 07/27.
    • Abdomen echo was arranged on 07/27, disclosed Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed. There were no fever, dyspnea, chest tightness, productive cough, purulent of sputum, appetite change with poor oral intake, nausea or vomiting noted after chemotherpy. She was discharged on 07/28 on relative stable condition and further OPD followed up was recommended.
  • Discharge prescription
    • Antica Syrup (orciprenaline, bromhexine, doxylamine) 10mL TID 7D
    • Deflam-K (diclofenac 25mg) 1# TID 7D
    • Micardis (telmisartan 80mg) 1# QD 7D
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# BID 7D
    • Ulstop (famotidine 20mg) 1# BID 7D
    • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC 14D
• 2023-06-02 ~ 2023-06-20 POMR Chest Medicine Huang JunYao
  • Discharge diagnosis
    • Adenocarcinoma of right upper lobe lung with multiple brain metastasis ypStage IVB, ypT2aN1M1c status post Video-Assisted Thoracic Surgery right upper lobe lobectomy + pneumolysis + lymph node sampling on 2022/06/27
    • Malignant neoplasm of unspecified part of right bronchus or lung
    • Malignant neoplasm of upper lobe, right bronchus or lung
    • Secondary malignant neoplasm of brain
    • Chronic Obstruction Pulmonary Disease
  • CC
    • Admision for brain MRI, PET, bone scan, CT guide biopsy or chest surgery for tissue, NGS
  • Present illness
    • Under the impression of RUL lung invasive NSCLC with brain metastasis, she was admitted for lung cancer survey, brain MRI, PET, bone scan, CT guide biopsy or chest surgery for tissue, NGS.
    • PET scan first for total body survey for possible metastasis. If definite LAPs, we will consulteed chest surgery for lymphnode excision, the sample will sent of NGS.
  • Course of inpatient treatment
    • After admission, re-staging as below brain MRI reveal regression cerebral nodules.
    • Whole body PET reported a right supraclavicular lymph node, in the right pulmonary hilar lymph nodes and in some right mediastinal lymph nodes.
    • Bone scan showed Increased activity in the sacrum and right S-I joint.
    • We consulted CS man will arrange Right VAT for Biopsy on 6/12.
    • Dermalogist consulted for Paronychia and cryotherapy complete.
    • VATS RLL wedge + RUL wedge was arrange smoothly on 06/14.
    • Painkiller with diclofenac plus Ketorolac prn was given.
    • MDI with symbicort + Spiriva for COPD treatment.Chest tube removal on 6/19.
    • Connect NGS tissue for genetic mutation survey on 6/20.
    • As present, stable vital sign and condition.She will discharge on 2023-06-20 then CS, CM OPD for further management.
  • Discharge prescription
    • Actein (acetylcysteine 200mg) 1# TID 9D
    • Cough Mixture (platycodon) 5mL TID 9D
    • Ulstop (famotidine 20mg) 1# BID 9D
• 2023-05-29 SOAP Chest Medicine Huang JunYao
  • S:
    • admision for brain MRI, PET, bone scan, CT guide biopsy or chest surgery for tissue, NGS
  • A:
    • NSCLC stage II ( ? ) w/o Op on targeted therapy since 2018.10 ( then QOD ) at NTUH & brain mets in June 2022. s/p Giotrif and tagrisso therapy with tumor progression
  • Plan
    • C/T with CDDP + alimta
    • arrange PET scan
• 2023-05-07 SOAP Hemato-Oncology He JingLiang
  • Prescription
    • Tagrisso (osimertinib 80mg) 1# QD 6D
    • Cough Mixture (platycodon) 5mL TID 7D
• 2023-04-19, -03-22 SOAP Hemato-Oncology Wan XiangLin
  • Prescription
    • Tagrisso (osimertinib 80mg) 1# QD 28D
• 2022-12-27, -12-13,-11-15, -11-01, -10-18, -10-04, -09-19, -09-05, -08-23, -07-11 SOAP Dermatology Wang ChunHua
  • Prescription
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
    • fusidic acid BID EXT
• 2022-09-05 SOAP Hemato-Oncology Zhang ShouYi
  • O: It’s puzzled that NHI grant approval of Tagrisso at this patient
  • Prescription
    • Tagrisso (osimertinib 80mg) 1# QD 28D
    • Sodicon (dextromethorphan 15mg) 1# TID 28D
    • Megejohn (megestrol acetate 160mg) 1# QD 28D
• 2022-08-08 SOAP Hemato-Oncology Zhang ShouYi
  • Prescription
    • Actein (acetylcysteine 200mg) 1# TID 28D
    • Tagrisso (osimertinib 80mg) 1# QD 28D
• 2022-07-11 SOAP Dermatology Wang ChunHua
  • Prescription
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
• 2022-06-26 ~ 2022-07-06 POMR Thoracic Surgery Xie MinXiao
  • Discharge diagnosis
    • Adenocarcinoma of right upper lobe lung with multiple brain metastasis ypStage IVB, ypT2aN1M1c status post Video-Assisted Thoracic Surgery right upper lobe lobectomy + pneumolysis + lymph node sampling on 2022/06/27
    • Subacute dermatitis
    • Pyogenic granuloma
  • CC
    • NSCLC (found 2018 in NTUH) with brain metastasis (found 2022) under Afatinib 40mg QDAC (since 2018), consult for multiple brain metastasis.        
  • Present illness
    • This 54 year old female patinet with underlying disease of NSCLC (found 2018 in NTUH) with brain metastasis (found 2022) under Afatinib 40mg QDAC (since 2018). She was previously treated in NTUH. This time she went to our OPD for help due to multiple brain metastasis.
    • Past history suggest: smoking(-), family history of lung canacer(-).
    • CXR showed subtle nodular increased opacity over medial RUL.
    • CT done on 2022/06/16 suggested right upper lobe lung cancer with pleura meta.
    • Brain MRI showed multiple brain metastasis.
    • According to the patient, there is no related symptoms including chest tightness, productive coughing, bloody sputum or other discomfort instead of body weight loss 4-5 kg in recent half year.
    • After discussing with the patient and her family on the benefits of surgical treatment as well as subsequent risks and possible complications.
    • Under the impression of RUL lung invasive NSCLC with brain metastasis, she was admitted for VATS RUL lobectomy + pneumolysis + LN sampling on 2022/06/27 for EGRF T790M mutation test.        
  • Course of inpatient treatment
    • After admission, pre-op assessment was done. Operation of video-assisted thoracoscopic wedge resection and lymph node dissection was performed smoothly on 2022-06-27. No complication was noted.
    • Prophylactic antibiotics was prescribed for 1 day. Right chest tube with LPS -18 cmH2O was done. Chest tube was removed on 2022-07-05. She was discharged under stable hemodynamics and OPD follow up will be arranged.
  • Discharge prescription
    • Zofran (onansetron 8mg) 1# QD 5D
    • Actein (acetylcysteine 200mg) 1# TID 5D
    • Acetal (acetaminophen 500mg) 1# Q6H if pain
    • Sindine (povidone iodine aq soln) QD EXT
• 2022-06-24 SOAP Radiation Oncology Wang YuNong
  • S: Mild nausea after RT. symptoms: headache. vomit due to target therapy.
  • O: 2022-06-17~ RT to the whole brain: 15 Gy/ 6 fx.
• 2022-06-23 SOAP Dermatology Wang ChunHua
  • S
    • Pyogenic granuloma on bil toenails for wks, severe painful and bleeding(+) after TKI
    • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching
  • Prescription
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
• 2022-06-21 SOAP Hemato-Oncology Zhang ShouYi
  • S: Dexa 4mg PO QD ( 3 wk ) on 6/21 22.
  • Prescription
    • Alcos-Anal Oint (sodium oleate) BID EXT
    • Zofran (ondansetron 8mg) 1# QD 7D
    • Nexium (esomeprazole 40mg) 1# QDAC 21D
    • Limeson (dexamethasone 4mg) 1# QD 21D
• 2022-06-14 SOAP Radiation Oncology Wang YuNong
  • S: for palliative brain irradiation. symptoms: headache. vomit due to target therapy.
  • O: Brain mets Dx on 6/7 22. by brain MRI (6/14 22)
  • Plan: CT-simulation will be arranged on 6/16. Plan to deliver 17.5 Gy/ 7 fx to the whole brain. Then boost the gross metastatic brain tumor to 37.5 Gy/ 15 fx.
• 2022-06-14 SOAP Hemato-Oncology Zhang ShouYi
  • S
    • EGFR mutation test (2018-10-11): positive.
    • On Afatinib since 2018.10.
    • will consult Dr Wang YuNong for brain R/T
    • will chest CT to identify recurrent lesion (6/14 22).
  • Prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 14D
    • Ulstop (famotidine 20mg) 1# BID 14D
    • Giotrif (afatinib 40mg) 1# QDAC 14D
• 2022-06-11 SOAP Hemato-Oncology Zhang ShouYi
  • 54 y/o female, a pt of NSCLC stage II ( ? ) w/o Op on targeted therapy since 2018.10 ( then QOD ) at NTUH & brain mets in June 2022.

[surgical operation]

• 2023-06-14
  • Op Method:
    • VATS RLL wedge + RUL wedge
  • Finding:
    • Multiple nodules were noted over right lung field and pleura.
    • One 24 Fr. straight chest tube was inserted via right 8th ICS.
• 2022-06-27
  • Op Method:
    • VATS RUL lobectomy + pneumolysis + LN sampling.
  • Finding:
    • One solid nodular lesion was noted over RUL, S3, size about 1.8cm in diameter. Previous pleural seeding was also noted. Diffuse adhesion was also noted over the whole right pleural cavity.
    • One 24 Fr. straight chest tube was inserted via right 8th ICS.

[immunochemotherapy]

• 2024-07-17 - amivantamab 350mg NS 240mL 12hr

  • methylprednisolone 40mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL

• 2024-07-16 - nivolumab 100mg NS 100mL 1hr

• 2024-07-15 - ramucirumab 500mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 50mL

• 2024-06-20 - amivantamab 350mg NS 240mL 12hr

  • methylprednisolone 40mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL

• 2024-06-19 - nivolumab 100mg NS 100mL 1hr

• 2024-06-18 - ramucirumab 500mg NS 250mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2024-05-28 - amivantamab 350mg NS 240mL 12hr

  • methylprednisolone 40mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL

• 2024-05-24 - nivolumab 100mg NS 100mL 1hr

• 2024-05-23 - ramucirumab 500mg NS 250mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2024-04-10 - nivolumab 100mg NS 100mL 1hr

• 2024-04-09 - ramucirumab 500mg NS 250mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2024-03-11 - ipilimumab 50mg NS 50mL 30min

• 2024-03-09 - nivolumab 100mg NS 100mL 1hr

• 2024-03-08 - ramucirumab 500mg NS 250mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2024-01-19 - ipilimumab 50mg NS 50mL 30min

• 2024-01-18 - nivolumab 100mg NS 100mL 1hr

• 2024-01-17 - ramucirumab 500mg NS 250mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2023-12-19 - nivolumab 100mg NS 100mL 1hr

• 2023-12-18 - ramucirumab 500mg NS 250mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2023-11-17 - nivolumab 100mg NS 100mL 1hr

• 2023-11-16 - ramucirumab 500mg NS 250mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2023-10-16 - ramucirumab 300mg NS 250mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2023-08-21 - ramucirumab 300mg NS 250mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

• 2023-07-26 - ramucirumab 300mg NS 250mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

==========

2024-07-18

[dermatologic side effects in in the patient on “amivantamab”, nivolumab, and ramucirumab]

The patient has developed a skin rash while on the regimen including amivantamab, nivolumab, and ramucirumab. Each of these drugs has documented dermatologic side effects:

• Amivantamab: Known to cause skin rash, including acneiform dermatitis, pruritus, and xeroderma. Severe rashes such as grade 3, paronychia, and toxic epidermal necrolysis have been observed. The median time to rash onset is 14 days, with a wide range of 1 to 276 days.
• Nivolumab: Associated with various immune-mediated rashes, including severe conditions such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Other cutaneous toxicities include skin rash, pruritus, and lichenoid dermatitis. Dermatologic toxicity typically appears between 2.8 to 6.1 weeks after treatment initiation.
• Ramucirumab: Reported to cause skin rash in 4% of patients.

Given the overlapping potential for dermatologic side effects from all three medications, it is challenging to pinpoint the exact cause of the rash. Our dermatologist recommended Sinpharderm (urea) and tetracycline for external use on 2024-07-10 as potential therapies that may effectively alleviate patient discomfort.

Amivantamab Dermatologic Toxicity Management

• Grade 1: Initiate supportive care. Reassess after 2 weeks.
• Grade 2: Initiate supportive care. Reassess after 2 weeks. If rash does not improve, consider dose reduction.
• Grade 3: Withhold amivantamab and initiate supportive care. Add oral steroids and consider dermatologic consultation. Upon recovery to ≤ grade 2, resume at reduced dose. If no improvement within 2 weeks, permanently discontinue.
• Grade 4: Permanently discontinue amivantamab.
• Severe Bullous, Blistering, or Exfoliating Skin Conditions (including Toxic Epidermal Necrolysis): Permanently discontinue amivantamab.

The patient is currently using 350 mg, the lowest recommended dose (second dose reduction). There are no lower documented doses. Considering potential risk factors related to dosage, it might be an option temporarily discontinuing the drug and observing if skin symptoms improve. If improvement occurs, reassess the possibility of re-challenge.

700930810

240716

[exam findings]

• 2024-07-14 ECG
  • Sinus tachycardia
  • Left anterior fascicular block
• 2024-06-24 ECG
  • Sinus tachycardia with occasional Premature ventricular complexes
  • Low voltage QRS
  • Inferior infarct, age undetermined
• 2024-06-04 CXR
  • A nodular opacity projecting in the right middle lung is suspected. Please correlate with CT.
  • Superior mediastinal widening
  • Enlargement of left hilum
  • Emphysematous change of upper lung zone
  • Pulmonary fibrosis at bilateral basal lungs is suspected.
• 2024-05-31 ECG
  • Normal sinus rhythm
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2024-05-30 PET
  • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm, left tonsil and right lung (stage IV).
• 2024-05-30 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 36) / 78 = 53.85%
    • 2D (M-Simpson) = 61
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Trivial MR, trivial TR and trivial PR
    • Preserved RV systolic function
• 2024-05-29 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — No evidence of lymphoma involvement
  • The sections show normocellular marrow (20%). M/E ratio = 5:1. The myeloid cells show good maturation with neutrophilia. The megakaryocytes are normal in number and morphology. No lymphoid aggregates. There is no evidence of lymphoma involvement in CD3 and D20 immunostains. Suggest further bone marrow smear evaluation and clinic correlation.
• 2024-05-24 Bronchodilator Test
  • Moderate obstructive ventilatory impairment with partial response to BD
• 2024-05-23 CXR erect
  • marked superior mediastinal widening and Enlargement of Rt and hila as well prominent soft-tissue in the neck, causing marrowing of the trachea result from huge tumor or extensive lymph node enlargement
  • emphysematous change of upper lung zone
  • basal lung pulmonary fibrosis
  • moderate enlarged cardiac silhoutte
• 2024-05-21 Patho - lymphnode biopsy (Y1)
  • PATHOLOGIC DIAGNOSIS
    • Lymph node, lower neck, left, sono guide biopsy — Diffuse large B cell lymphoma, non-GC
  • MACROSCOPIC DESCRIPTION
    • Operation procedure: sono guide biopsy
    • Topology: left lower neck
    • Specimen size and number: several pieces, up to 0.4x0.1x0.1 cm
  • MICROSCOPIC EXAMINATION
    • Histology type:
      • B-cell neoplasms - Diffuse large B cell lymphoma
        
    • Immunohistochemical stain profiles:
      • CK(-), CD56(-), P40(-), Ki-67 index: 90%, CD20(diffuse+), CD3(+ at background T-cells), Bcl-2(+), Bcl-6(+), cyclin D1(-), c-myc(+), MUM-1(+), CD10(-)
• 2024-05-18 CT - chest
  • With and without contrast enhancement CT of chest shows:
    • Multiple enlarged lymph nodes, more severe in left neck, bilateral axilla, mediastinum, and pericardial regions.
    • Multiple nodular lesions, up to 2.8cm, in right lung.
    • Emphysema in both lung fields.
  • Impression
    • Multiple enlarged lymph nodes. Suggest further evaluation.
    • Right lung nodules
    • Lung emphysema
    • Suggest further evaluation
• 2024-05-18 Neck soft tissue
  • Prominent soft tissue radiopacity over lower neck
  • Suspect prevertebral soft tissue swelling
• 2024-05-18 CXR
  • Mediastinal widening
  • Right lung nodules
• 2024-05-18 ECG
  • Sinus tachycardia with frequent Premature ventricular complexes
  • Inferior infarct, age undetermined
  • Nonspecific T wave abnormality
• 2024-02-26 SONO - nephrology
  • Interpretation:
    • Parenchymal renal disease
    • Simple cyst, right
• 2023-05-23 SONO - nephrology
  • Interpretation:
    • Bilateral parenchymal renal disease, c/w diabetic kidney disease
    • Single renal cyst, right kidney

[consultation]

• 2024-05-29 General and Gastroenterological Surgery
  • Q
    • for Port-A implantment
    • Thus, he was admitted to our ward for further evaluation with treatment. 5/27 Pathology showed Diffuse large B cell lymphoma, non-GC. So we sincerely need your help for Port-A implantment.
  • A
    • S: a 72 y/o male patient is a case of Diffuse large B cell lymphoma. Port-A insertion is consulted.
    • O:
      • vital signs: stable, no fever
        
      • PE: no central vein stenosis
        
      • lab data: see chart
    • A: Diffuse large B cell lymphoma,
    • P: I will arrange Port-A insertion, L’t on 20240529
• 2024-05-28 Hemato-Oncology
  • Q
    • For highly suspect lymphoma
    • Diffuse large B cell lymphoma, non-GC. Due to highly suspect lymphoma, we sincerly your special evaluation and help. TKS !!
  • A
    • This 72-year-old man has a history of hypertension (HTN) and diabetes mellitus (DM). We are consulted regarding his case of diffuse large B-cell lymphoma, triple expressor.
    • Please transfer him to the 11A ward under Dr. Gao service and arrange for a PET/CT scan and a 2D heart echo. Additionally, please arrange for port A implantation. We may handle the bone marrow procedure in the 11A ward.
• 2024-05-21 Diagnostic Radiology
  • Q
    • for Multiple enlarged lymph nodes, more severe in left neck guiding evaluation and arrange
    • Due to CT showed Multiple enlarged lymph nodes, more severe in left neck, we sincerely need yourhelp for guidingevaluationadn arrange. Thanks a lot !!!
  • A
    • This 72-year-old patient is a case of meck and mediastinum masses, r/o malignancy. Sono-guided biopsy of neck mass is indicated.
    • Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, hemorrhage, infection, and penetration injury to the patient and the family.

[immunochemotherapy]

• 2024-06-26 - rituximab 375mg/m2 650mg ND 500mL 8hr D1 + cyclophosphamide 400mg/m2 690mg NS 250mL 30min D2 + doxorubicin 25mg/m2 40mg NS 50mL 10min D2 + vincristine 1mg/m2 1.7mg NS 50mL 10min D2 + prednisolone 40mg/m2 35mg BID PO D2-6 (R-miniCHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-05-31 - rituximab 375mg/m2 688mg ND 500mL 8hr D1 + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min D2 …………………………………… + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2

==========

2024-07-16

[Elevated Labs Suggest Sepsis - Antibiotics Started]

Recent lab data and interpretation:

• 2024-07-15 Urine Bacteria 2+ /HPF: Indicates the presence of bacteria in the urine, which could suggest a urinary tract infection (UTI).
• 2024-07-14 Lactic Acid 4.7 mmol/L: Elevated lactic acid levels can indicate tissue hypoxia, which might be due to poor oxygen delivery or uptake. High levels are commonly associated with sepsis, shock, or other severe illnesses.
• 2024-07-14 NT-proBNP 668.7 pg/mL: Elevated levels of NT-proBNP are indicative of cardiac stress, often seen in heart failure, but can also elevate in cases of acute stress from other severe conditions, including sepsis.
• 2024-07-14 D-dimer 1854.00 ng/mL FEU: Elevated D-dimer levels suggest an increased fibrin formation and degradation, which is common in conditions involving clot formation such as deep vein thrombosis (DVT), pulmonary embolism (PE), or disseminated intravascular coagulation (DIC), often seen in the context of sepsis or severe infection.
• 2024-07-14 CRP 9.8 mg/dL: High C-reactive protein levels indicate significant inflammation, which could be due to infection or other inflammatory conditions.
• 2024-07-14 WBC 14.06 x10^3/uL: Elevated white blood cell count is a marker of infection or inflammation.

Given the combination of the following evidences, there is a high probability that this patient is experiencing sepsis. This condition requires urgent medical attention to identify the source of infection, provide appropriate antimicrobial therapy, and manage any organ dysfunction.

• Significant inflammation (high CRP and WBC count)
• Evidence of infection (urine bacteria)
• Elevated lactic acid (indicative of metabolic stress or hypoxia)
• Elevated NT-proBNP and D-dimer

Blood cultures were ordered and the broad-spectrum antibiotic Cefim (cefepime) 2g Q8H IVD is currently being used. No medication discrepancies were noted.

701059219

240715

[exam findings]

• 2024-06-05 CT - abdomen
  • Findings: Comparison: prior CT dated 2024/02/20.
    • Prior CT identified a large LN (2.2cm) at left lower neck is noted again, stationary. Metastatic node S/P C/T shows stable disease.
    • Prior CT identified some LNs at the mediastinum, mesentery, and aortocaval space are noted again, increasing in size.
      • Metastatic nodes S/P C/T show progressive disease.
    • Prior CT identified several metastases on both lungs are noted again, decreasing in size that is c/w bilateral lung metastases S/P C/T with partial response.
    • S/P Whipple operation and S/P cholecystectomy.
    • Pneumobilia on both lobe IHDs is noted.
    • Atherosclerosis of the abdominal aorta and bilateral common iliac artery.
• 2024-04-23 Tc-99m MDP bone scan
  • In comparison with the previous study on 2023/08/30, the lesions in the middle T-spines and bilateral S-I joints are slightly more evident. The nature is to be determined (degenerative change in a little more severe status? other nature?). Please correlate with other imaging modalities for further evaluation.
  • No prominent change is noted in other bone lesions, possibly more benign in nature.
• 2024-03-05 Patho - lung wedge biopsy
  • Lung, ? Side, CT-guide biopsy — Consistent with metastatic adenocarcinoma from bile duct
  • Sections show mucinous glandular cells proliferating along the alveolar wall. The immunohistochemical stains reveal CK7(+), CK20(-), CDX2(+), and TTF-1(-). The results are consistent with metastatic adenocarcinoma from bile duct. Please correlate with the clinical presentation and image study.
• 2024-02-20 CT - abdomen
  • History and indication: Malignant neoplasm of extrahepatic bile duct
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation. A large LN (2.2cm) at left lower neck.
    • Some LNs at mediastinum and mesentery.
    • Bil. lung nodules.
    • Grade 4 fatty liver.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P operation. A large LN (2.2cm) at left lower neck.
    • Some LNs at mediastinum and mesentery.
    • Bil. lung nodules.
    • Grade 4 fatty liver.
• 2023-10-23 CT - abdomen
  • Indication: extrahepatic cholangiocarcinoma with pancreas invasion s/p whipple operation
  • Abdominal CT with and without enhancement revealed:
    • s/p whipple op. with stent placement at pancreatic duct
    • s/p small intestinal op.
    • There is no recurrent/residual tumor in the study.
  • Imp:
    • s/p whipple op. with stent placement at pancreatic duct
    • s/p small intestinal op.
    • THere is no recurrent/residual tumor in the study.
• 2023-08-30 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in the right rib cage, maxilla, some L-spine, right sternoclavicular junction, bilateral shoulders, elbows, S-I joints, hips, and knees.
• 2023-08-28 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.

[MedRec]

• 2023-12-19 SOAP Hemato-Oncology He JingLiang
  • S
    • extrahepatic cholangiocarcinoma with pancreas invasion s/p whipple operation
    • she came for chemotherapy
      • 2023-09-05 C/T with CDDP+gemzar C1D8, add oral TS-1
      • 2023-09-19 CDDP+Gemzar C2D1, intolerence to TS-1
      • 2023-09-26 CDDP+Gemzar C2D8
      • 2023-10-11 CDDP+Gemzar C3D1
      • 2023-10-17 CDDP+Gemzar C3D8, GI upset, postpond to next week, arrange CT abdomen
      • 2023-10-24 CDDP+Gemzar C3D8
      • 2023-11-07 CDDP+Gemzar C4D1, CT abdomen: no recurrence
      • 2023-11-21 CDDP+Gemzar C4D8
      • 2023-12-05 CDDP+Gemzar C5D1
      • 2023-12-19 CDDP+Gemzar C5D8, reduced dose owing to nausea and vomiting
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC 14D
    • Nexium (esomeprazole 40mg) 1# QDAC 14D
    • Anxiedin (lorazepam 0.5mg) 1# PRNHS 14D
    • Alpraline (alprazolam 0.5mg) 1# QN 14D
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID 14D
    • MgO 250mg 1# TID 14D
    • Buscopan (hyoscine-N-butylbromide 10mg) 1# PRNTID 7D
    • Acetal (acetaminophen 500mg) 1# PRNTID 7D
    • Hepac Lock Flush 100 USP units/mL 10mL ST IRRI
• 2023-09-05 SOAP Hemato-Oncology He JingLiang
  • S
    • extrahepatic cholangiocarcinoma with pancreas invasion s/p whipple operation
    • she came for chemotherapy
      • 2023-09-05 C/T with CDDP+gemzar C1D8, add oral TS-1
  • Prescription
    • Hepac Lock Flush 100 USP units/mL 10mL ST IRRI
    • Baraclude (entecavir 0.5mg) 1# QDAC 14D
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 14D
    • Nexium (esomeprazole 40mg) 1# QDAC 14D
    • TS-1 25 (tegafur 25mg, gimeracil 7.25mg, oteracil 24.5mg) 1# BID 7D
• 2023-08-27 ~ 2023-08-31 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Distal common bile duct tumor S/P pylorus oreserving pancreaticoduodenectomy on 2023/07/26. Pathology: Bile duct, extrahepatic, common S/P Whipple procedure, adenocarcinoma. pancreas Whipple procedure, invaded by adenocarcinoma. Intestine, small, duodenal, Whipple procedure, invaded by adenocarcinoma with lymph nodes metastasis (1/1), pT2N1M0
    • Chronic viral hepatitis B without delta-agent
    • Essential (primary) hypertension
  • CC
    • for chemotherapy
  • Present illness
    • This 72-year-old woman, a patient of distal common bile duct tumor S/P pylorus oreserving oancreaticoduodenectomy on 2023/07/26, she presented with tea-color urine for post fure days and developed jaundice on her face and eyes over the last two days. She visited to local clinic where bilirubi levels were detected and she came to FuRen Univ Hospital for further evaluaiton and survey on 2023/07/21.
    • At FuRen Univ Hospital laboratory showed ALT:481, GGT:1068, TBI:6.28, DBI:4.5 and ALP:513. Abdominal CT (2023/07/21) showed suspicious distal common bile duct lesion. ERCP was performed. During the procedure, high resistance and couldn’t successfully insert the guidewire into the CBD. Given the unsuccessful ERCP, PTGBD was recommended.
    • The Pathology (2023/08/01) proved Bile duct, extrahepatic, common S/P Whipple procedure, adenocarcinoma. pancreas, Whipple procedure, invaded by adenocarcinoma. Intertine, small, duodenal, Whipple procedure, invaded by adenocarcinoma with lymph nodes metastasis (1/1), pT2N1M0 was diagnosed 2023/07/27 at FuRen Univ Hospital.
    • The HBsAg/Anti-Hbc showed positive on 2023/08/23. Tumor marker showed CA:199: 10.632 U/ml , CEA: 0.953 ng/ml.
    • Today, she was admitted for chemotherapy and port-A installation on 2023/08/27.
  • Course of inpatient treatment
    • After admission, port-A was inserted on 8/28 23. Hydration & chemotherapty with Gemzar (800mg/m2) plus Cisplatin (40mg/m2) were given on 8/29 23, smoothly without obvious side effect.
    • Bone scan was done on 8/30 23. She was discharged on 8/31 23 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
• 2023-08-23 SOAP Hemato-Oncology He JingLiang
  • S
    • extrahepatic cholangiocarcinom with pancreas invasion s/p whipple operation
    • she came for chemotherapy
  • P
    • check CBC, CEA, CA199, bio

[consultation]

• 2024-03-04 Radiation Oncology
  • Q
    • for lung biopsy.
    • This 73-year-old woman, a patient of Distal common bile duct tumor S/P pylorus oreserving oancreaticoduodenectomy on 2023/07/26.
    • Pathology: Bile duct, extrahepatic, common S/P Whipple procedure, adenocarcinoma.
      • pancreas Whipple procedure, invaded by adenocarcinoma.
      • Intestine, small, duodenal, Whipple procedure, invaded by adenocarcinoma with lymph nodes metastasis (1/1), pT2N1M0,
    • the abdomen CT was done 2024/02/20, the report showed
      • S/P operation.
      • A large LN (2.2cm) at left lower neck.
      • Some LNs at mediastinum and mesentery.
      • Bil. lung nodules c/w lung metastases.
      • Grade 4 fatty liver.
    • So we need your help for lung biopsy.
  • A
    • This 73-year-old female patient is a case of LUL lung nodule, r/o lung metastasis. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.

[chemotherapy]

• 2024-07-15 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-06-24 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-06-03 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4050mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-05-13 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4050mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-04-22 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-04-01 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-16 - gemcitabine 800mg/m2 1000mg NS 250mL 30min + cisplatin 40mg/m2 30mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-02 - gemcitabine 800mg/m2 1000mg NS 250mL 30min + cisplatin 40mg/m2 30mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-19 - gemcitabine 800mg/m2 1000mg NS 250mL 30min + cisplatin 40mg/m2 30mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-05 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-11-21 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-11-07 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-10-24 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-10-11 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-09-26 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-09-19 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-09-05 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-08-29 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

Systemic therapy for advanced cholangiocarcinoma - 2024-03-05 - https://www.uptodate.com/contents/systemic-therapy-for-advanced-cholangiocarcinoma

• INITIAL THERAPY
  • Good performance status and no hyperbilirubinemia
    • Gemcitabine plus cisplatin and durvalumab
    • Gemcitabine plus cisplatin and pembrolizumab
    • Gemcitabine plus cisplatin
    • Gemcitabine plus oxaliplatin
    • Gemcitabine plus capecitabine
    • Gemcitabine plus nabpaclitaxel
    • Gemcitabine plus S-1
    • Non-gemcitabine-based regimens
  • Good performance status and persistent biliary obstruction
    • Fluorouracil-based regimens
  • Borderline performance status
    • Leucovorin-modulated fluorouracil
    • Capecitabine
    • Gemcitabine alone
    • Biweekly gemcitabine plus cisplatin
• SECOND-LINE THERAPY AND BEYOND
  • Cytotoxic chemotherapy
    • Patients initially treated with gemcitabine plus cisplatin
      • FOLFOX
      • Liposomal irinotecan
      • Capecitabine plus oxaliplatin
      • Capecitabine plus irinotecan
      • Fluoropyrimidine alone
      • Antiangiogenic therapy
        • Bevacizumab
        • Regorafenib
        • Ramucirumab
    • Patients initially treated with gemcitabine plus oxaliplatin
      • Gemcitabine plus capecitabine
      • Capecitabine plus cisplatin
      • FOLFIRI with or without bevacizumab
  • Molecularly targeted therapy
    • Next-generation sequencing to identify actionable molecular abnormalities
      • Immunotherapy
        • Biomarker-selected patients
          • dMMR/MSI-H
          • PD-L1 overexpression
          • Tumor mutational burden
        • Biomarker-unselected patients
          • Combined immunotherapy for patients with intrahepatic cholangiocarcinoma
      • FGFR inhibitors for FGFR fusion-positive tumors
        • Pemigatinib
        • Infigratinib
        • Futibatinib
        • Erdafitinib
      • Ivosidenib for IDH-mutated cholangiocarcinoma
      • TRK inhibitor therapy for TRK fusion-positive cancers
      • BRAF V600E-mutated cancers
      • RET fusion-positive tumors
      • HER2-positive tumors
        • Trastuzumab plus pertuzumab
        • Trastuzumab plus tucatinib
        • Fam-trastuzumab deruxtecan
        • Zanidatamab
        • Lapatinib
      • KRAS G12C mutant tumors
        • Adagrasib
      • What is the role of EGFR inhibitors? - There is no established role for EGFR inhibitors in the treatment of metastatic cholangiocarcinoma.

==========

2024-03-05

[lung biopsy planned for extrahepatic bile duct cancer, 2nd line treatment options]

The patient was diagnosed with a malignant neoplasm of the extrahepatic bile duct in the 3rd quarter of 2023 at FuRen University Hospital and subsequently sought chemotherapy treatment at our facility with a regimen of gemcitabine and cisplatin. An attempt to coadminister TS-1 at the beginning of treatment was made but was quickly discontinued due to the patient’s intolerance.

The final dose of the gemcitabine and cisplatin regimen was administered on 2024-01-16, marking nearly six months of treatment, followed by a CT scan on 2024-02-20 that suggested potential disease progression. Currently, the patient is being prepared for a lung biopsy to investigate suspected metastasis.

The patient’s underlying hypertension is now being managed with Concor (bisoprolol) and Exforge (amlodipine, valsartan), aligning with the repeat prescriptions recorded in the PharmaCloud database. The patient’s vital signs and lab results (2024-03-04) were grossly within normal limits, with no discrepancies in medication identified.

Should disease progression be confirmed, several candidate regimens for second-line therapy could be contemplated, encompassing: FOLFOX; liposomal irinotecan; capecitabine combined with oxaliplatin; capecitabine paired with irinotecan; fluoropyrimidine as a standalone treatment; and antiangiogenic therapies, which include bevacizumab, regorafenib, and ramucirumab.

Molecularly targeted therapy represents an alternative approach when next-generation sequencing is employed to identify actionable molecular abnormalities.

701073310

240715

[exam findings]

• 2024-05-20 SONO - nephrology
  • Parenchymal renal disease
  • Simple cyst
• 2024-05-13 CT - abdomen
  • R/O bilateral renal cysts, up to 2cm in right kidney.
  • Unremarkable change of the liver, spleen, pancreas.
  • Post-op at lumbar spine.
  • Left inguinal hernia.
• 2024-03-28 Abdomen - standing (diaphragm)
  • S/P posterior instrumentation fixation from L4 To L5.
  • Disk space narrowing and suggestive bone graft implantation at L4-5 disk space.
• 2024-02-26 Patho - stomach biopsy
  • PATHOLOGIC DIAGNOSIS
    • Esopgaus, lower, biopsy — Mantle cell lymphoma
    • Stomach, body, biopsy — Mantle cell lymphoma
    • Stomach, antrum, biopsy — Mantle cell lymphoma
  • Immunohistochemical stain profiles: CD20(diffuse +), Bcl-2(+), CD10(-), SOX-11(+), Cyclin D1(+)
• 2024-02-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (96 - 32.5) / 96 = 66.16%
    • M-mode (Teichholz) = 66
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Mild MR, AR, TR and PR
    • No regional wall motion abnormalities
• 2024-02-20 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Mantle cell lymphoma with bone marrow involvement
  • The sections show normocellular marrow (25%). M/E ratio = 3:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. No definite lymphoid aggregates can be found.
  • IHC, scattered single and small clusters of CD3-/CD20+/Cyclin D1+ lymphoma cells in interstitium can be identified.
• 2024-02-26 PET scan
  • The FDG PET findings are compatible with lymphoma involving bilateral tonsils and multiple lymph nodes on both sides of the diaphragm as mentioned above.
  • Increased FDG uptake in the stomach. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
• 2024-02-15 SONO - abdomen
  • Pancreatic cystic lesion, body
  • Pancreatic or peripancreatic lesion, head/neck, r/o lymphadenopathies
  • Renal cysts, RK
• 2024-02-06 CT - neck
  • Marked enlargement of both palatine tonsils with adjacent mucosal thickening. Comaptible with lymphoma. Several mildly enlarged nodes over both submandibular spaces. Suggest tissue proof.
• 2024-01-30 Patho - tonsil biopsy (Y1)
  • Left tonsil, biopsy— Mantle cell lymphoma
  • Immunohistochemical stain profiles:
    • CD20(diffuse +), CD3(focal + at background T cells), Bcl-2(+), CD10(-), Ki-67 index: 10%, SOX-11(+), CD5(+), Cyclin D1(+).
    • p53: wild type, c-myc: negative
• 2024-01-29 Nasopharyngoscopy
  • Left tonsillar hypertrophy, r/o neoplasm, such as lymphoma
  • Lingutal tonsil hypertrophy, r/o neoplasm, such as lymphoma
  • Left sinusitis, chronic?

[MedRec]

• 2024-03-11 SOAP Gastroenterology Xiao ZongXian
  • P: Start TAF for antiviral therapy since 2024-02-15
  • Prescription x2
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2024-02-18 ~ 2024-02-26 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Mantle cell lymphoma with bone marrow involvement, Lugano stage IV, mIPI: 6.0 points
    • Obstructive sleep apnea (adult) (pediatric)
    • Chronic viral hepatitis B without delta-agent anti-Hbc: positive
    • Gastro-esophageal reflux disease without esophagitis
    • Gastric shallow ulcers S/P biopsy
  • CC
    • for further staging (including bone marrow exam), mIPI stage and first cycle of chemotherapy.
  • Present illness
    • This 64-year-old man, a patient of mantle cell lymphoma IHC stain — p53: wild type, c-myc: negative, CD20 (diffuse +), CD3 (focal + at background T cells), Bcl-2 (+), CD10 (-), Ki-67 index: 10%, SOX-11 (+), CD5 (+), Cyclin D1 (+) was diagnosed on 2024/01/30, suffered from lump throat, dysphagia for 3-4 months and visited to ENT OPD for evaluation and survey.
    • Image study with Nasopharyngoscopy (2024/01/29) showed Left tonsillar hypertrophy, r/o neoplasm, such as lymphoma. Lingutal tonsil hypertrophy, r/o neoplasm, such as lymphoma.
    • Left tonsil, biopsy (2024/01/30) proved Mantle cell lymphoma, IHC stain — p53: wild type, c-myc: negative, CD20 (diffuse +), CD3 (focal + at background T cells), Bcl-2 (+), CD10 (-), Ki-67 index: 10%, SOX-11 (+), CD5 (+), Cyclin D1 (+).
    • Neck CT (2024/02/06) showed marked enlargement of both palatine tonsils with adjacent mucosal thickening. Comaptible with lymphoma. Several mildly enlarged nodes over both submandibular spaces. Suggest tissue proof.
    • PET scan (2024/02/16) revealed lymphoma involving bilateral tonsils and multiple lymph nodes on both sides of the diaphragm as mentioned above.
    • Today, he was admitted for further staging (including bone marrow exam), mIPI stage and first cycle of chemotherapy.
  • Course of inpatient treatment
    • After admission, bone marrow was done on 2024/02/21 and pathology showed Mantle cell lymphoma with bone marrow involvement.
    • Heart echo (2024/02/21) showed LVEF 66%, Adequate LV and RV systolic function/Possibly impaired LV relaxation
    • Mild MR, AR, TR and PR. EGD (2024/02/23) revealed reflux esophagitis LA Classification grade A, Esophageal mucosal lesions, r/o glycogen acanthosis, s/p biopsy (C); Gastric shallow ulcers, antrum, s/p biopsy (A). PPI therapy was added.
    • Chenmotherapy with R-CHOP was given on 2024/02/22 ~ 23, smoothly without obvious side effect.
    • He was discharged on 2024/02/26 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Norvasc (amlodipine 5mg) 1# QD
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Compesolon (prednisolone 5mg) 10# BID - for 2/26 1800 ~ 2/27 1800

[immunochemotherapy]

• 2024-07-02 - rituximab 375mg/m2 660mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 927mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-05-06 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cisplatin 100mg/m2 180mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 1820mg NS 500mL 3hr Q12H D3 + dexamethasone 40mg/m2 36mg BID PO D2-5 (R-DHAP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-04-15 - rituximab 375mg/m2 690mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1380mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-03-18 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cisplatin 100mg/m2 180mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3690mg NS 500mL 3hr Q12H D3 + dexamethasone 40mg/m2 36mg BID PO D2-5 (R-DHAP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-02-22 - rituximab 375mg/m2 690mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1380mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2

==========

2024-07-15

[switching medication due to deteriorating kidney function]

The patient’s renal function is deteriorating, with the latest eGFR dropping below 15 as of 2024-07-13.

The package insert for Vemlidy (tenofovir alafenamide) advises against its use in patients with CrCl < 15. However, Baraclude (entecavir 0.5mg) may be considered as an alternative, administered every three days (Q3D) in patients with CrCl between 10 and <30 mL/minute.

• 2024-07-13 eGFR 14.43 ml/min/1.73m^2
• 2024-07-12 eGFR 16.01 ml/min/1.73m^2
• 2024-07-09 eGFR 21.83 ml/min/1.73m^2
• 2024-07-06 eGFR 25.74 ml/min/1.73m^2
• 2024-07-04 eGFR 30.89 ml/min/1.73m^2

701173809

240715

[exam finding]

• 2024-05-15 Patho - colorectal polyp
  • Rectum, biopsy — Adenocarcinoma, moderately differentiated
  • The sections show adenocarcinoma, moderately differentiated, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction.
• 2024-05-14 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Post-op at the colon.
    • Enhancing tumor in right pelvic cavity, 4.7x2.7cm, r/o recurrence.
    • Left renal tumor with adjacent psoas muscle involvement, r/o metastasis.
    • Poor enhancing nodule, 1cm in S7 liver, r/o liver metastasis.
    • There are multiple enlarged lymph nodes in the paraaortic region, right common iliac and external iliac, obturator regions. Could be due to metastatic lymph nodes.
    • Enlarged lymph nodes in left neck region, r/o lymph nodes metastasis.
    • Small nodules in RUL, r/o lung metastasis.
  • Impression:
    • Post-op at the colon.
    • R/O recurrence in RLQ, progression.
    • Left renal tumor with adjacent psoas muscle involvement, r/o metastasis.
    • Multiple lymph nodes metastasis (paraaortic and pelvic cavity, left lower neck).
    • Small nodules in RUL, r/o lung metastasis.
• 2024-01-30 Patho - lymphnode biopsy
  • Lymph node, supraclavicula, left, excision — Adenocarcinoma, metastatic, consistent with colorectal primary
  • The sections show a picture of metastastic adenocarcinoma, composed of lymphoid tissue with nests of columnar neoplastic cells, arranged in glandular and cribriform patterns with extensive dirty necrosis. IHC, tumor cells reveal: CK20(+), CK7(-), and CDX2(+). The finding is consistent with colorectal primary.
• 2024-01-23 Sonography - vein
  • Conclusion:
    • Suspected cancer associated thrombus in right proximal vein (iliofmeoral) with partial vessel recanalization, residual thrombosis at Rt CFV, iliac vein but not femroal veins
    • no varricose vein at both GSV and SSV
    • slow flow at both lower leg vein
    • The MVO/SVC ratio showed realtively lower level at both site (RT > Lt) suggesting partial venous thrombosis at more proximal level
    • The elastic bandage might improve venous return 78% (80% 14.5, 77% 16.5) vs 82% (84% 21.9, 81 25.7%) at both legs
• 2024-01-22 Whole body PET scan
  • Increased FDG uptake in the right anterior lower pelvis, and in celiac, bilateral para-aortic, right common iliac, and bilateral internal iliac lymph nodes, highly suspected tumor recurrence with lymph nodes metastases, suggesting biopsy for investigation.
  • Increased FDG uptake in the left infra-clavicular and supra-clavicular lymph nodes, and in a right mediastinal lymph node, highly suspected tumor recurrence with distant lymph nodes metastases.
  • Increased FDG uptake in the posterolateral aspect of the left 11th-12th intercostal space is old and comes to more prominent, highly suspected tumor recurrence with distant metastases.
  • A glucose hypermetabolic lesion in the middle part of the left kidney is old and comes to more evident, suggesting recurrent malignancy in progression. Please also correlate with other clinical findings for further evaluation.
  • S-colon s/p treatment with tumor recurrence and multiple distant metastases; left renal cancer s/p treatment with tumor recurrence, by this F-18 FDG PET scan.
• 2023-11-14 CT - abdomen
  • S/P colon and left renal operation. A hypodense nodule (2.1cm) at left kidney. Some enlarged LNs (up to 1.7cm) at retroperitoneum along aorta and IVC.
  • S/P Port-A infusion catheter insertion.
  • Small liver cyst and hemangioma.
  • Lipomas (3.8cm, 4.9cm) at right thigh.
• 2023-08-08 CT - abdomen
  • S/P colon and left renal operation. A hypodense nodule (1.6cm) at left kidney.
  • S/P Port-A infusion catheter insertion.
  • Small liver cyst and hemangioma.
• 2023-04-28 CT - abdomen
  • S/P partial nephrectomy at left kidney upper pole.
    • Prior CT identified a poor enhancing lesion 1.2 x 0.7 cm in left kidney middle pole is noted again, stationary. Follow up is indicated.
  • Prior CT identified a cyst 7 mm in S4 and a hemangioma 1.3 cm in S7 of the liver are noted again, stationary.
  • S/P right hemicolectomy and S/P LAR with autosuture retention over the sigmoid colon.
• 2023-02-09 CT - abdomen
  • S/P colon and renal operation.
  • Small liver cyst and hemangioma.
• 2022-09-30 CT - abdomen
  • History:
    • 20190323 CT: sigmoid colon cancer with total obstruction.
    • 20190327 surgery: Sigmoid cancer with obstruction and invasion to the cecum s/p Sigmoid colectomy + Right hemicolectomy. Patho: pT4bN2bM0, pstage IIIC
    • 20191231 S/P partial Lt nephrectomy:RCC, clear cell, pT1aN0M0
    • 20220413 CT: a lesion in Lt 11th rib intercostal space, Suspected meta.
    • 20220502 CT-guided biopsy patho favor metastasis c/w colon origin. a lesion in Lt kidney middle pole, suspected recurrent RCC? clinician favor old hematoma.
  • Findings:
    • S/P partial nephrectomy at left kidney upper pole.
      • Prior CT identified a poor enhancing lesion 1.6 x 1.3 cm in left kidney middle pole is noted again, mild decreasing in size to 1.2 x 0.7 cm. Follow up is indicated.
      • Prior CT identified a metastasis measuring 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib intercostal space is not noted again in the current CT that is c/w metastasis S/P surgical resection.
    • Prior CT identified a cyst 7 mm in S4 and a hemangioma 1.3 cm in S7 of the liver are noted again, stationary.
    • S/P right hemicolectomy and S/P LAR with autosuture retention over the sigmoid colon.
  • Impression:
    • S/P partial nephrectomy at left kidney upper pole.
    • There is no evidence of tumor recurrence.
• 2022-05-27 Patho - peritoneum biopsy
  • Diaphragm, left, excision — Metastatic adenocarcinoma, consistent with colorectal origin
  • Sections show fibroadipose and skeletal muscular tissue with invasive neoplastic glandular cells.
  • The immunohistochemical stain of CDX2 is positive. Lymphovascular invasion is found. The result and morphology are consistent with metastatic adenocarcinoma from colorectal origin. The peripheral resection margins are free of tumor. The tumor is very close (<0.1cm) to the serosal surface.
• 2022-05-26 CXR
  • Thoracic aortic arch calcified atheriosclerotic plaque
• 2022-05-19 Whole body PET scan
  • Glucose hypermetabolism in a focal area in the posterior lateral aspect of left 11th-12th intercostal space, in a focal area in the posterior aspect of left kidney, in a focal area in the middle lower pelvis just in the left anterolateral aspect of rectum and in a focal area in the right anterior lower pelvis. Multiple metastatic lesions should be considered. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • A glucose hypermetabolic lesion in the middle pole of left kidney. Recurrent malignancy should be watched out. Please also correlate with other clinical findings for further evaluation.
• 2022-05-03 Patho - soft tissue nontumor/mass/lipoma/debridement
  • Labeled as “left 11 rib”, (clinically: sigmoid colon cancer and renal cell cancer), CT guided biopsy — metastatic adenocarcinoma.
  • IHC stains:
    • CD10 (-) and RCC (-): dis-favor RCC,
    • CK20 (+): compatible with colon origin;
    • TTF-1 (-): dis-favor pulmonary origin;
    • PSA (-): dis-favor prostatic origin.
  • Section shows soft tissue with many small nests of criform pattern adenocarcinoma.
• 2022-04-13 CT - abdomen
  • History:
    • 20190323 CT:sigmoid colon cancer with total obstruction.
    • 20190327 surgery: Sigmoid cancer with obstruction and invasion to the cecum s/p Sigmoid colectomy + Right hemicolectomy
      • Patho: pT4bN2bM0, pstage IIIC
    • 20191231 S/P partial Lt nephrectomy: RCC, clear cell, pT1aN0M0
  • Findings
    • S/P partial nephrectomy at left kidney upper pole.
      • Prior CT identified a poor enhancing lesion 0.9 cm in left kidney middle pole is noted again, mild increasing in size to 1.6 x 1.3 cm.
      • A newly-developed renal cell carcinoma is suspected. Please correlate with contrast enhanced dynamic CT or MRI.
      • In addition, another newly-developed heterogeneous poor enhancing mass measuring 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib rintercostal space is noted that may be tumor seeding.
    • Prior CT identified a cyst 7 mm in S4 and a hemangioma 1.3 cm in S7 of the liver are noted again, stationary.
    • S/P right hemicolectomy and S/P LAR with autosuture retention over the sigmoid colon.
  • Impression
    • RCC 1.6 x 1.3 cm in Lt kidney middle pole is suspected.
    • Tumor seeding 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib rintercostal space is highly suspected. please correlate with clinical condition and biopsy.
• 2021-12-30 SONO - abdomen
  • Diagnosis
    • Negative finding
    • Pancreas not shown
  • Suggestion
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2021-07-01 CT - abdomen
  • S/P colon operation.
  • Small liver cyst and hemangioma.
  • Left renal tumors (0.9cm, 2.7cm) without interval change.
• 2021-04-01 CT - abdomen
  • S/P colon operation.
  • Small liver cyst and hemangioma.
  • Left renal tumors (0.9cm, 2.7cm).
• 2020-03-20 CT - abdomen
  • dilated small bowel. suspected small bowel ileus.
  • recent renal infarction in the left kidney.
• 2020-01-02 Surgical pathology Level V
  • PATHOLOGIC DIAGNOSIS:
    • Kidney, left, partial nephrectomy — Clear cell renal cell carcinoma with sarcomatoid feature
      
    • Pathology stage: pT1aNx, stage I at least
  • MICROSCOPIC EXAMINATION
    • Histological type: Clear cell renal cell carcinoma
      
    • Sarcomatoid features: Present (80%)
      
    • Rhabdoid features: Not identified
      
    • Histologic grade: Grade 4
      
    • Tumor necrosis: Present (20%)
      
    • Tumor Extension: Tumor limited to kidney
      
    • Margins: Uninvolved by invasive carcinoma
      
    • Lymphovascular invasion: Not identified
      
    • Regional lymph nodes (pN): No lymph node found
      
    • Distant metastasis (pM): Not applicable
      
    • Nonneoplastic kidney: Chronic pyelonephritis
• 2019-12-02 MRI - liver, spleen
  • A hemangioma (1.3cm) in S7 of liver. A cyst (0.5cm) in S4 of liver.
  • A poor enhancing tumor (2.7cm) in left kidney suspected hypovascular RCC.
• 2019-09-26 CT - abdomen
  • Colon cancer s/p operation with colostomy. No evidence of tumor recurrence.
  • A poor enhancing tumor (2.7cm) in left kidney (mild increased size).
  • A poor enhancing tumor (1.1cm) in S7 of liver without interval change.
• 2019-06-25 CT - abdomen
  • No evidence of recurrent tumor in the study.
• 2019-03-27 Surgical pathology Level VI
  • PATHOLOGIC DIAGNOSIS
    • Sigmoid colon, colectomy — Adenocarcinoma, moderately differentiated
    • Ascending colon, R’t hemicoloectomy — Adenocarcinoma, compatible with direct tumor invasion from sigmoid cancer
    • Proximal & distal surgical margins — Free of tumor invasion
    • Lymph nodes, mesocolic, dissection — Positive for tumor metastasis (8/43) with extracapsular extension (2/8)
    • Appendix, terminal ileum — Free of tumor invasion
    • AJCC pathologic stage — pT4bN2bMx, stage IIIC at least
  • MICROSCOPIC EXAMINATION
    • Histology: sigmoid adenocarcinoma directly invades to ascending colon
    • Histology Grade: G2: moderately differentiated
      
    • Depth of invasion: direct invades adjacent colon
    • Angiolymphatic invasion: Present
    • Perineural invasion: NOT identified
    • Discontinuous extramural tumor extension: Not identified.
    • Circumferential (radial) margin of rectosigmoid: Involved
    • Lymph node metastasis, mesocolic: Positive for tumor metastasis (8/43)
    • Lymph node metastasis, IMA / SMA: N/A
    • Extranodal involvement: Present (2/8)
    • Pathological TNM Stage: pT4bN2bMx, stage IIIC at least
    • Type of polyp in which invasive carcinoma arose: N/A
    • Additional pathologic findings: N/A
    • TNM descriptors: N/A
      
    • Tumor regression grading S/P CCRT: N/A
    • Proximal & distal margins: free from tumor invasion
• 2019-03-26 Surgical pathology Level IV
  • Colon, sigmoid, 20 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2019-03-23 CT - abdomen
  • Indication: Abdominal dull pain for 2-3 days, mostly over the right, abdominal fullness with no stool passage for 2 days, N∕V(+), no chest pain, no SOB, no flank pain, denied OP history
  • Imaging Report Form for Colorectal Carcinoma
  • Impression:
    • Dilated colon and small intestines with transitional point at sigmoid colon, suspected foreign body related or sigmoid colon cancer.
      
    • T3N1Mx, IIIB

[MedRec]

[surgical operation]

• 2022-05-27 Excision of chest wall and repair of diaphragmatic defect.

  • One solid nodular lesion was noted over left CP angle, near diaphram and 11th intercostal muscle, size about 3cm in max. diameter.
  • One J-P drain was inserted beneth the wound.

• 2020-03-23 Enterolysis with bowel decompression

  • Adhesion band and causing small bowel dilatation

• 2019-12-31 Partial nephrectomy

• 2019-10-30 Closure of enterostomy or Colostomy (loop or double-barrel)

• 2019-03-27 Left hemicolectomy or sigmoid colectomy with anastomosis with lymph node

• 2019-03-23 Enterostomy for suspected S-colon cancer with obstruction

• drug allergy

  • Eloxatin (oxaliplatin 50 mg/vial) - whole body rash, fever all over

[immunochemotherapy]

• 2024-07-12 - cetuximab 400mg/m2 800mg 2hr + irinotecan 120mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-13 - cetuximab 400mg/m2 800mg 2hr + irinotecan 130mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 760mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-19 - cetuximab 400mg/m2 800mg 2hr + irinotecan 130mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 760mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-02 - ………………………… irinotecan 180mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 760mg NS 250mL 2hr + fluorouracil 400mg/m2 760mg NS 250mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-02-06 - irinotecan 180mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 760mg NS 250mL 2hr + fluorouracil 400mg/m2 760mg NS 250mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-01-16 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
• 2022-12-27 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
• 2022-12-07 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
• 2022-11-03 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
• 2022-10-17 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
• 2022-09-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
• 2022-09-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
• 2022-08-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 400mg/m2 760mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
• 2022-08-02 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 400mg/m2 760mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg …………….. + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
• 2022-06-29 - bevacizumab 5mg/kg 400mg 90min + irinotecan 120mg/m2 230mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg …………….. + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
• 2022-06-14 - ………………………….. irinotecan 120mg/m2 225mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 200mg/m2 380mg 10min + fluorouracil 2400mg/m2 4570mg 46hr (FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + granisetron 2mg
• 2019-07-08 ~ 2019-09-18 - Adjuvant chemotherapy with mFOLFOX6 for 6 times.

==========

2024-07-15

[strategies for handling liver deterioration]

The patient’s liver function is deteriorating, as indicated by recent rapid increases in ALT, AST, bilirubin, and decreased albumin levels.

It is recommended to add BaoGan (silymarin) and delay the next session of “Erbitux + FOLFIRI” until there is evidence of recovery. In addition, it is recommended to monitor HBV DNA levels (check for HBV reactivation) to determine whether the dose of Baraclude (entecavir) should be adjusted from 0.5mg to 1mg or switched to Vemlidy (tenofovir alafenamide, if resistance develops).

• 2024-07-15 ALT 106 U/L
  

• 2024-07-12 ALT 34 U/L

• 2024-07-15 AST 160 U/L
  

• 2024-07-12 AST 48 U/L
  

• 2024-07-08 AST 40 U/L
  

• 2024-06-24 AST 21 U/L

• 2024-07-15 Bilirubin total 1.79 mg/dL
  

• 2024-07-12 Bilirubin total 1.35 mg/dL
  

• 2024-07-08 Bilirubin total 1.12 mg/dL
  

• 2024-06-24 Bilirubin total 0.62 mg/dL

• 2024-07-15 Bilirubin direct 1.12 mg/dL
  

• 2024-07-12 Bilirubin direct 0.64 mg/dL
  

• 2024-05-13 Bilirubin direct 0.19 mg/dL

• 2024-07-15 Albumin (BCG) 2.7 g/dL
  

• 2024-07-12 Albumin (BCG) 3.2 g/dL
  

• 2024-07-08 Albumin (BCG) 3.0 g/dL

• 2024-07-12 CEA 8.08 ng/mL
  

• 2024-05-28 CEA 5.35 ng/mL
  

• 2024-05-21 CEA 5.19 ng/mL
  

• 2024-05-09 CEA 4.64 ng/mL
  

• 2024-04-25 CEA 3.10 ng/mL
  

• 2024-03-27 CEA 2.73 ng/mL

2022-12-28

• The CEA and CA199 markers did not show any obvious trend over the past six months.
• Lab data for 2022-12-27 showed a WBC level of 3.82K/uL and a neutrophil percentage of 37%. The possibility of potential infectious events and neutropenia might be kept in mind.
• The most recent CT was dated on 2022-09-30. Possibly, the lesion in the middle pole of the left kidney should be followed up. It may be updated if it is considered to be beneficial to clinical decision-making.
• The active prescription does not pose a problem.

2022-10-18

The patient’s vital signs, laboratory data (2022-10-11), and the disease are in a generally stable state.

2022-09-28

There is no issue with the active prescription. It is recommended that the last abdomen CT image be updated as it is dated 2022-04-13. A metastatic adenocarcinoma around the left 11th and 12th ribs (2022-05-03 pathology) might be surgically removed if it is symptomatic and feasible.

2022-09-14

There was a generally normal lab result on 2022-09-12 and a relatively stable TPR and BP reading during this hospital stay. With the current regimen, the patient has tolerated it. In this case, the patient has only a muscle power of 4 or less, so some assistive devices might be beneficial.

701304319

240715

[MedRec]

• 2024-06-25 ~ 2024-07-03 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Squamous cell carcinoma of the right tongue base, P16(-), cT4aN2cM0 stage IVA, s/p concurrent chemoradiotherapy with 5000cGy/25 fractions of the tongue base tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the tongue base tumor to involved nodal lesions, and weekly Cisplatin from 2024/05/31~
    • Pneumonia, unspecified organism
    • Fever
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Chronic Insomnia
    • Chronic viral hepatitis B without delta-agent, Anti-HBc reactive
  • CC
    • Fever up to 38.5’C was noted yesterday, and feel weakness
  • Present illness
    • This 57 year-old male patient has had HTN and type II diabetes mellitus under regular medication control for many years.
    • Initial, purulent rhinorrhea and hyposmia were noted after an COVID infection 2 months ago. He went to ENT OPD for help, right tongue base tumor was noted. He had foreign body sensation at throat and recent BW loss over 5 kg in recent 2 months. He has had cigarette smoking 1-3 PPD/day for 40 years, alcohol drinking quitted for 2 years, and betel nut chewing quitted for 2 years.
    • PE revealed whitish mass lesion over right tongue base, leukoplakia over buccal area, submucosal fibrosis over right buccal area, erythematous change over the soft palate and uvula.
    • Biopsy of right tongue base lesion was done on 2024/04/11, and the pathology revealed squamous cell carcinoma.Then he received tumor staging work up.
    • Nasopharyngeal MRI on 2024/04/24 showed oropharnx cancer T4aN2cM0, stage: IVA.
    • Upper GI pandescopy revealed oropharngeal cavity tumor, reflux esophagitis LA and gastric ulcers.
    • PET on 2024/04/25 showed glucose hypermetabolism involving the tongue base, right aspect of the tonge and right oropharyngeal wall, compatible with primary malignancy in this region; mild glucose hypermetabolism in two left neck level II lymph nodes; mild glucose hypermetabolism in the upper lobe of right lung and in bilateral pulmonary hilar regions. Inflammatory process is more likely.
    • Oral surgery suggested extracted all the tooth at once under GA. Due to difficult intubation were occurred, tracheostomy was performed on 2024/05/15. Then he received complicated extraction of tooth 11, 12, 13, 14, 15, 16, 17, 22, 23, 24, 26, 27, 31, 32, 33, 34, 35, 36, 41, 42, 43, 44, 46, and 47; alveoloplasty of maxilla and mandible of both sides, left port-A insertion on 2024/05/15.
    • Cancer treatment plan with concurrent chemoradiotherapy, radiotherapy with 5000cGy/25 fractions of the tongue base tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the tongue base tumor to involved nodal lesions, since 2024/05/31~. Weekly chemotherapy with Cisplatin from 2024/05/03, 06/07, 06/14, 06/20.
    • This time, he suffered from chillness with fever. Initially went to ShuangHe Hospital, but all are treated in our hospital, transferred to our hospital for help. At ER, he conscious level is E4VTM6, vital signs: BT: 38.3’C, PR: 113 bpm/min, RR: 20 time/min, BP: 131/75mmHg, room air SpO2: 98%. Laboratory results: WBC 8.93 x10^9/L, PLT 209 x10^9/L, Hb 10.7 g/dL, CRP 15.4 mg/L.
    • Urine and blood cultures were obtained. Chest X-ray showed right pneumonia. Treatment included Cravit, Tramador, and Panadol. Under the tentative diagnosis of right pneumonia, he was admitted to our ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, Tapimycin 4.5g/vial 4.5g IVD Q6H for infection control from 2024/06/25~07/02.
    • Shitan 8mg/tab 1# PO QID and Actein 66.7mg/gm, 3gm/pk 1pk PO TID for cough with sputum.
    • Due to blood culture showed Parvimonas micra, verbal consultation with an infectious disease physician, expressed as contaminating bacteria.
    • Morphine 15mg/tab 2# PO Q6H for pain control.
    • Consult ENT for change Tr, but tracheal stenosis noted, tracheostomy tube can’t totally inserted, remove tracheostomy tube.
    • Diovan F.C. 160mg/tab 0.5# PO QD、Norvasc 5mg/tab 1# PO QD was treated with hypertension.
    • Diet control and check finger sugar for Type 2 diabetes mellitus was treated with Amepiride 2mg/tab 2# PO QDAC and Uformin 500mg/tab 2# PO BID.
    • For chemotherapy, Vemlidy 25 mg/tab 1# PO QD was given for Anti-HBc reactive.
    • Chronic Insomnia with Eurodin 2mg/tab 1# PO HS and Anxiedin 0.5mg/tab 1# PO BID.
    • After infection control, get improved. He restart radiotherapy (15/35Fx) and receive weekly chemotherapy with cisplatin on 2024/07/02(C5).
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, he was discharged on 2024/07/03 and OPD followed up later.
• 2024-05-30 SOAP Hemato-Oncology Xia HeXiong
  • P: Tx plan: CCRT with weekly CDDP
• 2024-05-13 ~ 2024-05-23 POMR Oral and Maxillofacial Surgery Xia YiRan
  • Discharge diagnosis
    • Squamous cell carcinoma of base of tongue, cT4aN2cM0, Stage: IVA
    • Multiple hopeless deep careis combined with local infection post of complicated extraction x24 and alveoloplasty of maxilla and mandible of both sides on 2024/05/15
    • local infection of both sides of jaw bones
    • Acute respiratory failure post of tracheotomy on 2024/05/15
    • Atrial fibrillation
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Chronic Insomnia
  • CC
    • He was admitted to remove many hopeless, inflammatory teeth before he underwent chemotherapy and radiotheapy due to tongue base cancer.
  • Present illness
    • According to the patient’s statement, he had protruding mass at his right tongue since the end of October, 2023. Some how he didn’t have further treatment for his malignant lump until this April. He went to ENT Huang TongCun for help and was received A biopsy at his right tongue base lesion on 2024/04/11. His pathology report showed squamous cell carcinoma. His nasopharyngeal MRI showed oropharnx cancer cT4aN2cM0, stage IVA. Because his treatment plans were chemotherapy and radiotheapy treatment before operations took place, he was referred to our O.S for dental evaluation. His mouth finding showed local inflammation, gingival swelling due to many hopeless teeth. Besides, gingivitis and gingival recession of full mouth were noted. After we explained the necessary tooth extraction of all of his hopeless teeth, he decided to take our advice. So, he was admitted to ward this noon for surgical intervention under general anesthesia.
  • Discharge diagnosis
    • Actein (acetylcysteine 200mg) 1# TID 7D
    • Anxiedin (lorazepam 0.5mg) 1# BID 7D
    • OxyNorm IR (oxycodone 5mg) 1# Q7H 7D
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Stilnox (zolpidem 10mg) 1# HS 7D
    • Parmason Gargle Solution (chlorhexidine) QD GAR
• 2024-04-22 ~ 2024-04-25 POMR Ear Nose Throat Huang TongCuan
  • Discharge diagnosis
    • Malignant neoplasm of base of tongue, cT4aN2cM0, Stage: IVA
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
  • CC
    • Right tongue base tumor noted incidentally since 2023/11.
  • Present illness
    • This 57 year-old male patient has had HTN and type II diabetes mellitus under regular medication control for many years. According to the patient’s statement, purulent rhinorrhea and hyposmia were noted after an COVID infection 2 months ago.
    • He went to our ENT OPD for help, right tongue base tumor was noted incidental by Dr. Guo YenJun. He had foreign body sensation at throat and recent BW loss over 5 kg in recent 2 months. He has had cigarette smoking 1-3 PPD/day for 40 years, alcohol drinking quitted for 2 years, and betel nut chewing quitted for 2 years.
    • He was referred to Dr. Huang OPD for further evaluation. At OPD, PE revealed whitish mass lesion over right tongue base, leukoplakia over buccal area, submucosal fibrosis over right buccal area, erythematous change over the soft palate and uvula.
    • Biopsy of right tongue base lesion was done on 2024/04/11, and the pathology revealed squamous cell carcinoma. Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of right tongue base cancer, the patient was admitted for cancer work-up.  
  • Course of inpatient treatment
    • After admission, serial tests were arranged for tumor staging work up.
    • Nasopharyngeal MRI showed oropharnx cancerT4aN 2cM0, stage: IVA.
    • Abdominal sonography showed mild fatty liver.
    • Upper GI pandescopy revealed oropharngeal cavity tumor, reflux esophagitis LA and gastric ulcers.
    • Pending PET result.
    • Consulted OS for teeth evaluation, which suggest extracted all the tooth at once under GA.
    • Under relative stable condition, the patient was dishcarged with OPD follow up
  • Discharge prescription
    • Nexium (esomeprazole 40mg) 1# QDAC 7D

==========

2024-07-15

[administering OxyNorm via feeding tubes]

When administering OxyNorm (oxycodone) Immediate Release capsules via nasogastric feeding or gastrostomy, start by flushing the tube with water. Open the capsule and directly pour the contents into the tube. Follow this with a flush of 15 mL of water, then rinse the tube at least two more times with 10 mL of water each. Milk or liquid nutritional supplements may be used in place of water.

701481418

240715

[lab data]

• 2023-07-14 BM Chromosome Analysis
  • Chromosome Analysis:
    • Tissue Examined: Bone marrow
    • Staining Method: G-Banding
    • Colony number: NA
    • Bands level: 500
    • Chromosome Counts:
      • 45-(2)、46-(17)、47-()、Other-(1) Total-(20)
    • Karyotype: 46,XX[16]
  • Interpretation:
    • Analysis of this bone marrow sample shows a female having 46,XX[16] karyotype. There was no significant clonal chromosomal abnormality detected. However, from 20 cells analyzed, four cells with abnormal karyotypes [44,XX,-14,-21; 45,XX,-11; 45,XX,-22 and 46,XX,t(2;7)(q11.2;q11.2), respectively] were observed. No clinical significance can be ascribed to these non-clonal findings at the present time.
  • Note:
    • ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

[exam findings]

• 2024-07-12 CT - abdomen
  • Findings: Comparison: prior CT dated 2024/04/08.
    • Prior CT identified enlarged LNs in para-aortic space are noted again, decreasing in size.
    • There is mild edematous wall thickening of the sigmoid colon. please correlate with clinical condition.
    • Prior CT identified splenomegaly is noted again, stable in size.
      • There are few geographic poor enhancing areas in the spleen that may be infarction secondary to prior TAE.
    • Prior CT identified cystic lesion with enhancing wall in left adnexa is noted again, stationary. Please correlate with GYN. sonography.
    • Prior CT identified a calcified stone in the distal CBD is noted again, stationary. A gallstone 0.6 cm is also noted.
  • Impression:
    • Prior CT identified enlarged LNs in para-aortic space are noted again, decreasing in size.
    • There is mild edematous wall thickening of the sigmoid colon. please correlate with clinical condition.
• 2024-05-14, -05-13 CXR
  • S/P port-A implantation.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
• 2024-05-14 Abdomen - Standing (Diaphragm)
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5 and L5-S1.
  • Avascular necrosis of right femoral head is highly suspected.
• 2024-05-02 PET
  • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm, liver and bones or bone marrow (stage IV). In comparison with the the previous study on 2023/06/16, multiple new FDG avid lesions are noted.
• 2024-04-08 CT - abdomen
  • History and indication: Diffuse large B-cell lymphoma
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Enlarged LNs (up to 2.7cm) at upper retroperitoneum.
    • Hypodense lesions (up to 1.3cm) in right hepatic lobe.
    • Some hypodense lesions in spleen.
    • Partial atelectasis at left lingual lung and LLL.
    • A LN (1.1cm) at left subphrenic region.
    • A cystic lesion (6.4cm) at left pelvic cavity. Small amount ascites.
    • Gallbladder and CBD stones (up to 5.3mm).
    • Atherosclerosis of aorta, iliac arteries.
• 2024-03-02 ECG
  • Normal sinus rhythm
  • Inferior infarct , age undetermined
  • Cannot rule out Anterior infarct, age undetermined
  • Abnormal ECG
• 2023-12-26 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Splenomegaly with heteregeneous enhancement, stationary.
    • Presence of gallbladder and CBD stones.
    • Liver cyst, 0.6cm in S5.
    • Cystic tumor, 5.9cm in left adnexa, stationary.
    • Presence of ascites.
    • Basal lung atelectasis in left lower lung.
  • Impression:
    • Splenomegaly with heteregeneous enhancement, stationary.
    • GB and CBD stones.
    • Left adnexal cystic tumor, stationary.
• 2023-11-27 CXR
  • S/P port-A implantation.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
• 2023-10-05 Tc-99m MDP bone scan
  • Increased activity in the left S-I joint and right femoral head. The nature is to be determined. Please correlate with other imaging modalities for further evaluation and to ule out the possibility of bone metastases.
  • Increased activity in the middle and lower C-spines, middle T-spines, L5 and right S-I joint. Degenerative change may show this picture. Please also correlate with other imaging modalities for further evaluation.
  • Increased activity in bilateral shoulders, left hip and left knee, compatible with benign joint lesions.
• 2023-09-20 CT - abdomen
  • Findings: Comparison prior CT dated 2023/05/02.
    • Prior CT identified enlarged in size and diffuse poor enhancing masses in the spleen and multiple enlarged nodes in para-aortic space are noted again, marked decreasing in size that is c/w malignant lymphoma of the spleen and para-aortic LNs S/P C/T with partial response to complete response. Follow up is indicated.
    • There are few geographic poor enhancing areas in the spleen that may be infarction secondary to prior TAE.
    • Prior CT identified cystic lesion with enhancing wall in left adnexa is noted again, stationary. Please correlate with GYN. sonography.
    • There is mild ascites in the cul-de-sac.
    • Prior CT identified a calcified stone in the distal CBD is noted again, stationary. A gallstone 0.6 cm is also noted.
  • Impression:
    • Malignant lymphoma of the spleen and para-aortic LNs S/P C/T show partial response to complete response. Please correlate with clinical condition. Follow up is indicated.
• 2023-06-26 Patho - bone marrow biopsy
  • Bone marrow, biopsy — No evidence of lymphoma involvement
  • The sections show normocellular marrow (35%). M/E ratio = 4:1. The myeloid cells show good maturation with mild neutrophilia. The megakaryocytes are normal in number and morphology. No lymphoid aggregates can be found.
  • IHC, there is no evidence of lymphoma involvement in CD3 and CD20 immunostains. Suggest further bone marrow smear evaluation and clinic correlation.
• 2023-06-19 CT - chest
  • Indication: Diffuse large B-Lymphoma
  • Comparison was made with abdominal CT on 2023/05/02
    • Lungs: partial relaxation atelectasis of LLL and lingula.
      • band subsegmental atelectasis at RML and basal segments of RLL.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels:
      • mild calcified plaques of the LAD coronary artery.
      • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch.
      • Central pulmonary arteries: mild dilated trunk (3.4cm) and right (2.8cm) pulmonary artery.
    • Heart: normal size of cardiac chambers.
    • Pleura: moderate Lt-sided effusion.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: marked splenomegaly with extensive poorly enhanced masses. abnormal masses in the pancreatic tail
      • extensive lymphadenopathy at the para-aortic, splenic hilum, retroperitoneum (peripancreatic region), and pelvic (bilateral iliac chains).
      • mild Lt hydronephrosis and delayed parenchymal enhancement due to compression at U-P junction lymphadenopahty.
      • unremarkable of the liver, GB, spleen, both adrenal glands
  • Impression:
    • no lymphadenopathy in the chest but moderate Lt pleural effusion.
    • intra-abdominal extensive lymphadenopathy with splenic and pancreatic involvement, in progression increase in size as compared with the previous abdominal CT on 2023/05/02
• 2023-06-16 PET
  • Findings: There was increased FDG uptake in multiple lymph node regions in the abdomen and pelvis and in multiple focal areas in the spleen.
  • IMPRESSION: The FDG PET findings are compatible with lymphoma involving the spleen and involving multiple lymph node regions below the diaphragm as mentioned above.
• 2023-06-02 Patho - peritoneum biopsy
  • Lymph node, para-aortic and left iliac, CT-guide biopsy — Diffuse large B-cell lymphoma, non-GCB type
  • Section shows cores of lymphoid and fibrous tissue with infiltration of large pleomorphic lymphoid cells.
  • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(-), BCL6(+), MUM-1(+), Cyclin D1(-), cMYC(-), and BCL2(+). The Ki-67 is about 90%.
• 2023-05-09 Gynecologic ultrasonography
  • Uterine myoma
  • R/O Lt Ovarian mass
  • EM: 11.2mm (+fluid)
• 2023-05-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (127 - 33) / 127 = 74.02%
    • LVEF (%) = 74
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Dilated LV; normal LV systolic function with normal wall motion.
    • LV posterior wall thickeing, dilated LA; impaired LV relaxation.
    • Normal RV systolic function.
    • Aortic valve sclerosis with no AS and AR; mild MR; mild TR; mild PR.
    • Possible mild pulmonary hypertension, estimated PASP: 37 mmHg.
• 2023-05-03 Embolization (TAE) - ABD for tumor
  • TAE of spleen via right common femoral artery puncture using Seldinger technique revealed:
    • Under local anesthesia, a 5 Fr arterial sheath was inserted into right common femoral artery smoothly.
    • Selective angiography of the splenic artery revealed splenomegaly with inhomogeneous vascularity. No definite contrast extravasation.
    • Proximal embolization with gelfoam pieces was performed. A decreased parenchymal vascularity after embolization.
    • No procedure-related complication during this procedure.
  • Impression
    • s/p proximal emobilization of left splenic artery
    • A Fr.5 arterial sheath was placed in right femoral artery. Please remove it in 3 days.
• 2023-05-02 CT - abdomen
  • Indication: left abdominal pain, no vomit, no tarry stool. no trauma. hx of HTN; Med: Bisoprolol, Amlodipine , Olmesartan; NKA
  • With and without contrast enhancement CT of abdomen shows:
    • Enlargement of spleen. Several poor enhancing lesions in spleen.
    • Hyperdense fluid in perisplenic and pelvic regions.
    • Soft tissue mass in para-aortic and left iliac artery regions.
    • A cystic lesion, with wall enhancement, 4.5x5.1cm, in left adnexa.
    • A hyperdense stone in distal CBD.
    • No bony destructive lesion on these images.
  • Impression
    • Splenomegaly and splenic mass lesions
    • Para-aortic and left iliac lymphadenopathy
    • Left ovarian cystic mass
    • The differential diagnosis includes, but is not limited to ovarian ca with lymph node and spleen metastasis
    • Suggest further evaluation

[MedRec]

• 2023-07-06 SOAP Hemato-Oncology Xia HeXiong
  • O
    • Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 2023-07-03
      • DLBCL (Diffuse Large B-Cell Lymphoma), stage IV
      • R-COP treatment plan (Start with COP x1, then add R, turning into R-COP x5).
    • Now on R-COP +/- H, C1D1 on 2023-06-27
• 2023-06-13 SOAP Hemato-Oncology Xia HeXiong
  • O
    • 2023/06/02 PATHO-peritoneum biopsy
      • Diffuse large B-cell lymphoma, non-GCB type
    • Lab
      • 2023/06/03 B2-Microglobulin = 4325 ng/mL;
      • 2023/06/02 LDH = 709 U/L;
      • 2023/06/02 Uric Acid = 9.0 mg/dL;
• 2023-05-18 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • CT:
      • Splenomegaly and splenic mass lesions, Favor lymphoma.
      • Para-aortic and left iliac lymphadenopathy
      • Left ovarian cystic mass
    • Suggestion:
      • antibiotic treatment
      • tumor biopsy for cancer survey
      • pain control
    • Arrange admission for CT-guided biopsy and check Beta2-microglobulin

[immunochemotherapy]

• 2024-07-03 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D1 + liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + prednisolone 60mg/m2 30mg BID PO D1-5 (R-CHOP)
  • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] (before rituximab) + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] (before cyclophosphamide)
• 2024-06-11 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-CHOP)
  • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D2
• 2024-05-16 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-CHOP)
  • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D2
• 2023-11-29 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 45mg BID PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
• 2023-10-30 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
• 2023-09-25 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
• 2023-09-01 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
• 2023-08-07 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
• 2023-07-17 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
• 2023-06-27 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4

==========

2024-07-15

[enhancing protein intake in hypoalbuminemia]

Hypoalbuminemia is worsening, and it may be beneficial to administer human albumin to quickly raise the level. Additionally, consulting a nutrition intervention to enhance the patient’s protein intake could also be helpful.

• 2024-07-15 Albumin (BCG) 2.6 g/dL
• 2024-06-09 Albumin (BCG) 3.5 g/dL
• 2024-05-14 Albumin (BCG) 3.7 g/dL
• 2024-05-10 Albumin (BCG) 4.1 g/dL

2023-08-08

According to the PharmaCloud database, the patient’s medical care has exclusively been provided by our hospital in the recent 3 months. Consequently, no discrepancies in medication reconciliation have been detected.

2023-07-18

Based on the PharmaCloud database, the patient has only received medical services from our hospital for the past three months. As a result, no medication reconciliation issues have been identified.

701515053

240715

[MedRec]

• 2024-07-12 ~ 2024-07-13 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Diffuse large B-cell lymphoma, Ann Arbor stage IV with CNA invasion (T spine cord involvement)
    • Myelopathy in diseases classified elsewhere
  • CC
    • for 5th chemotherapy
  • Present illness
    • This is a 62 year-old male with underlying (1) Diffuse large B cell lymphoma, (2)Benign prostactic hyperplasia. This time, he suffered from shortness of breath for 2 days.
    • The patient was ADL totally dependent, living in a nursing home.
    • He had become bed-reidden for 3 months. According to the patient and his sister, he was in his usual status living in PengHu until 3 months ago, when he suddenly lost sensation over his bilateral legs and later lost motor function. He was sent to Tanshui Mackey Hospital.
    • He was diagnosed of diffuse large B cell lymphoma Ann Arbor stage IV with CNS invasion (T spine cord involvement) s/p T9,10,11 laminectomy and partialremoval of spinal tumor and T8,9,11,12 internal fixation with bone cement consolidation and posterolateral fusion on 2024/03/01 s/p C/T s/p R/T with paraparesis.
    • He came to our hospital for neurorehabilitation and diffuse large B cell lymphoma treatment since 2024/04. Till 2024/04/30, he had undergone 4th-6th R-CHOP which will be followed by HDArac/MTX plus high dose MTX to prevent CNS relapse.
    • Recent R-CHOP was done on 2024/04/15. He first came to our oncology OPD on 2024/04/22.
    • He denied fullness in 1 month, so he was admitted for C5 R-CHOP on 2024/07/12.
  • Course of inpatient treatment
    • After admission, isolation at first due to from nursing home. He received C5 R-CHOP on 2024/07/12-07/13. Under the stable condition, he can be discharged on 2024/07/13. OPD follow up is arranged.
  • Discharge prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD 14D
    • Ulstop (famotidine 20mg) 1# BID 5D
    • Compesolon (prednisolone 5mg) 16# QD 5D

[immunochemotherapy]

• 2024-07-12 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + doxorubicin 50mg/m2 70mg NS 50mL 30min D2 + vincristine 1.4mg/m2 1.9mg NS 50mL 10min D2 + prednisolone 60mg/m2 80mg QD PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-05-17 - rituximab 375mg/m2 500mg NS 500mL 5hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D1 + doxorubicin 50mg/m2 70mg NS 50mL 30min D1 + vincristine 1.4mg/m2 1.9mg NS 50mL 10min D1 + prednisolone 60mg/m2 80mg QD PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

700396247

240712

[exam findings]

• 2024-07-04 Tc-99m MDP bone scan
  • The scintigraphic findings suggest multiple bone metastases. As compared with the previous study on 2024-03-15, some previous bone lesions are a little less evident. However, some lesions in the posterior aspect of right ribs and left iliac bone are slightly more evident.
• 2024-05-19 KUB
  • s/p cholecystectomy
  • c/w blastic metastasis of bony structures
• 2024-05-19 CXR (erect)
  • A nodular lesion in right lung zone
  • T10, T11, and L2 compression fractures
• 2024-05-14 Lung Perfusion Scan
  • Tc-99m MAA perfusion lung scan - IMPRESSION:
    • Mildly inhomogenous radiotracer uptake in bilateral lung fields with no prominent medium or large segmental lung perfusion defect noted. Pulmonary embolism was less likely. However, please correlate with clinical findings for further evaluation.
• 2024-05-14 Spirometry
  • Moderate restrictive pulmonary function impairment
• 2024-05-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 25) / 91 = 72.53%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Trivial MR and trivial TR
    • Preserved RV systolic function
• 2024-05-10, -04-12 CXR erect
  • Multiple bony metastases.
  • Atherosclerotic change of aortic arch
• 2024-03-18 CT - chest
  • Indication: NPC with neck lymph node and bone mets
  • Comparison was made with CT on 2023/12/15
    • Lungs: normal appearance of bilateral lungs.
      • two small solid nodules at RLL measuring up to 11mm.
      • reticular opacities at both lower lobes, lingula, and RML.
    • Mediastinum and hila: multiple small LNs in the visceral space
    • Vessels: mild coronary arterial calcification
    • Thoracic aorta: normal caliber,Central pulmonary arteries: normal caliber. Heart: normal size of cardiac chambers.
    • Pleura: minimal Rt and Lt effusion.
    • Chest wall and visible lower neck: no enlarged LN.
    • Visible abdominal contents:
      • S/P cholecystectomy
      • multiple, ill-defined hepatic tumors, measuring up to 3cm.
      • diffuse destructive lytic/ blastic lesion in almost all visible bones.
  • Impression:
    • NPC with bony and hepatic metastases, stationary, and RLL metastais of lung. Platelike lung atelectasis, LLL, RLL, lingula, and RML.
• 2024-03-15 Tc-99m MDP bone scan
  • As compared with the previous study on 2023-07-17, some new bone lesions are noted and some previous bone lesions are more evident, indicating multiple bone metastases in progression.
• 2024-03-14 Pelvis-THR & Bilat. Hip Lat
  • Multiple bony metastases.
• 2023-12-15 CT - chest
  • Indication: Nasopharyngeal non-keratinizing carcinoma with neck lymph node, liver and bone metastases, stage IVB
  • Chest CT with and without IV contrast ehnancement shows:
    • Consolidation of right lower lobe is found.
    • Paraseptal Emphysematous change over both upper lobes is also noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Small lymph nodes are found at both sides of the mediastinum and bilatearal lower neck. In comparison with CT dated on 2023-05-10, the lesions are stationary.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Some lymph nodes are found at hepatic hilum.
    • Low density lesions are found at S4 and S8 of liver up to 2.3cm in largest dimension. Liver meta is considered. The lesions are more necrotic but the size is stationary.
  • IMp:
    • NPC with bone, thoracic and abdominal lymph nodes meta and liver meta. Stationary.
• 2023-12-13 Pelvis-THR & Bilat. Hip Lat
  • Multiple bony metastases.
• 2023-12-13, -08-04, -07-31 CXR erect
  • S/P port-A implantation.
  • Multiple bony metastases.
  • Atherosclerotic change of aortic arch
• 2023-07-31 Abdomen - Standing (Diaphragm)
  • Multiple bony metastases.
• 2023-07-17 Tc-99m MDP bone scan
  • Several new lesions of increased radioactivity in some upper T-spine, bilateral rib cages, left scapula, and left femur compared with the previous study on 2023-01-10, indicating metastatic bone disease in progression.
• 2023-05-10 CT - chest
  • Indication: Malignant neoplasm of superior wall of nasopharynxL - MRI: multiple bone metastasis with pathological compression fracture at L2 vertebral body; r/o liver metastasis and LUNG METASTASES
  • Comparison was made with previous CT dated on 2023/01/07
    • Lungs: several plate atelectases at bilateral lower lobes.
      • substantial subpleural paraseptal emphysema/bullae and mild centrilobular emphysema at both upper lobes.
      • no abnormal nodule in the lungs.
      • as compared with previous CT study on.
    • Mediastinum and hila: significant decrease in size of enlarged LNs in the visceral space and both hila compared with previous CT dated on 2023/01/07
      • mild calcified plaques of the LAD coronary artery.
    • Chest wall and visible lower neck: significant decrease in size of enlarged LNs compared with previous CT dated on 2023/01/07
    • Visible abdominal-pelvic contents: significant decrease in size of the hepatic tumors compared with previous CT dated on 2023/01/07
    • Visualized bones: diffuse destructive mixed lytic and blastic change in all visible bones.
  • Impression:
    • nasopharyngeal tumor with bones, distant LNs, and liver metastases, significant regression in liver and LNs metastases, but progression of bony metastassis as compared with previous CT dated on 2023/01/07
• 2023-04-19 SONO - abdomen
  • Hepatic tumors R/O metastasis
  • Postcholecystectomy
• 2023-02-02 MRI - nasopharynx
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:T1(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-01-19 Patho - nasopharyngeal/oropharyngeal biopsy
  • PATHOLOGIC DIAGNOSIS
    • Nasopahrynx, right, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
      • IHC stains: CK (+).
    • Nasopahrynx, left, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
      • IHC stains: CK (+).
  • MACROSCOPIC EXAMINATION
    • Number of tissue fragments: 01: right: 1 piece; 02 left: 4 pieces
    • Specimen size: 01 right: 0.2 x 0.1 x 0.1 cm; 02: left: 0.5 x 0.4 x 0.1 cm.
  • MICROSCOPIC EXAMINATION
    • Histologic Type - Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B)
    • Treatment Effect - no previous treatment
    • Additional Pathologic Findings - None identified
    • Ancillary Studies - IHC stains: CK (+).
    • Clinical History (select all that apply) - left neck tumor metastasis
• 2023-01-18 PET scan
  • No significant glucose hypermetabolism lesions in bilateral lungs is noted, suggesting further investigation and follow-up.
    
  • Glucose hypermetabolism in the left nasopharyngeal region, in lymph node regions on both sides of the diaphragm, right lobe of the liver and multiple bone marrows, highly suspected malignancy with distant metastases, suggesting biopsy (lesions in the right lobe of the liver) for investigation.
    
  • Malignancy (lung, lymphoma or others ?) with multiple bone metastases, c-stage IV, by this F-18 FDG PET scan.
• 2023-01-17 EGD
  • Diagnosis:
    • Suspect duodenal tumor, bulb, AW, s/p biopsy (A)
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • R/o gastric intestinal metaplasia, prepyloric antrum, s/p biopsy(B)
    • Duodenal shallow ulcers, bulb to 2nd portion
    • Duodenitis, bulb
    • Duodenal subepithelial lesions, 2nd portion, suspect lymphatic cyst
• 2023-01-12 Patho - lymph node region resection
  • Lymph node, left neck, excision — Metastatic squamous cell carcinoma, non-keratinized
  • The specimen submitted consisted of one lymph node tissue measuring 1.2 x 1.1 x 0.6 cm in size, fixed in formalin. All embedded for sections.
  • Microscopically, the sections show a picture of metastatic squamous cell carcinoma characterized by solid tumor cells infiltrated in lymphoid parenchyma.
  • Immunohistochemistry of CK(+), P40(+), TTF-1(-), Napsin-A(-) and CD56(-) for tumor, compatible with metastatic squamous cell carcinoma, non-keratinized. Clinical correlation is advised.
• 2023-01-10 Tc-99m MDP bone scan
  • The scintigraphic findings are compatible with multiple bone metastases.
• 2023-01-10 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 29.6) / 116 = 74.48%
    • M-mode (Teichholz) = 74.5
  • Conclusion:
    • Borderline aortic root size, normal AV with no AR
    • Thickened and prolapse of MV, no MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, no TR, normal IVC size
• 2023-01-07 CT - chest
  • Indication: R/O lung cacner with neck lymph node and bone metastases
    • Chest CT with and without IV contrast ehnancement shows:
      • Several atelectatic change at bilateral lower lobes is found.
      • Bilateral subclavicular lymphadenopathy is also noted.
      • Enlarged lymph nodes are found at both sides of the mediastinum.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Paraseptal Emphysematous change over bialteral upper lobes is found.
      • Calcified coronary arteries is found.
      • Low density lesions are found at both lobes of liver measuring 3.7cm in largest dimension. Liver meta is considered.
      • Relatively prominent sulci, fissue and dilated ventricles indicate brain atrophy.
  • Imp:
    • Diffuse bone meta, liver meta and bilateral lung atelectasis, mediastinal and subclavicular lymphadenopathy, r/o lung cancer with extensive meta. Suggest tissue proof from subpraclavicular lymph nodes
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T: Tx(T_value) N: N3(N_value) M: M1(M_value) STAGE: ____(Stage_value)
• 2023-01-04 MRI - L-spine
  • multiple bone metastasis with pathological compression fracture at L2 vertebral body
  • r/o liver metastasis

[MedRec]

• 2024-07-06 SOAP Dermatology Wang ChunHua
  • S
    • Generalized erythematous papule-palques on face, trunk and 4-limbs for years,off and on,severe itching(+)
    • Lip and eyelid swelling (+)
    • Poor response to LMD Tx
  • O
    • generalized eczeam on face and trunk and 4 limbs for yrs,severe itching recently (+)
    • Angioedema(+)
    • PHx:
      • sea food allergy(+-)
      • allergic rhinitis(+)
  • Prescription
    • Xyzal (levocetirizine 5mg) 1# QN
    • Limeson (dexamethasone 4mg) 1# QD
    • Ulex Cream (crotamiton 100mg, hydrocortisone 2.5mg; per gm) BID TOPI
    • Jaline lotion (benzyl benzoate 250mg/mL QN TOPI
• 2023-10-24 SOAP Dermatology Wang ChunHua
  • Prescription
    • Zalain Cream (sertaconazole nitrate 2%) BID TOPI
    • Allegra (fexofenadine 60mg) 1# BID
    • Royalsense (clindamycin 10mg/gm) BID TOPI
    • doxycycline 100mg 1# BID

[chemotherapy]

• 2024-05-22 - docetaxel 75mg/m2 160mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-04-18 - docetaxel 75mg/m2 160mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-03-14 - docetaxel 75mg/m2 160mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-02-16 - docetaxel 75mg/m2 160mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-01-12 - docetaxel 75mg/m2 160mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-12-14 - docetaxel 75mg/m2 160mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-10 - docetaxel 75mg/m2 160mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-10-14 - docetaxel 75mg/m2 160mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-09-08 - docetaxel 75mg/m2 160mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-08-09 - docetaxel 75mg/m2 160mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-07-04 - carboplatin AUC 5 485mg NS 250mL 2hr + fluorouracil 1000mg/m2 2100mg NS 500mL 22hr D1-4 (PF Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-06-01 - cisplatin 100mg/m2 200mg NS 500mL 4hr + NS 500mL 1hr (after CDDP) + fluorouracil 1000mg/m2 2100mg NS 500mL 20hr D1-4 (PF Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP)
• 2023-04-17 - cisplatin 100mg/m2 200mg NS 500mL 4hr + NS 500mL 1hr (after CDDP) + fluorouracil 1000mg/m2 2100mg NS 500mL 20hr D1-4 (PF Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP)
• 2023-03-13 - cisplatin 100mg/m2 200mg NS 500mL 4hr + NS 500mL 1hr (after CDDP) + fluorouracil 1000mg/m2 2090mg NS 500mL 20hr D1-4 (PF Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP)
• 2023-02-17 - cisplatin 100mg/m2 200mg NS 500mL 4hr + NS 500mL 1hr (after CDDP) + fluorouracil 1000mg/m2 2090mg NS 500mL 20hr D1-4 (PF Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP)
• 2023-01-20 - cisplatin 100mg/m2 200mg NS 500mL 4hr + NS 500mL 1hr (after CDDP) + fluorouracil 1000mg/m2 2100mg NS 500mL 20hr D1-4 (PF Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP)

==========

2024-06-21

[Worsening Normocytic Anemia: Potential Impact on Docetaxel Regimen

]

There has been a concerning trend of worsening normocytic anemia over the past three months. Two recent hemoglobin (HGB) readings have fallen below 8 g/dL.

• 2024-06-20 HGB 7.9 g/dL *
• 2024-06-07 HGB 8.7 g/dL
• 2024-05-31 HGB 9.0 g/dL
• 2024-05-23 HGB 7.9 g/dL *
• 2024-05-19 HGB 8.3 g/dL
• 2024-05-10 HGB 9.3 g/dL
• 2024-04-25 HGB 9.3 g/dL
• 2024-04-15 HGB 8.4 g/dL
• 2024-04-12 HGB 9.5 g/dL
• 2024-03-22 HGB 9.0 g/dL
• 2024-03-13 HGB 9.1 g/dL
• 2024-03-08 HGB 9.2 g/dL

While the mean corpuscular volume (MCV) remains within the normal range, a noticeable decrease toward microcytosis is evident.

• 2024-06-20 MCV 83.9 fL
• 2024-06-07 MCV 84.4 fL
• 2024-05-31 MCV 83.5 fL
• 2024-05-23 MCV 86.6 fL
• 2024-05-19 MCV 84.9 fL
• 2024-05-10 MCV 84.7 fL
• 2024-04-25 MCV 86.2 fL
• 2024-04-15 MCV 86.5 fL
• 2024-04-12 MCV 87.9 fL
• 2024-03-22 MCV 88.3 fL
• 2024-03-13 MCV 86.7 fL
• 2024-03-08 MCV 89.1 fL

Iron supplementation may be beneficial. However, it’s important to consider that docetaxel itself is associated with a high incidence of anemia (ranging from 65% to 97%, with 8% to 9% developing severe grades 3/4). If the anemia continues to worsen and blood transfusions become intolerable, adjustments to the treatment regimen might be necessary.

2024-03-14

[antihyperglycemic meds not used: review T2DM diagnosis (limited data)]

The patient was found to have hyperuricemia and hypomagnesiemia. Magnesium sulfate and Feburic (febuxostat) are being administered to manage these conditions.

• 2024-03-13 Uric Acid 8.8 mg/dL
• 2024-03-13 Mg (Magnesium) 1.5 mg/dL
• 2023-08-18 Glucose (serum) 170 mg/dL
• 2023-01-06 HbA1c 7.0 %

There is a single data point for serum glucose on 2023-08-18, with no additional test results present in the HIS5 lab records. Type 2 DM continues to be listed as a diagnosis in recent visit records since 2023-02-09, including the admission note from this hospitalization, yet no antiglycemic medications are currently being administered. It is advisable to review whether this diagnosis should be maintained.

2024-01-12

[episodic hyperuricemia: inconsistent Feburic use impedes control]

The patient exhibited episodic hyperuricemia throughout the past year, suggesting inadequate control of his uric acid levels.

• 2024-01-11 Uric Acid 9.6 mg/dL ++
• 2023-12-18 Uric Acid 3.7 mg/dL
• 2023-12-14 Uric Acid 8.5 mg/dL +
• 2023-11-13 Uric Acid 6.5 mg/dL
• 2023-11-09 Uric Acid 8.2 mg/dL +
• 2023-09-07 Uric Acid 7.8 mg/dL +
• 2023-08-21 Uric Acid 6.9 mg/dL
• 2023-08-07 Uric Acid 3.5 mg/dL
• 2023-07-31 Uric Acid 9.1 mg/dL ++
• 2023-07-03 Uric Acid 8.6 mg/dL +
• 2023-06-05 Uric Acid 11.0 mg/dL ++++
• 2023-05-31 Uric Acid 9.0 mg/dL ++
• 2023-03-12 Uric Acid 6.5 mg/dL
• 2023-02-16 Uric Acid 5.8 mg/dL
• 2023-01-23 Uric Acid 8.2 mg/dL +
• 2023-01-06 Uric Acid 5.2 mg/dL

In response to these hyperuricemic episodes, Feburic (febuxostat) therapy was administered during several hospitalizations. However, outpatient visits did not consistently prescribe this medication, potentially contributing to the elevated serum uric acid levels.

Therefore, it is recommended to consider either extending Feburic therapy or exploring alternative options such as benzbromarone (on prescription at the OPD visits) for improved management of serum urate levels.

701025127

240712

[exam findings]

• 2024-06-25 Holter 24hr ECG
  • Baseline was sinus rhythm
  • No VPC
  • Rare isolated APCs
  • No long pause
  • No significant tachyarrhythmia
• 2024-06-14 CT - abdomen
  • Prior CT identified a fatty content lesion (lipoma) 1.1 x 0.7 mm in the pancreatic head (Srs:4, Img:29) is noted again, stationary.
    • In addition, Prior CT identified another poor enhancing nodule 5 mm in the pancreatic head is noted again, stationary. Follow up is indicated.
  • A renal stone 5 mm in right middle pole is noted.
  • S/P hysterectomy.
• 2024-06-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (85.4 - 15.7) / 85.4 = 81.62%
    • M-mode (Teichholz) = 81
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Mild MR and TR
    • No regional wall motion abnormalities
• 2024-06-13 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • R’t : 15 dB HL, WNL
  • L’t : 20 dB HL, WNL except 8k Hz.
• 2024-04-15 Patho - soft tissue biopsy/simple excision
  • Labeled as “right inguinal mass derived from round ligament”, excisional biopsy — papillary adenocarcinoma.
  • IHC stains: PAX-8 (+), p53 (wild type), ER (+, 100%, strong intensity); Napsin-A (+), CK7 (+), CK20 (-), WT-1 (+), TTF-1 (+), vimentin (+), CD10 (-), RCC (-) CAIX (-), a pattern of suggestive of Mullerian origin. The tumor is less than 1 mm from un-oriented and unspcified margin. Separated foci of aggregates of foamy histiocyte, cholesterol clefts are present. Few isolated bland endometriosis-like glands are found. Please correlate with clinical, and if available, image findings.
• 2024-03-14 CT - pelvis
  • A nodule (2.7cm) at right inguinal region.
  • A lipoma (6.3x2.5x10.3cm) at left inguinal region.
  • S/P hysterectomy.
  • Right renal stones (2-3mm).
• 2023-07-22 Anoscopy
  • Stool color : normal
  • Rectal mucosa : normal
  • Anal canal : abnormal
  • Impression : Mixed hemorrhoids

[MedRec]

• 2024-06-25 SOAP Cardiology Liu GuangLiang
  • S
    • CC: palpitation sometimes, after chemotherapy and entecavir
    • HBV on entecavir
    • Ovary cancer s/p …
  • A/P
    • EKG to rule out ACS or arrhythmia
    • Holter to rule out structural heart disease
    • Lifestyle modification
    • Return to OPD if effort angina developed
• 2024-06-12 ~ 2024-06-17 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Ovarian Serous borderline papillary adenocarcinoma with right inguinal metastasis, right inguinal mass derived from round ligament status post tumor excision on 2024/04/15, FIGO:IVB
    • Insomnia
    • Chronic viral hepatitis B without delta-agent
    • Encounter for antineoplastic chemotherapy
  • CC
    • Preparing for chemotherapy
  • Present illness
    • She received bilateral inguinal tumor resection on 2024/04/15.
    • Pathology showed Labeled as “right inguinal mass derived from round ligament”, excisional biopsy — papillary adenocarcinoma.
      • IHC stains: PAX-8 (+), p53 (wild type), ER (+, 100%, strong intensity); Napsin-A (+), CK7 (+), CK20 (-), WT-1 (+), TTF-1 (+), vimentin (+), CD10 (-), RCC (-) CAIX (-), a pattern suggestive of Mullerian origin.
    • Port-A implantation on 2024/05/08. Refer to Obstetrics and Gynecology and Hematology and Oncology.
    • This time, she was admitted to our ward for scheduled chemotherapy.
• 2024-05-08 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • Admission for C/T with TP, 24 hours CCr, heart echo, PTA
    • Consider check BRCA1/2 or even HRD
• 2024-04-14 ~ 2024-04-16 POMR General and Gastroenterological Surgery Wu ChaoQun
  • Discharge diagnosis
    • Left inguinal area tumor status post tumor excision on 2024/04/15
    • Right inguinal mass derived from round ligament status post tumor excision on 2024/04/15
  • CC
    • bilateral inguinal mass noted for 3 months
  • Present illness
    • This is a 62 y/o female with history of:
      • Abdominal Total Hysterectomy (A.T.H.)
      • Bilateral Salpingo-Oophorectomy (B.S.O.)
      • right renal stone s/p ESWL at Cardinal Tien Hospital. (Urologist Yang DengKai) in 2018/03
    • This time, bilateral inguinal mass has been noted for 3 months. A well defined mass about 2 cm with mild tenderness was found during PE at right inguinal hernia.
    • CT showed a nodule (2.7cm) at right inguinal region and a lipoma (6.3x2.5x10.3cm) at left inguinal region. Due to above, she was admitted for operation.
  • Course of inpatient treatment
    • After admitted, bilateral inguinal tumor resection was processed successfully on 2024/04/15. The post-operative course was relatively smooth without complication.
    • During the hospitalization, the empiric antibiotic, stool softener and analgesic agent were administered and the wound management was performed.
    • There were no nosocomial infection and other complications. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable.
    • Under improved general condition, she was allowed to discharge today and outpatient department follow up was arranged.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID 7D
    • MgO 250mg 1# QID 7D
    • Through (sennoside 12mg) 2# HS 7D
  • Course of inpatient treatment
    • After admission, collect 24hr Ccr showed 113.1 mL/min.
    • PTA was done for survey on 2024/06/13 showed Reliabilty Fair, R’t : 15 dB HL, WNL, L’t : 20 dB HL, WNL except 8k Hz.
    • 2D echo was arrange for heart disease survey on 2024/06/13 showed LVEF:81%. Normal chamber size; Adequate LV and RV systolic function; Mild MR and TR and No regional wall motion abnormalities.
    • Limeson 4mg/tab 5#(20mg) PO and Stogamet 300mg/tab 1# PO before chemotherapy with Taxol 12 hrs on 2024/06/13 at 23:00 and before chemotherapy with Taxol 6 hrs on 2024/06/14 at 05:00, then she received chemotherapy with TP (Paclitaxel 175mg/m2, Carboplatin Ccr:100, AUC:5) on 2024/06/14 (C1), during Taxol injection, chest tightness, fast heartbeat was noted, Pronolol 10mg/tab 1# PO ST was given and adjust rate to 50ml/hr (run 6hrs), then get improving.
    • Abdominal CT re-staging was performed on 2024/06/14 showed 1. Lipoma 1.1 x 0.7 cm at the pancreatic head is highly suspected. In addition, Prior CT identified another poor enhancing nodule 5 mm in the pancreatic head is noted again, stationary. Follow up is indicated.
    • Insomnia with Alpraline 0.5mg/tab 0.5# PO HS
    • Rozerem 8mg/tab 0.5# PO PRNHS (self paid) for insomnia.
    • Caricalm 175,350,32mg/tab 1# PO PRNQ8H for soreness.
    • Nincort Oral Gel 1mg/gm, 5gm/tube for oral ulcer.
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, she was discharged on 2024/06/17 and OPD followed up later.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Nincord Oral Gel (triamcinolone 1mg/gm) BID TOPI
    • Alpraline (alprazolam 0.5mg) 0.5# HS
    • Caricalm (carisoprodol 175mg, acetaminophen 350mg, caffeine 32mg) 1# PRNQ8H for pain

[surgical operation]

• 2024-04-15 - Op Method:
  • Excision of right retroperitoneal tumor
  • Excision of left inguinal area tumor
  • Finding:
    • Right inguinal mass 3.52.51.5cm derived from round ligament with serous fluid within, suspecting malignancy
    • Left inguinal area deep mass 12.06.53.0cm

[chemotherapy]

• 2024-07-12 - paclitaxel 175mg/m2 250mg NS 500mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-13 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-07-12

[monitoring chest symptoms during TP regimen]

During the first administration of paclitaxel in the last hospital stay, the patient complained of chest tightness and palpitations. On 2024-06-25, the patient reported similar symptoms to our cardiologist, but the 24-hour Holter ECG showed no significant abnormalities.

Please monitor the patient closely for any adverse reactions during this second session of the TP regimen.

700567387

240711

[exam findings]

[MedRec]

• 2024-05-15 ~ 2024-05-23 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Adenocarcinoma of sigmoid colon with lumen narrowing, urinary bladder invasion and lymph nodes metastasis(unresectable), cT4bN2bM1a, stage IVA (non-regional lymph nodes metastases)
    • Chronic kidney disease, stage 5 under hemodialysis
    • Type 2 diabetes mellitus with diabetic chronic kidney disease
    • Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
    • Bilateral hydronephrosis and hydroureter
    • Proliferative diabetic retinopathy with vitreous hemorrhage
    • Iron deficiency anemia
    • Hypokalemia, potassium level: 2.7 mmol/L
  • CC
    • For sigmoid colon management
  • Present illness
    • This is a 60y/o female with underlying history of (1) DM under drug control; (2) ESRD s/p hemodialysis W246; (3) HTN under drug control, she was ADL dependent in her usual status.
    • She live in nursing home. She was admitted due to UTI on 2024/04/09, and abdominal CT on 2024/04/11 revealed sigmoid cancer cT4bN2bM0. So the colonoscopy and biopsy was arranged later, showed S-colon adenocarcinoma.
    • This time she was admitted for S-colon adenocarcinoma survey and treatment.
    • Accroding to the patient’s statement, she denied fever, constipation, abdominal pain and body weight loss. Diarrhea and bloody stool was complained. DRE in the OPD showed loose anal tonicity, mixed hemorrhoids, fecal incontinence, no blood, no mass. After admission, PET scan was arranged for tumor survey. Pre-operation perparation was arranged too.
    • Under the impression of S-colon adenocarcinoma cT4bN2bM0, stageIII, she was admitted for futher management.
  • Course of inpatient treatment
    • After admission, pre-op preparation with lung function test and cardiac echo was arranged. Lung function test showed mild restrictive pulmonary function impairment and Mild obstructive pulmonary function impairment.
    • Cardiac echo revealed 1. Dilated LA; 2. Trivial pericardial effusion; 3. Concentric LV hypertrophy; 4. Adequate LV and RV systolic function; 5. Possibly impaired LV relaxation; 6. Calcified mitral annulus with mild MR, mild TR and PR; 7. AV sclerosis with mild AR; 8. No regional wall motion abnormalities.
    • OPH VS was consulted for patient complained about right side eye blurred vision and bleeding, transamin 1# PO BID + sinomin 1gtt QID ou + Alminto 1gtt QID ou was suggested with OPD follow up.
    • PET scan was arrange later for tumor survey, and reported on 2024/05/17: 1. Glucose hypermetabolism in the sigmoid colon with possible invasion to the urinary bladder, compatible with primay colon malignancy with possible invasion to the urinary bladder. 2. Mild glucose hypermetabolism in some regional lymph nodes. Metastatic lymph nodes can not be ruled out. 3. Mild glucose hypermetabolism in the right supraclavicular fossa, right pulmonary hilar lymph nodes and bilateral shoulders. Inflammation may show this picture. 4. Mildly increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.
    • GU and RT VS was consulted for tumor management. We arranged a family meeting on 2024/05/22, explanation of the medical condition and future plan was discussed.
      • Colon cancer with partial obstruction and invasion of the bladder. Chemoradiotherapy is recommended initially, but due to poor kidney function (requiring dialysis), only radiation therapy is feasible (approximately 28 sessions). Subsequent evaluation will determine the feasibility of tumor resection.
      • Currently, it is recommended to undergo colostomy surgery to alleviate impending intestinal obstruction issues.
      • After dialysis tomorrow (2024/05/23), discharge to the original care facility is planned, with readmission scheduled for 2024/06/04 and colostomy surgery on 2024/06/06.
      • Social services will assist in finding postoperative care facilities.
    • After above management, staging change to adenocarcinoma of sigmoid colon with lumen narrowing, urinary bladder invasion and lymph nodes metastasis (unresectable), cT4bN2bM1a, stage IVA.
    • She was discharged on 2024/05/23 and readmission will be arranged on 2024/06/04.
  • Discharge prescription
    • …
• 2024-04-09 ~ 2024-04-29 POMR Neurology Wu ZheXiong
  • Discharge diagnosis
    • Post herpetic neuralgia with crusting wounds (left chest and back)
    • Iron deficiency anemia
    • Chronic kidney disease stag 5 on hemodialysis status post perm catheter implantation 113/04/22
    • Broad-base papillary tumor with hypervascularity was noted in posterior wall of bladder.
    • S-colon tumor with lumen narrowing
    • Type 2 diabetes mellitus
    • Urinary tract infection, Urine culture on 2024/04/12 showed Klebsiella pneumoniae
    • Essential (primary) hypertension
    • Hyperuricemia
  • CC
    • dizziness for 2 days
  • Present illness
    • This 60-year-old woman who had histories of CKD, HTN, DM regular medication control in Cardinal Tien Hospital.
    • She justed discharged from Cardinal Tien Hospital on 2024/03/26 due to hypoNa and CKD.
    • According to the statements of the patient. This time, she suffered from general discomplain for 2 days. Dizziness for 2 days was noted. Hematuria was noted today. There was no fever/headache, no sorethroat/rhinorrhea, no chest tightness/pain, no dysuria, no diarrhea/tarry stool, no TOCC found. So she was sent to ER for help. At ER, conscious showed GCS’s:E4V5M5 vital sign showed BP:120/58mmHg, TPR:36.4/82/18. The serum examination show leukocytosis and anemia (WBC:12.71 *10^3/uL, N.Seg: 83.9 % and Band 0.3 %,Hb: 6.1 g/dl), elevated of CRP 7.8 mg/dL, impair renal function with Hyponatremia (BUN/Cr:116/6.34 mg/dl , Na:120mmol/L). Urinalysis showed pyuria, bacteriuria, hematuria and positive nitrite (RBC:30-49,WBC:>=100/HPF, bacteria:3+). CXR revealed no active lung lesion.
    • Under impression of 1) UTI; 2) Hyponatremia; 3) CKD with Anemia, she was admitted to our ward for further management and care.
  • Course of inpatient treatment
    • After adnission, empirical antibiotic with Sintrix was prescribed for UTI.
    • Blood transfusion with LPRBC 2U was prescribed on 2024/04/10.
    • We consulted Dermatology for Post herpetic neuralgia with crusting wounds. Who suggested
      • apply wet gauze to the scab wound for 15 minutes. After the scab softens, can gently peel it off.
      • then apply ointment topical biomycin  BID
      • oral neurontin 1# BID, oral ultracet 0.5# BID for pain control
      • During hospitalization, the patient can be sent to the dermatology department for No.263 consultation and low-energy helium-neon laser QW135
    • We consulted Gynecology for bleeding via vaginal survey, who suggested
      • Treat active problem as your expertise.
      • Advise patient follow up EM thickness at OBGYN after discharge.
      • Educate patient warning signs including increased vaginal bleeding or abdominal pain.
    • The renal echo showed Hydronephrosis with hydroureter, bilateral Parenchymal renal disease with small sized kidney, bilateral, favor chronic change
    • The abdominal CT revealed 1) Some air in urinary bladder. Bil. hydronephrosis and hydroureter. 2) Retroversion of uterus within some air densities.
    • We also consulted Urology for bil. hydronephrosis and hydroureter. Consider her current infection status, cystoscopy may be postponed until infection is well controlled. He suggested collecing three sets of urine cytology in three different days as initial survey.
      • 2024-04-17 17:12:53 The patient was in delirium status when I visited her this afternoon. Therefore it is impossible to discuss about the indication and risk of ureteroscopic examination with her. I also contacted her sister but she refused to come to hospital to sign permit for the patient. The ureteroscopic examination may only be arranged if her family agrees and fully understands the risk of surgery. Otherwise, we cannot arrange any invasive intervention for her.
    • We also consulted Physchology for acute delirium and depression treatment. Who suggested
      • Treat the underlying medical illness, such as UTI.
      • Avoid sedative agents.
      • Binin-U (5mg) 1amp IM prn q4-6h if needed.
      • Other psychiatric disorder, such as depression or anxiety, could not be confirmed.
    • Blood transfusion with LPRBC 2U was prescribed on 2024/04/10 and 2024/04/23.
    • Antibiotics was escalated to Brosym for urine culture showed MDR K.P. infection.
    • We suggested renal replacement therapy for uremia, Insertion perm cath on 2024/04/22 and start hemodialysis since 2024/04/22.
    • Cystoscopy was done on 4/25 and revealed Broad-base papillary tumor with hypervascularity was noted in posterior wall of bladder.
    • Colonscopy was done on 4/29 and revealed S-colon tumor with lumen narrowing.
    • Under stable condition, she was discharged on 04/29 and further hemodialysis would be peroformed at local hemodilaysis clinic later.
  • Discharge prescription
    • …

[surgical operation]

700629397

240711

[MedRec]

• 2024-05-22 ~ 2024-05-23 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Right breast ductal carcinoma in situ status ER: positive (2+, 70%), PR (2+, 90%), Her2/neu: equivocal (Dako score 2+, >10%), pT2(m)N0(i+), cM0, stage IIA, pStage IB, post bilateral transaxillary endoscopic nipple sparing mastectomy (left breast prophylactic mastectomy) + right axillary sentinel lymph node biopsy + immediate silicon-gel-implant reconstruction for bilateral breasts on 2024/03/26, chemotherapy with Liposome Doxorubicin plus Cyclophosphamide from 2024/05/22~
  • CC
    • admission for AC
  • Present illness
    • This 43-year-old female patient has past history of left tumor status post left thyroidectomy on 2022/01/18, with regular follow up in outpatient department; right breast cancer status post bilateral ipple sparing mastectomy, right axillary lymph node biopsy and bilateral silicon-gel implant reconstruction on 2024/03/26. She denied any TOCC histories in recent 3 months.
    • She noted a abnomal mass at right breast by breast sono in our outpartient department health examinon in 2024/03/08. Breast sono showed Right 12 o’clock / 2 cm, Size: 2.09 x 1.40 x 2.20 cm, rule out malignancy suggest biopsy. Core needle biopsy revealed ductal carcinoma in situ (DCIS). She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss. Physical examination: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 3*3 cm without discharge. The nipple without dimping, exudative nor bloody discharge and no retraction. The right breast skin had no cellulitis change.
    • After fully explaination the treatment surgical of method, this patient decided to bilateral transaxillary endoscopic nipple sparing mastectomy (left breast endocopic prophylactic mastectomy) and silicon-gel implants immediate reconstruction. She received surgery of bilateral transaxillary endoscopic nipple sparing mastectomy (left breast endocopic prophylactic mastectomy) + sentinel lymph node biopsy + silicon-gel implants immediate reconstruction on 2024/03/26. This time, she was admitted to our ward for AC.
  • Course of inpatient treatment
    • After admission, she receive chemotherapy with AC (Liposome Doxorubicin 30mg/m2, self paid, Cyclophosphamide 600mg/m2) on 2024/05/22 (C1) smoothly. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/05/23 and OPD followed up later.
  • Discharge prescription
    • Emend (aprepitant 125mg) 1# QD 2024/05/24

[chemotherapy]

• 2024-07-10 - liposome doxorubicin 30mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-15 - liposome doxorubicin 30mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-22 - liposome doxorubicin 30mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

700884632

240711

[exam findings]

[MedRec]

• 2024-03-11 ~ 2024-04-03 POMR General and Gastroenterological Surgery Wu ChaoQun

• 2022-04-11 ~ 2022-04-15 POMR Hemato-Oncology Gao WeiYao

  • Discharge diagnosis
    • poorly differentiated of adenocarcinoma of stomach post subtotal gastrectomy and BII anastamosis with LN (1/16) metastasis, cT1aN0(micrometastasis)M0, stageIA, under TS-1 Capsule 120mg at LinKou CGMH
    • Chronic viral hepatitis B without delta-agent
  • CC
    • for chemotherapy
  • Present illness
    • This 73 year old male was diagnosed of poorly differentiated of adenocarcinoma of stomach post subtotal gastrectomy and BII anastamosis with LN (1/16) metastasis, cT1aN0(micrometastasis)M0, stageIA, under TS-1 Capsule 120mg at LinKou CGMH.
    • Owing to personal reason, he was transfered to our ONC OPD for followed. CT was performed on 2022/03/18 revealed Gastric CA, s/p subtotal gastrectomy. Wall thickening of small bowel and cecum, c/w enterocolitis (neutropenic enterocolitis?). Suggest clinical correlation. Port-A insertion on 2022/04/01.
    • This time,he was admitted for chemotherapy
  • Course of inpatient treatment
    • After admission, chemotherapy with C1D1 FOLFOX wwas administered on 2022/04/12-14 after fully explaination. Patient tolerated the chemotherapy. With the relatively stable condition, he was discharged on 2022/04/15 and will OPD follow up later.
  • Discharge prescription
    • Stogamet (cimetidine 300mg) 1# TID
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Promeran (metoclopromide 3.84mg) 1# PRNTIDAC
    • Through (sennoside 12mg) 1# HS

• 2022-03-19 ~ 2022-03-23 POMR Gastroenterology Su WeiZhi

  • Discharge diagnosis
    • Infectious gastroenteritis and colitis
    • Malignant neoplasm of stomach, unspecified(diagnosed in another hospital, unknown stage)
    • Hypokalemia
  • CC
    • Fever, vomit and epigastric pain for 2 days
  • Present illness
    • This 73 y/o male underlying gastric cancer s/p op on 2021.12.01 in CGMH was admitted with the chief complaint of epigastric pain for 2 days. He started to have epigastric pain for 2 days, associated with vomiting and fever. He denied headache, chest pain, nor dyspnea. He also mentioned diarrhea for one week after he took target therapy medication. He lost 10kg in three months due to poor appetite after operation. He visited GI OPD two days before admission, ileus was diagnosed.
    • At ER, his vital sign was BP:120/58; HR:100; BT:37.1’C; RR:18; Con’s:E4V5M6, SpO2:98%. PE showed epigastric and RLQ tenderness, normoactive bowel sounds, rebound tenderness(+). Lab data showed WBC: 5320, Band:10%, Hb:12, CRP 12.09. ABD CT showed gastric CA, s/p subtotal gastrectomy, wall thickening of small bowel and cecum, c/w enterocolitis. Under the impression of enterocolitis, he was admitted to our ward for further treatment and evaluation.
  • Course of inpatient treatment
    • After admission, NPO, IVF and empirical IV antibiotics were give for enterocolitis favor infectious colitis. Fever persisted for 2 days after admission the subsided. The pain also improved after admission. Stool culture yielded negative. Follow up lab showed improving also. There was no more discomfort after we start oral intake. With stable condition, he was discharged and will OPD follow up
  • Discharge prescription
    • Radi-K (potassium gluconate 595mg) 2# TID
    • Cinolone (ciprofloxacin 250mg) 2# BIDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC

701248989

240711

[MedRec]

• 2024-06-21 SOAP Hemato-Oncology Gao WeiYao
  • S
    • He received massive transfusion in the past 1 week at TaoYuan City Saint Paul’s Hospital
    • Her daughter worked in Hualien TzuChi
  • A/P
    • Pancytopenia nature?
    • significant weight loss 6 kg in 1 month
• 2024-03-27 SOAP Psychosomatic Medicine Chen WenJian
  • Prescription x3
    • Zolon (zopiclone 7.5mg) 1# PRNHS start taking half a pill
    • Eurodin (estazolam 2mg) 2# HS
    • Mirtapine (mirtazapine 30mg) 1# HS
    • Rozerem (ramelteon 8mg) 1# HS 10D self-paid
• 2021-08-25 SOAP Psychosomatic Medicine Chen WenJian
  • Prescription x3
    • Zolon (zopiclone 7.5mg) 1# PRNHS start taking half a pill
    • Eurodin (estazolam 2mg) 2# HS
    • Mirtapine (mirtazapine 30mg) 1# HS

701453601

240711

[exam findings]

• 2024-01-08 CT - abdomen
  • Small cell neuroendocrine carcinoma, cT2N2M0, s/p OP on 2023/03/09, pT4aN3a(cM0), stage IIIB, PD s/p chemotherapy with EP for 6 cycles with metastatic nodes in left para-aortic space, under FOLFOX from 2023/10/07
  • Imp:
    • s/p subtotal gastrectomy.
    • Enlarged lymph nodes are found at bilateral paraaorti region up to 6.03cm in largest dimension. In comparison with CT dated on 2023-09-06, the lesions enlarged markedly
• 2023-12-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (144 - 32) / 144 = 77.78%
    • M-mode (Teichholz) = 77
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA and LV
    • Trivial MR, mild to moderate AR, mild TR
    • Preserved RV systolic function
• 2023-12-05 Tc-99m MDP bone scan
  • Mildly increased activity in the lower C-spine, L3 and L5 spines. Degenerative change may show this picture.
  • Some faint hot spots in the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, left sternoclavicular junction, bilateral elbows, hips and knees, compatible with benign joint lesions.
• 2023-09-22 Patho - omentum biopsy
  • Soft tissue, left para-aortic space, CT-guide biopsy — Metastatic neuroendocrine carcinoma
  • Microscopically, the sections show a picture of small blue round cells with focal crush artifact, which immunohistochemistry shows CK (equivocal), CD56 (+) and synaptophysin (+, focal). No lymph node parenchyma is included. According to histopathologic findings and patient’s past history, it is compatible with metastatic neuroendocrine carcinoma.
• 2023-09-06 CT - abdomen
  • History: small cell neuroendocrine carcinoma of gastric with a 4.2cm ulcerative mass, cT2N2M0, s/p radical subtotal gastrectomy with D2 LN dissection Roux-en-Y GJ anastomosis, pathology showed Neuroendocrine carcinoma, pT4aN3a(cM0), stage IIIB on 3/14, with Perineural invasion+, Lymphovascular invasion, Ki-67＝ 60%.
    
  • Findings:
    • There are several newly developed enlarged nodes in left para-aortic space and the largest one 2.4 x 1.8 cm in size.
      • Metastatic nodes are highly suspected.
    • Abdominal aorta shows atherosclerosis, ectasia 2.2 cm and mild intramural thrombus formation.
    • S/P subtotal gastrectomy
    • Right. renal stones (<5mm).
  • Impression:
    • Metastatic nodes in left para-aortic space are noted.
• 2023-06-12 CT - abdomen
  • History and indication: Gastric tumor
  • IMP:
    • S/P gastric operation. No evidence of tumor recurrence.
    • Bil. renal stones (2-4mm).
    • R/O CBD stone (5mm).
• 2023-04-01 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • R’t : 41 dB HL, normal to severe mixed type HL
  • L’t : 45 dB HL, normal to profound mixed type HL.
• 2023-03-17 CXR
  • S/P Port-A infusion catheter insertion.
  • Interstitial pattern at LLL.
• 2023-03-10 Patho - stomach subtotal/total (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Stomach, subtotal gastrectomy — Neuroendocrine carcinoma
    • Margins, bilateral cutting ends, subtotal gastrectomy — Free of tumor invasion
    • Lymph nodes, D2 LN dissection — Metastatic neuroendocrine carcinoma (10/28)
    • AJCC Pathologic staging — pT4aN3a(cM0), stage IIIB
  • MACROSCOPIC EXAMINATION
    • Specimen type: Stomach and regional lymph nodes
    • Specimen size: 22.5 cm along greater curvature and 12.5 cm along the lesser curvature
    • Number of lesions: Solitary
    • Tumor site: Low body, lesser curvature, 6.0 cm from distal margin
    • Tumor size: 4.8 x 4.2 cm in size
    • Tumor configuration: Ulcerative mass
    • Representative sections as follows: A1= proximal margin, A2= distal margin, A3-A6= tumor, B= LN 1, C= LN 3, D1-D2= LN 4, E= LN 5, F= LN 6, G1-G3= LN 7,8,9,11p
  • MICROSCOPIC EXAMINATION
    • Histologic type: Neuroendocrine carcinoma, combined small cell and large cell types
    • Histologic grade: Poorly differentiation (G3)
    • Depth of tumor invasion: Tumor invades the serosa
    • Margins: Radial margin is involved by carcinoma
    • Perineural invasion: Present
    • Lymphovascular space invasion: Present
    • Regional lymph nodes: Metastatic carcinoma (10/28)
      • 0 (LN 1), 5/5 (LN 3), 1/3 (LN 4), 0/1 (LN 5), 0/3 (LN 6), 4/16 (LN 7, 8, 9, 11p); (Number of LN involved/Number of LN examined)
    • Extracapsular extension: Present
    • Additional pathologic findings: Non-atrophic chronic gastritis
    • Pathologic Staging: pT4aN3a(cM0), stage IIIB
    • IHC (S2023-03207): CK(+), CD56(+), Synaptophysin(+), TTF-1(+), Ki-67= 60%
• 2023-03-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 30) / 116 = 74.14%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; impaired LV relaxation.
    • Normal RV systolic function.
    • Moderate MR; mild to moderate AR; mild to moderate TR; mild PR.
    • Mildly dilated ascending aorta.
    • A calcified atheroma (1.04cm of thickness) at aortic root.
• 2023-03-06 ECG
  • Normal sinus rhythm
  • ST & T wave abnormality, consider inferolateral ischemia
  • Abnormal ECG
• 2023-02-27 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Ulcerative mass at gastric body measuring 4.2cm in largest dimension is found. Huge lymph nodes are found at celiac trunk (3.4cm) and gastrohepatic ligment (n＝4) is found.
  • Imp: Gastric cancer at body with reiongal lymphadenopathy (n＝4)
  • Imaging Report Form for Gastric Carcinoma
  • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-02-22 Patho - stomach biopsy
  • Stomach, angularis, biopsy — small cell neuroendocrine carcinoma, origin?, please see microdescription
  • Sections show gastric mucosa with infiltration of large nests of small hyperchromatic tumor cells, scanty cytoplasm and marked crushing artifact.
  • The immunohistochemical stains reveal CK(+), CD56(+), Synaptophysin(+), TTF-1(+), and LCA(-). The Ki-67 is about 60%. Small cell neuroendocrine carcinoma of stomach may also be positive for TTF-1. Please correlate with the clinical presentation and image study to confirm tumor origin from lung, stomach, or other area.
• 2023-02-22 Esophagogastroduodenoscopy, EGD
  • Findings
    • Esophagus: No mucosa break was seen. No definite lesion.
    • Stomach: One A2 ulcer (large 3.5 cm , deep with some old blood clot) over angularis, biopsy was done
  • Diagnosis
    • Gastric ulcer, big, A2 ulcer over angularis

[MedRec]

• 2023-10-03 SOAP Hemato-Oncology Xia HeXiong
  • A/P: Due to disease in progression after tissue proof by CT-guided retroperitoneal LN biopsy, admission for C/T with or without contrast, plus IO on 2023-10-03
• 2023-09-12 SOAP General and Gastrointestinal Surgery Wu ChaoCun
  • Prescription x3
    • hydroxocobalamin 1mg/mL/amp Q2W IM
    • Mopride (mosapride citrate 5mg) 1# TID
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Ulstop (famotidine 20mg) 1# BID
• 2023-04-28 ~ 2023-04-30 POMR Hemato-Oncology
  • Course of inpatient treatment
    • After admission, he receice chemotherapy with EP (Cisplatin 75mg/m2 D1 –> due to Cr:1.31, eGFR :57, change to Carboplatin AUC:5, Etoposide 100mg/m2 D1-D3) on 2023/04/28-04/30, with adequate hydration. Mopride 5mg/tab 1# TID and Primperan 1amp IVD PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg/tab 1# PO QDAC. Chronic gastric ulce with Nexium 40mg/tab 1# PO QDAC. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/04/30 and OPD followed up later.
  • Prescription
    • Granocyte (lenograstim 250ug) QD SC 3D (on 2023-05-04,05,06)
    • Acetal (acetaminophen 500mg) 1# PRNQ6H (post GCSF, if bone pain or BT > 38’C)
• 2023-04-27 SOAP Hemato-Oncology
  • O - AE: Gr 4 neutropenia -> improved
• 2023-04-20 SOAP Hemato-Oncology
  • O - AE: Gr 4 neutropenia
• 2023-04-13 SOAP Hemato-Oncology
  • O
    • Cancer Treatment - Chemoradiation/Targeted Therapy Side Effects Assessment (2023-04-13)
      • Renal function (Creatinine level): Grade 2: > 1.5-3 times the upper limit of normal.
      • Renal function (Creatinine level) Management: Supportive care.
• 2023-03-31 ~ 2023-04-06 POMR Hemato-Oncology
  • Discharge diagnosis
    • Small cell neuroendocrine carcinoma, cT2N2M0, s/p radical subtotal gastrectomy with D2 lumph node dissection and Roux-en-Y gastrojejunostomy anastomosis on 2023/03/09, pT4aN3a(cM0), stage IIIB, with Perineural invasion+, lymphovascular space invasion
    • Chronic viral hepatitis B without delta-agent
  • Course of inpatient treatment
    • After admission, he received PTA and record 24 hrs Ccr before chemotherapy, PTA on 2023/04/01 showed reliabilty fair, 24 hrs Ccr showed 101.0 mL/min, total urine 1300ml. He receice chemotherapy with EP (Cisplatin 75mg/m2 D1, Etoposide 100mg/m2 D1-D3) on 2023/04/03-04/05, with adequate hydration. Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg/tab 1# PO QDAC. Patient tolerated the chemotherapy with mild nausea without vomiting and hiccup were noted, after treatment improving. With the stable condition, he was discharged on 2023/04/06 and OPD followed up later.
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Through (sennoside 12mg) 2# HS
    • Bafen (baclofen 5mg) 1# PRNQ8H
• 2023-03-28 SOAP Hemato-Oncology
  • S
    • For further management of the disease
    • Hbs Ag (-), Anti-HBc (+), Anti-HBs (+), Anti-HCV (-)
  • O
    • 2023/03/16 HBsAg = Nonreactive;
    • 2023/03/16 HBsAg (Value) = 0.42 S/CO;
    • 2023/03/16 Anti-HCV = Nonreactive;
    • 2023/03/16 Anti-HCV Value = 0.11 S/CO;
    • 2023/03/16 Anti-HBs = >1000.00 mIU/mL;
    • 2023/03/16 Anti-HBc = Reactive;
    • 2023/03/16 Anti-HBc-Value = 5.76 S/CO;
  • P
    • admisision
      • chest CT (+/- contrast) for complete work up
      • check 24 urine CCR, auditory test,
      • Adjuvant chemotherapy (4-6 cycle platinum-based chemotherapy [etoposide plus cisplatin or carboplatin]).
      • Prophylatic anti HBV medication
    • Arrange admission for 24 hours CCr, audiometry and C/T with EP
• 2023-03-06 ~ 2023-03-18 POMR General and Digestive Surgery
  • Discharge diagnosis
    • Neuroendocrine carcinoma of gastric lower body, pT4aN3a(cM0), stage IIIB status post radical subtotal gastrectomy with D2 lumph node dissection and Roux-en-Y gastrojejunostomy anastomosis on 2023/03/09. ECOG:1
    • Encounter for adjustment and management of vascular access device with port-A on 2023/03/17
  • CC
    • Epigastric pain and regurgitation for 6 months.       
  • Present illness
    • This is a 73-year-old man without specific past history. The patient had epigastric pain for 6 months, so he went to OPD for help since 2022/09. However, symptoms did not improved even after medication by H2 bloker. The pain was postprandially but did not refer to back or RUQ. Paendoscopy was arranged on 2023/02/22 with a finding of a big ulcer at gastric angularis. Pathology showed small cell neuroendocrine carcinoma. Thus, under the impression of Gastric cancer, he is admitted to our ward for subtotal gastrectomy.    
  • Course of inpatient treatment
    • After admmision, he was arranged with radical subtotal gastrectomy with D2 LN dissection with Roux-en-Y GJ anastomosis. After OP, he had moderate pain at wound and surgical site. The pain was tolerable after given pain killer PCA for post OP pain control. TPN starting on 2023/03/10 with NPO and NG decompression, NG removed. He had flatulence on 2023/03/13 and watery diarrhea passage on 2023/03/14. We started PG1 diet and the patietnt tolerated well without nausea or vomiting. Pathology of stomach tumor came out on 2023/03/14, showing Neuroendocrine carcinoma AJCC Pathologic staging pT4aN3a(cM0), stage IIIB. We consulted hematology doctor for further evaluation. Port-A was arranged on 2023/03/17 for future chenotherpay usage. Under good condition with good pain control and diet recovery to PG3 diet, he was discharged on 2023/03/18 for OPD followup and further treatment.
  • Prescription
    • Mopride (mosapride citrate 5mg) 1# TID
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Acetal (acetaminophen 500mg) 1# QID

[consultation]

• 2024-01-23 Radiation Oncology
  • Q
    • for arrange R/T for left waist pain (2024/01/08 CT shows Enlarged lymph nodes are found at bilateral paraaorti region up to 6.03cm in largest dimension.)
    • will arrange CCRT then IO.
    • This is a 74-year-old man without specific past history. The patient had epigastric pain for 6 months, so he went to OPD for help since 2022/09. However, symptoms did not improved even after medication by H2 bloker. The pain was postprandially but did not refer to back or RUQ.
      • Panendoscopy was arranged on 2023/02/22 with a finding of a big ulcer at gastric angularis.
      • Pathology showed stomach, angularis, biopsy —- small cell neuroendocrine carcinoma, origin ? immunohistochemical stains reveal CK (+), CD56 (+), synaptophysin (+), TTF-1 (+), and LCA (-). The Ki-67 is about 60%. Small cell neuroendocrine carcinoma of stomach may also be positive for TTF-1.
      • Abdominal CT was done on 2023/02/27 showed gastric cancer at body with reiongal lymphadenopathy (n＝4).
      • He received radical subtotal gastrectomy with D2 LNdissection、Roux-en-Y GJ anastomosis on 2023/03/09.
      • Pathology showed stomach, subtotal gastrectomy — Neuroendocrine carcinoma, pT4aN3a(cM0), stage IIIB, IHC (S2023-03207): CK (+), CD56 (+), Synaptophysin (+), TTF-1 (+), Ki-67 = 60%.
      • Thus, diagnosis was small cell neuroendocrine carcinoma, cT2N2M0, s/p radical subtotal gastrectomy with D2 lumph node dissection and Roux-en-Y gastrojejunostomy anastomosis on 2023/03/09, pT4aN3a(cM0), stage IIIB, with Perineural invasion, lymphovascular space invasion.
      • Port-A catheter implantation on 2023/03/17. PTA and record 24 hrs Ccr before chemotherapy, PTA on 2023/04/01 showed reliabilty fair, 24 hrs Ccr showed 101.0 mL/min, total urine 1300ml.
      • He receice chemotherapy with EP (Cisplatin 75mg/m2 -> due to Cr:1.31 eGFR :57, change to Carboplatin AUC:5 D1, Etoposide 100mg/m2 D1-D3) on 2023/04/03(C1), 2023/04/28(C2), 2023/05/22(C3), 2023/06/13(C4), 2023/06/30(C5), 2023/07/25(C6) with adequate hydration.
      • Abdomen CT on 2023/06/12 showed S/P gastric operation, no evidence of tumor recurrence. Bil. renal stones (2-4mm) and R/O CBD stone (5mm).
      • Follow-up, Abdominal CT on 2023/09/10 showed metastatic nodes in left para-aortic space are noted.
      • Arranged Retroperitoneal lymph node CT Guide biopsy on 2023/09/22, pathology showed Soft tissue, left para-aortic space, CT-guide biopsy — Metastatic neuroendocrine carcinoma, immunohistochemistry shows CK (equivocal), CD56 (+) and synaptophysin (+, focal). S/p chemotherapy with FOLFOX on 2023/10/06(C1D1), 2023/10/30(C1D15), 2023/11/17(C2D1), 2023/12/05(C2D15), 2023/12/19(C3D1), 2024/01/05(C3D15).
      • This time, he was admitted to our ward for due to disease progression, for discuss further treatment.
    • We sincerely need your professional assistance!!
  • A
    • This 74-year-old man was diagnosed of small cell neuroendocrine carcinoma, cT2N2M0, s/p radical subtotal gastrectomy with D2 lumph node dissection and Roux-en-Y gastrojejunostomy anastomosis on 2023/03/09, pT4aN3a(cM0), stage IIIB, with Perineural invasion, lymphovascular space invasion. s/p adjuvant C/T. Abdominal CT on 2023/09/10 showed metastatic nodes in left para-aortic space are noted. Biopsy proved Metastatic neuroendocrine carcinoma, s/p C/T with disease progression and Lt back pain.
    • CCRT for symptoms relief and possible disease control is indicated. CT-simulation will be arranged today.
    • Plan to deliver 44~50 Gy/ 22~25 fx to the bil. paraaortic LAPs. RT will start around 2024/01/25 or 26. Thank you very much.
• 2023-03-18 Hemato-Oncology
  • Q
    • This is a 73-year-old man without specific past history. The patient had epigastric pain for 6 months, Panendoscopy was arranged on 2023/02/22 showed a small cell neuroendocrine carcinoma of gastric with a 4.2cm ulcerative mass, cT2N2M0, s/p radical subtotal gastrectomy with D2 LN dissection Roux-en-Y GJ anastomosis on 2023/03/09, pathology showed Neuroendocrine carcinoma, pT4aN3a(cM0), stage IIIB on 2023/03/14.
    • We need your expertise for further evaluation and treatment, Thx!!
  • A
    • Pathology showed Neuroendocrine carcinoma, pT4aN3a(cM0), stage IIIB, with Perineural invasion+, Lymphovascular space invasion+, margin+, Ki-67= 60%. We are consulted for further evaluation and treatment.
    • Please arrange chest CT(+/- contrast) for complete work up.
    • Adjuvant chemotherapy +/- RT is indicated in this case (4-6 cycle platinum-based chemotherapy [etoposide plus cisplatin or carboplatin]).
    • Please check 24 urine CCR, auditory test, HbsAg, antiHbs, AntiHbc, anti HCV. Arrange port A insertion.
    • Arrange our OPD after discharge. Thanks for your consultation.

[surgical operation]

• 2023-03-09
  • Surgery
    • radical subtotal gastrectomy with D2 LN dissection
    • Roux-en-Y GJ anastomosis
  • Finding
    • 4.5 x 4.5 cm ulcerative mass at lower body lesser curvature with serosa invole
    • large LN4 cm at station 9

[chemotherapy]

• 2024-04-19 - (FOLFIRI)

• 2024-04-02 - (FOLFIRI)

• 2024-03-04 - [leucovorin 20mg/m2 35mg NS 100mL 10min + fluorouracil 400mg/m2 709mg NS 100mL 10min] D1-2 (5-FU CCRT)

• 2024-02-29 - [leucovorin 20mg/m2 35mg NS 100mL 10min + fluorouracil 400mg/m2 709mg NS 100mL 10min] D1-2 (5-FU CCRT)

• 2024-01-31 - [leucovorin 20mg/m2 35mg NS 100mL 10min + fluorouracil 400mg/m2 709mg NS 100mL 10min] D1-4 (5-FU CCRT)

• 2024-01-05 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-12-19 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-12-05 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-11-17 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-10-30 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-10-06 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-07-24 - etoposide 80mg/m2 140mg NS 500mL 2hr D1-3 + carboplatin AUC 4 370mg NS 250mL 2hr D1 (Fytosid 100mg/m2 -> 80mg/m2. eGFR 67 carbo AUC 4)

  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3

• 2023-06-30 - etoposide 80mg/m2 140mg NS 500mL 2hr D1-3 + carboplatin AUC 4 370mg NS 250mL 2hr D1 (Fytosid 100mg/m2 -> 80mg/m2. eGFR 69 WBC 2980 carbo AUC 4)

  • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3

• 2023-06-13 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1

  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3

• 2023-05-22 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1 (Cre 1.08, CrCl 59, carbo AUC 5)

  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3

• 2023-04-28 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1 (Cre 1.31, cis -> carbo AUC 5)

  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1

• 2023-04-03 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + NS 500mL 3hr (before cisplatin) + cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + NS 1000mL 3hr (post cisplatin)

  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-2 + NS 250mL D1

==========

2024-07-11

[Veklury (remdesivir) dosage consideration for patient with low eGFR]

Veklury (remdesivir) is not recommended for patients with an eGFR less than 30 mL/min. The patient’s eGFR is 46.82 mL/min (2024-07-10), so this is not a contraindication.

The dosing regimen is IV 200 mg as a single dose on day 1, followed by 100 mg once daily.

The package insert and literature do not provide an alternative approach for missing the loading dose. Since the patient received a single dose yesterday evening (ST) and only about half a day has passed before the next daily dose (QD), administering 200 mg this morning may result in a higher-than-expected blood concentration then the trial design. Therefore, it is not recommended to make up for the missed loading dose today.

[HGB drop and bilirubin rise: hemolysis possibility]

Current iron supplementation (Foliromin 50mg ferrous sodium citrate 1# BID PO) is in place (although the MCV of 94 does not indicate microcytosis). An elevation of bilirubin following a decrease in hemoglobin level could suggest hemolysis, which might warrant further investigation.

• 2024-07-10 Bilirubin total 1.75 mg/dL
  

• 2024-07-10 Bilirubin direct 0.47 mg/dL

• 2024-07-10 HGB 10.4 g/dL
  

• 2024-07-08 HGB 8.6 g/dL
  

• 2024-07-06 HGB 9.3 g/dL
  

• 2024-06-25 HGB 10.2 g/dL

2024-03-01

[CCRT for enlarged paraaortic LAP: everolimus as potential next-line treatment, monitoring PLT]

This patient is currently receiving CCRT for his enlarged paraaortic lymph nodes (LAP). The disease eventually developed resistance to the etoposide + carboplatin regimen and the FOLFOX regimen. Newer treatment options, such as everolimus, might need to be considered after the completion of CCRT.

Recent lab data showed values of PLT less than 100K/uL. While this does not yet constitute a critical level, it warrants close monitoring. Other lab findings were unremarkable. No medication discrepancies were identified.

• 2024-02-29 PLT 94 x10^3/uL
• 2024-02-21 PLT 61 x10^3/uL
• 2024-02-02 PLT 126 x10^3/uL
• 2024-01-22 PLT 129 x10^3/uL
• 2024-01-04 PLT 119 x10^3/uL
• 2023-12-18 PLT 123 x10^3/uL
• 2023-12-04 PLT 135 x10^3/uL
• 2023-11-17 PLT 181 x10^3/uL
• 2023-10-30 PLT 189 x10^3/uL

2023-11-20

[elevated LDH: a sign of underlying tissue and/or liver damage?]

An increasing trend in LDH levels might suggest potential tissue or liver damage, warranting further investigation.

• 2023-11-17 LDH 362 U/L *
• 2023-10-30 LDH 314 U/L *
• 2023-10-18 LDH 263 U/L
  
• 2023-10-03 LDH 243 U/L
  
• 2023-09-12 LDH 138 U/L
  
• 2023-09-05 LDH 126 U/L
  
• 2023-08-08 LDH 129 U/L
  
• 2023-07-19 LDH 132 U/L
  
• 2023-07-12 LDH 116 U/L
  
• 2023-06-27 LDH 116 U/L
  
• 2023-06-08 LDH 102 U/L
  
• 2023-06-01 LDH 110 U/L
  
• 2023-05-16 LDH 154 U/L
  
• 2023-05-09 LDH 96 U/L

2023-07-25

As per the available records, the patient’s general and gastroenterology surgeon issued a prescription on 2023-06-20, following the subtotal gastrectomy. The prescribed medications include B-Red (hydroxocobalamin), Mopride (mosapride citrate), Foliromin (ferrous sodium citrate), and Ulstop (famotidine). These medications were appropriately incorporated into the active medication list, and there were no identified reconciliation problems.

2023-07-03

As per the records, our general and gastroenterological surgery department prescribed a 28-day course of B-Red (hydroxocobalamin), Mopride (mosapride citrate), Foliromin (ferrous sodium citrate), and Ulstop (famotidine) to this patient on 2023-06-20 due to his post subtotal gastrectomy status. These drugs have been correctly incorporated into the active medication list, and no reconciliation issues were identified.

2023-05-23

• A review of the PharmaCloud database shows that all of the patient’s most recent medications were prescribed by our hospital, and no medication reconciliation issues were identified.
• This patient was diagnosed with advanced neuroendocrine carcinoma of the stomach. The patient underwent radical subtotal gastrectomy with D2 lymph node dissection on 2023-03-09. Following this surgery, a chemotherapy regimen of cisplatin and etoposide was initiated on 2023-04-03. However, due to alternations in the patient’s renal function, the chemotherapy regimen was changed to carboplatin and etoposide on 2023-04-28. Neutropenia was noted with a white blood cell (WBC) count of 2.29K/uL on 2023-04-20. Prophylactic granulocyte colony stimulating factor (G-CSF) was prepared for the patient prior to the next round of chemotherapy.
• Lab data on 2023-05-16 showed grossly normal readings and vital signs in the TPR panel indicate that the patient’s condition is stable. All current medications seem appropriate and there appear to be no concerns found with the patient’s current drug regimen.

700541394

240710

[exam findings]

• 2024-05-21 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 26 dB HL; LE 28 dB HL.
  • Bil normal to mild SNHL.
• 2024-04-22 CXR erect
  • Plate density in right lower, r/o atelectasis.
• 2024-04-15 Patho - ovary (tumor)
  • Diagnosis:
    • Ovary, right, debulking surgery — mucinous carcinoma, grade 1 — Mucinous borderline tumor
    • Ovary, left, debulking surgery — negative for malignancy
    • Fallopian tube, left, debulking surgery — lymphangioma
    • Fallopian tube, right, debulking surgery — negative for malignancy
    • Cervix, debulking surgery — Nabothian cyst
    • Myometrium, debulking surgery — intramural myomata
    • Endometrium, debulking surgery — endometrial polyp
    • Omentum, debulking surgery — negative for malignancy
    • Lymph node, left iliac, dissection — negative for malignancy
    • Lymph node, left obturator, dissection — negative for malignancy
    • Lymph node, right iliac, dissection — negative for malignancy
    • Lymph node, right obturator, dissection — negative for malignancy
    • Lymph node, left paraaortic, dissection — negative for malignancy (
    • Lymph node, right paraaortic, dissection — negative for malignancy (adipose tissue only)
    • AJCC 8th edition pathology stage: pT1c1N0 (if cM0); FIGO stage IC1
  • Gross description:
    • Procedure (select all that apply)
      • Debulking surgery (total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + infracolic omentectomy)
      • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
    • Specimen size:
      • Ovary, right: 15x 10 cm
      • Ovary, left: 3x 2 cm
      • Fallopian tube, right: 6x0.5 cm
      • Fallopian tube, left: 5x0.5 cm
      • Uterus: 9x7x6 cm
      • Omentum: 18x5x1.5 cm
    • Specimen Integrity
      • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.
      • Specimen Integrity of Right Ovary (if applicable)
        • Capsule ruptured (surgical spill)
      • Specimen Integrity of Left Ovary (if applicable)
        • Capsule intact
      • Specimen Integrity of Right Fallopian Tube (if applicable)
        • Serosa intact
      • Specimen Integrity of Left Fallopian Tube (if applicable)
        • Serosa intact
      • Tumor Site:
        • Note: Please select the primary tumor site only
        • Right ovary
      • Ovarian Surface Involvement (required only if applicable)
        • Absent
      • Fallopian Tube Surface Involvement (required only if applicable)
        • Absent
      • Tumor Size
        • Note: For bilateral tumors, please report maximum dimension for each primary tumor, specifying by laterality.
        • Mucinous carcinoma: Greatest dimension (centimeters): 0.8 cm
        • Mucinous borderline tumor: Greatest dimension (centimeters): 14 cm
      • Sections are taken and labeled as:F2024-143FSA1-3＆F2024-143A1-15 : right ovarian tumor, A1:left iliac LN, A2:left obturator LN, A3:right iliac LN, A4:right obturator LN, A5:left paraaortic LN, A6:right paraaortic LN,A7:left ovary, A8:left tube, A9:right tube, A10:cx, A11-15:corpus, A16:omentum
  • Microscopic Description:
    • Histologic Type:
      • Mucinous carcinoma & mucinous borderline tumor
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
      • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.
      • WHO Grading System - G1: Well differentiated
    • Implants (required for advanced stage serous/seromucinous borderline tumors only)
      • Note: Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.
      • Not identified
    • Other Tissue/ Organ Involvement (select all that apply):
      • Not identified
    • Largest Extrapelvic Peritoneal Focus (required only if applicable)
      • Not identified
    • Peritoneal/Ascitic Fluid
      • Negative for malignancy (normal/benign)
    • Regional Lymph Nodes:
      • Left iliac: 0/9
      • Left obturator: 0/8
      • Right iliac: 0/3
      • Right obturator: 0/6
      • Left paraaortic: 0/4
      • Right paraaortic: adipose tissue only
    • Additional Pathologic Findings
      • Lymphangioma at left fallopian tube
      • Enodmetrial polyp
      • intramural myomata
    • Comment(s): none
    • Immunohistochemical stain: CK7(+), CK20(focal+), PAX-8(focal+)
• 2024-04-01 CT - abdomen
  • With and without contrast enhancement CT of abdomen:
    • S/P cholecystectomy.
    • Cystic tumor, 15.1x9.5cm in right pelvic cavity with internal septum, r/o malignancy.
    • Uterine tumors, up to 4.7cm.
    • Liver cysts, up to 1.3cm in left lobe liver.
  • Impression:
    • S/P cholecystectomy.
    • Cystic tumor, r/o right ovarian malignancy.
    • Liver cysts.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T1c__(T_value) N:N0(N_value) M:M0(M_value) STAGE:IC__(Stage_value)

[MedRec]

• 2024-06-15 ~ 2024-06-18 POMR Hemato-Oncology Xia HeXiong
  • Course of inpatient treatment
    • After admission, Limeson 4mg/tab 5# (20mg) po and Stogamet 300mg/tab 1# po before chemotherapy with Taxol 12 hrs on 2024/06/16 at 23:00 and before chemotherapy with Taxol 6 hrs on 2024/06/17 at 05:00.
    • Chemotherapy with Taxol (175mg/m2) / Carboplain (AUC:5) on 2024/06/17 (C2), due to allergy of taxol last time add premedication with Hydrocortisone 100mg/vial 1vial for relief. Then get improving, extend infusion time to 6 hours. Reflux esophagitis LA Classification grade A with PPI oral form.
    • Patient tolerated the chemotherapy without nausea and vomiting, but mild redness of body without itchy. Allegra oral form for back. With the stable condition, she was discharged on 2024/06/18 and OPD followed up later.
  • Discharge prescription
    • Emend (aprepitant 125mg) 1# QD
    • Allegra (fexofenadine 60mg) 1# BID
• 2024-04-11 ~ 2024-04-23 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of right ovary
    • Right ovarian malignancy (mucinous carcinoma , grade 1, pT1c1N0(if cM0); FIGO stage IC1 post Debulking surgery on 2024/04/15)
    • Abnormal vaginal bleeding
  • CC
    • Vaginal spotting for 10 days
  • Present illness
    • This 68-year-old, P3 (vaginal delivery) woman had history of mymectomy 5 years ago and cholecystectomy 10 years ago. She has menopaused for near 20 years. Her last pap smear was normal on 2024/03. There was no food or drug allery. She denied the useage of Hormonal therapy.
    • This time, she came to our GYN OPD for help due to vaginal spotting for 10 days. The amount like first day of her menstruation but no abdominal pain or abnormal discharge. However she did not has body weight loss, decreased appetite, progressively weakness and urinary frequency. Furthremore, there was no fever, dyspnea, change the bowel habbit or other discomfort.
    • At GYN OPD on 2024/03/28, the transvaginal sonography revealed the uterus was 7159mm and 2 myomas (3731mm and 34*29mm). The endometrium was 10.6 mm. The right ovarian mass (122mmx85mm), with septum,no boold flow was found.
    • The CT abdomen on 2024/04/01 revealed a cystic tumor, 15.1x9.5cm in right pelvic cavity with internal septum, r/o malignancy and no ascites or enlarged lymph node. According to her medical record, the CA-125 level was 85.9, CEA level was 33.5 and CA199 level was <2.
    • Under the impression of right ovarian cancer which cannot be excluded, surgical intervention was suggested. After well explained and discussion with patient, she accepted the operation on 2024/04/15 and was admitted to our ward on 2024/04/11. On arrival, the vital signs were stable, Blood test showed Hgb level as 14.7 g/dL (normal). The preoperative evaluation and preparation including upper GI panendoscopy and colonscopy for her was arranged as cancer surveys.
  • Course of inpatient treatment
    • This patient was admitted on 2024/04/11. The GU doctor was consulted and done cystoscopy and bilateral ureter insertion on 2024/04/15.
    • And she later underwent Debulking surgery (total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + infracolic omentectomy) on 2024/04/15.
    • We gave her Cefazolin and Gentamycin IV form for post op prophylaxis antibiotics for days. We checked the lab datas and revealed no infection signs and then we shifted her antibiotics to Cephalexin of oral form since her post-op course was uneventful. Post-operation wound was dry and clean without dehiscence, discharge, or oozing.After flatus, her food taking and defecation were all in good conditon.
    • The pathology showed right ovarian malignancy (mucinous carcinoma, grade 1, pT1c1N0(if cM0); FIGO stage IC1). The GYN tumor conference was held on 2024/04/25. She was then arranged with chemotheraphy and Port-A insertion by GS Dr. on 2024/04/22.
    • Since all her general conditions were all improved and relatively stable, we arranged her discharge on 2024/04/23. She would under further OPD follow up for her recovery status and surgical wound conditions.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • MgO 250mg 2# QID
    • cephalexin 500mg 1# QID

[surgical operation]

• 2024-04-15
  • Surgery
    • Diagnosis:
      • Right ovarian malignancy (Ovary, right, frozen section — Mucinous adenocarcinoma)
    • Operation:
      • Debulking surgery (total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + infracolic omentectomy)   - Finding Right ovarian malignancy (Ovary, right, frozen section — Mucinous adenocarcinoma)
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, the posterior wall was tense contact with sigmoid colon, s/p adhesiolysis
    • Adnexa:
      • LOV: 3x2x2 cm , capsule intact , smooth surface. Adhesion with sigmoid colon, s/p adhesiolysis
      • ROV: one multicystic right ovarian mass, 20x10 cm , capsule intact, intra-operative rupture(+) with mucus contents(900ml)
      • Fallopian tube: bilateral grossly normal
    • Cul-de-sac: invisible due to tumor mass occupied and adhesion.
    • Ascites: bloody, sent for cytology test
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+, at left site), indurated(-)
    • Omentum: grossly normal. mild adhesion to peritoneum, s/p adhesiolysis
    • Liver: grossly normal & smooth
    • Subdiaphragmatic surface: miliary tumor seeding(-)
    • Appendix: grossly normal
    • Optimaldebulking surgery was achieved
    • Optimal cytoreduction: R0 : there was no residual tumor
    • Estimated blood loss: 500ml
    • Blood transfusion: none
    • Complication: nil
    • Antiadhesion agent: none
    • J-vac x2 at bilateral cul-de sac   

[chemotherapy]

• 2024-07-10 - hydrocortisone 100mg + paclitaxel 175mg/m2 240mg NS 500mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr (TP Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-17 - hydrocortisone 100mg + paclitaxel 175mg/m2 240mg NS 500mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr (TP Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-21 - paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AUC 5 590mg NS 250mL 2hr (TP Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-07-10

Lab results on 2024-07-09 were within normal limits, and vital signs remained stable throughout the hospitalization. No medication discrepancies were identified.

700716410

240710

[MedRec]

• 2024-06-26 SOAP General and Gastroenterological Surgery Zhang YaoRen

  • Prescription x2
    • Aromasin (exemestane 25mg) 1# QD 28D
    • Kisqali (ribociclib 200mg) 3# QD 7D

• 2024-06-14 ~ 2024-06-15 POMR General and Gastroenterological Surgery Zhang YaoRen

  • Discharge diagnosis
    • Left breast cancer with thoracic spine and liver metastasis stage IV. IHC revealed ER(+, 90%), PR(-), HER(-). ECOG performance score:0
  • CC
    • for Cyclin-dependent kinases 4/6 with Kisquli
  • Present illness
    • This 60-year-old post menopausal woman has
      • 1. Left knee grade II~III osteoarthritis with lateral patella subluxation post arthroscopic shaving and lateral patella release on 2020/11/25.
      • 2. Left breast cancer pT2N2M0 stage IIIA status post left partial mastectomy and axillary lymph node dissection on 2016/05/06.
    • She was admitted for implantation port-a catheteriplatation and arrange adjuvant chemotherapy. She denied any TOCC histories in recent 3 months.
    • She was diagnosed with left breast cancer then underwent of left breast cancer pT2N2M0 stage IIIA status post left partial mastectomy and axillary lymph node dissection on 2016/05/06. The finally pathlogy revealed invasive carcinoma with lymph node metastatic carcinoma (2016/06/18), pT2N2M0 stage IIIA. IHC revealed ER (Ab): Positive (100%), PR (Ab): Positive (10%), HER-2/Neu (Ab): Negative, Ki-67: 20%, p53: 5%.
    • She received adjuvant chemotherapy EC follow by T since 2016/05/23 and completed Radiotherapy. AI since 2016/11/14 and advise extension therapy.
    • Unfortunately, MRI revealed multiple hepatic tumors at both lobes of liver and spine metastaisis on 2023/03/16.
    • She received Cyclin-dependent kinases 4/6 with Ibrance since 2023/04/03 then shift to Afinitor due to increased of tumor marker since 2023/09/04.
    • Abdominal CT revealed multiple metastases on both hepatic lobes on 2024/05/11.
    • CT guild biospy showed consistent with metastatic invasive carcinoma of breast. IHC showed ER: Positive (90%), PR (Ab): Negative, HER-2/Neu (Ab): Negative, GATA3: Negative.
    • After well explain the possible treatment modality were well explained to the patient. This time, she was admitted to our ward for Cyclin-dependent kinases 4/6 with Kisqali.
  • Course of inpatient treatment
    • After admission, Kisquli was given. Under the stable condition, she was discharged today, and will follow at OPD two weeks later.
  • Discharge prescription
    • Kisqali (ribociclib 200mg) 3# QD 14D

• 2024-06-12 SOAP General and Gastroenterological Surgery Zhang YaoRen

  • Prescription
    • Aromasin (exemestane 25mg) 1# QD 28D

• 2024-06-03 SOAP General and Gastroenterological Surgery Zhang YaoRen

  • Prescription
    • Aromasin (exemestane 25mg) 1# QD 14D

• 2024-05-13 SOAP General and Gastroenterological Surgery Zhang YaoRen

  • Prescription
    • Aromasin (exemestane 25mg) 1# QD 21D
    • Afinitor (everolimus 5mg) 1# BID 12D

• 2024-02-26 SOAP General and Gastroenterological Surgery Zhang YaoRen

  • Prescription x3
    • Aromasin (exemestane 25mg) 1# QD 28D
    • Afinitor (everolimus 5mg) 1# BID 28D
    • BioCal chewable tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# BID 28D

• ….-..-..

• 2017-03-20 SOAP General and Gastroenterological Surgery Zhang YaoRen

  • S: Lt breast ca proved by CNB at YiLan YangMing Hospital on 2016-04-25
  • Diagnosis
    • Malignant female breast neoplasm, NOS [C50.912]
    • Sleep disturbance, unspecified [G47.8]
  • Prescription x3
    • Femara (letrozole 2.5mg) 1# QD 28D

==========

2024-07-10

[ribociclib treatment schedule and neutropenia management]

Kisqali (ribociclib) was initiated on 2024-06-15 with a standard daily dose of 600mg. However, the prescribed regimen did not exactly match the recommended “21 days of use followed by a 7-day rest period to complete a 28-day treatment cycle,” as there was no clear 1-week rest period.

Ribociclib is associated with neutropenia (69% to 78%; grade 3: 46% to 55%; grade 4: 7% to 10%). The recommendations for managing neutropenia are:

• Grade 1 or 2 neutropenia (ANC 1,000/mm³ to below the lower limit of normal): No ribociclib dosage adjustment necessary.
• Grade 3 neutropenia (ANC 500 to <1,000/mm³): Interrupt ribociclib treatment until recovery to grade 2 or lower, then resume ribociclib at the same dose. For recurrent grade 3 neutropenia, interrupt treatment until recovery and then resume ribociclib at the next lower dose level.
• Grade 3 neutropenic fever (a single episode of fever >38.3°C or fever >38°C for >1 hour and/or concurrent infection): Interrupt ribociclib treatment until recovery (of neutropenia) to grade 2 or lower and then resume ribociclib at the next lower dose level.
• Grade 4 neutropenia (ANC <500/mm³): Interrupt ribociclib treatment until recovery to grade 2 or lower and then resume ribociclib at the next lower dose level.

Grade 3 neutropenia was noted on 2024-07-08 for the first time with ribociclib. It is recommended to interrupt ribociclib treatment until recovery to grade 2 or lower, then resume ribociclib at the same dose.

• 2024-07-08 WBC 1.63 x10^3/uL
  
• 2024-07-08 Neutrophil 30.8 %

700769705

240710

[exam findings]

• 2024-05-21 Tc-99m MDP bone scan with SPECT
  • In comparison wtih the previous study on 2022/12/09, some new faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please correlate with other clinical findings and follow up bone scan for further evaluation.
  • The lesions in bilateral femoral necks are less evident, possibly more benign in nature.
  • No prominent change is noted in other bone lesions, possibly also more benign in nature.
• 2024-05-18 ECG
  • Nonspecific T wave abnormality
• 2024-05-18 CT - chest
  • With and without contrast enhancement CT of chest shows:
    • Multiple nodular lesions in both lung fields.
    • s/p right chest surgery.
    • A small paraseptal emphysema in LUL, B1-2.
    • No enlarged mediastinal lymph node.
    • A nodular lesion, 1.9cm, in liver dome.
    • No bony destructive lesion on these images.
  • Impression
    • c/w lung metastasis
    • suspect liver or right hemidiphragm metastasis
• 2024-04-30 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, lower lobe, wedge resection —- Consistent with metastatic endometrioid carcinoma x 2
  • MACROSCOPIC EXAMINATION:
    • Specimen: Lung, size: 5.2 x 2.1 x 1.2 cm, 6 g
      • Lymph nodes: not received
    • Tumor Site: Periphery
    • Tumor Size: Multiple (Number: two ), Maximal one (tumor A): 1.5 x 1.4 x 1.2 cm
    • Other sizes (tumor B): 0.5 x 0.5 x 0.5 cm
    • Gross tumor patterns: poorly defined
      
    • Tissue for sections: A1: resection margin; A2-4: tumor A; A5: tumor B.
  • Microscopic Description
    • Tumor Focality: Separate tumor nodules of same histopathologic type (intrapulmonary metastases) in same lobe
    • Histologic Type (select all that apply): Consistent with metastatic endometrioid carcinoma x 2; The immunohistochemical stains reveal CK7(+), CK20(-), PAX8(+), PR(+), TTF-(+), and Napsin A(-).
    • Histologic Grade: grade 2
      
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Not identified
    • Lymphovascular Invasion (select all that apply): Present, Lymphatic
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.2 cm
      • Specify closest margin: wedge resection margin
    • Treatment Effect: No known presurgical therapy
    • Regional Lymph Nodes: No lymph nodes submitted or found
    • Extranodal Extension: Cannot be determined
    • Additional Pathologic Findings (select all that apply): None identified
• 2024-04-29 CT - chest
  • Comparison was made with CT on 2024/03/05
    • Lungs: multiple randomly distributed pulmonary nodules and masses of varying sizes, measuring up to 33mm at RLL
      • cyst mild subpleural fibrosis at bilateral apical lungs
    • Mediastinum and hila: no enlarged LN
      • the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal size of cardiac chambers.
    • Pleura: no effusion.
    • Chest wall and visible lower neck: unremarkable.
  • Impression:
    • multiple metastatic tumors in both lungs ,stationary as compared with CT dated on 2023/03/05
• 2024-04-29 Flow Volume Chart
  • r/o mild restrictive ventilatory defect
• 2024-03-15 CT - chest
  • Hx: Endometrial cancer III C1 operated on 2014-07-21
  • Chest CT with and without IV contrast ehnancement shows:
    • Lobulated nodule at right upper lobe measuring 2.19cm and right lower lobe measuring 2.98cm in largest dimension are found. Smaller lesions are found at both lungs. Lung meta is considered.
  • Imp:
    • Bilateral lung meta.
• 2023-11-21 Patho - colon biopsy
  • Intestine, large, rectum, biopsy removal — tubular adenoma
  • Intestine, large, rectum, biopsy removal— tubular adenoma
• 2023-11-21 Flow Volume Chart
  • Mild restrictive ventilatory impairment
• 2023-11-21 SONO - abdomen
  • Diagnosis:
    • Fatty liver,mild to moderate
    • Suspected fatty infiltration of pancreas
  • Suggestion:
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2023-10-23 SONO - nephrology
  • Parenchymal change of bilateral kidneys
• 2023-10-21 CXR
  • Multiple nodules at bil. right lung.

[MedRec]

• 2024-04-21 ~ 2024-04-23 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of endometrium
    • Abdominal pain
  • CC
    • Sudden left lower abdominal and flank pain for 1 day.
  • Present illness
    • This 46-year-old menopaused woman (unmarried, G0P0) with medical history of Endometrial adenocarcinoma with lymph node metastasis (4/40), pT3aN1M0, FIGO pStage IIIC1,
      • s/p staging operation (TAH + BSO + BPLND + BALND + washing cytology + omentectomy, on 2014/07/21)
      • s/p chemotherapy with Lipo-Dox(self-paid)/CDDP
      • recurrent with bilateral lung metastasis, diagnosed in 2017
      • under monthly tranditional chinese medical OPD followup
      • under GYN OPD followup every 3 months, under Megejohn 160mg 1# QD
    • According to her statement and medical records, Endomterial adenocarcinoma with lymph node metastasis (4/40), pT3aN1M0, FIGO pStage IIIC1 was diagnosed in 2014 and she had regular GYN OPD followup after staging operation and chemotherapy. Left chest pain with dyspnea was noted in 2017. Tc-99m MDP Whole body bone scan on 2017/01/24 showed two faint hot spots in the anterior aspect of left 1st and 7th ribs respectively. Chest CT on 2017/02/21 revealed multiple lungs nodules of variable sizes due to metastasis. She accepted chemotherapy then, and keep OPD followup. Blood tumor markers test on 2023/11/21 showed CA-199 (NM) = 6.493 U/ml; 2023/11/21 CEA (NM) = 1.116 ng/ml; 2023/11/21 CA125 = 5.4 U/mL.
    • Her recent chest CT scan on 2024/3/15 showed 1. lobulated nodule at right upper lobe measuring 2.19cm and right lower lobe measuring 2.98cm in largest dimension are found. Smaller lesions are found at both lungs. Lung meta is considered. 2. No evidence of bilateral pleural effusion.
    • This time, she came to emergency room on 2024/04/21 with complaint of sudden left lower abdominal and flank pain for 1 day. She ever been visited to Taoyuan VGH for help where suspicious of left renal stone was diagnosed. Pain killer was given but in vain so she came to our ER for further management. On arrival, vital signs were stable. Lab data showed leukocytosis without left shifted(WBC = 14.58 x10^3/uL) and hematuria. Tramadol IV was prescribed. Due to the above reasons and after discussion with Professor Huang, she was then admitted to our ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, empiric antibiotics with cefazolin 1 gm q8h was given. Adequate hydration and pain control also prescribed.
    • The KUB rechecked on 04/23 and revealed no abnormal finding. With improved symptoms, she was discharged today and OPD follow up arranged on 2024/05/14.
  • Discharge prescription
    • cephalexin 500mg 1# QID 5D
    • Acetal (acetaminophen 500mg) 1# PRNQ6H 5D if pain

[immunochemotherapy]

• 2024-07-09 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-06-12 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-05-20 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 340mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-07-10

Hypokalemia was noted on 2024-07-08. Oral potassium supplementation (Const-K) is currently used, no medication problems found.

• 2024-07-08 K (Potassium) 3.2 mmol/L

701496322

240708

[lab data]

2023-11-28 HLA A-high 11:01
2023-11-28 HLA A-high 24:02
2023-11-28 HLA B-high 27:04
2023-11-28 HLA B-high 35:01
2023-11-28 HLA C-high 08:01
2023-11-28 HLA C-high 12:02

2023-11-28 HLA DQ-high 03:01
2023-11-28 HLA DQ-high 03:03

2023-11-28 HLA DR-high 12:01
2023-11-28 HLA DR-high 12:02

2023-09-13 FLT3-D835 (bone marrow) Undetectable
2023-09-11 CD2 NA
2023-09-11 CD3 3.4
2023-09-11 CD4 NA
2023-09-11 CD5 1.3
2023-09-11 CD7 98.6
2023-09-11 CD8 NA
2023-09-11 CD10 2.4
2023-09-11 CD11b 32.8
2023-09-11 CD13 94.7
2023-09-11 CD14 1.2
2023-09-11 CD15 NA
2023-09-11 CD16 0.76
2023-09-11 CD19 6.2
2023-09-11 CD19/kappa NA
2023-09-11 CD19/Lambda NA
2023-09-11 CD20 1.8
2023-09-11 CD23 NA
2023-09-11 CD25 NA
2023-09-11 CD33 85.2
2023-09-11 CD34 90.6
2023-09-11 CD38 NA
2023-09-11 CD56 0.4
2023-09-11 CD103 NA
2023-09-11 CD117 98.5
2023-09-11 CD138 NA
2023-09-11 FMC7 NA
2023-09-11 HLA-DR 99.1
2023-09-11 MPO NA
2023-09-11 TdT NA
2023-09-11 FLT3/ITD (bone marrow) Presence of mutation
2023-09-11 NPM1 (bone marrow) Undetectable
2023-09-11 LDH 276 U/L
2023-09-09 LDH 513 U/L
2023-09-05 LDH 2394 U/L

2023-09-04 HBsAg Nonreactive
2023-09-04 HBsAg (Value) 0.57 S/CO
2023-09-04 Anti-HBc Nonreactive
2023-09-04 Anti-HBc-Value 0.43 S/CO
2023-09-04 Anti-HCV Nonreactive
2023-09-04 Anti-HCV Value 0.14 S/CO

2023-09-03 LDH 1578 U/L

2023-08-31 Uric Acid 9.2 mg/dL
2023-08-31 LDH 1428 U/L

2023-08-31 WBC 351.74 x10^3/uL
2023-08-31 HGB 8.4 g/dL
2023-08-31 PLT 33 x10^3/uL

[exam findings]

• 2023-12-11 CXR erect
  • S/P PICC catheter insertion via left forearm.
  • Spondylosis of the T-spine
  • Gallstone is suspected. Please correlate with CT.
• 2023-10-20 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy
  • Microscopically, it shows normal cellularity (approximately 45%), 3:1 of M:E ratio . Both myeloid and erythroid lineages demonstrate maturation. Megakaryocytes are present in normal in numbers (2-3 per HPF) and demonstate no significant morphologic abnormalities. Blast-like cells (CD117+, <1%) are present.
  • Immunohisotchemical stain reveals CD34 (-), CD138 (focal+, 1%), MPO (+), CD71 (+), CD61 (+), TdT (-).
  • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular cytogenetic study, flow cytometery and clinical findings is recommended.
• 2023-10-20 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 30.3) / 106 = 71.42%
    • M-mode (Teichholz) = 71.4
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Trivial MR and AR, mild TR and PR
    • Impaired LV relaxation
    • Dilated LA, thick IVS and LVPW
• 2023-10-19 CXR
  • S/P PICC catheter insertion via left forearm.
  • Spondylosis of the T-spine
  • Large gallstone is highly suspected. Please correlate with CT.
• 2023-10-19 Cardiac Catheterization
  • We perform PICC at our cath room
    • Under the peripheral echo guiding, we successful puncture left basilic vein, Under the fluroscopy guiding, PICC one way catheter was implanted to SVC smoothly.
  • We check SvO2 64%.
    • Estimated Fick Cardiac index 1.81 L/min/m2 (normal cardiac index 2.4~4L/min/m2)
    • Cardiac output 2.76 L/min
• 2023-09-05 Cardiac Catheterization
  • Indication: for chemotherapy
  • We perform PICC under the cath room (fluroscopy guiding)
    • Under the peripheral echo guiding, we successful puncture left basilic vein. Then wire advanced smoothly under the fluroscopy. Then microcatheter was advanced in basilic vein. The PICC catheter was advnaced to left SVC to atrium junction.
• 2023-09-04 Patho - bone marrow biospy
  • Bone marrow, iliac crest, biopsy — Compatible with acute myeloid leukemia with maturation
  • The sections show hypercellular marrow (80%). The marrow space is replaced by a population of medium to large-sized immature cells with round to oval nucleus and moderate amount cytoplasm.
  • IHC, markedly increased CD34+ and or CD117+ blasts, constitue 80% of marrow cells. Most immature cells are also positive for MPO and some are positive for CD163 (10%).
  • The finding is compatible with acute myeloid leukemia with maturation. Suggest bone marrow smear evaluation and clinic correlation.
• 2023-09-01 SONO - abdomen
  • Diagnosis:
    • Fatty liver,mild
    • Suspected fatty infiltration of pancreas
    • Propable liver cysts, bil
    • Mild hydronephrosis, left
    • GB not shown due to non-fasting
      
  • Suggestion:
    • Consult GU for Mild hydronephrosis, left
    • Follow liver function test and AFP
    • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
• 2023-08-31 CXR (erect)
  • Thoracic spondylosis

[MedRec]

• 2023-08-31 ~ 2023-10-02 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Flt3-ITD mutated acute myeloblastic leukemia, not having achieved remission
    • Bacteremia
    • Severe sepsis with septic shock
    • Agranulocytosis secondary to cancer chemotherapy
    • Fever, unspecified
    • Spontaneous ecchymoses
  • CC
    • whole body spontaneous ecchymosis for one month
  • Present illness
    • This 63-year-old female denied any past medical history.
    • This time, she suffered from some spontaneous ecchymosis was noted over whole body for 1+ weeks. Associate with SOB, fatigue, dizziness and dry cough for 5-6 days. She denied of lost of appetite, unintentional weight loss, abdominal or urinary tract disconfort. The patient initially went to Cardinal Tien Hospital for help, however they refered patient to our hospital for better medical care, so he was sent to our ER for help on 2023/08/31.
    • At ER, vital signs: BT:38C, HR:99/min, RR:20/min, BP:128/80 mmHg, SpO2:96% under room air. Physical exam showed ecchymosis all over the body. The laboratory data showed anemia (8.4 g/dL), leukocytosis (351.74 x10^3/uL) (Blast:95%), thromocytopenia (PLT 33*10^3/uL), elevated serum CRP (12.4 mg/dL), normal PT/aPTT level, elevated uric acid 9.2 mg/dL and elevated LDH 1428 U/L. CXR showed no obvious lung marking.
    • Under the impression of suspected AML without remission, so she was admitted to our ward for further evaluation and management on 2023/08/31.  
  • Course of inpatient treatment
    • After admitted to ward, she received critical care and antibiotics with Mepem + Targocid for infection control at first. IVF hydration and Feburic 1# qd for elevated UA level. Bone marrow showed AML. CXR showed infiltraction over both lower lung. Hydrea 2# tid for leukocytosis, but hold it during 7+3 chemo as Dornorubicin + Ara-C on 9/4-9/10. Keep antibiotics as Mepem + Targocid + Mycamine + oral form Baktar. Continue posaconazole 3# qd and added Rydapt 2# q12h since 9/13-10/4.
    • Sudden onset, she suffered vomitting, weakness and high fever were noted on 9/18 17:30. B/C from PICC and peripheral were yield Klebsiella pneumoniae.
    • On 9/19 morning, BP dropped and dizziness were noted. Fluid resuscitation and foley, CVC insertion for shock monitor. Drawn the series of cultures, DIC profiles and broadspectrum antibiotic as Mepem and Targocid.
    • Due to unstable hemodynamic and impressed with bacteremia with sepsis, she was transferred to MICU for intensive care on 2023/09/19.
    • After transferred to MICU, she received oxygen therapy with O2 nasal cannula supply and kept protective isolation. Empirical antibiotic with Mepem (9/18-) + Targocid (9/18-) + Baktar PO (9/19-) were prescribed for infection control. Blood transfusion with FFP for 3 days (9/19-9/21) and adequate IV fluid were administered to manage shock status. LRP transfusion was also given to correct thrombocytopenia. Acetal ragularly used due to fever on and off.
    • AML treatments were continued as Rydapt 2# PO Q12H (9/13-10/4) + Posaconazole 3# PO QD (9/6-10/4). We administered KCL, Const-K, Calglon, Magnesium Sulfate, and MgO to correct imbalance of electrolyte (hypokalemia, hypocalcemia, and hypomagnesemia). Blood transfusion with LPRBC was prescribed to correct anemia and stool OB was obtained, which showed 3+. Thus, self-payment PPI with Nexium was given.
    • We collected AFS/TB culture(3 sets) and sputum PJP as well as obtained blood Aspergillus Ag and Crypto. Ag on 9/25 for further infection survey. Localized warmth and erythema in the right shoulder area was noticed and suspected cellulitis. Therefore, we added antibiotic with Ciprofloxacin (9/22-) for infection control and consulted PS physician who replied this is a case of cellulitis of right shoulder. Then the conservative treatment (antibiotic use) is suggested. As a result of relief of shock status and stable conditions after all treatments, she will be transferred to ordinary ward if the bed is available.
    • After transfer to ONC ward on 2023/09/27. Her WBC level increase and no fever or SOB. Right shoulder cellulitis without discharge or tenderness. After treatment, her general condition got improvement, so she can be discharged on 2023/10/02. OPD follow up is arranged.
  • Discharge prescription
    • Posanol (posaconazole 100mg) 3# QD
    • Cinolone (ciprofloxacin 250mg) 2# BIDAC
    • Rydapt (midostaurin 25mg) 2# Q12H
• 2023-08-31 SOAP Medical Emergency Jian DaSen
  • A: preliminary impression: C92.00 Acute myeloblastic leukemia, not having achieved remission

[consultation]

• 2023-10-18 Cardiology

  • Q
    • The 63 y/o woman has Flt3-ITD mutaed acute myeloblastic leukemia. She was admitted for 2nd chemotherapy, so we need your help for PICC insertion one way. Thanks!
  • A
    • Chemotherapy was planed We will arrange PICC after well explain the procedure, possible risk and benefit for patient and familes.
    • It will be arrange on Oct. 19 morning (around 8:10 AM)

• 2023-09-25 Reconstructive and Plastic Surgery

• 2023-09-01 Psychosomatic Medicine

[chemotherapy]

• 2024-03-09 - cytarabine 3000mg/m2 4900mg NS 500mL 3hr Q12H D1,3,5 (10 doses) (HD Ara-C Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1,3,5
• 2024-01-10 - cytarabine 2000mg/m2 3000mg NS 250mL 2hr Q12H D1-6 (10 doses) (HD Ara-C Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-6
• 2023-12-11 - daunorubicin 45mg/m2 70mg NS 100mL 30min D1-2 + cytarabin 100mg/m2 156mg NS 500mL 24hr D1-5
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
• 2023-10-25 - daunorubicin 45mg/m2 68mg NS 100mL 30min D1-2 + cytarabin 100mg/m2 152mg NS 500mL 24hr D1-5
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
• 2023-09-04 - daunorubicin 45mg/m2 70mg NS 100mL 30min D1-3 + cytarabin 100mg/m2 158mg NS 500mL 24hr D1-7
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-7

Rydapt (midostaurin 25mg) 2# Q12H - 2023-08-31 ~ 2023-11-07

In-hospital chemotherapy formulary (2023-02-20)

• High Dose Ara-C +/- daunorubicin
  • Regimen
    • Cytarabine
      • 3000 mg/m2; IVD 3h Q12H; D1, D3, D5, total 6 doses
      • 2000 mg/m2; IVD 3h Q12H; D1-D4, total 8 doses
    • Daunorubicin
      • 45 mg/m2; IV; 1-3 days
  • References
    • N Engl J Med 1994;331:896

Cytarabine (conventional) - 2024-03-11 - https://www.uptodate.com/contents/cytarabine-conventional-drug-information

• Acute myeloid leukemia salvage treatment (off-label use):
  • HiDAC (high-dose cytarabine) ± an anthracycline: IV:
    • 3,000 mg/m2 over 1 hour every 12 hours for 6 days (total of 12 doses)
    • Ref: High-Dose Cytosine Arabinoside Therapy With and Without Anthracycline Antibiotics for Remission Reinduction of Acute Nonlymphoblastic Leukemia. J Clin Oncol. 1985;3(7):992-997.

==========

2027-07-08

[U-Vanco dosage recommendations based on TDM results]

U-Vanco (vancomycin) 1000mg Q12H IVD is currently in use, with a TDM trough result of 9.6 µg/mL on 2024-07-07, below the recommended range of 10 to 15 µg/mL. It is advised to adjust the dosage to 1500mg Q12H or 1000mg Q8H to achieve the target range.

2024-03-11

[HD-AraC (2nd session) & fever response (Tapimycin) - BP WNL (Sevikar hold considered)]

High-dose Ara-C, without anthracycline, was initiated on 2024-01-10. The 2nd session of this regimen was administered during this hospitalization.

A fever of 38.7’C on 2024-03-10, decreased to below 37’C today, 2024-03-11, after administration of Tapimycin (piperacillin, tazobactam).

BP since 2024-03-10, has been approximately 100/55 mmHg for 2 days. Sevikar (amlodipine, olmesartan) might be held for a few days and monitored before restarting.

2023-10-26

[restarting posaconazole after discontinuation]

If posaconazole has been discontinued for several days (considered as washed out), it’s recommended to reintroduce the drug with a loading dose, specifically, 300 mg BID for two doses, then switch to a maintenance dose of 300 mg QD.

2023-09-14

[leukopenia]

The patient was administered her initial dose of the cytarabine/daunorubicin (7+3) regimen on 2023-09-04. A week later, on 2023-09-11, her WBC count reached its lowest point at 0.84K/uL, after which an upward trend was noted.

2023-09-13 WBC 1.23 x10^3/uL 2023-09-11 WBC 0.84 x10^3/uL * 2023-09-10 WBC 1.02 x10^3/uL 2023-09-09 WBC 1.05 x10^3/uL 2023-09-08 WBC 1.09 x10^3/uL 2023-09-07 WBC 1.69 x10^3/uL 2023-09-06 WBC 8.35 x10^3/uL 2023-09-06 WBC 24.86 x10^3/uL 2023-09-05 WBC 247.70 x10^3/uL 2023-09-04 WBC 355.71 x10^3/uL 2023-09-03 WBC 366.64 x10^3/uL 2023-09-02 WBC 370.59 x10^3/uL 2023-09-02 WBC 361.09 x10^3/uL 2023-09-01 WBC 335.15 x10^3/uL

[thrombocytopenia]

Prior to receiving her first dose of the cytarabine/daunorubicin (7+3) regimen on 2023-09-04, the patient was already in a state of thrombocytopenia. Following the administration of chemotherapy, her platelet count (PLT) continued to decline, reaching 23K/uL on 2023-09-13, the day a blood transfusion was performed. Blood transfusions were also administered on the following dates: 2023-08-31, 2023-09-04, and 2023-09-08.

2023-09-13 PLT 23 x10^3/uL * 2023-09-11 PLT 54 x10^3/uL
2023-09-10 PLT 83 x10^3/uL
2023-09-09 PLT 124 x10^3/uL
2023-09-08 PLT 29 x10^3/uL
2023-09-07 PLT 52 x10^3/uL
2023-09-06 PLT 102 x10^3/uL
2023-09-06 PLT 125 x10^3/uL
2023-09-05 PLT 48 x10^3/uL
2023-09-04 PLT 69 x10^3/uL
2023-09-03 PLT 79 x10^3/uL
2023-09-02 PLT 75 x10^3/uL
2023-09-02 PLT 102 x10^3/uL
2023-09-01 PLT 111 x10^3/uL

2023-09-01

For this admission, the patient was initially admitted through the emergency department and this is her first time seeking medical care at this hospital. There are no records available from PharmaCloud and no medication reconciliation issues have been identified.

700376342

240704

[exam findings] (not completed)

• 2024-06-26 SONO - abdomen

  • Symptoms:
    • Liver:
      • Coarse echotexture. Enlarge left lobe.
      • one 1.92cm hypoechoic lesion at S2.
      • one 0.47cm anechoic lesion with PAE at S3.
      • One anechoic lesion was noted at S5 Size 0.64 cm
    • Bile duct and gallbladder:
      • several up to 1.21cm hyperechoic lesions with PAS in GB.
    • Portal veins and blood vessels:
      • negative
    • Kidney:
      • one 1.61cm hyperechoic lesion with PAS in right kidney.
    • Pancreas:
      • Some parts of pancreas blocked by bowel gas, especially body and tail
    • Spleen:
      • Splenomegaly
    • Ascites:
      • Minimal ascites
    • Other:
      • negative
  • Diagnosis:
    • Cirrhosis of liver with hepatomegaly of left lobe
    • Liver tumor, S2
    • Liver cysts
    • GB stones
    • Renal stone, right
    • Splenomegaly, mild
    • Minimal ascites
  • Suggestion:
    • correlate with other image and tumor markers.

• 2024-05-20, -05-19, -05-05 CXR

  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • a focal Rt-sided convexity of the azygoesophageal recess interface, raise suspicious of esophageal tumor
  • Rt paratracheal stripe paratracheal lymph node enlargement
  • widening of Rt paratracheal stripe due to paratracheal lymph node enlargement
  • emphysematous change in peripheral both upper lobes?
  • old fracture of Lt M/3 clavicle

• 2024-05-09 Bronchoscopy

  • Bronchoscopic finding:
    • The nasal mucosa was hypertrophic.
    • The nasal lumen was moderately narrowed.
    • The was no mucoid nasal discharge retained in the nasal cavity.
    • Mucosa of nasopharynx was hypertrophic.
    • Nasopharynx was moderately narrowed.
    • Mucosa of pharynx cobble-stone in shape.
    • Movement of the both. vocal cord(s) was normal.
    • Bilateral arytenoid proceww was normal.
    • Trachea whole segment: patent and the mucosa was normal.
    • Main carina: sharp and movable on deep breathing.
    • Bilateral endobronchial trees:
      • No any visible endobronchial lesion, tumor, for foreign body.
      • Esophageal tumor not invade the airway.
    • Under fluorescent bronchoscopy:
      • normal mucosa in upper and low airways.

• 2024-05-09 Miniprobe Endoscopic Ultrasound

  • Indication: Cancer staging
  • Pre-EUS diagnosis: Esophageal cancer
  • Endoscopic findings
    • Esophageal lesion involving 50% of the circumference, was noted at middle to lower esophagus, from 28cm below incisors. The scope could not pass through due to stricture. Using magnifying endoscopy with narrow-band imaging (ME-NBI), the IPCL pattern according to JES was B3, with multiple large avascular areas.
  • EUS findings：
    • Using EUS-DP 25, mucosal thickening was noted at middle to lower esophagus, involving 5cm, distal to 28cm below incisors. The lesion involves beyond the muscular layer. At least 4 enlarged lymph nodes were noted.
  • Management：
    • Lugol solution was not sprayed due to bleeding.
  • Diagnosis：
    • Esophageal cancer, middle to lower esophagus, at least T3N2
    • Esophageal stricture due to cancer

• 2024-05-08 Tc-99m MDP bone scan

  • The hot spot in the right iliac bone is old and shows less evident compared with the previous study on 2023-10-16, the nature still is to be determined (urine retention, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, some C-spine, bilateral sternoclavicular junctions, left clavicle, shoulders, knees, and feet.

• 2024-05-07 PET

  • A glucose hypermetabolic lesion in the middle to lower portion of the esophagus, compatible with primary esophageal malignancy.
  • Glucose hypermetabolism in an adjacent lymph node lymph node, three upper bilateral paratracheal lymph nodes, a lymph node in the upper abdomen just between stomach and liver and a left supraclavicular lymph node. Multiple metastatic lymph nodes may show this picture.
  • Glucose hypermetabolism in a focal area in the right parotid gland. Some kind of parotid lesion, either malignant or benign, may show this picture. Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys and right ureter. Physiological FDG accumulation may show this picture.

• 2024-05-06 MRI - brain

  • Brain atrophy.
  • No brain nodule or metastasis.

• 2024-05-06

  • Impression:
    • low exercise capacity
      
    • Normal cardiopulmonary exercise response during exercise
      
  • Suggestions:
    • Treat underlying disease and symptoms
      
    • Arrange exercise training before or after operation

• 2024-05-06 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (82 - 22) / 82 = 73.17%
    • LVEF (%) = 73
    • M-mode (Teichholz) = 73
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH; normal LV diastolic function.
    • Normal RV systolic function.
    • Aortic valve sclerosis with mild AR; mild MR; mild TR.

• 2024-04-24 Bladder Sonography

  • PVR: 4.79 mL

• 2024-04-24 Uroflowmetry

  • Q max : fair
  • flow pattern : obstructive

• 2024-04-23 Microsonography

  • OD: tesslated, exudate, retinal v narrwing, C/D 0.51 NFL 99 CRT 251, 256 ; no RD
  • OS: tesslated, exudate, retinal v narrwing, CRT 239, C/D 0.45 NFL 99 CRT 244, 251

• 2024-04-12 CT - chest

  • For Propable esophageal tumor, upper esophagus
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Focal Bronchiectatic change over right upper lobe is found.
      • Patent airway is found.
      • Esophageal submucosal soft tissue measuring 3.7cm in largest dimension is noted. (Se301 Im44). GIST is favored.
      • One paratracheal lymphadenopathy is found measuring 1.8cm.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
      • Right renal pelvis stone is noted measuring 2.45cm is found.
      • There is stone at dependent portion of GB. GB stone(s) are noted.
  • Imp:
    • Esophageal submucosa tumor with paratracheal lymphadenopathy. GIST is favored.

• 2024-04-10 Patho - esophageal biopsy

  • Labeled as “middle to lower esophagus, 28-32 cm below incisors”, biopsy (B) — squamous cell carcvinoma
  • Section shows pieces of squamous mucosa lined tissue with squamous cell carcvinoma.
  • IHC stains: CK7 (-), CK20 (-), p40(+), CK5/6 (+), CDX-2 (-).

• 2024-04-03 SONO - abdomen

  • Symptoms:
    • Liver:
      • Coarse echotexture. Enlarge left lobe.
      • one 1.5cm hypoechoic lesion at S2.
      • one 0.4cm anechoic lesion with PAE at S3.
    • Bile duct and gallbladder:
      • several 1.0cm hyperechoic lesions with PAS in GB.
    • Portal veins and blood vessels:
      • negative
    • Kidney:
      • one 0.8cm hyperechoic lesion with PAS in right kidney.
    • Pancreas:
      • Some parts of pancreas blocked by bowel gas, especially body and tail
    • Spleen:
      • Splenic index from hilium: 5.7 x6.2 cm.
    • Ascites:
      • negative
  • Diagnosis:
    • Cirrhosis of liver with hepatomegaly of left lobe
    • Liver tumor, S2
    • Liver cyst, small, S3
    • GB stone
    • Renal stone, right
    • Splenomegaly, mild
    • pancreatic body and tail masked by gas.
  • Suggestion:
    • correlate with other image and tumor markers.

• 2024-03-27 Microsonography

  • OD: tesslated, exudate, retinal v narrwing, C/D 0.51 NFL 99 CRT 251; no RD
  • OS: tesslated, exudate, retinal v narrwing, CRT 239, C/D 0.45, NFL 99 CRT 244.

• 2024-01-10 SONO - abdomen

• 2023-10-26 MRI - prostate

  • Imaging Report Form for Prostate Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:Mo(M_value) STAGE:IVA__(Stage_value)
  • Impression:
    • Prostate cancer with lymph nodes metastasis, cstage T3bN1M0.
    • Right renal stones.
    • Liver cirrhosis.
      
    • GB stones.
      
    • R/O liver cysts.

• 2023-10-23 CT - abdomen

• 2023-10-18 SONO - abdomen

• 2023-10-16 Tc-99m MDP bone scan

  • A hot spot in the right iliac bone, the nature is to be determined (urine retention, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, some C-spine, bilateral sternoclavicular junctions, shoulders, knees, and feet.

• 2023-10-03 Patho - prostate needle biopsy

  • Prostate, right, TRUSP biopsy
    • Prostatic adenocarcinoma, Gleason grade 4+4
    • 6 out of 6 tissues involved, occupying 70% of tissues
  • Microscopically, section shows Gleason-grade 4+4 adenocarcinoma composed of a proliferation of crowded, fused and irregular neoplastic glands and invasive growth pattern.The neoplastic acini are lined by a single layer of epithelial cells and absent of basal layer. The tumor cells are cuboidal and have amphophilic cytoplasm, nuclear hyperchromasia, pleomorphim and increased N/C ratio.
  • Immunohistochemical stain reveals AMACR(+) and 34BE12(-).

• 2023-10-03 Patho - prostate needle biopsy

  • Prostate, left, TRUSP biopsy
    • Prostatic adenocarcinoma, Gleason grade 4+4
    • 6 out of 6 tissues involved, occupying 60% of tissues
  • Microscopically, section shows Gleason-grade 4+4 adenocarcinoma composed of a proliferation of crowded, fused and irregular neoplastic glands and invasive growth pattern.The neoplastic acini are lined by a single layer of epithelial cells and absent of basal layer. The tumor cells are cuboidal and have amphophilic cytoplasm, nuclear hyperchromasia, pleomorphim and increased N/C ratio.
  • Immunohistochemical stain reveals 34BE12(-) and AMACR(+).

• 2023-07-26 SONO - abdomen

[MedRec]

[consultation]

• 2024-05-10 Hemato-Oncology
  • Q
    • A 68-year-old man, an alcoholism and smoker for decades, had past history of gastroesophageal reflux disease, Hypertriglycemia, Hyperuricemia, HBV (Anti-HBc) related and Alcoholic early cirrhosis child pugh score A, elevated PIVKA-II, Gallstones, and Prostate cancer with lymph nodes metastasis stage IVA status post radiation therapy. His surgical history was cataract OU operation.
    • He had been under regular GI OPD follow up at our hospital due to his alcoholic cirrhosis of liver. EGD was arranged and done on 2024/04/09 for continuous of dyspepsia, and biopsy of esophagus was done due to suspected esophageal cancer seen. Pathology report of esophagus later revealed: squamous cell carcinoma.
    • This time, he was admitted to CS ward for squamous cell carcinoma of esophagus staging. After admission, the cancer staging was complteted and revealed squamous cell carcinoma of middle to lower third of esophagus cT3N2M0, stage III. Port-A implantation will be arranged on 2024/05/13. Thus we need consult you for arrange neoadjuvent CCRT. Thank you very much.
  • A
    • We will assume management of this case after port A insertion. Our plan is to discuss concurrent chemoradiotherapy with platinum and 5-fluorouracil (PF) regimen with the patient.

[chemotherapy]

• 2024-07-02 - NS 500mL 2hr (before CDDP) + cisplatin 60mg/m2 100mg NS 500mL 4hr D1 + NS 500mL 2hr (after CDDP) + fluorouracil 700mg/m2 1259mg NS 500mL 24hr D1-4 (PF, CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-29 - NS 500mL 2hr (before CDDP) + cisplatin 60mg/m2 100mg NS 500mL 4hr D1 + NS 500mL 2hr (after CDDP) + fluorouracil 800mg/m2 1400mg NS 500mL 24hr D1-4 (PF, CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-07-04

[anemia progression despite blood transfusion]

This patient has been receiving the PF regimen since 2024-05-29, and has since experienced a significant decline in HGB, reaching grade 3 (severe) anemia by July. The PF regimen, which includes cisplatin and fluorouracil, is associated with anemia incidences of up to 40% for cisplatin and unspecified rates for fluorouracil.

Although the sharp decline in HGB occurred after chemotherapy, suggesting a possible causal relationship, the patient’s HGB levels had already started decreasing before starting the PF regimen. Given that the latest PF regimen administration was at least a month ago, HGB levels would typically be expected to recover; however, the patient’s HGB has been continuously decreasing.

The patient received a blood transfusion on 2024-07-02 (the same day as the 2nd session of chemotherapy). Despite the transfusion, HGB levels have continued to fall. If the patient cannot regain hematopoietic ability or tolerate frequent transfusions (if needed), it may be necessary to further reduce the dosage or change the regimen.

• 2024-07-04 HGB 7.5 g/dL
• 2024-07-02 HGB 7.7 g/dL
• 2024-06-24 HGB 8.4 g/dL
• 2024-06-19 HGB 9.3 g/dL
• 2024-06-03 HGB 9.5 g/dL
• 2024-05-29 HGB 11.2 g/dL
• 2024-05-19 HGB 11.7 g/dL
• 2024-05-05 HGB 12.7 g/dL
• 2023-12-22 HGB 14.1 g/dL
• 2023-12-08 HGB 14.4 g/dL
• 2023-11-24 HGB 14.8 g/dL
• 2023-10-11 HGB 14.7 g/dL
• 2023-10-03 HGB 15.0 g/dL

[deteriorating liver function and treatment options]

The patient’s liver function is deteriorating, and BaoGan (silymarin) is currently being used. Given that BDI is increasing and is the main contributor to elevated BTI, adding Uliden (ursodeoxycholic acid) might be beneficial if clinically appropriate.

• 2024-07-02 ALT 90 U/L

• 2024-06-24 ALT 21 U/L

• 2024-07-02 AST 113 U/L

• 2024-06-24 AST 24 U/L

• 2024-07-02 Bilirubin direct 0.35 mg/dL

• 2024-06-03 Bilirubin direct 0.24 mg/dL

• 2024-05-29 Bilirubin direct 0.21 mg/dL

701524290

240703

[exam findings]

• 2024-05-20 Pure Tone Audiometry, PTA
  • R’t : 31 dB HL
  • L’t : 35 dB HL
  • Bil normal to severe SNHL.
• 2024-05-16 Tc-99m MDP bone scan
  • Mildly increased activity in the lower C- and lower T-spines. Degenerative change may show this picture.
  • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and knees, compatible with benign joint lesions.
• 2024-05-15 Patho - lung transbronchial biopsy
  • Lung, main bronchus, bronchoscopic biopsy — squamous cell carcinoma, origin ?
  • Sections show bronchial mucosa with invasive squamous cell carcinoma. Focal keratinization is seen. Please correlate with the clinical presentation and image study for tumor origin.
• 2024-05-15 Bronchoscopy
  • Bronchoscopic finding:
    • The nasal mucosa was reddish. The nasal lumen was mild narrowed. The was no mucoid nasal discharge retained in the nasal cavity.
    • Mucosa of nasopharynx hypertrophic. Nasopharynx was mild narroweing.
    • Mucosa of pharynx normal.
    • Mevement of the both. vocal cord(s) normal. Bilateral anytenoid proceww was normal.
    • Trachea whole segment. endotracheal mass at trachea (at 3 cm above carina), s/p bronchial forceps biopsy with 6 pieces of specimen
    • Main carina: sharp and movable on deep breathing.
    • Bilateral side bronchi were normal appearance.
• 2024-05-14 PET
  • Glucose hypermetabolism in the the upper and middle thirds of the esophagus with invasion to the posterior wall of the trachea and upper lobe of right lung, compatible with primary esophageal malignancy with invasion to the posterior wall of the trachea and upper lobe of right lung.
  • Mild glucose hypermetabolism in a left supraclaivcular lymph node, an A-P window lymph node and three right precarinal lymph nodes. Metastatic lymph nodes can not be ruled out.
  • Mild glucose hypermetabolism in some bilateral pulmonary hilar lymph nodes. Inflammation is more likely. Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
• 2024-05-13 Patho - esophageal biopsy
  • Esophagus, upper, 18 cm below incisors, biopsy — Squamous cell carcinoma, moderately differentiated
  • The specimen submitted consists of seven small pieces of gray-tan soft tissue, labeled upper esophagus, 18 cm below incisors, measuring up to 0.3 x 0.2 x 0.1 cm. All for section.
  • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.
• 2024-05-13 Miniprobe Endoscopic Ultrasound
  • Indication: Cancer staging
  • Pre-EUS diagnosis: Esophageal cancer
  • Endoscopic findings：
    • Ulcerative mass lesion with annular growth and Lumen narrowing was noted at 18 cm below incisors, and endoscope was unable to pass through. Magnified endoscope with NBI revealed focal JES type B1 vessels; though, the detailed examination was disturbed by the blood and mucous material on the mucosal surface. Biopsy was done.
  • EUS findings：
    • EUS using miniprobe (Olympus UM-DP20-25R) showed a circumferential hypoechoic wall thickening with loss of normal esophageal layering, up to 17.9mm in depth, at least involving the adventitia of esophageal wall.
  • Management：
    • The ME-NBI and EUS study was incomplete due to the technical difficulty (location near the esophageal inlet) and presence of blood and mucous material on the mucosa.
  • Diagnosis：
    • Advanced esophageal cancer, upper to middle third, at least T3NxMx, s/p biopsy
  • Suggestion:
    • Pursue biopsy.
• 2024-05-13 SONO - abdomen
  • Symptoms:
    • Liver:
      • Homogenous liver parenchyma.
      • One 0.54cm anechoic lesion was noted at S2/3.
      • One hyperechoic lesion was noted at S7 Size 0.48 cm
    • Bile duct and gallbladder:
      • No gallbladder stone. No CBD dilatation.
      • Thickened GB wall.
    • Portal veins and blood vessels:
      • Patent portal vein.
    • Kidney:
      • Anechoic lesion was noted at left kidney Size 1.26 cm
    • Spleen:
      • Some parts of pancreas blocked by bowel gas, especially head and tail
    • Spleen:
      • No splenomegaly
    • Ascites:
      • No ascites
  • Diagnosis:
    • Liver cyst
    • Liver calcification
    • Cholecystopathy
    • Renal cyst, LK
• 2024-05-11 MRI - brain
  • With- and without-contrast multiplanar cerebral MRI, cerebral TOF MRA revealed
    • unremarkable change in the intraventricular and extraventricular CSF spaces
    • some white matter gliosis in the right frontal and bilateral parietal lobes.
    • unremarkable change in the skull base
    • no abnormal brain parenchymal enhancement
  • IMP:
    • no evidence of brain metastasis.
• 2024-05-08 CT - abdomen
  • Findings:
    • There is long segmental circumferential asymmetrical wall thickening at the upper and middle third esophagus (Srs:305 Img:9-23), 9 cm in size (the cranial-caudal dimension), with severe lumen narrowing and proximal esophagus dilatation.
      • In addition, this lesion shows right lateral exophytic bulging into RUL of the lung that is c/w direct invasion RUL of the lung.
      • This lesion shows indentation into the posterior wall of the trachea that is c/w direct invasion the trachea.
      • Squamous cell carcinoma of the upper-middle third esophagus (T4b) with near total obstruction is suspected.
      • Please correlate with gastroscopy and biopsy.
    • There are nine enlarged nodes in right paratracheal space and subcarinal space that may be regional metastatic nodes (N3）.
    • There are two small poor enhancing nodules in S3 and S6 of the liver that may be cysts. Follow up is indicated.
    • A renal cyst 1.6 cm in left middle pole is noted.
    • The residual lung shows no focal lesion.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N3(N_value) M:M0(M_value) STAGE:IVA(Stage_value)

[MedRec]

• 2024-06-16 SOAP Hemato-Oncology Xia HeXiong
  • O
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2024-05-28
      • cT4bN3M0 stage IVA => definitive CCRT.
    • Now on definitive CCRT with PF4, C/T C1D1 on 2024-05-27, R/T C1D1 on 2024-06-13, 14th / 28 Fx on 2024-06-13
• 2024-06-07 SOAP Radiation Oncology Wang YuNong
  • O:
    • 20240524~ RT to the esophagus and adjacent lymphatic drainage area: 19.8 Gy/ 11 fx.
  • P:
    • Plan to deliver 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area.
    • Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fx.
• 2024-05-09 ~ 2024-06-01 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Squamous cell carcinoma of upper to middle third of esophagus; with trachea invasion, cT4b N3 M0 stage: IVA status post feeding jejunostomy and left port-A implantation on 2024/05/17, s/p concurrent chemoradiotherapy radiotherapy with 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area, chemotherapy with PF from 2024/05/27~
    • Squamous cell carcinoma of upper to middle third of esophagus; with trachea invasion, cT4b N3 M0 stage: IVA
    • Main bronchus squamous cell carcinoma
    • Chronic viral hepatitis B without delta-agent, Anti-HBc reactive
  • CC
    • dysphagia for 2-3 months
  • Present illness
    • This 62-year-old male denied systemic history in the past. He experienced dysphagia for 2-3 months. There was no weight loss, no nausea, no vomit, no URI symptoms, no chest tightness, no epigastric pain, no tarry/bloody stool. He ever visited LMD for help, but in vein. Thus, he came to Fu Jen Catholic University Hospital, where EGD was performed on 2024/05/07 and revealed esophageal cancer.
    • Due to personal reason, he came to our GI OPD and recommend hospitalization.
    • Chest CT on 2024/05/08 reportes as 1. Squamous cell carcinoma of the upper-middle third esophagus (T4b) with near total obstruction is suspected. 2. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for esophageal cancer: T4b N3 M0; stage: IVA.
    • Under the impression of esophageal cancer: T4b N3 M0; stage: IVA, he was admitted to the ward for furter evaluation and management.
  • Course of inpatient treatment
    • After admission, chest surgeon was consulted for surgical evaluation. Neutrition supply with PPN plus NAKO NO5 was prescribed.
    • Brain MRI 2024/05/11 and whole body bone scan on 2024/05/16 revealed no evidence of brain and bone metastasis.
    • Abdominal sonography on 2024/05/13 revealed 1. Liver cyst, 2. Liver calcification, 3. Cholecystopathy, 4. Renal cyst, LK.
    • Miniprobe Endoscopic Ultrasound on 2024/05/13 revealed advanced esophageal cancer, upper to middle third, at least T3NxMx, s/p biopsy.
    • Whole body PET scan on 2024/05/14 showed compatible with primary esophageal malignancy with invasion to the posterior wall of the trachea and upper lobe of right lung.
    • Bronchoscopy on 2024/05/15 revealed endotracheal mass at trachea, bronchial tumor biopsy revealed squamous cell carcinoma.
    • After all examinations were done, the cancer staging revealed squamous cell carcinoma of upper to middle third of esophagus; with trachea invasion, cT4b N3 M0 stage: IVA. He was transferred to our chest surgery ward for further care on 2024/05/16. We had well explaining with patient and his family about further treatment. They understood and agreed. Then he underwent operation of feeding jejunostomy and port-A implantation on 2024/05/17. He was then tried on jejunostomy feeding and the amount gradually increased to NG high protein diet 16000 kcal/day. He has well digestion under jejunostomy feeding.
    • Under stable condition he was transfer to Hema-Oncology ward for further CCRT on 2024/05/23.
    • CT-simulation on 2024/05/22. RT start since 2024/05/24~. Radiotherapy Plan 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fx. RT start from 2024/05/24~.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO HS was given for Anti-HBc reactive.
    • Chemotherapy with PF (Cisplatin 75mg/m2 D1, 5-Fu 1000mg D1-D4, (MgSO4 1amp and Lasix 1amp after Cisplatin)) on 2024/05/27~2024/05/30 (C1). Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2024/06/01 and OPD followed up later.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Baraclude (entecavir 0.5mg) 1# HS
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
• 2024-05-08 SOAP Gastroenterology Zhao YouCheng
  • S
    • He has suffered dysphagea for months. Gastroscopy showed esophageal cancer at a LMC on 2024-05-07 at a LMC.
    • He came for consultation.
  • O
    • BH: 168 cm; BW:63 kg; BMI:22.3
    • P.E.: No icteric sclera, soft abdomen, no leg pitting edema.
    • 2024-05-07: alb: 3.7, Cr: 0.9. (at a LMC)

[consultation]

• 2024-05-18 Hemato-Oncology
  • A
    • This 62-year-old man has been newly diagnosed with squamous cell carcinoma of the upper to middle third of the esophagus, with tracheal invasion, classified as cT4b N3 M0, stage IVA. He underwent feeding jejunostomy and Port-A insertion on 2024-05-17. We are considering concurrent chemoradiotherapy (CCRT) and will discuss this with the patient. Please check Anti HBc, Anti HBs, HBsAg and Anti HCV.
• 2024-05-17 Radiation Oncology
  • A
    • Neoadjuvant CCRT is indicated. The risk of T-E fistula after tumor shinkage has been well explained.
    • CT-simulation will be arranged on 5/22. Plan to deliver 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area.
    • Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 5/27.
• 2024-05-09 Thoracic Surgery

[chemotherapy]

• 2024-07-02 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y-sited 5FU) + MgSO4 10% 20mL NS 100mL 1hr furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1600mg NS 500mL D1-4 (PF)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-27 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y-sited 5FU) + MgSO4 10% 20mL NS 100mL 1hr furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1600mg NS 500mL D1-4 (PF)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

701269961

240702

[exam findings]

• 2024-07-01 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (58.5 - 7.17) / 58.5 = 87.74%
    • M-mode (Teichholz) = 87.7
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, mild TR, normal IVC size
• 2024-05-27 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Low voltage QRS
  • Abnormal ECG
• 2024-05-16 ECG
  • Normal sinus rhythm
  • Low voltage QRS
  • Abnormal QRS-T angle, consider primary T wave abnormality
• 2024-05-06 Nasopharyngoscopy
  • smooth NPx, OPx, HPx
• 2024-04-01 MRI - nasopharynx
  • No obvious nasopharynx, oropharynx, hypopharynx or larynx mass.
  • No evident bony destructive lesion.
  • No evident abnormal enlarged lymph node in the visible neck.
  • No obvious abnormal enhancement after contrast medium administration.
  • No other significant abnormality.
  • Suggest clinical correlation.
• 2024-03-29 PET
  • Glucose hypermetabolism in the right breast, compatible with primary breast malignancy.
    
  • Glucose hypermetabolism in two right axillary lymph nodes, compatible with metastatic lymph nodes.
    
  • Glucose hypermetabolism in the left breast. The nature is to be determined (another breast malignancy? other nature?). Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in the nasopharynx. The nature is to be determined (severe inflammation? malignancy? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the anterolateral aspect of right 5th rib (post-traumatic change? other nature?). Please follow up other imaging modalities for further evaluation.
  • Mild glucose hypermetabolism in some bilateral neck level II and III lymph nodes. Inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Increased accumulation of FDG in both kidneys and bilateral ureters, probably physiological accumulation of FDG.
• 2024-03-29 Nasopharyngoscopy
  • no finding suggestive of malignancy
• 2024-03-28 Patho - breast biopsy (no need margin) Y1
  • Breast, left, core biopsy — Invasive carcinoma [-> ADENOSIS with ATYPICAL DUCTAL HYPERPLASIA]
  • Section shows core(s) of breast tissue with irregular neoplastic ducts infiltration.
  • IHC stains (S2024-6031): CK5/6 (rim pattern and cribriform ductal epithelium: suggestive of ductal carcinoma in situ and few ducts loss of ductal epithelium and myoepithelial layer stain: suggestive of invasive component, and adenosis with ductal epithelium and myoepithelium stained positive).
    • Neoplastic tissue: ER (-), PR (-), HER2/neu : positive (score=3+), Ki67: 20%.
  • Addtional IHC stains: p63 (+), 34betaE12 (+), SMA (rim pattern).
    • The additional IHC stains pattern show presence of myeepithelial layer. Although the initially an invasive cancer is considered, after further work up with multiple immunohistochemical stain markers, a diagnosis of ADENOSIS with ATYPICAL DUCTAL HYPERPLASIA is more appropriate.
• 2024-03-27 MRI - breast
  • Clinical history: 42 y/o female patient with breast malignancy.
  • With and without enhancement MRI of breast:
    • Indistinct margin tumor (around 5cm) in subareolar region of right breast, proven malignancy.
    • Mild right periareolar skin thickening.
    • Indistinct margin tumor, 1.9cm in left breast, subareolar (outer), suggest biopsy.
      
    • Right axillary lymph nodes.
  • Impression:
    • Right breast malignancy.
    • Left breast tumor, r/o malignancy, suggest biopsy.
    • Right axillary lymph nodes.
  • BI-RADS: Category 6-proven malignancy.
• 2024-03-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (62 - 13) / 62 = 79.03%
    • M-mode (Teichholz) = 79.4
  • Conclusion:
    • Adequate LV, RV systolic function with normal wall motion
    • Mild LV hypertrophy, Impaired LV relaxation
• 2024-03-26 ECG
  • Sinus bradycardia
  • Low voltage QRS
• 2024-03-20 Tc-99m MDP bone scan
  • A hot spot in the lateral aspect of the right chest wall, probably s/p right breast cancer biopsy.
  • Suspected benign lesions in the maxilla, some C-. T- and L-spine, bilateral sternoclavicular junctions, shoulders, elbows, S-I joints, and hips.
• 2024-03-19 CT - chest
  • Indication: right breast Invasive carcinoma of no special type
  • Findings
    • Lungs: normal appearance of bilateral lungs.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
    • Heart: normal size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: ill-defined and lobulated enhancing mass lesion in the right breast (44mm in longest axial dimension), no underlying muscles and skin involvement. a slight enlarged LN at Rt axilla.
    • Visible abdominal-pelvic contents: unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, both kidneys, uterus, U-bladder. no abnormality of visible GI tract based on CT images.
    • Visualized bones: unremarkable.
  • Impression:
    • Rt breast cancer T2N1?
• 2024-03-08 Patho - breast biopsy (no need margin) Y1
  • Breast, right 9’, core needle biopsy — Invasive carcinoma of no special type
  • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid to ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity. Ductal carcinoma in situ is also seen.
  • Immunohistochemical study demonstrates:
    • ER: negative
    • PR: negative
    • Her2/neu: positive (3+)
    • p63: negative
    • CK5/6:negative
    • Ki-67 index: 20%
• 2024-03-01 SONO - breast
  • Diagnosis:
    • Right fibroadenomas as described
    • R/O bil. breast tumors (#3, #4)
  • BI-RADS:
    • 4c. suspicious abnormality, biopsy should be considered (high suspicion for malignancy: 50-95%)
• 2024-03-01 Mammography
  • Impression:
    • Dense breast.
    • Architectural distortion with diffuse amorphorus calcifications in right breast (mainly in UOQ), r/o malignancy.
      
    • Diffuse amorpohrus calcifications in left breast, suggest close follow up.
  • BI-RADS:
    • Category 4: suspicious abnormality-biopsy should be considered.
• 2023-05-19 SONO - gynecology
  • EM:8.4mm
• 2023-05-19 SONO - obstetrics
  • IUP at 33+6 wks
  • R/O Low-lying placenta
• 2023-04-07 SONO - obstetrics
  • IUP at 27+6 wks
  • R/O Low-lying placenta
• 2023-03-03 SONO - obstetrics
  • IUP at 22+6 wks
  • R/O Low-lying placenta
• 2022-11-25 SONO - obstetrics
  • IUP at 9 wks
• 2021-07-17 SONO - gynecology
  • EM:3.3mm.
• 2021-02-22 SONO - obstetrics
  • IUP at 25 wks

[MedRec]

• 2024-03-27 ~ 2024-04-04 POMR Hemato-Oncology Yang MuJun
  • Discharge diagnosis
    • Malignant neoplasm of unspecified site of right female breast, ER: negative, PR: negative, her2/neu: positive( 3+), p63: negative, CK5/6:negative, cT2N1M0, stage IIB
    • Malignant neoplasm of lower-outer quadrant of left female breast, T1cN0M0, stage IA
    • Encounter for antineoplastic chemotherapy
  • CC
    • for neoadjuvant therapy with TCHP (C1)
  • Present illness
    • This 42-year-old woman history of Antiphospholipid syndrome 3 years ago at CGMH follow up. She is a case of HER2-positive right breast cancer, cT2N1.
    • Tracing back the past history, she present to our GS OPD with right breast lump was noted for several weeks on 2024/02/24.
    • Breast sono shows right fibroadenomas as described, suspect bil. breast tumors (#3, #4). Mammography on 2024/03/01 shows 1. Architectural distortion with diffuse amorphorus calcifications in right breast (mainly in UOQ), r/o malignancy. 2. Diffuse amorpohrus calcifications in left breast. S/p sono-guided biopsy for right breast tumor on 2024/03/08. Chest CT image on 2024/03/19 revealed to favor Rt breast cancer T2N1.
    • Bone scan on 2024/03/20 and revealed 1. A hot spot in the lateral aspect of the right chest wall, probably s/p right breast cancer biopsy. 2. Suspected benign lesions in the maxilla, some C-. T- and L-spine, bilateral sternoclavicular junctions, shoulders, elbows, S-I joints, and hips.
    • MRI of breast on 2024/03/27 and shows 1. Right breast malignancy. 2. Left breast tumor, r/o malignancy, suggest biopsy. 3. Right axillary lymph nodes.
    • At MER, the vital sign: blood pressure: 137/74 mmHg; pulse: 73 rate/min; temperature: 36’C; respiratory rate: 16 rate/min; Con’s: E4V5M6; saturation: 97%.
    • The laboratory data disclosed WBC= 7.03*10^3/uL, N.seg= 72.6%. The chest film showed normal heart size, no definite lung lesion, bilateral clear costophrenic angles.
    • Under the impression of breast cancer, she was admitted to oncology ward for neoadjuvant therapy with TCHP.
  • Course of inpatient treatment
    • After admission, for complete stage of breast cancer, thus arrange MRI of breast image, 2D echo, PET scan. Prot-a insertion on 2024/03/27.
    • Due to productive coguh, running nose with yellowish snot since 3/29 with empirical antibiotic curam oral form plus supportive care medication. left breast mass arrange sono guiding on 2024-04-01 and Breast, left, core biopsy of Invasive carcinoma. An addendum report of the result of ER, PR, Her2/neu, Ki-67, and p63 will be followed.
    • Due to PET shows glucose hypermetabolism in the nasopharynx, C/S ENT and arrangenasopharynx MRI with contrast shows no obvious nasopharynx, oropharynx, hypopharynx or larynx mass.
    • The neoadjuvent chemotherapy with TCHP (docetaxel 75mg/m2, carboplatin AUC:5, herceptin 600mg SC, Perjeta 840mg) by self-payment from 2024/04/02(C1).
    • Dexamethasone 2#(8mg) BID po and famotidine 1# BID po for 3 days (2024/04/01~2024/04/01) for Docetaxel side effection prevention.
    • The antibiotic with curam oral form to back. Due to nausea intermittent, steroid with Limeson 4mg/tab 1# PRNQD for 3 days to back.
  • Discharge prescription
    • Limeson (dexamethasone 4mg) 1# PRNQD if nausea or vomitting
    • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# Q12H
    • Antica Syrup (orciprenaline, bromhexine, doxylamine) 10mL TID
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • Acetal (acetaminophen 500mg) 1# QID
    • Mecater (procaterol 25ug) 1# BID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H if pain
    • Ulstop (famotidine 20mg) 1# BID D1-3
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 90mg, lysozyme 20mg) 1# TID
    • Xyzal (levocetirizine 5mg) 1# HS
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2024-03-25 SOAP Hemato-Oncology Yang MuJun
  • Refer for HER2 positive breast cancer, cT2N1, for neoadjuvant
  • Plan:
    • Arrange PET scan, 2D heart echo
    • TCHP (docetaxel/carboplatin/trastuzumab/pertuzumab) (Apply NHI for Herceptin and patient-paid Perjeta)

[consultation]

• 2024-03-29 Ear Nose Throat
  • Q
    • This 42 year old woman is a case of right breast cancer. PET show nasopharynex FDG uptake. We need your help for ENT scopy examination and further suggestion. Thank you!
  • A
    • Scope:
      • some Clear mucus discharge over nasopharynx; smooth nasopharynx, oropharynx and hypopharynx.
    • Impression:
      • No finding suggestive of nasopharyngeal malignancy in the endoscopic study.
    • Plan:
      • The increase of FDG uptake may be due to acute inflammation.
      • However, embedded malignant lesion such as lymphoma cannot be ruled out.
      • It is suggested that the nasopharynx / PET scan be followed after the URI subsides.
      • Nasopharyngeal biopsy for tissue proof can be performed after the URI subsides at either IPD or OPD.
      • In addition, we have prescribed Mecater for coughing treatment, if the patient feels discomfort after taking the medication, it can be discontinued.
• 2021-02-22 Obstetrics and Gynecology
  • Q
    • Diarrhea twice since this morning and intermittent epigastric dull pain (frequency about 1 hr & duration about 1min) since 3pm.
    • lower abdomen pain during diarrhea.
    • No vaginal discharge.
    • G4P0AA2SA1
    • GA 25+2 wks.
    • No headache/ dizziness/ cough/ chest tightness/ dyspnea
    • PH:
      • systemic diseases: denied.
      • Major OP: denied
    • Allergy: NKA
  • A
    • G4P0A3
    • EDC:6/5/2021
    • diarrhea for 2 times
    • echo: vertex. EBW: 850gm, BPD: 6.6gm
    • NST: irregular seesaw shape contraction
    • epigastric pain (+)
    • provided yutopar 2# po st
    • symptomatic treatment and revisit if symptom didn’t improve

[immunochemotherapy]

• 2024-07-02 - docetaxel 75mg/m2 _92mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 250mL 1hr (TCHP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-06-11 - docetaxel 75mg/m2 _92mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 250mL 1hr (TCHP, doce 75% due to neutropenia fever episode)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-18 - docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 250mL 1hr (TCHP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-24 - docetaxel 75mg/m2 100mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 250mL 1hr (TCHP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1
• 2024-04-02 - docetaxel 75mg/m2 100mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 840mg NS 250mL 1hr (TCHP, Perjeta loading 840mg, Herceptin no loading)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1

==========

701338866

240701

[lab data]

• 2024-06-04 HBsAg (NM) Negative
  
• 2024-06-04 HBsAg Value (NM) 0.383
  
• 2024-06-04 Anti-HBs (NM) Positive
  
• 2024-06-04 Anti-HBs value (NM) 54.6 mIU/mL
  
• 2024-06-04 Anti-HBc (NM) Positive
  
• 2024-06-04 Anti-HBc Value (NM) 0.009
  
• 2024-06-04 Anti-HCV (NM) Negative
  
• 2024-06-04 Anti-HCV Value (NM) 0.047

[exam findings]

• 2024-06-07 PD-L1 (28.8)
  • Cellblock No. S2024-11120 A6
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS >= 5
    • Combined Positive Score (CPS): 10
• 2024-06-04 Esophagography
  • Esophagography with water soluble contrast medium revealed:
    • s/p total gastrectomy.
    • Smooth passage of barium meal from oral cavity through esophagus to small bowel smoothly without obstruction.
    • No contrast leakage.
• 2024-05-31 Patho - stomach subtotal/total (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Stomach, total gastrectomy — Poorly cohesive carcinoma, mixed signet-ring cell type and tubular type
      • Margins, bilateral cutting ends, ditto — Free of tumor invasion
      • Margin, esophageal cutting end, frozen — Free of tumor invasion
      • Lymph nodes, LN 1, dissection — Free of tumor metastasis (0/3)
      • Lymph nodes, LN 2, ditto — Free of tumor metastasis (0/3)
      • Lymph nodes, LN 5, ditto — Fat only
      • Lymph nodes, LN 6, ditto — Metastatic carcinoma (1/3) without extracapsular extension (0/1)
      • Lymph nodes, LN 7,8,9,10,11, ditto — Metastatic carcinoma (1/6) with extracapsular extension (1/1)
      • Lymph nodes, LN 12a, ditto — Free of tumor metastasis (0/1) , but tumor deposits present
      • Lymph nodes, LN 10 splenic hilum, ditto — Fat only
      • Lymph nodes, omentum, ditto — Free of tumor metastasis (0/1)
      • Lymph nodes, lesser curvature, ditto — Metastatic carcinoma (12/16) with extracapsular extension (6/12)
      • Lymph nodes, greater curvature, ditto — Metastatic carcinoma (1/2) without extracapsular extension (0/1)
    • Omentum, omentectomy — Tumor invasion
    • Serosa of transverse colon, excision — Tumor seeding
    • Serosa of small intestine, excision — Tumor seeding
    • Appendix, appendectomy — Tumor seeding
    • AJCC Pathologic staging — pT4aN3aM1, stage IV
  • MACROSCOPIC EXAMINATION
    • Specimen type: stomach with LN 3,4, regional lymph nodes, omentum, appendix, serosa of transverse colon and serosa of small intestine
    • Specimen size:
      • Stomach: Greater curvature: 30 cm; Lesser curvature: 9 cm
      • Omentum: 60 x 20 x 1.2 cm with a few small firm nodules measured up to 0.3 cm
      • Serosa of transverse colon: 2 small pieces, up to 9 x 3.8 x 0.7 cm with some firm white nodules measured up to 0.9 x 0.7 cm
      • Serosa of small intestine: multiple small pieces, up to 3.5 x 1.7 x 1.0 cm with some firm white nodules measured up to 0.7 cm
      • Appendix: 4.4 cm in length, up to 0.8 cm in diameter, a few tiny periappendiceal nodules, up to 0.3 cm
    • Number of lesions: solitary mass
    • Tumor site: low body
    • Tumor size: 6.7 cm
    • Tumor configuration: ulcerative mass
    • Representatively embedded for sections as A1-A2: LNs of lesser curvature, A3: LNs of greater curvature, A4: gastric polyp + distal margin (ink), A5: esophageal margin + tumor, A6-A8: tumor, A9: tumor + distal margin (ink), A10: LNs of lesser curvature, A11-A12: tumor + serosa, A13: LNs of greater curvature, A14-A15: tumor + serosa, B: LN 1, C: LN 2, D: LN 5, E: LN 6, F: LN 7,8,9,10,11, G: LN 12a, H: LN 10 splenic hilum, I: omentum, J: serosa of transverse colon, K: serosa of small intestine and L1-L3: appendix [Reference: F2024-00223 FS esophageal cutting end, one small piece measured 3.5 x 0.5 x 0.4 cm in size with staples]
  • MICROSCOPIC EXAMINATION
    • Histologic type: poorly cohesive carcinoma, mixed signet-ring cell type with focal mucin production and tubular type
    • Histologic grade: grade 3
    • Depth of tumor invasion: visceral peritoneum
    • Lymph nodes: metastatic carcinoma (15/35) with extracapsular extension (7/15) in total number
      
    • Omentum: tumor invasion. Besides, one reactive lymph node and one accessory spleen measured 0.8 x 0.4 cm are also identified
    • AJCC Pathologic Staging: pT4aN3aM1
    • Bilateral Margins: free of tumor invasion
    • Additional pathologic findings: atrophic gastritis with intestinal metaplasia and ulcer
    • Perineural invasion: present
    • Lymphovascular space invasion: present
    • Ascites cytology: positive
    • Gastric polyps: hyperplastic polyps
• 2024-05-28 PET
  • Glucose hypermetabolism in the lower body of the stomach, compatible with primary gastric malignancy.
  • Mild glucose hypermetabolism in some regional lymph nodes. The nature is to be determined (inflammation? metastatic lymph nodes of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in a focal area in the right lateral aspect of the maxilla. The nature is to be determined (dental problem? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the right shoulder and bilateral hips. Inflammatory process may show this picture.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2024-05-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (98 - 20) / 98 = 79.59%
    • M-mode (Teichholz) = 80
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • LV posterior wall thickening, dilated LA; Normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR.
    • Dilated ascending aorta.
• 2024-05-27 Patho - stomach biopsy
  • Stomach, body, biopsy — moderately differentiated adenocarcinoma
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, high N/C ratio and mitotic figures.
  • Immunostain — Her2/neu: negative (1+), CK: positive
• 2024-05-24 CT - abdomen gastric filling with water
  • Findings:
    • There is circumferential asymmetrical wall thickening at the gastric low body, 6.7 cm in size, with irregular contour.
      • Adenocarcinoma of the stomach (T4a) is highly suspected.
    • There are six enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament that may be regional metastatic nodes (N2).
    • There are few hepatic cysts in both lobes (up to 1.8 cm in S2/4).
    • There are several renal cysts on both kidney (up to 2 cm).
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
• 2024-05-24 EGD
  • Diagnosis:
    • Suboptimal study, due to food residues
    • Reflux esophagitis LA Classification grade A (minimal)
    • Suspect gastric malignancy, Borrnann typ IV, if tissue approved
    • Gastric polyp, antrum, GC
  • CLO test: not done
  • Suggestion:
    • Pursue pathology report

[consultation]

• 2024-06-29 Urology
  • Q
    • Patient was 73 year old men, history of Poorly cohesive carcinoma of gastric body, pT4aN3aM1, stage IV status post total gastrectomy with lymph node D2 dissection and intraabdominal multiple tumors excision and appendectomy and feeding jejunosotmy and Hyperthermic Intraperitoneal Chemotherapy on 2024/05/30.
    • for BPH hx (under Avodart 0.5mg/cap and Urief F.C 8mg/tab Tx), we need your consultation for evaluation. Thanks a lot!!!
  • A
    • Frequent feeling of thirsty and urinary frequency are complained.
    • No other voiding symptom is complained.
    • Oxybutynin may be given.
    • We will follow up flow rate and PVR.
    • Please keep recording voiding diary and U/O.
• 2024-06-28 Gastroenterology
  • Q
    • Patient was 73 year old men, history of Poorly cohesive carcinoma of gastric body, pT4aN3aM1, stage IV status post total gastrectomy with lymph node D2 dissection and intraabdominal multiple tumors excision and appendectomy and feeding jejunosotmy and Hyperthermic Intraperitoneal Chemotherapy on 2024/05/30.
    • for GOT:93、GPT:405 U/L, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • We were consulted for abnormal liver function
    • S+O
      • fair appetite and spirit
      • 5/30 C/T
      • Cons clear, E4V5M6
      • sclere: anicteric
      • Abdomen soft, normoactive
      • No abdominal tenderness
    • Lab
      • 2024-06-28 ALT 405 U/L ***
        
      • 2024-06-20 ALT 44 U/L
        
      • 2024-06-13 ALT 122 U/L
        
      • 2024-06-10 ALT 211 U/L
        
      • 2024-06-06 ALT 251 U/L
        
      • 2024-06-03 ALT 33 U/L
        
      • 2024-06-28 AST 93 U/L *
      • 2024-06-20 AST 29 U/L
        
      • 2024-06-13 AST 47 U/L
        
      • 2024-06-10 AST 87 U/L
        
      • 2024-06-06 AST 152 U/L
        
      • 2024-06-03 AST 20 U/L
        
      • 2024-06-28 Bilirubin total 0.41 mg/dL
        
      • 2024-06-20 Bilirubin total 0.40 mg/dL
        
      • 2024-06-13 Bilirubin total 0.36 mg/dL
        
      • 2024-06-10 Bilirubin total 0.46 mg/dL
        
      • 2024-06-06 Bilirubin total 0.77 mg/dL
        
      • 2024-06-03 Bilirubin total 0.64 mg/dL
        
      • 2024-06-28 Albumin(BCG) 3.4 g/dL
        
      • 2024-06-13 CA125 140.7 U/mL
        
      • 2024-06-13 CEA 0.87 ng/mL
        
      • 2024-06-13 CA199 7.44 U/mL
        
      • 2024-06-13 AFP 3.0 ng/mL
        
      • 2024-06-10 APTT 26.8 sec
        
      • 2024-06-10 PT 10.3 sec
        
      • 2024-06-10 INR 0.98
        
      • 2024-06-04 HBsAg (NM) Negative
        
      • 2024-06-04 HBsAg Value (NM) 0.383
        
      • 2024-06-04 Anti-HBs (NM) Positive
        
      • 2024-06-04 Anti-HBs value (NM) 54.6 mIU/mL
        
      • 2024-06-04 Anti-HBc (NM) Positive
        
      • 2024-06-04 Anti-HBc Value (NM) 0.009
        
      • 2024-06-04 Anti-HCV (NM) Negative
        
      • 2024-06-04 Anti-HCV Value (NM) 0.047
        
    • Image
      • CT 5/24
        • There is circumferential asymmetrical wall thickening at the gastric low body, 6.7 cm in size, with irregular contour.
          • Adenocarcinoma of the stomach (T4a) is highly suspected.
        • There are six enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament that may be regional metastatic nodes (N2).
        • There are few hepatic cysts in both lobes (up to 1.8 cm in S2/4).
        • There are several renal cysts on both kidney (up to 2 cm).
        • Impression (Imaging stage): T:T4a(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
    • Impression
      • Abnormal liver function, cause?
    • Suggestion
      • Arrange abdominal sonography
      • Check ALP, rGT, PT, APTT, ammonia to complete liver study
      • Check Anti HAV IgM exclude viral hepatitis
      • Regular/close monitor AST/ALT, TBI, PT, APTT, GGT, ALP
      • Avoid hepatic toxic agent if possible(or adjust dose), simplify medication
• 2024-06-28 Cardiology
  • Q
    • Patient was 73 year old men, history of Poorly cohesive carcinoma of gastric body, pT4aN3aM1, stage IV status post total gastrectomy with lymph node D2 dissection and intraabdominal multiple tumors excision and appendectomy and feeding jejunosotmy and Hyperthermic Intraperitoneal Chemotherapy on 2024/05/30.
    • for Arrhythmias hx (the patient expressed that he has been feeling unwell due to his rapid heartbeat recently), we need your consultation for evaluation. Thanks a lot!!!
  • A
    • This 72 y/o male patient is a case of poorly cohesive carcinoma of gastric body, pT4aN3aM1, stage IV status post total gastrectomy with lymph node D2 dissection and intraabdominal multiple tumors excision and appendectomy and feeding jejunosotmy and Hyperthermic Intraperitoneal Chemotherapy on 2024/05/30.
      • He had previous history of cardiac arrythmia (unknwon etiology) and took antiarrythmic drugs in Cardinal Tein hospital (amiodarone 1# QD, bisoprolol 1.25mg 1# QD and aspirin 1# QD).
      • This time, he was admitted to Oncology ward for further management. We are consulted.
    • O
      • BP:120/71 HG HR:85
      • Heart: RHB at present, no significant murmur
      • EKG: no avaialble
      • Lab: LDH 2024-06-28 151
        
      • Uric Acid 2024-06-28 5.7
        
      • Bilirubin total 2024-06-28 0.41
        
      • Na (Sodium) 2024-06-28 134
        
      • Mg (Magnesium) 2024-06-28 2.1
        
      • K(Potassium) 2024-06-28 4.6
        
      • ALT 2024-06-28 405
        
      • AST 2024-06-28 93
        
      • Creatinine 2024-06-28 1.40
        
      • Ca (Calcium) 2024-06-28 2.06
        
      • BUN 2024-06-28 22
        
      • Albumin(BCG) 2024-06-28 3.4
        
      • eGFR 2024-06-28 52.80
        
      • WBC 2024-06-28 13.40
        
      • RBC 2024-06-28 4.05
        
      • HGB 2024-06-28 12.0
        
      • HCT 2024-06-28 36.0
        
      • MCV 2024-06-28 88.9
        
      • MCH 2024-06-28 29.6
        
      • MCHC 2024-06-28 33.3
        
      • PLT 2024-06-28 375
        
      • RDW-CV 2024-06-28 12.9
        
      • MPV 2024-06-28 8.5
        
      • Neutrophil 2024-06-28 82.5
        
      • Lymphocyte 2024-06-28 11.3
        
      • Monocyte 2024-06-28 5.7
        
      • Eosinophil 2024-06-28 0.1
        
      • Basophil 2024-06-28 0.4
        
  • Suggestion:
    • There is no documented EKG for cardiac arrythmia in our hospital, thus adjustment for anti-arrythmic drugs is impossible.
    • Please obtains baseline EKG, and get documented EKG if palpitation recurs.
    • Check thyroid function for possible amiodarone related hypothyroidism.
    • Continue amiodarone and bisoprolol use for treatment of cardiac arrythmia. May taper amiodarone to 1/2# QD if sinus rhythm is documented.
• 2024-06-07 Hemato-Oncology
  • Q
    • For futher chemotherapy
    • This 72 y/o male a case of gastric cancer with tumor seeding s/p total gastrectomy with LND2 + dissection, intraabdominal multiple tumors excision, appendectomy, feeding jejunosotmy and HIPEC with Mitomycin (25mg/m2) 47mg + Oxaliplatinum (300mg/m2) 560mg on 2024/05/30.
    • The pathology showed poorly cohesive carcinoma, mixed signet-ring cell type and tubular type, pT4aN3aM1, stage IV. Now, he try oral intake to semi-liquid diet and jejunostomy feeding 800kcal/day since today. We need your expertise for futher chemotherapy. Thanks for your times.
  • A
    • This 72-year-old man is a case of gastric cancer with tumor seeding. He underwent a total gastrectomy with LND2+ dissection, excision of multiple intra-abdominal tumors, appendectomy, feeding jejunostomy, and HIPEC with Mitomycin (25 mg/m², 47 mg total) and Oxaliplatin (300 mg/m², 560 mg total) on 2024/05/30. The pathology showed poorly cohesive carcinoma, mixed signet-ring cell type and tubular type, pT4aN3aM1, stage IV.
    • We are consulted for chemotherapy. Please send PD-L1 (28.8) and arrange for Port-A implantation. We will discuss further systemic chemotherapy with the patient.
• 2024-05-31 Gastroenterology
  • Q
    • For TPN use
    • This is a 72 years old man with diagnosis of gastric cancer.
    • He underwent total gastrectomy with feeding jejunostomy and HIPEC on 5/30
    • We would like to consult your expertise on evaluation of the TPN use of the patient, thank you!
  • A
    • A case of gastric cancer who request post-op nutrition support.
      • General appearance: ill looking
      • GI tract: Total gastrectomy + feeding jejunostomy on 5/30
      • Feeding: NPO
      • Allergy: NKA
      • Nutrition assessment:
        • BH 175cm BW 72.3kg
        • IBW 67.4kg 107%IBW BMI 23.6
        • BEE 1449kcal TEE 2260kcal
      • Lab data: Alb 3.3 K 3.6 Mg 1.6 GOT 51 GPT 72 BS 172
        • According to the patient`s present conditions, parenteral nutrition will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
    • PN Use Suggestion:
      • DC YF5 1500ml QD
      • Stat Oliclinomel 1500ml, 62.5ml/hr
      • SMOFkabiven central 1477ml QD, 61.5ml/hr since 6/1
      • Lyo-Povigent 4ml/QD (add in TPN) (if not available, use alternative B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
      • Addaven 10ml/QD (add in TPN)
      • KCL 10ml/QD (add in TPN)
      • Nephrosteril 500ml/QD, drip > 3H each bottle
    • Items that should be monitored when using PN:

      • TPN is a single-route administration method. Do not mix TPN medications with other drugs.”

      • Check BW QW5 and record I/O Q8H

      • Check one touch Q6H x2 days, if stable QD check

      • Please control BS < 200 mg/dl with RI sliding scale

      • QW1 check CBC/DC

      • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin

      • If TPN is not available, substitute with YF5 or D10W.

• 2024-05-28 Anesthesia
  • Q
    • CVC insertion for nutrition support
    • This 72 y/o male was a case suspect of gastric cancer cT4N2M0 stage III by CT image. Body weight loss was also noted in recent. We need your help for CVC insertion for nutrition support first. Thanks for your time!!
  • A
    • We will perform CVC insertion for this patient.

[surgical operation]

• 2024-05-30
  • Surgery
    • total gastrectomy with LND2+ dissection
    • intraabdominal multiple tumors excision
    • appendectomy
    • feeding jejunosotmy
    • HIPEC with Mitomycin (25mg/m2) 47mg at 42 c 60mins and Oxaliplatinum (300mg/m2)560mg at 42 c 30mins
  • Finding
    • gastric body annular mass with serosa and regional mesentericc invasion
    • multiple small tumor seeding at peritoneal douglas and mesentery
    • PCI 9/39
    • apeendix tumor seeding (+)
    • ascite (-)

[chemotherapy]

• 2024-05-30 - oxaliplatin 300mg/m2 560mg 1hr IP
• 2024-05-30 - mitomycin-C 25mg/m2 47mg 1.5hr IP

==========

2024-07-01

[alternative needed: Avodart and tube-feeding issues]

Avodart (dutasteride) is not suitable for tube-feeding due to its formulation and potential adverse effects.

• Soft capsule form: The drug is encapsulated in a soft gelatin shell that is not designed to be crushed or dissolved. Crushing or dissolving the capsule could release the medication too quickly, potentially leading to complications.
• Non-divisible formulation: The medication is not intended to be split or halved, as this could alter the dosage and distribution of the drug within the body. The manufacturer’s instructions advise against breaking or dividing the capsules.
• Mucosal irritation: The drug may cause irritation to the lining of the digestive tract if administered directly through a feeding tube. This irritation could lead to discomfort.

Urief (Silodosin 8mg) may be considered as an alternative and is currently in use.

Our urologist suggested (2024-06-29) that Oxbu (oxybutynin) could be given. This drug is designed as an extended release and can be halved, 0.5# BID may be an option.

[hepatic impairment and medication adjustment]

Liver damage is observed.

Amiorone (amiodarone) dosage adjustment is likely necessary in patients with significant hepatic impairment. No specific guidelines available. If hepatic enzymes exceed 3 times normal or double in a patient with an elevated baseline, consider reducing the dose or discontinuing amiodarone.

Use of Tramacet is not recommended (acetaminophen and tramadol undergo extensive hepatic metabolism).

• 2024-07-01 ALT 234 U/L

• 2024-06-28 ALT 405 U/L

• 2024-06-20 ALT 44 U/L

• 2024-07-01 AST 69 U/L

• 2024-06-28 AST 93 U/L

• 2024-06-20 AST 29 U/L

• 2024-07-01 Albumin (BCG) 2.9 g/dL

• 2024-06-28 Albumin (BCG) 3.4 g/dL

• 2024-07-01 r-GT 155 U/L

• 2024-06-03 r-GT 15 U/L

701518841

240701

[exam findings]

• 2024-06-15 CT - abdomen
  • Clinical history: 87 y/o male patient with Gastric cardiac adenocaricnomaca with EC-junction involvment with multiple liver metastases T3N1M1 stage IV.
  • With and without contrast enhancement CT of abdomen:
    • There are multiple poor enhancing tumors, up to 3.4cm in left lobe liver, r/o liver metastasis. Progression.
    • Presence of duodenal diverticulum.
    • Outpouching lesions in sigmoid colon, suggesting diverticula.
    • Presence of ascites.
    • Right pleural effusion.
    • Atherosclerosis of abdominal aorta.
    • Coronary artery calcifications.
  • Impression:
    • Clinical gastric cardiac malignancy, with multiple liver metastsis (progression).
    • Right pleural effusion. Ascites.
    • Sigmoid colon diverticula.
• 2024-04-22, -03-29 ECG
  • Normal sinus rhythm
  • Left ventricular hypertrophy with repolarization abnormality
  • Abnormal ECG
• 2024-04-22, 03-29 CXR erect
  • Several nodular opacities or calcification projecting at right upper lung.
  • Atherosclerotic change of aortic arch
• 2024-04-16 CXR erect
  • Multiple nodules at RUL.
  • Atherosclerosis of the aorta.

[MedRec]

• 2024-05-27 SOAP Cardiology Liu GuanLiang
  • S
    • CAD s/p stenting for LAD/RCA in 2015, on plavix
    • HFpEF
    • T2DM 6.2%
    • LDL 69
  • A/P
    • Lifestyle modification
    • Return to OPD if effort angina developed
  • Prescription
    • Plavix (clopidogrel) 1# QD
    • Caduet (amlodipine 5mg, atorvastatin 20mg) 1# QD
    • Forxiga (dapagliflozin 10mg) 1# QDAC
    • Amamet (glimepiride 2mg, metformin 500mg) 1# BID
    • Nebilet (nebivolol 5mg) 1# QD
• 2024-04-21 ~ 2024-04-25 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Adennocarcinoma of esophageal cardiac junction, cT3N1M1 stage with GEJ involvement with multiple liver metastases in Jan 2024
    • Type 2 diabetes mellitus without complications
    • Chronic viral hepatitis B anti-Hbc positive
    • Unspecified hearing loss, bilateral
  • CC
    • Feeling light weakness.
  • Present illness
    • This 87-year-old man, who had past history of:
      • CAD post stenting and on plavix;
      • Disbetes mellitus, type II;
      • Adennocarcinoma via esophageal cardiac junction, cT3N1M1 stage with GEJ involvement with multiple liver metastases in Jan 2024, which was diagnosed in XinGuang hospital.
      • He had hesitated to receive IV chemo and CCRT and only received UFT (Tegafur and Uracil) at XinGuang hospital.
      • After the professional persuasion from Dr. Gao. He has changed his mind to more active treatment.
      • He was admitted for C1D1 chemotherapy with FOLFOX6 on 2024/04/21.
  • Course of inpatient treatment
    • The patient started the first IV form chemotherapy on 2024/04/22 (FOLFOX). IV drip last 50 hours, which last till 2024/04/24 morning. The patient didn’t experience obvious discomfort during and after the chemotherapy.
    • After one more day of close observation, the patient was discharged on 2024/04/25 and he was arranged for the next admission.
  • Discharge prescription
    • Bafen (baclofen 5mg) 1# PRNHS
    • Ulstop (famotidine 20mg) 1# BID

[chemotherapy]

• 2024-06-29 - oxaliplatin 85mg/m2 112mg D5W 250mL 2hr + 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W, old 20% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-06-14 - oxaliplatin 85mg/m2 112mg D5W 250mL 2hr + 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W, old 20% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-29 - oxaliplatin 85mg/m2 112mg D5W 250mL 2hr + 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W, old 20% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-06 - oxaliplatin 85mg/m2 112mg D5W 250mL 2hr + 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W, old 20% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-04-22 - oxaliplatin 85mg/m2 112mg D5W 250mL 2hr + 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W, old 20% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-07-01

[monitoring slowed decline in CEA levels; liver metastases progression on current FOLFOX]

Lab data indicates that the CEA level continues to decline, however the rate of decrease has slowed, warranting further attention. Additionally, the 2024-06-15 CT scan showed progression of liver metastases. The current FOLFOX regimen remains unchanged, as liver and kidney functions are stable, and no dosage adjustments are necessary.

• 2024-06-28 CEA (NM) 473.620 ng/ml
• 2024-06-11 CEA (NM) 667.550 ng/ml
• 2024-05-17 CEA (NM) 1667.800 ng/ml
• 2024-05-07 CEA (NM) 3387.500 ng/ml

2024-05-30

[FOLFOX treatment, decreasing CEA

]

The patient received FOLFOX chemotherapy on 2024-04-22, 2024-05-06 and 2024-05-29.

A noticeable decrease in CEA (carcinoembryonic antigen) levels has been observed. This could be an indication of the treatment’s effectiveness.

• 2024-05-17 CEA (NM) 1667.800 ng/ml
  
• 2024-05-07 CEA (NM) 3387.500 ng/ml
  
• 2024-04-24 CEA 4071.75 ng/mL
  
• 2024-04-03 CEA (NM) 2383.600 ng/ml

No inconsistencies were found in the patient’s medication list upon cross-referencing HIS5 and PharmaCloud databases.

701129626

240628

[exam findings]

• 2024-06-27 Tc-99m MDP bone scan
  • Increased activity in the middle and lower T-spines, lower L-spines and sacrum. Degenerative change is more likely.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips and knees, compatible with benign joint lesions.
• 2024-06-26 CXR erect
  • There are multiple nodular opacities projecting in both lung that may be metastases. Please correlate with CT.
  • There is a heterogeneous hyperdense lesion projecting at right lobe liver that is c/w HCC S/P TACE with lipiodol retention.
• 2024-04-30 CT - abdomen
  • With and without contrast enhancement CT: ABD - Liver, Spleen, Biliary duct, Pancreas:
    • HCCs in right lobe liver, s/p TACE with some viable tumors.
    • Bilateral lower lung nodules, r/o lung metastasis.
  • Impression:
    • HCCs s/p TACE with some viable tumors.
    • Bilateral lower lung nodules, r/o lung metastasis.
• 2024-04-18, -02-16 Embolization (TAE) - abdomen for tumor
  • HCCs at RIGHT hepatic lobe s/p TACE.
• 2024-02-15 MRI - liver, spleen
  • With and without contrast MRI of liver revealed:
    • Right HCC (6.3cm) at right hepatic lobe s/p TACE with some viable parts. R/O a hemangioma (1.1cm) at S8 of liver. Small liver and renal cysts (up to 0.9cm).
  • IMP:
    • Right HCC (6.3cm) at right hepatic lobe s/p TACE with some viable parts.
• 2024-01-19 Embolization (TAE) - abdomen for tumor
  • HCCs at RIGHT hepatic lobe s/p TACE.
• 2023-12-19 ECG
  • Normal sinus rhythm
  • Left ventricular hypertrophy with repolarization abnormality
• 2023-12-08 CT - abdomen
  • Findings:
    • Prior CT identified HCC at right hepatic lobe (12.6 cm) S/P TAE is noted again, decreasing in size to 9.2 cm (the largest dimension).
      • Part of this tumor show heterogeneous hyperdense material that is c/w S/P TAE with lipiodol retention.
      • Part of this tumor show non-enhancement that is c/w HCC S/P TACE with tumor necrosis.
      • Non-lipiodol retention lesion shows no enhancement in arterial phase images.
      • HCC S/P TACE with complete response is highly suspected.
      • Please correlate with MRI.
    • There is another lesion 2 x 1.3 cm in S8 of the liver, showing peripheral lipiodol retention and central necrosis.
      • HCC S/P TACE with complete response is also suspected.
    • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
  • Impression:
    • HCC S/P TACE with complete response is highly suspected.
    • Please correlate with MRI.
• 2023-11-03 Embolization (TAE) - abdomen for tumor
  • HCCs at RIGHT hepatic lobe s/p TACE.
• 2023-11-02 CT - abdomen
  • History and indication: HCC
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Right HCCs s/p TACE with some viable tumors.
• 2023-10-13 Embolization (TAE) - abdomen for tumor
  • HCCs at RIGHT hepatic lobe s/p TACE.
• 2023-10-04 Acoustic Radiation Force Impulse

pen_spark , ARFI - Number of image frames: 12 - Parameter Value - Median: 1.57 m/s - IQR: 0.21 m/s - IQR/Median: 13.1 % - Equivalent to Metavir Score: F2 - Hepatic fibrosis degree adopted by health insurance Instrument reference value - F0： ARFI < 1.30 m/s F0： ARFI < 1.35 m/s - F1： 1.3 <= ARFI < 1.50 m/s F1： 1.35 ~ 1.66 m/s - F2： 1.5 <= ARFI < 1.81 m/s F2： 1.66 ~ 1.77 m/s - F3： 1.81 <= ARFI < 1.98 m/s F3： 1.77 ~ 1.99 m/s - F4： 1.98 <= ARFI F4： 1.99 < ARFI

• 2023-10-04 SONO - abdomen
  • Indication: HCC
  • Symptoms:
    • Liver:
      • Smooth liver surface; homogeneous echotexture; sharp liver edge.
      • A huge mixed echoic tumor sized up to 10.33 cm in right liver.
    • Kidney:
      • A cyst of 0.76 cm in LK
    • Pancreas:
      • Some parts of pancreas blocked by bowel gas, especially head and tail
  • Diagnosis:
    • Large hepatic tumor, compatible with HCC
    • Left renal cyst
• 2023-09-08 Embolization (TAE) - abdomen for tumor
  • HCCs at RIGHT hepatic lobe s/p TACE.
• 2023-08-29 MRI - liver, spleen
  • History and indication:
    • HCC
  • With and without contrast MRI of liver revealed:
    • An enhancing tumor (8.6x10.3x12.7cm) at S5-6-7-8 of liver with venous wash out pattern and central necrosis. R/O a hemangioma (1.1cm) at S8 of liver. Small liver and renal cysts (up to 0.9cm).
  • IMP:
    • A HCC (8.6x10.3x12.7cm) at S5-6-7-8 of liver with central necrosis. R/O a hemangioma (1.1cm) at S8 of liver.
• 2023-08-23 CT - abdomen
  • Hx
    • HBV carrier was noted this time.
    • US: PLD with fatty change, right liver tumor r/o HCC (9.92 cm)
  • Findings:
    • There is a well-defined heterogeneous hypodense mass in right hepatic lobe, measuring 12.6 cm in size (the largest dimension). During dynamic study, this mass shows contrast enhancement in arterial phase images and contrast washout in portal venous phase and delayed phase images. It is c/w HCC.
    • There is a poor enhancing lesion 1.4 cm in S8 of the liver. Please correlate with MRI.
    • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
  • Imaging Report Form for Hepatocellular Carcinoma
    • Impression (Imaging stage) : T:T1b(T_value) N:N0(N_value) M:M0(M_value) STAGE:IB(Stage_value)

[immunochemotherapy]

• 2024-06-28 - durvalumab 1200mg NS 500mL 1hr (Imfinzi)
  • diphenhydramine 30mg + NS 250mL
• 2024-05-28 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-05-07 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-04-18 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-03-22 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-02-16 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-01-19 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-12-29 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-24 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-03 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 500mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-10-13 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 500mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-09-08 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 500mg NS 100mL 30min (Tecentriq + Avastin)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2024-06-28

[potential drug-induced thrombocytopenia]

Historical lab data shows a long-term decline in platelet levels. The patient’s treatment with atezolizumab and bevacizumab overlaps with this period, so the influence of these medications cannot be ruled out. Literature reports an incidence of immune thrombocytopenia of less than 1% with atezolizumab, while bevacizumab is associated with a much higher incidence of thrombocytopenia (58%; grades 3/4: 20% to 40%).

If clinically judged to be at risk of bleeding, a platelet transfusion might be considered.

The current treatment regimen has been switched to durvalumab, which has also been reported to cause immune thrombocytopenia. Please continue to monitor platelet levels.

• 2024-06-26 PLT 49 *10^3/uL
• 2024-05-28 PLT 62 *10^3/uL
• 2024-04-26 PLT 64 *10^3/uL
• 2024-04-19 PLT 61 *10^3/uL
• 2024-04-17 PLT 71 *10^3/uL
• 2024-02-15 PLT 118 *10^3/uL
• 2024-01-18 PLT 120 *10^3/uL
• 2023-12-19 PLT 151 *10^3/uL
• 2023-12-08 PLT 118 *10^3/uL
• 2023-11-24 PLT 120 *10^3/uL
• 2023-11-04 PLT 117 *10^3/uL
• 2023-11-03 PLT 139 *10^3/uL
• 2023-11-02 PLT 131 *10^3/uL
• 2023-10-14 PLT 130 *10^3/uL
• 2023-10-12 PLT 169 *10^3/uL
• 2023-09-09 PLT 123 *10^3/uL
• 2023-09-07 PLT 172 *10^3/uL
• 2023-08-28 PLT 215 *10^3/uL

701352408

240628

[exam findings]

• 2024-05-18 CT - brain
  • With and without-contrast CT of brain shows:
    • No intracranial hemorrhage or space-occupying lesion.
    • No abnormal low attenuation in brain parenchyma.
    • Normal size of the ventricles.
    • No midline shift.
    • No skull lesion.
    • Well pneumatization of paranasal sinuses and mastoid air cells.
    • No abnormal enhancing lesion after contrast administration.
  • Impression
    • No definite abnormality in this study
• 2024-04-02 CT - abdomen
  • With and without contrast enhancement CT of abdomen - whole:
    • Rectal cancer s/p concurrent chemoradiotherapy.
    • Liver cysts, up to 1.5cm in S4.
    • Minimal ascites.
  • Impression:
    • Rectal cancer s/p concurrent chemoradiotherapy. Stationary.
    • Liver cysts.
• 2024-02-20 Patho - colon biopsy
  • Colorectum, rectum, biopsy — acute inflammatory exudaes and fibrous tissue only.
• 2024-02-29 Colonoscopy
  • Rectal cancer, compatible with post CCRT change, s/p biopsy
  • Internal hemorrhoid
• 2024-01-11 Sigmoidoscopy
  • Findings
    • Rectal cancer s/p chemotherapy; a long fibrotic segment from dentate line up to 8 cm AAv
    • Np obvious tumor was noted, no tumor obstruction was noted
  • Diagnosis:
    • Rectal cancer s/p chemotherapy
• 2024-01-02 CT - abdomen
  • History and indication: Mucinous adenocarcinoma of rectal, cT3N2bM1a, stage IVA, s/p concurrent chemoradiotherapy with 5-Fu
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Progression of rectal cancer with regional LAP.
    • Liver cysts (up to 1.3cm).
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Progression of rectal cancer with regional LAP.
• 2023-10-03 PET scan
  • Glucose hypermetabolism in the lower portion of the rectum, compatible with primary malignancy of the rectum.
  • Mild glucose hypermetabolism in four regional lymph nodes. The nature is to be determined (inflammatory process? metastatic lymph nodes of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation may show this picture.
  • No prominent abnormal FDG uptake was noted in the right inguinal lymph node and elsewhere.
• 2023-09-22 MRI - pelvis
  • Findings:
    • There is a soft tissue mass in the right lateral posterior wall of the low rectum, measuring 2 cm in size.
      • Adenocarcinoma (T3) of the rectum is highly suspected.
    • There are eight enlarged nodes in the peri-rectal space, left internal iliac chain, and sigmoid mesocolon that are c/w metastatic nodes (N2b).
    • There is one enlarged node 1 cm in right inguinal area that may be non-regional metastatic node (M1a).
      • Please correlate with PET scan. Otherwise, follow up is indicated.
    • There are several hepatic cysts in both lobes and the largest one 1.5 cm in size at S4.
    • A renal cyst 1.3 cm in right lower pole is noted.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
• 2023-09-19 Patho - colorectal polyp
  • Labeled as “An circumferential ulcer at low rectum, 5cm from AV”, biopsy (A) — granulation tissue and ulcer debris only. No epithelial component present for evaluation. IHC stain CK (-).
  • Labeled as “Low rectal whitish mucosa around the ulcer, cause ?”, biopsy (B) — benign squamous epithelium with parakeratosis.

[MedRec]

• 2024-04-29, -04-08 SOAP Dermatology Wang ChunHua
  • S
    • Multiple painful erythematous papule-nodules on face,trunk and 4-limbs
    • Multiple erythematous scars and keloids on scalp for months, progressive enlarged recently, Itching(+)
  • O
    • Imp: acne on face and trunk for months,multiple pustule(+), inflammation(+), painful(+)
    • NSAID for pain release
    • Multiple erythematous scars and keloids for months, progressive enlarged recently, Itching(+), keloid(+)
  • Plan:
    • education about drug side effec and explain
    • Strongly suggested OPD f/u
  • Prescription
    • Shincord (triamcinolone acetonide 50mg/5mL/vial) ST IS
    • doxycycline 100mg 1# BID
    • Kolincin Gel (clindamycin 10mg/g) TOPI
• 2024-02-20 SOAP Dermatology
  • Prescription
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
    • Zalain Exteral Gel (for scalp) (sertaconazole 2%) Q3D EXT
    • fusidic acid 20mg/gm BID EXT
• 2024-02-16 ~ 2024-02-20 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Mucinous adenocarcinoma of rectal, cT3N2bM1a, stage IVA, s/p concurrent chemoradiotherapy with 5-Fu, status post chemotherpy with FOLFOX from 2023/12/11~2023/12/29, progression of rectal cancer with regional LAP, status post FOLFIRI from 2024/02/01~
    • Schizophrenia, unspecified
    • Chronic viral hepatitis B without delta-agent
    • Constipation, unspecified
    • Encounter for antineoplastic chemotherapy
    • Neutropenia, grade1
    • Hypokalemia
  • CC
    • for chemotherapy with FOLFIRI C1D15
  • Present illness
    • The 56 y/o female had suffered from difficult defecation with bloody stool since 2023/06. She was visted to Taipei Hospital first, Colonoscopy was arranged on 2023/08/17 showed internal hemorrhoid and suspect advanced colon cancer, s/p biopsy (A), and pathology showed Intestine, large, rectum, colonoscopic biopsy, adenocarcinoma with mucinous features.
    • Abdominal + Pelvis CT on 2023/08/30 showed c/w rectal cancer, cT1-2N1Mx. Due to personal reason, she visted to our CRS for survey.
    • Sigmoidoscopy was arranged on 2023/09/19 showed rectal cancer s/p biopsy, Low rectal mucosa inflammation s/p biopsy and pathology showed PATHO - colorectal polypA. Labeled as “An circumferential ulcer at low rectum , 5cm from AV”, biopsy (A) — granulation tissue and ulcer debris only. No epithelial component present for evaluation. IHC stain CK (-). B. Labeled as “Low rectal whitish mucosa around the ulcer , cause?”, biopsy (B) — benign squamous epithelium with parakeratosis.
    • Pelvis MRI was done on 20223/09/22 showed 1. Adenocarcinoma (T3) of the rectum is highly suspected. AJCC staging system, 8th edition for colon cancer: T3 N2b M1a. stage: IVA. Denied TOCC history in recent three months.
    • Under the impression of Mucinous adenocarcinoma of rectal, cT3N2bM1a, stage IVA. She received TNT concurrent chemoradiotherapy, deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT start on 2023/10/09~11/20, with infusional 5-FU (400mg/m2)/Covorin (20mg/m2) from 2023/10/11(C1), 2023/11/14(C2).
    • Then, she received TNT chemotherapy with FOLFOX(Oxalip 85mg/m2, LV 400mg/m2, 5FU 2400mg/m2) on 2023/12/11(C1D1), 2023/12/29(C1D15).
    • Follow up Abdominal CT on 2024/01/02 showed progression of rectal cancer with regional LAP. Sigmoidoscopy on 2024/01/11 showed Rectal cancer s/p chemotherapy; a long fibrotic segment from dentate line up to 8 cm AAv, no obvious tumor was noted, no tumor obstruction was noted. Refer to GS OPD for surgery (APR) with a permant colostomy, they refuse.
    • Plan to change regimen with FOLFIRI (Irino 120mg/m2, LV 400mg/m2, 5FU 2400mg/m2), she received 1st Palliative chemotherapy from on 2023/02/01(C1D1).
    • This time, she was admitted for chemotherapy with FOLIRI (Irino 120mg/m2, LV 400mg/m2, 5FU 2400mg/m2) on 2023/02/16(C1D15).
  • Course of inpatient treatment
    • After admission, she received chemotherapy with FOLFIRI(Irino 120 -> 90mg/m2, due to WBC:2310, ANC:1561), LV 400mg/m2, 5FU 2400mg/m2) from 2023/02/16~2024/02/18(C1D15).
    • Mosapin 5mg/tab 1# PO TID and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
    • Tramacet 37.5 & 325mg/tab 0.5# PO Q6H for pain control.
    • GASMIN 40mg/tab 1# PO TID for abdominal fullness.
    • Tranexamic Acid 250mg/cap 1# PO BID
    • Alcos-Anal Oint 20g/tube 1qs for bloody stool relief.
    • Arrange colonoscopy on 2024/02/19 showed Rectal cancer, compatible with post CCRT change, s/p biopsy. For cancer survey and will sent All RAS.
    • Constipation with Through 12mg/tab 2# PO HS.
    • Schizophrenia with Otsuka Abilify Discmelt 15mg/tab 1# PO HS
    • Depakine 200mg/tab 1# PO HS
    • Cardiolol 10mg/tab 1# PO HS, hold if SBP < 110mmHg, and PSY OPD follow up.
    • Chronic viral hepatitis B with Baraclude 0.5mg/tab for HBsAg, Anti-HBc reactive.
    • Hypokalemia with Const-K Extended-Release Tablets 750mg/10mEq/tab 1# PO QD for supportive.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/02/20 and OPD followed up later.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Pronolol (propranolol 10mg) 1# HS
    • Const-K (KCl 750mg 10mEq) 1# QD
    • Depakine (valproate sodium 200mg) 1# HS
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Otsuka Ability Discmelt (aripiprazole 15mg) 1# HS
    • Through (sennoside 12mg) 1# HS
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
    • Alcos-Anal Oint (sodium oleate) BID EXT
• 2024-01-18 SOAP Dermatology Zhou WeiTing
  • Prescription
    • doxycycline 100mg 1# BID
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI for forehead
    • Zalain External Gel (sertaconazole 2%) Q3D EXT
    • fusidic acid 20mg/gm BID EXT
• 2024-01-11 SOAP Dermatology Wu RuoWei
  • S
    • Improving but oily scalp and severe dandruff
    • Forehead lesion improving
  • O
    • Hair less patch with erythema, scaling and pus formation over vertex scalp
    • Erythematous plaques with scaling and excoriation over right side forehead
    • Oily scalp with severe scaling -> probably due to poor hygiene
  • A
    • Scalp: seborrheic dermatitis with secondary bacterial infection, tinea capitis should also ruled out
    • Forehead: seborrheic dermatitis
  • Plan:
    • Oral doxycyline
    • Oral orolisin
    • Topical mycomb, zalain, OTM
  • Prescription
    • doxycycline 100mg 1# BID
    • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# TID
    • tetracycline eye ointment BID EXT for scalp wound
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI for forehead
• 2023-12-14 SOAP Dermatology Wu RuoWei
  • S: Lesion over scalp
  • O: Scalp erythema with scaling and wound over scalp
  • A:
    • Wound with secondary infection
    • Seborrheic dermatitis
  • P:
    • oral doxycycline, orolisin
    • topical zalain, OTM
  • Prescription
    • doxycycline 100mg 1# BID
    • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# BID
    • tetracycline eye ointment BID EXT for scalp wound
    • Zalain External Gel (sertaconazole 2%) Q3D EXT wash hair
• 2023-09-21 SOAP Radiation Oncology Huang JingMin
  • S: For preoperative TNT due to rectla cancer.
  • A: Adenocarcinoma of the rectum, stage cT1-2N1Mx.
  • P: Radiotherapy is indicated for this patient with the following indicators: stage cT2N1
    • Goal: curative
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her father. She understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be s1030, 2023-09-25.
• 2023-09-21 SOAP Hemato-Oncology Xia HeXiong
  • P: Propose TNT
    • CCRT with infusional FU -> FOLFOX for 12-18 weeks (favor 8 cycles) -> Evaluate OP
• 2023-09-18 SOAP Colorectal Surgery Xiao GuangHong
  • S: First visit patient, rectal cancer diagnosed at Taipei City Hospital
  • P: Arrange sigmoidoscopy for R/O colonic lesion

[consultation]

• 2024-05-21 Oral and Maxillofacial Surgery
  • Q
    • for Tooth Decay
  • A
    • S: We had viewed the patient
    • O
      • Panoramic finding:
      • Caries: 12 13 17 22 28
      • Residual root 24 25 35 37 38 44
      • Crown and bridge: 14XX17 45 46
    • P
      • Suggest tooth extraction of all the residual root and tooth 28
      • Endodontic treatment of tooth 12 13 22
      • Please arrange our OPD for the further treatment
• 2024-05-16 Obstetrics and Gynecology
  • Q
    • for a soft mass of left labia, nature?
  • A
    • This is a 56 y/o, sex (-) woman with advanced rectal cancer who was admitted for chemotherapy. Due to suspected vulvar mass, we were consulted for evaluation. Reviewing her history, he has visited Pro. Huang’s clinic on 2024/05/14 for similar complaints. Biomycin ointment was prescribed at that time.
    • CC
      • Left vulvar mass and left perineal pain.
    • ObGyn history
      • sex (-)
    • PV
      • a 2 X 1 cm lesion at the left labia minora, skin intact without redness or oozing
      • Multiple small erosions at left inguinal skin, no pus discharge noted, tenderness (+)
    • Impression
      • Left vulvar mass, nature undetermined
      • Left inguinal skin erosion, mild, suspect infection related
    • Suggestion
      • Please keep Biomycin ointment use for left inguinal skin erosion.
      • Biopsy is suggested for left vulvar mass, but is not suitable to perform during chemotherapy course. Please arrange GYN f/u.
      • Unsteady gait is noted at the clinic. Please consider brain CT for evaluation.
• 2024-05-15 Infectious Disease
  • Q
    • for skin rash of bottom, suspect herpus
  • A
    • 56-year-old rectal cancer female patient is admitted for scheduled chemotheapy.
      • Grouped dry shallow ulcers noted over left buttock, which herpes zoster over one week is likely.
      • Patient has seborrheic dermatitis and acnes problems, which also possible
      • Since there is no sign of active infection or cellulitis presentation, iv antibiotic should be not necessary.
      • One-week oral anti-viral Famvir or Valtrex may be still helpful.
    • Suggestion:
      • Continue doxycycline, DC Baktar
      • Add oral Famvir 250mg po tid for one week.
• 2024-03-18 Psychosomatic Medicine
  • Q
    • For schizophrenia lost follow up.
    • The patient claimed to have traveled through time today.
  • A
    • Imprssion
      • Schizophrenia, in partial remission
      • Rectal adenocarcinoma
    • S/O:
      • The 56 year old woman was consulted for disorganized speech without medical control of her disease. According to her father, she was diagnosed as schizophrenia at 20s and she had ever admitted for chronic ward at Bali Psychiatric Center MOHW.
      • She was fully capable in self-care at home and there was no psychosis detected, only sometimes argument with sister without severe conflict. There was also no mood episodes ever happened.
      • Interveiwing with the patient, there was no delusion or hallucination, only trivial loosen and circumferential speech and sometimes irrelevant.
      • MSE:
        • sloppy, alert, euthymic, fluent but sometimes irrelevant speech, trivial loosen and circumferential speech, no delusion, no hallucination, fair self-care
    • Plan
      • keep current psychiatric medicaitons
      • arrange OPD follow-up
• 2024-01-04 Dermatology
  • Q
    • Patient was 55 years old women diagnosis was Rectal adenocarcinoma with mucinous features in 2023-09, cT1-2N1Mx, Schizophrenia irregular medication control.
    • 2023/12/14
      • Wound with secondary infection
      • Seborrheic dermatitis
    • Plan:
      • oral doxycycline, orolisin
      • Topical zalain, OTM
    • for skin lesions, we need your further evaluation and management.
  • A
    • CC: Scalp and forehead lesions
    • Cutaneous findings:
      • Hair less patch with erythema, scaling and pus formation over vertex scalp
      • Erythematous plaques with scaling and excoriation over right side forehead
      • Oily scalp with severe scaling -> probably due to poor hygiene
    • PH:
      • Rectal adenocarcinoma with mucinous features
      • Schizophrenia, poor self-care and poor Hygiene
    • Imp:
      • Scalp: seborrheic dermatitis with secondary bacterial infection, tinea capitis should also ruled out
      • Forehead: seborrheic dermatitis
    • Plan:
      • Oral doxycycline 1#BID
      • Oral orolisin 1#TID
      • Topical Zalain gel TIW for scalp wash
      • Topical Mycomb BID for scalp and forehead lesions
      • Had education of scalp washing
      • Arrange dermatology OPD follow up after discharge
• 2024-01-03 Colorectal Surgery
  • Q
    • Due to disease progression，we need your further evaluation and management. (OP? or keep TNT treatment?) Thanks a lot!!!
  • A
    • I’ve visited this case. The patient is a case of rectal cancer s/p CCRT with tumor progression. She also complained frequent abdominal cramping pain.
    • PE: abd: soft; mild distension; no tendernss
    • Imp : Rectal cancer s/p CCRT with tumor progression, suspect tumor partial obstruction
    • Please arrange OPD after discharge and surgery will be arranged
• 2023-12-30 Psychosomatic Medicine
  • Q:
    • Cancer inpatients with suicidal thoughts score >= 2.
  • A:
    • Psychiatric impression:
      • schizophrenia
      • insomnia
    • Current chief problem: suffered form rectal pain related anxiety and poor sleep.
    • MSE: conscious alert and oriented, mostly incoherent and irrelevent speech, mild talktiveness, paralogical thinking pattern, less persecutory ideation, residual AH, tangential thoughts.
    • Suggestion:
      • keep abilify 15mg 1# HS, and Depakine 200mg HS,
      • may add anxiedin 1~2# HS for anxiety and insomnia
      • arrange PSY OPD follow up
• 2023-10-03 Radiation Oncology
  • Q
    • The patient is an 55 year-old female with a history of Schizophrenia, Adenocarcinoma of the rectum, stage cT1-2N1Mx, diagnosed at MOHW Taipei Hospital.
    • VS Huang: Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
    • PET on 2023/10/03, Port-A will arrange on 2023/10/04.
    • Positioning mark was washed by the patient, we need your further evaluation and management.
  • A
    • The patient is an 55 year-old female with a history of Schizophrenia, Adenocarcinoma of the rectum, stage cT1-2N1Mx, diagnosed at MOHW Taipei Hospital
    • 2023-10-03 PET:
      • Glucose hypermetabolism in the lower portion of the rectum, compatible with primary malignancy of the rectum.
      • Mild glucose hypermetabolism in four regional lymph nodes. The nature is to be determined (inflammatory process? metastatic lymph nodes of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • 2023-09-22 MRI:
      • There is a soft tissue mass in the right lateral posterior wall of the low rectum, measuring 2 cm in size. Adenocarcinoma (T3) of the rectum is highly suspected.
      • There are eight enlarged nodes in the peri-rectal space, left internal iliac chain, and sigmoid mesocolon that are c/w metastatic nodes (N2b).
      • There is one enlarged node 1 cm in right inguinal area that may be non-regional metastatic node (M1a).
      • T3 N2b M1a. stage: IVA
    • Under the impression of rectal cancer, cT3 N2b M1a. stage: IVA, neoadjuvant CCRT is indicated. CT-simulation will be arranged today. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT might start around 10/11 or later. Thank you very much.
• 2023-09-28 Psychosomatic Medicine
  • Q
    • Patient was 55 years old women diagnosis was Rectal adenocarcinoma with mucinous features in 2023-09, cT1-2N1Mx , Schizophrenia with irregular medication control.
    • This time, she was admitted for cancer survey and chemotherapy, We need your consultation for evaluation. Thanks a lot!!!
  • A
    • This 55 y/o single woman was admitted for scheduled chemotherapy. She now lives with his parents, and not employed.
      • According to the patient and her father, her highest education: high school and worked as a office worker, until her 30s, she developed referential and persecutory delusion, auditory hallucination, disorganized speech, isolated behaviors for over 1 months and was brought to MOHW Bali Psychiatric Center and stayed for 1 year.
      • She could help housechore at home but can’t never return to work, regular follow up at RenJi Hospital, and been to RenJi Day Ward in recent 1 year, taking abilify 15mg/d, risperidal 1mg/d, quetiapine 100mg/d, depakine 200mg/d, akinfree. She ever received 1 monthly depot last year for few months.
      • In recent 2 months, she discharged from RenJi Day Ward, not taking medications nor return to OPD for 2 months, stated residure AH and referential ideation: throat is sore and needs to be cleared, always worried that someone is watching her, auditory hallucination, and multiple somatic complaints and preoccupation: spots on the arm, pimples on the head that are bleeding. limited insight: don’t want to go to day classes or take medication anymore, want to do many things, Japanese and English studies were interrupted and not learned, want to learn.
    • MSE: thin, spots on the arm, social smile, mild euphoric mood, talkative, stooped posture and mild restlessness, residure AH, referential ideation, somatic preoccupation, tangential thoughts.
    • IMP: Schizophrenia, chronic
    • Suggestion:
      • Add back antipsychotics: abilify 15mg 1# HS, adjunctive with Depakine 200mg HS, inderal 1# HS.
      • Arrange PSY OPD follow up.

[radiotherapy]

[chemotherapy]

• 2024-06-27 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-19 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-02 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-15 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-02-16 - irinotecan 90mg/m2 120mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-02-01 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-12-29 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-11 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-11-13 - leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 400mg/m2 580mg NS 100mL 10min (CCRT)
  • dexamethasone 4mg + NS 250mL
• 2023-10-16 - leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 400mg/m2 580mg NS 100mL 10min (CCRT)
  • dexamethasone 4mg + NS 250mL
• 2023-10-11 - leucovorin 20mg/m2 30mg NS 100mL 10min D1-3 + fluorouracil 400mg/m2 580mg NS 100mL 10min D1-3 (CCRT)
  • dexamethasone 4mg D1-3 + NS 250mL D1-3

==========

2024-05-15

[pain management]

Patient’s pain score on VAS was recorded as 5 on 2024-05-14. Please assess the adequacy of the current acetaminophen regimen for pain management.

2024-03-18

[reconciliation]

Vital signs during this hospitalization are stable, and lab results on 2024-03-15 were unremarkable. No medication discrepancies are noted.

2024-02-01

[check to see if the tachycardia is transient]

Lab results from 2024-01-31 were largely within normal ranges, and vital signs from the TPR panel remained within normal limits, with the exception of tachycardia, noted as HR 113 this morning. Should the tachycardia prove to be transient, proceeding with chemotherapy administration should not be deemed contraindicated.

2024-01-02

[reconciliation]

This patient’s PhamaCloud record shows receipt of Epine (quetiapine 200mg) on 2023-12-15 from MOHW Bali Psychiatric Center. It has now been replaced with Otzuka (aripiprazole 15mg). Notably, both medications carry boxed warnings regarding increased mortality in elderly patients with dementia-related psychosis and potential suicidal thoughts or behavior. HIS5 records showed the patient’s 2 past consultations for suicidal thoughts scores of 2 or higher in the Psychosomatic Medicine department, close monitoring of potential suicidal ideation and behavior is strongly advised.

Additionally, our Psychosomatic Medicine specialist suggested lorazepam on 2023-12-30, yet it isn’t listed in the active medication list. It is recommended a check of the need for lorazepam.

701017888

240626

[exam findings]

• 2024-06-25 CXR erect
  • nodular/reticular opacities over Rt and left lungs zone, and subsegmental opacity over Rt midlung zone, due to infection/ or inflammation
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • mild enlarged cardiac silhoutte
  • Compression fracture of many vertebral bodies
• 2024-06-25 CT - brain
  • Indication: r’t side face contusion few days ago.
  • Cranial CT scans without IV contrast medium enhanced was performed smoothly and show:
    • Heterogenous hyperdense masses, up to 38 mm, favor left temporo-occipital metastases with prominent perifocal edema.
    • Left convexity thin SDH. Brain herniation.
  • Imp:
    • Favor left temporo-occipital metastases with prominent perifocal edema. Left convexity thin SDH. Brain herniation.
    • Fractures in: left zygomatic arch and bil. maxillary sinus walls.

[MedRec]

• 2024-06-25 SOAP Medical Emergency Hu YuHui
  • Note
    • possible lung tumor with brain mets was told, family preferred no OP nor hung cancer evaluation
    • CXR: RLU tumor mass, about 3 cm
• 2017-02-15 SOAP Rheumatology Liu JinXiu
  • Diagnosis
    • Rheumatoid arthritis [M05.70]
    • Sicca syndrome; Keratoconjunctivitis sicca; Sjogren`s disease [M35.00]
    • Discoid lupus erythematosus of eyelid [H01.129]
    • Osteoporosis, unspecified [M81.0]
    • Close fracture of dorsal (thoracic) without mention of spinal cord injury [S22.022A]
    • OA, localized,not specified whether primary or secondary, lower leg [M17.9]
    • Constipation [K59.00]
  • Prescription x3
    • Tie Shr Shu Pap (flurbiprofen 40mg/patch) QD EXT
    • MgO 250mg 1# BID
    • Sandinnum Neoral (ciclosporin 100mg) 1# QD
    • Metisone (methylprednisolone 4mg) 0.5# QD
    • Azamun (azathioprine 50mg) 0.5# QD
    • Eurodin (estazolam 2mg) 1# HS
    • Arheuma (leflunomide 20mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# BID
    • Salazine (sulfasalazine 500mg) 1# BID
    • Plaquenil (hydroxychloroquine 200mg) 1# BID
    • folic acid 5mg 1# QD
    • Trexan (methotrexate 2.5mg) 4# QW6
• 2017-01-16 SOAP Ophthalmology Peng YiJie
  • Diagnosis:
    • Sicca syndrome; Keratoconjunctivitis sicca; Sjogren`s disease [M35.00]
    • Rheumatoid arthritis [M05.70]
    • Open-angle glaucoma, unspecified [H40.10X3]
    • Cronic conjunctivitis, unspecified [H10.403]
  • Prescription x3
    • Sinomin (sulfamethoxazole 40mg/mL) QID OU
    • Lumigan (bimatoprost 0.01%) HS OU
    • Azarga (brinzolamide, timolol) BID OU
    • Vidisic Gel (carbomer) BID OU

==========

700938172

240625

[exam findings]

• 2024-04-13 CT - abdomen
  • Indication: Gastric adenocarcinoma status post subtotal gastrectomy with D2 LNs dissection B-II reconstruction with Braun anastomosis on 2023/11/08. pT4apN0(if cM0), pStage : IIB, s/p FOLFOX
  • With and without contrast enhancement CT of abdomen shows:
    • Gastric cancer, s/p gastrectomy with B-II anastomosis. No local recurrent tumor.
    • No enlarged lymph nodes in para-aortic and pelvic regions. Suspect a right supraphrenic lymph node, 1.5*2.6cm, (Srs:302;Img:45); DDx: focal fluid collection.
  • Impression
    • Gastric cancer, s/p gastrectomy
    • Suspect a right supraphrenic lymph node. Suggest follow up evaluation.
• 2023-11-09 Patho - stomach subtotal/total (tumor)
  • Diagnosis
    • Stomach, distal 2/3, subtotal gastrectomy with D2 LNs dissection — adenocarcinoma poorly differentiated. Margins free.
    • Lymph nodes, gastric, and group, 1, 7, (8,9), 12, , subtotal gastrectomy with D2 LNs dissection — free (0/30).
    • PT4a pN0 (if cM0); pStage : IIB, at least.
  • Gross Description:
    • Procedure - subtotal gastrectomy with D2 LNs dissection
    • Tumor Site - lower body, LC side
    • Tumor Size : 2.1 x 1.5 x 1.0 cm
    • Gross configuration
      • For advanced carcinoma (Borrmann classification) - Type IV: Infiltrative, predominantly intramural lesion, poorly demarcated
      • For early carcinoma
    • Sections are taken and labeled as:
      • A1: bilateral margins; A2-9: ulcerative mass; A10-16: GC side Lns; A17: ometum; A18-19: LC side Lns; A20: group 1 LNs; A21: group 7, LNs; A22: group (8,9), LNs; A23: group 12, Lns.
  • Microscopic Description:
    • Histologic Type - Adenocarcinoma
      • Lauren classification of adenocarcinoma: Diffuse type
    • Histologic Grade - G3: Poorly differentiated, undifferentiated
    • Tumor Extension - Tumor invades the serosa (visceral peritoneum)
    • Margins
      • Proximal margin: uninvolved by invasive carcinoma
      • Distal margin: uninvolved by invasive carcinoma
      • Radial margin: involved by invasive carcinoma
    • Lymphovascular Invasion: not identified
    • Perineural Invasion: not identified
    • Regional Lymph Nodes
      • Number of lymph nodes examined/involved: 0/30
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition) – pStage: IIB, at least.
      • TNM Descriptors (required only if applicable) – not applicable.
      • Primary Tumor (pT)- pT4a: Tumor invades the serosa (visceral peritoneum)
      • Regional Lymph Nodes (pN)- pN0: No regional lymph node metastasis
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case) - if cM0
    • Additional Pathologic Findings - None identified
    • Ancillary Studies - Her2/neu: S2023-19017
• 2023-10-11 CT - chest
  • Findings
    • Infrarenal aortic aneurysm is found up to 2.32cm in largest dimension.
  • Imp:
    • No evidence of lung tumor at both lungs.
• 2023-10-02 CT - abdomen
  • History and indication: Gastric ulcerative lesion, rule out gastric cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of gastric antrum and lower gastric body with adjacent fat stranding and small regional LAP.
    • Atherosclerosis of aorta, iliac arteries.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
• 2023-09-22 Patho - colon biopsy
  • Intestine, large, ascending colon, polypectomy — tubular adenoma
• 2023-09-22 Patho - stomach biopsy
  • Stomach, low body, LC, biopsy — poorly differentiated adenocarcinoma with signet-ring cell differentiation
  • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of malignant tumor cells arranged in solid to glandular architecture, and focal signet-ring cell diffferentiation. Helicobacter pylori are seen.
  • Immunohistochemical stain: CK (+) at tumor, HER2/NEU: negative (1+).
• 2023-09-22 Bone densitometry - hip
  • Hip BMD performed by DXA revealed:
    • Left hip, BMD is 0.706 gms/cm2, about 1.3 SD below the peak bone mass (83%) and 0.0 SD below the mean of age-matched people (100%).
  • Impression
    • Osteopenia
• 2023-09-22 SONO - abodmen
  • Diagnosis:
    • Fatty liver, mild
    • Liver cyst, small, S8
    • suspicious, Renal stone, bilateral
    • fat infiltration of pancreas.
  • Suggestion:
    • encourage exercise and diet adjustment.
    • visit Urology if symptoms revealed.
    • semi-annual US f/u

[MedRec]

• 2023-12-12 SOAP Hemato-Oncology He JingLiang
  • S: adjuvant C/T with FOLFOX, anti-HBc: reactive, add HB medication
  • Prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Hepac Lock Flush 100 USP/mL 10mL ST IRRI
• 2023-11-28 SOAP Hemato-Oncology He JingLiang
  • S: adenocarcinoma of stomach, pT4aN0M0, stage IIB, suggest adjuvant C/T with FOLFOX x10 cycles
• 2023-11-07 ~ 2023-11-19 POMR General and Gastrointestinal Surgery Chen YanZhi
  • Discharge diagnosis
    • Gastric adenocarcinoma status post subtotal gastrectomy with D2 LNs dissection B-II reconstruction with Braun anastomosis on 2023/11/08. pT4apN0(if cM0), pStage : IIB. ECOG:0.
  • CC
    • Incidental finding of gastric cancer during health checkup.
  • Present illness
    • This is an 59-years-old man with underlying disease of (1) gastric helicobacter pylori infection without treament for 3+ years. (2) hemorrhoid s/p hemorrhoidectomy around 30 years ago. This time he admited for laparoscopic gastrectomy.
    • According to patient’s statement and medical record, he underwent routine health checkup at 2023/09/22. At that time, during upper GI endoscopic examination, there is a gastric ulcerative lesion at stomach lower body. Biopsy was done and pathology report revealed gastric poorly differentiated adenocarcinoma with signet-ring cell differentiation.
    • Patient complained about increase flatus recently. He denied any early fullness after meal. No loss of appetite or body weight. No stomach pain or nausea and vomiting. He has family history of cousin (father side) passed away due to gastric cancer.
    • He then refered to general surgery OPD and was on Dr. Chen’s service. Further abdominal CT done at 2023/10/02 showed wall thickening of gastric antrum and lower gastric body with adjacent fat stranding and small regional lymadenopathy. Stage III gastic cancer with T4aN2M0 staging was diagnosed.
    • After the explaination and discussion with patient. Subtotal gastrectomy surgery was suggest. Patient understood the risk and benifit of operation and consent to it.
    • Under the impression of gastric adenocarcinoma, Stage III. He was admitted for surgery and hospitalize to our GS ward for further evaluation and treatment.
  • Course of inpatient treatment
    • After admitted, he received subtotal gastrectomy with D2 LNs dissection + B-II reconstruction with Braun anastomosis was performed on 2023/11/08.
    • After operation, we observed patient recovery and keep empiric antibiotic, PPI, adequate IVF and SmofKabiven supplement, analgesic agent were administered and the wound management was performed.
    • Removed NG tube and have flatus passage on 2023/11/11. Then he try water, clear liquid diet, full liquid diet and semi-liquid diet and defecation was smooth after no fever, nausea,vomiting intake.
    • Remove right JP draine on 2023/11/18. Remove left JP draine on 2023/11/19. The patient was allowed to discharge today and outpatient department follow up was arranged.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Ulstop (famotidine 20mg) 1# BID
    • MgO 250mg 1# TID

[surgical operation]

• 2023-11-08
  • Surgery
    • subtotal gastrectomy with D2 LNs dissection
    • B-II reconstruction with Braun anastomosis
  • Finding
    • ulcerative lesion at lower body, LC side, about 1cm in diameter, serosa invasion (+), T4a
    • no significant enlarged LNs over perigastric LNs and group 8,9, and 12

[chemotherapy]

• 2024-06-25 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-05-31 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2400mg/m2 4170mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-05-10 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2400mg/m2 4180mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-04-10 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2400mg/m2 4180mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-03-22 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2400mg/m2 4190mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-02-21 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2400mg/m2 4150mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-02-02 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-11 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-03-22

[reconciliation]

The lab results from 2024-03-21 were generally within normal ranges, and the patient has maintained stable vital signs throughout the hospital stay.

There appears to be no contraindication to proceeding with the 5th session of FOLFOX chemotherapy, and no discrepancies in medication have been noted.

701187248

240625

[exam findings]

• 2024-06-06 CT - abdomen
  • History and indication:
    • Adenocarcinoma of gastric antrum, pT3N2M0 stage IIIA, status post radical D2 subtotal gastrectomy and cholecystectomy and Braun’s anastomosis on 2023/09/14. chemotherapy with FOLFOX from 2023/11/09.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P gastric operation.
    • Enlargement of prostate with calcifications.
    • Enlarged LNs (up to 1.5cm) at mediastinum.
    • Wall edema of colon.
    • Duodenal diverticulum.
    • Renal cysts (up to 1.0cm).
    • S/P cholecystectomy.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P gastric operation.
    • Enlargement of prostate with calcifications.
    • Enlarged LNs (up to 1.5cm) at mediastinum.
    • Wall edema of colon.
• 2024-04-11 KUB
  • Spondylosis of the L-spine is noted.
  • Fecal material store in the colon.
• 2024-02-05 CT - abdomen
  • Indication: Adenocarcinoma of gastric antrum, pT3N2M0 stage IIIA, status post radical D2 subtotal gastrectomy and cholecystectomy and Braun’s anastomosis on 2023/09/14. Chemotherapy with FOLFOX from 2023/11/09.
  • Abdominal and Chest CT with and without IV contrast ehnancement shows:
    • S/p port-A placement with its tip at left brachiocephalic vein.
    • s/p subtotal gastrectomy.
  • Imp:
    • s/p subtotal gastectomy.
    • No evidence of recurrent/residual tumor in the study.
• 2023-11-08 Tc-99m MDP bone scan
  • Faint hot spots in both rib cages, cancer with early bone mets may be considered, suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, mandible, sternum, some C-, T- and L-spine, sacrum, bilateral shoulders, elbows, S-I joints, and hips.
• 2023-11-06 CXR (erect)
  • Atherosclerotic change of aortic arch
• 2023-10-02, -09-29 KUB
  • Degeneration and spondylosis of L-S spine.
• 2023-09-14 Patho - stomach subtotal/total (tumor)
  • Diagnosis
    • Stomach, antrum, radical D2 subtotal gastrectomy — Adenocarcinoma, moderately differentiated, pStage IIIA, pT3N2 (if cM0)
    • Duodenum, radical D2 subtotal gastrectomy — Negative for malignancy
    • Omentum, radical D2 subtotal gastrectomy — Negative for malignancy
    • Gallbladder, cholecystectomy — Negative for malignancy
    • Lymph node, No 1, dissection — Negative for malignancy (0/2)
    • Lymph node, No 3, dissection — Metastatic adenocarcinoma (1/ 4)
    • Lymph node, No 4, dissection — Metastatic adenocarcinoma (2/ 5)
    • Lymph node, No 5, dissection — Negative for malignancy (0/ 0)
    • Lymph node, No 6, dissection — Metastatic adenocarcinoma (2/ 4)
    • Lymph node, No 7, 8, 9, 11p, dissection — Metastatic adenocarcinoma (1/ 15)
    • Lymph node, No 12a, dissection — Negative for malignancy (0/1)
    • Lymph node, No 14v, dissection — Negative for malignancy (0/1)
  • Gross Description:
    • Procedure:
      • radical D2 subtotal gastrectomy
      • cholecystectomy
        
    • Specimen size:
      • specimen 1: Greater curvature: 15.0 cm, Lesser curvature: 9.2 cm,
      • specimen 2: Omentum: 37.5 x 23.0 x 1.3 cm
      • speicmen: 11 Gallbladder: 1.7 x 1.2 x 0.5 cm (all submitted)
    • Tumor Site: Antrum, posterior wall
    • Tumor Size: 6.3 x 5.0 x 1.0 cm
    • Gross configuration: For advanced carcinoma (Borrmann classification): Type II: Fungating, ulcerated with sharp raised margins
    • Sections are taken and labeled as: A1: proximal resection margin; A2: distal resection margin; A3: stomach, non-tumor; A4-8: tumor (A4-5: the same level); B1-2: omentum; C: lymph node, No 1; D: lymph node, No 3; E : lymph node, No 4; F: lymph node, No 5; G: lymph node, No 6; H1-3: lymph node, No 7, 8, 9, 11p; I: lymph node, No 12a; J: lymph node, No 14v; K1-2: gallbladder.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma: Lauren classification of adenocarcinoma: Intestinal type; WHO: Tubular, moderately differentiated
      
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
    • Margins
      • Proximal margin: uninvolved by invasive carcinoma: 5.0 cm
      • Distal margin: uninvolved by invasive carcinoma: 1.2 cm
      • Radial margin: very close, ＜ 0.1 cm
    • Lymphovascular Invasion: present
      
    • Perineural Invasion: present
      
    • Regional Lymph Nodes: please see diagnosis
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pT3: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
        • Regional Lymph Nodes (pN): pN2: Metastasis in three to six regional lymph node
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
    • Additional Pathologic Findings:
      • Intestinal metaplasia: present
      • Low-grade dysplasia: absent
      • High-grade dysplasia: present
      • Helicobacter pylori-type gastritis: absent
      • Autoimmune atrophic chronic gastritis: absent
        
      • Polyp(s) : absent
• 2023-09-01 CT - abdomen
  • CC: Epigastralgia, R/O PUD; 20230830 gastroscopy: A 3-5cm mass with deep ulcer was noted at PW of antrum, s/p biopsy 6 (A). Suspected advanced gastric cancer, Bormann 2.
  • Indication: Gastric cancer staging
  • Findings:
    • There is segmental wall thickening in the gastric antrum, measuring 5 cm in size, that is c/w adenocarcinoma (T3).
    • There are two enlarged nodes in the peri-gastric antrum area that may be metastatic nodes (N1).
    • There is no focal lesion in both lungs.
      • There are two enlarged nodes in right paratracheal space and paraaortic space. Follow up is indicated.
    • A renal cyst 1 cm in right upper pole is noted.
    • The gallbladder shows small contracted.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE:III(Stage_value)
• 2023-08-30 Patho - stomach biopsy (Y1)
  • Stomach, PW of antrum, biopsy — poorly differentiated adenocarcinoma
  • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of atypical tumor cells arranged in solid to glandular architecture and invasive growth pattern.
    • Tumor cells show nuclear hyperchromasia, pleomorphism and prominent nucleoi.
    • Both H.pylori and fungal hyphae are seen at the superficial mucosa.
  • IHC stain — CK: positive and Her2/neu: neagtive at tumor
• 2023-08-30 EGD
  • Reflux esophagitis, LA A
  • Esophageal lesion, upper esophagus, s/p biopsy (B)
  • Suspected advanced gastric cancer, Bormann 2, PW of antrum, s/p biopsy (A)
  • Superficial gastritis, antrum, s/p CLO test

[MedRec]

• 2023-11-06 ~ 2023-11-11 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Adenocarcinoma of gastric antrum, pT3N2M0 stage IIIA, status post radical D2 subtotal gastrectomy and cholecystectomy and Braun’s anastomosis on 2023/09/14. ECOG:1
    • Chronic superficial gastritis without bleeding
    • Cachexia
  • CC
    • for bone scan (for right low rib pain) and C1 FOLFOX
  • Present illness
    • This 73-year-old male with past history of type 2 diabetes with medications control. He also sufferred from presented with progressive constipation lasting 1-2 years, experiencing stool every third day. He has no history of bloody or tarry stools, no small caliber stool, but reported a sensation of tenesmus. No significant weight loss was noted, and there is no family history of gastrointestinal (GI) cancer.
    • According for his statement, his national health insurance fecal immunochemical test (NHI FIT) in 2023 was negative. On examination in July, the decision was made to arrange for an IVG CFS in late A colonoscopy in 202308 showed the presence of several polyps, which were removed. One was in the ascending colon, two in the hepatic flexure, and one in the transverse colon. By late 202308, the patient had added complaints of occasional epigastric pain and acid reflux for months. An EGD was ordered. The gastroscopy showed possible reflux esophagitis, a lesion in the upper esophagus, a suspected gastric cancer in the antrum of the stomach, and superficial gastritis. A biopsy was taken from the gastric lesion. The clostridium-like organism (CLO) test was negative, implying the absence of Helicobacter pylori infection. The biopsy results from the stomach confirmed a poorly differentiated adenocarcinoma.
    • A subsequent CT scan for staging of the gastric cancer in September showed that the cancer is at stage T3N1M0, which corresponds to stage III disease. The cancer involves the gastric antrum wall but does not penetrate the serosa or adjacent structures. There are metastases to one to two regional lymph nodes, but no evidence of distant metastasis. Therefore, laparosocpe D2 subtotal gastrectomy was suggested. However, status post radical D2 subtotal gastrectomy and cholecystectomy and Braun’s anastomosis on 2023/09/14. ECOG:1. Port A inserted thro’ left cephalic vein on 2023/10/18.
    • This time, admission for bone scan (for right low rib pain) and C1 FOLFOX.
  • Course of inpatient treatment
    • After admitted, bone scan was done on 11/08 and shows 1. Faint hot spots in both rib cages, cancer with early bone mets may be considered, suggesting follow-up with bone scan in 3 months for further evaluation. 2. Suspected benign lesions in the maxilla, mandible, sternum, some C-, T- and L-spine, sacrum, bilateral shoulders, elbows, S-I joints, and hips.
    • Adjuvent chemotherapy with FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) from 2023/11/09~2023/11/11.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/11/11 and admission was arrange later.
  • Discharge prescription
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Kludone (gliclazide 60mg) 0.5# QD
    • MgO 250mg 1# QID
    • Stilnox (zolpidem 10mg) 1# HS
    • Stogamet (cimetidine 300mg) 1# TID
    • Through (sennoside 12mg) 2# HS
    • Tulip (atorvastatin 20mg) 1# HS
    • Uformin (metformin 500mg) 1# BIDCC
    • Bisadyl supp (bisacodyl 10mg/pill) 1# Q3D RECT
• 2023-10-19 SOAP Hemato-Oncology Xia HeXiong
  • P
    • Admission for bone scan (for right low rib pain) and FOLFOX
    • Plan: FOLFOX x 6 -> CCRT -> FOLFOX x 6
  • Prescription
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Megest (megestrol 40mg/mL) 10mL QD
    • Bisadyl supp (bisacodyl 10mg/pill) 1# Q3D RECT
• 2023-09-11 ~ 2023-10-05 POMR General and Gastrointestinal Surgery Chen YenZhi
  • Discharge diagnosis
    • Adenocarcinoma of gastric antrum, pT3N2M0 stage IIIA, status post radical D2 subtotal gastrectomy and cholecystectomy and Braun’s anastomosis on 2023/09/14. ECOG:1
  • CC
    • Epigastralgia or acid reflux sensation for months.
  • Present illness
    • This 73-year-old male with past history of type 2 diabetes with medications control. He also sufferred from presented with progressive constipation lasting 1-2 years, experiencing stool every third day. He has no history of bloody or tarry stools, no small caliber stool, but reported a sensation of tenesmus. No significant weight loss was noted, and there is no family history of gastrointestinal (GI) cancer.
    • According for his statement, his national health insurance fecal immunochemical test (NHI FIT) in 2023 was negative. On examination in July 2023, the decision was made to arrange for an IVG CFS in late A colonoscopy in 202308 showed the presence of several polyps, which were removed. One was in the ascending colon, two in the hepatic flexure, and one in the transverse colon.
    • By late 202308, the patient had added complaints of occasional epigastric pain and acid reflux for months. An EGD was ordered. The gastroscopy showed possible reflux esophagitis, a lesion in the upper esophagus, a suspected gastric cancer in the antrum of the stomach, and superficial gastritis. A biopsy was taken from the gastric lesion. The clostridium-like organism (CLO) test was negative, implying the absence of Helicobacter pylori infection. The biopsy results from the stomach confirmed a poorly differentiated adenocarcinoma.
    • A subsequent CT scan for staging of the gastric cancer in September 2023 showed that the cancer is at stage T3N1M0, which corresponds to stage III disease. The cancer involves the gastric antrum wall but does not penetrate the serosa or adjacent structures. There are metastases to one to two regional lymph nodes, but no evidence of distant metastasis. Therefore, laparosocpe D2 subtotal gastrectomy was suggested and scheduled. Due to the above reasons, the patient was admitted for scheduled surgery and further management.
  • Course of inpatient treatment
    • On admission, the patient underwent a thorough pre-operative survey which showed no abnormalities. Subsequently, he successfully underwent a radical D2 subtotal gastrectomy with Braun’s anastomosis and cholecystectomy on 2023-09-14.
    • After the surgery, we closely monitored the patient’s recovery and administered empiric antibiotics, nutrition support via partial parenteral nutrition (PPN), and analgesic agents. We also observed poor bowel movement with minimal flatus and substantial gastric juice drainage via NG tube. To promote bowel movement, we administered Zirocin and Promeran from 2023-09-19 and supported nutrition via total parenteral nutrition (TPN) from 2023-09-22.
    • A small bowel series conducted on 20th September showed no abnormal bowel loop displacement or ileus pattern. Despite initial struggles with the NG tube, the patient later tolerated it well with intermittent clamping. We continued the current treatment, maintaining close monitoring of vital signs.
    • As of today’s date (2023-10-01), some metrics show slight fluctuations from their initial results at admission, but none are cause for concern. This includes liver function tests, renal function tests, a slight decrease in albumin levels, and a slight increase in Creatinine values, reducing the eGFR. However, the blood picture remained stable with CBC values within normal range. White blood cells count increased to 10.26 on 2023-09-25 likely due to the surgical procedure and has returned to 3.71 as of 2023-10-02.
    • The patient remains on a comprehensive medication management plan including pain management (Acetaminophen asneeded), GI care (Rabeprazole), nutrition support (SmofKabiven),electrolytes and trace elements replenishment, and hydration (Saline 0.9%).
    • In this weeks started from 2023/10/01. His had fair acitivity and he started soft diet on 2023/10/03. He denied nausea/vomiting, abdominal pain. And we removed two JP drain on 2023/10/02 and 2023/10/04. Under relative stable condition, he was discharged on 2023/10/05 and will follow up at our OPD next week.
  • Discharge prescription
    • Zirocin (azithromycin 250mg) 1# QD
    • Through (sennoside 12mg) 2# HS
    • Stilnox (zolpidem 10mg) 1# HS
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Harnaldge (tamsulosin 0.4mg) 1# QDAC
    • Mopride (mosapride citrate 5mg) 1# TID
    • Acetal (acetaminophen 500mg) 1# PRNQ6H

[consultation]

• 2024-02-16 Radiation Oncology
  • Q
    • This hospitalization is for the sixth FOLFOX treatment, followed by CCRT.
    • This 75-year-old male with past history of type 2 diabetes with medications control. He also sufferred from presented with progressive constipation lasting 1-2 years, experiencing stool every third day. He has no history of bloody or tarry stools, no small caliber stool, but reported a sensation of tenesmus. No significant weight loss was noted, and there is no family history of gastrointestinal (GI) cancer.
    • According for his statement, his national health insurance fecal immunochemical test (NHI FIT) in 2023 was negative. On examination in July 2023, the decision was made to arrange for an IVG CFS in late A colonoscopy in 202308 showed the presence of several polyps, which were removed. One was in the ascending colon, two in the hepatic flexure, and one in the transverse colon. By late 202308, the patient had added complaints of occasional epigastric pain and acid reflux for months.
    • An EGD was ordered. The gastroscopy showed possible reflux esophagitis, a lesion in the upper esophagus, a suspected gastric cancer in the antrum of the stomach, and superficial gastritis. A biopsy was taken from the gastric lesion. The clostridium-like organism (CLO) test was negative, implying the absence of Helicobacter pylori infection.
    • The biopsy results from the stomach confirmed a poorly differentiated adenocarcinoma. A subsequent CT scan for staging of the gastric cancer in September 2023 showed that the cancer is at stage T3N1M0, which corresponds to stage III disease. The cancer involves the gastric antrum wall but does not penetrate the serosa or adjacent structures.
    • There are metastases to one to two regional lymph nodes, but no evidence of distant metastasis. Therefore, laparosocpe D2 subtotal gastrectomy was suggested. However, status post radical D2 subtotal gastrectomy and cholecystectomy and Braun’s anastomosis on 2023/09/14.
    • Port A inserted thro’ left cephalic vein on 2023/10/18. The chemotherapy with FOLFOX on 2023/11/09 (C1D1), 2023/12/04 (C1D15), 2023/12/25 (C2D1), 2024/01/15 (C2D15). This time, admission for chemotherapy with FOLFOX on 2024/02/15 (C3D15).
  • A
    • This 75 y/o male patient was diagnosed of gastric ca., cT3N1M0, s/p resection and D2 dissection on 2023-09-14. pT3N2(cM0). s/p FOLFOX x6.
    • Adjuavnt CCRT is indicated. CT-simulation will be arranged on 2024/02/29. Plan to deliver 45 Gy/ 25 fx to the preOP gastric tumor bed and adjacent lymphatic drainage area. RT will start around 2024/03/04 or 03/05. Thank you very much.

[surgical operation]

• 2023-09-14
  • Surgery
    • radical D2 subtotal gastrectomy
    • cholecystectomy
    • Braun’s anastomosis
  • Finding
    • cT4aN2M0
    • distal gastric tumor with serosa involve
    • no peritoneal seeding
    • LN enlarge at station 4 and 6

[radiotherapy]

• 2024-03-04 ~ - RT to the remnant stomach and adjacent lymphatic drainage area: 43.2 Gy/ 24 fx.

[chemotherapy]

• 2024-06-24 - leucovorin 300mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2024-06-03 - leucovorin 300mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2024-05-17 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2024-04-25 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2024-04-01 - [leucovorin 400mg/m2 675mg NS 250mL 24 + fluorouracil 600mg/m2 1000mg NS 250mL 24hr] D1-2 (CCRT)

• 2024-03-08 - [leucovorin 400mg/m2 675mg NS 250mL 24 + fluorouracil 600mg/m2 1000mg NS 250mL 24hr] D1-2 (CCRT)

• 2024-02-15 - oxaliplatin 65mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + hydroxocobalamin 1mg IM (Vit B12, post oxa)

• 2024-02-01 - oxaliplatin 65mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + hydroxocobalamin 1mg IM (Vit B12, post oxa)

• 2024-01-15 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + hydroxocobalamin 1mg IM (Vit B12, post oxa)

• 2023-12-25 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + hydroxocobalamin 1mg IM (Vit B12, post oxa)

• 2023-12-04 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-11-09 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-06-25

[enlarged lymph nodes on CT scan]

During this hospitalization, the patient’s blood glucose levels ranged from approximately 120 to 170 mg/dL, which is elevated but still acceptable. A CT scan on 2024-06-06 showed enlarged lymph nodes (up to 1.5 cm) in the mediastinum that were not previously described in earlier imaging and should be followed up. Except for pancytopenia, the lab results on 2024-06-24 were generally good. No medication discrepancies were identified.

2024-04-02

[reconciliation]

Laboratory results from 2024-04-01 were grossly normal, revealing no evidences that would prevent the administration of chemotherapy as part of the CCRT plan. Additionally, a review of medications found no discrepancies.

2024-03-11

[leukopenia trend with FOLFOX - CCRT considerations for immune function]

Leukopenia episodes (WBC < 4K/uL) were observed before and during the 6 administrations of the FOLFOX regimen from 2023-11-09 to 2024-02-16, with a slowly declining trend. Therefore, the influence of FOLFOX on leukopenia cannot be excluded.

• 2024-03-08 WBC 2.00 x10^3/uL
• 2024-02-29 WBC 3.78 x10^3/uL
• 2024-02-15 WBC 2.40 x10^3/uL
• 2024-01-31 WBC 3.21 x10^3/uL
• 2024-01-15 WBC 2.77 x10^3/uL
• 2024-01-02 WBC 4.49 x10^3/uL
• 2023-12-25 WBC 2.36 x10^3/uL
• 2023-12-04 WBC 3.01 x10^3/uL
• 2023-11-06 WBC 3.54 x10^3/uL
• 2023-10-05 WBC 3.10 x10^3/uL
• 2023-10-02 WBC 3.71 x10^3/uL

LV + 5-FU for CCRT was administered on 2024-03-08 and 2024-03-09, but its effect is unlikely to have influenced the laboratory data on 2024-03-08. G-CSF has not been used since 2024-03-08. It is recommended to use G-CSF prior to CCRT if leukopenia is expected to compromise immunity.

2024-01-16

Lab testing demonstrated a blood ferritin level of 18.9 ng/mL (2024-01-15), which falls below the normal range. Therefore, initiating oral iron supplementation may be beneficial to maintain adequate iron stores in this patient.

2023-12-26

[reconciliation]

Leukopenia was identified in lab results on 2023-12-25. Consequently, the 5-FU bolus was omitted, and the Oxaliplatin dose was adjusted to 75mg/m2 from the originally planned 85mg/m2 for this chemotherapy session.

• 2023-12-25 WBC 2.36 x10^3/uL
• 2023-12-04 WBC 3.01 x10^3/uL
• 2023-11-06 WBC 3.54 x10^3/uL
• 2023-10-05 WBC 3.10 x10^3/uL
• 2023-10-02 WBC 3.71 x10^3/uL
• 2023-09-28 WBC 5.49 x10^3/uL

Despite vitamin B12 supplementation during this chemotherapy session, the patient’s mean corpuscular volume (MCV) on 2023-12-25 (79fL) remained below the lower limit of normal. This suggests mild microcytic anemia, potentially due to iron deficiency. Iron supplementation could therefore be helpful to raise the iron content of RBC, addressing this issue.

2023-12-05

2023-12-04 HGB 11.5 g/dL < 13.5 and MCV 77.8 fL < 80. It is suggested to consider some vitamin and mineral supplements:

• Vitamin B12: Absorption of vitamin B12 can be significantly affected after gastrectomy because the stomach produces intrinsic factor, which is essential for its absorption. Vitamin B12 injections or high-dose oral supplements might be necessary.
• Iron: Iron deficiency is common, particularly if the duodenum is bypassed. Iron supplements might be needed, and it’s important to monitor iron levels regularly.

700577401

240624

[exam findings] (not completed)

• 2021-12-20 EGD
  • Diagnosis:
    • Reflux esophagitis LA grade A(minimal)
    • Superficial gastritis, antrum and body, s/p CLO test
    • Gastric erosions, low body
  • CLO test: Negative
  • Suggestion: Pursue CLO test result
• 2021-12-20 SONO - abdomen
  • Hepatic cyst
  • Bilateral hydronephrosis
  • Suspect right renal stones
• 2021-12-14 C-spine AP + Lat.
  • Increased kyphosis of cervical spine.
  • Degenerative change of the spine with marginal spur formation.
• 2021-09-07 CT - chest
  • stationary enlarged Rt paratracheal space LNs as compared with previous CT on 2021/04/20, may be post treatment change.
  • presence mild fibrosis in LLL and RLL, stationary.
• 2021-07-20 Mammography
  • Impression: Benign calcifications in bilateral breasts. Suggest regular screening.
  • BI-RADS: Category 2: benign findings - annual screening.
• 2021-07-20 SONO - gynecology
  • Uterine myoma
• 2021-04-20 CT - chest
  • stationary enlarged Rt paratracheal space LN as compared with previous CT on 2020/12/15, may be post treatment change.
  • presnece fibrosis in LLL and RLL, stationary.
• 2021-04-06 SONO - gynecology
  • Uterine myoma
• 2020-12-15 CT - chest
  • Indication: A case of Hodgkin lymphoma post chemtoehrapy. Evaluation tumor status
  • Comparison: prior CT dated on 2020/08/28
    • Lungs:
      • extensive, Lt greater than Rt, reticular and patchy ground-glass opacities in LLL and RLL.
      • normal appearance of LUL, RUL, and RML.
      • as compared with previous CT study.
    • Mediastinum: no interval change in size a slightly enlarged LNs in Rt paratracheal space as compared with previous CT on 2020/08/28
    • Hila: no enlarged LN or mass.
    • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no effusion or nodule.
    • Chest wall and lower neck: no enlarged LN or mass
    • Visible abdominal contents: a 5 mm cyst in S7 of liver.
    • Visualized bones: unremarkable.
  • Impression:
    • stationary slightly enlarged Rt paratracheal space LN as compared with previous CT on 2020/08/28, may be post treatment change.
    • fibrosis in LLL and RLL.
• 2020-08-28 CT - chest
  • Indication: mediastinal Hodgking’s lymphoma.
  • Chest CT with and without IV contrast enhancement shows:
    • Small lymph nodes are found at AP window, paratracheal and subcarina region. In comparison with CT dated on 2020-05-12, these lymph nodes decreased in size.
  • Imp:
    • Small lymph nodes are found at mediastinum. Slightly in regression.
• 2020-06-05 L-spine flex. & ext. (including sacrum)
  • There is no evidence of spondylolisthesis or subluxation.
• 2020-06-05 C-spine flex. & ext. view
  • No obvious fracture.
  • Presence of retrolordotic curve change of the spine.
• 2020-05-29 SONO - gynecology
  • Uterine myoma
  • Endometrial thickening (em 9.9mm)
• 2020-05-12 CT - chest
  • Findings: Comparison: prior CT dated on 2019/12/12 (other hospital).
    • Lungs and large airways:
      • linear opacities in LLL.
      • normal appearance of LUL and Rt lungs.
      • as compared with previous CT study.
    • Mediastinum: decreased in size enlarged LNs in Rt paratracheal space (14mm in short axis of the largest LAP) compared with previous CT on 2019/12/12
    • Hila: no enlarged LN or mass.
    • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no effusion or nodule.
    • Chest wall and lower neck: unremarkable.
    • Visible abdominal contents: normal appearance of gallbladder.unremarkable of the liver, spleen, adrenal glands, pancreas, and kidneys. bile ducts: No dilatation. no enlarged lymph node.
    • Visualized bones: unremarkable.
  • Impression:
    • small residual mediastinal LAP (14mm in short axis of the largest LAP), partial response of tumor to C/T based on CT criteria.
• 2020-04-24 CXR
  • Soft tissue bulging mass in right upper mediastinum shows partial resolving that is c/w CT findings of soft tissue mass in PTRC space Status post C/T with partial response .
• 2020-03-05, -02-13, -02-10 CXR
  • Soft tissue bulging mass in right upper mediastinum is noted that is c/w CT findings of soft tissue mass in PTRC space.
• 2020-02-14 EGD
  • Superficial gastritis
• 2020-02-13 PET
  • Some glucose hypermetabolic lesions in the upper mediastinum and in the upper abdominal left paraaortic region, compatible with lymphoma involving lymph nodes on both sides of the diaphragm (Deauville score 5).
  • A mild glucose hypermetabolic lesion in the right lateral chest wall. Post-operative inflammation may show this picture. Please correlate with other clinical findings for further evaluation.
• 2020-02-12 Patho - bone marrow biopsy
  • Bone marrow, iliac, suspicious for Hodgkin lymphoma (NTUH), biopsy — Negative for malignancy.
  • IHC stains: CD3 (+, 5-10%), CD20 (+, 5-10%), CD30 (-), CD15 (equivocal), bcl-2 (-).
• 2019-07-27 Surgical Pathology Level IV
  • Endometrium, D&C — Compatible with endometrial polyp
  • The sections show a picture compatible with endometrial polyp, composed of tubular glands, abundant cellular stroma, and thick-walled blood vessels. Fragments of cervical squamous epithelium without remarkable change can be found also.
• 2019-06-24 MRI - brain
  • C/W bilateral trigeminal neuromas, stationary as compared with MRI on 20170823.
  • Partial empty sella.
  • Leukoaraiosis.
  • Left maxillary sinusitis.
• 2017-08-23 MRI - brain
  • Bilateral trigeminal neuromas, stationary as compared with MRI on 20150205.

[immunochemotherapy]

• 2024-06-22 - rituximab 375mg/m2 572mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg TID PO D2-6 (R-COP Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-05-27 - rituximab 375mg/m2 578mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg TID PO D2-6 (R-COP Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-05-06 - rituximab 375mg/m2 588mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg TID PO D2-6 (R-COP Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2020-08-11 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-07-24 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-07-10 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-06-26 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-06-12 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-05-29 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-05-15 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-04-24 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-04-10 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-03-20 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-03-06 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2020-02-21 - doxorubicin 25mg/m2 38mg NS 50mL 10min + bleomycin 10mg/m2 15mg NS 50mL 10min + vinblastine 6mg/m2 9mg NS 50mL 10min + dacarbazine 375mg/m2 570mg NS 500mL 3hr (ABVD)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL

700369852

240621

[exam findings]

• 2024-05-02 RAS + BRAF
  • Cellblock No. S2024-06725
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2024-04-03 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Metastatic adenocarcinoma, consistent with colorectal primary
  • The specimen submitted consists of a strip of yellow gray soft tissue, labeled liver, measuring 0.7 x 0.1 x 0.1 cm. All for section.
  • The sections show a picture of adenocarcinoma, composed of nests and cords of columnar neoplastic cells with focal glandular differentiation, embedded in fibrous stroma.
  • IHC, the tumor cells show: CK7(-), CK20(+), and CDx2(+). The finding is consistent with metastatic colorectal adenocarcinoma.
• 2024-03-25 PET
  • No previous study for comparison.
  • Increased FDG uptake in a focal lesion at the rectum, compatible with recurrent tumor s/p treatment.
  • Increased FDG uptake in the right lobe of the liver, highly suspected rectal cancer with liver metastasis, suggesting biopsy for investigation.
  • Increased FDG accumulation in bilateral kidneys, ureters, and colon, probably physiological uptak of FDG.
  • Recurrent rectal cancer s/p treatment with highly suspected liver metastasis, yrcTxNxM1a, stage IVA (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2024-03-12 MRI - pelvis
  • History and indication: Rectal flat tumor s/p TAMIS + Anoplasty on 20230208
  • With and without contrast MRI of pelvis revealed:
    • Wall thickening of rectum.
    • Poor enhancing nodules (0.9cm, 1.3cm) in S7 of liver.
    • Left renal cyst (1.3cm).
    • Enlargement of prostate.
    • S/P cholecystectomy.
  • IMP:
    • Wall thickening of rectum r/o tumor recurrence.
    • Poor enhancing nodules (0.9cm, 1.3cm) in S7 of liver r/o metastases.
• 2024-02-01 Sigmoidoscopy
  • Rectal cancer s/p local excision with local recurrence, s/p CCRT with tumor regression
• 2023-12-08 ECG
  • Sinus tachycardia
  • Junctional ST depression, probably normal
  • Borderline ECG
• 2023-12-05 ECG
  • Sinus tachycardia
  • Possible Inferior infarct, age undetermined
• 2023-11-10 MRI - pelvis
  • Indication: Rectal flat tumor s/p TAMIS + Anoplasty on 20230208 pT2N0M0; stage I R/O local recurrence
  • Findings:
    • There is wall thickening at the right lateral anterior aspect of the rectum (Srs:8 Img:20-24), measuring 3.2 x 1.6 cm.
      • Recurrent adenocarcinoma (T3) of the rectum is highly suspected.
      • In addition, there is a soft tissue lesion in right lateral perirectal space, measuring 1.6 x 0.8 cm in size, that may be tumor direct invasion right perirectal space (Srs:8 Img:24).
      • The differential diagnosis includes metastatic node.
    • S/P cholecystectomy.
    • A renal cyst measuring 1 cm in left middle pole is noted.
    • Abdominal aorta shows atherosclerosis and ectasia 2 cm.
  • IMP:
    • Recurrent adenocarcinoma (T3) of the rectum is highly suspected.
    • In addition, there is a soft tissue lesion in right lateral perirectal space, measuring 1.6 x 0.8 cm in size, that may be tumor direct invasion right perirectal space (Srs:8 Img:24).
    • The differential diagnosis includes metastatic node.
• 2023-11-07 Patho - colorectal polyp
  • Colorectum, rectum, 8 cm above anal verge, anterior, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
• 2023-11-07 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P rectal operation.
    • S/P cholecystectomy.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • S/P rectal operation. No evidence of tumor recurrence.
• 2023-11-07 Colonoscopy
  • Findings
    • The scope reach the cecum under good colon preparation.
    • One mass was noted in the rectum ( 8 cm from anal verge) ; anterior
    • Management: Biopsy
      
  • Diagnosis:
    • Rectal cancer s/p TAMIS with local recurrence
• 2023-08-08 SONO - abdomen
  • Post cholecystectomy

[immunochemotherapy]

• 2024-06-20 - cetuximab 400mg/m2 600mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-31 - cetuximab 400mg/m2 600mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-09 - irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-28 - irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-06-21

[Improved CA199 Marker Suggests Potential Treatment Benefit

]

A negative RAS/BRAF test (2024-05-02) suggests potential benefit from EGFRi therapy.

CA199 Marker: While the CA199 tumor marker level showed an increase in May, it appears to have decreased somewhat recently.

• 2024-06-14 CA-199 (NM) 113.712 U/ml
• 2024-05-21 CA-199 (NM) 197.230 U/ml
• 2024-05-03 CA-199 (NM) 115.435 U/ml
• 2024-03-29 CA-199 (NM) 27.080 U/ml
• 2024-03-19 CA-199 (NM) 24.680 U/ml
• 2024-02-23 CA-199 (NM) 34.449 U/ml
• 2024-01-19 CA-199 (NM) 16.926 U/ml
• 2024-01-03 CA-199 (NM) 20.681 U/ml
• 2023-11-10 CA-199 (NM) 29.448 U/ml

Possible Treatment Effect: This decline could potentially indicate positive effects from the FOLFIRI plus Erbitux treatment regimen being administrated on 2024-05-09 and 2024-05-31.

Lab results on 2024-06-20 revealed mild hyperbilirubinemia. However, this finding is unlikely to prevent the patient from proceeding with the planned therapy.

No medication discrepancies were found.

700550666

240621

[exam findings]

• 2024-05-06 Small Intestine
  • Small bowel series revealed:
    • S/P operation.
    • No abnormal bowel loop displacement.
    • The passage time is about 120 minutes.
• 2024-05-03 KUB
  • Diffuse small bowel ileus.
  • S/P drainage tubes in the pelvic cavity.
• 2024-04-30 Patho - ovary (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Ovary, right, BSO — Serous carcinoma, high grade
    • Lymph nodes, pelvic and para-aortic, bil., BPLND + paraarotic LN dissection — Metastatic carcioma (1/47)
    • Pathology stage: ypT2aN1aM1; stage IVB; FIGO stage IVB
  • MACROSCOPIC EXAMINATION
    • Procedure: ATH+BSO+infracolic omentectomy+BPLND+para-aortic LN dissection
    • Specimen Size: 6.5 x 5.2 x 4.1 cm (Rt ovary), 5.5 x 1.7 cm (Rt tube), 2.1 x 1.6 x 1.1 cm (Lt ovary), 4.5 x 0.7 cm (Lt tube), 7.0 x 6.0 x 4.2 cm (uterus), 17 x 7.0 x 2.2 cm (omentum)
    • Specimen Integrity
      • Right ovary: Capsule intact
      • Left ovary: Capsule intact
      • Right fallopian tube: Serosa intact
      • Left fallopian tube: Serosa intact
    • Tumor Site: Right ovary
    • Ovarian Surface Involvement: Present
    • Fallopian tube Surface Involvement: Present in right tube
    • Tumor Size: 6.5 x 5.2 x 4.1 cm
    • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic    - Representative parts are taken for section and labeled as: A1-A2= left iliac LNs, B 1-B2= left obturator LNs, C= right iliac LNs, D1-D3= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1= cervix, G2-G3= uterine corpus, G4= parametrium, G5= left ovary, G6= left fallopian tube, H1-H4= right ovarian tumor, H5-H7= right fallopian tube, I1-I2= omentum.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Serous carcinoma
    • Histologic grade: High grade
    • Other Tissue/Organ Involvement: Uterine parametrium and right fallopian  tube
    • Peritoneal Fluid: Not submitted
    • Chemotherapy response score (CRS): CRS2 (moderate response)
    • Regional Lymph Nodes: Metastatic carcinoma (1/47)
      • number of lymph node examined: 5 (left iliac), 12 (left obturator), 2 (right iliac), 16 (right obturator), 7 (left para-aortic) and 5 (right para-aortic)
      • number with metastases ＞10 mm: 0
      • number with metastases 10 mm or less: 1 (right iliac)
      • number with isolated tumor cells (≦0.2mm): 0
    • Pathologic Stage
      • Primary Tumor: ypT2a (tumor extension and/or implants on the uterus and fallopian tube)
      • Regional Lymph Nodes: ypN1a (metastasis up to 10 mm)
      • Distant Metastasis: M1
    • FIGO Stage: Stage IVB
    • Lymphovascular invasion: Abesnt
    • Perineural invasion: Absent
    • Additional Pathologic Findings:
      • Cervix: Chronic cervicitis with Nabothian cysts
      • Endometrium: Endometrial polyp
      • Myometrium: Leiomyoma
      • Ovary, left: No remarkable change
      • Fallopian tube, left: Partubal cysts
      • Omentum: No remarkable change
• 2024-01-26 Patho - Omentum biopsy
  • PATHOLOGIC DIAGNOSIS
    • Ovary, right? pelvic mass biopsy — Serous carcinoma, high-grade
    • Omentum, omentun biopsy — Free of carcinoma
  • MACROSCOPIC EXAMINATION
    • The specimen is submitted in two parts. Part (1) consists of  a pinkish gray soft tissue, labeled “ovarian”, received for frozen section, measuring 1.2 x 1.0 x 0.3 cm. All for frozen section, then totally embedded for paraffin dsection as: F2024-00027FS. (2) a piece of yellowish greasy adipose tissue, labeled omentum, measuring 10.8 x 5.5 x 1.5 cm. On section, no focal lesion can be found. Representative parts are taken for section as: S2024-01955A1-A2.
  • MICROSCOPIC EXAMINATION
    • The sections of “ovarian” show a picture of high-grade serous carcinoma, composed cof pleomorphic rumor cells arranged in solid, glandular and subtle papillary patterns. IHC, tumor cells reveal: PAX8(+), WT1(+), PR(-), Napsin A(-) and p53(wide type).        - The sections of “omentum” shows focal hemorrhage and neutrophil infiltration. There is no evidence of malignancy in the sections examined.
• 2024-01-26 Patho - Colon biopsy
  • DIAGNOSIS:
    • Colorectum, sigmoid, 20 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: PAX-8 (+); CK7 (+), CK20 (-), favor ovarian orign and dis-favor colonic origin.
  • GROSS DESCRIPTION:
    • Specimen submitted in formalin consists of 1 pieces of tan, irregular  tissue measuring 0.2 x 0.1 x 0.1  cm. All for section in one cassette.
  • MICROSCOPIC DESCRIPTION:
    • Section shows pieces of colonic tissue with poorly differentiated carcinoma in the submucosa. IHC stains: PAX-8 (+); CK7 (+), CK20 (-), favor ovarian orign and dis-favor colonic origin.
• 2024-01-19 CT - abdomen
  • Findings:
    • There is a lobulated heterogeneous mass in the pelvis, with mixed solid and cystic component, 13 in size (the largest dimension), with suggestive direct invasion the uterus.
      • Malignant ovarian cancer (T2a) is highly suspected.
      • In addition, there is right side hydroureteronephrosis and delayed contrast excretion of right kidney that is c/w pelvic mass with passive compression right M/3 ureter.
    • There are several enlarged nodes in the pelvis mesentery, < 1 cm (the largest dimension).
      • Regional metastatic nodes (N1a) are highly suspected.
    • There are few enlarged nodes in aortocaval space (up to 2.5 x 1.2 cm) that is c/w non-regional metastatic nodes (M1a).
    • There is a poor enhancing lesion 0.7 cm in S6 of the liver.
      • The differential diagnosis includes metastasis and cyst.
      • Please correlate with sonography and MRI.
    • There is smudgy appearance of the omentum at the pelvis.
      • The differential diagnosis includes carcinomatosis and reactive change.
    • There is a homogeneous enhancing mass 4.4 cm in the uterus that is c/w myoma.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T2a (T_value) N:N1a (N_value) M:M1b (M_value) STAGE:IVB (Stage_value)
• 2024-01-16 SONO - gynecology
  • R/O Huge pelvis mass: 133x132mm
  • Uterine myoma
  • IUD in situ
  • Ascites

[MedRec]

• 2024-02-22 ~ 2024-02-27 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Malignant neoplasm of right ovary
    • Hypertension
    • hypercholesterolemia
  • CC
    • Scheduled admission to oncology ward for neo-adjuvent chemotherapy
  • Present illness
    • Dx
      • Right ovarian serous carcinoma, high-grade (biopsy on 20240126), stage IV (T4N1M1), with sigmoid colon metastasis (biopsy on 20240126), with metastatic lesions such as regional metastatic lymph nodes and aortocaval space lymph node (PET scan on 20240216), status post exploratory laparotomy on 20240126, status post bilateral DBJ stent insertion on 20240126, status post port-A insertion on 20240130, status post whole body PET scan on 20240216.
    • Hx
      • Hypertension
      • Hypercholesterolemia
      • HBV carrier, under medication of Baraclude
  • Course of inpatient treatment
    • A 62-year-old female patient, with a confirmed diagnosis of high-grade serous carcinoma of the right ovary, at stage IV with T4N1M1 status, was hospitalized in our oncology ward, having undergone various interventions including exploratory laparotomy, bilateral DBJ stent insertion, and port-A insertion for chemotherapy access. Her initial presentation highlighted severe symptoms, including a marked increase in urinary frequency, unmanageable abdominal bloating, and a remarkably high CA-125 level indicative of her ovarian malignancy’s aggressive nature.
    • Her current hospitalization, initiated on 20240222 and ongoing, is primarily for the administration of neo-adjuvant chemotherapy to manage her advanced-stage cancer, which includes regional lymph node metastasis and sigmoid colon involvement confirmed through biopsies and PET scans.
    • Since admission, her complex management has included anticoagulation therapy for elevated D-dimer levels, symptomatic treatment for gastrointestinal symptoms, and the implementation of the Placitaxel + carboplatin chemotherapy regimen starting on 20240226.
    • Despite the severity of her condition, her clinical status has shown a degree of stability post-chemotherapy, with a notable decrease in D-dimer levels from > 10000 to 7462 ng/mL(FEU), a mild improvement in her anemia from a hemoglobin level of 10.1 to 9.8 g/dL, and minimal reduction in CA-125 levels.
    • Her vital signs have remained stable, and she has been able to maintain self-care. The consistent focus of care has been on diligent monitoring of vitals, symptom management, therapy adherence, and providing capable support to address arising complications and the psychological burden of the disease.
    • The patient has withstood the first cycle of chemotherapy without significant immediate adverse effects and her continued treatment progress necessitates close observation, including regular lab monitoring especially for CA-125, to guide ongoing treatment, potential surgical intervention post-chemotherapy, and management of her bilateral DBJ stents to preserve renal function.
    • Due to the relatively stable condition, the patient was able to be discharged and OPD follow up was scheduled
  • Discharge prescription
    • Crestor (rosuvastatin 10mg) 1# QD
    • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
    • MgO 250mg 1# TID
    • Morcasin (sulfamethoxazole 400mg, trimethoprim 80mg) 2# BID
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2024-01-24 ~ 2024-02-02 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Ovarian cancer post Exploratory laparotomy pelvic mass biopsy on 2024/01/26
    • High-grade ovarian serous carcinoma, stage III at least.
    • Abdominal pain
  • CC
    • Urinary frequency for more than half year   
  • Present illness
    • This is a 62-year-old married female, G4P1AA3, with Last menstrual period: Menopause (52 year old). Her menstrual cycle was as follows: interval/duration: 28/5 days, Amount: moderate. She had HTN and was under medical control.
    • This time, she suffered from urinary frequency for more than half year. At beginning she had nocturia for 4 times/night, now she urinate 1 time/hr. There was no urgency, dysuria, constipation, or diarrhea. She also complained about abdominal bloating for one month and didn’t improve after famotidine. She visited GI OPD at Taipei City Hospital at first, and lab data showed elevated CA-125 (6467.0 U/ml), so she went to our OPD for help. Her CA-125 elevated (15477.4 U/ml).
    • Her GYN sonar was done and revealed myoma: 3.6x3.1cm, 2.5x2.0cm, 2.4x1.3cm; IUD in situ; CUL-DE-SAC: with fluid; R/O Huge pelvis mass: 13.3x13.2cm.
    • Abdominal CT showed: 1. Malignant ovarian cancer is highly suspected. 2. Regional metastatic nodes, non-regional metastatic nodes, and liver metastasis is highly suspected.
    • Under the impression of uterine myoma with ovarian mass, she was admitted of surgical intervention. Therefore she was admitted for TAH + BSO on 2024/01/26.
  • Course of inpatient treatment
    • The patient was admitted on 2024/01/24. The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey.
    • The colonoscopy showed suspected ovarian cancer with sigmoid invasion, partial colonic obstruction. Before operation, we consult CRS for combine surgery.
    • She underwent exploratory laparotomy post pelvic mass biopsy on 2024/01/26. arrange FDP-Ddimer: 8699 ng/mL, with clexan 60 mg QD injection.
    • Her lab data on 2024/01/30 and 02/02 also showed elevated elevated D-dimer and Hypokalemia.
    • Surgical pathology revealed right ovarian high-grade serous carcinoma, with stage III at least. The postoperative course was smooth and she recovered well. Eating and self voiding, defecation were all ok. The Gyn tumor conference suggest furrher chemotherapy for her after operation.
    • The CVP line was remove on 2023/02/02. Plavix F.C. 75mg/tab 1 tab QD for FDP-Ddimer: 7271 ng/mL. She is discharged on 2024/02/02.
    • Her follow up appointment hemo-oncology clinic and GU (Removed double-J ureteral stent) and GS (for port-A) and GYN arrange PET (Positron Emission Tomography) is scheduled.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • MgO 250mg 2# QID
    • Plavix (clopidogrel 75mg) 1# QD
    • Nexium (esomeprazole 40mg) 1# QDAC

[consultation]

• 2024-05-03 Infectious Disease

• 2024-04-29 Urology

• 2024-02-23 Urology

• 2024-02-01 Hemato-Oncology

• 2024-01-25 Colorectal Surgery

• 2024-01-24 Urology

[surgical operation]

• 2024-01-30
  • Operation
    • Port-A (47080B)
    • Fluoroscopy (32026C)         
  • Finding:
    • Insertion via left cephalic vein.
    • Port: Polysite, 3007, 7Fr,
    • Fluorosopy: catheter tip in SVC above RA         
  • Procedure: 　 　Under LA, prepared the OP field as usual. Made a skin incision over left anterior chest wall. Made vascular exploration of the vein. Commenced insertion of catheter. Made fluorosocpy. Fixed the reservior over anterior chest wall. Closed the wound with 3-0 Vicryl and 5-0 Nylon.
• 2024-01-26 - Op Method:
  • bilateral DBJ stent insertion        
  • Finding:
    • Outside Mass compression at posterior wall of bladder
    • No obvious tumor was noted in bladder         
  • Procedure:
    • Under endotracheal anesthesia, the patient was placed in the lithotomy position. 21 Fr cystoscopy was inserted. After retrograde insertion of guidewire under fluroscopy, bilateral 6 Fr x 24 cm DBJ were inserted smoothly. 14 Fr. Foley was inserted.         
• 2024-01-26  Op Method:
  • Diagnosis:
    • huge pelvic mass, r/o ovarian malignancy
  • Operation:
    • Exploratory laparotomy - pelvic mass biopsy         
  • Finding:
    • Uterus: adhesion to pelvic wall with some papillary lesion at posterior wall
    • RAD: about 20x 15 cm, with irregular shape and papillary mass, no rupture, adhesion to small bowel and rectum
    • LAD: grossly normal
    • CDS: obliterated with mass
    • Minimal ascites
    • Estimated blood loss: 200ml
    • Blood transfusion: nil
    • Complication: nil         
  • Procedure:
    • Put the patient on the lithotomy position, vaginal douching, and on Foley.
    • Skin disinfection with beta-iodine and skin draping.
    • Make a vertical skin incision and open the abdominal wall layer by layer.
    • Apply autoretractorand pack up the intestines to expose uterus.
    • Adhesiolysis was performed

[chemotherapy]

• 2024-06-21 - paclitaxel 175mg/m2 278mg NS 250mL 3hr + carboplatin AUC 5 430mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-05-29 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 430mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-04-09 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 430mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-03-19 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 430mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-02-26 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 430mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-06-21

[Laboratory Results Favorable for Paclitaxel and Carboplatin Treatment]

Recent lab tests on 2024-06-20 show mostly normal results, including tumor markers CA125 and CA199. This suggests no significant obstacles to proceeding with the planned fifth cycle of paclitaxel and carboplatin treatment.

A review of medication records revealed no discrepancies.

700578300

240621

[diagnosis] - 2023-03-21 admission note

• Descending colon adenocarcinoma obstruction with peritoneal seeding, lung and liver metastases, cT4aN2bM1c, stage IVC, s/p T-loop colostomy excisional biopsy of omental seeding on 2022/11/21 and palliative chemotherapy with FOLFIRI from 2022/12/02 and Target therapy with Avastin from 2022/12/16
• Unspecified viral hepatitis B without hepatic coma
• Essential (primary) hypertension

[past history]

• The patient had hypertension for 10 years ago under regular medical control, and hyperlipidemia
• History of operation:
• Myoma, s/p total hysterectomy for 20 years ago in FuYou Hospital
• T-loop colostomy excisional biopsy of omental seeding on 2022/11/21

[allergy]

• NKDA             

[family history]

• Her mother had hypertension and DM, while her father had hemorrhagic stroke
• There is no family history of cancer, mental diseases or asthma.

[exam findings]

• 2024-02-16 CT - abdomen
  • History: D-colon adenocarcinoma obstruction with peritoneal seeding, lung and liver meta, cT4aN2bM1c, stage IVC
  • Findings: Comparison: prior CT dated 2023/11/11.
    • Prior CT identified a metastasis in S6 of the liver 1 cm (Srs:7 Img:28) is noted again, increasing in size to 2 cm (Srs:303 Img:53) at the current CT that is c/w liver metastasis S/P C/T with progressive disease.
    • Prior CT identified a metastasis 1 cm in LLL of the lung is noted again, stable in size.
    • Prior CT identified omentum seeding are not noted again that also c/w carcinomatosis S/P C/T with complete response.
    • S/P left hemicolectomy, right transverse colostomy and para-stromal hernia, and S/P hysterectomy
    • Liver cysts and left renal cyst (up to 9.0cm).
    • Gallbladder stones (up to 1.9cm).
  • Impression:
    • Liver metastasis 2 cm in S6 of the liver S/P C/T show progressive disease.
• 2023-11-11 CT - abdomen
  • History and indication: D-colon adenocarcinoma obstruction with peritoneal seeding, lung and liver meta, cT4aN2bM1c, stage IVC
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Stable condition of D-colon cancer, peritoneal seeding, LNs, lung and liver metastases. Small bowel ileus. Partial consoliation at RLL.
    • Invisible uterus.
    • Liver and renal cysts (up to 9.0cm).
    • Gallbladder stones (up to 1.9cm).
  • IMP:
    • Stable condition of D-colon cancer, peritoneal seeding, LNs, lung and liver metastases. Small bowel ileus. Partial consoliation at RLL.
• 2023-11-08 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, descending colon, s/p chemotherapy, left hemicolectomy and closure of T-colostomy —- adenocarcinoma, moderately differentiated.
      • others: Transverse colon, left hemicolectomy and closure of T-colostomy — colostomy confirmed and free of tumor.
    • Resection margins: free
    • Lymph node, mesocolic, s/p chemotherapy, dissection —- metastatic adenocarcinoma (1/15), no extranodal extension.
    • Lymph node, IMA / SMA, dissection —– N/A.
    • ypT4a ypN1a (if cM1c) yPathology stage: IVC.
  • Gross Description:
    • Procedure - left hemicolectomy: 10 x 3.0 x 3.0 cm and closure of T-colostomy + lymph node dissection
    • Tumor Site - Descending colon, grossly 3.0 cm from cut end.
    • Tumor Size: 3 x 2 x 2 cm.
      
    • Macroscopic Tumor Perforation: Not identified
    • Macroscopic Intactness of Mesorectum- Incomplete
    • Sections are taken and labeled as: A1-4: tumor; A5: bilateral margins; A6-16: lymph nodes; B: Transverse colon colostomy.
  • Microscopic Description:
    • Histologic Type - Adenocarcinoma
    • Histologic Grade - G2: Moderately differentiated
    • Tumor Extension - Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
    • Margins -
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Involved
        
    • Lymphovascular Invasion: Not identified
    • Perineural Invasion: Not identified
    • Tumor Budding
      • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2) - Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: none.
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes
      • Number of Lymph Nodes Involved/Examined: s/p chemotherapy, 1/15, no extranodal extension.
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition): ypStage: IVC.
      • TNM Descriptors - y (posttreatment)
      • Primary Tumor (pT) - ypT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
      • Regional Lymph Nodes (pN) - ypN1a: One regional lymph node is positive
      • Distant Metastasis (pM) - if cM1c.
    • Additional Pathologic Findings - None identified
    • Ancillary Studies - IHC MMR- S2022-20638
• 2023-09-22 CT - abdomen
  • Findings:
    • Prior CT identified wall thickening of the D-colon is noted again, mild decreasing in size that is c/w descending colon cancer S/P C/T with stable disease.
    • Prior CT identified a metastasis 1 cm in LLL of the lung is noted again, stable in size.
    • Prior CT identified a metastasis in S6 of the liver 1.2 cm is noted again, decreasing in size to 0.6 cm and no enhancement that is c/w liver metastasis S/P C/T with near complete response.
    • Prior CT identified omentum seeding are not noted again that also c/w carcinomatosis S/P C/T with complete response.
    • S/P right transverse colostomy and para-stromal hernia,
    • S/P hysterectomy
    • Liver cysts and left renal cyst (upt o 9.0 cm).
    • Gallbladder stones (up to 1.9 cm).
  • Impression:
    • Distal descending colon cancer with lung metastasis S/P C/T show stable disease.
    • Liver metastasis S/P C/T show near complete response.
    • Omentum tumor seeing S/P C/T show complete response.
• 2023-06-23 CT - abdomen
  • Findings:
    • Prior CT identified wall thickening of the D-colon is noted again, mild decreasing in size that is c/w descending colon cancer S/P C/T with partial response.
    • Prior CT identified a metastasis 1 cm in LLL of the lung is noted again, mild decreasing in size to 0.9 cm.
    • Prior CT identified a metastasis in S6 of the liver 2.8 cm is noted again, decreasing in size to 1.2 cm and no enhancement that is c/w liver metastasis S/P C/T with near complete response.
    • Prior CT identified omentum seeding are not noted again that also c/w carcinomatosis S/P C/T with complete response.
    • S/P right transverse colostomy and para-stromal hernia,
    • S/P hysterectomy
    • Liver cysts and left renal cyst (upt o 9.0cm).
    • Gallbladder stones (up to 1.9cm).
  • Impression:
    • Distal descending colon cancer with lung metastasis S/P C/T show partial response.
    • Liver metastasis and omentum tumor seeing S/P C/T show complete response.
• 2023-03-23 CT - abdomen
  • History and indication:
    • D-colon adenocarcinoma obstruction with peritoneal seeding, lung and liver meta, cT4aN2bM1c, stage IVC
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Much regression of D-colon cancer, peritoneal seeding, LNs, lung and liver metastases.
    • Liver and renal cysts (upt o 9.0cm).
    • Gallbladder stones (up to 1.9cm).
  • IMP:
    • Much regression of D-colon cancer, peritoneal seeding, LNs, lung and liver metastases.
• 2023-01-30 KUB
  • There are three gallstones.
  • S/P colostomy at right lower abdomen?
  • Spondylosis of the L-spine is noted.
• 2022-11-22 All-RAS + BRAF
  • Cell Block: S2022-20638 A1
  • RESULTS：
    • There was no variant detect in the KRAS/NRAS gene.
    • There was no variant detect in the BRAF gene.
• 2022-11-22 Patho - omentum biopsy
  • Omentum, excisional biopsy — metastatic adenocarcinoma, colorectal origin
  • Microscopically, it shows adenocarcinoma composed of invasive neoplastic glands with tumor necrosis and stromal fibrosis. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • Immunohistochemical stain reveals CK7(-), CK20(+), EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2022-11-18 ECG
  • Sinus bradycardia
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2022-11-18 Flow Volumn Loop
  • Normal ventilation
• 2022-11-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 14) / 83 = 83.13%
    • M-mode (Teichholz) = 83
  • Conclusion:
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial MR; mild TR.
    • Multiple liver cysts with variable sizes (the largest one up 8.8 cm).
• 2022-11-17 CT - abdomen
  • History and indication: Advanced D-colon cancer with obstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of D-colon with adjacent fat stranding and regional LAP.
    • Some soft tissues (up to 2.9cm) in peritoneal cavity.
    • Right thyroid nodule (0.8cm).
    • A nodule (0.9cm) at LUL.
    • Invisible uterus.
    • Liver and renal cysts (upt o 8.8cm). A poor enhancing tumor (2.4cm) in right hepatic lobe.
    • Gallbladder stones (up to 1.9cm).
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1c(M_value) STAGE:IVC(Stage_value)

[surgical operation]

• 2022-11-21
  • Surgery
    • T-loop colostomy        
    • Excisional biopsy of omental seeding     
  • Finding
    • Carcinomatosis, omental seeding     
    • T-loop colostomy was created at RUQ area 

[immunochemotherapy]

• 2024-06-21 - ………………………………….. oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracilo 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1 + lorazepam 2mg Q12H D1-3 + NS 250mL D1-3
• 2024-05-31 - ………………………………….. oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracilo 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1 + lorazepam 2mg Q12H D1-3 + NS 250mL D1-3
• 2024-05-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracilo 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1 + lorazepam 2mg Q12H D1-3 + NS 250mL D1-3
• 2024-04-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracilo 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1 + lorazepam 2mg Q12H D1-3 + NS 250mL D1-3
• 2024-04-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracilo 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1 + lorazepam 2mg Q12H D1-3 + NS 250mL D1-3
• 2024-03-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracilo 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1 + lorazepam 2mg Q12H D1-3 + NS 250mL D1-3
• 2024-03-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracilo 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1 + lorazepam 2mg Q12H D1-3 + NS 250mL D1-3
• 2024-02-15 - (Avastin + FOLFIRI)
• 2024-02-01 - (Avastin + FOLFIRI)
• 2024-01-16 - (Avastin + FOLFIRI)
• 2023-10-19 - (Avastin + FOLFIRI)
• 2023-09-22 - (Avastin + FOLFIRI)
• 2023-08-31 - (Avastin + FOLFIRI)
• 2023-08-10 - (Avastin + FOLFIRI)
• 2023-07-27 - (FOLFIRI)
• 2023-07-13 - (Avastin + FOLFIRI)
• 2023-06-30 - (Avastin + FOLFIRI)
• 2023-06-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI without bolus 5FU)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL Q12H D1-2 + aprepitant 125mg PO D1-3 + lorazepam 1mg Q12H D1-3
• 2023-05-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI without bolus 5FU)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-04 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-21 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-03 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-30 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-28 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-02 - + irinotecan 120mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-04-23

[latest lab results and ongoing neuropathy prevention strategies]

No recent imaging updates are available since the last CT scan conducted on 2024-02-16.

The tumor marker CEA has continued to decrease, while CA199 has returned to normal levels. Other lab results from 2024-04-22, were also unremarkable.

B-Red (hydroxocobalamin) is currently being used as a prophylactic measure against chemotherapy-induced neuropathy. While there is evidence supporting the use of vitamin B12 for diabetic neuropathy, its efficacy in preventing chemotherapy-induced neuropathy remains inconclusive, according to the latest reviews in the UpToDate database.

• 2024-04-22 CEA 7.38 ng/mL

• 2024-04-09 CEA 7.89 ng/mL

• 2024-03-06 CEA 13.98 ng/mL

• 2024-04-22 CA199 23.71 U/mL

• 2024-04-09 CA199 22.84 U/mL

• 2024-03-06 CA199 23.57 U/mL

2024-02-02

[reconciliation]

No inconsistencies in medication management were found during a detailed review of both the HIS5 and PharmaCloud databases.

2023-06-20

The patient visited a local clinic on 2023-06-13 for her primary hypertension. She was prescribed Norvasc (amlodipine 5mg) to be taken once daily. This medication is now on the patient’s active medication list as a self-carried item with no reconciliation issues identified.

2023-05-05

During this hospital stay, the patient has experienced vomiting 3 to 4 times while on metoclopramide. If the symptom persists, it may be worth considering prescribing prochlorperazine upon discharge.

2023-04-14

On 2023-04-06, the patient’s lab data showed normal readings except for an elevated CEA of 6.38ng/mL. It seems that the patient is tolerating the treatment well.

2023-03-23

On 2023-03-07, the patient was observed to have neutropenia. However, there was no administration of G-CSF and no reduction of the regimen dosage. Despite this, there have been no new episodes of neutropenia observed as of the present time.

• 2023-03-16 WBC 6.12 x10^3/uL
  

• 2023-03-07 WBC 2.92 x10^3/uL
  

• 2023-03-02 WBC 6.36 x10^3/uL
  

• 2023-02-14 WBC 4.11 x10^3/uL

• 2023-03-16 Neutrophil 66.7 %
  

• 2023-03-07 Neutrophil 39.1 %
  

• 2023-03-02 Neutrophil 67.7 %
  

• 2023-02-14 Neutrophil 63.0 %

According to today’s (2023-03-23) CT results, there is a significant regression of D-colon cancer, peritoneal seeding, lymph nodes, lung, and liver metastases. These findings suggest that the Avastin + FOLFIRI regimen is still effective.

The patient’s medical history indicates that her mother had DM. However, there is no record of the patient’s HbA1c test result in HIS 5, which is a recommended test to monitor and manage diabetes.

701011695

240620

[exam findings]

• 2024-06-13, -06-04 CXR
  • S/P port-A implantation.
  • Multiple metastases on both lungs.
  • S/P Percutaneous nephrostomy of right kidney
• 2024-05-16 CT - abdomen
  • History and indication:
    • Small cell neuroendocrine carcinoma and UC of bladder, cT1N0M0, stage I
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P urinary bladder operation. S/P right PCN.
    • Progression of lung metastases.
    • S/P Port-A infusion catheter insertion.
    • Liver and renal cysts (up to 3.5cm).
    • Bil. adrenal tumors (up to 1.9cm).
    • S/P cholecystectomy.
  • IMP:
    • S/P urinary bladder operation. S/P right PCN.
    • Progression of lung metastases.
• 2024-04-16 CXR erect
  • S/P port-A implantation.
  • Multiple metastases on both lungs.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • S/P Percutaneous nephrostomy of right kidney
• 2024-03-08 PD-L1 IHC
  • Cellblock No. S2023-04998 A4
  • RESULTS：
    • Tumor cell (TC) staining assessment:
      • Percentage of PD-L1 expressing tumor cells (%TC): 0%
    • Combined Positive Score (CPS) assessment:
      • Combined Positive Score (CPS): 0
• 2024-03-08 PD-L1 (22C3)
  • Cellblock No. S2023-04998 A4
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS < 1
    • Combined Positive Score (CPS): < 1
• 2024-03-08 PD-L1 (SP142)
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • S2023-4998 A4
    • Tumor type: small cell neuroendocrine carcinoma, in favor of metastatic from prostate
    • Tumor location: lung
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark XT
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: Pass,
    • Adequate tumor cells present (>=50 viable tumor cells): Yes,
      
  • Result:
    • Tumor cell (TC) staining assessment: TC category: TC < 1%
    • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
  • Note:
    • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
    • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2024-02-19 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • s/p PCN at right kidney.
    • s/p total cystectomy with ileoneobladder. There is interruption of right ureter and the ileoneobladder. However, no evidence of soft tissue mass is found. Please correlate with other imaging modalities.
    • s/p cholecystectomy.
    • Scattered bilateral pulmonary nodules/mass up to 3.54cm in largest dimension are found. Lung meta is considered. In comparison with CT dated on 2023-11-17, the lesions are enlarged in size and numbers.
  • Imp:
    • s/p PCN.
    • Bilateral lung meta. In progression.
    • s/p total cystectomy with ileoneobladder. There is interruption of right ureter and the ileoneobladder. However, no evidence of soft tissue mass is found. Please correlate with other imaging modalities.
• 2023-11-28 Antegrade Pyelography
  • Antegrade pyelography revealed stricture of right ureter-neobladder anastomosis. The double-J catheter can not pass through the stricture site.
• 2023-11-17 CT - abdomen
  • History: small cell neuroendocrine carcinoma and UC of bladder, cT1N0M0, s/p Robotic-assisted radical cystoprostatectomy (RARC) with neobladder reconstruction on 2022/04/11, ypT1N0(0/25) M0.
    • 20230317 s/p VATS RUL, RML, RLL wedge resection: lung metastases
    • 20231107 Renal US: right hydronephrosis.
  • Indication: right hydronephrosis r/o cancer related
  • Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
  • Findings: Comparison: prior CT dated 2023/07/03.
    • There is mild wall thickening at right M/3 ureter (Srs:7 Img:94-97), causing hydroureteronephrosis but no delayed contrast excretion of right kidney. Recurrent tumor is highly suspected.
    • Prior CT identified multiple metastases on both lungs are noted again, mild increasing in size and number. please correlate with clinical condition.
    • S/P radical cystoprostatectomy with neobladder reconstruction
    • Liver and renal cysts (up to 3.3cm).
    • S/P cholecystectomy.
  • Impression:
    • Recurrent tumor at right M/3 ureter is highly suspected.
    • Prior CT identified multiple metastases on both lungs are noted again, mild increasing in size and number.
• 2023-11-10 Intravenous pyelography and post-voiding study, IVP
  • Findings
    • Dilatation of right pelvicaliceal system and ureter with obstruction level around anastomosis region.
      
    • S/P cystectomy and neobladder reconstruction.
  • IMP:
    • S/P cystectomy with neobladder reconstruction.
    • Right hydronephrosis and hydroureter with obstruction around the anastomosis region.
• 2023-11-07 Bladder Sonography
  • PVR: 1.65 mL
• 2023-09-28 CT - chest
  • Indication: Bladder Cancer with lung mets
  • Chest CT without IV contrast ehnancement shows:
    • Nodular lesions are found at both lungs up to 1.6cm at left lower lobe is found. (Se401 Im33), In comparison with CT dated on 2023-07-03, the lesions are enlarged slightly.
    • S/p port-A placement with its tip at Superior vena cava.
    • Hepatic cysts at both lobes of liver up to 3.09cm at dome is found.
    • s/p total cystectomy with ileoneobladder.
  • Imp:
    • Bilateral lung meta, slightly in enlargement.
• 2023-07-21 All-RAS + BRAF mutation
  • ALL-RAS: There was no variant detect in the KRAS/NRAS gene.
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-07-03 CT - abdomen
  • Indication
    • Small cell neuroendocrine carcinoma and UC of bladder, cT1N0M0, s/p neoadjuvant Etoposide and cisplatin (4), s/p RARC with neobladder reconstruction on 2022/04/11, ypT1N0 (0/25) M0 with lung metastasis s/p VATS RUL, RML, RLL wedge resection + LND on 2023/03/17 and chemotherapy with EP (Etoposide 80mg/m2 x3 days / Cisplatin 25mg/m2 x3 days) on 2023/04/20~ check from pelvis to chest, please 3Q
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • S/p port-A placement with its tip at Superior vena cava.
      • s/p right upper lobe,
      • Tiny nodule at right lower lobe measuring 0.2cm is found. Some perifissural nodule at right lower lobe measuring 0.3cm is also noted. still other comet tail like nodule at left lingula lobe up to 0.4cm, right upper lobe tup to 0.2cm, 0.6cm and left upper lobe measuring 0.23cm are found. In comparison with CT dated on 2023-02-04, the lesions are statianry.
    • Visible abdomen:
      • s/p ileoneobladder.
      • s/p cholecystectomy.
  • Imp:
    • s/p cystectomy and ileoneobladder.
    • Recurrent/residual tumor at both lung fields. Stationary.
• 2023-06-08, -05-09, -05-02 CXR
  • S/P port-A implantation.
  • There is multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
• 2023-04-18 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 25 dB HL, LE 25 dB HL
  • bil normal to mild SNHL
• 2023-04-11 CXR
  • Port-A catheter inserted into cavo-atrial junction via right subclavian vein.
  • elevation of Rt hemidiaphragm
  • Multiple nodules of variable sizes in both lungs due to metastases
  • a Rt minor fissure loculated effusion 44mm?
• 2023-03-17 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, upper lobe, wedge resection —- small cell neuroendocrine carcinoma, in favor of metastatic
    • Lung, right, middle lobe, wedge resection —- small cell neuroendocrine carcinoma, in favor of metastatic
    • Lung, right, lower lobe, wedge resection —- small cell neuroendocrine carcinoma, in favor of metastatic
    • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
    • Lymph node, right, group No.10, lymphadenectomy —- Negative for malignancy (0/1)
    • Lymph node, right, group No.11, lymphadenectomy —- Negative for malignancy (0/2)
• 2023-02-14 CT guide biopsy
  • RUL nodule, s/p CT-buided biopsy
• 2023-02-04 CT - chest
  • Indication: Urinary bladder with lung mets
  • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • S/p port-A placement with its tip at Superior vena cava.
      • Diffuse nodular lesions scattered at both lungs are found. Lung meta is considered. In comparison with CT dated on 2022-01-09, the lesions are enlarged in size and numbers.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Hepatic cysts at both lobes of liver is found.
      • s/p cholecystectomy.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp: Bilateral lung meta. In progression.
• 2023-02-02 CT - abdomen
  • History and indication: Bladder tumor
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P urinary bladder operation.
    • Some nodules at bil. lungs.
    • Liver and renal cysts (up to 3.5cm).
    • Normal appearance of spleen, pancreas, adrenals.
    • S/P cholecystectomy.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
  • IMP:
    • S/P urinary bladder operation.
    • Some nodules at bil. lungs suspected metastases.
• 2022-11-09, -08-17 CT - abdomen
  • History: small cell neuroendocrine carcinoma and UC of bladder, cT1N0M0, s/p neoadjuvant Etoposide and cisplatin (4), s/p Robotic-assisted radical cystoprostatectomy (RARC) with neobladder reconstruction on 2022-04-11, ypT1N0(0/25)M0
  • Indication: FU
  • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • S/P radical cystoprostatectomy with neobladder reconstruction
    • Liver and renal cysts (up to 3.3cm).
    • S/P cholecystectomy.
    • Others
      • There is no focal abnormality in the biliary system, pancreas, and spleen.
        
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • S/P radical cystoprostatectomy with neobladder reconstruction
      • There is no evidence of tumor recurrence.
    • Detailed findings, please see description.
• 2022-08-18, -05-26 Uroflowmetry
  • Q max: low
  • Flow pattern: obstructive
• 2022-08-18 Bladder Sonography
  • PVR 1.59mL (post-void residual)
• 2022-05-26 Bladder Sonography
  • PVR 1mL (post-void residual)
• 2022-05-26 SONO - urology
  • Miction pain, treated outside in 2020-09, and 2021-02, s/p diverticulectomy, open 20 years ago. nocturia 3/n, SUI(+), wound: well
  • Diagnosis:
    • Right hydronephrosis
    • Bilateral renal stones
    • Left renal stone
• 2022-04-20 Cystography
  • Cystography via foley catheter administration revealed:
    • The bladder capacity is about 100cc.
    • No evidence of contrast medium leakage.
• 2022-04-12 Patho - urinary bladder partial/total resection
  • PATHOLOGIC DIAGNOSIS:
    • Urinary bladder, Robotic-assisted radical cystoprostatectomy (s/p TURBT) — infiltrating urothelial carcinoma, high-grade
    • Prostate, RARC (s/p TURP) — Non-invasive papillary urothelial carcinoma, high-grade (at prostatic urethra) — Free of apex margin
    • Seminal vesicles, bilateral, RARC — Negative for malignancy
    • Ureter cuff end, right, RARC — low-grade urothelial dysplasia
    • Ureter cuff end, left, RARC — Negative for malignancy
      
    • Lymph node, left iliac, dissection — Negative for malignancy (0/1)
    • Lymph node, right iliac, dissection — Negative for malignancy (0/3)
    • Lymph node, left obturator, dissection — Negative for malignancy (0/9)
    • Lymph node, right obturator, dissection — Negative for malignancy (0/12)
    • AJCC 8th edition Pathology stage: pT1N0(if cM0); AJCC pathologic stage I
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: Robotic-assisted radical cystoprostatectomy
    • Specimen size:
      • Urinary bladder: (12) x (8) x (5) cm
      • Prostate: (4.8) x (3.5) x (3.2) cm
      • Tumor size: 0.5 cm
      • Tumor site: Posterior wall
      • Sections are taken and labeled as: F2022-153FSC: right cuff end, F2022-153FSD: left cuff end, A1-11: prostate, A12: bil seminal vesicles, A13-20: bladder, B: left iliac LN, C: right iliac LN, D1-2: left obturator LN, E1-2: right obturator LN
  • MICROSCOPIC EXAMINATION (for urinary bladder):
    • Histological type
      • Urothelial: Papillary urothelial carcinoma, invasive
    • Histological grade: High grade
    • Pathological staging (pTNM, AJCC 8th edition):
      • TNM Descriptors: (required only if applicable) (select all that apply)
        • m (multiple primary tumors)
        • r (recurrent)
        • y (posttreatment)
      • Primary tumor (pT): pT1: Tumor invades lamina propria (subepithelial connective tissue)
      • Regional lymph nodes (pN): pN0: No lymph node metastasis
      • Distant metastasis (pM): N/A
    • Section margins:
      • Involved by noninvasive low-grade urothelial carcinoma/ urothelial dysplasia, site:right ureter curr end
    • Explanatory note:
      • Immunohistochemical stain for prostate: AMACR(-), 34BE12(+) and GATA3(+).
• 2022-04-11 Frozen Section
  • Left ureter cuff end, frozen section — Negative for malignancy
  • Right ureter cuff end, frozen section — High-grade dysplasia
  • Right ureter cuff end, frozen section — Low-grade dysplasia
  • Left ureter cuff end, frozen section — Negative for malignancy
• 2022-03-23 CT - abdomen
  • History and indication: Bladder tumor
  • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is diffuse wall thickening of the urinary bladder and few calcifications within the wall that is c/w urothelial cell carcinoma. Please correlate with cystoscopy.
    • Liver and renal cysts (up to 3.8cm).
    • S/P cholecystectomy.
  • Impression:
    • There is diffuse wall thickening of the urinary bladder and few calcifications within the wall that is c/w urothelial cell carcinoma. Please correlate with cystoscopy.
• 2022-03-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (90 - 14) / 90 = 84.44%
    • M-mode (Teichholz) = 84.2
  • Dilated LA - Adequate LV, RV systolic function with normal wall motion
  • LV hypertrophy, Impaired LV relaxation
  • Mild MR, TR, AR, PR
• 2022-02-09 Spirometry
  • Normal spirometry
• 2021-12-21 MRI - prostate
  • With and without enhancement MRI: Prostate
  • Findings
    • Mucosal thickening at lower portion of urinary bladder and near urinary bladder orifice. suspected urinary bladder tumors.
    • Relative wall thickening at right urinary bladder wall.
    • Outpouching lesion in right aspect of urinary bladder, suggesting urinary bladder diverticulum.
    • Non-enhancing tumors in the liver, 4.1cm in S8 and 2.6cm in S2, suspected liver cysts.
    • Non-enhancing tumors in bilateral kidneys, up to 1.97cm in left kidney, suspected renal cysts.
    • No enlarged lymph node in the pelvic cavity and paraaortic region.
    • No ascites.
  • Impression:
    • Mucosal thickening at lower portion of urinary bladder and near urinary bladder orifice. suspected urinary bladder tumors.
    • Relative wall thickening at right urinary bladder wall.
    • Urinary bladder diverticulum.
    • LIver and renal cysts.
• 2021-12-07 Tc-99m MDP whole body bone scan with SPECT
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the lower C-spine, some L-spines, bilateral shoulders, hips and knees in whole body survey.
  • IMPRESSION:
    • Mildly increased activity in the lower C-spine and some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
• 2021-12-02 CT - abdomen
  • History and indication: Bladder tumor
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of urinary bladder with adjacent fat stranding and regional LAP. S/P foley catheter indwelling.
    • Liver and renal cysts (up to 3.5cm).
    • Normal appearance of spleen, pancreas, adrenals.
    • S/P cholecystectomy.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • No abnormal density at bilateral basal lungs.
  • Addendum Imaging Report Form for Urinary Bladder Carcinoma
    • Impression (Imaging stage) : T:T4b(T_value) N:N2(N_value) M:M0(M_value) STAGE:IVA(Stage_value)
• 2021-12-01 Patho - prostate TUR
  • Prostate, TUR-P biopsy — Small cell neuroendocrine carcinoma and invasive urothelial carcinoma, high-grade
    
  • The sections show a picture of small cell neuroendocrine carcinoma, composed of sheets of poorly differentiated tumor cells seperated by scant stroma. The neoplastic cells have small to intermediate-sized, round to oval nuclei and high N/C ratio. Mitosis are numerous.
    • IHC shows: CD56(+), synaptophysin(+), and PSA(-).
      
  • The overlying urothelium shows invasive urothelial carcinoma, high-grade. Tumor cell invades subepithelial connective tissue.
    • IHC, these tumor cells reveal: CK5/6(focal+), GATA3(+).
• 2021-12-01 Patho - urinary bladder TUR
  • Urianry bladder, TURBT — Invasive papillary urothelial carcinoma, high-grade
    
  • The sections show following features:
    • Histologic type: Papillary urothelial carcinoma, invasive
      
    • Histologic grade: High-grade
      
    • Tumor configuration: Papillary
      
    • Muscularis propria: Present
      
    • Lymphovascular invasion: Not identified
      
    • Microscopic tumor extension: Tumor invades subepithelial connective tissue
• 2021-11-13 Uroflowmetry
  • Q max: fair
  • flow pattern: obstructive
• 2021-11-13 Bladder Sonography
  • PVR 107mL (post-void residual)
• 2021-04-30 Bone densitometry - hip
  • Hip BMD performed by DXA revealed:
    • Left hip, BMD is 0.616 gms/cm2, about 2.1 SD below the peak bone mass (72%) and 1.2 SD below the mean of age-matched people (83%).
  • Impression
    • Osteopenia
• 2021-04-30 SONO - abdomen
  • Diagnosis
    • Liver cyst, S2 and S7
    • Liver hemangioma, S6
    • post cholecystectomy
    • Renal stone, right
    • Renal cyst, left
    • Dilated pelvis of left kidney
    • pancreatic body and tail masked by gas.
  • Suggestion
    • ultrasound follow up
    • visit urology if symptoms revealed.
• 2021-04-10 Bladder Sonography
  • PVR 148mL (post-void residual)
• 2021-04-10 Uroflowmetry
  • Q max: fair
  • flow pattern: obstructive

[MedRec]

• 2023-05-02 SOAP Hemato-Oncology
  • O
    • Cancer Treatment Radiotherapy/Targeted Therapy Side Effect Assessment (2023-05-02)
      • Sensory abnormalities: G1: Asymptomatic; loss of DTR (Deep Tendon Reflex) or abnormal skin sensation.
        • Management of sensory abnormalities: Observation.
      • White blood cell reduction: G1: 3000 - 4000/mm3
        • Management of white blood cell reduction: Observation.
• 2023-03-30 SOAP Hemato-Oncology
  • P: Admission for 24 hours CCr, Audiometry and EP
• 2023-03-30 SOAP Thoracic Surgery
  • A: small cell neuroendocrine carcinoma, metastatic.
  • P: refer back to Onco. Dr. Xia for adjuvant therapy.
• 2023-02-23 SOAP Thoracic Surgery
  • A/P: arrange admission on 3/16; 3/17 VATS RML, RLL wedge, for tissue proof.
• 2023-02-09 SOAP Hemato-Oncology
  • A/P: Admission for CT-guided biopsy (Already discuss with radiologist Dr. Chang)
• 2023-02-02 SOAP Hemato-Oncology
  • A/P
    • Arrange Chest CT
    • May consider Biopsy after Chest
    • Then discuss the appropriate regimen of treatment
• 2022-04-28 SOAP Urology
  • O
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-04-25
      • Subsequent imaging follow-up, focusing on chest imaging.
    • 2022-01-12 ~ 2022-03 - neoadjuvant Etopside, cisplatin (4) - AE: nasuea, vomiting, hicccup
• 2022-01-25 SOAP Urology
  • O
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-01-03
      • The patient is considering cystectomy and may need to undergo urethrectomy again.
    • Cancer Multidisciplinary Team Meeting Conclusion> Meeting Date: 2021-12-20
      • Recommend neoadjuvant chemotherapy + radical cystectomy
      • Prostate cancer workup (Lung CT, prostate MRI, PSA) for double cancer.

[consultation]

• 2024-06-19 Neurology
  • Q
    • Patient was 56 years old men, history of Small cell neuroendocrine carcinoma and UC of bladder, cT1N0M0, stage I, s/p RARC with neobladder reconstruction on 2022/04/11, ypT1N0(0/25)M0, with lung metastasis s/p VATS RUL, RML, RLL wedge resection + LND on 2023/03/17 and chemotherapy with EP on 2023/04/20~2023/08/08. EP 50mg/tab oral form on 2023/08/31~2023/12/14. right hydronephrosis s/p right PCND on 2023/11/27. chemotherapy with FOLFOX from 2023/12/29. progression of lung metastasis thus shift to FOLFIRI from 2024/03/07~2024/04/15, with disease progression, under TAMOS 260mg Q4W D1-D5 for treatment since 2024/05/17(C1)~.
    • This time, he was admitted for cancer treatment.
    • Plan: Brain MRA on 2024/06/20.
    • Due to dizziness and right leg numb were noted, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • The patient mentioned that he has generalized weakness and associated dizziness since end of May 2024 after radiotherapy. Then right lower limb clumsiness with numbness was noted and in progression.
    • Plan: Brain MRA on 2024/06/20.

[surgical operation]

• 2023-03-17
  • Surgery
    • VATS RUL, RML, RLL wedge resection + LND.
  • Finding
    • Multiple lung nodules over RUL, RML and RLL, size range from 1.2cm to 0.5cm.
    • One 24 Fr. straight chest tube was inserted via right 8th ICS.
• 2022-04-11
  • Surgery
    • Robotic-assisted radical cystoprostatectomy with neobladder reconstruction.  
  • Finding
    • Bladder tumor over dome.
    • severe adhesion over anterior bladder wall
    • blood loss: 1000ml (urine included)
    • console time: 300 mins    
• 2021-12-01
  • Surgery
    • TUR-BT
    • TUR prostate biopsy
    • EC of bladder diverticulum
  • Finding
    • Mild kissing prostate appearance
    • Papillary uneven prostate mucosa over bilateral lobes, right side dominate
    • Papillary bladder tumors over BN 4-5 o’clock
    • Papillary bladder tumors over right posterolateral wall to bladder dome, large amount
    • Large diverticulum over right side lateral wall
    • Papillary tumors in diverticulum
    • Perfrom EC after tumor resection
    • Clear urine output from bilateral UO
    • Bilateral UO and ES remained intact after the procedure

[chemotherapy]

• 2024-05-15 ~ undergoing - Tamos (temozolomide) 260mg QDAC

• 2024-04-15 - irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

• 2024-03-27 - irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

• 2024-03-07 - irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

• 2024-02-15 - oxaliplatin 85mg/m2 146mg D5W 250mL 2hr + leucovorin 400mg/m2 685mg NS 250mL 2hr + fluorouracil 400mg/m2 685mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + hydroxocobalamin 1mg IM D2

• 2024-01-31 - oxaliplatin 85mg/m2 146mg D5W 250mL 2hr + leucovorin 400mg/m2 685mg NS 250mL 2hr + fluorouracil 400mg/m2 685mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + hydroxocobalamin 1mg IM D2

• 2024-01-15 - oxaliplatin 85mg/m2 146mg D5W 250mL 2hr + leucovorin 400mg/m2 685mg NS 250mL 2hr + fluorouracil 400mg/m2 685mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + hydroxocobalamin 1mg IM D2

• 2023-12-29 - ………………………………….. leucovorin 400mg/m2 685mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (Yang MuJun)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-08-31 ~ 2023-12-14 - Vepesid (etoposide 50mg) 1# QDAC PO

• 2023-08-08 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)

  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3

• 2023-07-19 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)

  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3

• 2023-06-29 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)

  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3

• 2023-06-08 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)

  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3

• 2023-05-16 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)

  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3

• 2023-04-20 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)

  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3

• 2022-03-22 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)

  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3

• 2022-03-01 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)

  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3

• 2022-02-08 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)

  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3

• 2022-01-12 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)

  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3

==========

2024-06-20

[initiation of temozolomide for lung metastases progression]

On 2024-05-16, a CT scan revealed progression of lung metastases, leading to the initiation of Tamos (temozolomide) at 260 mg QDAC. Lab results on 2024-06-18 were grossly normal. No medication discrepancies were identified after reviewing HIS5 and PharmaCloud.

2024-01-04

[neutropenia]

(not used) The patient’s last chemotherapy treatment before the lab result on 2023-12-28 was on 2023-08-08. Due to the long time interval between the treatment and the neutropenia episode, it is difficult to conclude with certainty that the neutropenia was directly caused by the previous chemotherapy.

A 28-day supply of oral etoposide was prescribed on 2023-11-16. This medication carries a known risk of leukopenia, with an incidence ranging from 60% to 91%. The severity can reach grade 4 in 3% to 17% of cases, with the nadir typically occurring 7 to 14 days after administration and recovery expected by day 20.

• 2023-12-28 WBC 3.67 x10^3/uL = Neutrophil 28.7 => ANC 1.53K/uL grade 2 neutropenia
• 2023-12-14 WBC 6.94 x10^3/uL
• 2023-11-26 WBC 4.79 x10^3/uL
• 2023-11-16 WBC 4.49 x10^3/uL
• 2023-10-19 WBC 4.21 x10^3/uL

In response to the patient’s leukopenia, two days of Granocyte (lenograstim 250ug) were promptly administered.

2023-08-09

The patient recently renewed his repeat prescription for Diovan (valsartan) for a 28-day supply on 2023-08-07. This medication has been added to the active list of medications without an identified reconciliation problem.

2023-06-30

According to the PharmaCloud database, this patient regularly refills his prescription for Diovan (valsartan) to treat his primary hypertension. This medication was correctly added to the active formulary and no issues were identified during the medication reconciliation process.

2023-06-09

According to PharmaCloud data, this patient has only sought medical treatment at our hospital. No issues with medication reconciliation were identified.

The latest lab data, collected on 2023-06-06, shows largely normal results and readings from the TPR panel are stable. There are no issues with the current prescription.

2023-05-17

The patient’s prostate cancer was pathologically confirmed as small cell neuroendocrine carcinoma on 2021-12-01. Given the histologic characteristics of small cell components, the regimens used for small cell lung cancer (SCLC) are considered preferable. Therefore, the patient received both cisplatin (25mg/m2) and etoposide (100mg/m2) on days 1 to 3 for 4 cycles in the first quarter of 2022. The same regimen was restarted (etoposide at 80mg/m2) on 2023-04-20 due to a lung wedge biopsy performed on 2023-03-17 that indicated metastatic small cell neuroendocrine carcinoma. The treatment is currently ongoing.

There were no notable abnormalities found in the TPR panel and lab data from 2023-05-16. In addition, no medication reconciliation issues were identified.

701446179

240620

{triple negative breast cancer}

[exam findings]

• 2024-06-20 ECG
  • Sinus tachycardia with Fusion complexes
  • Rightward axis
  • Left atrial enlargement
  • Right bundle branch block
  • Abnormal ECG
• 2024-06-20 CXR erect
  • S/P port-A implantation.
  • S/P Mastectomy, left.
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Increased lung markings on both lower lungs are noted. Please correlate with clinical condition.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-06-04 Tc-99m MDP bone scan
  • In comparison with the previous study on 2024/05/20, the lesions in the middle C-spines and L3-5 spines are a little more evident. The nature is to be determined (degenerative change in a little more severe status? other nature?). Please correlate with other clinical findings and follow up bone scan for further evaluation.
  • No prominent change is noted in other bone lesions.
• 2024-05-20 Tc-99m MDP bone scan
  • The lesion of increased activity in the sternum is old and comes to less evident compared with the previous study on 2023-07-05, suggesting more benign in nature. Please correlate with other imaging modalities and follow-up with bone scan for further evaluation.
  • Suspected benign lesions in the L3-5 spines, bilateral shoulders, hips and knees.
• 2024-05-12 Pelvis - THR
  • No evidence of bony fracture based on this study.
  • Lumbar spondylosis.
• 2024-05-12 KUB + L-spine Lat
  • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
  • Non-specific bowel gas pattern.
  • Lumbar spondylosis.
  • Disc space narrowing at L3/4, L4/5 and L5/S1.
• 2024-02-27 CT - chest
  • without & with contrast enhancement, coronal and sagittal reconstructed images shows: comparison: prior CT on 2023/10/25
    • Lungs: patchy ground-glass and reticular opacities at lingula RML, may be post treatment change and fibrosis. intercal increase in size of a subpleural nodule at LLL-S6 (17mm) compared with CT on 2023/10/25
    • Mediastinum and hila: no enlarged LN
      • mild calcified plaques of the coronary arteries.
    • Thoracic aorta: normal caliber, extensive atherosclerotic change mainly involving the ascending segment, aortic root, and aortic arch.
    • Central pulmonary arteries: dilated trunk (3.7cm in caliber) and right main artery.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no nodule or effusion.
    • Chest wall and visible lower neck: extensive skin thickening, over both sides of the anterior chest wall, associated nodular
      • enhanced lesions with central loe density at Rt breast and decreased size of metastatic lymphadenothy at Lt axillary region compared with CT on 2023/10/25
    • Visible abdominal-pelvic contents: several tiny hepatic calcifications.
      • unremarkable of the GB,spleen, both adrenal glands, pancreas, and both kidneys.
    • Visualized bones: sclerotic change at xyphoid process and distal sternal body.
  • Impression:
    • left breast cancer with axillary LN metastasis, in regression, but new lesions at R breast (metastatic or abscess lesions) and extensive sking thickening of anterior chest wall, and LLL metastasis as compared with CT on 2023/10/25.
    • pulmonary hypertension
• 2023-10-25 CT - chest
  • comparison made with CT on 2023/07/13
    • Lungs: patchy ground-glass and reticular opacities at lingula and both lower lobes, may be post treatment change and fibrosis.
      • a subpleural nodule at LLL-S6, may be dependent nodular atelectasis, stable.
    • Mediastinum and hila: no enlarged LN
      • mild calcified plaques of the coronary arteries.
    • Thoracic aorta: normal caliber, extensive atherosclerotic change mainly involving the ascending segment, aortic root, and aortic arch.
    • Central pulmonary arteries: dilated trunk (3.7cm in caliber) and right main artery.
    • Chest wall and visible lower neck: soft-tissue defect with area of skin thickening and disappearance of the huge left breast tumor stationary, but further enlarged metastatic lymphadenopathies at Lt axillary region compared with CT on 2023/07/13
    • Visible abdominal-pelvic contents: several tiny hepatic calcifications.
    • Visualized bones: sclerotic change at xyphoid process and distal sternal body.
  • Impression:
    • left breast cancer with axillary LNs metastasis, stationary of primary tumor but axillart LAP enlarged compared with CT on 2023/07/13
• 2023-09-18 ECG
  • Sinus tachycardia
  • Inferior infarct, age undetermined
  • T wave abnormality, consider anterolateral ischemia
• 2023-09-18 CXR
  • absence of Lt breast
  • extensive hazy areas of increased opacity over RUL and lower lung zone
  • Tortousity of thoracic aorta and calcified atherosclerotic change
  • Dilation of pulmonary trunk
• 2023-07-13 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Contracted soft tissue mass at left breast is found. In comparison with CT dated on 2023-01-03, the lesion is stationary.
    • Lymphadenopathy at left axillary and pectoralis muscle is found. In comparison with CT dated on 2023-01-03, the lesion is enlarged.
    • The lung fields are clear.
    • Some skin thickening is found.
    • No evidence of bilateral pleural effusion.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
  • Imp:
    • Left breast cancer with left axillary lymphadenopathy. The primary tumor is stationary but the lymphadenopathy enlarged.
    • Bone meta. Suggest correlate with bone scan study
• 2023-07-05 Tc-99m MDP bone scan
  • Increased activity in the body of the sternum, the nature is to be determined (bone mets, post-traumatic change, or other nature ?). Please correlate with other imaging modalities and follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the L3-4 spines, bilateral shoulders, hips and left knee.
• 2023-07-05 SONO - breast
  • Diagnosis:
    • Left breast cancer with axillary LAP
    • Bil. fibroadenomas as described
  • BI-RADS: 6. known biopsy-proven malignancy
• 2023-03-07 CT - brain
  • Imp: No brain nodule or metastasis. Mild Chronic left mastoiditis.
• 2023-03-06 CXR (erect)
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
• 2023-03-06 KUB
  • Spondylosis of the L-spine is noted.
• 2023-02-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (62 - 19.1) / 62 = 69.19%
    • M-mode (Teichholz) = 69.2
  • Conclusion
    • Normal AV/MV, no AR/MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, no TR, normal IVC size
• 2023-01-03 CT - chest
  • Findings
    • Lungs: subpleural ground-glass opacity and reticular opacities at LUL and both lower, may be post treatment change and combined dependent density at lower lobes. partial atelectasis of inferior lingular segment.
      • no abnormal nodule in the lungs
    • Mediastinum and hila:no enlarged LN
      • mild calcified plaques of the LAD and LCX coronary arteries.
    • Thoracic aorta: normal caliber, extensive atherosclerotic change mainly involving the ascending segment, aortic root, and aortic arch.
    • Central pulmonary arteries: dilated trunk (3.7cm in caliber) and right main artery.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no nodule or effusion .
    • Chest wall and visible lower neck: soft-tissue defect with area of skin thickening and disappearance of the huge left breast tumor in regression, and further regression of metastatic lymphadenopathy at axillary region compared with CT on 2022/11/9.
    • Visible abdominal-pelvic contents: several tiny hepatic calcifications.
      • normal appearance of gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys.
      • no enlarged lymph node.
      • Mild atherosclerotic change of the abdominal aorta.
    • Visualized bones: sclerotic change at xyphoid process and distal sternal body.
  • Impression:
    • left breast cancer with axillar LNs metastasis further regression compared with previous CT exam. on 2022/11/09
• 2022-11-18 SONO - breast
  • findings
    • Parenchymal pattem
      • Loosely (inhomogeneously) sonodense
    • Focal sonographic lesion
      • already known left breast cancer with LAP metastasis, receviing chemotherapy now
      • right axillary LAP, distant metastasis of left breast cancer? or double primary breast cancer related?
      • multiple small FAs and cysts over right breast, less likely malignancy
  • diagnosis
    • Highly suspicious of malignancy, with sonographic negative axillary LNs
  • treatment
    • no need to biopsy
  • suggestion and plan
    • Regular OPD follow-up
    • BI-RADS - 6. Known Biopsy - Proven Malignancy
• 2022-11-09 CT - chest
  • Indication: invasive carcinoma of left breast, ER(-) PR(-) Her-2/neu(-), Ki-67: 90%, T4bN3M1, stage IV
    
  • Findings:
    • Lungs: subpleural ground-glass opacity and reticular opacities at LUL and both lower, may be post treatment change and combined dependent density at lower lobes.
      • no abnormal nodule in the lungs
    • Mediastinum and hila: no enlarged LN
    • Vessels:
      • mild calcified plaques of the LAD and LCX coronary arteries.
      • Thoracic aorta: normal caliber, extensive atherosclerotic change mainly involving the ascending segment, aortic root, and aortic arch.
      • Central pulmonary arteries: dilated trunk (3.3cm in caliber) and right main artery.
      • Heart: normal in size of cardiac chambers.
    • Pleura: no nodule or effusion .
    • Chest wall and visible lower neck: soft-tissue defect with area of skin thickening and disappearance of the hugeleft breaar tumor and significant regression of metastatic lymphadenopathy at axillary region compared with CT on 8/15.
    • Visible abdominal-pelvic contents: several tiny hepatic calcifications.
      • normal appearance of gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys.
      • no enlarged lymph node.
      • Mild atherosclerotic change of the abdominal aorta.
    • Visualized bones: sclerotic change at xyphoid process and distal sternal body.
  • Impression:
    • left breast cancer with good response to treatment compared with previous CT exam.
• 2022-11-08 Whole body PET scan
  • Mild glucose hypermetabolism in a left axillary lymph node and a right axillary lymph node, compatible with metastatic lymph nodes s/p treatment change.
  • Mild glucose hypermetabolism in the left anterior chest wall, compatile with primary breast malignancy s/p treatment change.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2022-10-14 SONO - abdomen
  • dilated pelvis of left kidney
  • pancreas masked by gas
• 2022-08-31 ECG
  • Low voltage QRS
  • Possible Inferior infarct , age undetermined
  • Nonspecific ST and T wave abnormality
• 2022-08-31 CXR
  • Lung markings: increased density in the left middle lung field.
• 2022-08-24 MRI - brain
  • no evidence of brain metastasis
  • high SI chnage on T2WI in the visible C-cord. Please correlate with C-spine MRI.
• 2022-08-19 CXR
  • Atherosclerotic change of aortic arch
  • Patchy opacity projecting at left lower chest wall is noted that is c/w left breast cancer after correlate with CT.
• 2022-08-16 Tc-99m MDP whole body bone scan
  • Decreased activity in the body of the sternum. Bone destruction may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the L3-4 spines. Degenerative change may show this picture.
  • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and left knee, compatible with benign joint lesions.
• 2022-08-15 CT - chest
  • left huge breast cancer T4bN3M1
• 2022-08-11 Patho - breast biopsy
  • Breast, left, biopsy — Invasive carcinoma of no special type
  • Section shows skin and breast tissue with irregular neoplastic glands infiltration.
  • IHC:
    • GATA3 (+)
    • ER (Ab) (-)
    • PR (Ab) (-, <1%, moderate)
    • Her-2/neu (Ab): (-, 0)
    • Ki-67 90%
• 2022-08-09 CXR
  • A mass at left breast.
  • Ground glass opacity in bilateral lower lungs.

[MedRec]

• 2023-02-23 Multiple Team - Social Services
  • Referral Date: 2023-02-23
  • Referral Reason: Economic issues related to medical care, caregiving, daily necessities, etc.
  • Processing Status: Case opened
  • Family Situation: On 2023.02.23, a meeting was held with the patient, and their past case records were summarized as follows:
    • The patient is suffering from breast cancer and is regularly monitored by the Hematology-Oncology department at our hospital. On 2023.02.20, the patient complained of fever, shortness of breath, and burns on the buttocks and groin due to using an electric blanket, which led to her seeking treatment at the emergency room and being admitted to the hospital. During her hospitalization, her son periodically came to the hospital to accompany her.
    • The patient is 68 years old and has been married twice. Both husbands are deceased. She has one daughter from her first marriage and one son from her second marriage. The patient used to work at a health resort but had to stop working due to her health condition. She retired and receives a monthly pension of 5,000 TWD. She mentioned that she has very little savings left. The patient has national health insurance and critical illness insurance but no private medical insurance. Her household registration is in Taipei City, Zhongshan District.
    • The patient’s daughter, who is in her 40s, is married and unemployed due to her weakened physical condition. She relies on her son-in-law for support. The patient mentioned that due to her remarriage, she has had a distant relationship with her daughter for many years, with no contact. She also doesn’t have her daughter’s contact information. However, her daughter and son still maintain contact. Her son is 28 years old, unmarried, and childless. He works at a convenience store and earns around 22,000 TWD per month. Sometimes, due to taking leaves, his monthly income is approximately 10,000 TWD. The patient mentioned that her son was born prematurely, which may have led to lower intellectual and learning abilities. Currently, the patient and her son live together in a rented apartment in Yonghe District. It’s a 5th-floor apartment with no elevator, and the monthly rent is 20,000 TWD, shared between the patient and her son.
    • The patient’s nephew, 29 years old, was raised by the patient since childhood because her younger brother was unable to care for him. However, the nephew currently does not live with the patient, and their relationship is somewhat distant. Nevertheless, they still maintain contact. The nephew has had an unstable job history, and his financial situation is not good.
    • The patient mentioned that her parents and many of her siblings have passed away, leaving her with almost no other relatives to maintain contact with.
    • The patient stated that she and her son are paying off debts. After debt negotiations, they now need to pay 5,000 TWD per month. Additionally, the patient mentioned that her son was previously evicted from their residence, and at that time, they took out a loan for rent, which now requires monthly repayments of approximately 10,000 TWD, including interest.
  • Main Issue: Economic issues
  • Detailed Issues: Daily necessities, food, accommodation expenses, medical expenses
  • Disposition:
    • Donations of medical equipment or nutritional supplements from the hospital
    • Referral for economic assistance
    • Provision of economic assistance
  • Responder: Luo YuChuan
  • Response Date: 2023-02-23
  • Doctor’s Response:
    • 02/23 16:47 Zhang Shou-Yi Response: Noted, will continue to assess the patient’s economic situation
• 2022-11-03 Multiple Team - Social Services
  • Referral Date: 2022-11-03
  • Referral Reason: Economic issues related to medical care, caregiving, daily necessities, etc.
  • Processing Status: Not opened
  • Reason for Not Opening: On 2022.11.03, a meeting was held with the patient, and their past case records were summarized as follows:
  • Family Situation:
    • The patient is 67 years old and has been married twice. Both husbands are deceased. She has one daughter from her first marriage and one son from her second marriage. The patient used to work at a health resort but had to stop working due to her health condition. She retired and receives a monthly pension of 5,000 TWD. She mentioned that she has very little savings left. The patient has national health insurance and critical illness insurance but no private medical insurance. Her household registration is in Taipei City, Zhongshan District.
    • The patient’s daughter, who is in her 40s, is married and unemployed due to her weakened physical condition. She relies on her son-in-law for support. The patient mentioned that due to her remarriage, she has had a distant relationship with her daughter for many years, with no contact. She also doesn’t have her daughter’s contact information. However, her daughter and son still maintain contact. Her son is 27 years old, unmarried, and childless. He works at a convenience store and earns over 9,000 TWD per month. The patient mentioned that her son was born prematurely, which may have led to lower intellectual and learning abilities. Currently, the patient and her son live together in a rented apartment in Yonghe District. It’s a 5th-floor apartment with no elevator, and the monthly rent is 20,000 TWD, shared between the patient and her son.
    • The patient’s nephew, 28 years old, was raised by the patient since childhood because her younger brother was unable to care for him. However, the nephew currently does not live with the patient, and their relationship is somewhat distant. Nevertheless, they still maintain contact. The nephew has had an unstable job history, and his financial situation is not good.
    • The patient mentioned that her parents and many of her siblings have passed away, leaving her with almost no other relatives to maintain contact with.
  • Assessment and Treatment:
    • A case was opened for the patient’s hospitalization in September 2022, and assistance from the Tzu Chi Foundation was arranged. The foundation provided one-time emergency assistance and is currently assessing long-term financial support. Volunteers from the foundation regularly visit the patient.
    • During this hospitalization, the patient mentioned that she can still take care of herself during the day, and her son comes to the hospital to accompany her in the evening. The Tzu Chi Foundation has been providing assistance and regular visits. Additionally, nutritional supplements were provided during this hospitalization.
    • The current referral provides the aforementioned treatment options. If there are additional social work assistance needs, please contact the social worker. Thank you.
  • Responder: Luo Yu-Chuan
  • Response Date: 2022-11-03
  • Doctor’s Response:
    • 11/04 08:11 Zhang Shou-Yi Response: Noted, will continue to follow up on the patient’s needs
• 2022-09-01 Multiple Team - Social Services
  • Referral Date: 2022-09-01
  • Referral Reason: During hospitalization, the patient has no self-care ability, and family members are unable to come to the hospital to care for her.
  • Processing Status: Case opened
  • Family Situation: On 2022.09.01, a meeting was held with the patient, and the following family situation was obtained:
    • On 2022.02, the patient experienced left chest pain and discomfort but did not seek medical attention. She occasionally used pain relievers. On 2022.08.09, she sought treatment at the hospital’s emergency room due to severe pain and bleeding in her left breast. She was diagnosed, received her first round of chemotherapy, and was discharged on 2022.08.24. She was readmitted to the hospital on 2022.08.31 due to a lack of appetite and nausea since her previous discharge. During hospitalization, the patient stays alone in the hospital during the day, and her son comes to the hospital to accompany her in the evening.
    • The patient is 67 years old and has been married twice. Both husbands are deceased. She has one daughter from her first marriage and one son from her second marriage. The patient used to work at a health resort but had to stop working due to her health condition. She retired and receives a monthly pension of 5,000 TWD. She mentioned that she has very little savings left. The patient has national health insurance and critical illness insurance but no private medical insurance. Her household registration is in Taipei City, Zhongshan District.
    • The patient’s daughter, who is in her 40s, is married and unemployed due to her weakened physical condition. She relies on her son-in-law for support. The patient mentioned that her relationship with her daughter has been distant for the past five years, with no contact. She also doesn’t have her daughter’s contact information. However, her daughter and son still maintain contact. Her son is 26 years old, unmarried, and childless. He works at a convenience store and earns over 9,000 TWD per month. The patient mentioned that her son was born prematurely, which may have led to lower intellectual and learning abilities. Currently, the patient and her son live together in a rented apartment in Yonghe District. It’s a 5th-floor apartment with no elevator, and the monthly rent is 20,000 TWD, shared between the patient and her son.
    • The patient’s nephew, 27 years old, was raised by the patient since childhood because her younger brother was unable to care for him. However, the nephew currently does not live with the patient, and their relationship is somewhat distant.
    • The patient mentioned that her parents and many of her siblings have passed away, leaving her with almost no other relatives to maintain contact with.
  • Main Issue: Economic issues, Family support system is weak, Distant relationships
  • Detailed Issues: Daily necessities, food, accommodation expenses, hiring caregiver expenses
  • Disposition: None
  • Responder: Luo Yu-Chuan
  • Response Date: 2022-09-01
  • Doctor’s Response:
    • 09/02 09:04 Zhang Shou-Yi Response: Will proceed according to the recommendations

[consultation]

• 2024-06-12 Radiation Oncology
  • Q
    • For evaluation of radiotherapy.
    • This 69-year-old female who has Invasive carcinoma of left breast, cT4bN3M1, stage IV, Dx in Aug 2022, and having treatment with chemotherpay and radiotherapy.
    • This time, she complained of lower back, left buttock, hip pain and weakness in bilateral leg, difficult to walk for 2-3 weeks. She was brought to our ER for help. The MRI of spine revealed Bone metastasis (L4 compression fracture with L1 lesion). So, we need your expertist for radiation therpy for this case. Thanks a lot!
  • A
    • The patient’s history was reviewed and patient was examined.
    • S:
      • For radiotherapy due to metastatic L spine lesions.
      • PI: The patient suffered from pain of the low back, left buttock, and hip area, and weakness of bilateral low limbs with difficult to walk for 2-3 weeks. She was brought to our ER for help. MRI of L spine (2024-6-11) showed Fracture of L4 vertebral body with ill-defined enhancing mass lesions, favor pathological fracture. Another enhancing lesion within L1 vertebral body, favor metastatic lesion. Then referred for radiotherapy.
      • Family history: (father: lung cancer)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
    • O:
      • ECOG: 3
      • PE: pain of bilateral hip area.
      • CT scan of lung (2022-08-15): left huge breast cancer T4bN3M1
      • Bone scan (2022-08-16): Decreased activity in the body of the sternum. Bone destruction may show this picture.
      • Pathology (S2022-13196, 2022-8-16): Breast, left, biopsy — Invasive carcinoma of no special type. ER (Ab): Negative, PR (Ab): Negative (<1%, moderate), Her-2/neu (Ab): Negative (0), Ki-67: 90%.
      • MRI of brain (2022-08-24): 1. no evidence of brain metastasis. 2. high SI chnage on T2WI in the visible C-cord. Please correlate with C-spine MRI.
      • PET (2022-11-08): 1. Mild glucose hypermetabolism in a left axillary lymph node and a right axillary lymph node, compatible with metastatic lymph nodes s/p treatment change. 2. Mild glucose hypermetabolism in the left anterior chest wall, compatile with primary breast malignancy s/p treatment change.
      • Bone scan (2023-07-05): Increased activity in the body of the sternum, the nature is to be determined (bone mets, post-traumatic change, or other nature ?).
      • CT scan of lung (2023-10-25): left breast cancer with axillary LNs metastasis, stationary of primary tumor but axillart LAP enlarged compared with CT on 2023/7/13.
      • RT (2023-11-16 ~ 2023-12-27): 5000cGy/25 fractions of the left breast to axilla, and 6000cGy/30 fractions of the reduced left breast and axilla tumor area.
      • Bone scan (2024-06-04): In comparison with the previous study on 2024/05/20, the lesions in the middle C-spines and L3-5 spines are a little more evident. The nature is to be determined (degenerative change in a little more severe status? other nature?).
      • CT scan of lung (2024-02-27): left breast cancer with axillary LN metastasis, in regression but new lesions at R breast (metastatic or abscess lesions) and extensive sking thickening of anterior chest wall, and LLL metastasis as compared with CT on 2023/10/25.
      • MRI of L spine (2024-06-11): 1. Fracture of L4 vertebral body with ill-defined enhancing mass lesions, favor pathological fracture. 2. Another enhancing lesion within L1 vertebral body, favor metastatic lesion. 3. Severe spianl stenosis at L4 level.
    • A:
      • Invasive carcinoma of no special type of the left breast, ER (Ab): Negative, PR (Ab): Negative (<1%, moderate), Her-2/neu (Ab): Negative (0), initial stage cT4bN3M1, s/p chemotherapy, with recurrence and progression of the left axillary nodal lesion, s/p radiotherapy, under chemotherapy.
        
    • P:
      • Raditherapy is indicated for this patient with the following indicators: L spine metastases
      • Goal: palliation
      • Treatment target and volume: L1 ~ L4
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 3000cGy/10 fractions of the L1 ~ L4 spine lesions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient. She understand and agree to receive radiotherapy. The treatment planning of radiotherapy was already started this afternoon.
• 2024-06-12 Orthopedics
  • Q
    • Chief Complaints:
      • Low back and left buttock pain aggravated
      • pain and numbness in left calf and foot.
      • unable to bear weight
    • PH : breast Ca , under C/T for 2 yrs
      • Invasive carcinoma of L breast, cT4bN3M1, stage IV, ER (Ab):  Negative  . PR (Ab): Negative ( ＜ 1%, moderate). Her-2/neu (Ab): Negative (0) Ki-67: 90%
      • Herpes Zoster at Right trunk-buttock and limb
      • Chronic viral hepatitis B without delta-agent
      • hyponatremia
      • constipation
      • mild Chronic left mastoiditis. 
    • Drug allergy: Denied
  • A
    • S
      • Severe and progressive lower back pain today
      • Invasive carcinoma of L breast, cT4bN3M1, stage IV, triple negative, under chemotherapy for 2 years
      • History of herpes zoster at right thigh, cured
    • O
      • Severe lower back pain, extending to left buttock area and left anterior leg, favor L5 distribution
      • Sensory : No nubness or parethesia
        • mild discomfort over right right, suspect post herpes zoster related
      • MP : Bilateral 5/5
      • DTR : bilateral ++/++
      • L-spine x-ray : moderate spurs formation
      • Tc-99m MDP whole body bone scan : Increased uptake near L3-5 area
      • MRI : suspect L4 vertebral body metastasis with collapse and L4 level neurocompression
    • P
      • Admit to Ortho ward for pain control
      • May consult Oncology man for further assessment and management
      • Explain the current condition and management to the patient and family (son)

[chemotherapy]

• 2024-05-28 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-05-14 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-04-30 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-04-16 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-04-02 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-03-19 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-03-12 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-02-20 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-01-30 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-01-23 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2024-01-09 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-12-19 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-11-28 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-11-14 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-11-07 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-10-17 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-09-12 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-09-05 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-08-22 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-08-15 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-08-01 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-07-28 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2023-02-13 - cyclophosphamide 600mg/m2 950mg NS 500mL 1hr + epirubicin 60mg/m2 95mg NS 100mL 30min + fluorouracil 600mg/m2 950mg NS 100mL 30min (CEF75, next time Epicin returns to 75mg/m2)

docetaxel 75mg/m2 and carboplatin AUC 6, cycled every 21 days x 4-6 cycles, preoperative setting only - NCCN 2022-06-21

• 2022-12-22 docetaxel 65mg/m2 100mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 1230 1.27)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
• 2022-12-01 docetaxel 65mg/m2 100mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 1210 1.88)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
• 2022-10-24 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 1102 0.80)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
• 2022-10-03 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
• 2022-09-12 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 0920 0.70)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
• 2022-08-23 docetaxel 60mg/m2 90mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 0830 0.68, 0831 0.74)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
• G-CSF
  • 2022-12-30 filgrastim 150ug SC (20221230 OPD)
  • 2022-12-26, -27 lenograstim 250ug SC (20221222 IPD)
  • 2022-12-10 lenograstim 250ug SC (20221210 OPD)
  • 2022-12-05, -06 lenograstim 250ug SC (20221201 IPD)
  • 2022-12-02, -03 lenograstim 250ug SC (20221201 IPD)
  • 2022-11-24 lenograstim 250ug SC (20221124 OPD)
  • 2022-11-02 filgrastim 150ug SC (20221102 OPD)
  • 2022-08-31 filgrastim 150ug SC (20220831 OPD, IPD)

PREOPERATIVE/ADJUVANT THERAPY REGIMENS - HER2-Negativeb (Breast Cancer NCCN Guidelines 20220621 Version 4.2022, BINV-L 1 OF 9, p55)

• Preferred Regimens:
  • Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
  • Dose-dense AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
  • TC (docetaxel and cyclophosphamide)
  • Olaparib, if germline BRCA1/2 mutations
  • High-risk triple-negative breast cancer (TNBC): Preoperative pembrolizumab + carboplatin + paclitaxel, followed by preoperative pembrolizumab + cyclophosphamide + doxorubicin or epirubicin, followed by adjuvant pembrolizumab
  • TNBC and residual disease after preoperative therapy with taxane-, alkylator-, and anthracycline-based chemotherapy: Capecitabine
• Useful in Certain Circumstances:
  • Dose-dense AC (doxorubicin/cyclophosphamide)
  • AC (doxorubicin/cyclophosphamide) every 3 weeks (category 2B)
  • CMF (cyclophosphamide/methotrexate/fluorouracil)
  • AC followed by weekly paclitaxel
  • Capecitabine (maintenance therapy for TNBC after adjuvant chemotherapy)
• Other Recommended Regimens:
  • AC followed by docetaxel every 3 weeksc
  • EC (epirubicin/cyclophosphamide)
  • TAC (docetaxel/doxorubicin/cyclophosphamide)
  • Select patients with TNBC:
    • Paclitaxel + carboplating (various schedules)
    • Docetaxel + carboplating (preoperative setting only)

==========

2023-09-19

According to PharmaCloud records, the patient has only been seen at our hospital for the past three months. After reviewing the HIS5 records, no medication reconciliation issues were identified.

[Trodelvy (sacituzumab govitecan)]

Trodelvy (sacituzumab govitecan) has received approval from the TFDA and is prescribed for two specific indications:

• It is used to treat adult patients with locally advanced or metastatic triple-negative breast cancer who have undergone at least two unsuccessful systemic treatments, with one of them being for advanced disease.
• It is also suitable for the treatment of adult patients with unresectable locally advanced or metastatic hormone receptor-positive, human epidermal growth factor receptor 2-negative (IHC 0, IHC 1+, or IHC 2+/ISH–) breast cancer who have previously received a minimum of two systemic treatments for metastatic breast cancer.

However, it’s important to note that this medication is not currently covered by the NHI program. Therefore, it may pose a financial burden for patients who are economically disadvantaged.

2023-01-01

• Several neutropenia events occurred around one week after the chemotherapy was administered.
  • 2022-12-30 WBC 1.27 *10^3/uL
  • 2022-12-10 WBC 1.88 *10^3/uL
  • 2022-11-02 WBC 0.80 *10^3/uL
  • 2022-09-20 WBC 0.70 *10^3/uL
  • 2022-08-31 WBC 0.74 *10^3/uL
  • 2022-08-30 WBC 0.68 *10^3/uL
• There is no problem with treating neutropenia with G-CSF (granulocyte colony stimulating factor).

2022-12-23

• The patient’s underlying condition of HBV carrier status is being managed with Baraclude (entecavir). Vital signs are stable and lab data showed no significant abnormalities.

2022-12-02

• The CT on 2022-11-09 indicated that the left breast cancer responded to the regimen of [docetaxel + carboplatin].

2022-10-04

• The use of olaparib may be an option in cases of germline mutations of BRCA1/2.
• The NCCN breast cancer evidence blocks (2022-06-21 version 4.2022): The use of platinum agents in the adjuvant setting is not recommended. If platinum agents are included in an anthracycline based regimen, the optimal sequence of chemotherapy and choice of taxane agent is not established.

700806859

240619

{gastric cancer, T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414}

[exam findings] (not completed)

• 2024-06-03 PET
  • Increased FDG uptake in the stomach, compatible with gastric cancer s/p treatment reaction.
    
  • Increased FDG uptake in the right lower and left lower lungs, highly suspected cancer with distant metastases, suggesting biopsy for further investigation.
  • Glucose hypermetabolism in both lobes of the thyroid glands, probably benign in nature.
    
  • Increased FDG accumulation in bilateral kidneys, ureters, and colon, probably physiological uptake of FDG.
    
  • HIghly suspected gastric cancer with bilateral lower lungs metastases, cTxNxM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2024-05-21 SONO - abdomen
  • Symptoms:
    • Liver:
      • Smooth liver surface. Increase brightness along the biliary tree especially left side.
    • Bile duct and gallbladder:
      • No gallbladder stone. No CBD dilatation. No gallbladder distention. Significant gall bladder wall layering was noted.
    • Portal veins and blood vessels:
      • Patent portal vein.
    • Kidney:
      • No definite stone or hydronephrosis.
    • Pancreas:
      • Some parts of pancreas blocked by bowel gas, especially head and tail
    • Spleen:
      • No splenomegaly
    • Ascites:
      • Minimal ascites near the liver surface.
    • Others:
      • Pleural effusion with thick septum was noted at left pleural cavity. Minimal right pleural effusion.
  • Diagnosis:
    • Cholecystopathy
    • Ascites, minimal
    • Complicated pleural effusion, left lung
• 2024-05-13 SONO - chest
  • left side minimal amount of pleural effusion
  • right side moderate amount of pleural effusion, pig-tail drainage via right 7th ICS posterior mid-axillary line was performed and serosangious fluid was drained out smoothly.
• 2024-05-11 KUB
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L2-3.
• 2024-05-09 SONO guiding aspiration
  • left pleural effusion, s/p drainage
• 2024-05-07 PD-L1 (28.8)
  • Cellblock No. S2024-08556
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS >= 5
    • Combined Positive Score (CPS): 20
• 2024-05-07 SONO - chest
  • Symptom: dyspnea
  • Indication: Gastric cancer with pleural metz and bilateral pleural effusion
  • Findings
    • Left-side of thorax:
      • Pleura positive Pleura Line thick
      • Effusion: Echogenicity clear extending from the posterior to the anterior
      • Size 2-3-ICS
      • Lung passive atelectasis
    • Right-side of thorax:
      • Pleura positive Pleura Line thick
      • Effusion: Echogenicity clear extensive
      • Size > 3-ICS
      • Lung passive atelectasis
  • Special Procedure
    • echo-assisted
    • Pleural tapping 16 #-needle Right side 1150ml serosanguineous
  • Echo diagnosis
    • Pleural effusion, massive amount, right, s/p tapping
    • Pleural effusion, moderate amount, left
    • Bilateral lower lung atelectasis
• 2024-05-03 SONO - chest
  • Special Procedure
    • Pleural tapping 16# needle Right side 1100 ml serosanguineous
  • Echo diagnosis
    • Pleural effusion, right, massive, s/p tapping
    • Pleural effusion, left, moderate amount
• 2024-04-30 Patho - pleural/pericardial biopsy
  • Pleura, right, biopsy — Consistent with metastatic gastric adenocarcinoma
    
  • Sections show fibroadipose and skeletal muscular tissue with glandular and solid nests of tumor cells and signet-ring cells.
  • The immunohistochemical stains reveal CK7(+), CK20(-), CDX2(+), TTF-1(-), and Calretinin(-). The results are consistent with metastatic gastric adenocarcinoma. Please correlate with the clinical presentation.
• 2024-04-29 SONO - chest
  • Special Procedure
    • Pleural tapping 16# needle Right side 50 ml serosanguineous
    • Abram’s needle pleural biopsy Right side 4 pieces of specimen
  • Echo diagnosis
    • left side trivial amount of pleural effusion
    • right side small amount of pleural effusion, 50cc serosangious fluid was aspirated for analysis, pleural biopsy was done and the speciment was sent for pathology and tissute TB culture.
• 2024-04-23 Bronchial challenge test
  • Pulmonary function test:
    • Basline:
      • FVC: 1.17
      • FEVI: 0.80
      • BORG:
    • Cutoef value:
      • FVC: 1.05
      • FEVI: 0.72
      • BORG:
    • Buffer:
      • FVC: 1.11
      • FEVI: 0.78
      • BORG:
    • Cotoef value:
      • FVC: 0.89
      • FEVI: 0.62
      • BORG:
    • 0.075
      • FVC: 1.17
      • FEVI: 0.84
      • BORG: 1
    • 0.15
      • FVC: 1.12
      • FEVI: 0.80
      • BORG: 1
    • 1.25
      • FVC: 1.03
      • FEVI: 0.68
      • BORG: 2
    • 2.50
      • FVC: 0.89
      • FEVI: 0.57
      • BORG: 3
    • 5.00
      • FVC:
      • FEVI:
      • BORG:
    • 10.00
      • FVC:
      • FEVI:
      • BORG:
    • 25.00
      • FVC:
      • FEVI:
      • BORG:
    • Bronchodilator
      • FVC: 1.08
      • FEVI: 0.78
      • BORG: 1
  • Result PC20: < 2.5 mg/ml (Reference Bronchodilator Norman Vaiue PC20 25 mg/ml)
  • Conclusion
    • Provocated obstructive ventilatory impairement with small airway obstruction
• 2024-04-02 SONO - chest
  • Echo diagnosis
    • Bilateral small amount pleural effusion; s/p drainage of 450 cc, left side, yellowish pleural effusion.
    • Severe cough during left side pleural effusion drainage; Remove the needle early
• 2024-03-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (89.1 - 21.9) / 89.1 = 75.42%
    • M-mode (Teichholz) = 75.4-79.2
    • 2D (M-Simpson) = 66.5
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, trivial TR, normal IVC size
• 2024-03-09 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Loculated effusion at bilatral hemithorax is found. Mild Consolidation of right lower lobe and left lower lobe is also noted. Diffuse tree in bud appearance at bilateral lungs is found. Bronchiolitis and pneumonitis with pleural effuison is favored.
    • s/p partial gastrectomy.
  • Imp:
    • Loculated effusion at bilatral hemithorax is found. Mild Consolidation of right lower lobe and left lower lobe is also noted. Diffuse tree in bud appearance at bilateral lungs is found. Bronchiolitis and pneumonitis with pleural effuison is favored.
• 2024-03-08 SONO - chest
  • Special Procedure
    • Pleural tapping 16# needle Left side 320 ml yellowish, cloudy
  • Echo diagnosis
    • Bilateral pleural effusion (Left: small and Right: trivial), post left diagnostic and therapeutic thoracentesis.
    • Ascites presented in abdominal cavity.
• 2024-03-04 SONO - chest
  • Special Procedure
    • Pleural tapping 16# needle Left side 500 ml serosanguineous
  • Echo diagnosis
    • right side trivial amount of pleural effusion
    • left side moderate amount of pleural effusion, 500cc serosangious fluid was aspirated for analysis.
• 2024-02-22 EGD
  • Reflux esophagitis LA Classification grade A(minimal)
  • Remnant gastritis
  • Bile reflux
  • Post subtotal gastrectomy with Billroth II anastomosis
• 2024-02-20 ECG
  • Normal sinus rhythm
  • Nonspecific T wave abnormality
  • Prolonged QT
• 2024-02-20 CT - abdomen
  • S/P operation. No evidence of tumor recurrence.
  • Grade 4 fatty liver.
  • Bil. pleural effusions.
• 2024-01-30 SONO - abdomen
  • Fatty liver, moderate with focal sparing
• 2023-09-27 CT - abdomen
  • History: gastric CA. T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 4/14 22 by Dr Wu ChaoQun.
  • Findings:
    • S/P subtotal gastrectomy.
    • Moderate fatty liver, grade 4-5.
      • There is fat sparing area in S1 and S2/3.
    • S/P hysterectomy
• 2023-09-04 SONO - abdomen
  • Diagnosis:
    • Fatty liver, moderate to severe
    • Fatty infiltration of pancreas
  • Suggestion:
    • Hepatic lesion may be masked by fatty liver background
• 2023-05-19 EGD
  • Reflux esophagitis LA Classification grade A
  • Remnant gastritis
  • Bile reflux
  • Post subtotal gastrectomy with Billroth II anastomosis
• 2023-05-16 CT - abdomen
  • S/P subtotal gastrectomy. Suggest follow up.
  • S/P hysterectomy.
  • Fatty liver and focal fatty sparying regions.
• 2023-03-14 SONO - abdomen
  • Diagnosis:
    • Fatty liver, severe
    • Non-fasting GB
  • Suggestion:
    • Vary poor echo quailty because of severe fatty liver. Please correlate with other image study
• 2023-02-17, -02-01 KUB
  • Disc space narrowing with marginal osteophyte formation of L2-3.
  • Fecal material store in the colon.
  • S/P metalic autosuture projecting at left upper abdomen that is c/w S/P subtotal gastrectomy.
• 2022-11-23 CT - abdomen
  • History: gastric CA. T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414
  • Findings:
    • S/P subtotal gastrectomy.
    • Moderate fatty liver, grade 4-5.
    • There is fat sparing area in S1 and S2/3.
    • S/P hysterectomy
  • Impression:
    • S/P subtotal gastrectomy.
    • There is no evidence of tumor recurrence.
• 2022-10-03 SONO - abdomen
  • suboptimal examination of liver
  • fatty liver, severe
  • fatty infiltration of pancreas
• 2022-09-20 CXR
  • right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2022-09-20, -06-24 KUB
  • Disc space narrowing with marginal osteophyte formation of L2-3.
  • Fecal material store in the colon.
• 2022-04-14 Patho - stomach subtotal/total (tumor)
  • Diagnosis
    • Stomach, lesser curvature midbody, laparoscope subtotal gastrectomy with LN D2 dissection — adenocarcinoma, moderately differentiated. invading muscularis mucosa, confirmed with IHC stain of cytokeratin.
    • Lymph node, LN 1,3-9, 11p ,12a, 14v, LN D2 dissection — metastatic carcinoma
    • pT1a pN3a (if cM0); pStage: IIB, at least.
  • Gross Description:
    • Procedure: laparoscope subtotal gastrectomy with LN D2 dissection
    • Tumor Site: lesser curvature midbody
    • Tumor Size: 1.8 x 1.5 cm
    • Gross configuration: Type IIc: Flat, slightly depressed
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
      • Lauren classification of adenocarcinoma: Intestinal type
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades the muscularis mucosae
    • Margins
      • Proximal margin: uninvolved by invasive carcinoma. > 4 cm away
      • Distal margin: uninvolved by invasive carcinoma. > 4 cm away.
      • Radial margin: uninvolved by invasive carcinoma.
    • Lymphovascular Invasion: not identified.
    • Perineural Invasion: not identified.
    • Regional Lymph Nodes
      • Number of lymph nodes involved/examined: 8/32.
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition): IIB, at least.
      • TNM Descriptors (required only if applicable): N/A.
        • Primary Tumor (pT): pT1a: Tumor invades the lamina propria or muscularis mucosa
        • Regional Lymph Nodes (pN): pN3a: Metastasis in seven to 15 regional lymph nodes
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case) (if cM0);
    • Additional Pathologic Findings- None identified
    • Ancillary Studies – IHC stains: (result of biopsy specimen S2022-06142): Her2/neu: negative (score=0)
• 2022-04-12 Patho - stomach biopsy
  • Stomach, LC side of low body, biopsy — Adenocarcinoma.
  • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
• 2022-04-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (96 - 28) / 96 = 70.83%
    • LVEF (%) = 71
    • M-mode (Teichholz) = 71
  • Normal LV systolic function with normal wall motion.
  • Normal LV diastolic function.
  • Normal RV systolic function.
  • Trivial MR; trivial TR; trivial PR.
• 2022-03-29 CT - abdomen
  • Imaging Report Form for Gastric Carcinoma
  • Impression (Imaging stage): T:Tx(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • Impression: Clinical gastric cancer, cstage T1N0M0. Suggest clinical correlation.
• 2022-03-16 Patho - stomach biopsy
  • Stomach, low body, biopsy — Adenocarcinoma
  • Microscopically, the sections show a picture of adenocarcinoma of the gastric tissue characterized by tumor cells arranged in tubular, fused glandular or cribriform pattern with enlarged and hyperchromatic nuclei infiltrating in ulcerative stroma.
  • Immunohistochemistry of CK(+) and Her2/neu (-, Dako score 1+) for tumor cells.
  • Besides, mild intestinal metaplasia and colony of Helicobacter pylori are also present.
• 2021-02-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 23) / 93 = 75.27%
    • M-mode (Teichholz) = 76
  • Conclusion:
    • Normal LV filling pressure; impaired RV relaxation.
    • Normal LV and RV systolic function.
• 2020-10-07 MRI - L-spine
  • Lumbar spondylosis, esp L2-3. Cervical spondylosis, esp C5-6-7.

[MedRec]

[consultation]

• 2022-10-19 Ophthalmology
  • Q
    • for left eye reddish & dry
    • This 55-year-old female, a pt of gastric CA. T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414 S/P C/T with FOLFOX. She was admitted for C/T.
    • She complained of left eye reddish & dry for days. We need expertise to evaluate her condition thanks!
  • A
    • Itchy and soreness ou for 3 days, redness os for days, no worsen BV
    • Gastric cancer T1a pN3a cM0, pStage: IIB, s/p op, under chemotherapy (Oxaliplatin, high-dose 5-fluorouracil)
      • HBV infection under entacavir
      • OPHx: op(-), nka
      • BCVA: OD 0.05(0.5X-2.50/-1.25X55) OS 0.05(0.5X-2.00/-1.50X95)
      • PT: 11/11mmHg
      • Pupil: 3mm, light reflex + ou, no RAPD
      • Conj: np od, temporal SCH os
      • K: clear ou
      • a/c: deep/clear ou
      • lens: co+ od, co++, psc + os
      • c/d 0.3 ou
      • fundus macula ok, retinal vessels ok ou
    • A:
      • Subconjunctival hemorrhage os
      • Cataract ou
    • P:
      • Kary 1gtt BID ou + Eyehelp 1gtt QID ou
      • oph opd f/u
• 2022-04-15 Rheumatology
  • Q
    • This 55yo female has underlying diseases of:
      • breast cancer
      • myasthenia gravis, prednisolone 15mg QD (0413 hold) and pyridostigmine
      • hypothyroidism
    • This time, she was admitted for gastrectomy on 20220414.
    • We would like to consult your expertise for post-operative medication (IV form) adjustment due to NPO for many days.
  • A
    • History review was perdormed. Patient was admitted for gastrectomy. She has medical Hx of MG & took prednisolone 15mg QD. For post-operation NPO, I was consulted for adjusting IV form steroid dosage.
    • Suggestion:
      • Treatment as current your expert’s maangement.
      • Please add Decan 4mg IV QD for 3-7 days. Then shift to regular oral prednisolone dosage.

[surgical operation]

• 2022-04-14 laparoscope subtotal gastrectomy with LN D2 dissection
  • subtotal gastrectomy with LN 1,3-9, 11p ,12a, 14v dissection
  • anticolic isoperistalsis B-II anastomosis

[radiotherapy]

• 2022-05-18 ~ 2022-06-24 - 4500cGy/25 fractions (6 MV photon) to stomach and regional lymphatics

[chemoimmunotherapy]

• 2024-06-19 - nivolumab 200mg NS 100mL 1hr + docetaxel 50mg/m2 75mg NS 250mL 1hr + cisplatin 30mg/m2 45mg NS 500mL 2hr + leucovorin 200mg/m2 300mg NS 250mL 2hr + fluorouracil 2600mg/m2 4000mg NS 500mL 46hr (FLOT. Due to the patient reaching her individual cumulative dose limit for oxaliplatin in the chemotherapy preparation room (not including data from external hospitals), cisplatin was substituted instead. The NP said that the patient had numbness in his hands about halfway through the previous course of FOLFOX treatment.)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-05-24 - docetaxel 50mg/m2 75mg NS 250mL + leucovorin 200mg/m2 300mg NS 250mL 2hr + fluorouracil 2600mg/m2 3950mg NS 500mL 46hr (FLOT without Oxa)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-05-09 - docetaxel 50mg/m2 75mg NS 250mL + leucovorin 200mg/m2 300mg NS 250mL 2hr + fluorouracil 2600mg/m2 4000mg NS 500mL 46hr (FLOT without Oxa)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-04-24 - (FOLFOX Q2W)
• 2023-03-24 - (FOLFOX Q2W)
• 2023-02-17 - (FOLFOX Q2W)
• 2023-01-30 - (FOLFOX Q2W)
• 2022-12-22 - (FOLFOX Q2W)
• 2022-12-07 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4780mg 46hr (FOLFOX Q2W)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
• 2022-11-04 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4750mg 46hr (FOLFOX Q2W)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
• 2022-10-19 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr (FOLFOX Q2W)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
• 2022-09-21 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4780mg 46hr (FOLFOX Q2W)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
• 2022-08-25 - oxaliplatin 80mg/m2 130mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4720mg 46hr (FOLFOX Q2W)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
• 2022-08-12 - oxaliplatin 70mg/m2 118mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4720mg 46hr (FOLFOX Q2W)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
• 2022-07-20 - oxaliplatin 60mg/m2 100mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4790mg 46hr (FOLFOX Q2W)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
• 2022-06-20 - fluorouracil 225mg/m2 380mg 24hr D1-5 (5-FU CCRT)
  • diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
• 2022-06-13 - fluorouracil 225mg/m2 380mg 24hr D1-5 (5-FU CCRT)
  • diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
• 2022-06-10 - fluorouracil 225mg/m2 380mg 24hr D1 (5-FU CCRT)
  • diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg

COXAL01 Oxalip package insert - 2024-06-19

• Oxaliplatin-induced neurotoxicity is dose-related. It involves peripheral sensory neuropathy, which can manifest as difficulty performing fine motor tasks due to sensory nerve damage. The risk of developing permanent symptoms is 10% and 20% for cumulative doses of 850 mg/m2 (10 administrations) and 1020 mg/m2 (12 administrations), respectively.

Chemotherapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) - 2024-05-24 - https://www.uptodate.com/contents/image?imageKey=ONC%2F120512

• Cycle length:
  • 14 days.
• Duration of therapy:
  • In the original trial, preoperative FLOT was given every 14 days for 4 cycles.
  • Following surgery, postoperative FLOT was given every 14 days for 4 cycles.
• Regimen
  • Docetaxel
    • 50 mg/m2 IV
    • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
    • Day 1
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (oxaliplatin and leucovorin can be administered concurrently in separate bags using a Y-connector).
    • Day 1
  • Leucovorin
    • 200 mg/m2 IV
    • Dilute in 250 mL D5W and administer over two hours concurrent with oxaliplatin.
    • Day 1
  • Fluorouracil (FU)
    • 2600 mg/m2 IV
    • Dilute in 500 to 1000 mL D5W and administer over 24 hours (begin immediately after completion of leucovorin infusion).
    • To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose can be diluted in 100 to 150 mL NS or D5W.
    • Day 1
• Suggested dose modifications for toxicity:
  • Myelotoxicity
    • Do not start a new cycle until WBC count is >=3000/microL independent of the granulocyte count, platelet count is >100,000/microL, and there is no other toxicity >grade 1. The original protocol specified a 25% dose reduction for docetaxel and oxaliplatin for patients who experienced febrile neutropenia despite G-CSF use, thrombocytopenia causing bleeding, or any other dose-limiting hematologic toxicity(ies). Further reduction of docetaxel and oxaliplatin to 50% of the original dose is recommended for recurrence of hematologic toxicity after the first dose reduction.
  • Hepatotoxicity
    • Do not treat with a new cycle unless the total bilirubin is <1.3 mg/dL. For intracycle increases of AST/ALT >2.5 but ≤5 times the ULN with ALP <2.5 times the ULN or AST/ALT >1.5 to <=5 times the ULN with ALP >2.5 to <=5 times the ULN, reduce docetaxel by 20%. Discontinue docetaxel if AST/ALT is >5 times the ULN and/or ALP is >5 times the ULN.
  • Diarrhea
    • For diarrhea exceeding grade 2, a 25% dose reduction for both docetaxel and FU is recommended. Do not restart treatment until diarrhea is <=grade 1.
    • Severe diarrhea, mucositis, and myelosuppression after FU should prompt evaluation for DPD deficiency.
  • Cardiotoxicity
    • Cardiotoxicity observed with FU includes angina, myocardial infarction/ischemia, dysrhythmias, acute pulmonary edema, heart failure, cardiac arrest, and sudden death.
    • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of FU administration following development of cardiac toxicity, and the drug should be discontinued.
  • Pulmonary toxicity
    • Withhold oxaliplatin for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis is excluded.
  • Cutaneous and mucosal toxicity
    • Hold FU for grade 2 or greater palmar-plantar erythrodysesthesia, and reduce subsequent dose by 20%. For mucositis exceeding grade 2, reduce dose of docetaxel and FU by 25%.
  • Neurologic toxicity
    • For paresthesia or dysesthesia persisting between cycles, reduce oxaliplatin dose by 25%. For paresthesia or dysesthesia with pain or functional impairment lasting between 7 and 14 days, reduce oxaliplatin by 50%. However, if paresthesia or dysesthesia with pain or functional impairment persists between cycles, oxaliplatin is omitted in further cycles until resolution.
    • There is no recommended dose for resumption of FU administration following development of hyperammonemic encephalopathy, acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances; the drug should be permanently discontinued.
  • Other nonhematologic toxicity
    • In the original protocol, all agents were reduced by 25% for nonhematologic toxicity(ies) exceeding grade 2. A further reduction of all agents to 50% of the original dose was recommended if toxicities recurred after the first dose reduction.
  • If there is a change in body weight of at least 10%, doses should be recalculated.

==========

2024-05-24

[Neutropenia Resolved, Leukocytosis Developed - FLOT Chemo Planned]

The neutropenia reached its nadir on 2024-05-20. There is no longer any evidence of neutropenia.

Conversely, leukocytosis has now developed. The second session of FLOT chemotherapy is scheduled for 2024-05-24.

• 2024-05-23 Neutrophil 70.8 %

• 2024-05-20 Neutrophil 19.6 % ***

• 2024-05-16 Neutrophil 80.4 %

• 2024-05-23 WBC 20.07 x10^3/uL

• 2024-05-20 WBC 1.56 x10^3/uL ***

• 2024-05-16 WBC 2.96 x10^3/uL

• 2024-05-13 WBC 8.18 x10^3/uL

• 2024-05-09 WBC 9.57 x10^3/uL

• 2024-05-07 WBC 9.30 x10^3/uL

• 2024-04-29 WBC 7.95 x10^3/uL

• 2024-04-23 WBC 8.23 x10^3/uL

2022-12-08

The serum ALT level trended upward.

• 2022-12-07 S-GPT/ALT 61 U/L
• 2022-11-22 S-GPT/ALT 66 U/L
• 2022-11-14 S-GPT/ALT 66 U/L
• 2022-10-19 S-GPT/ALT 52 U/L
• 2022-09-20 S-GPT/ALT 58 U/L
• 2022-08-25 S-GPT/ALT 25 U/L
• 2022-08-16 S-GPT/ALT 36 U/L
• 2022-08-11 S-GPT/ALT 22 U/L
• 2022-07-26 S-GPT/ALT 14 U/L
• 2022-07-19 S-GPT/ALT 26 U/L
• 2022-06-20 S-GPT/ALT 14 U/L
• 2022-06-13 S-GPT/ALT 18 U/L
• 2022-06-10 S-GPT/ALT 26 U/L
• 2022-06-01 S-GPT/ALT 25 U/L

The use of oxaliplatin has been associated with an increase in ALT levels (incidence of 36% with monotherapy)

There is no need to adjust the dosage of the components in the current regimen of FOLFOX.

The addition of pyridostigmine as a self-carried item is recommended for the patient with myasthenia gravis since this medication has no known heavy interactions with the active prescription.

700567611

240618

[exam findings]

• 2024-06-07 Patho - mediastinum mass
  • Soft tissue, chest wall, CT-guide biopsy — T-cell lymphoma
  • Specimen submitted in formalin consists of 4 strips of tan, irregular tissue measuring up to 1.5 x 0.4 x 0.3 cm. All for section in one cassette.
  • Section shows diffusely infiltrative medium to large lymphoid cells.
  • The immunohistochemical stains reveal CK(-), p40(-), CD3(+), CD20(-), CD4(+), CD8(focal +), CD5(+), TdT(-), Granzyme B(-), CD56(-), CD34(-), CD30(-), and CD21(-). The Ki-67 is about 30%. The results are suspicious of peripheral T-cell lymphoma or T-lymphoblastic lymphoma. Please correlate with the clinical presentation.
• 2024-06-04 CT - chest
  • without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • a huge, homogeneous density, soft-tissue tumor lesion (about 13x13x82mm in size), with small areas of necrosis, occupying the lower anterior mediastinal compartment and adjacent anterior chest wall, that extends to adjacent abdominal cavity. the lesion severely compresses and posteriorly displaces the Rt ventricle of heart and left lobe of liver.
    • massive pericardial effusion and moderate Lt pleural effusion with partial relaxation atelectasis LLL of lung.
    • a large left supraclavicular lymphadenopathy is visible.
    • nodular ground glass opacities in both upper lobes of lungs.
    • a tiny gallstone. mild splenomegaly. unremarkable of the pancreas and both kidneys and adrenal glands. no enlarged LN.
  • Impression:
    • huge chest wall or anterior mediastinal tumor involving the chest wall and abdomen, with massive pericardial effusion and moderate pleural effusion, and metastatic Lt supraclivular LN, malignant lymphoma d/d metastasis or plasmacytoma.
• 2024-05-30 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 22.8) / 81.3 = 71.96%
    • M-mode (Teichholz) = 72
  • Conclusion:
    • Normal chamber size
    • Large pericardial effusion without cardiac tamponade
    • About 5x6 cm mass lesion with external compression to RV
    • Adequate LV and RV systolic function
    • Mild MR and TR
    • No regional wall motion abnormalities
• 2023-05-29 Patho - gingival/oral mucosa biopsy
  • Buccal tissue, premaxilla area, left, removal of tumor — Organizing granulation tissue with chronic inflammation, fibrosis and pseudoepitheliomatous hyperplasia
  • The sections show a picture of moderate chronic inflammatory cells and mild neutrophils infiltrate, vascular proliferation, and fibrosis. The overlying squmous epithelium shows pseudoepitheliomaous hyperplasia. There is no evidence of malignancy in the sections examined.

[MedRec]

• 2023-12-31 ~ 2024-01-02 POMR Gastroenterology Wang JiaQi
  • Discharge diagnosis
    • Right flank pain, favor colon lesion.
    • Gallbladder stone
    • Calcificated uterine myomas
    • Major depressive disorder, recurrent episode,moderate
    • Panic disorder [episodic paroxysmal anxiety] without agoraphobia
    • Other sleep disorders
  • CC
    • Right flank pain and right side lower back pain for 2 days
  • Present illness
    • This 58 year-old male who had past history of Major depressive disorder regular at our Psychiatry follow up. According to the statement of the patient’s families and ER medical record.
    • This time, she suffered from right flank pain for 2 days. There was no fever, no uri s/s, no chest pain, no dyspnea, no N/V, no diarrhea, no tarry or bloody stool, no dysuria. Therefore, she was sent to our ER.
    • At MER, physical exam showed flat and soft, normoactive bowel sound; no tenderness; no rebounding pain; no CV angle tenderness. the TPR showed SBP:117/77mmHg; HR:108; BT:37.7’C; RR:18; Con’s:E4V5M6; SpO2:97%. The laboratory studies disclosed no leukocytosis with increase of CRP level; Normocytic anemia; The KUB showed Nonspecific increased bowel gas pattern in the abdomen, the Abdominal CT disclosed Ileus with gas-filled distended large bowel loops of the abdomen.
    • Under impress of Right side abdominal pain suspect severe ileus with colitis. She was admitted for further evaluation and management.
  • Course of inpatient treatment
    • After admission, NPO with IV fluid supplement. Medicines as Psychiatrist suggestion were used. Right flank pain and lower back pain were improving after medical treatment.
    • In addition, Sketa 1# po TID was used for pain control.
    • GYN was consulted for pelvic calcified tumor and the impression of calcificated uterine myomas who suggested regular GYN OPD follow up.
    • Orthopaedist was consulted for management of lower back pain. Abdominal sonography was arranged for GB stone further survey.
    • Diet was tried since 1/2 and there was no more abdominal pain. We Explained this condition to herself (including do colonscopy for further survey), she understood but request against medical advice discharge.
    • After discussion about the risk and consequence, she agrees to afford the risk. Under a stable condition, she was AAD on 2024/01/02 and further GI/GYN/Ortho OPD were arranged later.
  • Discharge prescription
    • none
• 2023-05-24 ~ 2023-06-02 POMR Oral and Maxillofacial Surgery Xia YiRan
  • Discharge diagnosis
    • Epulis (biting-induced fibroma) of the premaxillary vestibule and fistular at the left maxilla combined with local inflammation post of removal of an oral tumor from the premaxilla of both sides, split-thickness graft reconstruction of the surgical defect (donor site is from left thight (5 *3 cm) and complicated tooth extraction of #23 on 2023/05/26.
    • infection of premaxillary vestibule
    • Major depressive disorder, recurrent, moderate
    • Panic disorder [episodic paroxysmal anxiety] without agoraphobia
    • Sleep disorders
  • CC
    • I was admitted for surgical intervention to remove a LUMP at my anterior upper gum which was present over half A year.
  • Present illness
    • According to her statement, the present illness should be traced back to half A year ago. This 58-year-old female patient noticed occasional pain with discomfort sensation at her anterior upper gum. Due to these symptoms, she aid to a local dental clinic for help, where a lump at her right lower jaw were told. She, therefore, visited to our O.S clinic for 2nd opinion. After the mouth exaination, a big epulis-like lump at her premaxillary vestibule combined with local inflammation at the premolar area were noted. Her panoramic film showed a bone root of #23. Besides, severe atrophy of the maxilla and periodontal bone loss WERE noted. After we had explained her conditions and treatment to the patient herself, she decided to have operations to solve her problems. She was admitted this noon for surgical intervention.
  • Course of inpatient treatment
    • After admission, a seris of pre-operation examination was done. Then we had arranged operation and evaluation anesthesia. She received soft tissue tumor excision from the premaxilla of both sides, STSG reconstruction of the surgical defect (donor site is from left thight (5 *3 cm) and complicated tooth extraction of #23 under GA on 2023/05/26.
    • Postoperatively, we keep monitor her STSG graft condition. Empirical antibiotic agent with Cefa 1g qd was prescribed.
    • Betamethasone was prescribed for the swelling control along with famotidine. Intraoral wound change dressing qd. Ice packing of face, cool liquid diet with high protein diet were educated. We found her flap partial dehiscence due to biting injury on 2023/05/29.
    • Because her general condition maintained stable after the operation. She was discharged this morning and arrange OPD follow-up.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ4H
    • amoxicillin 250mg 2# Q8H

[consultation]

• 2024-06-07 Diagnostic Radiology
  • Q
    • The 59 y/o has bipolar disorder. Her CT showed huge chest wall or anterior mediastinal tumor involving the chest wall and abdomen, so we need your help for biopsy. Thanks
  • A
    • This 59-year-old female patient is a case of mediastinal mass, r/o malignancy. CT-guided biopsy is indicated.
    • Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
• 2024-06-07 Vascular Surgery
  • Q
    • The 59 y/o has bipolar disorder. Her CT showed massive pericardial effusion and moderate pleural effusion. We need your help for assessment. Thanks
  • A
    • I have had the pleasure of involving with this patient’s care. In brief, She is a 59 year old female seen in consultation for opinion regarding treatment options for PP window for large amount of pericardial effusion. 　
      • Previous hx: huge mediastinal mass, compressing the ant. wall of the heart, with large pericardial effusion
      • upon my visit, her con’s clear, no O2 requirement, VSS
      • CT guided bx scheduled today
    • SUGGESTION & PLAN:
      • We have current evidence for large amount of pericardial effusion.
        
      • I think we have reached a point where there is prudence in considering surgical intervention (PP window) both for tissue proof aiding staging.
      • ok to MBD today, readmit on 2024/06/11 (TUE) on my service
      • also, pursue the pathology of the bx to determine if aggressive surgical resection warranted.
      • PP window will be scheduled on 2024/06/12 (WED)
      • SICU post-op
    • The patient is agreeable with my surgical consultation.
• 2024-03-15 Psychosomatic Medicine
  • Q
    • Triage level: 2 Chest pain/chest tightness > Suspected psychogenic chest pain/chest tightness. The patient has been angry recently and now feel that the air is accumulated in the chest. It cannot be dissipated and chest pain is now present.
  • A
    • To whom it may concern:
      • Relapse and recurrence of somatic anxiety including palpitation and chest pain had been noted sine one week ago
      • The patient herself reduced the prescribed drug Anxiedin 1# TID to QD and BID
    • Imp:
      • palpitation and chest pain, cause ??
      • depressive disorder with anxious distress
    • Plan to do :
      • It is recommended to add back Anxiedin 1# TID — routine prescription
      • OPD follow up
• 2024-01-02 Obstetrics and Gynecology
  • Q
    • for management of pelvic calcified tumor
    • This 58 year-old male who had past history of Major depressive disorder regular at our Psychiatry follow up. According to the statement of the patient’s families and ER medical record. This time the patient suffered from Right flank pain for 2 days, no fever, no uri s/s, no chest pain, no dyspnea, no N/V, no diarrhea, no tarry or bloody stool, no dysuria.therefore she was sent to our ER. At MER, physical exam showed flat and soft, normoactive bowel sound; no tenderness; no rebounding pain; no CV angle tenderness.the TPR showed SBP:117/77mmHg; HR:108; BT:37.7’C; RR:18; Con’s:E4V5M6; SpO2:97%. The laboratory studies disclosed no leukocytosis with increase of CRP level; Normocytic anemia; The KUB showed Nonspecific increased bowel gas pattern in the abdomen, The Abdominal CT disclosed Ileus with gas-filled distended large bowel loops of the abdomen.
    • Under impression of Right side abdominal pain suspect severe ileus with colitis?? She was admitted for further evaluation and management
    • Now, we need your management of pelvic calcified tumor. Thanks a lot!!
  • A
    • This is a 58 y/o female with Major depressive disorder regular at our Psychiatry follow up.
      • She was admitted for Right side abdominal pain suspect severe ileus with colitis
      • We were consulted for a pelvic calcified tumor
    • GYN:
      • menopaused (maybe 3 yrs according to the patient)
      • G0, sex(-)
    • Abd CT:
      • Ileus with gas-filled distended large bowel loops of the abdomen. No obvious obstructive lesion.
      • The both kidneys show normal contrast excretion, size, and contour without evidence of renal stone or tumors.
      • The liver parenchyma reveals no evidence of focal lesion.
      • The gallbladder is normal in size and wall thickness.
      • The pancreas & spleen appears normal in size and contour.
      • No evidence of ascites or intra-abdominal fluid collection.
      • No evidence of paraaortic or pericaval lymphadenopathy in this study.
        
    • TAS:
      • uterus 79*39mm, EM 2.4mm
      • Myoma 4036mm, 3128mm (both calcification)
      • ROV 118mm, LOV 1513mm
      • CDS no fluid
    • Impression:
      • calcificated uterine myomas
    • Suggestion:
      • GYN OPD f/u (The patient said she is followed up at NTUH, and 0.5-1 year inverval is recommended)
      • please contact us if other GYN lesion noted
• 2023-10-03 Psychosomatic Medicine
  • Q
    • Triage level: 4 Anxiety/Agitation > Mild anxiety/excitement, indicating random thoughts, crying during the examination, hyperventilation, indicating general discomfort
      • A lot of negative thoughts recently
      • Has difficulty waiting for her next psychiatry appointment
      • Also experiences shortness of breath, headaches, and chest pain
    • Allergy: nil
    • PH: panic disorder, depression, allergic rhinitis
  • A
    • S:
      • The case is a 58-year-old female. She has been diagnosed with major depression and panic disorder and has been receiving medical treatment in the Department of Psychosomatics of our hospital for a long time. In the past 2-3 weeks, she has had stressful events, mainly disputes over tooth extraction (the dentist’s attitude was lighthearted, and the patient suffered from nasal bleeding on the night of tooth extraction), symptoms such as mood swings, irritability, verbal abuse, anxiety, and physical symptoms (palpitations, numbness of hands).
    • O:
      • Mental Status Examination:
      • Appearance：Clear
      • Consciousness: well dressing
      • Attitude：Cooperation
      • Attention：Concentrated
      • Affect：irritable
      • Speech：Coherent and Relevant
      • Thoughts：No delusion of persecution and reference, no death thinking, denial of suicidal thinking
      • Behaviors：mild social avoiding, restlessness,
      • Perception：No illusion and hallucination
      • Insight：partial insight
      • JOMAC: Grossly intact
        
    • A:
      • Major depressive disorder, recurrent episode,moderate
    • P:
      • Arrange OPD follow up at Dr. Wang ZongXi.
      • Add paroxetine 0.5# and utapine 0.5# for 3 days.

[surgical operation]

• 2024-06-17
  • Surgery
    • Port-A insertion (RIJV approach, B Braun 8.5Fr)    
    • Thoracoscopic Pericardial Window
  • Finding
    • Intra-operative sonography finding:
      • Adequate size of RIJV     
      • Large amount of pericardial effusion with bulging pericardium noted.
      • generous window was created
      • a huge mass compressed upon RV ant. wall
    • 318 cc turbid, dark reddish effusion drained, sent for cytology, routine and culture.
    • Pericardium was sent for pathology.
    • LP: 325cc effusion was also drained from newly placed chest tube.

==========

2024-06-07

[large mediastinal tumor compressing heart]

A CT scan conducted on 2024-06-04 revealed the following findings:

• A large, homogeneous density, soft-tissue tumor lesion (approximately 13x13x82 mm in size), with small necrotic areas, occupying the lower anterior mediastinal compartment and adjacent anterior chest wall, extending to the adjacent abdominal cavity. This lesion severely compresses and displaces the right ventricle of the heart and the left lobe of the liver.
• Massive pericardial effusion and moderate left pleural effusion with partial relaxation atelectasis of the left lower lobe of the lung.
• A large left supraclavicular lymphadenopathy is visible.
• Nodular ground glass opacities in both upper lobes of the lungs.

A WBC differential count on 2024-06-06 showed a left-shifted distribution. Normal blood IgG, IgA, IgM levels were observed, along with elevated kappa and lambda free light chains and beta-2 microglobulin.

• 2024-06-05 FKLC 43.42 mg/L
  
• 2024-06-05 FLLC 29.02 mg/L
  
• 2024-05-31 B2-Microglobulin 3683 ng/mL

Lymphoma and/or mediastinal tumors are suspected. The pericardial effusion appears symptomatic; percutaneous pericardiocentesis might be considered. This approach, if feasible, could physically relieve the pressure on the heart more effectively than medication.

700716483

240618

[exam findings]

• 2024-06-02 CXR erect
  • Multiple nodules at RUL.
• 2024-05-27 Microsonography
  • Report: OCT-M: macula ok, small focal choroidal excavation os
  • OCT-D: 105/0.46/WNL od, 105/0.47/WNL os
• 2024-05-15 CT - abdomen
  • Findings:
    • S/P hysterectomy
    • Liver and left renal cysts (up to 2.5cm).
    • Gall stone (4mm).
    • There are Fibro-calcified lesions in right apical lung, which may be old TB. Please correlate with clinical history.
  • Impression:
    • S/P hysterectomy.
    • There is no evidence of tumor recurrence.
• 2024-02-15 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 11 dB HL; LE 13 dB HL
  • Bil WNL.
• 2024-01-16 Patho - uterus (with or without SO) neoplastic
  • PATHOLOGIC DIAGNOSIS
    • Ovarian tumor, right, frozen + debulking surgery — Clear cell carcinoma
    • Fallopain tube, right, ditto — Free of tumor invasion
    • Cervix, uterus, ditto — Mild dysplasia and free of tumor invasion
    • Endometrium, uterus, ditto — Endometrial polyp and free of tumor invasion
    • Myometrium, uterus, ditto — Free, leiomyomas and adenomyosis
    • Lymph node, left iliac, dissection — Free of tumor metastasis (0/17)
    • Lymph node, left obturator, ditto — Free of tumor metastasis (0/5)
    • Lymph node, right iliac, ditto — Fat only
    • Lymph node, right obturator, ditto — Free of tumor metastasis (0/7)
    • Lymph node, left para-aortic, ditto — Free of tumor metastasis (0/3)
    • Lymph node, right para-aortic, ditto — Free of tumor metastasis (0/2)
    • Omentum, infracolic omentectomy — Free of tumor invasion and three reactive lymph nodes(0/3)
    • AJCC Pathologic staging — pT1c2N0, if cM0, stage IC / FIGO stage IC2 (ascites data is not available)
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: frozen sections and debulking surgery (ATH + BSO + LN dissection + omentectomy)
    • Specimen type: uterus, pelvic LNs, and infracolic omentum
    • Specimen size:
      • R’t ovarian tumor (frozen): rupture cystic tumor with surface involvement, 13.5 x 13 x 4.2 cm
      • R’t fallopian tube (frozen): 5 cm in length, 0.7 cm in diameter, no tumor invasion
      • L’t adnexa: absent  
      • Uterus: 110 gm, 11 x 6.7 x 4.5 cm, one endometrial polyp measured 1.7 x 1.1 cm and some myomas measured up to 3.1 x 2.6 cm
      • Omentum: 55 x 15 x 1 cm, normal appearance
    • Tumor site: right ovary  
    • Tumor size: 13.5 x 13 x 4.2 cm
    • Tumor appearance: cystic tumor with multiple solid masses
    • Specimen integrity: ruptured ovarian tumor with tumor on surface
    • Lymph node: left iliac LNs, left obturator LNs, right iliac LNs, right obturator LNs, left para-aortic LNs and right para-aortic LNs
    • Representatively embedded for section as A1-A2: left iliac LNs, B: left obturator LNs, C: right iliac LNs, D: right obturator LNs, E: left para-aortic LNs, F: right para-aortic LNs, G1-G2: bilateral parametrium, G3: cervix, G4-G6: endometrium + myometrium, G7: myomas, G8-G9: left peri-adnexal soft tissue and H: omentum
    • Reference: frozen section: F2024-00016, FSA1-FSA2: tumor, A1-A2: R’t fallopian tube and A3-A8: solid tumor and A9-A10: smooth cyst
  • MICROSCOPIC EXAMINATION
    • Histologic type: clear cell carcinoma     
    • Histologic grade: no well validated grading system, but high grade is considered at present
    • Contralateral ovary involvement: can not be assessed
    • Tumor side ovarian surface involvement: involved
    • Contralateral ovary surface involvement: can not be assessed
    • Right tube involvement: absent
    • Left tube involvement: can not be assessed
    • In situ adenocarcinoma in right and/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: absent
    • Left adnexa soft tissue involvement: absent
    • Pelvic soft tissue involvement: not received
    • Uterine serosa involvement: absent
    • Omentum involvement: not involved
    • Uterine cervix involvement: absent. Focal mild dyaplasia is found. IHC of P16(-)
    • Endometrium involvement: absent. One endometrial polyp is included
    • Myometrium involvement: absent. Leiomyomas and adenomyosis
    • Appendix involvement: not received
    • Lymph nodes metastasis: Free of tumor metastasis (0/37) in total number
    • Other organs or specimens involvement: not received
    • Immunohistochemistry:
      • Ovarian tumor: Napsin-A(+, scatter), AMACR(+), CK7(+), WT-1(-), ER(-) and P53: wild type for tumor
      • Cervix: P16(-)
    • Ascites report: not available. So T1c3N0 can not be excluded entirely. Clinical correlation is advised
• 2024-01-15 Patho - stomach biopsy
  • Gastric polyp, fundus, biopsy — Compatible with fundic gland polyp
• 2024-01-07 CT - abdomen
  • History and indication: Abdominal Pain
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A cystic lesion (17x19x26cm) with solid part in peritoneal cavity r/o ovary tumor.
    • Liver and renal cysts (up to 2.5cm).
    • Gall stone (4mm).
  • IMP:
    • A cystic lesion (17x19x26cm) with solid part in peritoneal cavity r/o ovary tumor.
• 2024-01-07 SONO - gynecology
  • IMP: r/o RT ovarian mass (236148mm, with solid part 10437mm)

[MedRec]

• 2024-01-11 ~ 2024-01-27 POMR Obstetrics and Gynecology Huang SiChen
  • Discharge diagnosis
    • Malignant neoplasm of right ovary
    • Right ovarian cancer (clear cell carcinoma) pT1c2N0, if cM0, stage IC / FIGO stage IC2 (ascites data is not available) post Debulking surgery and Hyperthermic Intraperitoneal Chemotherapy on 2024/01/15
    • Abdominal pain
    • Anemia
  • CC
    • Abdominal pain with nausea since last week
  • Present illness
    • This is a 52-year-old, G0P0, sex experience (+, 20 yrs ago), menopaused at 46 y/o, woman without any underlying disease. Previous operation was left ovarian chocolate cyst (around 10cm), s/p left oophorecotomy 10+years ago at KFSYSCC. Previous health exam showed right ovarian cyst, around 10cm, last follow up was 2 years ago.
    • Last week, she came to our ER on 2024/01/07 with complaint of abdominal pain for days, exacerbated on that day. She also had nausea sensation, but no vomiting. There was no fever, diarrhea, vaginal discharge or body weight loss recently.
    • Physical examination showed soft abdomen with low abdominal tenderness (Rt’ > Lt’). No peritoneal signs was noted.
    • CT showed a cystic lesion (17x19x26cm) with solid part in peritoneal cavity r/o right ovarian tumor. No ascites or hydronephrosis seen.
    • TAS and TVUS showed Uterus grossly normal with endometrial thickness 3.5mm. A right abdominal mass 2315cm, with solid part 104cm was noted.
    • She came back to our GYN OPD for further evaluation. After well explained and discussion with patient, she decided to accepted operation and admitted to our ward on 2024/01/11. On arrival, the vital signs were stable, Blood test showed Hgb level as 12.5 g/dL, WBC level as 7430, D-dimer as 987 and albumin level as 4.4 g/dL. We will arranged preoperative evaluation and preparation including upper GI panendoscopy and colonscopy for her as cancer surveys. The CA125 level was 131.6, CA199 was 337.1 and the CEA level was 1.27. 
  • Course of inpatient treatment
    • The patient was admitted on 2024/01/11. The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey. She underwent (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para aortic lymph note sampling + infracolic omentectomy + hyperthermic intraperitoneal chemotherapy) on 2024/01/15.After operation, she was transferred SICU for intensive care then condition stable transferred word on 2024/01/16.
    • We gave her Cefazolin and Gentamycin IV form for 3 day and then shifted her antibiotics to Cephalexin oral form. Post-operation wound was dry and clean without dehiscence, discharge, or oozing. Her lab data on 2024/01/16 also showed no specific positive findings.
    • Due to elevated FDP and clexan 60 mg injection on 2024/01/23 .Her condition was stable without fever and special complaints since 3 days after the debulking surgery. After flatus, her eating, self voiding and defecation were all stable.
    • The JP drain was removed on 2024/01/24 smoothly. Since all her general conditions were all improved and relatively stable, we arranged discharge for her for further OPD follow up of her recovery status and surgical wound conditions.
  • Discharge diagnosis
    • Acetal (acetaminiphen 500mg) 1# QID
    • MgO 250mg 2# TID
    • Through (sennoside 12mg) 2# HS
    • cephalexin 500mg 1# QID
    • Plavix (clopidogrel 75mg) 1# QD

[consultation]

• 2024-04-12 Dermatology
  • Q
    • for scalp folliculitis after chemotherapy
    • This is a 53-year-old, G0P0, sex experience (+, 20 yrs ago), menopaused at 46 y/o, woman without any underlying disease. Previous operation was left ovarian chocolate cyst (around 10cm), s/p left oophorecotomy 10+ years ago at KFSYSCC. Previous health exam showed right ovarian cyst, around 10cm, last follow up was 2 years ago. Initial, she came to our ER on 2024/01/07 with the complaint of abdominal pain for days, exacerbated on that day. She also had nausea sensation, but no vomiting. There was no fever, diarrhea, vaginal discharge or body weight loss recently. Physical examination showed soft abdomen with low abdominal tenderness (Rt’>Lt’). No peritoneal signs was noted.
    • Abdominal CT on 2024/01/07 showed a cystic lesion (17x19x26cm) with solid part in peritoneal cavity r/o right ovarian tumor. No ascites or hydronephrosis seen. TAS and TVUS showed Uterus grossly normal with endometrial thickness 3.5mm. A right abdominal mass 2315cm, with solid part 104cm was noted.Then, she came back to our GYN OPD for further evaluation, then admitted to GYN ward. The Upper G-I panendoscopy and Colon fiberoscopy were done on 2024/01/12 for work up and tumor survey.
    • She underwent (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para aortic lymph note sampling + infracolic omentectomy + hyperthermic intraperitoneal chemotherapy) on 2024/01/15.
    • Pathology showed Ovarian tumor, right, frozen + debulking surgery — Clear cell carcinoma, AJCC Pathologic staging — pT1c2N0, if cM0, stage IC / FIGO stage IC2 (ascites data is not available). Diagnosis was Right ovarian clear cell carcinoma, pT1c2N0, if cM0, stage IC / FIGO stage IC2 (ascites data is not available) a/p Debulking surgery and Hyperthermic Intraperitoneal Chemotherapy on 2024/01/15. On 2024/02/26 the CA125 level was 13.2 U/mL, CA199 was 7.99 U/mL and the CEA level was 0.91 ng/mL. Check PTA, 24hr CCR before chemotherapy on 2024/02/16.
    • He received chemotherapy with Paclitaxel(175mg/m2)/Carboplatin(AUC:5) from 2024/02/16(C1), 2024/03/16(C2). This time, she was admiited for chemotherapy with TP(C3) .
  • A
    • CC: Lesions over scalp
    • Skin findings:
      • Erythematous papulse over scalp
    • Hx: Right ovarian clear cell carcinoma, under chemotherapy currently
    • Imp: Acneiform eruptions, chemotherapy related
    • Plan:
      • Oral doxycycline 1# BID for one week
      • Topical clindamycin gel BID for scalp lesions
      • Arrange Derm OPD follow up after discharge

[surgical operation]

• 2024-01-15
  • Operation
    • Excision of intraabdominal malignant tumor
    • HIPEC   - Finding
    • huge left ovarian cancer
    • PCI: total = 4
      • region – score
      • central – 1
      • RU – 0
      • epigastrium – 0
      • LU – 0
      • left flank – 0
      • LL – 1
      • pelvis – 1
      • RL – 1
      • right flank – 0
      • upper jejunum – 0
      • lower jejunum – 0
      • upper ileum – 0
      • lower ileum – 0
    • HIPEC regimen
      • Lipodox 30mg/m^2 + Carboplatin AUC 5
    • Drain:
      • 15 Fr J-VAC x2 in the pelvic cavity
• 2024-01-15
  • Surgery
    • Diagnosis: Pelvic mass, r/o ovarian cancer. Frozen section: Adenocarcinoma
  • Operation:
    • Debulking surgery (ATH + BSO + BPLND + PALND + infracolic omentectomy)
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with the bladder and pelvic mass
    • Adnexa:
      • LOV: absent
      • ROV: huge pelvic mass around 40 X 30 X 15 cm, intraoperative rupture with 3400 c.c. chocolate-like fluid content and solid part
    • CDS: invisible due to tumor mass occupied
    • Ascites: bloody
    • Bilatera lpelvic lymph nodes: normal(-), enlarged(+), indurated(-)
    • Omentum: pigmentation with chocolate-like content
    • Liver: grossly normal & smooth
    • Appendix: grosslt normal
    • After the operation, optimal debulking surgery was achieved with R0 resection.
    • Estimated blood loss: 350 mL
    • Blood transfusion: nil
    • Complication: nil  

[chemotherapy]

• 2024-06-18 - paclitaxel 175mg/m2 350mg NS 500mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1
• 2024-05-16 - paclitaxel 175mg/m2 350mg NS 500mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-12 - paclitaxel 175mg/m2 350mg NS 500mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-16 - paclitaxel 175mg/m2 350mg NS 500mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-16 - paclitaxel 175mg/m2 350mg NS 500mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2024-01-11 - liposome doxorubicin 30mg/m2 60mg D5W 100mL 90min + carboplatin AUC 5 600mg NS 100mL 90min (for HIPEC)

==========

2024-06-18

Lab readings on 2024-06-17 showed grossly normal values and no medication discrepancies identified after review of HIS5 and PharmaCloud database.

701072034

240618

[exam findings]

• 2024-04-22 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • s/p nearly total gastrectomy.
    • One cystic change at pancreatic body measuring 0.65cm in largest dimension is found. In comparison with CT dated on 2024-01-20, the lesion is stationary.
    • Mild bilateral pleural effusion is found.
    • Calcified dot at B6 of right lower lobe measuring 1.0cm in largest dimension. Old insult is considered.
  • Imp:
    • s/p nearly total gastrectomy.
    • No evidence of recurrent/residual tumor in the study.
    • Pancreatic cyst at body. 0.65cm, stable. Suggest follow up.
• 2023-10-16 Patho - stomach subtotal/total (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Stomach, total gastrectomy — Tubular adenocarcinoma
    • Margins, bilateral cutting ends, total gastrectomy — Free of tumor invasion
    • Lymph nodes, regional, LN dissection — Metastatic adenocarcinoma (4/25)
    • Omentum, total gastrectomy — Metastatic adenocarcinoma
    • Liver, S2-3, partial hepatectomy — Free of carcinoma
    • Spleen, splenectomy — Free of carcinoma and accessory spleen
    • Pathologic staging: pT3N2M1; Stage IV
  • MACROSCOPIC EXAMINATION
    • Specimen type: Stomach, small intestine, liver and spleen
    • Specimen size: (a) Stomach: 12.5 cm (greater curvature), 7.2 cm (lesser curvature) (b) 9.3 cm in length (small intestine), 4.5 x 2.2 x 1.0 cm (liver) and 8.9 x 6.1 x 3.0 cm, 70.7 gm (spleen)
    • Number of lesions: Solitary
    • Tumor site: Posterior wall of remnant stomach
    • Tumor size: 3.0 x 2.2 x 1.0 cm
    • Tumor configuration: Ulcerative tumor
    • Representative sections as follows: A1= proximal margin, A2= distal margin, A3-A10= tumor, A11-A12= liv er, A13= non-tumor gastric tissue, A14-A15= greater curvature LNs, A16-A17= lesser curvature LNs, B1= spleen, B2= spleen hilum LNs
  • MICROSCOPIC EXAMINATION
    • Histologic type: Tubular adenocarcinoma with small focus of signet-ring cell component
      • Lauren classification: intestinal type
    • Histologic grade: Moderately differentiation (G2)
    • Depth of tumor invasion: Tumor invades the subserosa
    • Margins: All margins are uninvolved by carcinoma
    • Perineural invasion: Absent
    • Lymphovascular space invasion: Present
    • Regional lymph nodes: Metastatic adenocarcinoma (4/25)
      • 2/9 (greater curvature LNs)
      • 1/14 (lesser curvature LNs)
      • 1/2 (spleen hilum LNs)
      • (Number of LN involved/Number of LN examined)
    • Extracapsular extension: Absent
    • Omentum: Metastatic adenocarcinoma
    • Liver: Fibrous adhesion and free of carcinoma
    • Spleen: Accessory spleen and free of carcinoma
    • Additional pathologic findings: Gastritis cystica profunda
    • Pathologic Staging: pT3N2M1, stage IV
    • IHC (S2023-17520): HER2 (Negative, score= 1+)
• 2023-09-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (149 - 50) / 149 = 66.44%
    • M-mode (Teichholz) = 66.6
  • Conclusion:
    • Dilated LA, LV
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Moderate MR, Mild AR
    • Calcified aortic valve and mitral valve
• 2023-09-06 Flow Volume Chart
  • Mild obstructive ventilatory impairment
• 2023-09-02 CT - abodomen
  • Indication: Gastrointestinal hemorrhage, unspecified
  • Imp: s/p subtotal gastrectomy. Hyperemic change of the residual gastric wall with clip is found. No evidence of active bleeding is found.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T0(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-09-01 Patho - stomach biopsy
  • Ulcerative tumor, PW side of remnant stomach to anastomosis, biopsy — Adenocarcinoma
  • The specimen submitted consisted of four small pieces of gastric tissue measuring up to 0.3 x 0.1 x 0.1 cm in size, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for section.
  • Microscopically, the section shows a picture of adenocarcinoma characterized by tumor cells arranged in tubular, fused glandular or focal signet-ring cell differentiation with enlarged and hyperchromatic nuclei infiltrating in ulcerative stroma.
  • Immunohistochemistry of CK(+) and Her2/neu (-, Dako score 1+) for tumor cell. Besides, intestinal metaplasia is also included.
• 2023-09-01 EGD
  • Diagnosis:
    • Suspect gastric cancer, Borrmann type 4, from PW side of remnant stomach to anastomosis site, s/p biopsy
    • Gastric vessel lesion, anastomosis site, s/p Sure Clip 11mm x1 and Vedkang 13mm x1.
    • Reflux esophagitis LA Classification grade A (minimal)
    • Status post subtotal gastrectomy with Billroth II anastomosis.
  • CLO test: not done
  • Suggestion:
    • High dose PPI
    • Pursue pathology report.
    • Consider to seek surgical intervention
    • Consider to arrange image for further intervention

[MedRec]

• 2023-10-12 ~ 2023-10-27 POMR General and Gastroenterological Surgery Wu ChaoQun
  • Discharge diagnosis
    • Gastric adenocarcinoma, pT3N2M1, Stage IV status post total gastrectomy with lymph node dissection, S2-3 partial hepatectomy and splenectomy with autospleen implantation on 2023/10/16; status post intrapertoneal chemotherapy with 5FU and intravenous chemotherapy with Mitomycin on 2023/10/19-2023/10/23. ECOG:2
    • Moderate protein-calorie malnutrition
  • CC
    • For laparotomy with total gastrectomy
  • Present illness
    • After last discharge on 2023-09-09, he complained intermittent epigastric dull pain, accompanied with decreased appetite to half amount. He denied fever, nausea/vomiting, dyspena, dysuria, tarry stool or diarrhea. He came to our GS OPD on 2023/09/19. And after discussion with the patient, he agreed for surgical intervention. Thus this time he was admitted for laparotomy with total gastrectomy.
  • Course of inpatient treatment
    • This 73 years old male patient was a case of gastric cancer. He underwent total gastrectomy with lymph node dissection, S2-3 partial hepatectomy, splenectomy with autosspleen implantation on 2023/10/16. The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable. NG was removed on 10/18 and he started PG1 diet on 10/19.
    • Pathology showed pT3N2M1, Stage IV, HER2 (Negative). We started intraperitoneal chemotherapy and intravenous chemotherapy since 10/19 for five days. Esophagography on 10/19 showed no obstruction or leakage. Low grade fever up to 38C happened once on 10/22. And we removed CVC and shift antibiotic from cefoxitin to brosym.
    • Under relative stable condition with increased oral intake amount, he started PG2 diet on 10/23 and started PG3 diet on 10/24. Left and right JP drain were removed on 10/26. He was discharged on 2023/10/27 and will follow up in our out-patient department next week.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Celebrex (celecoxib 200mg) 1# QD
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Urief (silodosin 8mg) 1# QD
• 2023-09-01 ~ 2023-09-09 POMR General and Gastroenterological Surgery Chen JiaHui
  • Discharge diagnosis
    • Gastric stump cancer, cT1N0M0, stage I, ECOG 1
    • Gastrointestinal hemorrhage
    • Acute posthemorrhagic anemia
    • Moderate protein-calorie malnutrition
    • Hypoalbuminemia
  • CC
    • tarry stool for one day
  • Present illness
    • The patient is a 72-year-old male who presented to the emergency room with a concerning episode of tarry stool lasting for one day. He also reports experiencing mild dyspnea, nausea, and dizziness. Notably, the patient denied any significant abdominal pain or vomiting during this time. He had past medical history:perforated peptic ulcer that required a subtotal gastrectomy over 40 years ago.
    • Laboratory Data: Hemoglobin (Hb): 8.6 g/dL, Platelet Count: 124,000/uL, Stool Analysis: Occult blood (OB) 4+, with a bloody appearance, Activated Partial Thromboplastin Time (aPTT): 20.5 seconds, Prothrombin Time (PT): 10.2 seconds.
    • Initial Management is the patient received a transfusion of 2 units of packed red blood cells (PRBCs), which successfully increased his hemoglobin level to 10.1 g/dL.
    • Endoscopy Findings: minimal mucosal breaks of less than 5mm were noted in the upper gastrointestinal tract. Additionally, there is suspicion of gastric cancer, specifically Borrmann type 4.
    • Under the impression of anemia cuased by GI bleeding and suspecious gastric cancer, he came for blood tranfusion and CT abdominal.
  • Course of inpatient treatment
    • After adimission, post-hemorrhagic anemia survey was done. NPO, adequate IV hydration, proton-pump inhibitor were given for his upper gastrointerstinal tract beeding.
    • Panendoscopy biopsy pathological report revealed Gastric stump cancer, cT1N0M0, stage I. Thus, abdominal CT and tumor marker test was arranged.
    • After NPO his UGI bleeding condition improved day by day and normal defecation and stool passage were noted. We let him try diet from clear liquid to soft diet step by step without any discomfort after meal. We also arranged heart echo and lung function test for pre-op evaluation.
    • Surgical treatment is indicated, but his family requested to copy the reports for second opinion. After good oral intake without tarry stool, no fever and improved general condition, the patient was allowed to discharge on 2023/09/09 and OPD follow up.
  • Discharge prescription
    • Rich (lansoprazole 30mg) 1# QDAC  

[surgical operation]

• 2023-10-16 - Op Method:
  • total gastrectomy with LN1,2,3,4,7,8,9,12,11,10 dissection
  • S2-3 partial hepatectomy
  • splenectomy with autosspleen implantation
  • Finding:
    • 3 x 2.2 cm ulcerative mass at GJ margin gastric posterior wall
    • cT2N1M0
    • regional LN at 8 ,9 and 10 enlarge+
    • moderate to severe adesion due to previous PPUs/p subtotal gastrectomy
    • peritoneal seeding-
    • ascite-

[chemotherapy]

• 2024-06-17 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-21 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-19 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-25 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-11 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3720mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-15 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-01-18 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-29 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-14 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-21 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg …………………. + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-19 - leucovorin 20mg/m2 32mg NS 250mL 2hr D1,3,5 + gentamicin 80mg D1 + mitomycin-C 20mg/m2 32mg NS 500mL 2hr D2 + [fluorouracil 750mg NS 800mL + gentamicin 40mg + sodium bicarbonate 4200mg/60mL] IP D1-5
  • betamethasone 4mg D2 + diphenhydramine 30mg D2 + palonosetron 250ug D2 + NS 250mL D2

==========

2024-06-18

[mild macrocytosis observed despite vitamin B12 supplementation]

The lab results on 2024-06-17 were grossly normal and did not pose an contraindication to the current FOLFOX therapy.

Iron storage appears adequate, as evidenced by normal ferritin levels. Mild macrocytosis is noted, and Kentamin, which includes Vitamin B12, is currently in use. If macrocytosis persists, the use of B-Red (hydroxocobalamin) and/or folate might be further considered.

• 2024-06-17 HGB 10.4 g/dL

• 2024-06-17 MCV 103.4 fL

• 2024-06-04 Ferritin 76.6 ng/mL

• 2024-04-30 Ferritin 72.9 ng/mL

701495605

240618

[exam findings]

• 2024-06-07 Tc-99m MDP bone scan
  • Increased activity in the right iliac bone, compatible with bone metastasis.
  • Increased activity in some T- and L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Increased activity in the mandible. Dental problem may show this picture.
  • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in the left shoulder, bilateral sternoclavicular junctions, knees and feet, compatible with benign joint lesions.
• 2024-06-06 Surgical pathology Level IV
  • Tissue, right pelvic, needle biopsy — clear cell renal cell carcinoma, grade 2
  • Microscopically, it shows grade II clear cell renal cell carcinoma characterized by sheets or alveolar arrangement of clear cells with distinct cell borders interpersed with thin-walled vessels. The tumor cells have round nuclei with uniform finely distributed chromatin. The nuclei is large with obvious but small visible nucleoli.
  • Immunohistochemical stains are positive for AMACR, vimentin and CD10, supportive of this diagnosis.
• 2024-06-05 CT - abdomen
  • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status can not be determined without IV contrast.
  • Findings:
    • There is a large heterogeneous hypodense mass in right kidney lower pole, 8 cm in size (the largest dimension).
      • Renal cell carcinoma (T2a) is highly suspected.
      • Please correlate with contrast enhanced dynamic CT or MRI.
      • In addition, both kidneys show small size, few cysts, and thin parenchyma that are c/w ESRD.
    • There is an osteolytic lesion with expansile soft tissue mass in right ilium and right acetabulum that is c/w bone metastasis (M1).
    • There are few enlarged nodes in para-aortic space and para-cava space that may be regional metastatic nodes (N1).
    • There is a soft tissue nodule in RLL of the lung, 5 mm in lung window setting. Follow up is indicated.
    • There are few gallstones (up to 1 cm).
  • IMP:
    • Renal cell carcinoma 8 cm in right kidney is highly suspected. Please correlate with contrast enhanced dynamic CT or MRI.
    • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for RCC: T2a N1 M1; stage: IV.
• 2024-06-04 MRI - hip joints
  • Op Hx: Right knee advanced osteoarthritis post total knee arthroplasty on 2024/04/01
  • Without-contrast multiplannar and multisequences MRI of right hip revealed:
    • An expansile mass lesion in right pelvic bone (16.011.414.9cm) with right greater sciatic foramen involvement. Isointensity on T1WI and hyperintensity on T2WI.
    • Mass effect on adjacent structures with edematous change.
    • Suspect a mass lesion in right renal fossa (Srs:4;Img:1).
  • Impression
    • Right pelvic bone lesion. Right renal cell carcinoma with bone metastasis is considered first. DDx: sarcoma.
    • Suggest further evaluation
• 2024-06-02 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
  • Right bundle branch block
• 2024-04-30 Merchant view (patella 45 0) RT
  • Degenerative change of the patella with marginal spurs. No definite bone fracture. No lateral subluxation. Status post total knee replacement.
• 2024-04-01 Knee Rt
  • Status post total knee replacement. Recent postoperative change with soft tissue swelling and placement of a drainage tube.
• 2024-03-20 Ultrasound guided injection
  • Technician: right genicular prolotherapy
    • Petella was identified under ultrasound.
    • Needle tip was placed towards medial and lateral side of femoral bone above petella, and midline below petella.
    • 1ml D50W + 1ml 2% Xylocaine + 4ml N/S was injected on each site.
• 2024-03-12 ECG
  • Sinus rhythm with Premature atrial complexes
  • Right bundle branch block
• 2024-03-12 Knee Bilat. Standing
  • Osteoarthritis change of both knees with joint space narrowing and marginal spur formation. Screws fixation over left tibial plateau.
• 2024-02-21 Ultrasound guided injection
  • Technician: Rt knee genicular nerve block
    • Petella was identified under ultrasound.
    • Needle tip was placed towards medial and lateral side of femoral bone above petella, and midline below petella.
    • 1ml D50W + 1ml 2% Xylocaine + 4ml N/S was injected on each site.
• 2023-08-25 Knee bilat. standing
  • S/P internal fixation of left upper tibia.
  • OA change of the both knees with joint space narrowing & marginal osteophytes in the medial femorotibial compartment and patellofemoral compartment.

==========

2024-06-18

[improving kidney function, but high Brosym dose needed adjustment]

The patient’s kidney function is showing signs of improvement based on recent eGFR lab results. However, her kidney function is still far from normal.

• 2024-06-18 eGFR 24.14 ml/min/1.73m^2
• 2024-06-11 eGFR 23.25 ml/min/1.73m^2
• 2024-06-02 eGFR 17.98 ml/min/1.73m^2

According to the Sanford Guide, sulbactam-cefoperazone dosage needs adjustment in patients with creatinine clearance below 30 mL/min to account for reduced sulbactam clearance.

• For creatinine clearance between 15-30 mL/min: the recommended maximum dose is 1 gram of sulbactam every 12 hours (maximum daily dose of 2 grams).
• For creatinine clearance below 15 mL/min: the recommended maximum dose is 500 milligrams of sulbactam every 12 hours (maximum daily dose of 1 gram).
• In severe infections, additional Cefoperazone might be necessary.

Currently, the patient is receiving Brosym 4 grams Q12H, which is double the recommended dose. It is recommended adjusting the Brosym dosage to 2 grams Q12H

[NCCN guidelines for ccRCC treatment and NHI reimbursement policies]

This patient was recently diagnosed with grade 2 clear cell renal cell carcinoma, T2aN1M1, stage IV, with right iliac bone metastasis.

According to the NCCN guidelines (version 2024-05-30), preferred regimens for favorable-risk patients include:

• Axitinib/pembrolizumab
• Cabozantinib/nivolumab
• Lenvatinib/pembrolizumab

The NHI reimbursement policy for each of the drugs in the regimens is as follows:

• Axitinib (Inlyta):
  • For patients with advanced renal cell carcinoma who have failed prior treatment with sunitinib or cytokines.
  • Not reimbursed if followed by temsirolimus.
  • Requires pre-approval, with each application covering a 3-month treatment course. Imaging data must be submitted for evaluation every 3 months.
• Cabozantinib (Cabometyx):
  • For untreated patients with intermediate/high-risk advanced renal cell carcinoma.
    • Not reimbursed if followed by temsirolimus.
    • Dose reduction is preferred if the patient experiences poor tolerance. Severe intolerance may warrant switching to another TKI.
  • For patients with advanced renal cell carcinoma who have failed prior anti-angiogenic therapy.
  • Requires pre-approval, with each application covering a 3-month treatment course. Imaging data must be submitted for evaluation every 3 months, and continued use is allowed only if there is no disease progression.
  • Reapplication is not allowed if the disease relapses or progresses after first-line use.
  • Limited to 1 tablet per day.
• Pembrolizumab or Nivolumab:
  • For adult patients with advanced renal cell carcinoma who have failed at least two prior lines of targeted therapy and have disease progression, specifically for those with clear cell renal carcinoma.
• Lenvatinib:
  • Not currently covered by NHI for renal cell carcinoma.

701504577

240618

[MedRec]

• 2024-06-14 ~ 2024-06-15 POMR General and Gastroenterological Surgery Zhang YaoRen

  • Discharge diagnosis
    • Right breast cancer with bilateral axillary lymph nodes metastasis , rpTxN1M1 (left axillary lymph nodes), stage IV. ECOG:0
  • CC
    • for Talzenna
  • Course of inpatient treatment
    • After admission, Talzenna adjust 3tab to to 2tab due to anemia and keep Foliromin. Under the stable condition, she was discharged today, arrange next admission.
  • Discharge prescription
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Talzenna (talazoparib 0.25mg) 2# QDCC 10D
    • Melux (mephenoxalone 200mg) 1# PRNTID
    • Acetal (acetaminophen 500mg) 1# PRNTID

• 2024-05-29 SOAP General and Gastrointestinal Surgery Chen JiaHui

  • S: for 2nd PG2 injection
  • Prescription
    • PG2 Lyo Injection (polysaccharides of Astragalus membranaceus) 500mg ST IVD 3hr
    • NS 500mL IVD
    • Hepac Lock Flush (heparin sodium 100 USP units/mL) 10mL ST IRRI

• 2024-05-23 ~ 2024-05-25 POMR General and Gastroenterological Surgery Zhang YaoRen

  • Discharge prescription
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Talzenna (talazoparib 0.25mg) 3# QDCC 10D

• 2024-05-05 ~ 2024-05-07 POMR General and Gastroenterological Surgery Zhang YaoRen

  • Discharge prescription
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Talzenna (talazoparib 0.25mg) 4# QDCC 14D

• 2024-04-17 ~ 2024-04-19 POMR General and Gastroenterological Surgery Zhang YaoRen

  • Discharge prescription
    • Talzenna (talazoparib 0.25mg) 3# QDCC 1D
    • Talzenna (talazoparib 0.25mg) 4# QDCC 8D
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID 7D

• 2024-04-15 SOAP General and Gastroenterological Surgery Zhang YaoRen

  • Prescription
    • Foliromin (ferrous sodium citrate 50mg) 1# BID

• 2024-04-08 SOAP General and Gastroenterological Surgery Zhang YaoRen

  • Prescription
    • Megejohn (megestrol acetate 160mg) 1# QD
    • Foliromin (ferrous sodium citrate 50mg) 1# BID 7D

• 2024-04-01 ~ 2024-04-02 POMR General and Gastroenterological Surgery Zhang YaoRen

  • Course of inpatient treatment
    • After admission, Talzenna since 2/12. poor appetite and anemia were noted after Talzenna. Talzenna shift to 3tab po QD. This time, laboratory data showed anemia and leukopenia, hold Talzenna treatment.
    • Blood transfusion with LRBC 2U stat for anemia (Hb: 5.6g/dl). When administering the second bag of PRBC, the patient experienced nausea, generalized rash, and itching.
    • Blood transfusion was temporarily halted, and Diphenhydramine 30mg IVD STAT was administered.
    • After 30 minutes with no improvement, the transfusion was discontinued, and Hydrocortisone 100mg IVD STAT was initiated, then be better.
    • Under the stable condition, she was discharged today, arrange follow up in outpatient department on 4/8.
  • Discharge prescription
    • none

• 2024-03-19 SOAP Surgical Emergency Wu MengYu

• 2024-03-15 ~ 2024-03-17 POMR General and Gastroenterological Surgery Zhang YaoRen

  • Present illness
    • Under the impression of right breast invasive carcinoma with recurrent axillary lymph nodes metastasis, she was admitted for Talzenna.
  • Course of inpatient treatment
    • After admission, Talzenna since 2024/02/12. poor appetite and anemia were noted after Talzenna. Talzenna shift to 3 tab po QD.
    • Under the stable condition, she was discharged today, arrange next admission.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 14D
    • Talzenna (talazoparib 0.25mg) 3# QDCC 15D

• 2024-01-01 ~ 2024-01-03 POMR General and Gastroenterological Surgery Zhang YaoRen

  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 3D hold if diarrhea
    • Talzenna (talazoparib 0.25mg) 4# QDCC 10D

• 2023-11-19 ~ 2023-11-21 POMR General and Gastroenterological Surgery Zhang YaoRen

  • Discharge diagnosis
    • Right breast cancer with axillary lymph nodes metastasis , rpTxN1M1 (left axillary lymph nodes), stage IV. ECOG:0
    • Encounter for antineoplastic chemotherapy
  • CC
    • She noted left axillary recurrent by PET at last month.
  • Present illness
    • This 54-year-old female patient has past history of right breast cancer s/p simple mastectomy + SLNB at MacKay Hospital in 2012-10 and AI 10 yrs, pT1c(2cm)N0M0, stage IA. ER (>67%), PR (>67%), HER2 (1+), Ki 67: 7%.
    • Rt axillary recurrence noted in 2022-06 and C/T with Taxotere x 6 cycles + Xeloda and radiotherapy were given by TMUH. She denied any TOCC histories in recent 3 months.
    • She was regular follow up at TMUH. However, She noted left axillary recurrent by PET at last month. She came to WanFang OPD for help. Left ALND on 2023-10-18. Triple negative, rpTxN1M1, srage IV. CEA 1.288 ng/ml. CA-153 14.169 U/ml.
    • Lung CT was arranged and RUL granuloma 4mm. multiple small discrete lymph nodes in both axillary regions. PE: old OP scar at rt breast and left axilla. Paillative ADCs Trodelvy 10mg/kg was suggest. But patient decide Lipo dox 35mg/m2 x 6 cycles.
    • Under the impression of right breast invasive carcinoma with recurrent axillary lymph nodes metastasis, she was admitted for palliative chemotherapy with lipo dox.
  • Course of inpatient treatment
    • After admission, 1st palliative chemotherapy with Lipo dox was given. No discomfort after chemotherapy.
    • Under the stable condition, she was discharged today, arrange next admission three weeks later.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC hold if diarrhea
    • loperamide 2mg 2# PRNQ8H if watery diarrhea > 2

[chemotherapy]

• 2024-01-22 - liposome doxorubicin 35mg/m2 57mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-01-02 - liposome doxorubicin 35mg/m2 57mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-12-11 - liposome doxorubicin 35mg/m2 57mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-20 - liposome doxorubicin 35mg/m2 57mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Talsenna (talazoparib 0.25mg) 2# QDCC - 2024-06-14 ~ 2024-06-24 Talsenna (talazoparib 0.25mg) 3# QDCC - 2024-05-23 ~ 2024-06-02 Talsenna (talazoparib 0.25mg) 4# QDCC - 2024-05-06 ~ 2024-05-16 Talsenna (talazoparib 0.25mg) 4# QDCC - 2024-04-18 ~ 2024-04-26 Talsenna (talazoparib 0.25mg) 3# QDCC - 2024-03-16 ~ 2024-06-02 Talsenna (talazoparib 0.25mg) 4# QDCC - 2024-01-01 ~ 2024-03-15

==========

2024-06-18

[potential need for further supplementation beyond iron]

In the past half-month, there has been a noticeable decline in WBC and HGB levels. During this period, Talsenna (talazoparib) was already being administered at a reduced dose of 0.75 mg daily. Due to the continued occurrence of leukopenia and anemia, the dosage was further reduced to 0.5 mg daily starting from 2024-06-14.

• 2024-06-14 WBC 1.64 x10^3/uL

• 2024-05-23 WBC 2.38 x10^3/uL

• 2024-05-05 WBC 3.80 x10^3/uL

• 2024-06-14 HGB 7.4 g/dL

• 2024-05-23 HGB 10.9 g/dL

• 2024-05-05 HGB 12.3 g/dL

Additionally, despite several months of Foliromin (ferrous sodium citrate) supplementation, the concurrent occurrence of macrocytosis suggests that the anemia may not be solely due to iron deficiency. It is recommended to further assess iron storage and/or Vitamin B12 (cobalamin) and folate levels to determine if supplementation of the latter two is needed.

• 2024-06-14 MCV 101.4 fL
• 2024-05-23 MCV 101.7 fL
• 2024-05-05 MCV 106.0 fL
• 2024-04-17 MCV 112.9 fL
• 2024-04-15 MCV 110.3 fL

2024-04-02

[neutropenia (ANC 576) - Talsenna withheld, consider restart at 0.5mg daily if ANC > 1.5K]

Talsenna (talazoparib) was last prescribed at a reduced dose of 0.75mg daily on 2024-03-17 for a 15-day course, ending on 2024-04-01.

Recent lab results, however, revealed grade 3 neutropenia with an ANC of 576/uL.

• 2024-04-01 WBC 1.02 x10^3/uL
  
• 2024-04-01 Neutrophil 56.5 %

It is recommended to hold Talsenna therapy until the neutrophil count recovers above 1,500/uL. If continuing treatment is deemed necessary, resuming therapy at a further reduced dose of 0.5mg daily should be considered.

2024-03-21

[guidelines for talazoparib dose reduction in case of low WBC]

The patient has been receiving the PARP inhibitor Talsenna (talazoparib) since the beginning of 2024 and continues to do so.

The regimen involves a standard dose of talazoparib, 1mg once daily.

• 2024-03-15 WBC 1.78 x10^3/uL

• 2024-02-23 WBC 3.49 x10^3/uL

• 2024-02-07 WBC 2.35 x10^3/uL

• 2024-02-01 WBC 4.53 x10^3/uL

• 2024-03-15 Neutrophil 66.3 %

• 2024-02-23 Neutrophil 69.9 %

• 2024-02-07 Neutrophil 70.6 %

• 2024-02-01 Neutrophil 72.8 %

As of the lab data on 2024-03-15, the patient’s renal and liver functions were within normal ranges.

Talazoparib is known to have a 68% incidence of neutropenia, with 17% of cases being grade 3 and 3% grade 4.

On 2024-03-15, the ANC was calculated to be 1.18 K/uL, indicating no need for dose reduction at this time. However, should the WBC count drop below 1K/uL, it is advisable to resume therapy at a reduced dose of 0.75mg daily.

The dosage of the medication was adjusted to 0.75mg once daily during the hospitalization on 2024-03-16.

701008186

240617

[lab data]

2023-11-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-11-08 HBsAg Nonreactive
2023-11-08 HBsAg (Value) 0.34 S/CO
2023-11-08 Anti-HBs 538.50 mIU/mL
2023-11-08 Anti-HBc Reactive
2023-11-08 Anti-HBc-Value 6.16 S/CO
2023-11-08 Anti-HCV Nonreactive
2023-11-08 Anti-HCV Value 0.11 S/CO

[exam findings]

• 2024-06-16 CXR
  • S/P port-A implantation.
  • Linear infiltration over both lung zone is noted. please correlate with clinical condition to R/O Bronchopneumonia.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • There is massive right side Pleura effusion.
• 2024-06-07 CT - abdomen
  • Findings: Comparison: prior CT dated 2024/03/06.
    • Prior CT identified one poor enhancing mass on right hepatic lobe is noted again, marked increasing in size to 13 cm (the largest dimension) in right lobe and S4 of the liver that is c/w lymphoma with liver involvement S/P C/T with progressive disease.
    • There are newly developed multiple kissing soft tissue lesions in right perirenal space that is c/w lymphoma with perirenal involvement.
    • There are several newly developed soft tissue masses in the peri-pancreatic head and mesentery at LUQ abdomen that is c/w lymphoma with progressive disease.
    • There are several newly developed soft tissue masses on both lungs that may be lymphoma with bilateral lung involvement.
      • In addition, right side Pleura effusion is noted.
    • Prior CT identified multiple enlarged nodes in para-aortic space and para-cava space are noted again, stable in size that is c/w lymphoma S/P C/T with stable disease.
    • Prior CT identified Wedge deformity and osteoblastic change of T12 vertebral body is noted again, stationary. Lymphoma with bone involvement is highly suspected. Please correlate with bone scan.
    • There are several renal cysts on both kidney and the largest one measuring 2.3 cm in size at right middle pole.
    • Abdominal aorta shows atherosclerosis and ectasia 2.4 cm.
  • Impression:
    • Lymphoma with liver, right perirenal space, peripancreatic head, LUQ mesentery, and both lungs involvement S/P C/T show progressive disease.
• 2024-05-17 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • PTA
    • R’t : 51 dB HL, mild to moderately severe SNHL
    • L’t : 55 dB HL, mild to profound SNHL.
• 2024-05-17 Brain Stem Response
  • R’t ABR show response at 50 dB nHL.
  • L’t ABR show response at 55 dB nHL.
• 2024-03-16 ENT Hearing Test
  • Tymp:
    • RE type A; LE type As.
  • ART:
    • Bil absent.
  • PTA:
    • Reliability FAIR
    • Average RE 54 dB HL; LE 65 dB HL.
    • RE mild to moderately severe SNHL.
    • LE moderate to profound mixed type HL.
• 2024-03-06 CT - abdomen
  • Findings: Comparison: prior CT dated 2023/11/03.
    • Prior CT identified several kissing poor enhancing masses on right hepatic lobe and several poor enhancing masses in the spleen are noted again, marked decreasing in size that are c/w lymphoma with liver and spleen involvement S/P C/T with partial response.
    • Prior CT identified multiple enlarged nodes in para-aortic space and para-cava space are noted again, marked decreasing in size that is c/w lymphoma S/P C/T with partial response.
    • Prior CT identified long segmental circumferential mild asymmetrical wall thickening at the terminal ileum is noted again, decreasing in wall thickness that is c/w lymphoma in the terminal ileum S/P C/T with partial response.
      • In addition, Prior CT identified one enlarged node 2.7 cm in the adjacent mesentery is not noted again that is c/w lymphoma S/P C/T with complete response.
    • Prior CT identified an ill-defined ulcerated soft tissue mass in the greater curvature side of the gastric fundus/high body, 4 cm in size (the largest dimension), with suggestive extra-gastric omentum invasion, is not noted again that is c/w gastric lymphoma S/P C/T with complete response. Please correlate with gastroscopy.
    • Prior CT identified multiple enlarged nodes in the peri-gastric fundus/high body area and gastrohepatic ligament are not noted again that is c/w lymphoma S/P C/T with complete response.
    • Prior CT identified a soft tissue mass 3 cm in RLL of the lung is not noted again that is c/w lymphoma with lung involvement S/P C/T with complete response.
    • There are several renal cysts on both kidney and the largest one measuring 2.3 cm in size at right middle pole.
    • Abdominal aorta shows atherosclerosis and ectasia 2.4 cm.
  • Impression:
    • Lymphoma with liver, spleen, para-aortic space, para-cava space, and terminal ileum involvement S/P C/T show partial response.
• 2024-01-24, -01-10, -01-08 CXR
  • S/P port-A implantation.
  • Linear infiltration over both lung zone is noted. please correlate with clinical condition to R/O Bronchopneumonia.
  • Pleura effusion of right and left costal-phrenic angle
  • Enlargement of cardiac silhouette.
• 2023-11-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (191 - 62.3) / 191 = 67.38%
    • M-mode (Teichholz) = 67.4
  • Conclusion:
    • Dilated LA, LV, Ao
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild PR,TR
    • Mild Pulmonary HTN
• 2023-11-14 PET
  • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, stomach, lung, liver, spleen and multiple bone/bone marrow as mentioned above (stage IV).
• 2023-11-13 Patho - bone marrow biopsy
  • Bone marrow, iliac, clinicallyL gastric lymphoma, biopsy — Negative for malignancy.
• 2023-11-03 CT - abdomen
  • Indication: Abdominal fullness for weeks tarry stool. BW loss. poor appetite
    • 20231102 gastroscopy: One over 2cm ulcerative base with necrotic tissue were noted at fundus/upper body, GC, s/p biopsy. favor gastric cancer.
  • Findings:
    • There is an ill-defined ulcerated soft tissue mass in the greater curvature side of the gastric fundus/high body, 4 cm in size (the largest dimension), with suggestive extra-gastric omentum invasion.
      • Adenocarcinoma of the stomach (T4b) is highly suspected.
      • The differential diagnosis includes lymphoma.
    • There are twelve enlarged nodes in the peri-gastric fundus/high body area and gastrohepatic ligament.
      • Regional lymph nodes metastases (N3a) are highly suspected.
      • The differential diagnosis includes lymphoma.
    • There are several kissing poor enhancing masses on right hepatic lobe, 8 cm in size (the largest dimension), and several poor enhancing masses in the spleen.
      • Liver and spleen metastases (M1) are highly suspected.
      • The differential diagnosis includes lymphoma with liver and spleen involvement.
      • In addition, there is a soft tissue mass 3 cm in RLL of the lung. Lung metastasis is highly suspected.
      • The differential diagnosis includes lymphoma with lung involvement.
      • Please correlate with chest CT.
    • There are multiple enlarged nodes in para-aortic space and para-cava space. Non-regional lymph nodes metastases are highly suspected.
      • The differential diagnosis includes lymphoma.
    • There is long segmental circumferential mild asymmetrical wall thickening at the terminal ileum and one enlarged node 2.7 cm in the adjacent mesentery.
      • Lymphoma at the terminal ileum is highly suspected.
      • Please correlate with colonoscopy.
    • There are several renal cysts on both kidney and the largest one measuring 2.3 cm in size at right middle pole.
    • Abdominal aorta shows atherosclerosis and ectasia 2.4 cm.
  • Impression:
    • Gastric cancer with liver, spleen, lung, and non-regional LNs metastases is highly suspected.
      • The differential diagnosis includes lymphoma with stomach, liver, spleen, lung, and lymphadenopathy involvement.
      • Please correlate with PET scan.
    • Lymphoma at the terminal ileum is highly suspected.
      • Please correlate with colonoscopy.
• 2023-11-03 Patho - stomach biopsy (Y1)
  • Stomach, fundus, biopsy — B-cell lymphoma
  • Final diagnosis: Suggestive of diffuse large B-cell lymphoma, GCB
  • Microscopically, it shows dense proliferation of monotonous B-cell type lymphoid cells with architectural effacement and focal necrosis. No H.pylori are identified.
  • Immunohistochemical stain reveals CK(- at tumor), CD56(-), CD20(diffuse +), CD3(patchy+ at background T cells), Ki67 index: >90%.
  • IHC stain: Bcl-6(+), c-myc(-, < 40%), MUM1(-), SOX11(-), CD10(-), lambda(+), kappa(+), cyclin D1(-), Bcl-2(focal+)
• 2023-11-03 Patho - stomach biopsy (Y1)
  • Stomach, body, GC, biopsy — B-cell lymphoma;
  • Final diagnosis: Suggestive of diffuse large B-cell lymphoma, GCB
  • Microscopically, it shows diffuse proliferation of B-cell type lymphoid cells with architectural effacement and focal necrosis. No H.pylori are identified.
  • Immunohistochemical stain reveals CD20(diffuse +), CD3(patchy+ at background T cells), CK(- at tumor), Ki67 index: >90%, CD56(-).
  • IHC stain: Bcl-6(+), c-myc(-, < 40%), MUM1(-), SOX11(-), CD10(-), lambda(+), kappa(+), cyclin D1(-), Bcl-2(focal+)

[MedRec]

• 2023-12-20 SOAP Hemato-Oncology He JingLiang
  • Prescription x3
    • Harnalidge (tamsulosin 0.4mg) 1# QDAC 28D
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD 28D
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD 28D
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID 14D
    • Ulstop (famotidine 20mg) 1# QN 14D
    • Through (sennoside 12mg) 2# HS 14D
• 2023-11-12 ~ 2023-11-23 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • B-cell lymphoma, intra-abdominal lymph nodes, involving multiple lymph nodes on both sides of the diaphragm, stomach, lung, liver, spleen and multiple bone/bone marrow as mentioned above, stage IV.
    • Gout
    • port-a catheter insertion at left cephalic vein on 2023/11/15.
    • upper gastrointestinal bleeding, stool OB:4+
    • hypomagnesemia
  • CC
    • for chemotherapy
  • Present illness
    • This 78 year-old male has the histories of 1) Hypertension, 2) Gastric cancer with liver, spleen, lung, and non-regional LNs metastases,T4bN3aM1, stage: IVB.
    • Followed-up Colonoscopy (2023/11/02) showed: No immediate complication. esophagogastroduodenoscopy (2023/11/02) revealed Gastric ulcerative lesions, body, GC, s/p biopsy(A). Gastric ulcer with necrotic lesion, fundus/upper body, GC, s/p biopsy(C). Reflux esophagitis LA Classification grade A-. Duodenal erosion, bulb, s/p biopsy(B), and the biopsy (2023/11/03): IHC stain: Bcl-6(+), c-myc(-, < 40%), MUM1(-), SOX11(-), CD10(-), lambda(+), kappa(+), cyclin D1(-), Bcl-2(focal+). Final diagnosis: Suggestive of diffuse large B-cell lymphoma, GCB. Immunohistochemical stain reveals CK(- at tumor), CD56(-), CD20(diffuse +), CD3(patchy+ at background T cells), Ki67 index: >90%.
    • Abdomen CT (2023/11/03): 1. Gastric cancer with liver, spleen, lung, and non-regional LNs metastases is highly suspected. The differential diagnosis includes lymphoma with stomach, liver, spleen, lung, and lymphadenopathy involvement. 2. Lymphoma at the terminal ileum is highly suspected.
    • He sufferred from abdominal fullness and back pain for days. No TOCC history was noted. He was admitted for further survey and management.
  • Course of inpatient treatment
    • After be admitted, he received bone marrow was done on 2023/11/13, the biopsy: Negative for malignancy.
    • Followed-up whole body PET (2023/11/14) revealed the FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, stomach, lung, liver, spleen and multiple bone/bone marrow as mentioned above (stage IV).
    • He suffered from bloody and tarry stool noted last night, now, no bloody syool, no tarry stool, and the lab of CBC/DC showed anemia, so gave PPI with Pantolc, Transamine, blood transfusion with LPRBC treatment.
    • After treatment, the symptom of bloody and tarry stool improved, so he received C1 chemothwerapy with R-COP on 2023/11/17. The port-a catheter insertion at left cephalic vein on 2023/11/15. Family meeting was done on 2023/11/15.
    • He suffered from fever noted, so gave antibiotic with Cravit for infection control, pending the cultures data. After treatment, he denide having a fever, vomiting, shortness of breathing, or tarry stool, no any bleeding signs.
    • Under the stable condition, he can be discharged on 2023/11/23, take oral antibiotic back, and the OPD follow-up will be arranged.
  • Discharge prescription
    • Alpraline (alprazolam 0.5mg) 0.5# HS
    • Harnalidge (tamsulosin 0.4mg) 1# QDAC
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • MgO 250mg 2# TID
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Through (sennoside 12mg) 2# HS
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Cravit (levofloxacin 500mg) 1.5# QDAC
• 2023-11-08 SOAP Gastroenterology Chen HongDa
  • S
    • explained EGD and colonoscopy report and abd CT scan report. and patho report
    • we’ve explained about terminal ileum lesion: may discuss with the oncologist or consider laparoscopic exam + biopsy of small bowel
    • PATHO: B-cell lymphoma
    • refer to Oncologist (11/8 AM Prof. Ho)
  • O
    • 2023/11/03 CT: ABD — whole abdomen, pelvis
      • Gastric cancer with liver, spleen, lung, and non-regional LNs metastases. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for gastric cancer: T4b N3a M1; stage: IVB
      • Lymphoma at the terminal ileum is highly suspected.
    • 2023/11/03 PATHO - stomach biopsy
      • Stomach, fundus and body GC, biopsy — B-cell lymphoma
  • Prescription x3
    • Nexium (esomeprazole 40mg) 1# QDAC

[immunochemotherapy]

• 2023-05-30 - rituximab 200mg/m2 300mg NS 300mL 8hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL
• 2023-12-11 - rituximab 375mg/m2 300mg NS 490mL 8hr + cyclophosphamide 75mg/m2 990mg NS 250mL 30min + vincrestine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 40mg/m2 40mg BID PO D1-5 (R-COP; R 70%, C 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO + aprepitant 125mg PO
• 2023-11-16 - rituximab 375mg/m2 300mg NS 300mL 8hr + cyclophosphamide 75mg/m2 700mg NS 250mL 30min + vincrestine 1.4mg/m2 1mg NS 50mL 10min + prednisolone 40mg/m2 40mg BID PO D1-5 (R-COP; R 50%, C 50%, O 50%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO + aprepitant 125mg PO

==========

2023-12-17

[expected dyspnea improvement post-drainage; monitoring calcium levels for tachyphylaxis]

On the afternoon of 2024-06-17, a right-sided pig-tail drainage was performed via the 7th intercostal space at the posterior mid-axillary line, resulting in the smooth drainage of serosanguinous fluid. This procedure is expected to improve dyspnea.

Miacalcic (calcitonin) 100 units Q8H was initiated on 2024-06-17 for hypercalcemia. Please closely monitor calcium levels for potential tachyphylaxis.

• 2024-06-17 Ca (Calcium) 3.35 mmol/L

2023-12-26

[reconciliation]

Following lab findings on 2023-12-25 (CRP 11.5 mg/dL and erect CXR demonstrating right lower lung consolidation and blunted costophrenic angles), Brosym (cefoperazone/sulbactam) was initiated. The patient’s fever has favorably responded, decreasing to 37’C as of 2023-12-26. No medication discrepancies were noted.

2023-12-11

This patient is currently undergoing the R-COP regimen and is also taking Vemlidy (tenofovir alafenamide) due to being anti-HBc positive. The patient’s vital signs are stable, and no discrepancies in medication have been identified.

701164607

240617

[MedRec]

• 2024-06-14 ~ 2024-06-15 POMR General and Gastroenterological Surgery Zhang YaoRen
  • Discharge diagnosis
    • Right breast invasive carcinoma with right cheast wall, right axillary lymph nodes and suspected right supraclavicular fossa lymph nodes metastasis. rpT2N1M1, stage IV. ECOG:0.
    • Dermatitis
    • Generalized skin eruption due to drugs and medicaments taken internally
  • CC
    • for chemotherapy
  • Present illness
    • This 54-year-old female patient has past history of Sicca syndrome and Rheumatism over 4 years with regular medicine control. Leiomyoma of uterus s/p LASH + bil salpingectomy 2019/01/24. She denied any TOCC histories in recent 3 months.
    • She had right breast invasive carcinoma with axillary lymph nodes metastasis post neoadjuvant chemotherapy since 2022/08/03 ~ 2022/12/14. And right breast simple mastectomy and sentinel lymph node dissection on 2023/01/06.
    • Pathologic report showed ypT2N0(sn)(cM0), stage IIA.
    • UFT 100mg/224 mg/cap 2 tab PO BID since 2023-01-16 (advise 2 year).
    • Radiotherapy was completed. And kept follow up in outpatient department.
    • However, right chest wall recurrence was noted on 2024/04/03.
    • Chest CT showed Chest wall and visible lower neck: enlarged LNs up to 19mm at Rt axilla.
    • Surgry of right cheat wall wide excision and axillary lymph node dissection and local flap on 2024/04/09.
    • Pathology showed right chest wall invasive carcinoma with micropapillary pattern,right axillary lymph nodes metastatic. ER(-, 0% ), PR(-, 0% ), Her2/neu(-, 1+).
    • After full explanation the treatment method, this patient decided to Halaven 1.4mg/m2 + Avastin 10mg/kg.
    • Under the impression of right breast invasive carcinoma with right cheast wall, right axillary lymph nodes and suspected right supraclavicular fossa lymph nodes metastasis, she was admitted for 3-2 Halaven 1.4mg/m2 and 4th Avastin 10mg/kg.
  • Course of inpatient treatment
    • After admission, 3-2 Halaven 1.4mg/m2 and 4th Avastin 10mg/kg were given. No discomfort after chemotherapy. Under the stable condition, she was discharged today and arrange next admission three weeks later.
  • Discharge prescription
    • Limeson (dexamethasone 4mg) 1# BID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2022-08-01 ~ 2022-08-03 POMR General and Gastroenterological Surgery Zhang YaoRen
  • Discharge diagnosis
    • Right breast invasive carcinoma with axillary lymph nodes status post port-A insertion 2022/08/02. Triple negative, cT2N1M0, stage IIB. ECOG:0.
    • Sicca syndrome, unspecified
    • Insomnia due to medical condition
    • Rheumatism, unspecified
  • CC
    • noted a palpable mass at right breast at last month.
  • Present illness
    • This 51-year-old female patient has past history of Sicca syndrome and Rheumatism over 2 years with regular medicine control. Leiomyoma of uterus s/p LASH + bil salpingectomy 2019/01/24. She denied any TOCC histories in recent 3 months.
    • She noted a palpable mass at right breast at last month. She came to our OPD for help. Breast sono showed Right breast malignancy with axillary lymph nodes metastasis suggest biopsy. Core needle biopsy revealed invasive carcinoma, ER (-), PR (-), Her2/neu: negatitive (0/1+), p53 (focal patchy weak+, wild-type), p63 (-), Ki-67 inedex: 70%. CA-153：28.29 U/ml, CEA: 0.836 ng/ml.
    • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
    • PE: a hard, nontender, movable mass and irregular margin at right breast around 9x6 cm and right axillary 2x2 cm without discharge. The nipple was dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
    • SDM for this patient in OPD. Neo-adjuvant chemotherapy was her choose. Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles was plan.
    • Surgery of MRM after chemotherapy.
    • Under the impression of right breast invasive carcinoma with axillary lymph node metastasis, she was admitted for surgery of port A insertion.
    • Arrange 1st neoadjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 on 2022/08/03.
  • Course of inpatient treatment
    • After admission, port A insertion was performed on 2022/08/02. 1st neo-adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 were given.
    • The wound is clean and dry. No discomfort after chemotherapy. Under the stable condition, she was discharged today, wound will be follow up on 2022/08/10. And arrange next admission three weeks later.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • MgO 250mg 1# TID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC

[radiotherapy]

• 2024-05-14 ~ 2024-06-03 - 1600cGy/8 fractions (4MeV electron beam) of the recurrent right chest wall tumor bed, and 3000cGy/15 fractions of the reduced recurrent right chest wall tumor bed.
• 2023-02-21 ~ 2023-03-28 - 5000cGy/25 fractions of the right chest wall to SCF.

[immunochemotherapy]

• 2024-06-14 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 600mg NS 250mL 90min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2024-06-05 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min
  • diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-05-29 - Avastin (bevacizumab) 10mg/kg 600mg NS 250mL 90min
  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
• 2024-05-22 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min
  • diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-05-15 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 600mg NS 250mL 90min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2024-04-29 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min
  • diphenhydramine 30mg + NS 250mL
• 2024-04-23 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 600mg NS 250mL 90min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2022-12-14 - docetaxel 75mg/m2 127mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-11-23 - docetaxel 75mg/m2 125mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-11-02 - docetaxel 75mg/m2 122mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-10-12 - docetaxel 75mg/m2 121mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-09-14 - cyclophosphamide 600mg/m2 952mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO
• 2022-08-24 - cyclophosphamide 600mg/m2 938mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 55mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO
• 2022-08-03 - cyclophosphamide 600mg/m2 958mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 55mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL

==========

2024-06-17

[comparing neutropenia rates: eribulin vs. bevacizumab]

Eribulin is more likely to be a major factor causing neutropenia than bevacizumab

Eribulin is associated with neutropenia incidence rates of 63% to 82%, with grades ≥3 occurring in 12% to 57% of cases. In contrast, bevacizumab is associated with neutropenia in 12% of cases, with grades 3/4 occurring in 8% to 21% of cases.

When chemotherapy-induced neutropenia develops, the use of G-CSF might be beneficial.

701428595

240614

[exam findings]

• 2024-04-20 MRI - brain
  • Findings
    • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • Multiple enhancing mass or nodular lesions over left putamen, right thalamus, and both cerebral hemispheres and cerebelli.
      
    • Left frontal skull destruction/metastasis also was noted.
  • Imp:
    • Multiple enhancing mass or nodular lesions over left putamen, right thalamus, and both cerebral hemispheres and cerebelli and left frontal skull, favor metastases.
• 2024-04-18 MRI - nasopharynx
  • The current study was compared to the prior one obtained on 2023/12/25.
  • Known a case of right parotid gland cancer S/P operation and right neck dissection. No recurrent tumor within right parotid space.
  • Multiple enhancing lesions over left putamen, right thalamus, left temporal lobe and both cerebellar lobes. Favor metastatic lesions.
  • Bone marrow signal change with T1-hypointensity, T2-hyperintensity and heterogeneous enhancement at left petrous bone with adjacent dura thickening. R/O bony metastases.
• 2024-04-17 CT - chest
  • Indication: right parotid cancer s/p parotidectomy and right modified radical neck dissection on 2022/07/15, pT3N3bM0, stage IVB
  • Findings - Comparison was made with CT on 2023/9/8
    • Lungs: moderate, bilateral, upper lobes predominant, centrilobular emphysema, in the lungs.
      • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine. no interval change of a tiny calcification in RUL and another tiny noncalcified nodule at anterior LUL.
      • posterior subsegmental atelectasis of RLL.
    • Pleura: mild to moderate Rt-sided effusion. minimal left effusion.
    • Chest wall and visible lower neck: increase in size and number of enlarged Rt axillary lymph node up to 33mm.
    • Visible abdominal-pelvic contents: two hypervascular tumors in left hepatic lobes up to 2cm. s/p double (J”) left ureteral catheter inserted. hyperplasia of left adrenal gland, and a 13mm nodule at base.
      • unremarkable of the GB, spleen, pancreas, and Rt kidney. no enlarged lymph node. enlarged prostate.
      • anterior and lateral wall thickening of the urinary bladder?
    • Extensive atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
    • Visualized bones: pathological compression fracture of T12 vertebral body. area of blastic change in multiple vertebrae.
      • a small blastic change in upper sternum. mixed lytic and blastic change in many ribs.
  • Impression:
    • right parotid cancer s/p op with lung?, bones, and Rt axillary LN metastases, in progression of Rt axillary LNs metastasis compared with CT on 2023/09/08.
• 2024-04-16 MRI - T-spine
  • Indication: Salivary duct carcinoma of right parotid with lymph node metastasis status post right parotidectomyand right modified radical neck dissection on 2022/07/15, pT3N3bM0, stage IVB
  • Thoraco-lumbar spine MRI without and with IV Gd-DTPA administration shows:
    • Multiple bony lesions with T1-hypointensity, mild T2-hyperintensity and heterogeneous enhancement involving every vertebral boy of T-, L spine. C/W bony metastases.
    • Body collapse of T12.
    • After IV contrast administration shows well or heterogenous enhancement in the spine.
    • Correlation with previous imaging study for comparison is suggested.
• 2024-02-06 Tc-99m MDP bone scan
  • The scintigraphic findings suggest multiple bone metastases.
• 2024-02-06 Pure Tone Audiometry
  • Reliabilty Fair
  • PTA
    • R’t : 28 dB HL, normal to moderately severe SNHL
    • L’t : 100 dB HL, severe to profound SNHL.
• 2024-01-26 Patho - skin cyst/tag/debridement
  • Skin, chest, skin biopsy — salivary ductal carcinoma, metastatic
  • Microscopically, it shows metastatic salivary ductal carcinoma composed of invaive tumor nests with ductal differentiation and nuclear atypia with mitotic activity.
  • Immunohistochemical stain reveals AR (+) andGATA3 (+) at tumor.
• 2024-01-09 Pure Tone Audiometry
  • Reliabilty Fair
  • PTA
    • R’t : 29 dB HL, normal to moderately severe SNHL
    • L’t : 73 dB HL, moderately severe to severe SNHL.
• 2024-01-08 MRI - T-spine
  • History
    • Right parotid tumor with neck LAP status post right parotidectomy and right MRND on 2022-07-15. (pT3N3bM0, stage IVB)
    • patho: Salivary duct carcinoma, pT3N3b; primary tumor close margin ＜0.1cm, PNI+, LVI +; LN 25/45, ENN +
    • post-op CCRT since 2022/08/15 to 2022/09/26
    • 20240103: For 2nd opinion of left temporal meningioma? and or T2 vertebrae pathologic fracture; left hearing loss; high pitch tinnitus; left cata(+)
  • Without- and with-contrast MRI of thoracic spine reveal:
    • Numerous bony lesions with T1-hypointensity, mild T2-hyperintensity and heterogeneous enhancement involving every vertebral boy of T-, L- and S-spine. C/W bony metastases.
    • Compression fracture of T12 vertebral body also noted.
    • No intramedullary lesion.
  • IMP:
    • Bony metastases involving T-L-S spine.
• 2024-01-02 Pure Tone Audiometry
  • Reliability FAIR
  • Average RE 29 dB HL; LE 66 dB HL.
    • RE normal to moderately severe SNHL.
    • LE moderate to severe SNHL.
  • Tinnitus (+)
• 2023-12-25 MRI - nasopharynx
  • Findings: comparison: 2023/09/19 MRI
    • Post operative appearance in or at the area of right parotid gland, no focal mass or nodule. -No evident abnormal enlarged lymph node in the visible neck. -Bone destruction at T2 body, metastasis? -After IV contrast administration shows well or heterogenous enhancement of the mass or tumor. -Right mandibular condylar head osteonecrosis? with well post contrast enhancement, also was noted on 2023/09/19 MRI, seems stationary. -Decreased pneumontization of the bilateral mastoid air cells indicating chronic mastoiditis. -A left temporal fossa, dural-based mass, meningioma? or metastasis.
  • IMP:
    • Post right parotidectomy, no local tumor recurrence. No neck LAP
    • R/O T2 metastasis
    • Left temporal bone metastasis or meningioma?
• 2023-12-25 Pure Tone Audiometry
  • Reliability FAIR
  • Average RE 28 dB HL; LE 58 dB HL.
    • RE normal to moderately severe SNHL.
    • LE moderate to moderately severe SNHL.
• 2023-12-18 Ear Nose Throat Hearing Test
  • Tymp:
    • Bil type A.
  • ART:
    • Bil absent.
  • PTA:
    • Reliability FAIR
    • Average RE 30 dB HL; LE 55 dB HL.
      • RE normal to moderately severe SNHL.
      • LE moderate to moderately severe SNHL.
• 2023-09-19 MRI - nasopharynx
  • Findings:
    • The current study was compared to the prior one obtained on 2023/04/14.
    • Known a case of right parotid gland cancer S/P operation and right neck dissection. No recurrent tumor within right parotid space.
    • Bilateral otitis media.
    • Bilateral mastoiditis.
    • Paranasal sinusitis.
    • Bone marrow signal change with T1-hypointensity, T2-hyperintensity and heterogeneous enhancement at left petrous bone with adjacent dura thickening. R/O bony metastases.
• 2023-09-08 CT - chest
  • Findings: Comparison was made with CT on 2023/3/23
    • Lungs: moderate, bilateral, upper lobes predominant, centrilobular emphysema in the lungs.
      • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine. small metastatic lung nodules in LUL and RUL.
    • Mediastinum and hila: no enlarged LN. small pericardial effusion.
    • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Chest wall and visible lower neck: enlarged RT axillary lymph node 19mm.
    • Visible abdominal-pelvic contents: two hypervascular tumors in left hepatic lobes up to 2cm.
      • anterior and lateral wall thickening of the urinary bladder.
      • enlarged prostate.
    • Extensive atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
    • Visualized bones: pathological compression fracture of T12 vertebral body. area of blastic change in multiple vertebrae.
      • a small blastic change in upper sternum. mixed lytic and blastic change in many ribs.
  • Impression:
    • right parotid cancer s/p operation with lung, bones, and Rt axillary LN metastases, in regression of Rt axillary LN metastasis compared with CT on 2023/03/23.
    • hepatic hemangiomas or metastasis.
• 2023-07-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (68 - 21) / 68 = 69.12%
    • M-mode (Teichholz) = 68
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild MR, TR
• 2023-07-04 CT - orbits
  • Findings:
    • Plaque-like mass lesion over left temporal fossa, causing permeation of left fronto-temporo-sphenoid bones. Homogeneous enhancement of this tumor. DDx: meningioma with malignant change or metastatic lesion.
    • Paranasal sinusitis.
• 2023-06-09 All-RAS + BRAF mutation
  • Cellblock No. S2023-10657
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-30 Patho - lymphnode biopsy (Y1)
  • Right axillary lymph node, sono-guided biopsy — Invasive carcinoma, metastatic
    • NOTE: Correlation with image study and clinical findings is recommneded.
  • Microscopically, it shows invasive carcinoma composed of invaive tumor nests with ductal differentiation, stromal fibrosis and nuclear atypai with mitotic activity.
  • Immunohistochemical stain reveals SOX10(-), CK5/6(-), GATA3(+), TRPS1(+), ER: negative, PR: negative, Her2/neu: positive (3+), Ki-67 index: 70%.
• 2023-05-22 PET
  • Compared with the previous study on 2022-07-13, most of old glucose hypermetabolic lesions in the right parotid gland and in the right cervical and SCF lymph nodes disappear or come to less evident, suggesting response to therapy. However, there are multiple new nodular lesions of increased FDG uptake in the right SCF, left neck and left SCF, highly suspected recurrent tumor with regional lymph nodes metastases.
    
  • Increased FDG uptake in the right axillary lymph nodes and in bilateral mediastinal lymph nodes, highly suspected cancer with distant lymph nodes metastases, suggesting biopsy (right axillary lymph node) for investigation.
    
  • Increased FDG uptake in the right upper lung, right lobe of the liver, and skeleton including skull, left part of the maxilla, sternum, both rib cages, left scapula, several C-, T- and L-spine, sacrum, bilateral pevic bones, and femurs, highly suspected cancer with lung, liver and bone metastases.
    
  • Right parotid cancer s/p treatment, with tumor recurrence and multiple distant metastases, rcTxN2-3M1, stage IVC (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-05-11 Nerve Conduction Velocity, NCV
  • Findings:
    • Facial NCV (ENOG): 22.7 % L/R amplitude ratio
    • delayed latency in bilateral facial nerve.
    • The blink reflex shows absence of R1 & ipsilateral R2 wave latency & contralateral R2 wave latency when stimulated with L trigeminal nerve.
  • Conclusion
    • These findings suggest left peripheral facial neuropathy & Complete left trigeminal lesion.
    • Advise clinical correlation.
• 2023-04-14 MRI - nasopharynx
  • Neck MRI without/with Gadolinium-based contrast enhancement shows:
    • Post-operation change with absence of right parotid gland and presence of soft tissue enhancement (granulation tissue?), stationary.
    • Mottled T2-hyperintensity effusion filling in right mastoid air cells, indicating mastoiditis.
    • Post-operation change at right submandibular space and neck due to lymph node dissection.
    • Bone marrow signal change with T1-hypointensity, T2-hyperintensity and faint enhancement at medial part of right clavicle, stationary. Etiology to be determined.
  • Impression:
    • Compatible with right parotid cancer s/p operation without evidence of residual or recurrent tumor. No cervical lymphadenopathy.
    • Right medial clavicular bone marrow lesion, stationary, etiology to be determined. Suggest follow-up.
    • Right mastoiditis.
• 2023-03-23 CT - chest
  • Imp:
    • COPD.
    • No evidence of metastatic lesion in the study
• 2023-02-23 Patho - bone fragment (non pathologic fracture)
  • Bone, right clavicular, CT-guide biopsy — No evidence of malignant tumor
    • NOTE: Correlation of imgae study and clinical findings is recommended.
  • Microscopically, it shows mature bone and chronoid tissues. There is no evidence of malignant tumor.
  • Immunohistochemical stain of CK is negative.
• 2022-12-28 CT - chest
  • extensive emphysema and no lung npdule.
• 2022-12-13 Tc-99m MDP bone scan
  • Increased activity in the proximal portion of the right clavicle and adjacent right sternoclavicular junction. The nature is to be determined (post-traumatic change? bone tumor? other nature?). Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the lower T-spine and some L-spines. Degenerative change may show this picture.
  • Increased activity in the maxilla. Dental problem and sinusitis may show this picture.
  • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
• 2022-11-16 MRI - nasopharynx
  • C/W right parotid cancer s/p oepration without evidence of residual or recurrent tumor. Right medial clavicular lesion (24 mm). Suggest follow-up.
• 2022-09-02 CXR
  • Atherosclerotic change of aortic arch
• 2022-07-21 CT - abdomen
  • Left liver hemangioma (2.2cm).
  • Left renal cyst (1.3cm).
• 2022-07-19 SONO - abdomen
  • Diagnosis
    • Possible liver lesion, S2
    • Gall stone
  • Suggestion:
    • 4 phase CT or dynamic MRI study
• 2022-07-18 Patho - salivary gland resection
  • PATHOLOGIC DIAGNOSIS
    • Parotid gland, right, total parotidectomy — Salivary duct carcinoma
    • Lymph nodes, righ neck, modified radical neck dissection — Metastatic carcinoma (25/45)
    • Pathology stage: pT3N3b; Stage IVB if cM0
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure(s): Total parotidectomy + right modified radical neck dissection
    • Specimen Type:
      • Main location: Parotid gland, right
      • Lymph node dissection: Yes, including right level Ia, Ib, II, III, IV, Vb, and Va
    • Specimen Integrity: intact
    • Specimen Size: 6.2 x 4.5 x 3.8 cm
    • Tumor Site: Parotid gland; Laterality: right
    • Tumor Focality: Single focus
    • Tumor Size: 5.5 x 4.0 x 3.2 cm
    • Gross Tumor Extension: Tumor invades adjacent soft tissue
      • Representative parts are taken for section and labeled: A1= tumor + superior margin, A2= tumor + inferior matgin, A3= tumor + anterior margin, A4= tumor + posterior margin, A5-A9= tumor, A10= LNs, B1-B2= parotid gland of deep + external jugular vein, C= parotid tissue of deep, D= level Ia, E1-E2= level Ib, F1-F3= LN level II, G1-G2= level III, H1-H2= level IV, I1-I2= level Vb, J1-J2= level Va. F2022-00327FSA and A= right neck lymph node, FSB1= inferior deep lobe and superior deep lobe, FSB2= posterior deep lobe and deep lobe lymph node.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Salivary duct carcinoma
    • Histologic Grade: High grade
    • Microscopic Tumor Extension: Tumor invades adjacent skeletal muscle
    • Margins: Margins free, Distance from closest margin: < 0.1 cm
    • Lymph-Vascular Invasion: Present
    • Perineural Invasion: Present
    • Neck Lymph Nodes: Metastatic carcinoma (25/45)
    • Ipsilateral:
      • Number of LN examined: 1 (level Ia), 3 (level Ib), 9 (level II), 6 (level III), 13 (level IV), 7 (level Vb), 4 (level Va)
      • Number of LN metastasis: 0 (level Ia), 3 (level Ib), 8 (level II), 5 (level III), 1 (level IV), 2 (level Vb), 4 (level Va)
      • Greatest dimension of metastatic focus: 2.2 cm
      • Extranodal Extension: Present
      • Specimen received for frozen section, labeled “neck lymph node”: Metastatic carcinoma (1/1)
      • Specimen received for frozen section, labeled “deep lobe lymph node”: metastatic carcinoma (1/1)
    • Surgical margins received for frozen section, including “inferior deep lobe” and superficial deep lobe”: involved by carcinoma
    • Surgical margin received for frozen section and labeled “posterior deep lobe”: Free of carcinoma
    • Specimen labeled “external jugular vein and parotid tissue of deep”: Involved by carcinoma and jugular vein is free but surrounded by tumor cells
    • Specimen labeled “parotid tissue of deep”: Free
    • IHC: Androgen receptor(+), HER2/neu(positive, score=3+)
• 2022-07-15 Frozen Section
  • Lymph node, neck, right, frozen section — Malignant (metastatic carcinoma)
  • Inferior deep lobe, right, frozen section — Involved by carcinoma
  • Superior deep lobe, right, frozen section — Involved by carcinoma
  • Posterior deep lobe, right, frozen section — Free of carcinoma
  • Deep lobe lymph node, right, frozen section — Metastatic carcinoma
• 2022-07-13 PET
  • Glucose hypermetabolic lesions in the right parotid gland, highly suspected right parotid gland cancer, suggesting biopsy for investigation.
    
  • Glucose hypermetabolic lesions in the right cervical levels II-V lymph nodes and in a right SCF lymph node, highly suspected cancer with regional lymph nodes involvement, suggesting biopsy for investigation also.
  • Probably reactive nodes in bilateral mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes.
  • Right parotid cancer (if proved), cTxN2bM0, stage IVA (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2022-07-07 CT - neck
  • Marked enlargement of right parotid gland with one large microlobulated mass lesion (3.2cm), showing avid enhancement. Suggest tissue proof to rule out malignancy.
  • Multiple variable-sized enlarged nodes over right level II and III of neck. May be malignant nodes. Suggest tissue proof.
• 2022-07-05 SONO - head and neck soft tissue
  • Clinical Impression/Intent: R paroti tumor with multiple LAPs, suspect malignancy
  • Salivary Gland: 2.273.56 R heterogenous hypoechoic parotid tumor, multiple LAPs hypoechoic, round shape, without hilum at L level Ib (1.241.26cm), L level II-III (0.60.91, 0.660.91), L level V (1.24*1.42cm)

[MedRec]

• 2024-04-15 ~ 2024-05-09 POMR Hemato-Oncology Xia HeXiong
  • Course of inpatient treatment
    • After admission, progression lower back pain was noted, after last time chemotherapy. Tramacet 37.5 & 325mg/tab 1# PO Q6H for pain control.
    • Arranged Nasopharynx MRI on 2024/04/18 showed Known a case of right parotid gland cancer S/P operation and right neck dissection. No recurrent tumor within right parotid space; multiple enhancing lesions over left putamen, right thalamus, left temporal lobe and both cerebellar lobes. Favor metastatic lesions; bone marrow signal change with T1-hypointensity, T2-hyperintensity and heterogeneous enhancement at left petrous bone with adjacent dura thickening. R/O bony metastases.
    • T-spine MRI on 2024/04/16 showed multiple bony lesions with T1-hypointensity, mild T2-hyperintensity and heterogeneous enhancement involving every vertebral boy of T-, L spine. C/W bony metastases; body collapse of T12. after IV contrast administration shows well or heterogenous enhancement in the spine.
    • Chest CT on 2024/04/17 showed right parotid cancer s/p op with lung?, bones, and Rt axillary LN metastases, in progression of Rt axillary LNs metastasis compared with CT on 2023/09/08. After explain and discussion, prescription with Casodex 50mg/tab 1# PO QD (self paid) for cancer treatment since 2024/04/19~.
    • Follow up Brain MRI on 2024/04/20 showed Multiple enhancing mass or nodular lesions over left putamen, right thalamus, and both cerebral hemispheres and cerebelli and left frontal skull, favor metastases.
    • Consult Radiation Oncology for brain metastasis, suggested brain metastasis for 3960cGy/12 fx (sparring bilateral hippocampi if feasible). CT simulation on 2024/04/23, start on 2024/04/25~5/12.
    • ULSTOP F.C 20mg/tab 1# PO BID and prescribe oral Steroid for prevention of IICP.
    • Hypothyroidism was treated Eltroxin 50mcg/tab 2# PO QDAC.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for AntiHBc (+).
    • Patient tolerated the radiotherapy without IICP sign.
    • With the stable condition, he was discharged on 2024/05/09 and OPD followed up later.
  • Discharge prescription
    • Alpraline (alprazolam 0.5mg) 1# PRNHS
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Casodex (bicalutamide 50mg) 1# QD
    • Compesolon (prednisolone 5m) 1# QD 2D
    • Compesolon (prednisolone 5m) 0.5# QD 3D
    • Eltroxin (levothyroxine 50ug) 2# QDAC
    • Feburic (febuxostat 80mg) 0.5# QD
    • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# BID
    • MgO 250mg 1# TID
    • Through (sennoside 12mg) 2# HS
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H if VAS > 3
    • Ulstop (famotidine 20mg) 1# BID
    • Zulitor (pitavastatin 4mg) 0.5# QN
• 2024-02-26 ~ 2024-03-07 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Salivary duct carcinoma of right parotid with lymph node metastasis status post right parotidectomyand right modified radical neck dissection on 2022/07/15, pT3N3bM0, stage IVB, status post concurrent chemoradiotherapy, with tumor recurrence and multiple distant metastases, rcTxN2-3M1, stage IVC, ER(+), PR(+), Her2/neu: positive (3+), Ki-67 inedex: 70%. status post taxol (paclitaxel 80mg/m2, self-payment) 120mg on 2024/02/28(C1D1), Due to Leukopenia thus decrease to 90mg on 2024/03/06(C1D8).
    • Agranulocytosis secondary to cancer chemotherapy
    • Encounter for antineoplastic chemotherapy
    • Encounter for antineoplastic radiation therapy
    • Chronic sinusitis, unspecified
    • Hypothyroidism, unspecified
    • Bell’s palsy
  • CC
    • For Pamisol, consult dentist, C/T or H/T
  • Present illness
    • This 66-year-old man has history of hypothyroidism for 4 years under regular medication control. Right parotid cancer with lymph node metastasis status post right parotidectomyand right modified radical neck dissection on 2022-07-15. (pT3N3bM0, stage IVB).
    • Tracing back the past history, the patient had a right infra-auricular mass noted for over 10 years. The mass was small initially, but it enlarged since 2022/01, especially in recent since 2022/03. The patient was referred from local clinic. At our ENT OPD, physical examination revealed right parotid hard tumor 43cm in size, right lymphadenopathy 1 1cm in size at right neck level III, 1.5*1.5cm lymphadenopathy at right supraclavicular fossa.
    • We arranged neck sono which revealed right heterogenous hypoechoic parotid tumor, multiple round-shaped hypoechoic LAPs without hilum at right neck level Ib, level II-III and level V. We arranged neck CT on 2022-07-07 which revealed enlargement of right parotid gland with one large microlobulated mass lesion (3.2cm), multiple variable-sized enlarged nodes over right level II and III of neck. Under the impression of right parotid tumor with right neck lymphadenopathy suspected malignancy, surgery of right parotidectomy and right neck dissection were suggested.
    • He underwent the operation of right total parotidectomy and right modified radical neck dissection on 2022/07/15, pathology reveled right parotid cancer with right neck matastasis , pT3N3bM0, stage IVB. Abdominal sono was arranged for cancer work up, revealed possible S2 liver lesion and gall stone. The tri-phase abdominal CT on 2022/07/23 revealed left liver hemangioma (2.2cm) and left renal cyst (1.3cm).
    • After teeth extraction, he received adjuvant CCRT to R’t parotid tumor bed and neck lymphatics for 6600cGy/33 fx for locoregional control, from 2022/08/15 to 2022/09/28, and weekly cisplatin from 2022/08/18 to 2022/09/28. He left facial palsy was noted in 2023/04/19.
    • Follow up Nasopharyax MRI on 2023/04/14 showed 1. Compatible with right parotid cancer s/p operation without evidence of residual or recurrent tumor. No cervical lymphadenopathy, 2. Right medial clavicular bone marrow lesion, stationary, etiology to be determined. Suggest follow-up, 3. Right mastoiditis.
    • Follow up Whole bady PET scan 2023/05/22 showed
      • Compared with the previous study on 2022/07/13, most of old glucose hypermetabolic lesions in the right parotid gland and in the right cervical and SCF lymph nodes disappear or come to less evident, suggesting response to therapy. However, there are multiple new nodular lesions of increased FDG uptake in the right SCF, left neck and left SCF, highly suspected recurrent tumor with regional lymph nodes metastases.
      • Increased FDG uptake in the right axillary lymph nodes and in bilateral mediastinal lymph nodes, highly suspected cancer with distant lymph nodes metastases, suggesting biopsy (right axillary lymph node) for investigation.
      • Increased FDG uptake in the right upper lung, right lobe of the liver, and skeleton including skull, left part of the maxilla, sternum, both rib cages, left scapula, several C-, T- and L-spine, sacrum, bilateral pevic bones, and femurs, highly suspected cancer with lung, liver and bone metastases.
      • Right parotid cancer s/p treatment, with tumor recurrence and multiple distant metastases, rcTxN2-3M1, stage IVC (AJCC 8th ed.), by this F-18 FDG PET scan.
    • Then, sonoguided biopsy of right axillary LN noted by PET-CT and CT scan on 2023/05/30, pathology showed right axillary lymph node, sono-guided biopsy — Invasive carcinoma, metastatic . IHC stain — ER: negative, PR: negative, Her2/neu: positive (3+), Ki-67 inedex: 70%.
    • Chemotherapy with AC on 2023/07/10(C1), on 2023/07/26(C2), s/p EC * 6 from 2023-08-24 to 2023-12-05.
    • RT to skin carcinomatosis for 3300cGy/10 fx for symptom control since 2024/02/19.
    • This time, he was admitted for Pamisol, consult dentist, C/T or H/T.
  • Course of inpatient treatment
    • After admission, Kept radiotherapy to skin carcinomatosis for 3300cGy/10 fx for symptom control 2/19 to 3/4.
    • For Pamisol, consult dentist and 1. maintain oral hygiene 2. well inform risk of osteonecrosis of jaw due to either radiation or medication-related.
    • Discuss with family of C/T or H/T, waiting for patient insurance amount and suggest: 1. taxotere 2. taxol 3. gemzar 4. navelbine 5. casodex, after discuss they choose “taxol”. The chemotherapy with taxol (paclitaxel 80mg/m2) was done smoothly on 2024/02/28(C1D1).
    • Hydration with N/S 500ML IVD BID. Pain control with tramacet 1# tid.
    • AntiHBc postive with baraclude 0.5mg/tab 1# qdac.
    • Hypothyroidism with eltroxin 50mcg/tab 2# qdac.
    • Recheck laboratory on 3/5 and WBC 2010uL, HB 8.4mg/dl, ANC 1449uL, Creatinine 1.34mg/dl.
    • The chemotherapy with taxol(paclitaxel 80mg/m2) was done smoothly on 2024/03/06(C1D8).
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2024/03/07 and OPD followed up later.
  • Discharge prescription
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
    • Zulitor (paitavastatin 4mg) 0.5# QN
    • MgO 250mg 2# TID
    • Eltroxin (levothyroxine 50ug) 2# QDAC
• 2024-02-07 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • Arrange admission for
      • Anti-HER2 with C/T (breast cancer regimen: taxotere or taxol or gemcitabine or navelbine or PFL, etc)
      • Androgen blocker due to AR (+) e.g., Casodex
      • Consult Dentist for Pamisol (pamidronate)

[consultation]

• 2024-04-19 Radiation Oncology
  • Q
    • This time, R/O disease progression, arranged work-up. MRI :
      • The current study was compared to the prior one obtained on 2023/12/25.
      • Known a case of right parotid gland cancer S/P operation and right neck dissection. No recurrent tumor within right parotid space.
      • Multiple enhancing lesions over left putamen, right thalamus, left temporal lobe and both cerebellar lobes. Favor metastatic lesions.
      • Bone marrow signal change with T1-hypointensity, T2-hyperintensity and heterogeneous enhancement at left petrous bone with adjacent dura thickening. R/O bony metastases.
    • Plan: Brain MRI arrange on 2024/04/20.
    • For brain metastasis, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • This 66 /O male is a case of
      • Right parotid cancer with lymph node metastasis status post right parotidectomy and right modified radical neck dissection on 2022-7-15. (pT3N3bM0, stage IVB)
      • Hypothyroidism.
    • s/p adjuvant CCRT on 2022/09/28.
    • Relapse with neck LAPs, lung, liver and bone metastases s/p C/T with EC x 6, 2023/08/24 to 12/05, with disease progression;
    • s/p RT to T6-L1 spines for 3000cGy/10 fx since 2024/01/18 to 01/31; to left skull base to skull for 4200cGy/14 fx since 2024/01/18 to 02/06;
    • RT to skin carcinomatosis for 3300cGy/10 fx for symptom control since 2024/02/19 to 2024/03/04;
    • Under chemotherapy with taxol (paclitaxel 80mg/m2) from 2024/02/28(C1D1), 2024/03/06(C1D8); leukopenia thus decrease to 60mg/m2 on 2024/03/06(C1D8), 2024/03/23(C2D1), 2024/04/01(C2D8).
    • ENT MRI on 2024/04/18: Known a case of right parotid gland cancer S/P operation and right neck dissection. No recurrent tumor within right parotid space. Multiple enhancing lesions over left putamen, right thalamus, left temporal lobe and both cerebellar lobes. Favor metastatic lesions. Bone marrow signal change with T1-hypointensity, T2-hyperintensity and heterogeneous enhancement at left petrous bone with adjacent dura thickening. R/I bony metastases. Imp Multiple brain metastasis and left petrous bone metastasis.
    • Brain MRI is arrange on 2024/04/20.
    • Plan:
      • I suggested RT to brain metastasis for 3960cGy/12 fx (sparring bilateral hippocampi if feasible).
      • CT simulation on 4/23 14:30 (will be moved forward if someone cancels).
      • Possible radiation dermatitis, hair loss & IICP are told to him and his wife.
      • Please prescribe oral dexamethasone 4mg 1# QD at least for prevention of IICP; BID or increase dose may be needed during brain RT. Thanks!
• 2024-03-28 Urology
  • Q
    • for Left moderate hydronephrosis by Kidney sono on 2024/03/26
  • A
    • Marked progression of left hydronephrosis is found ( if compare with 2024/01 MRI)
    • Due to elevated creatinine level (accompany with CEA CA 199 rising), tumor stent may be inserted.
    • I will explain to him today (03/28) Operation may be arranged on 03/29.
  • A 2024-03-28 09:46:20
    • 03/28 09:45 I had explained to him on pros and cons of tumor stent insertion. He decided to discuss after family member come
  • A 2024-03-28 14:18:42
    • After explaining the benefit of procedure (renal function improvement) and side effect(frequency urgency), they want more time to think and was upset on general malaise since 2023 December
• 2024-03-05 Ophthalmology
  • Q
    • for Cata follow up
  • A
    • VA OD 0.1 OS 0.2 PT 19/16mmHg
      • tear meniscus thinning
      • K: clear AC: deep Lens: NS+++
    • well explain the blurred vision due to cataract
    • Dx:
      • dry eye (OU)
      • cataracat (OU)
    • Rx:
      • OSMD 1gtt (OU) qid
      • Dura tear oint (OS) qhs
• 2024-02-26 Oral and Maxillofacial Surgery
  • Q
    • for assessment pre-Pamisol (pamidronate)
    • This 66-year-old man has history of hypothyroidism for 4 years under regular medication control. The patient had a right infra-auricular mass noted for over 10 years. The mass was small initially, but it enlarged since 2022/01, especially in recent since 2022/03. The patient was referred from local clinic.
      • At our ENT OPD, physical examination revealed right parotid hard tumor 43cm in size, right lymphadenopathy 1 1cm in size at right neck level III, 1.5*1.5cm lymphadenopathy at right supraclavicular fossa.
      • We arranged neck sono which revealed right heterogenous hypoechoic parotid tumor, multiple round-shaped hypoechoic LAPs without hilum at right neck level Ib, level II-III and level V. We arranged neck CT on 2022-07-07 which revealed enlargement of right parotid gland with one large microlobulated mass lesion (3.2cm), multiple variable-sized enlarged nodes over right level II and III of neck.
      • Under the impression of right parotid tumor with right neck lymphadenopathy suspected malignancy, surgery of right parotidectomy and right neck dissection were suggested.
      • He underwent the operation of right total parotidectomy and right modified radical neck dissection on 2022/07/15, pathology reveled right parotid cancer with right neck matastasis , pT3N3bM0, stage IVB.
      • Abdominal sono was arranged for cancer work up, revealed possible S2 liver lesion and gall stone.
      • The tri-phase abdominal CT on 2022/07/23 revealed left liver hemangioma (2.2cm) and left renal cyst (1.3cm).
      • After teeth extraction, he received adjuvant CCRT to R’t parotid tumor bed and neck lymphatics for 6600cGy/33 fx for locoregional control, from 2022/08/15 to 2022/09/28, and weekly cisplatin from 2022/08/18 to 2022/09/28.
      • He left facial palsy was noted in 2023/04/19.
      • Follow up Nasopharyax MRI on 2023/04/14 showed
        • Compatible with right parotid cancer s/p operation without evidence of residual or recurrent tumor. No cervical lymphadenopathy.
        • Right medial clavicular bone marrow lesion, stationary, etiology to be determined. Suggest follow-up.
        • Right mastoiditis.
      • Follow up Whole bady PET scan 2023/05/22 showed
        • Compared with the previous study on 2022/07/13, most of old glucose hypermetabolic lesions in the right parotid gland and in the right cervical and SCF lymph nodes disappear or come to less evident, suggesting response to therapy. However, there are multiple new nodular lesions of increased FDG uptake in the right SCF, left neck and left SCF, highly suspected recurrent tumor with regional lymph nodes metastases.
        • Increased FDG uptake in the right axillary lymph nodes and in bilateral mediastinal lymph nodes, highly suspected cancer with distant lymph nodes metastases, suggesting biopsy (right axillary lymph node) for investigation.
        • Increased FDG uptake in the right upper lung, right lobe of the liver, and skeleton including skull, left part of the maxilla, sternum, both rib cages, left scapula, several C-, T- and L-spine, sacrum, bilateral pevic bones, and femurs, highly suspected cancer with lung, liver and bone metastases.
        • Right parotid cancer s/p treatment, with tumor recurrence and multiple distant metastases, rcTxN2-3M1, stage IVC (AJCC 8th ed.), by this F-18 FDG PET scan.
      • Then, sonoguided biopsy of right axillary LN noted by PET-CT and CT scan on 2023/05/30, pathology showed right axillary lymph node, sono-guided biopsy — Invasive carcinoma, metastatic. IHC stain — ER: negative, PR: negative, Her2/neu: positive (3+), Ki-67 inedex: 70%.
      • Chemotherapy with AC on 2023/07/10(C1), on 2023/07/26(C2), s/p EC * 4 from 2023-08-24 to 2023-11-07.
      • This time, he was admitted for palliative chemotherapy.        
  • A
    • Considering the ongoing palliative radiation on the tumor site, dental extraction of remaining hopless teeth is disencouraged
    • plan:
      • maintain oral hygiene
      • well inform risk of osteonecrosis of jaw due to either radiation or medication-related
    • thank you for your consultation

[chemotherapy]

• 2024-04-01 - paclitaxel 60mg/m2 90mg NS 300mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-03-23 - paclitaxel 60mg/m2 90mg NS 300mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-03-06 - paclitaxel 60mg/m2 90mg NS 300mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-02-28 - paclitaxel 80mg/m2 120mg NS 300mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-11-07 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr (EC)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-10-04 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr (EC)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-09-20 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr (EC)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-08-24 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr (EC)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-07-27 - doxorubicin 60mg/m2 100mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr (AC)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-07-10 - doxorubicin 60mg/m2 100mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr (AC)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2022-09-28 - cisplatin 40mg/m2 75mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CDDP QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2022-09-23 - cisplatin 40mg/m2 75mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CDDP QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2022-09-16 - cisplatin 40mg/m2 75mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CDDP QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2022-09-02 - cisplatin 40mg/m2 75mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CDDP QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2022-08-26 - cisplatin 40mg/m2 75mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CDDP QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2022-08-19 - cisplatin 40mg/m2 75mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CDDP QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-06-14

[decline in liver and kidney function; managing AKI and hyperuricemia; Euricon and hydration requirements]

The patient’s liver and kidney function appear to be declining, as evidenced by increasing bilirubin levels and decreasing eGFR, with AKI confirmed by an increase in serum creatinine by ≥0.3 mg/dL within 48 hours, meeting the KDIGO guidelines for AKI.

• 2024-06-13 Bilirubin total 2.16 mg/dL
  

• 2024-06-11 Bilirubin total 1.75 mg/dL
  

• 2024-05-06 Bilirubin total 0.88 mg/dL

• 2024-06-13 Creatinine 2.03 mg/dL
  

• 2024-06-11 Creatinine 1.69 mg/dL

• 2024-06-13 eGFR 35.10 ml/min/1.73m^2
  

• 2024-06-11 eGFR 43.37 ml/min/1.73m^2
  

• 2024-05-15 eGFR 65.01 ml/min/1.73m^2
  

• 2024-05-06 eGFR 73.49 ml/min/1.73m^2

Euricon (benzbromarone) has been prescribed for hyperuricemia. When taking this drug, it is important to drink plenty of water to help excrete uric acid in the urine. However, if the patient has decreased urine output, this medication may not be suitable, and its use is not recommended for patients with an eGFR <30 mL/minute (EULAR Richette 2017). As an alternative, Feburic (febuxostat) is recommended, with the dose limited to 40 mg daily for patients with a CrCl of 15-29 mL/min according to the package insert.

• 2024-06-11 Uric Acid 8.2 mg/dL

[evaluating treatment options for edema and hyperbilirubinemia]

Given the patient’s 3+ pitting edema in the limbs and worsening hyperbilirubinemia, considering the administration of furosemide and Uliden (ursodeoxycholic acid) may be appropriate if there are no contraindications.

2024-03-25

[renal function decline: Zulitor adjusted, caution advised for Pamisol]

The patient’s serum creatinine levels remained around 1mg/dL from 2023-11 to 2024-01. However, starting from 2024-02, the levels increased to approximately 1.5mg/dL, with the latest eGFR being 47. Consequently, the dosage of Zulitor (pitavastatin) has been adjusted in accordance with the patient’s renal function status.

• 2024-03-22 eGFR 47.56 ml/min/1.73m^2
  
• 2024-03-22 Creatinine 1.56 mg/dL
  
• 2024-03-14 Creatinine 1.72 mg/dL
  
• 2024-03-05 Creatinine 1.34 mg/dL
  
• 2024-02-26 Creatinine 1.69 mg/dL
  
• 2024-01-03 Creatinine 0.95 mg/dL
  
• 2023-12-04 Creatinine 1.06 mg/dL
  
• 2023-11-06 Creatinine 0.97 mg/dL

If there are plans to use Pamisol (pamidronate) for the patient, it’s important to maintain good renal function, as Pamisol is not recommended for patients with osteolytic bone metastases if their CrCl < 30 mL/minute or their SCr > mg/dL.

701510462

240614

[lab data]

• 2024-02-22 Anti-HBc Reactive
  
• 2024-02-22 Anti-HBc Value 8.27 S/CO
  
• 2024-02-22 Anti-HBs 0.64 mIU/mL
  
• 2024-02-22 Anti-HCV Nonreactive
  
• 2024-02-22 Anti-HCV Value 0.12 S/CO
  
• 2024-02-22 HBsAg Reactive
  
• 2024-02-22 HBsAg Value 4354.14 S/CO

[exam findings]

• 2024-05-28 CT - abdomen
  • History and indication: Gastric cancer
  • Non-contrast CT of abdomen-pelvis revealed:
    • Gastric cancer s/p operation. Some LNs (up to 12mm) at mesentery and paraaortic region.
    • A hypodense nodule (2.9cm) at right kidney.
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • S/P Port-A infusion catheter insertion.
    • Degeneration and spondylosis of L-S spine.
  • IMP:
    • Gastric cancer s/p operation. Some LNs (up to 12mm) at mesentery and paraaortic region.
    • A hypodense nodule (2.9cm) at right kidney r/o cyst.
• 2024-03-05 SONO - nephrology
  • Chronic parenchymal renal disease
  • Single renal cyst, right kidney
• 2024-02-08 CTA - brain + CTP
  • Indication: l’t side weakness and slurred speech. poor intake recently.
  • Without contrast helical Head CT - 4mm thickness in each slice from the axial and saggital projections showed
    • unremarkable change in the Intraventricular and extraventricular CSF spaces
    • unremarkable change in the brain parenchyma
    • unremarkable change in the skull base
    • nodular lesions in the bilateral thyroid gland.
    • artherosclerotic change at the bilateral distal VAs and bilateral cavernous ICAs. Moderate stenosis at the right proximal ICA was noted.
    • CBF less than 30%: 0 ml; Tmax more than 6sec: 0ml.
  • IMP:
    • moderate stenosis at the right proximal ICA.
• 2024-01-16 Patho - stomach subtotal/total (tumor)
  • Diagnosis
    • Stomach, subcardial area, total gastrectomy — moderately differentiated adenocarcinoma
    • Lymph node, LN 1, dissection— negative for malignancy
    • Lymph node, LN 2, dissection— negative for malignancy
    • Lymph node, LN 3, dissection— negative for malignancy
    • Lymph node, LN 4, dissection— negative for malignancy
    • Lymph node, LN 5, dissection— negative for malignancy
    • Lymph node, LN 6, dissection— negative for malignancy
    • Lymph node, LN 7,8,9,11,12, dissection— negative for malignancy
    • Lymph node, LN10, dissection— negative for malignancy
    • Omentum, total gastrectomy— negative for malignancy
    • AJCC 8th edition pathology stage: pT3N0 (if cM0); AJCC prognostic stage IIA
  • Gross Description:
    • Procedure:
      • Open total gastrectomy
    • Specimen size:
      • Stomach: lesser cutvature: 12 cm; greater curvature: 19 cm
      • Omentum: 55x 12x 2 cm
    • Tumor Site:
      • High body, lesser curvature
    • Tumor Size: 2 x 2 cm
    • Gross configuration
      • For advanced carcinoma (Borrmann classification)
      • Type III: Ulcerated with poorly defined infiltrative margins
    • Sections are taken and labeled as: A1-2:LN1, A3:LN2, A4-7:LN3, A8-10:LN4, A11:LN5, A12-13:LN6, A14-16:LN7,8,9,11,12, A17:LN10,A18:D-margin, A19:P-margin, A20-26:tumor and mucosa, A27:omentum
  • Microscopic Description:
    • Histologic Type:
      • Adenocarcinoma
      • Lauren classification of adenocarcinoma: Intestinal type
    • Histologic Grade:
      • G2: Moderately differentiated
    • Tumor Extension:
      • Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
    • Margins
      • Proximal margin: uninvolved by invasive carcinoma
      • Distal margin: uninvolved by invasive carcinoma
      • Radial margin: uninvolved by invasive carcinoma
    • Lymphovascular Invasion: not identified
    • Perineural Invasion: present
      
    • Regional Lymph Nodes
      • LN 1, dissection — negative for malignancy (0/8)
      • LN 2, dissection — negative for malignancy (0/1)
      • LN 3, dissection — negative for malignancy (0/13)
      • LN 4, dissection — negative for malignancy (0/8)
      • LN 5, dissection — negative for malignancy (0/1)
      • LN 6, dissection — negative for malignancy (0/8)
      • LN 7,8,9,11,12, dissection — negative for malignancy (0/18)
      • LN10, dissection — negative for malignancy (0/1)
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
      • Primary Tumor (pT):
        • pT3: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
      • Regional Lymph Nodes (pN):
        • pN0: No regional lymph node metastasis
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case)
        • Not applicable
    • Additional Pathologic Findings :
      • Intestinal metaplasia
    • Ancillary Studies: none
    • Comment(s): none
• 2024-01-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (89.6 - 32.5) / 89.6 = 63.73%
    • M-mode (Teichholz) = 63.7
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild TR, trivial MR
    • Dilated LA; thick IVS and LVPW
    • Mild posterior mitral annulus calcification
• 2024-01-06 CT - abdomen
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
  • Without contrast enhancement CT of abdomen shows:
    • Wall thickening of gastric body with perigastric fat stranding.
    • Enlarged regional lymph nodes.
    • Suboptimal study of the liver, spleen, pancreas, and kidneys based on this plain CT study.
  • Impression
    • Gastric CA with subserosal penetration and lymph node metastasis
    • Suboptimal study based on this plain CT study
• 2024-01-05 SONO - abdomen
  • Diagnosis:
    • GB sludge
    • Suspicious tiny gallbladder polyp
    • Renal cyst, right kidney
• 2024-01-03 EGD
  • Gastric ulcer, Forrest IIa, high body, LC side, s/p hemostasis with Argon plasma coagulation.
  • Reflux esophagitis LA Classification grade A (minimal)
• 2024-01-02 Patho - stomach biopsy
  • Stomach, high body, LC, biopsy — Adenocarcinoma.
  • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands with intestinal metplasia.
  • IHC stains: CK highlights infiltrative neoplastic glands. Her2/neu: negative (score = 1+).
• 2023-12-29 EGD
  • Gastric ulcer, Forrest IIa, high body, LC side, r/o malignancy, Borrmann type III, s/p biopsy
    
  • Reflux esophagitis LA Classification grade A (minimal)
  • Superficial gastritis

[MedRec]

• 2024-02-20 SOAP General and Gastrointestinal Surgery Chen YanZhi
  • Prescription
    • B-Red (hydroxocobalamin 1mg/mL/amp) 1# Q1M
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • MgO 250mg 1# TID
• 2024-01-10 ~ 2024-02-05 POMR General and Gastrointestinal Surgery Chen YanZhi
  • Discharge diagnosis
    • Adenocarcinoma of high body, pT3N0(M0) stage IIA status post total gastrectomy with lymph node dissection on 2024/01/15. ECOG:1
    • Acute pancreatitis
    • Chronic kidney disease, stage 3 (moderate)
    • Type 2 diabetes mellitus with diabetic chronic kidney disease
    • Essential (primary) hypertension
  • CC
    • Tarry stool associated with upper gastrointestinal bleeding, which was diagnosed as gastric cancer for 1 week.
  • Course of inpatient treatment
    • After admission, pre-operation survey was done and no abnormality. Nutrition with TPN for pre-operation was also performed. Sugar with RI control and keep < 200mg/dl.
    • He received total gastrectomy with LN dissection was processed successfully on 2024/01/15. Postoperatively, we observed patient recovery and keep empiric antibiotic, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed. Esophagelgraphy was performed which revealed no evidence of anastomosis leakage is found. Removed NG tube was done smoothly and try to introduced liquid diet with step by step and can tolerate well for semi-liquid diet. Much ascites via JP drainage was noted after operation, we add oral Aldactone support for ascites control. However, abdomen fullness with nausea and vomit intermittent were noted since 2024/01/24. Leukocytosis (WBC:15740) noted on 2024/01/25, then add antibiotic with Tapimycin support.
    • KUB was follow which showed no abnormaly bowel gas is found. So we keep NPO for 1 day, add nutrition with PPN then symptoms was improved on 2024/01/26. Try PG1 diet since 26 but persisted intermittent nausea with vomit still noted on 2024/01/27. So we keep NPO until to 2024/01/29.
    • Lab examination on 2024/01/29 also revealed pancreatitis (Amy:255, Lipase:845). On the result, keep clear liquid for 2 days, then symptoms improving. Try PG1 diet since 2024/01/30 until now without abdomen discomfort was complain. On 2/1-2/5, her diet shift to PG3 (2/1), also vomited 2 times on 2/1 (without blood or bile acid) and constipation for many days, relief with ST primperan; we checked KUB at the same day, which was showed no ileus nor other abdnormal finding.
    • On 2024/02/05, due to his general condition was stable, we removed his JP balls, dischared and followed up at OPD on 2024/02/08.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Spiron (spironolactone 25mg) 1# BID
    • Syntrend (carvedilol 25mg) 1# QD
    • Uretropic (furosemide 40mg) 1# QD
• 2023-12-29 ~ 2024-01-06 POMR Gastroenterology Xiao ZongXian
  • Discharge diagnosis
    • Gastric cancer, Borrmann type III, high body, LC side; cT3N2M0 stage IIIA
    • Hematemesis due to bleeding from the gastric cancer, post endoscopic hemostasis with argon plasma coagulation
    • Acute posthemorrhagic anemia
    • Acute kidney failure, unspecified
    • Chronic kidney disease, stage 3 (moderate)
    • Type 2 diabetes mellitus with diabetic chronic kidney disease
    • Essential (primary) hypertension
  • CC
    • Dizziness with cold sweating and hematemesis at 2023/12/29 midnight
  • Present illness
    • This 68-year-old male has past history of 1. Hypertension, 2. Type 2 DM, 3. CKD stage III, 4. GERD. This time, he was suffered from vomiting of bloody substance accompanied with dizziness and cold sweating at 2023/12/29 midnight. Tarry stool was noted thereafter. Thus, he was brought to our ER by EMT.
    • At ER, vital signs showed TPR: 35.4’C / 86bpm / 20bpm, BP 113/88 mmHg, Con’s E3V4M6, SpO2 97%. Serum data revealed anemia (Hb 8.9 g/dL) and impaired renal function. Blood transfusion was given to correct anemia. Chest X-ray showed cardiomegaly. There was no fever, shortness of breath or pedal pitting edema. He denied significant TOCC history.
    • Under the impression of upper gastrointestinal bleeding, he was admitted to GI ward for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, we arranged an emergent EGD for hematemesis with anemia, and it showed an active gastric ulcer, Forrest IIa, at the LC side of high body. Gastric cancer of Borrmann type III was suspected, and biopsy was done.
    • Endoscopic hemostasis with argon plasma coagulation was not done due to the high risk of bleeding with regard to the large exposed vessel on the ulcer base. Due to the high risk of rebleeding, he was transferred to MICU on 2023/12/29 for post-endoscopy monitoring. High-dose PPI treatment was maintained after the endoscopy. His hemodynamic status was stable in MICU, and he was transferred back to the ward on 2023/12/30.
    • He had stable conditions without signs of rebleeding in the following hospitalization days. The Hb levels remained stable. He underwent second-look endoscopy on 2024/01/03, and it revealed partial healing of the ulcer. Hemostasis with argon plasma coagulation was done at the residual stigma of recent hemorrhage (SRH) on the ulcer base. He started oral intake trial with clear liquid after the endoscopy, and then tried liquid diet on the next day.
    • The pathology of the endoscopic biopsy reported adenocarcinoma on 2024/01/04. Serum tumor marker profile was checked, revealing normal CEA level and mild elevation of CA19-9 (37.87 U/mL).
    • Abdominal echo and CT scan were performed for staging workup, and the radiologic staging was T3N2M0 stage IIIA. GS was consulted for the further surgical treatment of the gastric cancer. Due to the patient’s desire to go home, he was discharged on 2024/01/06, and was referred to the GS clinic for the surgical treatment of the gastric cancer.
  • Discharge prescription
    • Pariet (rabeprazole 20mg) 1# BIDAC

[surgical operation]

• 2024-01-15 - Op Method:
  • total gastrectomy with LN1-12a dissection
  • Finding:
    • 2.5 x 2.0 cm ulcerative mass at subcardial area cT3N2M0
    • 2.0 1.5cm submucosal tumor at ypper body posterior wall R/O GIST
    • peritoneal seeding-

[chemotherapy]

• 2024-06-13 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2000mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-28 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2000mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-05-08 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2000mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-17 - oxaliplatin 65mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2000mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-01 - oxaliplatin 65mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2000mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-11 - oxaliplatin 65mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2000mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-06-14

[adjusted oxaliplatin dose in FOLFOX]

There appears to be a slow upward trend in serum creatinine. The oxaliplatin in the FOLFOX regimen has been reduced to 100 mg during this hospitalization. Oral potassium supplementation is being used for hypokalemia, and Vemlidy (tenofovir alafenamide) is administered for reactive Anti-HBc (2024-02-22). No medication discrepancies were identified.

• 2024-06-13 Creatinine 1.96 mg/dL
  

• 2024-06-05 Creatinine 1.91 mg/dL
  

• 2024-05-27 Creatinine 1.88 mg/dL
  

• 2024-05-14 Creatinine 1.83 mg/dL
  

• 2024-05-09 Creatinine 1.47 mg/dL

• 2024-06-13 K (Potassium) 3.1 mmol/L

2024-04-16

[consistent creatinine levels despite oxaliplatin, hydroxocobalamin effect on hemoglobin stability]

B-Red (hydroxocobalamin) was administered intermittently, approximately biweekly to monthly, stabilizing hemoglobin levels at around 10 ± 0.5 g/dL over the past two months without significant fluctuations.

Serum creatinine levels have consistently been maintained at approximately 1.5 mg/dL during this period, indicating no renal deterioration attributable to oxaliplatin.

Blood glucose levels were recorded at 250 and 184 mg/dL, slightly elevated but remain manageable.

2024-04-02

[reconciliation]

Oxaliplatin dosage adjustments are advised for patients with CrCl < 30. Given the lab results from 2024-04-01 showing eGFR > 50, there is currently no necessity for dosage modification.

2024-03-12

[FOLFOX begins for post-gastrectomy patient]

The patient was admitted on 2024-03-11 for his first session of FOLFOX therapy.

B-Red (hydroxocobalamin) was administered on 2024-03-12 for this post-gastrectomy patient. The active medication list currently includes only one antiglycemic agent, Dibose (acarbose). This follows the discontinuation of several medications: Amepiride (glimepiride), Forxiga (dapagliflozin), Crestor (rosuvastatin), and Sevikar (amlodipine, olmesartan). While there is no current elevated BP, the blood sugar readings of 263 mg/dL on 2024-03-11 and 229 mg/dL on 2024-03-12 could potentially benefit from further management.

701525511

240614

[lab data]

• 2024-05-20 HBsAg Nonreactive
  
• 2024-05-20 HBsAg Value 0.34 S/CO
  
• 2024-05-20 Anti-HBs 1.69 mIU/mL
  
• 2024-05-20 Anti-HCV Nonreactive
  
• 2024-05-20 Anti-HCV Value 0.09 S/CO
  
• 2024-05-20 Anti-HBc Reactive
  
• 2024-05-20 Anti-HBc Value 5.27 S/CO

[exam findings]

• 2024-05-22 Patho - liver biopsy needle/wedge

  • Pancreatic head? CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with recurrent gallbladder carcinoma
  • The specimen submitted consists of four tiny pieces of yellow gray soft tissue, labeled “mass lesion”, measuring up to 0.1 x 0.1 x 0.1 cm. All for section.
  • The sections show a picture of adenocarcinoma, composed of nests of columnar neoplastic cells, arranged in glandular and cribriform patterns, in fibrous stroma.
  • IHC shows: CK7(-), CK20(-), CDX2(-) and DPC-4(+). The finding is compatible with recurrent gallbladder carcinoma. Suggest clinic and imaging correlation.

• 2024-05-22 Patho - duodenum biopsy

  • Duodenal lesion, SDA to 2nd portion, biopsy — Ulcer

• 2024-05-21 PTCD (percutaneous transhepatic cholangial drainage)

• 2024-05-21 EGD

  • Diagnosis:
    • Suspect tumor invasion with ulcer, SDA to 2nd portion, s/p biopsy.
    • Duodenal ulcers, bulb, PW, SDA, and 2nd portion.
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, antrum, s/p CLO test
    • Duodeanl ulcer scar with pseudodiverticulum
  • CLO test: Negative
  • Suggestion:
    • Pursue CLO test and pathology report
    • PPI use

• 2024-05-21 SONO - abdomen

  • Diagnosis:
    • Suspected pancreatic head tumor
    • S/p choleyctectomy
    • CBD dilatation
    • IHD dilatation,bil
  • Suggestion:
    • OPD f/u
    • Please correlate with other image and CA-199,CEA
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed

• 2024-05-19 CT - abdomen

  • Findings
    • A mass lesion (8.2cm) in gallbladder fossa with pancreatic head involvement. Mass effect on IVC.
    • Dilatation of IHDs. s/p cholecystectomy.
  • Impression
    • c/w local recurrent gallbladder CA with biliary obstruction; DDx: periampullary tumor.

[MedRec]

• 2024-05-19 ~ 2024-06-07 POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • Gallbladder cancer, stage III post operation at Cathay General Hospital in 2023, with recurrent in 202405
    • Recurrent gallbladder cancer with obstructive jaundice and gastrointestinal tract and portal vein invasion
    • Upper gastrointestinal bleeding
    • Obstruction of bile duct
    • Anemia, unspecified
  • CC
    • Epigastric pain, vomiting 3 times, tarry stool and jaundice for 3 days.
  • Present illness
    • This 80 years old male with past history of HTN, gallbladder CA, stag3, s/p OP at Cathay General Hospital last year.
    • According to himself, he has been in total independent ADL.
    • This time, he has been sufferred from epigastric pain since three days ago, which was accompanied with vomiting 3 times, tarry stool and jaundice. He denied headache, dizziness, coffee ground, dysuria, or diarrhea.
    • On arrival, the vital signs were stable, E4V5M6, SpO2 97%. The PE showed icteric sclera, jaundice, epigastric tenderness. The labs showed normal white count with neutrophil predominant, elevated CRP/ ALT/ GGT/ ALP/ bilirubin, hyponatremia.
    • The abd. CT showed c/w local recurrent gallbladder CA with biliary obstruction, r/o periampullary tumor.
    • Under the impression of 1.) pancreatic head tumor, suspicious recurrenet GB cancer with obstructive jaundice and possible GI tract and portal vein invasion; 2.) UGI bleeding; 3.) GB cancer s/p OP in 2023. He was admitted for further treatments.
  • Course of inpatient treatment
    • After admission, NPO with IV fluid supplement and high dose PPI pump was given to correct favor tumor invastion related GI bleeding. Tumor markers and hepatic markers were all checked.
    • Upper GI endoscopy and abdominal sonography were all performed which revealed suspect tumor invasion with ulcer, SDA to 2nd portion, s/p biopsy on EGD; abdominal sonography showed CBD dilatation and IHD dilatation, bil. Explained this condition to his family, they understood and discussed with p’t and family about the possible treatment strategy: palliative C/T or R/T, or hospice care.
    • Radiologist was consulted for PTCD insertion and CT quiding biopsy. A 8 Fr pig-tail catheter was inserted into the biliary tree smoothly on 2024/05/21 and the CT quide biopsy was done on 2024/05/22 without complications. There was no fever nor abdominal pain found after procedure. Follow up hemogram, electrolyte and TBI that revealed Hb stable and hyperbilirubinemia improving (TBI down to 9.7 mg/dL).
    • Try soft diet since 2024/05/22 and he can tolerate it. High dose PPI pump was tapper to Q12H used.
    • Radiation Oncologist and Oncologist were all consulted due to pathology showed adenocarcinoma, moderately differentiated, compatible with recurrent gallbladder carcinoma.
    • Follow up blood test on 2024/05/27 that showed hyperbilirubinemia mproving (TBI down to 4.5 mg/dL). He was transfer to Oncology ward.
    • After Oncology ward, titration IV fluid support. Discuss with futher treamtment with family. Then consult family medicine for hospice combine care.
    • Anemia was noted, blood transfusion with LPRBC 2u on 2024/05/30, 2024/05/31, 2024/06/06. Waiting for arrange radiotherapy. There were no nausea, vomiting, SOB or chest pain. Only mild general malaise was mentioned and improved after bed rest and medical treatment.
    • Under the stable condition, he was discharged on 2024-06-07 and OPD follow was arranged.
  • Discharge diagnosis
    • Harnalidge (tamsulosin 0.4mg) 1# HS
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Pilian (cyproheptadine 4mg) 1# TID
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H

[MultiTeam]

• 2024-05-31 Multidisciplinary Team Recommendations - Palliative Care
  • Consultation Date: 2024-05-30
  • Response:
    • The co-care nurse and Dr. Xia from the Family Medicine Department visited the patient. The patient was in good spirits but hard of hearing. He reported occasional pain but no current pain. On 2024-05-27, the patient completed an advance directive for palliative care. The co-care nurse confirmed the patient’s wishes, which were: “Do everything possible to save me, but if it’s not possible, do not prolong my suffering,” and “In the end, I do not want intubation, chest compressions, or defibrillation.” The patient was not fully aware of his condition, thinking he was hospitalized for a stomach issue, though he was actually admitted (at Cathay Hospital) for gallbladder cancer surgery due to gallstones last year.
    • The co-care nurse explained the concept of palliative care to the patient’s son. The son mentioned that they hadn’t fully explained the patient’s condition to him to give him some hope. They decided to continue with the current treatment (radiotherapy) and consider palliative care if the situation worsens. They agreed to co-care palliative support for now and left the co-care nurse’s contact information for palliative-related inquiries.
    • Conclusion and Recommendation: Co-care palliative support.
    • Responder: Chen Hui
    • Response Date: 2024-05-30 16:21
  • Doctor’s Response:
    • Date: 2024-05-31 08:31
    • Doctor: Yang MuJun
    • Response: Acknowledged and will proceed as recommended.

==========

2024-06-14

[continuous decline in elevated bilirubin levels, potential need for intensive nutritional intervention]

Although bilirubin levels are still above the reference range, they have shown a continuous decline, with Uliden (ursodeoxycholic acid) currently in use. Baraclude (entecavir) is being appropriately administered following the 2024-05-20 lab results indicating reactive Anti-HBc.

• 2024-06-12 Bilirubin total 1.97 mg/dL

• 2024-06-06 Bilirubin total 2.20 mg/dL

• 2024-06-03 Bilirubin total 2.77 mg/dL

• 2024-05-30 Bilirubin total 3.44 mg/dL

• 2024-05-27 Bilirubin total 4.50 mg/dL

• 2024-05-22 Bilirubin total 9.70 mg/dL

• 2024-05-19 Bilirubin total 15.30 mg/dL

• 2024-06-12 Bilirubin direct 0.96 mg/dL

• 2024-06-06 Bilirubin direct 1.15 mg/dL

• 2024-05-30 Bilirubin direct 1.76 mg/dL

• 2024-05-19 Bilirubin direct 9.59 mg/dL

• 2024-06-12 DBI/TBI 48.73 %

• 2024-06-06 DBI/TBI 52.27 %

• 2024-05-30 DBI/TBI 51.16 %

• 2024-05-19 DBI/TBI 62.68 %

The patient’s weight has decreased from 49.4 kg on 2024-05-19 to 46.7 kg on 2024-06-13. Currently, the patient is receiving Bfluid amino acids supplementation and Megest (megestrol). If the weight loss continues, intensive nutritional intervention might be necessary.

700175888

240613

[exam findings]

• 2024-05-09 MRA - brain
  • Pre- and post-contrast multiplanar cerebral MRI
  • Imp: No evidence of brain metastasis.
• 2024-03-25 CT - abdomen
  • Indication: Secondary malignant neoplasm of liver and intrahepatic bile duct
  • Abdominal CT with and without enhancement revealed:
    • Splenomegaly, gastric varices formation and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
    • s/p colostomy with its orifice at RLQ.
    • Low density lesions are found at both lobes of liver up to 2.88cmm at left lateral segment. In comparison with CT dated on 2023-12-15, the lesions are stationary.
    • One soft tissue mass at myometrium measuring 3.7cm is found. Myoma is favored but follow up is suggested.
    • Focal wall thickening at rectum and presacral region is found.
  • Imp:
    • Rectal cancer with liver meta, stationary.
    • Liver cirrhosis.
    • Uterine myoma. Suggest follow up.
• 2024-02-19 Sigmoidoscopy
  • The scope can only reach the rectum (10cm AAV) due to previous tumor obstruction s/p CCRT.
  • Radiation proctitis with diffuse erythema with petechia was found.
• 2024-02-15 PET
  • In comparison with the previous study on 2023/03/03, the glucose hypermetabolism in the rectosigmoid colon and in multiple focal areas in the right and left lobes of the liver is less evident, suggesting partial response to the therapy.
  • Glucose hypermetabolism in the lower T-spine. The nature is to be determined (degenerative change? other nature?). Please follow up other imaging modalities for further evaluation.
  • Mild glucose hypermetabolism in the left shoulder and bilateral hips. Inflammation may show this picture.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
• 2024-01-24 Tc-99m MDP bone scan
  • The lesions of increased activity in some lower T-spine come to less evident compared with the previous study on 2023-09-26, severe degenerative change with partial resolution is more likely, suggesting follow-up with bone scan in 3-6 months.
  • Suspected benign lesions in bilateral rib cages, maxilla, some L-spine, L5-sacrum junction, bilateral shoulders, right sternoclavicular junction, knees and feet.
• 2023-12-15 CT - abdomen
  • History: Adenocarcinoma of middle rectum with impending obstruction and liver metastases and possible LLL metastases, cT4aN2bM1a, stage IVA
  • Findings: Comparison: prior CT dated 2023/09/14.
    • Prior CT identified several poor enhancing lesions on both hepatic lobes are noted again, stable in size.
      • It is c/w liver metastases S/P C/T with stable disease.
    • S/P colostomy at right transverse colon.
    • Prior CT identified mild wall thickening of the rectum and few small LNs at the pelvis is noted again, stationary.
    • Splenomegaly (long axis: 14 cm).
    • Uterine myoma 3.2 cm is noted.
  • Impression:
    • Liver metastases S/P C/T show stable disease.
• 2023-09-26 Tc-99m MDP bone scan with SPECT
  • Increased activity in the lower T-spines. Either severe degenerative change or bone metastases may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Mildly increased activity in the L5 and L5-sacrum junction. Degenerative change may show this picture.
  • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, knees and feet, compatible with benign joint lesions.
• 2023-09-14 CT - abdomen
  • History and indication: Adenocarcinoma of middle rectum with impending obstruction and liver metastases and possible LLL metastases, cT4aN2bM1a, stage IVA
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation. Mild regression of rectal cancer and liver metastases.
    • Splenomegaly.
    • Regression of LLL nodule.
    • Some LNs at pelvic cavity.
    • Bony erosion of T12.
    • Atherosclerosis of aorta.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P operation. Mild regression of rectal cancer and liver metastases.
• 2023-06-26 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Suspect Barrett’s esophagus, s/p biopsy
    • Superficial gastritis, s/p CLO test
    • Pseudodiverticulum, bulb
    • Deformed pylorus and bulb
  • CLO test: Positive
• 2023-06-19 CT - abdomen
  • History and indication: Adenocarcinoma of middle rectum with impending obstruction and liver metastases and possible LLL metastases, cT4aN2bM1a, stage IVA
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation. Much regression of rectal cancer but progression of liver metastases.
    • A nodule (5mm) at LLL.
    • Splenomegaly.
    • Some LNs at pelvic cavity.
    • Atherosclerosis of aorta.
  • IMP:
    • S/P operation. Much regression of rectal cancer but progression of liver metastases. A nodule (5mm) at LLL.
• 2023-06-19 Sigmoidoscopy
  • Rectal cancer s/p CCRT with partial regression (middle rectum, 8-9cm AAV)
• 2023-06-17 CXR
  • Tortuosity of the aorta with atherosclerotic change.
  • Increased lung markings over both lungs.
• 2023-06-01 Esophagogastroduodenoscopy, EGD
  • Superfical gastritis, antrum
  • Duodenal ulcer scar, bulb, AW, LC
• 2023-03-22 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2023-03-03 PET
  • Glucose hypermetabolism involving the rectosigmoid colon, compatible with primary colon malignancy.
  • Glucose hypermetabolism in a regional lymph node. A metastatic lymph node may show this picture.
  • Mild glucose hypermetabolism in some small regional lymph nodes. The nature is to be determined (metastatic lymph nodes of low FDG uptake? inflammation?). Please correlate with other clinical findings for further evaluation.
  • Multiple glucose hypermetabolic lesions in the right and left lobes of the liver, suggesting multiple liver metastases.
  • No prominent FDG uptake was noted in the small nodule in the upper lobe of left lung delineated in the CT scan. Please follow up chest CT scan for further evaluation.
  • Increased FDG uptake/accumulation in a small focal area in the soft tissue in the left upper arm. The nature is to be determined (physiological FDG uptake/accumulation in the vein of the left upper arm? other nature?).
• 2023-03-01 All-RAS + BRAF gene mutation
  • ALL-RAS:
    • There was no variant detected in the KRAS/NRAS gene
  • BRAF
    • There was no variant detected in the BRAF gene.
• 2023-02-21 CT - abdomen
  • Clinical history: 61 y/o female patient with Newly diagnosis of middle rectal adenocarcinomafor staging
  • With and without contrast enhancement CT of abdomen - whole:
    • Thickening wall at rectosigmoid colon with pericolonic infiltrates, r/o colon malignancy.
    • There are liver tumors, up to 3cm in left lobe, r/o liver metastasis.
    • There are lymph nodes in pericolonic and bilateral obturator regions.
    • Left upper lung nodular density, nature?
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4aT_value) N:N2bN_value) M:M1a(M_value) STAGE: IVa Stage_value)
  • Impression:
    • Rectosigmoid colon cancer with lymph nodes and liver metastasis. cstage T4aN2bM1a.
    • Left upper lung nodular density, nature?
• 2023-02-13 Patho - colon biopsy
  • Tumor, middle rectum, biopsy — Adenocarcinoma
  • Microscopically, the sections show a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltration with desmoplasia.
  • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.

[MedRec]

• 2024-04-25 SOAP Hemato-Oncology Xia HeXiong
  • P: if PD in CT of 2024-06, Ramucirumab (or avastin) maybe considered added again.
• 2024-03-06 SOAP Hemato-Oncology Xia HeXiong
  • P: Admission for Avastin + FL, arrange CT, not MBD immeiately after C/T, due to quick bleeding after C/T.
• 2023-10-17 SOAP Hemato-Oncology Xia HeXiong
  • Prescription
    • Nexium (esomeprazole 40mg) 1# QDAC EGD 2023-06-01
    • Strocain (oxethazine, polymigel; 5mg) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
    • TieShrShuPap (flurbiprofen) QD EXT
    • Revolade (eltrombopag 25mg) 1# QDAC 9D
• 2023-03-15 SOAP Hemato-Oncology
  • A
    • adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVa (at least)
  • P
    • suggest CCRT followed by C/T + target therapy, then re-evaluation for curative surgery 3-6 months later
    • admission for CCRT with FOLFOX with targeted therapy (already discuss with beva or cetuximab)

[consultation]

• 2024-05-09 Neurology
  • Q
    • for right headache (throbbing pain, VAS 8) for a week, acompany with tinnitus, denied dizziness
    • MRA of brain (c+) on 2024/05/09 showed no brain meta, no ICH
    • This 63 year-old woman pateitn sustained frequently anal bleeding, low abdominal pain, appetite less, tenesmus, anal pain, frequent defecation, change in bowel habit in 2023-01 and weight loss of 8-9 kg in 2 months. He visited our outpatient department for help. DRE/Anoscopy showed normal anal tonicity; mixed hemorrhoids with congestion and engorged vessels, a palpable tumor mass at fingertip!
    • Sigmoiodsocpy on 2023/02/13 revealed the scope can only reach the middle rectum (8-9cm AAV), a circumferential ulcerative tumor is found and biopsy was done. Middle rectum tumor biopsy and pathology proved adenocarcinoma, Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
      • ALL-RAS: There was no variant detected in the KRAS/NRAS gene.
      • BRAF: There was no variant detected in the BRAF gene.
    • Abdominal CT on 2023/02/21 showed 1) Rectosigmoid colon cancer with lymph nodes and liver metastasis. cstage T4aN2bM1a, stage IVA. 2) Left upper lung nodular density, nature? T-loop colostomy on 2023/03/02.
    • Port-A catheter implantation on 2023/03/02.
    • Whole body PET scan on 2023/03/03 showed rectosigmoid colon with regional lymph node, right and left lobes of the multiple liver metastases.
    • Radiotherapy for 45 Gy/ 25 fx to the pelvis and then boost the rectal tumor (with the invaded uterus) and LAPs to 50.4 Gy/ 28 fx from 2023/03/16~2023/04/28.
    • Chemotherapy with FOLFOX (Oxalip 85mg/m2, Leuco 400mg/m2, 5-Fu 400mg/m2 and 2400mg/m2) on 2023/03/23(C1D1), 2023/04/11(C1D15), 2023/04/28(C2D1), 2023/05/29(C2D15), 2023/06/26(C3D1).
    • Reduce chemotherapy with Oxalip and 5FU dose for neutropenia and severe vomiting.
    • Targeted therapy with Avastin(5mg/kg) on 2023/05/29(C1).
    • PES on 2023/06/01 showed superfical gastritis, antrum and duodenal ulcer scar, bulb, AW, LC.
    • Sigomoidoscopy on 2023/06/19 showed rectal cancer s/p concurrent chemoradiotherapy with partial regression (middle rectum, 8-9cm AAV).
    • Abdominal CT on 2023/06/19 showed s/p operation, much regression of rectal cancer but progression of liver metastases and a nodule (5mm) at LLL.
    • PES on 2023/06/26 showed reflux esophagitis LA, classification grade A, suspect Barrett’s esophagus, s/p biopsy, superficial gastritis, s/p CLO test, pseudodiverticulum, bulb and deformed pylorus and bulb. Esophagus, EC junction pathology showed columnar-lined esophagus without intestinal metaplasia.
    • Palliative chemotherapy with FOLFIRI (Campto 120mg/m2, LV 300mg/m2, 5FU 2400mg/m2) on 2023/07/12(C1D1), 2023/08/01(C1D15), 2023/08/17(C2D1), 2023/09/08(C2D15, Hold Campto due to Thrombocytopenia since C2D15), 2023/09/27(C3D1), 2023/11/09(C3D15), 2023/12/08(C4D1), 2023/12/29(C4D15), 2024/01/18(C5D1), 2024/03/22(C5D15), 2024/04/17(C6D1).
    • Targeted therapy with Avastin (5mg/kg) was given on 2023/08/01(C2), 2023/08/17(C3), 2023/09/08(C4), 2023/09/27(C5), 2023/11/09(C6), 2023/12/08(C7), 2023/12/29(C8), 2024/01/18(C9) then applications have been exhausted.
    • Now, she was admitted to ward for palliative chemotherapy with FOLFIRI (Campto 120mg/m2, LV 300mg/m2, 5FU 2400mg/m2) on 2024/05/08(C6D15).
    • We sincerely need your professional assistance!!
  • A
    • This is a 63-year-old woman with history of rectosigmoid colon cancer with lymph nodes and liver metastasis, stage T4aN2bM1a, stage IVA. She complained of intermittent right parietal throbbing headache for one week. She denied focal weakness, sensory loss, unsteady gait.
    • NE
      • Consciousness: E4V5M6, alert
      • pupil: 3mm/3mm, light reflex +/+
      • visual field: intact
      • EOM: no limitation, no nystagmus
      • no facial palsy
      • no dysarthria
      • no tougue deviation
    • MP
      • right upper 5, right lower 5
      • left upper 5, left lower 5
      • Sensory: intact and symmectric to pinprick and light touch
      • FNF and HKS: no dysmetria
      • Gait: intact
    • Exam
      • Brain MRI with/without contrast showed no brain metastasis
    • Assessment
      • Tension type headache
    • Suggestion
      • Keep Tramacet 1#Q8HPRN if headache
      • Add Melux (mephenoxalone) 200 mg HS.
• 2023-06-20 Hemato-Oncology
  • Q
    • For continue chemotherapy ?
    • The 61 years old female patient had hepatitis B carrier, and is a case of adenocarcinoma of middle rectum with impending obstruction and liver metastases and possible LLL metastases, cT4aN2bM1a, stage IVA status post T-loop colostomy on 2023/03/02, radiotherapy to rectal tumor and LAPs from 2023/03/16~ and concurrent chemotherapy with FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 5FU 2400mg/m2) from 2023/03/23~
    • This time, she suffered from massive bloody stool noted on yesterday evening (6/17), accompanying with dizziness, abdominal pain, chills, sweating, and back pain. Also, colostomy bag had much blood clot was told. She denied having fever, dysuria, or shortness of breath. While visited our emergency department, her vital signs showed hypotension (98/53mmHg) and tachycardia (107 bpm). Drowsiness consciuosness was found. With the impression of lower GI bleeding, she was admitted for further management.
    • Lab data: Hb: 9.8 (6/17) -> 8.4 -> 10.5 g/dl (6/19).
    • Now the patient no dizziness, no passage bloody stool. So we consult you for evaluation of continue chemotherapy ?
  • A
    • This 61 year old woman is a case of middle rectum with impending obstruction and liver metastases cT4aN2bM1a, stage IVA status post post T-loop colostomy on 2023/03/02, radiotherapy to rectal tumor and LAPs from 2023/03/16~4/28 and concurrent chemotherapy with FOLFOX [FOLFOX on 2023/03/23(C1D1), FOLFOX on 2023/04/11(C1D15), FOLFOX on 2023/04/28(C2D1), FOLFOX on 2023/05/29(C2D15). + Avastin].    
    • She was admiited due to massive bloody stool and accompanying with dizziness, abdominal pain, chills, sweating, and back pain. Also, colostomy bag had much blood clot was told.
    • Sigmoid scopy show rectal cancer s/p CCRT with partial regression (middle rectum, 8-9cm AAV). BUT the scope can not pass through it due to lumen stenosis. Some blood clots retention but no active bleeding. Abdominal CT 2023/6/19 show much regression of rectal cancer but progression of liver metastases. We are consulted for further evaluation.
    • Please arrange panendoscopy and keep PPI and transamin. We will take over this case. Please transfer to 11A and 10B. On Dr Xia.
• 2023-03-03 Hemato-Oncology
  • Q
    • For further evaluation of CCRT
    • A 61 year-old female patient was admitted for adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. After fully explained of the condition, T-loop colosotmy first for tumor impending obstruction then suggest CCRT and C/T+ target therapy. Surgery of T-loop colostomy will arrange on 2023/03/02 on call. We needs your expert experience for evaluation. Thanks a lot !!
  • A
    • This 61 year old woman is a case of middle rectal adenocarcinoma with liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. She will receive T-loop colostomy on 3/2. We are consulted for CCRT.
    • Systemic chemotherapy +/- target therapy is indicated for metastasis rectal cancer.
    • Please arrange port A insertion. Consider arrange PET scan for complete work up. Check All-RAS/BRAF.
    • Arrange our OPD after discharge. Thanks for your consultation.
• 2023-03-02 Radiation Oncology
  • Q
    • For further evaluation of CCRT
    • A 61 year-old female patient was admitted for adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. After fully explained of the condition, T-loop colosotmy first for tumor impending obstruction then suggest CCRT and C/T+ target therapy. Surgery of T-loop colostomy will arrange on 2023/03/02 on call. We needs your expert experience for evaluation. Thanks a lot !!
  • A
    • This 61 year-old female patient was admitted for adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. Plan to establish T-loop colosotmy first for tumor impending obstruction then suggest CCRT and C/T+ target therapy.
    • CT-simulation will be arranged on 3/14. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor (with the invaded uterus) and LAPs to 50.4 Gy/ 28 fx. RT will start around 3/16 or 17. If resection is not feasible by the end of the planned CCRT and C/T + target therapy course, additional RT to the rectal tumor might be considered for longer local control. Thank you very much.
• 2022-12-30 Ophthalmology
  • Q
    • Acute or sudden change in vision - Black spot appears in the right eye, ophthalmological examination reveals retinal detachment.
    • RD, arrange OP today
    • NKDA
  • A
    • S
      • VFD today
    • O
      • Acute floaters for 3 days
      • visited LMD and RRD was told
      • VAcPG od 0.6 os 0.6
      • Pupil od iatrogenic dilated os 3mm +/+
      • Conj np ou
      • K clear ou
      • AC D/clear ou
      • Lens ns+ ou
      • Fd od RRD 11-2 oc, flap tear at 12oc, macula on, fovea on
    • A
      • Phakic RRD od
    • P
      • Arrange admission TKS
      • OP will be arrange today
      • inform the risk of operation

[radiotherapy]

• 2023-10-31 ~ 2023-11-13 - completed RT to spine T10-L1: 30 Gy/ 10 fx.

• 2023-03-16 ~ 2023-04-28 - completed RT to the rectal tumor and regional LNs: 45 Gy/ 25 fx. The rectal tumor (with the invaded uterus) and LAPs: 54 Gy/ 30 fx.

[chemotherapy]

• 2024-05-28 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-09 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-17 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-22 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-01-18 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-12-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-12-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-11-09 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-09-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-09-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-08-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-01 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-12 - ………………………………….. irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-26 - ………………………………….. oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-29 - bevacizumab 5mg/kg 300mg NS 200mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-28 - ………………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-11 - ………………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-23 - ………………………………….. oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 250mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-05-28

[monitoring upward trend in CEA and CA199, addressing liver cirrhosis and metastasis, potential sodium supplementation for hyponatremia]

Lab results on 2024-05-27 showed hyponatremia (130 mmol/L), hypomagnesemia (1.7 mg/dL), hyperalbuminemia (3.3 g/dL), and hyperbilirubinemia (total 1.22 mg/dL, direct 0.40 mg/dL). The latter two are likely related to liver cirrhosis and metastases. Currently, MgSO4 and BaoGan are in use. The addition of sodium supplementation might be further considered.

The CT imaging conducted on 2024-03-25 showed that the rectal cancer with liver metastases remained stationary. However, the updated markers CEA and CA199 seem to be trending upward and should be closely monitored.

• 2024-05-15 CEA 52.67 ng/mL

• 2024-04-25 CEA 41.73 ng/mL

• 2024-04-01 CEA 26.22 ng/mL

• 2024-03-12 CEA (NM) 18.827 ng/mL

• 2024-02-02 CEA (NM) 9.794 ng/mL

• 2024-01-18 CEA 15.20 ng/mL

• 2024-01-16 CEA (NM) 4.550 ng/mL

• 2024-05-15 CA199 46.60 U/mL

• 2024-04-25 CA199 36.37 U/mL

• 2024-04-01 CA199 27.00 U/mL

• 2024-03-12 CA199 (NM) 52.022 U/mL

• 2024-02-02 CA199 (NM) 37.571 U/mL

• 2024-01-18 CA199 27.25 U/mL

• 2024-01-16 CA199 (NM) 34.438 U/mL

2023-12-13

[thrombocytopenia]

Thrombocytopenia was first observed in April 2023 and has not yet returned to the lower limit of normal range (150K/uL). Since December, platelet counts have been consistently below 50K/uL. Bevacizumab was started in August 2023.

• 2023-12-11 PLT 41 *10^3/uL
• 2023-12-08 PLT 41 *10^3/uL
• 2023-11-30 PLT 70 *10^3/uL
• 2023-11-16 PLT 45 *10^3/uL
• 2023-11-07 PLT 80 *10^3/uL
• 2023-10-17 PLT 57 *10^3/uL
• 2023-10-11 PLT 65 *10^3/uL
• 2023-09-20 PLT 77 *10^3/uL
• 2023-09-13 PLT 69 *10^3/uL
• 2023-09-08 PLT 65 *10^3/uL

Both bevacizumab and fluorouracil are known to cause thrombocytopenia, with bevacizumab showing a higher incidence rate of up to 58% (grades 3/4: 20% to 40%).

According to UpToDate recommendations, in cases of hemorrhage caused by bevacizumab, such as hemoptysis (recent history of >= 2.5 mL), bevacizumab should be withheld. For Grade 3 or 4 hemorrhage, bevacizumab should be discontinued. As there has been no recent documentation of hemorrhage found in the medical records, it may not be necessary to temporarily stop the use of bevacizumab at this time.

Blood transfusion has been scheduled according to the progress note.

2023-07-13

The patient has only visit our hospital in the last 3 months according to the PharmaCloud database, our gastroenterologist prescribed Baraclude (entecavir) for she is a carrier of viral hepatitis B. Baraclude is in the active medication list, no reconciliation issues found.

2023-06-20

On 2023-06-18, the patient’s fecal occult blood test was 2+, indicating a possible GI bleeding. On this date, the patient has been prescribed lansoprazole and tranexamic acid. The prescription for lansoprazole is set to expire on 2023-06-21. It would be beneficial to evaluate whether signs of bleeding persist to decide whether to continue the PPI.

701506134

240613

[exam findings]

• 2024-04-17 Tc-99m MDP bone scan
  • Findings:
    • mildly increased activity in the skull, multiple T- and L-spine, sternum, bilateral multiple ribs and bilateral pelvic bones in whole body survey.
  • IMPRESSION:
    • All of above-mentioned bone lesions, either they are new or old with more evident compared with the previous study on 2023-11-23, indicating metastatic bone disease in progress.
• 2024-03-20 CT - abdomen
  • Indication:
    • 20231121 CT: R/O CCC with bone metastasis, T3N1M1, STAGE: IV.
    • 20231122 CT-guided biopsy and pathology: cholangiocarcinoma
  • Findings: Comparison: prior CT dated 2023/11/21.
    • Prior CT identified multiple enhancing and poor enhancing masses on both hepatic lobes (more concentrate on left lobe) with left lobe portal vein encasement is noted again, decreasing in size and number that is c/w cholangiocarcinoma on both hepatic lobe S/P C/T with partial response.
    • Prior CT identified multiple metastatic nodes in hepatoduodenal ligament, para-aortic space and para-cava space are noted again, decreasing in size that is c/w metastatic nodes S/P C/T with partial response.
    • Prior CT identified osteolytic lesion in left acetabulum is noted again, decreasing in size.
    • Prior CT identified osteolytic lesion in T-and L-spine are noted again, decreasing in size.
  • Impression:
    • Cholangiocarcinoma of the liver with multiple LNs and bone metastases S/P C/T with partial response is highly suspected. please correlate with clinical condition.
• 2023-12-25 SONO - gynecology
  • EM 2.9mm, multiple myomas
• 2023-12-02 CT - chest
  • Indication: choalngiocarcinoma with liver, bone metastasism T3N1M1, stage IV
  • Findings:
    • Consolidation of bilateral lower lobes and part of right middle lobe and left lingula lobe with bilateral moderate pleural effusion is found.
    • Confluent soft tissue mass at left lobe liver measuring 14.9cm in largest dimension. Smaller lesions are found at both lobes of liver. Liver meta is considered.
    • Necrotic lymphadenopathy at celiac trunk region and paraaortic area.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
  • Imp:
    • Bilateral lower lobes pneumonia with pleural effusion.
    • Liver meta, bone meta and celiac trunk, paraaortic lymphadenopathy
• 2023-12-01 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 33) / 112 = 70.54%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; mildly dilated LA.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; mild MR.
    • Minimal amount pericardial effusion ( < 50ml).
    • Sinus tachycardia.
• 2023-11-24 EGD
  • Diagnosis:
    • Superficial gastritis
    • Gastric erosion and shallow ulcer, antrum
  • CLO test: Positive
• 2023-11-24 SONO - abdomen
  • Diagnosis:
    • Parenchymal liver disease
    • multiple liver tumor, c/w, cholangiocarcinoma with liver metastasis and left PV incasement
    • pancreatic head masked by gas.
• 2023-11-23 Tc-99m MDP bone scan with SPECT
  • Adding up all the bone lesions as mentioned above, multiple bone metastases should be considered first.
• 2023-11-22 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated, compatible with intrahepatic cholangiocarcinoma
  • The sections show a picture of adenocarcinoma, poorly differentiated, composed of nests, cords, and single polygonal to cuboidal neoplastic cells in fibrous stroma. Focal glandular differentiation and moderate lymphoplasma cells infiltrate are present.
  • IHC shows: CK(+), CK7(+), CK20(-), CD56(-), and Hepatocyte(-). The finding is compatible with intrahepatic cholangiocarcinoma.
• 2023-11-21 CT - abdomen
  • With and without contrast enhancement CT: ABD
    • Huge liver tumor, up to 15x9cm in left lobe liver, with heteregeneous enhancement and multiple small liver tumors, r/o cholangiocarcinoma with liver metastasis.
    • Multiple enlarged lymph nodes in paraaortic and retroperitonerum with adhesion/abutting to the pancrease.
    • Presence of ascites.
    • Lung nodule, 0.7cm in left lingular lobe, r/o lung metastasis.
    • More prominent right ovary.
    • Osteolytic lesions in T-L spine, left iliac and acetabulum bone, r/o bone metastasis.
  • Imaging Report Form for Cholangiocarcinoma
    • Impression (Imaging stage) : T:T3__(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)
  • Impression:
    • Huge liver tumor with multiple small liver tumors, r/o choalngiocarcinoma with liver metastasis.
    • Multiple enlarged lymph nodes in retroperitoneum and paraaortic region, r/o lymph nodes metastasis.
    • Multiple bone metastasis.
    • Left lingular nodule, r/o metastasis.
    • More prominent right ovary.

[MedRec]

• 2023-11-21 ~ 2023-12-08 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • choalngiocarcinoma with liver, bone metastasism T3N1M1, stage IV
    • chronic viral hepatitis B without delta-agent
    • port-a catheter insertion at left cephalic vein on 2023/11/28
    • pneumonia at righr lower lung, sputum culture: pending.
  • CC
    • suspect choalngiocarcinoma with liver, lymph nodes, bone metastasis for further survey and management
  • Present illness
    • This 50-year-old female patient has the history of HBV. She was regular followed up at LMD.
    • She received abdominal sonography found hepatic tumors, multiple at the local clinic. So she referred to our GI OPD for work up. Abdominal CT was performed on 2023/11/21 and revealed 1. Huge liver tumor with multiple small liver tumors, r/o choalngiocarcinoma with liver metastasis. 2. Multiple enlarged lymph nodes in retroperitoneum and paraaortic region, r/o lymph nodes metastasis. 3. Multiple bone metastasis. 4. Left lingular nodule, r/o metastasis. 5. More prominent right ovary. She denied nausea or vomiting, abdominal distension or pain, diarrhea or constipation, rhinorrhea or sorethroat, cough or dyspnea, dysuria. No body weigh loss was noted. No TOCC history was noted.
    • Under the impression of suspect choalngiocarcinoma with liver, lymph nodes, bone metastasis, she was admitted for further management and investigation.
  • Course of inpatient treatment
    • After admission, tumor markers and hepatitis markers were all checked. Radiologist was consulted for arrange liver biopsy. Liver biopsy was performed without complications on 2023/11/22. Oncologist was consulted for management of suspect cholangiocarcinoma with lung, liver and bone metastasis, s/p liver biopsy who suggested 1. port A insertion 2. do chemotherapy, later. Bone scan was done on 2023/11/23. There was no fever but intermittent epigastric pain was found.
    • In addition, pain control with Scanol 1# po TID was used for symptoms relief. Upper GI endoscopy and abdominal sonography were all performed which revealed gastric erosion and shallow ulcer, antrum on EGD; abdominal sonography showed 1. Parenchymal liver disease 2. multiple liver tumor, c/w, cholangiocarcinoma with liver metastasis and left PV incasement 3. pancreatic head masked by gas. GS man was consulted for port-A insertion. Consulted Radiation Oncologist for further survey. Now, we will be arrange oncology ward and on the Dr. He JingLiang service. Observed clinical symptoms.
    • At Hema ward, she received C1D1 chemotherapy with Imfinzi 1200mg (self-paid) / Gemzar (1000mg/m2) / Cisplatin (25mg/m2), two weeks on and one week off on 2023/11/29.
    • The lab of CBC/DC showed anemia, so gave blood transfusion with LPRBC 2U, Vemlidy for Anti-HBc: reactive, Bao-gan for poor liver function. Imperan for vomiting.
    • After chemotherapy, she denied having a fever, vomiting, shortness of breathing, or diarrhea. She suffered from shortness of breathing sometimes, and she couldn’t lay down at night time, so gave nasal cannula support, followed-up chest x-ray revealed the patch at left lower lung, and the visiting saff expressed to keep obs first (due to the patient no fever, or any infection signs), the cardiac enzyme not finding. Folowed-up heart echo (2023/12/01) showed LVEF: 71%, 1.Septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; mildly dilated LA. 2.Normal LV and RV systolic function. 3.Mild aortic valve sclerosis; mild MR. 4.Minimal amount pericardial effusion ( < 50ml). 5.Sinus tachycardia, so gave Diuretics with furosemide 0.5tab st.
    • Followed-up chest CT (2023/12/02) revealed Bilateral lower lobes pneumonia with pleural effusion. Liver meta, bone meta and celiac trunk, paraaortic lymphadenopathy, so gave Albumin by self-paid *3 days plus Lasix, nasal cannula support. The chest x-ray showed pneumonia at right lower lung with shortness of breathing, so gave antibiotic with Brosym, Decan treatment. After treatment, re-checked chest x-ray revealed pneumonia at right lower lung, the shortness of breathing improved, the chemotherapy with C1D8 Gemzar (1000mg/m2) / Cisplatin (25mg/m2), 2wo weeks on and one week off on 2023/12/07.
    • After chemotherapy, she denide having a fever, SOB, vomiting, or any complaints. Under the stable condition, she can be discharged on 2023/12/08, the OPD follow-up will be arranged.
  • Discharge prescription
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • MgO 250mg 1# TID
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Allegra (fexofenadine 60mg) 1# BID
    • BaoGan (silymarin 150mg) 1# TID
    • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# TID
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Ceficin (cefixime 100mg) 2# Q12H
    • Compesolon (prednisolone 5mg) 1# BID

[chemotherapy]

• 2024-06-13 - durvalumab 1200mg NS 250mL 1hr + gemcitabine 1000mg/m2 1600mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C8D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-05-29 - ………………………….. gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C7D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-05-24 - durvalumab 1200mg NS 250mL 1hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C7D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-04-16 - ………………………….. gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C6D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-04-08 - durvalumab 1200mg NS 250mL 1hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C6D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-03-26 - ………………………….. gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C5D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-03-19 - durvalumab 1200mg NS 250mL 1hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C5D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-02-21 - ………………………….. gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C4D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-02-16 - durvalumab 1200mg NS 250mL 1hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C4D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-23 - ………………………….. gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C3D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-16 - durvalumab 1200mg NS 250mL 1hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C3D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-26 - ………………………….. gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C2D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-19 - durvalumab 1200mg NS 250mL 1hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C2D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-07 - ………………………….. gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C1D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-11-29 - durvalumab 1200mg NS 250mL 1hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 25mg/m2 40mg NS 500mL 3hr + NS 500mL 2hr (after CDDP) (C1D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-06-13

[potential resistance to current regimen noted]

A bone scan on 2024-04-17 indicated progression of metastatic bone disease compared to the previous study on 2023-11-23. This suggests that the disease may be developing resistance to the current regimen of durvalumab, gemcitabine, and cisplatin. Lab results on 2024-06-12 were generally normal, and no medication discrepancies were identified.

700573214

240612

[exam findings]

• 2024-04-19 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 18 dB HL; LE 18 dB HL
  • RE WNL
  • LE normal to mild SNHL
• 2024-03-29 Patho - omentum biopsy (Y1)
  • DIAGNOSIS: Sigmoid colon serosa, laparoscopic biopsy — adenocarcinoma, seeding
  • Final diagnosis: High-grade serous carcinoma, in favor of ovary origin
  • Microscopically, it shows adenocarcinoma composed of invasive tumor nests arranged in solid to papillary architecture, and stromal fibrosis. The tumor cells display hyperchromatic nuclei,pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • IHC stain — CK7(+), p53: aberrant (complete absence of staining), CK20(-), vimentin (focal+), WT-1(+)
• 2024-03-29 Patho - omentum biopsy (Y1)
  • DIAGNOSIS: Omentum, laparoscopic biopsy— adenocarcinoma, seeding
  • Final diagnosis: High-grade serous carcinoma, in favor of ovary origin
  • Microscopically, it shows adenocarcinoma composed of tumor nests arranged in solid architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei,pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • IHC stain — CK7(+), p53: aberrant (complete absence of staining), CK20(-), vimentin (focal+), WT-1(+)
• 2024-03-27 ECG
  • Normal sinus rhythm
  • Right bundle branch block
  • Nonspecific ST abnormality
  • Abnormal ECG
• 2024-03-20 CT - abdomen
  • Findings:
    • There is ascites and soft tissue nodules in the cul-de-sac, and omentum cake that is c/w carcinomatosis.
      • In addition, there are soft tissue lesions in bilateral adnexa.
      • Ovarian carcinoma with carcinomatosis is highly suspected.
      • The differential diagnosis includes primary peritoneal serous carcinoma.
    • There is a gallstone 1.4 cm.
  • Impression:
    • Ovarian carcinoma with carcinomatosis is highly suspected.
    • The differential diagnosis includes primary peritoneal serous carcinoma. Please correlate with biopsy.
• 2024-03-18 gynecology sonography
  • R/O abdominal mass (122x42mm, 90x30mm)
  • The border is unclear, but maybe size : 62x62 mm, some cloudy fluid content in side, the border is uneven, Suggest CT

[MedRec]

• 2024-04-18 ~ 2024-04-20 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Ovarian malignancy (High-grade serous carcinoma) with peritoneal carcinomatosis, stage IIIc, Neo-adjuvant chemotherapy with TP (Paclitaxel + Carboplatin) from 2024/04/19
    • Encounter for antineoplastic chemotherapy
  • CC
    • For neo-adjuvant chemotherapy with TP (C1)
  • Course of inpatient treatment
    • After admission, Check PTA, 24hr CCR first.
    • Dexamethasone 5#(20mg) po and Cimetidine 1# po before chemotherapy with Taxol 12hr on 2024/04/18 at 23:00 and before chemotherapy with Taxol 6hr on 2024/04/19 at 05:00.
    • Chemotherapy with TP (Paclitaxel 175mg/m2 + Carboplatin AUC:5) from 2024/04/19 (C1).
    • AntiHBc postive with baraclude 0.5mg/tab 1# qdac.
    • Kept OPD medication with micardis for hypertension.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/04/20 and OPD followed up later.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2024-04-11 SOAP Obstetrics and Gynecology Huang SiCheng
  • A/P: Cancer Multi-Specialty Team Meeting Conclusions, Meeting Date: 2024-04-11
    • Treatment Plan: Neo-adjuvant chemotherapy + Debulking + Adjuvant chemotherapy
• 2024-03-27 ~ 2024-04-02 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of unspecified ovary
    • Suspected left ovarian malignancy with peritoneal carcinomatosis, stage IIIc post laparoscopic exploration and tissue biopsy on 2024/03/29
  • CC
    • Lower abdominal dull pain for 2 months
  • Present illness
    • This is a 65 years old woman with underlying disease of hypertension. She is a heavy smoker. She was menopause at 56 years old. She gets regular annual pap smear.
    • According to the patient, dull lower abdominal pain was noted 2 months ago. It was intermittent pain associated with motion. Incomplete defecation was also noted recently. There was no fever, no diarrhea, no change of bowel habit, no abnormal vaginal discharge, no unintentional weight loss. She visited LMD (WuLai AnTai Clinic). Ultrasound revealed a ovarian mass and fluid in cul-de-sac. She was referred to our GYN OPD. Recheck transabdominal ultrasound showed abdominal mass sized 122x42mm. The border was uneven with some cloudy fluid content. Abdominal CT showed highly suspected ovarian carcinoma with carcinomatosis. Lab datas showed CEA 2.438 U/mL, CA125 2,333.3 U/mL, CA19-9 5.21 U/mL.
    • After discussing with the patient, she agreed to get complete tumor survey. The patient was admitted today. Upper GI endoscopy & colonscopy was arranged on 3/28. LSC biopsy was arranged on 3/29.
  • Course of inpatient treatment
    • The patient was admitted on 2024/03/27. The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey.
    • She underwent laparoscopic exploration and tissue biopsy on 2024/03/29.
    • We gave her Cefazolin and Gentamycin IV form for 1 day and then shifted her antibiotics to Cephalexin oral form.
    • Post-operation wound was dry and clean without dehiscence, discharge, or oozing.
    • Her lab data on 2024/03/30 also showed no specific positive findings.
    • The pathology report showed High-grade serous carcinoma, in favor of ovary origin.
    • After flatus, her eating, self voiding and defecation were all stable.
    • Since all her general conditions were all improved and relatively stable, we arranged discharge for her for further OPD follow up of her recovery status and surgical wound conditions. 
  • Discharge prescription
    • cephalexin 500mg 1# QID
    • MgO 250mg 1# QID
    • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

• 2024-04-01
  • Operation
    • Port-A (47080B)
    • Fluoroscopy (32026C)         
  • Finding:
    • Insertion via left external jugular vein.
    • Port: Polysite, 3007, 7Fr,
    • Fluorosopy: catheter tip in SVC above RA         
• 2024-03-29 - Op Method:
  • Impression:
    • pelvic mass r/o left ovarian malignancy with peritoneal carcinomatosis and omentum cake
  • Procedure:
    • laparoscopic exploration and tissue biopsy
  • Finding:
    • Huge pelvic mass, size ref to image, r/o left ovarian malignancy with peritoneal carcinomatosis and omentum cake; the cancer has spread widely to the abdominal/pelvic cavity and colorectal. Omental (omentum cake) biopsy and sigmoid colon surface papillary mass biopsy were done.
    • Uterus: grossly normal, with smooth surface
    • Right ovary: with papillary surface.
    • Liver: smooth surface, but there were some papillary lesions were noted over peritoneum nearby.
    • Cul-de sac: bloody asctites; s/p washing cytology     
    • Blood loss 5 ml

[chemotherapy]

• 2024-06-12 - paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-21 - paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-19 - paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-06-12

[positive CA125 response to chemotherapy]

The marker CA125 has been steadily decreasing since the initiation of chemotherapy on 2024-04-19, which is a positive sign.

The remaining lab data were unremarkable, with no contraindicating results to prevent proceeding with the new session of chemotherapy scheduled for today.

• 2024-06-04 CA125 124.4 U/mL
• 2024-05-20 CA125 507.0 U/mL
• 2024-04-19 CA125 3801.1 U/mL
• 2024-03-18 CA125 2333.3 U/mL

2024-05-21

[optional addition of silymarin for elevated liver enzymes]

The first two sessions of the TP regimen were administered on 2024-04-19 and 2024-05-21. Following the administration, there was a mild elevation remaining in liver enzymes AST and ALT. Adding BaoGan (silymarin) might be considered as an optional supplement.

• 2024-05-20 AST 40 U/L

• 2024-05-02 AST 44 U/L

• 2024-04-25 AST 54 U/L

• 2024-04-18 AST 38 U/L

• 2024-05-20 ALT 45 U/L

• 2024-05-02 ALT 42 U/L

• 2024-04-25 ALT 56 U/L

• 2024-04-18 ALT 28 U/L

700710186

240612

[exam findings]

• 2024-05-24 MRI - nasopharynx
  • Imp: C/W advanced NPC S/P CCRT with residual abnormal intensity at skull base and intracranial region. Stationary as compared with MRI on 20240124.
• 2024-01-24 MRI - nasopharynx
  • Imp: heterogeneous enhancing soft tissue lesions in the left clivus, the apex of left petrous bone and left nasopharynx; no interval change.
• 2023-10-16 MRI - nasopharynx
  • Indication: NPC s/p C/T
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows: comparison: 2023/06/21 MRI
    • Well regression of left clivus-skull base-nasopharynx-cavernous sinus tumor with residual tumor mass.
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor..
    • Markedly regression of bil. neck LAPs. Markedly regression of left parotid gland LNs.
    • Well regression of left temporal lobe brain edema.
• 2023-07-13 Pure Tone Audiometry, PTA
  • Reliability FAIR to POOR (tinnitus+, inconsistent response)
  • Average RE 24 dB HL; LE 65 dB HL.
  • RE normal to moderately severe SNHL.
  • LE mild to severe mixed type HL.
• 2023-06-23 Tc-99m MDP bone scan
  • Increased activity in the skull base. Malignancy with local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in a middle T-spine. The nature is to be determined (degenerative change? other nature?). Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the lower L-spine. Degenerative change may show this picture.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2023-06-21 MRI - nasopharynx
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:4(T_value) N:3(N_value) M:0(M_value) STAGE:IVA(Stage_value)
  • Findings
    • The left nasopharyngeal tumor involving left side of clivus, longus colli muscle, foramen ovale, foramen lacerum, and cavernous sinus, and encasing left ICA.
    • White matter edema in left anterior temporal lobe also noted.
    • Enlarged lymph nodes at both sides of the neck, also at left parotid gland and right paratracheal region.
• 2023-06-13 Patho - nasopharyngeal/oropharyngeal
  • DIAGNOSIS:
    • Nasopharynx, left, biopsy — Non-keratinizing nasopharyngeal carcinoma, undifferentiated
  • GROSS DESCRIPTION:
    • Specimen submitted in formalin consists of several pieces of tan, irregular tissue measuring up to 0.3 x 0.2 x 0.1 cm. All for section in one cassette.
  • MICROSCOPIC DESCRIPTION:
    • Section shows several pieces of nonkeratinzing squamous cell carcinoma.
    • The immunohistochemical stains reveal CK(+) and p40(+).
  • MICROSCOPIC EXAMINATION:
    • Histologic Type (select all that apply): Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B)
    • Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy): patient not received
    • Additional Pathologic Findings (select all that apply): None identified
    • Ancillary Studies: not applicable
    • Clinical History (select all that apply): Neoadjuvant therapy: No
• 2023-06-15 Nasopharyngoscopy
  • left NP tumor, with extension to lateral pharyngeal wall
  • easily touch bleeding, biopsy done

[MedRec]

• 2024-02-29, 2023-12-08 SOAP Metabolism and Endocrinology Qiu QuanTai & Zhou Fan
  • Prescription x3
    • Concor (bisoprolol 5mg) 1# QD
    • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
    • Dibose (acarbose 100mg) 1# TIDAC
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# QD
• 2023-10-11 SOAP Radiation Oncology Huang JingMin
  • S: The patient was referred for radiotherapy due to NPC s/p induction chemotherapy.
    • PI: The patient suffered from left headache, left tinnitus, left neck pain, and left face numbness for about several months.
    • Induction chemotherapy: 2023-07-18 ~ 2023-09-29
    • Family history: (-)
    • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
    • Personal Hx: DM (+); HTN (+)
    • Allergy (-)
    • Previous RT Hx: (-)
  • A: Non-keratinizing nasopharyngeal carcinoma, undifferentiated, stage cT4N3M0 (IVA), s/p induction chemotherapy.
  • P: Induction chemotherapy followed by CCRT is indicated for this patient with the following indicators: stage cT4N3M0 (IVA)
    • Goal: curative
    • Treatment target and volume: nasopharyngeal tumor, peripheral involved, to bilateral neck.
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 5000cGy/25 fractions of the nasopharyngeal tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the involved nasopharyngeal tumor and bilateral neck nodal lesions.
    • The treatment planning of radiotherapy will be started at 1330, 2023-10-17.
• 2023-10-13 SOAP Metabolism and Endocrinology Zhou Fan
  • Prescription x2
    • Galvus Met (vidagliptin 50mg, metformin 500mg) 1# QD
    • Dibose (acarbose 100mg) 1# TIDAC
    • Glimet (glimepiride 2mg, metformin 500mg) 1# QDAC
    • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
    • Concor (bisoprolol 5mg) 1# QD
• 2023-06-19 ~ 2023-06-24 POMR Ear Nose Throat
  • Discharge diagnosis
    • Malignant neoplasm of nasopharynx T4N3M0, STAGE:IVA
  • CC
    • Blood-tinged rhinorrhea and headache for 2 months
  • Present illness
    • This is a 68-year-old woman with underlying hypertension, hyperlipidemia and diabetes mellitus under medication control for over 2 years. She had noticed blood-tinged rhinorrhea and left headache for 2 month. Left tinnitus, left neck pain and left face numbness were noted too, no body weight loss.
    • She visited LoTung PohAi Hospital for help, left nasopharyngeal lesion was noted and suggested biopsy. Denied drinking, cigarette and betel nuts. Therefore, she came to our ENT OPD for second opinion. Fiberscopic exam showed left nasopharyngeal tumor, with extension to lateral pharyngeal wall. Left otitis media with effusion and left neck mass about 8cm, can’t movable, tenderness. Biopsy of the tumor was done, and the pathology report non-keratinizing nasopharyngeal carcinoma, undifferentiated. Admission for further examination was suggested, and she agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, she was admitted for cancer work-up.   
  • Course of inpatient treatment
    • After admission, serial tests were arranged for tumor staging work up. Nasopharyngeal MRI showed nasopharyngeal carcinoma T4N3M0, STAGE IVA. Abdominal sonography showed gall stone. Whole body bone scan showed increased activity in the skull base. Malignancy with local bony involvement may show this picture. Under relative stable condition, the patient was dishcarged with OPD follow up.
  • Discharge prescription
    • OxyNorm (oxycodone 5mg) 1# Q6H 7D

[consultation]

• 2023-09-01 Ophthalmology
  • Q
    • This 67-year-old woman patient is a case of Non-keratinizing nasopharyngeal carcinoma, undifferentiated, cT4N3M0, stage IVA s/p chemotherapy with TPF from 2023/07/14~. Type 2 diabetes mellitus medical history.
    • This time. for sepsis with 2023-08-28 Blood Culture showed Klebsiella pneumoniae bacteremia and Urinary tract infection 2023/08/29 Urine/C showed Klebsiella pneumoniae bacteriuria.
    • Now, for evaluate endophthalmitis of Type 2 diabetes mellitus medical history and Klebsiella pneumoniae bacteremia. Thank you.
  • A
    • S: For DR survey (HbA1c=6.7% at 2023/07), and endophthalmitis screen due to bacteremia
      • No bv
      • Admitted due to sepsis
      • 08/28 B/C: Klebsiella pneumoniae
      • 08/29 U/C: Klebsiella pneumoniae
      • phx: HTN, DM, nasopharyngeal carcinoma stage IVA s/p chemotherapy
    • O:
      • BCVA: OD 0.5X+2.00/-2.25X70 OS 0.3X0/-1.25X15
      • PT: 17/16mmHg
      • Pupil: 3mm, light reflex + ou, no RAPD
      • Conj: np ou
      • K: clear ou
      • ac: deep/clear ou
      • lens: CO2+, NS+, PSC+ ou
      • c/d 0.4
      • Fundus: exudate at paramacula od, blod hemorrahge os, c/w mild NPDR ou
      • no infiltration/no vitritis ou
    • A:
      • Mild NPDR ou
      • Cataract ou
      • No evidence of endophthalmitis at present
    • P:
      • kary 1gtt BID ou for cataract
      • Keep control underlying diseasse
      • If increased floater/red eye/increaed discharge/blurred vision, please contact us ASAP
      • I will f/u this case about 1 wk later
  • A 2023-09-08 12:00:52
    • F/U 1wk, no increased bv, no increased floater, no discharge, no FBS
      • BCVA: OD 0.15X(0.2x+2.50/-2.50X50) OS 0.0.2(0.3x+1.0/-2.00x100)
      • PT: 18/17mmHg
      • Pupil: 3mm, light reflex + ou, no RAPD
      • Conj: np ou
      • K: clear ou
      • ac: deep/clear ou
      • lens: CO2+, NS+, PSC+ ou
      • c/d 0.4
      • Fundus: exudate at paramacula od, blood hemorrahge os, c/w mild NPDR ou
      • no infiltration/no vitritis ou
    • A: No evidence of endophthalmitis at present
    • P:
      • keep kary 1gtt BID ou for cataract
      • Keep control underlying diseasse
      • If increased floater/red eye/increaed discharge/blurred vision, please contact us ASAP
      • oph opd f/u 6M for cataract and DR survey

[radiotherapy]

• 2023-10-30 ~ 2023-12-15 - 5000cGy/25 fractions (6MV photon) of the nasopharyngeal tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the involved nasopharyngeal tumor and and bilateral neck nodal lesions.

[chemotherapy]

• 2024-06-11 - NS 500mL 2hr (before CDDP) + cisplatin 30mg/m2 40mg NS 500mL 4hr + NS 500mL 2hr (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-2 (PF Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-21 - NS 500mL 2hr (before CDDP) + cisplatin 30mg/m2 40mg NS 500mL 4hr + NS 500mL 2hr (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-2 (PF Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-04-18 - NS 500mL 2hr (before CDDP) + cisplatin 30mg/m2 40mg NS 500mL 4hr + NS 500mL 2hr (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-2 (PF Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-03-20 - NS 500mL 2hr (before CDDP) + cisplatin 30mg/m2 40mg NS 500mL 4hr + NS 500mL 2hr (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-2 (PF Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-20 - carboplatin AUC 2 130mg D5W 250mL 1hr (QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-12-06 - carboplatin AUC 2 130mg D5W 250mL 1hr (QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-11-29 - carboplatin AUC 2 130mg D5W 250mL 1hr (QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-11-20 - carboplatin AUC 2 130mg D5W 250mL 1hr (QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-11-06 - carboplatin AUC 2 130mg D5W 250mL 1hr (QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-10-30 - carboplatin AUC 2 130mg D5W 250mL 1hr (QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-09-25 - docetaxel 40mg/m2 60mg NS 200mL 1hr D1 + carboplatin AUC 4 300mg NS 250mL D2 + fluorouracil 1000mg/m2 1000mg NS 500mL D2-5 (TPF Q3W)
  • dexamethasone 4mg D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4 + NS 250mL D1-4
• 2023-08-07 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + carboplatin AUC 4 300mg NS 250mL D2 + fluorouracil 1000mg/m2 1200mg NS 500mL D2-5 (TPF Q3W)
  • dexamethasone 4mg D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4 + NS 250mL D1-4
• 2023-07-14 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + carboplatin AUC 4 300mg NS 250mL D2 + fluorouracil 1000mg/m2 1200mg NS 500mL D2-5 (TPF Q3W)
  • dexamethasone 4mg D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4 + NS 250mL D1-4

==========

2024-06-12

[MRI shows stable disease under PF regimen]

The current PF regimen has kept the disease stable, as confirmed by MRI on 2024-05-24. The eGFR of 48 on 2024-06-11 remains around 50, with no significant deterioration observed. Other lab results were unremarkable, and no medication discrepancies were found.

2024-05-22

[stable kidney function and well-managed comorbidities]

The moderately impaired renal function has remained stable over the past three months.

The underlying conditions of hypertension, hyperglycemia, hyperuricemia, and positive anti-HBc are currently managed with Concor (bisoprolol), Exforge (amlodipine, valsartan), Dibose (acarbose), Galvus Met (vildagliptin, metformin), Feburic (febuxostat), and Vemlidy (tenofovir alafenamide) effectively, with no medication discrepancies identified.

It may be beneficial to repeat the nasopharyngeal MRI. (last 2024-01-24)

2024-03-21

[persistent anemia despite chemo (prior CCRT ended dec 2023): possible other contributing factors]

Despite undergoing chemotherapy during this hospitalization, the prior CCRT had already concluded by the end of Dec 2023. However, anemia persists, suggesting that factors other than chemotherapy might be contributing to the patient’s ongoing anemia.

For example, gastrointestinal bleeding?

2024-03-20 Stool OB 1+

2024-03-20 HGB 8.7 g/dL 2024-01-29 HGB 9.1 g/dL 2024-01-03 HGB 9.1 g/dL 2023-12-20 HGB 9.7 g/dL 2023-12-06 HGB 10.2 g/dL

2023-11-20

[Kidney function fluctuates downward]

Lab:

• 2023-11-17 eGFR 60.17 ml/min/1.73m^2
  

• 2023-11-06 eGFR 80.68 ml/min/1.73m^2

• 2023-11-17 BUN 44 mg/dL
  

• 2023-11-06 BUN 19 mg/dL

It is recommended that 50% of the usual total daily dose of metoclopramide be given if CrCl falls between 10 and 60 mL/minute.

2023-10-31

[decline in renal function over the last month]

The patient’s renal function has deteriorated over the past 30 days.

• 2023-10-26 BUN 60 mg/dL
  

• 2023-10-11 BUN 48 mg/dL
  

• 2023-10-05 BUN 34 mg/dL
  

• 2023-09-25 BUN 19 mg/dL

• 2023-10-26 Creatinine 1.12 mg/dL
  

• 2023-10-11 Creatinine 0.99 mg/dL
  

• 2023-10-05 Creatinine 0.92 mg/dL
  

• 2023-09-25 Creatinine 0.85 mg/dL

Carboplatin is associated with decreased creatinine clearance (27%), increased blood urea nitrogen (14% to 22%)

Valsartan may be associated with increased serum creatinine and/or acute kidney injury. Increases in serum creatinine secondary to angiotensin receptor blockers usually stabilize within 20% to 30% from baseline and are expected; additional increases may indicate renal artery stenosis or volume depletion.

Adverse events reported post-marketing include interstitial nephritis with famotidine, acute interstitial nephritis with amlodipine, and acute kidney injury, Fanconi syndrome, proximal tubular nephropathy, and renal tubular necrosis with tenofovir alafenamide.

2023-08-30

After reviewing the PharmaCloud and HIS5 records for this admission, no medication reconciliation issues were identified.

2023-08-08

No medication reconciliation issues were found when this admission after reviewing PharmaCloud and HIS5.

701527903

240612

[exam findings]

• 2024-06-11 CT - abdomen
  • History and indication: IAI (Intra-abdominal Infection?)
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A poor enhancing tumor (9.6cm) at pancreatic tail with gastric, spleen, left adrenal and left renal invasion. Multiple soft tissues in peritoneal cavity. Multiple liver tumors.
    • Small amount ascites. Some LNs at upper abdomen and retroperitoneum.
    • Ventral hernia with fat herniation.
    • Right pleural effusion with adjacent lung collapse.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • A poor enhancing tumor (9.6cm) at pancreatic tail with gastric, spleen, left adrenal and left renal invasion r/o malignancy. Peritoneal carcinomatosis, LNs and liver metastases.
    • Right pleural effusion with adjacent lung collapse.
• 2024-06-11 MRA - brain
  • MRI of the brain in multiplanar projections, multisequences imaging acquisition without IV Gd-DTPA administration shows:
    • Acute right frontal brain infarct, in cortex and subcortical white matter.
      
    • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • The interhemispheric fissure is centered on the midline.
    • Sella and pituitary are normal. The parasellar structures are unremarkable.
    • There are no abnormalities in the cerebellopontine angle areas on both sides.
    • There are no abnormalities in the calvarium.
      
  • The MRA study shows mild arteriosclerosis of the neck and intracranial vessels with irregular outline, focal severe stenosis at right proximal A1 segment was noted.
  • Imp:
    • Acute right frontal brain infarct.
• 2024-06-11 CT - brain
  • Non-contrast brain CT revealed:
    • R/O minimal SDH at right frontal region.
    • No midline shift.
    • Low attenuation in right frontal region.
    • Intact bony structures.
    • Widening of cortical sulci and dilatation of ventricles.
    • A retention cyst (1.0cm) at right maxillary sinus.
  • IMP:
    • R/O minimal SDH at right frontal region.
    • Infarct in right frontal region.
• 2024-06-11 ECG
  • Sinus tachycardia
  • Left axis deviation
  • Low voltage QRS
  • Inferior infarct, age undetermined
  • Possible Anterolateral infarct, age undetermined

==========

2024-06-12

[check for blood clots, infection, heart and liver issues]

Leukocytosis with a left shift, elevated fibrinogen, D-dimer, NT-proBNP, and prolonged PT were observed.

• 2024-06-12 Fibrinogen (quantita) 502.2 mg/dL
  
• 2024-06-12 D-dimer 7628.00 ng/mL(FEU)
  
• 2024-06-12 PT 16.3 sec
  
• 2024-06-11 NT-proBNP 210.7 pg/mL
  
• 2024-06-11 Band 1.7 %
  
• 2024-06-11 Neutrophil 89.9 %
  
• 2024-06-11 WBC 52.61 x10^3/uL

Please check for the presence of blood clots, infection or inflammatory conditions, heart problems (inferior infarct and possible anterolateral infarct on 2024-06-11 ECG), and liver issues (multiple liver tumors and ascites as indicated by the 2024-06-11 CT scan).

The PharmaCloud database shows recent refills of Concor (bisoprolol), Blopress (candesartan), Zulitor (pitavastatin), and Zcough (benzonatate). These medications are now on the active medication list with no discrepancies found.

Brosym (cefoperazone, sulbactam) is currently being used empirically; no culture results are available yet.

700145771

240611

[lab data]

2023-07-18 CA-199 (NM) 52.608 U/ml
2023-07-04 CA-199 (NM) 38.491 U/ml
2023-06-09 CA-199 (NM) 39.33 U/ml
2022-05-26 CA-199 53.04 U/mL

2023-06-09 HBsAg (NM) Negative
2023-06-09 HBsAg Value (NM) 0.373
2023-06-09 Anti-HCV (NM) Negative
2023-06-09 Anti-HCV Value (NM) 0.042
2023-06-09 Anti-HBc (NM) Positive
2023-06-09 Anti-HBc Value (NM) 0.009
2023-06-09 Anti-HBs (NM) Negative
2023-06-09 Anti-HBs value (NM) 4.06 mIU/mL

2022-05-26 HBsAg Nonreactive
2022-05-26 HBsAg (Value) 0.63 S/CO
2022-05-26 Anti-HCV Nonreactive
2022-05-26 Anti-HCV Value 0.08 S/CO

[exam findings]

• 2024-06-04 CXR
  • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
  • Rt greater than Lt, bilateral pleural effusions.
  • dependent partial atelectasis of both lower lobes.
  • extensive atherosclerotic change of aortic arch and descending thoracic aorta.
  • enlarged cardiac silhoutte due to dilated chambers and prominent cardiophrenic angle mediastinal fat pad /supine position
  • L1 and L2 compression fractures
  • Joint space narrowing at bilateral glenohumeral joints due to inflammatory arthritis
• 2024-05-26 CXR
  • Cardiomegaly and tortuosity of the thoracic aorta.
  • Widening of the mediastinum.
  • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
  • Bilateral pleural effusion.
  • S/P port-A catheter insertion.
• 2024-05-26 CT - brain
  • Hypodense change foci over left corona radiata and lentiform nucleus. Suggest check MRI.
  • The brain shows age-related cortical atrophy, sulcal space widening, proportionate ventricular dilatation and white matter ischemic change including the periventricular, subcortical and subinsular regions. There is no intracranial hemorrhage seen.
  • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
  • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
• 2024-05-23 Pelvis & Lt. Hip Lat
  • Normal bone alignment
  • severe decreased bilateral hip joint spaces
• 2024-05-21 CT - chest
  • without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Rt greater than Lt, large volume of bilateral pleural effusions.
    • lungs: dependent partial atelectasis of both lower lobes.
    • Mediastinum and hila: no enlarged LN
      • extensive coronary arterial calcification
    • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Heart: dilated LA and RA, mild calcified aortic valves.
    • Visible abdominal-pelvic contents:
      • ill-defined infiltrative tumor in left hepatic lobe (at least 52mm in longest axial dimension encasing left hepatic portal vein), causing mild focal IHD dilatation. small ascites and extensive fat stranding the small bowel mesentery. Enlarged lymph node in upper abdomen, along the splenic vessel, favor metastatic lymph node
    • L1 and L2 compression fractures
  • Impression:
    • Left liver cholangiocarcinoma with upper abdominal LN metastasis, increase in size of primary tumor and increased volume of pleural effusion as compared with the abdominal CT on 2024/02/19
• 2024-05-21 CXR erect
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2024-05-02 SONO - chest
  • Special Procedure
    • Pleural tapping 16 #-needle Right side 600 ml straw-color
  • Suggestion:
    • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
• 2024-04-19 ECG
  • Atrial fibrillation with rapid ventricular response
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2024-03-21 Bladder Sonography
  • PVR: 44.6 mL
• 2024-02-23 ECG
  • Atrial fibrillation with rapid ventricular response
  • Abnormal ECG
• 2024-02-19 CT - abdomen
  • History and indication: Cholangiocarcinoma
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Left liver cholangiocarcinoma (2.6x4.1cm) with IHD dilatation. Fat stranding of mesentery.
    • Bil. pleural effusion with adjacent lung collapse.
    • Bil. renal cysts (up to 1.0cm).
    • Small amount ascites.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • Compression fracture of L1-3.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Left liver cholangiocarcinoma (2.6x4.1cm) with IHD dilatation (stable).
• 2024-01-26 ECG
  • Atrial flutter with variable A-V block
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2023-10-31 CT - abdomen
  • With and without contrast enhancement CT of abdomen - whole:
    • Cholangiocarcinoma in left lobe liver with mild focal IHD dilatation, with regression.
    • Enlarged lymph nodes in upper abdomen, r/o metastatic lymph node. Regression size.
    • Outpouching lesions in the sigmoid colon, suggesting sigmoid colon diverticula.
    • Left renal cyst, 1.4cm.
    • L1 and L2 compression fractures.
    • Small right lower lung nodule, r/o lung metastasis.
    • Right pleural effusion.
  • Impression:
    • Cholangiocarcionoma with IHD dilatations and lymph nodes metastasis. Regression.
    • Sigmoid colon diverticula.
    • L1 and L2 compression fractures.
      
    • Small right lower lung nodule, r/o lung metastasis.
    • Right pleural effusion, progression.
• 2023-09-21 SONO - abdomen
  • Diagnosis:
    • Fatty liver, mild
    • Propable liver tumor, left with dilatation of left IHD. Propable cholangiocarcinoma
    • Thick GB wall. Propable cholecystopathy or hypoalbuminemia related
    • Suspected fatty infiltration of pancreas
  • Suggestion:
    • OPD f/u
    • Please correlate with other image
    • Follow liver function test and AFP, CA-199
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2023-08-02 T-L spine AP + Lat
  • Compression fracture of L1 and L2 vertebral body with near total collapse causing mild Kyphosis of the T-and L-spine.
  • Spondylosis of the T-spine and L-spine
• 2023-08-01 Tc-99m MDP bone scan with SPECT
  • Increased activity in the L1-2 spines. Compression fractures may show this picture. Please correlate with other imaging modalities for further evaluation and to rule out the possibility of pathologic compression fractures.
  • Increased activity in the upper C-spine and lower L-spine. Degenerative change may show this picture.
  • Some hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please correlate with the clinical history and follow up bone scan for further evaluation.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • Increased activity in bilateral shoulders and knees. Severe degenerative change may show this picture. However, please orrelate with the other clinical findings for further evaluation
• 2023-07-28 MRI - L-spine
  • Marked degenerative spinal and disc disease.
  • Severe L1, L2 compression fracture. Osteonecrosis at L2. Favor benign etiology.
  • Mild chronic L3, L4 compression fracture.
  • Grade 1 degenerative spondylolisthesis at L4-5 level.
  • Grade 1 spondylolytic spondylolisthesis at L5-S1 level, with mild bilateral L5-S1 neuroforaminal narrowing.
• 2023-07-27 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with cholangiocarcinoma
  • The specimen submitted consists of two strips of yellow gray soft tissue, labeled liver, measuring up to 1.2 x 0.1 x 0.1 cm. All for section.
  • The sections show a picture of adenocarcinoma, composed of nests and cords of large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation and moderate inflammatory cell infiltrate are evident.
  • IHC shows: CK7(+), CK20(-), Arginase-1(-), and Hepatocyte(-). The finding is compatible with cholangiocarcinoma.
• 2023-07-11 CT - abdomen
  • Clinical history: 85 y/o female patient with cholangiocarcinoma post CCRT (xeloda) at ShinKuan hospital and received CCRT there. But progression was noted 3 months after CCRT.
  • With and without contrast enhancement CT of abdomen - whole:
    • Focal IHD dilatation in left lateral segment of liver.
    • Ill-defined low density lesion, 5.2cm in S2 liver with adjacent vascular compression, r/o cholangiocarcinoma with progression.
    • Enlarged lymph nodes in upper abdomen, r/o metastatic lymph node.
    • Small liver cyst, 4.2cm in S6.
    • Outpouching lesions in the sigmoid colon, suggesting sigmoid colon diverticula.
    • Left renal cyst, 0.9cm.
    • L1 and L2 compression fractures.
  • Impression:
    • Cholangiocarcionoma with IHD dilatations and lymph nodes metastasis. Progression.
      
    • Sigmoid colon diverticula.
    • Liver and left renal cysts.
    • L1 and L2 compression fractures.
• 2023-06-16 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
• 2023-06-16 ECG
  • Normal sinus rhythm
  • T wave abnormality, consider lateral ischemia
  • Abnormal ECG
• 2023-04-17 Microsonography
  • clinical diagnosis: end stage glaucoma ou
  • Report: OCT-D x/72, x/2.14, x/0.86
    • CRT: 209/286 um, high myopia change ou
• 2022-12-13 L-spine AP + Lat. (including sacrum)
  • L1, L2, L3 compression fracture.
  • Grade 1 spondylolisthesis at L5-S1 level.
  • Degenerative change of the spine with marginal spur formation.
  • Osteopenia of visible bones.
• 2022-11-14 Hip BMD performed by DXA
  • Finding: Left hip, BMD is 0.477 gms/cm2, about 3.4 SD below the peak bone mass (56%) and 0.2 SD below the mean of age-matched people (97%).
  • Impression: Osteoporosis
• 2022-05-26 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
  • ST & T wave abnormality, consider lateral ischemia
  • Prolonged QT
• 2022-05-25 CT - abdomen
  • Clinical history: 84 y/o female patient with low back pain, lower abdominal distension, dysuria, bilateral lower limb edema.
  • With and without contrast enhancement CT of abdomen - whole:
    • Focal IHD dilatation in left lateral segment of liver.
    • Ill-defined low density lesion, 5cm in S2 liver, r/o cholangiocarcinoma.
    • Small liver cyst, 4.2cm in S6.
    • Outpouching lesions in the sigmoid colon, suggesting sigmoid colon diverticula.
    • Left renal cyst, 0.9cm.
    • Right pleural effusion with basal lung collapse.
    • L1 and L3 compression fractures.
    • Gr I spondylolisthesis at L5-S1.
  • Impression:
    • Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver. R/O cholangiocarcinoma, suggest further study.
    • Sigmoid colon diverticula.
    • Liver and left renal cysts.
    • Right pleural effusion with basal lung collapse.
    • L1 and L3 compression fractures. Gr I spondylolisthesis at L5-S1.
• 2022-05-25 CXR
  • Mild bunting of costophrenic angle, both sides.
  • Cardiomegaly.
  • Intimal calcification of thoracic aorta.
  • L1 compression fraccture.
  • Narrowing of right shoulder joint.
• 2022-05-25 KUB
  • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
  • Non-specific bowel gas pattern.
  • Clear margin of bilateral psoas muscles.
  • Lumbar spondylosis.
  • L2 and L4 compression fractures.
  • Osteoporosis of the bones.

[MedRec]

• 2023-07-26 POMR ProgressNote
  • The patient requested to self-administer her own medication, adjusting it based on her daily condition. She expressed doubts about receiving medications from nurses. The nurse practitioner informed her about the safety of administering medication through the nursing team, but the patient was unable to accept it. Therefore, the patient’s outpatient medication was canceled.
• 2023-06-23 SOAP Hemato-Oncology
  • A: She requested self-paid Xeloda as before duringt her preparation for vertioplasty by ortho doctors
  • Prescription
    • Xeloda (capecitabine 500mg) 2# BID
• 2023-06-20 SOAP Hemato-Oncology
  • A: She preferred to be treated for her back first and hold the chemotherapy according to her decision.
• 2023-06-16 ~ 2023-06-16 POMR Hemato-Oncology
  • Discharge diagnosis
    • cholangiocarcinoma post CCRT (xeloda) at ShinKuan hospital
  • CC
    • for port-A insertion and further treatment
  • Present illness
    • This 84 years old female with history of
      • HTN
      • Chronic ischemic heart disease
      • Cerebral artherosclerosis
      • cholangiocarcinoma post CCRT (Xeloda) at ShinKuan hospital
      • COVID-19 test (+). Confirmed on 2022-05-17, and discharged on 2022-05-20.
    • According to her daughter, CT at ShinKuan hospital told progression. This time,she was admitted for port-A insertion and further treatment.
  • Course of inpatient treatment
    • After admission, labortaory test revealed fair CBC level. plan to receive port-A insertion on 2023-06-21 but patient requsted for against medical advice discharge due to the next bed had influenza-A on 2023/06/16. OPD follow up was arranged
• 2023-06-02 SOAP Hemato-Oncology Gao WeiYao
  • S: A documented cholangiocarcinoma post CCRT (Xeloda) at ShinKuan hospital and received CCRT there. But progression was noted 3 months after CCRT.
  • P: Ask her and her daughter to bring back the patho report and CT imaging.
• 2022-12-13 SOAP Orthopedics
  • A
    • spinal orthosis
    • prolia 1st dose since 2022/12/13
    • warm packing
    • add density
  • Prescription
    • Arcoxia (etoricoxib 60mg) 1# QD
    • Prolia (denosumab 60mg) SC
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# BID
• 2022-05-25 ~ 2022-06-04 POMR Gastroenterology
  • Discharge diagnosis
    • COVID-19, virus identified
    • Urinary tract infection (Urine culture grew PDR-Chryseobacter indologene)
    • Left lobe liver tumor with focal intrahepatic bile duct dilatation in left lateral segment of liver. Rule out cholangiocarcinoma
    • Sigmoid colon diverticula
    • Right pleural effusion with basal lung collapse
    • Edema, unspecified
    • Hypo-osmolality and hyponatremia
    • Hypokalemia
    • Lumbar spondylosis
    • Lumbar 2 and Lumbar 4 compression fractures
    • Liver cysts
    • Left renal cysts
    • Chronic ischemic heart disease, unspecified
  • CC
    • abdomen distension and pitting edema for few days
  • Present illness
    • This 84 years old female with history of
      • HTN
      • Chronic ischemic heart disease
      • Cerebral artherosclerosis
    • She just discharged from our Hospital, due to COVID-19 test(+). Confirmed on 2022-05-17, and discharged on 2022-05-20.
    • This time, she was suffered from abdomen distension and pitting edema for few days, the s/s was progressive. She was sent to our ER for help. At MER, physical examination revealed acute on chronic ill-looking, the CXR showed Mild bunting of costophrenic angle, both sides, Cardiomegaly. Abd CT was performed and revealed Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver, R/O cholangiocarcinoma, suggest further study. Lab data revealed elevated CRP 9.90mg/dL. Under the impression of Left lobe liver tumor R/O cholangiocarcinoma. She was admitted to our ward for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, adquat IV fluid support, IV Lasix empirical antibtioic were both given. We Well informed current condition of liver tumor R/O cholangiocarcinoma to herself and her son and suggested tissue proof later. They understand and wait for their answer. Nephrologist was consulted for hyponatremia. WE Checked HBsAg, anti-HCV, AFP, CEA, Ca19-9, ALP and rGT st and arrange abdomen echo. However, her SARS-CoV-2 RT-PCR reported Positive today and after we contact our infection control unit, suggested COVID-19 ward for isolation and for further management.
    • After isolation ward, keep current treatment and antibiotic with Brosym 4gm ivd (20220526~20220601) was perscribed. Diuretics with lasix was given for lower limbs edema. Intravenous infusion with 3% NaCL was given for one day for hyponatremia, then shift 0.9% NaCL 500ml/day. Follow-UP lab, revealed hypokalemia, Radi-K po was given (20220530 - 20220604). Due to COVID-19 CT value > 30, she was transfer to GI ward for further management. After transferring to ordinary ward, we kept the medical treatment. WE SUGGESTED LIVER BIOPSY AND DUPLEX STUDY FOR HER LEFT LEG EDEMA. FAMILY WISH EARLY DISCHARGE. Under stable condition, she was discharged on 2022/06/04 and GI OPD follow-up was arranged later.
  • Discharge prescription
    • Through (sennoside 12mg) 2# HS
    • Uretropic (furosemide 40mg) 0.5# QD
    • Alpraline (alprazolam 0.5mg) 1# HS
• 2017-07-18 SOAP Ophthalmology
  • Diagnosis
    • Tear film insufficiency, unspecified [H04.123]
    • Lens replaced by other means [Z96.1]
    • Exotropia, unspecified [H50.10]
  • Prescription x3
    • Vidisic Gel (carbomer) QID OU
    • tetracycline BID OD
    • Sinomin (sulfamethoxazole) QID OU
• 2017-03-09 SOAP Neurology
  • Diagnosis
    • Chronic ischemic heart disease, unspecified [I25.9]
    • Cerebral atherosclerosis [I67.2]
    • Arteriosclerotic dementia, uncomplicated [F01.50]
    • Displacement of lumbar intervertebral disc without myelopathy [M51.27]
  • Prescription x3
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Syntam (piracetam 1200mg) 1# BID
    • Schnin (ginkgo biloba 9.6mg) 1# BID
    • Rivotril (clonazepam 0.5mg) 1# HS

[consultation]

• 2022-05-26 Nephrology
  • Q
    • This 84 y/o female with history of 1) HTN 2) Chronic ischemic heart disease, just discharge from our Hospital, due to COVID-19 test(+). This time, she was suffered from low back pain and pitting edema for few days, the s/s was progressive. She was sent to our ER for help. At MER, physical examination revealed acute on chronic ill-looking, the CXR showed Mild bunting of costophrenic angle, both sides, Cardiomegaly. Abd CT was performed and revealed Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver. R/O cholangiocarcinoma, suggest further study. Lab data revealed elevated CRP 9.90mg/dL. Under the impression of Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver, R/O cholangiocarcinoma. She was admitted to our ward for further evaluation and treatment.
    • we need your expertis for hyponatremia
  • A
    • Consult for hyponatremia
    • Lab data :
      • WBC: 10.83, Hb: 14.8,Plt: 155
      • Na: 131(5/17) -> 123, K: 3.3, CRP: 9.9, NTproBNP: 446
      • BUN: 19, cre: 0.57
      • Lipase: 45, T bil: 0.79, albumin: 3.6, gucose: 108
      • HBV (-), HCV (-), ALKP: 75 ,r GT: 68
      • AFP: 4.0, CEA: 3.3, CA199: 53.04
      • U/A: light yellow, clear, SG: 1.008, PH: 7.0, Nit: -, glu: -, pro: -, OB: -, RBC: 3-5, WBC: 0-5, Cast: 0, bacteria :-
      • CXR: cardiomegaly and bilateral costophrenic angle bunting and slight pulmonaty congestion
      • KUB: L2-L4 compression fracture
      • CT abdomen: Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver. R/O cholangiocarcinoma
      • PE: EDEMA 2-3+
      • Current medication : lasix 20mg IV QD
    • Impression:
      • Hyponatremia cause to be determined
    • Suggestion :
      • Check plasma osmolality, urine osmolarity, Ur Na, Ur K, Ur cre, Ur Cl, Fe uric acid
      • Check lipid profile, total protein
      • Check thyroid function and ACTH, cortisol
      • Please arrange cardiac echo to rule out heart failure
      • Follow up Na, K,
      • Thank you very much for your consultation.

[chemotherapy]

• 2024-04-12 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-03-29 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-03-08 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-02-02 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-01-12 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-12-29 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-12-14 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-12-01 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-11-17 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-11-03 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-10-20 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-10-06 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-09-22 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-09-12 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-08-29 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-08-22 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-08-04 - gemcitabline 1000mg/m2 1600mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2024-06-11

[evaluating potential causes of hyponatremia]

Hyponatremia has been noted for several days. There is no report linking gemcitabine to hyponatremia. Currently, 3% NaCl is being administered.

• 2024-06-11 Na (Sodium) 127 mmol/L
• 2024-06-10 Na (Sodium) 123 mmol/L
• 2024-06-09 Na (Sodium) 120 mmol/L
• 2024-06-08 Na (Sodium) 112 mmol/L
• 2024-06-08 Na (Sodium) 117 mmol/L
• 2024-06-07 Na (Sodium) 114 mmol/L
• 2024-06-04 Na (Sodium) 113 mmol/L

No evidence of hyperglycemia is present (random glucose on 2024-06-08 was 92 mg/dL), making hyperglycemia-induced hyponatremia unlikely.

No evidence of jaundice (2024-06-11), hyperlipidemia (2024-03-08), or hyperproteinemia (2024-06-07) is present, making pseudohyponatremia unlikely.

No thiazide diuretics are in use, and eGFR is not impaired (2024-06-11). Hypotonic hyponatremia with edema and/or ascites might be suspected (2024-06-04 CXR showed bilateral pleural effusions, 2024-05-21 CT showed small ascites). Recent urine osmolality data is not available; it might be beneficial to check for low effective arterial blood volume.

• 2024-06-11 eGFR 106.89 ml/min/1.73m^2
  
• 2024-06-11 Bilirubin total 0.59 mg/dL
  
• 2024-06-07 Total protein 6.1 g/dL
  
• 2024-03-08 Triglyceride (TG) 87 mg/dL
  
• 2024-03-08 Cholesterol total 163 mg/dL
  
• 2024-03-08 LDL-C 107 mg/dL

2023-07-26

[medication reconciliation]

This patient just refilled Betmiga (mirabegron) on 2023-07-10 for her urinary incontinence for a 28-day valid duration at Far Eastern Hospital, this drug is not included in the active medication list, please confirm if this drug is not necessary for the patient’s current condition.

[poor medication compliance, non-adherence to medication regimen]

The 2023-07-26 progress note states, “The patient requested to self-administer her medications, adjusting them based on her daily condition. She expressed concern about receiving medications from nurses. The nurse practitioner educated her about the safety of medication administration by the nursing team, but the patient was unable to accept it. As a result, the patient’s outpatient medication was discontinued”.

On 2023-07-26, I visited the patient and her caregiver at approximately 11:00 am to address the concerns raised in the progress note regarding the patient’s medication compliance.

The patient said she is a member of TzuChi and was diagnosed with suspected cholangiocarcinoma in 2022-05 and subsequently treated at ShinKong Hospital. During the visit, I found that the patient tends to be selective in taking prescribed medications, believing that certain medications are more effective and should be taken more, while she perceives little efficacy from other prescribed medications. In addition, the patient mentioned that she does not always take her prescribed painkiller.

I have tried to help the patient understand the importance of adhering to the prescribed medication regimen. However, it appears that the patient still holds strong personal beliefs regarding medication, which may lead to inaccurate assessments of treatment effectiveness.

Regarding the issue of low sodium levels, I advised the patient to increase her salt intake, the patient attributed this to the caregiver’s cooking, as she felt that the meals were not seasoned enough. However, upon further discussion with the nurses, the caregiver mentioned that she already added an adequate amount of salt to the meals.

701518334

240611

[exam findings]

• 2024-05-19, -05-07, -04-26, -04-24 CXR erect

  • There are multiple nodular and linear infiltrations on both lungs.

• 2024-04-30 SONO - abdomen

  • CBD and bilateral IHD dilatation
  • Pancreatic cystic lesion

• 2024-04-25 PD-L1 (28.8)

  • Cellblock No. S2024-06846
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS < 1
    • Combined Positive Score (CPS): 0

• 2024-04-19 Surgical pathology Level IV

  • Intestine, small, duodenum, 2nd portion, biopsy — chronic duodenitis
  • The specimen submitted consists of 6 tissue fragments measuring up to 0.2x0.2x0.2 cm in size, fixed in formalin. Grossly, they are brownish and elastic.
  • It shows chronic duodenitis with lymphocytic infiltrate.
    
  • Immunohistochemical stain reveals CD20(+), CD3(+), CD43(+) and CK(-).

• 2024-04-19 Patho - stomach biopsy

  • Stomach, prepyloric antrum, AW, biopsy — ulcer with Helicobacter infection
  • Microscopically, it shows ulcer with necrotic debris, granulation tissue,and leukocytic infiltrate. Helicobacter-like bacilli are seen.

• 2024-04-19 EGD

  • Reflux esophagitis LA Classification grade C
  • Superficial gastritis
  • Gastric mass-like leison with central ulcer, supsect malignant, prepyloric antrum, AW, s/p biopsy(A)
  • Deformity of antrum
  • Duodenal mucosal lesion, suspect reative change, 2nd portion, s/p biopsy(B)
  • suboptimal study due to much food residue

• 2024-04-17 PET

  • Glucose hypermetabolic lesions in pleurae/parenchyma of the right upper and lower lungs, compatible with the secondary lung cancer.
    
  • Increased FDG uptake in pleurae/parenchyma of the left upper and lower lungs, probably inflammation/infection process or metastatic lung cancer.
    
  • Increased FDG uptake in bilateral mediastinal spaces and in two gastrohepatic lymph nodes, the nature is to be determined (reactive or metastatic nodes ?), suggesting further investigation.
  • Increased FDG uptake in the pelvic region, the nature is to be determined also, suggesting colon fibroscopy for further investigation.

• 2024-04-16 Upper GI series

  • UGI series with water soluble contrast medium revealed:
    • Passage of contrast medium passage from oral cavity through esophagus to stomach smoothly without obstruction.
    • Distended stomach with much contrast medium retension.
    • Poor expansion of gastric pylorus.
  • Impression
    • c/w gastric pylorus lesion with partial obstruction

• 2024-04-10 T-tube cholangiography

  • Cholangiography via PTCCD catheter administration revealed:
    • S/P operation.
    • Patency of the catheter and CBD.
    • Tiny filling defects in distal CBD.

• 2024-04-08 Patho - pleural/pericardial biopsy

  • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated, origin ?
  • Specimen submitted in formalin consists of 3 strips of tan, irregular tissue measuring up to 1.2 x 0.1 x 0.1 cm. All for section in one cassette.
  • Sections show mucinous glandular cells infiltrating in a fibrotic stroma and proliferating along the alveolar wall. Lymphovascular invasion is seen.
  • The immunohistochemical stains reveal CK7(+), CK20(focal +), CDX2(focal +), TTF-1(-), and Napsin A(-). Please correlate with the clinical presentation and image study for tumor origin, such as GI tract and others.

• 2024-04-03 CT - chest

  • Multiple nodules in bil. lungs r/o metastases. high resolution lung CT
  • the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images and axial slab MIP images shows:
    • lungs: multiple ill-defined patchy and nodular consolidations (a few with central cavitation) and reticular opacities in peripheral of both lungs,upper and mid lung zones predominance
      • posterior linear band subsegmental atelectasis at both lower lobes too.
    • mild coronary arterial calcification
    • Thoracic aorta: normal caliber, mild atherosclerotic change.
    • heart: normal size of cardiac chambers. conventric LVH?
      • mild calcified aortic valves.
    • collapse of the gall bladder s/p PTGBD. s/p a drain at RUQ of abdomen.
    • gastric wall thickening at antral involving thr pylorus.
    • Mild dilatation of p-duct
    • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • favor infection r/o septic embolic d/d eosinophilic pneumonia and organzing pneumonia, metastatic lesions less likely.

• 2024-04-02 MRI - pancreas

  • History and indication: obstructive jaundice
  • With and without contrast MRI of pancreas revealed:
    • Wall thickening of gastric antrum and pylorus with adjacent fat, pancreas and CBD invasion. Some LNs at gastrohepatic ligament. Mild wall thickening of gastric fundus.
    • Multiple nodules in bil. lungs.
    • Increased soft tissues in peritoneal cavity.
    • S/P PTGBD.
    • Mild dilatation of p-duct (4.5mm).
  • IMP:
    • Wall thickening of gastric antrum and pylorus with adjacent fat, pancreas and CBD invasion r/o malignancy. Some LNs at gastrohepatic ligament. Mild wall thickening of gastric fundus.
    • Multiple nodules in bil. lungs r/o metastases.
    • Increased soft tissues in peritoneal cavity r/o tumor seeding.

• 2024-04-02 Percutaneous gall bladder drainage, PTGBD

• 2024-03-28 Patho - stomach biopsy

  • Stomach, antrum, laparoscopic biopsy — Chronic gastritis, H pylori NOT present
  • Specimen submitted in formalin consists of 1 piece(s) of tan, irregular tissue measuring 1.5 x 0.6 x 0.5 cm. All for section in one cassette.
  • Section shows benign gastric mucosal tissue with chronic inflammation. H. pylori NOT present.

• 2024-03-23 CT - abdomen

  • Clinical history: 64 y/o male patient with BW loss, Abdominal fullness.
  • With and without contrast enhancement CT of abdomen - whole:
    • Thickneng wall at posterior gastric pylorus with gastric distention. Malignancy? may further study.
    • Mild dilatation of bilateral IHDs and P-duct.
    • Multifocal grouna glass and tree-in bud infiltrates in bilateral lungs, r/o inflammation, suggest clinical correlation.

• 2024-03-22 Upper GI & Small Intestine

  • Double contrast upper GI series shows
    • Delayed passage of the water soluble contrast medium into doudenum is found.
    • The peristasis of the stomach and doudenum is decresaed.
    • Some air pockets are found outside the doudenum. (Se3 Im25)
  • Imp:
    • r/o doudenal ulcer with perforation.

• 2024-03-22 SONO - abdomen

  • Suspicious pancreatic cyst, body
  • Prominent P-duct
  • Cholecystopathy
  • Distended stomach with fluid retention

• 2024-03-15 Miniprobe Endoscopic Ultrasound

  • Indication: Subepithelial lesion
  • Symptoms: abdomen pain
  • Pre-EUS diagnosis: r/o malignancy
  • Endoscopic findings：
    • Minimal mucosa break was noted at EC junction.
    • Erythematous change of gastric mucosa was noted.
    • Some shallow ulcers were noted at antrum.
    • Stenosis was noted at pylorus, and endoscope was unable to pass through.
    • Biopsy was performed around the pylorus.
    • Much food residues were noted at stomach.
  • Suggestion:
    • Further image study for suspect malignancy
    • Consider to arrange repeat biopsy by endoscope or surgical intervention, if negative finding in pathology

[MedRec]

• 2024-03-21 ~ 2024-04-30 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • suspect gastric adenocarcinoma cancer with lung metastasis, stage IV, status post laparoscopic biopsy for stomach on 2024-03-28, status post Nivolumab (self-paid)/ FOLFOX.
    • Secondary malignant neoplasm of lung, adenocarcinoma of unknown primary, stage IV, status post Nivolumab (self-paid)/ FOLFOX.
    • Gastric pylorus stenosis
    • Obstructive jaundice status post Percutaneous transhepagtic drainage of gallbladder on 2024/04/02
    • Abnormal weight loss
    • Type 2 diabetes mellitus without complications
    • Chronic viral hepatitis B without delta-agent
    • port-a catheter insertion at left cephalic vein on 2024/04/18
    • constipation
    • insomnia
    • Hyperbilirubinemia
  • CC
    • abdominal fullness, intermittent vomiting since one year ago
  • Present illness
    • This is a 64 year-old male patient has the histories of DM.
    • He suffered from abdominal fullness, intermittent vomiting since one year ago. Poor appetite and Body weight loss 19kg in one year. He visited MiaoLi WeiGong Hospital, TouFen ChongGuang Hospital, DaQian Hospital, LinKou ChangGang Hospital, CMU Hospital for help. Where Chronic gastritis and Linitis Plastica (Brinton’s disease, leather bottle stomach）was impressed. But the symptoms did not improved. So he visited our GI OPD for help.
    • Tumor makers was checked and showed Ca-199 94.99 U/mL. EUS was arranged on 3/15 and showed 1) Suboptimal study, due to much food residues; 2) Stenosis at pylorus, r/o malignancy, s/p biopsy; 3) Reflux esophagitis LA grade A-; 4) Superficial gastritis.
    • Biopsy pathology showed Chronic gastritis with intestinal metaplasia, H pylori NOT present. He denied headache or dizziness, no sorethroat or rhinorrhea,no cough or dyspnea, no chest tightness or pain, no myalgia or arthralgia. No TOCC history was noted.
    • Under the impression of 1) Pylorus stenosis, R/O Malignancy, he was admitted to our ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, adequate IV fluid supplement was administered. Upper GI, Small Intestine series was arranged on 3/22, showed r/o doudenal ulcer with perforation.
    • Abdominal sonography was performed on 3/22, revealed 1) Suspicious pancreatic cyst, body 2) Prominent P-duct 3) Cholecystopathy 4)Distended stomach with fluid retention.
    • Abdominal CT was arranged on 3/23, revealed 1. Thickneng wall at posterior gastric pylorus with gastric distention. Malignancy? may further study. 2. Mild dilatation of bilateral IHDs and P-duct. 3. Multifocal grouna glass and tree-in bud infiltrates in bilateral lungs, r/o inflammation, suggest clinical correlation. GS was consulted and will be arrange laparoscopic biopsy on 3/28.
    • PPN supply was prescribed for neutrition support. Pain control with analgesic agent was administered. the Stomach, antrum, laparoscopic biopsy reported Chronic gastritis, H pylori NOT present.
    • We keep J-VAC drainage and arrange MRCP for further survay of pancreas which reported Wall thickening of gastric antrum and pylorus with adjacent fat, pancreas and CBD invasion r/o malignancy. Some LNs at gastrohepatic ligament. Mild wall thickening of gastric fundus.Multiple nodules in bil. lungs r/o metastases.Increased soft tissues in peritoneal cavity r/o tumor seeding.
    • PTGBD drainage was arranged for obstructive jaundice. High resolution lung CT was ashceduled for Multiple nodules in bil. lungs r/o metastases and reported as favor infection r/o septic embolic D/D eosinophilic pneumonia and organzing pneumonia, metastatic lesions less likely.
    • Lung biopsy was performed and pathology reported adenocarcinoma, moderately differentiated, origin ? The immunohistochemical stains reveal CK7(+), CK20(focal +), CDX2(focal +), TTF-1(-), and Napsin A(-). Please correlate with the clinical presentation and image study for tumor origin, such as GI tract and others.
    • Consulted Hematolopgist for further advise and Systemic therapy with chemotherapy and immunotherapy is indicated for metastais gastric ca, After Oncologist discussed treatment plan with the patient, patient decided to have chemotheraphy.
    • port-A implantation on 4/18. Second EGD was scheduled for tissure proof and pathology showed chronic duodenitis on 2024/04/19.
    • He received chemotherapy with #1 Nivolumab (400mg/m2, self-paid) plus C1D1 FOLFOX on 2024/04/22-04/24, Bao-gan for poor liver function, Baraclude for Anti-HBc: reactive.
    • After chemotherapy, the lab of BCS showed poor liver function, and hyperbilirubinemia, so gave Uliden for hyperbilirubinemia, and keep Bao-gan, Baraclude treatment.
    • Abdomen echo was done on 2024/04/30, the report showed CBD and bilateral IHD dilatation. Pancreatic cystic lesion.
    • After the symptom of poor liver function, hyperbilirubinemia improved. He can be discharged on 2024/04/30, the OPD follow-up will be arranged.
  • Discharge prescription
    • Emend (aprepitant 125mg) 1# QD
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 90mg, lysozyme 20mg) 1# HS
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 90mg, lysozyme 20mg) 1# BID
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
    • Uliden (ursodeoxycholic acid 100mg) 1# BID
    • BaoGan (silymarin 150mg) 1# TID
    • Cough Mixture (platycodon) 10mL QID
    • Through (sennoside 12mg) 2# HS
    • Ulstop (famotidine 20mg) 1# HS
    • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC
    • Bisadyl supp (bisacodyl 10mg/pill) 2# PRNQD RECT
• 2024-03-13 SOAP Gastroenterology Zhao YouCheng
  • S
    • He has suffered postprandial discomfort, nausea, anorexia and vomiting (billous vomitus) since 2 months ago. Loss 8 Kgs in the past 1 month.
    • Small gastric ulcer over angle and enlarged intraabdominal L.Ns were told at a LMC. Ca 19-9 was also high.
    • Past history: D.M. for 1 year.
  • O
    • 20240313: BP:104/64; HR:78 次/分; BH:160 cm; BW:48 kg; BMI:18.8
    • P.E.: Chronic ill-looking. No icteric sclera, soft abdomen, no leg pitting edema.

[consultation]

[surgical operation]

• 2024-03-28
  • Surgery
    • laparoscopic biopsy for stomach
  • Finding
    • no ascites
    • no peritoneal seeding tumor
    • severe adhesion over peritoneum and omentum, suspect previous appendectomy related
    • no sginficant serosa invasion lesion at antrum
    • but wall thickening and easy bleeding over antrum

[immunochemotherapy]

• 2024-06-11 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 115mg D5W 120mg 2hr + leucovorin 400mg/m2 540mg NS 500mL 2hr + fluorouracil 2800mg/m2 3830mg NS 500mL 46hr (Opdivo + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-05-22 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 115mg D5W 120mg 2hr + leucovorin 400mg/m2 560mg NS 500mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (Opdivo + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-04-22 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 120mg 2hr + leucovorin 400mg/m2 570mg NS 500mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Opdivo + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-06-11

[potential need for intensive nutrition in cachexia]

The patient’s weight has decreased by 16% within one month (from 48.9 kg on 2024-05-07 to 41.1 kg on 2024-06-11), indicating evident cachexia. Currently, Megest (megestrol) is being administered. If the weight loss continues, more intensive nutritional intervention might be necessary.

CA-199 has shown a slight increase over the past month, while bilirubin levels have remained stable under BaoGan (silymarin) and Uliden (ursodeoxycholic acid). No medication discrepancies have been identified.

• 2024-06-07 CA-199 (NM) 143.470 U/ml
• 2024-05-10 CA-199 (NM) 128.115 U/ml

2024-05-20

[first dose of nivolumab and FOLFOX administered, tumor markers increasing despite treatment; hyperbilirubinemia managed with ursodeoxycholic acid]

Possible GI-originated adenocarcinoma biopsied from the lung was pathologically proven, and PD-L1 (28.8) showed CPS < 1. The first dose of nivolumab plus FOLFOX was administered on 2024-04-22. The readings of tumor markers CEA and CA199 have continued to increase until early-mid May.

• 2024-05-10 CA-199 (NM) 128.115 U/ml
  

• 2024-03-14 CA199 94.990 U/mL

• 2024-05-10 CEA (NM) 3.451 ng/ml
  

• 2024-03-14 CEA 2.850 ng/mL

The hyperbilirubinemia was primarily due to elevated conjugated bilirubin. Currently, Uliden (ursodeoxycholic acid) is in use, and the direct bilirubin readings appear to be decreasing.

• 2024-05-19 Bilirubin direct 0.55 mg/dL
  
• 2024-04-29 Bilirubin direct 0.71 mg/dL
  
• 2024-04-26 Bilirubin direct 2.10 mg/dL

No medication discrepancies were found after reviewing PharmaCloud and HIS5.

700183379

240607

[exam findings]

• 2024-05-07 CT - chest
  • Visible abdominal contents:
    • intermediate density fluid collection in right perihepatic space and lesser sac, and diffuse soft tissue nodules in the omentum.
    • a tiny Rt renal stone 2mm and small Lt kidney with lobulated contour and several tiny stones.
  • Impression:
    • no abnormality in both lungs and mediastinum.
    • pseudomyxoma peritonei.
• 2024-04-25 Patho - omentum biopsy
  • Soft tissue, omentum, laparoscopic excision — Pseudomyxoma peritonei / mucinous carcinoma peritonei, low grade
    • NOTE: Please check “appendix” or colon for primary tumor origin first. However, the ovary for tumor origin also cannot completely excluded. Corelation with imagining study and clinical findings is recommended.
  • Microscopically, it shows low grade mucinous carcinoma peritonei composed of foci of low-grade mucinous tumor nests with abundant mucinous pools.
  • Immunohistochemical stain — PAX-8(-), ER(-), CDX-2(+), CK20(+), CK7(+)
• 2024-04-25 Patho - peritoneum biopsy
  • Peritoneum, laparoscopic excision — Pseudomyxoma peritonei / mucinous carcinoma peritonei, low grade
    • NOTE: Please check “appendix” or colon for primary tumor origin first. However, the ovary for tumor origin also cannot completely excluded. Corelation with imagining study and clinical findings is recommended.
  • Microscopically, it shows low grade mucinous carcinoma composed of foci of low-grade mucinous tumor nests with abundant mucinous pools.
• 2024-03-27 CT - abdomen
  • Findings:
    • There is loculated fluid (or mucin) collection in right subphrenic space, right perihepatic space, and lesser sac, and multiple soft tissue nodules in the omentum.
      • Carcinomatosis is highly suspected.
      • The differential diagnosis includes pseudomyxoma peritonei.
      • Please correlate with ascites cytology.
    • There are loculated fluid-like lesion in bilateral adnexa.
      • Ovarian cancer is highly suspected.
      • The differential diagnosis includes cystic tumor seeding.
    • There is a tubular-like cystic lesion in the cecal base (Srs:7 Img:61), 9 mm in diameter.
      • Mucocele or mucinous adenocarcinoma of the appendix is suspected.
      • The differential diagnosis includes normal variation.
    • Left kidney shows multi-focal parenchyma atrophy that is c/w old inflammatory process. Few small stones in bilateral kidney are noted.
  • Impression:
    • Carcinomatosis is highly suspected.
      • The differential diagnosis includes pseudomyxoma peritonei.
      • Please correlate with ascites cytology.
        
    • Ovarian cancer is highly suspected.
      • The differential diagnosis includes cystic tumor seeding.
    • Mucocele or mucinous adenocarcinoma of the appendix is suspected.
      • The differential diagnosis includes normal variation.

[MedRec]

• 2024-05-23 ~ 2024-05-27 POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • Pseudomyxoma peritonei mucinous carcinoma peritonei, low grade, cTxNxM1, stage IV
    • Secondary malignant neoplasm of retroperitoneum and peritoneum
    • Barrett’s esophagus without dysplasia
    • Chronic viral hepatitis B without delta-agent, Anti-HBc reactive
  • CC
    • for neoadjuvant chemotherapy with a modified FOLFOX6 regimen.
  • Present illness
    • This is a 62-year-old female with underlying disease of Barrett’s esophagus under medicine treatment, has been diagnosed with Pseudomyxoma Peritonei (PMP)/mucinous carcinoma peritonei, low grade, cTxNxM1, stage IV in 2024/04/25.
    • Pathology was Peritoneum, laparoscopic excision — Pseudomyxoma peritonei / mucinous carcinoma peritonei, low grade; Soft tissue, omentum, laparoscopic excision — Pseudomyxoma peritonei / mucinous carcinoma peritonei, low grade.
    • Under the impression of Pseudomyxoma Peritonei (PMP)/mucinous carcinoma peritonei, low grade, cTxNxM1, stage IV, and is deemed unresectable.
    • Due to her being unfit for CRS + HIPEC, she has been referred to our oncology ward for neoadjuvant chemotherapy with a modified FOLFOX6 regimen.
  • Course of inpatient treatment
    • After admission, she receive chemotheraoy with modified FOLFOX6 (Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2, 1st all 80%) on 2024/05/24 ~ 2024/05/26 (C1D1) smoothly.
    • Acetal 500 mg/tab 1# PO HS and Acetal 500 mg/tab 1# PO PRNQID for pain control.
    • Barrett’s esophagus without dysplasia was treated with Dexilant 60mg/cap 1# PO QD.
    • ROMICON-A 20,90,20mg/cap 1# PO TID for chronic cough.
    • Domperidone 10mg/tab 1# PO TIDAC.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO HS was given for Anti-HBc (+).
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/05/27 and OPD followed up later.
  • Discharge prescription
    • Allegra (fexofenadine 60mg) 1# BID
    • Baraclude (entecavir 0.5mg) 1# HS
    • Acetal (acetaminophen 500mg) 1# PRNQID if VAS > 3
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
• 2024-04-24 ~ 2024-04-29 POMR General and Gastrointestinal Surgery Chen YanZhi
  • Discharge diagnosis
    • Elevated carcinoembryonic antigen (CEA)
    • Barrett’s esophagus without dysplasia
    • Other ascites
  • CC
    • Elevated CA199 and CEA with ascites since 2024/01
  • Present illness
    • This is a 62 years old female with underlying disease of barret esophgus under medicine treatment. This time she was suffered from elevated CA199 and CEA with ascites since 2024/01.
    • According to patient herself and previous medicine record, she was accidently found ascites in CT on 2024/01/08. Therfore she was transferred to GI OPD. At OPD, elevated CA199 and CEA was noted.
    • EGD showed Barrett (Bx proved, no dysplasia) on 2024/02/05. She suffered from bilateral waist pain and lower abdominal pain somtimes. She denied bowel habit change, tarry stool.
    • GYN was consult and arrange echo which shoed left ovarian cyst but may not cause ascies. Due to unknown caused ascites and elevated CEA, CA199, she was referred to GS OPD for help.
    • After discuss with patient, she decided to underwent laparoscopic examination.
    • Under the impression of unknown caused ascites and elevated CEA, CA199, she was admitted for laparoscopic examination on 2024/04/25 and pre operation assessment.
  • Course of inpatient treatment
    • After admission, she was under pre opeation assessment, She underwent laparoscopic examination on 04/25 which found mucin-like ascites with diffuse seeding tumor over omentum and peritoneum and distended appendix, severe adhesion with cecum, favor primary site of malignancy. Pathology was pending.
    • There were no specific complain after surgery. Due to stable clinical condition, she was discharged on 04/29 and arrange OPD follow up for pathology and next step treatment.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

• 2024-04-25 - Op Method:
  • laparoscopic excision of intraabdominal tumor, malignancy
  • Finding:
    • mucin-like ascites (+)
    • diffuse seeding tumor over omentum and peritoneum
    • PCI: 23/39
    • RUQ: 3/3
    • epigastric: 3/3
    • LUQ: 3/3
    • right flan: 1/3
    • central: 1/3
    • left flank:1/3
    • RLQ: 3/3
    • lower abdomen: 3/3
    • LLQ: 3/3
    • proximal jejunum: 0/3
    • distal jejunum: 0/3
    • proximal ileum: 1/3
    • terminal ileum: 1/3
    • normal ovary
    • distended appendix, severe adhesion with cecum, favor primary site of malignancy

[chemotherapy]

• 2024-06-06 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg D5W 250mL 2hr + fluorouracil 400mg/m2 580mg D5W 250mL 10min + fluorouracil 2400mg/m2 3500mg D5W 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-24 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg D5W 250mL 2hr + fluorouracil 400mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 3100mg D5W 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-06-07

[normal lab results clear for FOLFOX regimen administration]

Lab results on 2024-06-03 showed no significant abnormalities.

These normal results allow for the planned FOLFOX regimen to proceed without contraindication.

Additionally, no discrepancies were found in the patient’s medication list.

700901494

240607

[exam findings]

• 2024-05-30 SONO - abdomen
  • Diagnosis:
    • Fatty liver, mild
    • Suspected fatty infiltration of pancreas
  • Suggestion:
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2024-05-06 CT - chest
  • comparison: prior CT on 2023/11/29
    • Lungs: interval decrease size and number as well as decreased solid portion of pulmonary nodules in both lungs.
    • enlarged thyroid gland with nodular calcifications that extends to superior mediastinum, paratracheal spaces, suggesting of intrathoracic thyroid goiter.
      • normal caliber of the thoracic aorta and pulmonary arteries
    • Heart: normal size of cardiac chambers. dilated LA, RA, LV.
  • Impression:
    • Endometrioid adenocarcinoma with lung metastasis in regression as compared with CT on 2023/11/29
• 2024-04-25 Standing KUB
  • Compression fracture of L2-3.
• 2024-01-25 CXR
  • Multiple nodules at bil. lungs.
• 2023-12-14 ENT Hearing Test
  • Tymp:
    • Bil type As.
  • ART:
    • RE ipsi 4k Hz absent, contra absent.
    • LE absent.
  • PTA:
    • Reliability FAIR
    • Average RE 28 dB HL; LE 21 dB HL.
    • RE normal to moderate SNHL.
    • LE normal to mild SNHL.
• 2023-12-11 Patho - lung transbronchial biopsy
  • Lung, right, CT-guide biopsy — consistent with metastatic endometrioid carcinoma
  • Sections show solid nests and glandular tumor cells infiltrating in a fibrotic stroma with focal tumor necrosis.
  • The immunohistochemical stains reveal CK7(+), CK20(-), PAX8(+), TTF-1(-), and Napsin A(-). The results are supportive for the diagnosis.
• 2023-12-11 CXR
  • Increase bilateral lung markings.
  • Mild cardiomegaly.
  • Intimal calcification of thoracic aorta.
  • Thoracic spondylosis.
• 2023-11-29 CT - chest
  • chest without contrast enhancement, coronal and sagittal reconstructed images shows:
    • Lungs: multiple randomly distributed pulmonary nodules of varying sizes measuring up to 9mm at RML.
      • enlarged thyroid gland with nodular calcifications that extends to superior mediastinum, paratracheal spaces, suggesting of thyroid goiter.
  • Impression:
    • Endometrioid adenocarcinoma S/P hysterectomy with lung metastasis.
• 2023-11-20 CT - abdomen
  • History and indication: Malignant neoplasm of endometrium
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy.
    • Nodules (up to 1.2cm) in bil. visible lungs.
    • Colonic diverticula.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • S/P hysterectomy.
    • Nodules (up to 1.2cm) in bil. visible lungs r/o metastases.
    • Colonic diverticula.
• 2023-11-13 SONO - abdomen
  • Diagnosis
    • Fatty liver, mild
    • Fatty infiltration of pancreas
  • Suggestion:
    • Hepatic lesion may be masked by fatty liver background
• 2023-09-13 SONO - vein
  • Conclusion:
    • No evidence of DVT, bilateral lower legs
    • Right LSV trivial reflux, involved right sphenofemoral junction(SFJ); proximal GSV 0.57 cm
    • Right CFV trivial reflux
    • Left LSV trivial reflux, involved left sphenofemoral junction(SFJ); proximal GSV 0.50 cm
    • Left CFV trivial reflux
    • Left leg MVO/SVC related low
  • Suggestion:
    • elastic sock using; if in vain, consider venography.
• 2023-07-31 CT - brain
  • Imp: Brain atrophy.
• 2023-07-28 CT - brain
  • Impression: No definite intracranial abnormality.
• 2023-03-02 Exercise ECG Bruce
  • Probably negative for myocardial ischemia (Upsloping ST change)
• 2022-10-26 EGD
  • Diagnosis:
    • Reflux esophagitis, LA A (minimal)
    • Superficial gastritis, antrum, s/p CLO test
    • Duodenitis, bulb
  • CLO test: Negative
  • Suggestion:
    • Please pursue CLO test
• 2022-07-27 Patho - uterus with or without SO non-neoplastic/prolapse
  • PATHOLOGIC DIAGNOSIS
    • Uterus, endometrium, total hysterectomy — endometrioid adenocarcinoma, grade 2.
    • Uterus, myometrium, total hysterectomy — endometrioid adenocarcinoma invading > ½ thickness of the myometrium; leimyoma.
    • Uterus, cervix, total hysterectomy — free
    • Ovaries and fallopian tubes, bilateral, BSO — free
      
    • Lymph node, bilateral pelvic, dissection — free
      
    • pT1b pN0 (if cM0); AJCC 8th edition/FIGO Pathology stage: IB, at lest.
      • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.” … “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, medical department and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: Laparoscopic gynecologic oncology staging surgery 
      
    • Specimens include: 01 left ilac lymph nodes; 02: left obturator lymph nodes; 03: right iliac lymph nodes; 04: right obturator lymph nodes; 05: uterus and bilateral adnexae.
    • Specimen size:
      • uterus: 180 gms; 12 x 8 x 5 cm,
        
      • right ovary: 2.4 x 1.2 x 0.5 cm;
        
      • left ovary: 2.4 x 1.2 x 0.5 cm;
        
      • right tube: 4 x 0.5 x 0.5 cm;
        
      • left tube: 4 x 0.5 x 0.5 cm;
        
    • Tumor site: The endometrium is diffusely thickened or diffusely involved by tumor.
      
    • Tumor size: 4.3 x 3.5 cm
      
    • The myometrium : invaded by tumor; ＞ ½ thickness of the myometrium and 0.8 cm from serosal surface.
    • The cervix : free of tumor: tumor is 4.3 cm from distal margin.
    • Adnexa: unremarkable
    • Lymph node: 01 left ilac lymph odes; 02: left obturator lymph nodes; 03: right iliac lymph nodes; 04: right obturator lymph nodes.
      • Tissue for sections: A1-2: left ilac lymph nodes; B: left obturator lymph nodes; C1-2: right iliac lymph nodes; D: right obturator lymph nodes; E1-2: left adnexa; E3-4: right adnexa; E5: cervix; E6: endometrium and endocervix; E7-12: endometrial cancer
  • MICROSCOPIC EXAMINATION
    • Histology type: Endometrioid carcinoma, NOS
    • Histology grade: FIGO grade 2
    • Depth of invasion: invade ＞1/2 thickness of the myometrial wall
      
    • Uterine Serosa Involvement- Not identified
    • Cervical Stromal Involvement- Not identified
    • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Bilateral ovary: free
      • Bilateral fallopian tube: free
    • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
      • Ectocervical/Vaginal Cuff Margin: Free
      • Parametrial/Paracervical Margin: Free
    • Lymphovascular Invasion: Absent
    • Regional Lymph Nodes: free
      • No lymph nodes submitted or found
      • Right Pelvic Node: 0/ 14= C1-2: right iliac lymph nodes 0/11; D: right obturator lymph nodes 0/3
        • Number of Right Pelvic Nodes with Macrometastasis (greater than 2 mm): 0
        • Number of Right Pelvic Nodes with Micrometastasis (greater than 0.2 mm and up to 2 mm):0
        • Number of Right Pelvic Nodes with Isolated Tumor Cells (0.2 mm or less) (if applicable)**:0
        • Total Number of Right Pelvic Nodes Examined: 14
      • Left Pelvic Node: 0/16= A1-2: left ilac lymph nodes 0/11; B: left obturator lymph nodes 0/5
        • Number of Left Pelvic Nodes with Macrometastasis (greater than 2 mm): 0
        • Number of Left Pelvic Nodes with Micrometastasis (greater than 0.2 mm and up to 2 mm):0
        • Number of Left Pelvic Nodes with Isolated Tumor Cells (0.2 mm or less) (if applicable)**: 0
        • Total Number of Left Pelvic Nodes Examined:16
      • Para-aortic Node: N/A
    • Additional Pathologic Findings - leimyoma
    • Ancillary Studies: result of D&C specimen: S2022-11711: IHC stains: ER (+, strong intensity 100%); PR (+, strong intensity 100%), Napsin-A (-), WT-1 (focal +), vimentin (diffuse strong +).
• 2022-07-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (92.0 - 13.7) / 92.0 = 85.11%
    • M-mode (Teichholz) = 85.1-88.0
    • 2D (M-Simpson) = 66.1
  • Conclusion:
    • Thickened AV with no AR
    • Normal MV with mild MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • No PR, mild TR, normal IVC size
• 2022-07-22 Bronchodilator Test
  • small airway dysfunction
  • with significant response to bronchodilator
• 2022-07-20 Patho - endometrium curretage/biopsy
  • Uterus, endometrium, D＆C — endometrioid adenocarcinoma, grade 2.
  • IHC stains: ER (+, strong intensity 100%); PR (+, strong intensity 100%), Napsin-A (-), WT-1 (focal +), vimentin (diffuse strong +).
• 2022-07-18 MRI - pelvis
  • With and without contrast enhancement MRI: Pelvis:
    • Diffuse soft tissue in the uterine cavity, r/o endometrial malignancy.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE:Ib(Stage_value)
  • Impression:
    • Soft tissue in the uterine cavity, r/o endometrial malignancy, if proven malignancy, cstage T1bN0M0.
• 2022-07-15 SONO - gynecology
  • Endometrial thickening:30.6mm
  • Uterine myoma

[MedRec]

• 2024-02-01, 2023-11-09, -08-17 SOAP Cardiology Xie JianAn
  • Prescription x3
    • Micardis (telmisartan 80mg) 1# QD
    • Norvasc (amlodipine 5mg) 0.5# QD
    • carvedilol 6.25mg 1# QD
    • Natrilix (indapamide 1.5mg) 1# QD
• 2023-12-27 SOAP Radiation Oncology Huang JingMin
  • S: Completion of radiotherapy on 2022-10-14. Lung metastases.
    • PI: Endometrioid adenocarcinoma, grade 2, of the uterine endometrium, stage pT1b pN0 (cM0); AJCC 8th edition/FIGO Pathology stage: IB, s/p Laparoscopic gynecologic oncology staging surgery on 2022-07-27.
    • Family history: (-)
    • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
    • Personal Hx: DM(-); HTN(-)
    • Allergy(+)
  • A: Endometrioid adenocarcinoma, grade 2, of the uterine endometrium, stage pT1b pN0 (cM0); AJCC 8th edition/FIGO Pathology stage: IB, s/p Laparoscopic gynecologic oncology staging surgery and s/p radiotherapy, with lung metastases.
  • P: Refer to medical oncology for further treatment.
    • RTC: after chemotherapy or if indicated.
• 2023-12-21 SOAP Hemato-Oncology Gao WeiYao
  • S: menopaused at 55 y/o
    • Endometrioid adenocarcinoma, grade 2, FIGO Pathology stage: IB, at least.
    • post Laparoscopic gynecologic oncology staging surgery on 2022/07/27
    • Recurrent 2023/12/11 PATHO - lung transbronchial biopsy, Lung, right, CT-guide biopsy — consistent with metastatic endometrioid carcinoma
  • A:
    • Conclusions of Cancer Multi-specialty Team Meeting, Meeting date: 20231214
      • Treatment plan: Transfer to the HemaOnco department for systemic chemotherapy (for relapse with lung metastasis).
    • The patient and her daughter is hesitating about chemotherapy. I have planned to refer her to port-A by GS Chen YJ but she is still hesitating about it.
    • Conclusions of Cancer Multi-specialty Team Meeting, Meeting date: 20231207
      • Treatment plan: If recurrence of lung metastasis is suspected, it is recommended to arrange chest CT quided biopsy for tissue prove.
• 2023-05-25, -03-02 SOAP Cardiology Xie JianAn
  • Prescription x3
    • Micardis (telmisartan 80mg) 1# QD
    • Norvasc (amlodipine 5mg) 1# QD
    • carvedilol 6.25mg 1# QD
    • Tricozide (trichlormethiazide 2mg) 0.5# QD
• 2023-05-25 SOAP Gastroenterology Chen ZhiXiang
  • Prescription x3
    • Gaslan (dimethylpolysiloxane 40mg) 2# TID
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# TID
    • Tone (imipramine 25mg) 0.5# TID
    • Ulstop (famotidine 20mg) 1# BID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2023-02-23 SOAP Gastroenterology Chen ZhiXiang
  • Prescription x3
    • Gaslan (dimethylpolysiloxane 40mg) 2# TID
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Synpylon (sulpiride 50mg) 1# TID
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC

[surgical operation]

• 2022-07-27
  • Surgery
    • Operation: Laparoscopic gynecologic oncology staging surgery        
  • Finding
    • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
    • Bilateral adnexa: grossly normal
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
    • CDS: free
    • Estimated blood loss: 50ml
    • Blood transfusion: nil
    • Complication: nil
• 2022-07-20
  • Surgery
    • D&C, diagnostic
    • MRI: Soft tissue in the uterine cavity, r/o endometrial malignancy, if proven malignancy, cstage T1bN0M0.
  • Finding
    • Uterus: Anteversion, 9 cm.
    • Some endometrial tissue were curetted out.
    • Estimated blood loss: 5 mL, Blood transfusion: nil, complication: nil.  

[radiotherapy]

[chemotherapy]

• 2024-06-06 - paclitaxel 175mg/m2 300mg NS 250mL + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-05-13 - paclitaxel 175mg/m2 300mg NS 250mL + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-04-16 - paclitaxel 175mg/m2 300mg NS 250mL + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-03-18 - paclitaxel 175mg/m2 300mg NS 250mL + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-02-26 - paclitaxel 175mg/m2 300mg NS 250mL + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

Why give Taxol (Paxel) before carboplatin? - 2024-02-26 - https://www.drugs.com/medical-answers/give-taxol-paxil-before-carboplatin-3562689/

• Medically reviewed by Carmen Pope, BPharm. Last updated on Oct 2, 2023.

• Official answer by Drugs.com

  • Taxol (paclitaxel, Paxel) must be given before carboplatin because if carboplatin is given before Taxol, it stops Taxol from having an effect on cancer cells. This is called a scheduling interaction because when Taxol is given before carboplatin, there is little interaction and both agents work as intended.
  • The combination of carboplatin and paclitaxel is widely used to treat multiple solid tumors including ovarian, lung, and breast cancer. Research has shown that the pretreatment or simultaneous treatment with carboplatin inhibited Taxol-induced I-kappa, B-alpha degradation, and BCL-2 phosphorylation. Further analyses demonstrated that carboplatin could significantly interfere with the cytotoxic effects of Taxol on both mitotic arrest and apoptotic cell death unless Taxol was administered before carboplatin. These results indicate that the interaction between paclitaxel and carboplatin is highly schedule-dependent and the optimal schedule is Taxol (paclitaxel, Paxel) followed by carboplatin.

• Why is Taxol and carboplatin used together?

  • A landmark study in 1996 showed that Taxol and carboplatin in combination was better for the treatment of advanced ovarian cancer because it was less toxic than the combination used at the time, Taxol and cisplatin. Carboplatin-Taxol in combination were also just as effective as cisplatin-Taxol. Carboplatin-Taxol have been a standard chemotherapy combination used for more than 25 years for the treatment of ovarian cancer. The combination is also used to treat many other solid tumors.

• How effective is Taxol and carboplatin?

  • The combination of carboplatin-Taxol is well tolerated and achieves a clinical response rate of 50% to 81% and an average progression free survival (PFS) of 13.6 to 19.3 months. Other findings include:
    • For patients with optimally debulked advanced ovarian cancer revealed the median PFS for carboplatin-Taxol was 20.7 months compared to 19.4 with cisplatin-Taxol
    • Overall survival was 57.4 months with carboplatin-Taxol compared to 48.7 months with cisplatin-Taxol
    • Gastrointestinal, renal, metabolic toxicity and leukopenia were significantly more in cisplatin-Taxol group compared with carboplatin-Taxol
    • Quality-of-life scores at the end of treatment were significantly better with carboplatin-Taxol (65.25) compared with cisplatin-Taxol (51.97).
    • Toxic side effects, such as nausea and weight loss, are less with carboplatin-Taxol
    • Carboplatin-Taxol can be administered safely and effectively over a 3-hour infusion period. Previously, cisplatin-Taxol was administered over 24 hours, requiring a hospital stay.

==========

2024-03-18

[previous neutropenia (paclitaxel/carboplatin) - risk of recurrence]

The patient experienced an episode of neutropenia 1-2 weeks following the last administration of paclitaxel and carboplatin on 2024-02-26. There is a risk of recurrent neutropenia with the 2nd administration of these medications.

• 2024-03-17 WBC 3.87 x10^3/uL
• 2024-03-12 WBC 1.84 x10^3/uL *
• 2024-03-05 WBC 1.51 x10^3/uL *
• 2024-02-26 WBC 6.06 x10^3/uL paclitaxel + carboplatin

2024-02-26

No repeat prescriptions have been issued by any healthcare provider other than ours according the the PharmaCloud database. Furthermore, the medications prescribed by our cardiologist on 2024-02-01 have been incorporated into the active medication list without any discrepancies.

The patient’s vital signs have remained stable throughout this hospital stay, and laboratory results from 2024-02-26 did not reveal any significant findings. There is no evidence to suggest any contraindications for the administration of the paclitaxel and carboplatin regimen.

701201523

240607

[exam findings]

• 2024-04-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (70 - 23) / 70 = 67.14%
    • M-mode (Teichholz) = 66
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
• 2024-04-09 PET
  • Mild glucose hypermetabolism involving multiple lymph nodes as mentioned above. Lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm may show this picture. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the stomach. Inflammatory process is more likely. Please also correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys. Physiological FDG accumulation may show this picture.
• 2024-04-08 ECG
  • Sinus rhythm with 1st degree A-V block
• 2024-04-06 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Lymphadenopathy at bilateral thoracic inlet, abdominal paraaortic, and mesenterric region is found. In comparison with CT dated on 2023-04-03, the lesions are enlarged slightly.
    • Small lymph nodes are found at both sides of the mediastinum
    • Bilateral renal cysts are found.
  • Imp:
    • Lymphadenopathy at bilateral thoracic inlet, abdominal paraaortic, and mesenterric region, in slightly progression.
• 2024-01-18 CXR
  • Atherosclerotic change of aortic arch.
  • Borderline cardiomegaly
  • Spondylosis of the T-spine
• 2023-04-03 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Lymphadenopathy at mesenterric and paraaotic region is found. In comparison with CT dated on 2022-11-25, these lymph nodes are decreased in size.
    • Bilateral renal cysts up to 3.73cm is found.
    • Some lymph nodes are found at left lower neck are found. In regression.
    • Small lymph nodes are found at bilateral axillary region.
  • Imp:
    • Lymphadenopathy at left lower neck and abdominal paraaortic and mesenterric region. In regression.
• 2022-12-12 ECG
  • Sinus rhythm with 1st degree A-V block
• 2022-11-25 CT - chest
  • Lymphadenopathy at left lower neck. Statioanry.
  • Lymphadenopathy at mesenterric and paraaortic region. In progression.
• 2022-07-29 CT - chest
  • Extensive lymphadenopathy at bilateral lower neck, axillary, and mesenterric region. Stationary in size.
• 2022-04-15 CT - chest
  • Lymphadenopathy at left supraclavicular region and bilateral axillary region, paraaortic and mesenterric region. In regression.
• 2022-01-06 CT - chest
  • Lymphadenopathy at bilateral thoracic inlet and axillary, mediastinal and abdominal paraaortic and paracaval region. In regression.
• 2021-10-19 CXR
  • Atherosclerotic change of aortic arch.
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2021-10-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (74 - 19) / 74 = 74.32%
    • M-mode (Teichholz) = 74
  • Normal LV systolic function with normal wall motion.
  • Normal LV diastolic function.
  • Normal RV systolic function.
  • Aortic valve sclerosis with no AS and AR; mild MR; moderate TR; mild PR.
• 2021-10-06 CT - chest
  • advanced malignant lymphoma involving both sides of diaphgram, stationary as compared with previous CT study on 2021/04/13
• 2021-04-13 CT - chest
  • advanced malignant lymphoma involving neck both sides of diaphgram, seem stationary as compared with previous CT study on 2020/12/22
• 2020-12-22 CT - chest
  • advanced malignant lymphoma involving neck, axillary regions, mediastinum, and abdomen (both sides of diaphgram), stationary as compared with previous CT study on 2020/07/15
• 2020-07-15 CT - chest
  • advanced malignant lymphoma involving neck, axillary regions, mediastinum, and abdomen (both sides of diaphgram), stationary as compared with previous CT study on 2019/12/05
• 2019-12-17 Surgical patholgoy Level IV
  • Clinical diagnosis: Lymphoma, other named variants, LN of head face and neck;
  • Pathological diagnosis:
    • Bone marrow, iliac, biopsy — Lymphoma involvement.
    • IHC stains: CD3 and CD20 show monoclonality. CD5 (+), CD23 (+).
  • Microsopic description
    • Section shows one piece of bone marrow with 50% cellularity and M:E ratio of approximately 5:1. There is a predominant subpopulation of small lymphoid cells.
    • IHC stains: CD3 and CD20 show monoclonality. CD5 (+), CD23 (+), compatible with clinical history of small lymphocytic lymphoma.
• 2019-12-05 CT - abdomen
  • Enlarged LNs at bil. neck, axillary regions, mediastinum, peritoneal cavity, pelvi cavity, retroperitoneum and bil. inguinal regions c/w lymphoma.
• 2019-11-01 PET
  • There was mildly or faintly increased FDG uptake involving multiple lymph nodes (SUVmax early: 1.10, delay: 1.15) including multiple bilateral neck, bilateral supraclavicular and axillary lymph nodes, some mediastinal, abdominal and bilateral inguinal lymph nodes. There was increased FDG uptake in the nasopharynx (SUVmax early: 1.94) and stomach (SUVmax early: 2.84, delay: 1.79).
  • IMPRESSION:
    • Mild or faint glucose hypermetabolism involving multiple lymph nodes as mentioned above. Lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the nasopharynx and stomach. The nature is to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.

[MedRec]

• 2024-04-07 ~ 2024-04-11 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Relapsed small lymphocytic lymphoma involving multiple lymph nodes, Lugano stage IV, PS:1, Lymphadenopathy at bilateral thoracic inlet, abdominal paraaortic, and mesenterric region, in slightly progression by chest CT exam on 2024/04/06.
    • Essential (primary) hypertension
    • Chronic viral hepatitis B without delta-agent anti-Hbc positive
  • CC
    • for chemotherapy                     
  • Present illness
    • This 83-year-old female patient has Hypertension and minor stroke (left hand numbness) with medication treatment and regular OPD follow up at YongHe Cardinal Tien Hospital.
    • She noticed a palpable tumor over left neck which existed for over one year, with body weight loss from 48 -> 43kg. Left neck biopsy was done and pathology showed malignancy lymphoma, B cell, CE 20 (+), CD 5 (+), bcl-2 (+), CD 23 (+), CD 10 (-),cyclin D1 (-), C?D 21 (-). Due to favoring small lymphocytic lymphoma, she was transferred to our ONC/HEMA OPD since 2019-10.
    • The PET scan images impression to 1. Mild or faint glucose hypermetabolism involving multiple lymph nodes as mentioned above. Lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm should be watched out. 2. Mild glucose hypermetabolism in the nasopharynx and stomach. The nature is to be determined (inflammatory process? other nature?).
    • 2019/12 CT of abdomen-pelvis revealed: Enlarged LNs at bil. neck, axillary regions, mediastinum, peritoneal cavity, pelvi cavity, retroperitoneum and bil. inguinal regions c/w lymphoma. Under the impression of favoring Small lymphocytic lymphoma, stage III and follow up CT showed advanced malignant lymphoma involving both sides of diaphgram), stationary as compared with previous CT study on 2021/04/13.
    • She has fatigue and BW loss 1kg for 1 month, who is admitted for chemotherapy as R-COP C1 on 2021/10/20, C2 on 2021/11/9, C3 on 2021/12/7. C4 on 2022/01/4.
    • Followed up CT on 2022/01/06, report showed Lymphadenopathy at bilateral thoracic inlet and axillary, mediastinal and abdominal paraaortic and paracaval region. In regression.
    • C5 on 2022/02/08-09. C6 R-COP on 2022/03/09-10.
    • The following CT of Lung on 2022/11/25 showed lymphadenopathy at mesenteric and para-aortic region in progression.
    • With the diagnosis of relapsed small lymphocytic lymphoma involving multiple lymph nodes as of bil. neck, axillary regions, mediastinum, peritoneal cavity, pelvi cavity, retroperitoneum and bil. inguinal regions, Lugano stage IV, PS 1.
    • She received the chemotherapy with C1 R-COP on 2022/12/13, C2 on 2023/01/06, C3 on 2023/03/01.
    • Follow up chest CT on 2024/04/06, report showed Lymphadenopathy at bilateral thoracic inlet, abdominal paraaortic, and mesenterric region, in slightly progression.
    • This time, she denied fullness or BW loss, who was admitted for newly chemotherapy on 2024/04/07.
  • Course of inpatient treatment
    • After admission, whole body PET scan was performed on 4/9 24 and report was pending.
    • Chemotherapy with C4 R-COP was administered on 2024/04/09-10, smoothly without obvious side effect.
    • She was discharged on 4/11 24 under stable condition and will follow-up at OPD.
  • Discharge diagnosis
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Through (sennoside 12mg) 2# HS
    • Compesolon (prednisolone 5mg) 8# BID (4/10~4/14 18:00)
    • Ulstop (famotidine 20mg) 1# BID

[immunochemotherapy]

• 2024-06-06 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 800mg NS 250mL 30min + vincrestine 1.4mg/m2 1.9mg NS 50mL 10min] D2 + prednisolone 60mg/m2 40mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2024-05-17 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 800mg NS 250mL 30min + vincrestine 1.4mg/m2 1.9mg NS 50mL 10min] D2 + prednisolone 60mg/m2 40mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2024-04-09 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 800mg NS 250mL 30min + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 40mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2023-03-01 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2023-01-06 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2022-12-13 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2022-03-08 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2022-02-08 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2022-01-03 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2021-12-07 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2021-11-09 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2021-10-19 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2

==========

2023-03-02

This patient with Small cell B-cell lymphoma was treated with a total of six cycles of R-COP regimen from 2021-10 to 2022-03. However, during regular CT follow-up on 2022-11-25, progression of lymphadenopathy was observed in the mesenteric and paraaortic regions. As a result, the patient was rechallenged with R-COP from 2022-12 onwards.

The lab results from 2023-03-01 indicated that there were no notable abnormalities in the patient’s liver and kidney functions or blood cell counts. And the TPR panel revealed that the patient’s vital signs and blood pressure were stable.

Entecavir is prescribed to suppress the replication of the hepatitis B virus with no issue.

700384079

240605

[exam findings]

• 2024-04-23 Patho - omentum biopsy
  • Omentum/abdominal wall, excision — consistent with metastatic duodenal adenocarcinoma
  • Specimen submitted in fresh consists of 2 pieces of tan, irregular tissue measuring up to 2.0 x 1.9 x 1.0 cm. On cutting, 2 solid and firm tumors, measuring up to 0.9 x 0.6 x 0.5 cm are seen. The tumors are very close (< 0.1 cm) to peripheral resection margins. Representative section is taken in one cassette for frozen examination. After formalin fixation, all residual tissue is submitted in a cassette X.
  • Sections show fibroadipose tissue with foreign body reaction and metastatic adenocarcinoma.
  • The immunohistochemical stains reveal CK7(+), CK20(-), and CDX2(-). The results are consistent with metastatic duodenal adenocarcinoma. Please correlate with the clinical presentation and image study.
• 2024-04-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (83.1 - 22.8) / 83.1 = 72.56%
    • M-mode (Teichholz) = 72.6
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Trivial mitral regurgitation
    • Thick IVS and LVPW, dilated LA
• 2024-04-17 CT - abdomen
  • Findings: Comparison: prior CT dated 2023/12/15.
    • Prior CT identified duodenal cancer (3rd portion) with exophytic growing and superior mesenteric vein encasement, and few enlarged LNs in the mesentery is noted again, stationary.
    • S/P cholecystectomy.
    • There are few metalic coils implantation at the gastroduodenal artery that are c/w TAE for prior GI bleeding.
    • Abdominal aorta shows atherosclerosis and mild intramural thrombus formation.
    • There is severe fatty liver, grade 5.
  • Impression:
    • Prior CT identified duodenal cancer (3rd portion) with exophytic growing and superior mesenteric vein encasement, and few enlarged LNs in the mesentery is noted again, stationary.
• 2024-04-16 ECG
  • Normal sinus rhythm
  • Right bundle branch block
• 2024-03-12 PET
  • Mild glucose hypermetabolism in the 3rd portion of the duodenum. Malignancy of low FDG uptake can not be ruled out. Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in the midline upper abdominal and right anterior lower abdominal walls. The nature is to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.
    
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likey.
• 2024-03-01 MRI - pancreas
  • Findings: Comparison: prior CT dated 2023/12/15.
    • Prior CT identified duodenal cancer (3rd portion) with exophytic growing and superior mesenteric vein encasement, and few enlarged LNs in the mesentery is noted again, stationary.
    • S/P cholecystectomy.
    • There are few metalic coils implantation at the gastroduodenal artery that are c/w TAE for prior GI bleeding.
    • Abdominal aorta shows atherosclerosis and mild intramural thrombus formation.
  • Impression:
    • Prior CT identified duodenal cancer (3rd portion) with exophytic growing and superior mesenteric vein encasement, and few enlarged LNs in the mesentery is noted again, stationary.
    • Follow up CT 3 months later is indicated.
• 2023-12-25 CT - abdomen
  • Findings: Comparison: prior CT dated 2023/09/12.
    • Prior CT identified duodenal cancer (3rd portion) with exophytic growing and superior mesenteric vein encasement, and few enlarged LNs in the mesentery is noted again, stationary.
    • S/P cholecystectomy.
    • There are few metalic coils implantation at the gastroduodenal artery that are c/w TAE for prior GI bleeding.
    • Abdominal aorta shows atherosclerosis and mild intramural thrombus formation.
  • Impression:
    • Prior CT identified duodenal cancer (3rd portion) with exophytic growing and superior mesenteric vein encasement, and few enlarged LNs in the mesentery is noted again, stationary.
• 2023-11-14 Patho - colon biopsy
  • Colon, descending, biopsy — tubular adenoma with low grade dysplasia
  • Section shows a fragment of polypoid colonic mucosal tissue with proliferative mucinous glands lined by cells containing hyperchromatic and elongated nuclei.
• 2023-11-13 Colonoscopy
  • Findings
    • The scope had been inserted up to cecum. Much stool in colon. A 0.3 cm Is polyp was noted at descending colon. Biopsy was done
    • Internal hemorrhoid was noted
  • Diagnosis:
    • Colon polyp, descending colon, s/p biopsy
    • Internal hemorrhoid
    • Poor colon preparation
• 2023-10-25 L-spine AP + Lat (including sacrum)
  • loss of the natural curvature of the spine
  • mild spondylolisthesis at L5-S1
  • mild decreased disc spaces in upper L-spine discs
  • unremarkable change in the paravertebral region
  • mild anterior spur formation at the L-spine.
• 2023-10-25 C-spine AP + Lat
  • Normal bone alignment
• 2023-10-17 Myocardial perfusion SPECT with persantin
  • Probably mild myocardial ischemia at the septum, inferoposterior wall and basal lateral wall.
• 2023-10-11 Nerve Conduction Velocity, NCV
  • Findings
    • MNCV: delayed CMAPs onset latency of left ulnar nerve; decreased CMAPs amplitude of left ulnar and bilateral peroneal nerves; slow motor conduction velocity of left median, bilateral ulnar nerves and bilateral peroneal nerves
    • SNCV: decreased SNAPs amplitude of all examined nerves; slow sensory conduction velocity of bilateral ulnar and left median nerve
    • F-wave: delayed responses of bilateral peroneal and tibial nerves
    • H-reflex: no recordable responses of bilateral lower limbs.
    • Thermal quantitative sensory test showed abnormal warm and cold threshold in right upper and lower limbs.
  • Conclusion
    • The NCV study suggested bilateral lumbosacral radiculopathy, left ulnar neuropathy with axonal injury, right ulnar neuropathy across elbow, left median distal neuropathy.
    • Thermal quantitative sensory test showed abnormal warm and cold threshold in right upper and lower limbs.
    • Please correlate with clinical features.
• 2023-10-04 ECG
  • Sinus tachycardia
  • Right bundle branch block
  • Right axis deviation
• 2023-10-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 14) / 83 = 83.13%
    • M-mode (Teichholz) = 83
  • Conclusion:
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial MR; mild PR.
    • Mild aortic root calcification.
• 2023-09-12 CT - abdomen
  • History and indication:
    • Duodenal cancer s/p C/T and CCRT
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P TAE.
    • Mild wall thickening of stomach and duodenum. Some LNs at upper abdomen with stable condition.
    • Hyperplasia of left adrenal gland.
    • Subcutaneous fat stranding at bil. abdominal wall.
    • Normal appearance of liver, spleen, pancreas and kidneys.
    • Invisible gallbladder.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Mild wall thickening of stomach and duodenum. Some LNs at upper abdomen with stable condition.
• 2023-05-08 CT - abdomen
  • Indication: Duodenal cancer s/p RT and bypass
  • Abdominal CT with and without enhancement revealed:
    • S/p port-A placement with its tip at Superior vena cava.
    • s/p doudenal op.
    • Minimal infiltration around the surgical region is found. Post op. change is favored. Suggest follow up.
    • s/p coil placement at doudenum.
  • Imp: s/p C/T and doudenal op.
    • No evidence of recurrent/residual tumor in the study but follow up is suggested.
• 2023-02-14 Patho - gallbladder (benign lesion)
  • Gallbladder, laparoscopic cholecystectomy — cholelithiasis with acute cholecystitis
  • Microscopically, it shows acute cholecystitis with congestion, submucosal fibrosis, mixed inflammatory cell infiltrate with Rokitansky-Aschoff sinus formation.
• 2023-02-07 CT - abdomen
  • Clinical history: 57 y/o male patient with duodenal cancer post C/T.
  • With and without contrast enhancement:
    • S/P TAE with vascular colin in gastroduodenal artery.
    • Duodenal wall thickening with enhancement, c/w duodenal malignancy. Irregular poor enhancing tumor, 2.2cm in medial aspect of the duodenal 2nd portion with mesentery fatty infiltrate, progression.
    • Prominent fluid retention in the stomach, could be due to gastric outlet obstruction.
    • Stationary lymph nodes hepatoduodenal ligament.
    • Presence gallbladder stones.
    • Bulging contour at left adrenal gland.
  • Impression:
    • S/P TAE with vascular colin in gastroduodenal artery.
    • Duodenal malignancy with gastric outlet obstruction.
    • Progression of irregular poor enhancing tumor in medial aspect of the duodenal 2nd portion with mesentery invasion.
    • Stationary regional lymph nodes.
• 2023-02-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (103 - 27) / 103 = 73.79%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR.
• 2023-02-06 ECG
  • Sinus rhythm with 1st degree A-V block
  • Right bundle branch block
• 2023-11-21 ECG
  • Sinus tachycardia
  • Right bundle branch block
• 2022-11-16, -09-28, -08-29, -08-25 CXR
  • Atherosclerotic change of aortic arch
• 2022-11-16 CT - abdomen
  • History: UGI bleeding
    • 20220808 gastroscopy: One 25mm ulcer with elevated margin was noted at AW side of bulb/SDA. Patho: duodenal adenocarcinoma
    • 20220817 CT: duodenal adenocarcinoma or metastatic node with superior mesenteric vein invasion? cT4N2M0, cstage: IIIB
  • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, arterial phase, and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings: Comparison: prior CT dated 2022/08/17.
    • Prior CT identified lobulated wall thickening in duodenal bulb measuring 1.5 cm in wall thickness is noted again, increasing in size to 2.1 cm. The stomach shows marked distension that may be gastric outlet obstruction?
      • Please correlate with gastroscopy.
      • In addition, There is a poor enhancing mass measuring 2.5 cm in the medial aspect of the duodenal 2nd portion with direct invasion the superior mesenteric vein is noted again, decreasing in size to 1.8 cm that may be metastatic node S/P C/T with partial response .
      • The differential diagnosis include adenocarcinoma with exophytic growth?
      • Prior CT identified two enlarged nodes in the hepatoduodenal ligament are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response.
    • There are several gallstones.
    • There are few metalic coils implantation at the gastroduodenal artery that are c/w TAE for prior GI bleeding.
    • Abdominal aorta shows atherosclerosis and mild intramural thrombus formation.
  • Impression:
    • Adenocarcinoma of the duodenal bulb shows mild increasing in size. However, metastatic nodes show decreasing in size.
• 2022-08-23 All-RAS + BRAF mutations assay
  • All-RAS mutations assay
    • Detection range
      • KRAS codon 12, 13, 59, 61, 117, 146
      • NRAS codon 12, 13, 59, 61, 117, 146
    • Results
      • There was no variant detected in the KRAS/NRAS gene.
    • Interpretation
      • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • BRAF mutations assay
    • Detection range
      • BRAF codon 600
    • Results
      • There was no variant detected in the BRAF gene.
    • Interpretation
      • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
• 2022-08-23 CT - chest
  • Pancreatic cancer with suspect duodenal bulb and SMV invasion
  • MDCT (256-detector rows, GE Revolution, was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
  • Findings
    • Lungs: minimal centrilobular nodules at posterobasal segment of RLL.normal appearance of RUL, RML, and left lung.
    • Mediastinum and hila: no enlarged LN or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion.
    • Vessels:
      • moderate calcified plaques of the LAD coronary artery.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta/aortic root.
      • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: Pancreatic head cancer with suspect duodenal bulb and SMV invasion
      • multiple small gall bladder stones
    • Visualized bones: multiple marginal spurs of vertebrae..
  • Impression:
    • minimal bronchiolitis in RLL-S10. moderate LAD CAD.
• 2022-08-17 CT - abdomen
  • History: UGI bleeding
    • 20220808 gastroscopy: One 25mm ulcer with elevated margin was noted at AW side of bulb/SDA. Patho: duodenal adenocarcinoma
  • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, arterial phase, and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is lobulated wall thickening in duodenal bulb measuring 1.5 cm in wall thickness.
      • Adenocarcinoma of the duodenal bulb is highly suspected.
      • In addition, There is a poor enhancing mass measuring 2.5 cm in the medial aspect of the duodenal 2nd portion with direct invasion the superior mesenteric vein that may be metastatic node.
      • The differential diagnosis include adenocarcinoma with exophytic growth?
      • There are two enlarged nodes in the hepatoduodenal ligament that may be metastatic nodes.
    • There are several gallstones.
    • There are few metalic coils implantation at the gastroduodenal artery that are c/w TAE for prior GI bleeding.
    • Abdominal aorta shows atherosclerosis and mild intramural thrombus formation.
  • Impression:
    • Adenocarcinoma of the duodenal bulb is highly suspected.
• 2022-08-10 Embolization (TAE: trans arterial embolisation) - abdomen
  • TAE of duodenal hemorrhage via right common femoral artery puncture using Seldinger technique revealed:
    • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
    • Under local anesthesia, a 4 Fr arterial sheath was inserted into right common femoral artery smoothly.
    • Active bleeding of gastroduodenal artery.
    • We used microcatheter for superselective catheterization due to easy spasm, tortuous, small size of bleeding artery.
    • TAE was performed using four microcoils (2-4-42mm x3 and 2-6-85mm x1) plus some gelfoam pieces.
    • No procedure-related complication during the whole procedure. Remain the arterial sheath (4 Fr) at right inguinal region. Thanks for your further care.
  • IMP: Active bleeding of gastroduodenal artery s/p TAE.
• 2022-08-09 Patho - duodenum biopsy (malignancy)
  • Duodenum, AW side of bulb/SDA, biopsy — moderately differentiated adenocarcinoma
  • Microscopically, it shows moderately differentiated adenocarcinoma composed of proliferation of irregular neoplastic glands with stromal invasion. The tumor shows nuclear hyperchromasia, pleomorphsim, prominent nucleoli and increased N/C ratio.
  • Immunohistochemical stain — CK(+), CDX-2(+)
• 2022-08-08 Panendoscopy
  • Diagnosis
    • Severe duodenal ulcer, Forrest classification type Ib, suspected tumor, s/p hemostasis with APC and biopsy
    • Incomplete of stomach
  • Suggestion
    • NPO and PPI pump for 3 days.
    • Due to anticipated prolonged NPO time, suggest TPN supply
      • Calories: 25kcal per ideal body weight
      • Protein: 1.5gm per ideal body weight
    • Consult interventional radiologist and surgical department if further bleeding.
    • Weaning ventilator ASAP
• 2022-08-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (74.7 - 17.0) / 74.7 = 77.24%
    • M-mode (Teichholz) = 77
  • Conclusion:
    • Normal chamber size
    • Septal hypertrophy
    • Adequate LV and RV systolic function
    • Mild MR and PR
    • No regional wall motion abnormalities
• 2022-08-01 Panendoscopy
  • Diagnosis
    • Superfical gastritis, antrum
    • Duodenal ulcer, junction of 1st and 2nd portion, LC side, Forrest classification IIb
  • Suggestion
    • NPO and give high dose PPI
• 2022-07-29 ECG
  • Sinus tachycardia
  • Right bundle branch block
  • Abnormal ECG
• 2022-04-19 SONO - abdomen
  • Fatty liver, mild to moderate
  • GB stone, multiple
• 2021-01-27 ECG
  • Sinus tachycardia
  • Right bundle branch block
• 2019-11-04 CPA, carotid phonoangiograph
  • Sonographic diagnosis:
    • Moderate atheromatous lesions in bil BIF and right proximal ICA.
    • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows; stenotic flow in left MCA, more severe over proximal segment; resistant flow in right CCA and left ECA, suspect distal stenosis, suggest clinical correlation and further evaluation.
      
    • Poor temporal windows for left PCA and right ACA.
    • Normal left ophthalmic arterial flows; reverse flow in right OA.
    • Suggest MRA (neck + intracranial arteries) for further study if no contraindication.
• 2018-03-26 SONO - hepatobiliary
  • Fatty liver.
  • GB stone.
• 2018-02-18 ECG
  • Sinus tachycardia
  • Right bundle branch block
• 2017-07-04 Barium Enema (double contrast)
  • Double contrast study of LGI series revealed:
    • The contrast medium passage from anus to terminal ileum smoothly without obstruction.
    • Redundancy of T-colon.
    • Much stool retention in colon.
    • Normal contour and mucosal pattern of the colon.
    • Normal haustration and peristalsis of the colon.

[consultation]

• 2024-06-04 Metabolism and Endocrinology
  • Q
    • This is a 58-year-old male with history of # Duodenal cancer, T4N2M0, Stage IIIB # DM # HTN. He has been diagnosed with dudenal cancer, T4N2M0, Stage IIIB in 2022 and received neoadjuvant FOLFIRINOX（folinic acid, fluorouracil, irinotecan, and oxaliplatin) and GOFL(2022-08-29 ~ 2023-05-23).
      • He then received Roux-en-Y hepatico-jejunostomy. GJ bypass. cholecystectomy on 2023/02/13 and CCRT with cisplatin, radiotherapy [RT (2023-06-12 ~ 2023-07-26): 4500cGy/25 fractions of the duodenal tumor bed to peripheral involved nodal lesions.] and FOLFIRI.
      • He received peritoneal tumor excision on 2024/04/22. Frozen tumor section pathology revealed metastatic adenocarcinoma, pathology showed Omentum/abdominal wall, excision — consistent with metastatic duodenal adenocarcinoma.
      • This time, he is admitted to our ward for chemotherapy with EEPFL.
    • Patient said his insulin administration:
      • Apidra 100U/mL, 3mL/prefilled pen 30unit TIDAC
      • Tresiba FlexTouch 100U/mL, 3mL/pre-filled pen 70unit HS (by himself at home usually use 50 units, if BS > 200 then use 70 units)
    • Due to DM poor control, we need your consultation for evaluation. Thanks a lot!!!.
  • A
    • This 58 year old male with duodenal cancer, DM, hypertension, and was admitted for chemotherapy. We were consulted for blood sugar control.
    • O:
      • BH:162 cm, BW:82.4 kg
        
      • Diet: As tolerance
      • Medication in OPD:
      • The patient said:
        • Apidra 30 unit TIDAC (records is 25U)
        • Tresiba n 70 unit HS (by himself at home usually use 50 units, if BS > 200 then use 70 units)
      • Medication during hospitalization:
        • Apidra 30 unit TIDAC
        • Tresiba n 50 unit HS
        • BUN/Crea(eGFR): 17/1/81
        • Na/K: 146/3.3
        • ALT/AST/CRP: 26/38/-
        • HbA1c: 4/28 7.6
        • F/S: no data
    • A:
      • Type 2 DM
    • P:
      • Book the DM diet 1800 kcal
      • Tresiba 50u HS
      • Apidra 25 U TIDAC correction scales (need to eat immediately after the injection)
        • F/S < 80 OR NPO, NovoRapid hold
        • F/S 081~090, NovoRapid -20U
        • F/S 091~100, NovoRapid -15U
        • F/S 101~110, NovoRapid -10U
        • F/S 111~120, NovoRapid -8U
        • F/S 201~250, NovoRapid +2U
        • F/S 251~300, NovoRapid +4U
        • F/S 301~350, NovoRapid +6U
        • F/S > 350, NovoRapid +8U
      • Check urine ACR before discharge.
      • Feel free to concact us, I would like to follow up this patient
      • Arrange META OPD follow up after discharge
• 2024-04-17 Plastic and Reconstructive Surgery
  • Q
    • Duodenal cancer with SMV invasion for further op with SMV reconstruction
    • This 58 y/o male was a case of duodenal cancer at 3rd portion with SMV invasion s/p double bypass s/p CCRT for 1 year. Liver MRI on 3/21 which showed duodenal cancer (3rd portion) with exophytic growing and superior mesenteric vein encasement, and few enlarged LNs in the mesentery is noted. This time, he was admitted for further op. We need your help for combine surgery for SMV reconstruction. Thanks for your time!!
  • A
    • I will discuss with Dr. Wu for the detailed of surgery
• 2022-08-24 Hemato-Oncology
  • Q
    • For neoadjuvant chemotherapy of pancreatic cancer suspected duodenal invasion suspected SMV invasion
    • THis is a 56 y/o male with history of DM, hypertension under medication control
    • He was admitted since 20220730 due to gastric ulcer with bleeding complicated with hypovolemic shock s/p ETT intubation (extubated), EGD hemostasis and active bleeding of gastroduodenal artery s/p TAE on 20220810. There was an incidental finding of duodenal neoplasm, pathology revealed adenocarcinoma. CT revealed adenocarcinoma of the duodenal bulb, suspect SMV invasion.
    • Further tumor biomarker study revealed CA-199 = 1089; while other biomarkers were within normal range, pancreatic cancer suspected duodenal bulb invasion was suspected.
    • Due to above, surgical intervention was not recommended in the first place, suggested by GS Dr. Wu.
    • We sincerely need your expertise for chemotherapy evaluation and management.
  • A
    • O
      • Abdominal CT show:
        • There is lobulated wall thickening in duodenal bulb measuring 1.5 cm in wall thickness.
        • Adenocarcinoma of the duodenal bulb is highly suspected.
        • In addition, There is a poor enhancing mass measuring 2.5 cm in the medial aspect of the duodenal 2nd portion with direct invasion the superior mesenteric vein that may be metastatic node. The differential diagnosis include adenocarcinoma with exophytic growth?
        • There are two enlarged nodes in the hepatoduodenal ligament that may be metastatic nodes.
      • Pathology: Duodenum, AW side of bulb/SDA, biopsy — moderately differentiated adenocarcinoma.
        • Immunohistochemical stain — CK(+), CDX-2(+)
    • Impression:
      • Duodenum adenocarcinoma with SMV invastion, T4N2Mx, stage IIIB at least
    • Suggestion:
      • Arrange chest CT, EUS for complete staging
      • For Locally unresectable duodenum cancer, systemic chemotherapy is indicated (goal for down stage)
      • Arrange port A insertion if patient agree further chemotherapy and check HbsAg, Anti Hbc, Anti HCV
      • Thanks for your consultation. If there is any problem, please feel free to let us known.
• 2022-08-18 General and Gastrointestinal Surgery
  • Q
    • For duodenal adenocarcinoma
    • This is a 56 y/o male with history of DM, hypertension under medication control
    • He was admitted since 07/30 due to gastric ulcer with bleeding complicated with hypovolemic shock s/p ETT intubation (extubated), EGD hemostasis and active bleeding of gastroduodenal artery s/p TAE on 08/10. There was an incidental finding of duodenal neoplasm, pathology revealed adenocarcinoma. CT revealed adenocarcinoma of the duodenal bulb, suspect SMV invasion.
    • We sincerely need your expertise for surgical intervention evaluation and management.
  • A
    • A case suspect of duodenal or pancreatic tumor
    • further op will arrange on 8/24
    • we will take over for this case on 8/22
    • Due to pancreatic neck ca with SMV invasion and tumor seeding is impression
    • Suggest further neoadjuvant chemotherapy first for tumor down stage
• 2022-08-11 Diagnostic Radiology
  • Q
    • For TAE (trans arterial embolisation)
    • The 57-year-old male patient, he has history of: 1. Type 2 diabetes mellitus for years. 2. Hypertension for years. He was under regular medical treatment in our GI and Family Medicine Department OPD in the recent years. He is a bus driver who fainted once in the toilet during his lunch break yesterday. This time, he complained of black stool for about a week. And also has dizziness again and cold sweat after going to the toilet last night.
    • At ER, his consciousness was clear. KUB showed: Increase bowel gas and presence of ileus.The serum examination showed : glucose: 336 mg/dL; BUN: 62 mg/dL; Creatinine: 1.83 mg/dL; WBC: 11.10 *10^3/uL; HGB: 8.8 g/dL. Under the impression of upper gastrointestinal bleeding, IV Panzolec pump were given and he was admitted for further evaluation and management. After admitted to ward, the EGD performed on 08/01 showed gastric ulcer Forrest class IIb. His tarry stool passage mildly subsided since then(no loosen nor sticky unshaped stool, hemoglobin level around 8.0-8.7) s/p PPI high dose pump and then Q12H since 08/05.
    • However, on 08/06, he was noted dizziness, bloody stool passage, the discharge was postponed. Following Hb today revealed 6.4, EGD was arranged this afternoon. Hematemesis with consciousness disturbance developed when undergo anesthesia surveillance, with cold and wet skin, tachycardia, pale appearance, suspect hypovolemic shock. ETT intubation was performed to secure airway(Dormicum x1, Esmeron x1), foley catheter and CVC were also inserted in the same time. Fluid resuscitated with N/S 500 cc and LPRBC 2U ST, vesopressor with levophed 2 amps in 500 N/S run 20 cc/hr, PPI pump with 5 amps in 500 N/S run 20 cc/hr. His family was informed and fully understood current situation. After emergent management, the patient’s condition was temporarily under control and was transferred to MICU for further evaluation and management on 2022-08-08.
      
    • After transferred to MICU, on ventilator full support and blood transfusion with LPRBC 4u, FFP 4u and cyro 10u stat. On vasopressor with levophed titration(8/8-) and N/S 500ml challenge for unstable hemodynamic condition. Arranged pandoscope immediately which report showed Severe duodenal ulcer, Forrest classification type Ib, suspected tumor, s/p hemostasis with APC and biopsy. Jusomin 5amp iv stat for metabolic acidosis. Extubation on 8/9 and then on nasal cannula support. However, fresh bloody around 200ml via NG tube was noted now, so we contact GI who suggested If active bleeding, arrange TAE. Therefore, we need your help for TAE examination. Thanks!!
  • A
    • According to the clinical condition and imaging findings, TAE is indicated.

[chemotherapy]

• 2024-06-04 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + cisplatin 25mg/m2 45mg NS 500mL 24hr (Y-sited Covorin 5-FU) + leucovorin 120mg/m2 230mg NS 250mL 24hr (Y-sited Kemoplat 5-FU) + fluorouracil 2200mg/m2 4200mg NS 500mL 24hr (Y-sited Covorin Kemoplat) (EEPFL)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• ….-..-..

• 2022-11-08 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 160mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2000mg/m2 4000mg 48hr

• 2022-10-25 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 160mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2000mg/m2 4000mg 48hr

• 2022-09-28 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr

• 2022-09-13 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr

• 2022-08-29 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr

GOLF regimen ref:

• Simplified/Same Day(s)-GOLF as First-line Treatment of Metastatic Carcinoma of Unknown Primary (CUP), Suggestive of Pancreatobiliary Tumors. JOP. 2019;20(5):121-124;
• Biweekly triple combination chemotherapy with gemcitabine, oxaliplatin, levofolinic acid and 5-fluorouracil (GOLF) is a safe and active treatment for patients with inoperable pancreatic cancer. J Chemother. 2008;20(1):119-125. doi:10.1179/joc.2008.20.1.119;
• A novel biweekly multidrug regimen of gemcitabine, oxaliplatin, 5-fluorouracil (5-FU), and folinic acid (FA) in pretreated patients with advanced colorectal carcinoma. Br J Cancer. 2004;90(9):1710-1714. doi:10.1038/sj.bjc.6601783

==========

2022-11-22

• The GOLF regimen was introduced as a neoadjuvant treatment since late August 2022 with the aim of downstaging the tumor. The CT (2022-11-16) revealed that the adenocarcinoma of the duodenal bulb showed a mild increase in size and that the metastatic nodes displayed a decrease in size. There appears to be a greater likelihood that this will improve the feasibility of the surgery.

• The decreased CA199 marker also served as a side evidence that the regimen is still effective.

  • 2022-11-21 CA199 346.54 U/mL
    
  • 2022-10-11 CA199 740.79 U/mL
    
  • 2022-09-13 CA199 1286.58 U/mL

• Data available indicate stable vital signs, and there is no problem with the active prescription.

700233401

240604

[exam findings]

• 2024-05-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 29) / 88 = 67.05%
    • M-mode (Teichholz) = 67
  • Conclusion: “Poor apical windows due to large breast mass”
    • Normal LV systolic function with normal wall motion.
    • Indeterminate LV diastolic function (EA fusion due to tachycardia, HR: 118bpm).
    • Normal RV systolic function.
    • Mild MR; mild TR.
• 2024-05-16 Tc-99m MDP bone scan
  • Increased activity in some L-spines and bilateral S-I joints. Degenerative change may show this picture.
  • Mildly increased activity in the right ischial bone. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, knees and feet, compatible with benign joint lesions.
• 2024-05-15 PET
  • Increased FDG uptake in the left breast with chest wall involvement, highly suspected the primary residual/recurrent breast cancer.
    
  • Increased FDG uptake in the left axilla region, highly suspected left breast cancer with regional lymph nodes metastases.
    
  • Increased FDG uptake in the left upper and left lower lungs, breast cancer with lung metastasis should be considered, suggesting biopsy, if necessary, for investigation.
  • Increased FDG accumulation in bilateral kidneys, ureters, and colon, probably physiological uptake of FDG.
    
  • Left breast cancer s/p treatment with residual/recurrent tumor, c/rcT4N2M0-1 (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2024-05-14 CT - abdomen
  • Clinical history: 38 y/o female patient with left Breast CA s.p chemotherapy 1 year ago, for tumor staging form chest to abdomen, pelvis.
  • With and without contrast enhancement CT of abdomen - whole:
    • Huge tumor, 16.2x11.1cm in left breast, could be due to malignancy.
    • Presence of splenomegaly.
    • Presence of ascites.
    • Bilateral pleural effusion.
    • Bilateral lung nodules, r/o lung metastasis.
    • Enlarged left axillary lymph nodes, r/o lymph nodes metastasis.
  • Impression:
    • Left breast malignancy with axillary lymph nodes metastasis.
    • Splenomegaly.
    • Lung nodules, r/o metastasis.
    • Bilateral pleural effusion.
• 2023-11-21 SONO - breast
  • Diagnosis
    • Uncertain breast tumor ,in favor of benign fibroadenoma (FA), Highly suspicious of malignancy, with sonographic negative axillary LNs
    • TNBC, stage II in March 2023 at Taiepi University s/p neoadjuvant chemotherapy (anthracycline x4 followed taxotere x4 with the last chemotherapy done in early Sep 2023.)
  • Suggestion
    • arrange snipple sparing mastectomy and SLNB on 1121130, medication, education, & OPD follow up
    • inform her the risk of wound infection 5% and nipple invasion 2%
  • BI-RADS:
    • 6-Known Biopsy - Proven Malignancy

[consultation]

• 2024-06-04 Plastic and Reconstructive Surgery
  • Q
    • This is a 38-year-old female with no known systemic diseases, has a history of a Cesarean section 15 years ago and admitted due to left breast cancer with left axillary and chset wall metastasis, suspect lung metastasis. ypT4N2M1, stage IV. triple negative. ECOG:3 18 x 15 x 4 cm³ suspect tumor rupture with infection this time.
    • ABx of Tapimycin for 15 days and shifted to Brosym and added Erasix on 6/3 with added was prescribed for infection control. However poor response was noticed and her lt. breast wound were still presenting contineous bloody discharge. We need your expertise to evaluated this patient for the possibility of surgical treatment or other management. Thank you.
  • A
    • I think wide-excision with extended mastectomy is a reasonable option for the patient, since chemotherapy is not very helpful.
    • If the defect caused by cancer-ablasion is too big, at least I can do skin grafting to resurface the wound. If the dimension of the defect is smaller or equal to the TRAM flap, technique of flap-reconstruction to chest wall is not a problem to me. However, the surgery takes much of patient’s strength, and she must have more daily calori BEFORE the flap surgery, and she may need some self-pay albumin AFTER the flap surgery.

[chemotherapy]

• 2024-05-24 - docetaxel 40mg/m2 60mg NS 100mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-05-17 - docetaxel 40mg/m2 60mg NS 100mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-06-04

[Chemotherapy-Induced Anemia]

Lab:

• 2024-06-02 HGB 8.5 g/dL
• 2024-05-29 HGB 9.0 g/dL
• 2024-05-27 HGB 6.4 g/dL
• 2024-05-23 HGB 8.1 g/dL
• 2024-05-16 HGB 10.8 g/dL
• 2024-05-13 HGB 6.5 g/dL
• 2023-11-09 HGB 13.1 g/dL

Docetaxel and Potential Contribution to Anemia

• The patient received Taxotere (docetaxel) on 2024-05-17 and 2024-05-24).

• While anemia was already present before these treatments, docetaxel is known to have a high incidence of anemia (65% to 97%, with 8% to 9% reaching grades 3/4). Therefore, it’s possible that the chemotherapy may have worsened (exacerbated) the existing anemia.

Management of Severe Chemotherapy-Induced Anemia

In cases of severe anemia caused by chemotherapy, leukocyte-reduced packed red blood cell (LPRBC) transfusions may be considered. (A blood transfusion was performed on 2024-05-27).)

[Trodelvy as alternative for severe anemia if current regimen not tolerated anymore]

If the treatment with docetaxel causes recurrent and severe anemia in this patient, it may be necessary to consider adjusting the regimen. In such a case, Trodelvy (sacituzumab govitecan) might be considered. The NHI coverage criteria for this drug are as follows:

• It is applicable for treating adult patients with unresectable locally advanced or metastatic triple-negative breast cancer who have previously received at least two systemic treatments (one of which must be for advanced disease) and meet the following conditions:
  • The patient’s physical condition is good (ECOG ≤ 1).
  • The patient must have used a taxane-based drug for at least one treatment course.
• Prior approval is required, and each application is limited to a treatment course of 3 months. The initial application must include test reports confirming ER, PR, and HER2 negativity.
• For subsequent applications, objective evidence (e.g., imaging) must be provided to confirm no disease progression for continued use.

700887413

240604

[exam findings]

• 2024-02-23 CXR
  • S/P tracheostomy.
  • Fibrotic infiltrate in left upper lung.
  • Blunting of costophrenic angle, left side, could be due to pleural effusion.
• 2024-02-23 ECG (emergency)
  • Sinus tachycardia
  • ST elevation, consider early repolarization, pericarditis, or injury
  • Abnormal ECG
• 2024-02-23 CT - brain
  • Without-contrast CT scan of the brain with 4-mm axial and sagittal images reveals:
    • Mild degree of general enlargement of ventricles, cisterns and cortical sulci indicating general brain atrophy.
    • No intracranial hemorrhage, nor space-occupying lesion.
    • No midline shift, nor mass effect.
    • No skull fracture.
    • S/P NG tube and tracheostomy.
  • IMP:
    • Mild general brain atrophy.

[MedRec]

• 2024-02-24 ~ 2024-03-23 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • hypophayngeal ca, squamous cell carcinoma, cT4a(b)N3bM1(L4), stage IVA, with metastases to right cervial level II, III, IV, right supraclavicular and right thoracic inlet nodes
    • Contusion of unspecified part of head, initial encounter
    • Major depressive disorder, single episode, unspecified
    • Other pneumonia, unspecified organism
    • Anemia, unspecified
    • Fever, unspecified
    • Cachexia
  • CC
    • Weakness and dizziness, then fall down at home.
  • Present illness
    • This 72-year-old male patient has histories of hypophayngeal ca, squamous cell carcinoma, cT4a(b)N3bM1(L4), GAP 4, PD-L1 Dako 22C/TPS 10%, CPS 29, stage IVA, status post laryngomicrosurgery biopsy + tooth extraction + tracheostomy.
    • Chemotherapy (afatinib + avastin + pembrolizumab) from 2024/05/23-06/30 and started Erbitux from 2024/07/28 in NTUH.
    • Neck MRI at NTUH reported hypopharyngeal cancer, staging T4aN3bMX.
    • Whole body PET at NTUH revealed hypopharyngeal maliganancy with metastases to right cervial level II, III, IV, right supraclavicular and right thoracic inlet nodes.
    • Today, fall down at home, that he was brought to ER for help. Mild deformity of occpital region, weakness and dizziness were noted. No conscious change and no wound, that he was brought to ER for help. At ER, physcial examination revealed ill-looking, GCS: E4VTM6, BT: 36.6’C, HR: 113/min, BP: 129/59 mmHg. EKG showed Normal sinus rhythm.
    • Brain CT showed Mild general brain atrophy. CxR revealed Fibrotic infiltrate in left upper lung and Blunting of costophrenic angle, left side, could be due to pleural effusion. Blood analysis showed no leukocytosis and normal renal function. But anemia, elevation of CRP level and Hyponatremia.
    • Under the impression of 1) hypophayngeal ca. 2) Sepsis with anemia, he was admitted to infection ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, broad spectrum antibiotics brosym was prescribed for pneumonia.
    • Rolikan INHL was given for much sputum.
    • Fever was still noted so acetaminophen was given PRN.
    • His sputum culture showed Pseudomonas growth. We shifted antibiotics to cefepime.
    • Serum data follow on 2024/02/29 still showed leukocytosis and high CRP. No dyspnea or fever was still noted.
    • Family meeting was held on 2024/02/29. His family decided not let the patient to receive hospice care.
    • Chest CT on 03/02 showed radiation pneumonitis at left lung with left pleurisy, left pleural meta is suspected, and bilateral pleural effusion. His clinical conditions were stable and improving.
    • During 03/02 to 03/09, his clincial conditions were stable. Chest Xray and lab data followed on 03/04 and 03/07 showed improving results. However, he complained about insominia related with pain around L-spine. We therefore consulted psychiatric department for medication adjusiment, prescribing Eurodin 1# HS and discontinue Xanax.
    • We arranged bone scan to rule out L-spine metastasis on 03/08. The results showed mildly increased activity in the lower C-spine, some T- and L-spines and bilateral S-I joints, favored degenerative change, no obvious evidence of metastasis.
    • During 03/09 to 03/16, chest xray and lab data followed on 03/11 and 03/15 showed leucocytosis and elevating CRP. Sputum Gram stain and sputum culture respectively showed GPC 4+, GNB 4+, and pseudomonas 4+, MRSA 4+. We therefore prescribed Avelox and Sintum for infection control. Contact isolation was also performed.
    • From 03/16 to 03/23, lab data and CXR followed on 03/18 and 03/21 showed better results. For his expired tracheastomy, we consulted ENT for him. We also arranged L-S spine Xray and consulted orthopedics for his L-spine protrusion with pain. Xray report showed Disk space narrowing of L4-5. Orthopedic surgeon gave Shincort for symptoms control. Gram stain of sputum on 03/20 showed not found. Sputum culture results were pending. Due to his better conditions and under his daughter’s request. He was allowed discharge today with OPD follow up arranged and medication prescribed.
  • Discharge prescription
    • Wecoli (bethanechol 25mg) 1# TIDAC
    • Utapine (quetiapine 25mg) 1# HS
    • Ulstop (famotidine 20mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# TID
    • Takepron (lansoprazole 30mg) 1# QDAC
    • Syntam Granules (piracetam 1200mg) 1# QD
    • Smecta (diotahedral smecitite 3gm) 1# TIDAC
    • Roumin (prochlorperazine maleate 5mg) 1# TID
    • Mirtapine Orally Disintegrating (mirtazapine 30mg) 1# HS
    • Megest (megestrol 40mg/mL) 5mL BID
    • MgO 250mg 1# TID
    • Fudecough (dextromethorphan 15mg) 1# TID
    • Eurodin (estazolam 2mg) 1# HS
    • Aelocon (thiamine B1 50mg, riboflavin B2 5mg) 1# QD
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Avelox (moxifloxacin 400mg) 1# QDAC
    • Urief (silodosin 8mg) 1# QD
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • Ceficin (cefixime 100mg) 2# Q12H
• 2024-02-23 SOAP Surgical Emergency He YaoCan
  • S: Blunt trauma to the head > Acute moderate central pain (4-7): Fall, blunt trauma to the head
    • Weakness and dizziness
    • Deny tarry stool
    • Hx of hypophayngeal ca post CT in NTUH
    • TRACHEOSTOMY (+)
  • O: Vital signs: BP:129/59; HR:113; BT:36.6’C; RR:20;
    • Con’s:E4VTM6
    • SpO2:95%
    • Alert consciousness
    • mild pale, S/P TRACHEOSTOMY
    • Mild deformity of occpital region
    • Free motion of four limbs
  • A: Preliminary impression S00.93XA Contusion of unspecified part of head, initial encounter
    • H.I, brain CT: no ICH. bil. PN, Brosym, CRP:9.1, COVID/FLU-. Hb:7.0. BT 2U, Hb8
      
    • Hx of hypophayngeal ca s/p C/T, f/u at NTUH, oa Onco.

[chemotherapy]

UFT (tegafur 100mg, uracil 224 mg)

==========

2024-06-04

[tube feeding - UFT handling precautions]

UFT (tegafur and uracil) is cytotoxic, posing a potential health hazard if directly contacted. Therefore, it is strongly recommended that healthcare personnel follow strict safety protocols when handling UFT granules to prevent exposure.

701496080

240604

[exam findings]

• 2024-03-13 Patho - soft tissue debridement
  • Soft tissue, right neck, incision and drainage — Squamous cell carcinoma, moderately differentiated
  • Section shows fibrous tissue with infiltration of nests of neoplastic squamous cells.
• 2024-01-20 MRI - nasopharynx
  • Regressed tumor in right submandibular space, invasion to carotid, parotid spaces, oropharynx wall and right pterygoid muscles.
  • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor, with necrosis change.
  • Possible necrotic LNs in right submandibular space
  • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
  • Correlation with previous imaging study for comparison is suggested.
• 2023-10-17 PD-L1 IHC
  • Cellblock No. S2023-20345
  • RESULTS：
    • Tumor cell(TC) staining assessment: TC >= 1% and < 5%
    • Percentage of PD-L1 expressing tumor cells (%TC): 1%
• 2023-10-13 Patho - soft tissue debridement
  • Soft tissue, neck, right, incision and drainage — Squamous cell carcinoma, moderately differentiated
  • The sections show a picture of squamous cell carcinoma, composed of sheets of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.
• 2023-10-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (123 - 32) / 123 = 73.98%
    • M-mode (Teichholz) = 73
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Mild AR, MR
• 2023-09-08 Tc-99m MDP bone scan
  • Increased activity in the lower C-spine and L3 spine. Degenerative change may show this picture.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2023-08-31 MRI - larynx
  • Impression (Imaging stage): T: 4(T_value) N: 3(N_value) M: 0(M_value) STAGE: ____(Stage_value)
• 2023-08-31 Patho - esophageal biopsy
  • Esophagus, EC junction,biopsy— chronic esophagitis
  • Esophagus, 34 cm below incisor, junction,biopsy— chronic esophagitis
  • All for sections: A: EC junction, B:34 cm below incisor
    
  • Microscopically, sections A and B show acanthosis with lymphoplasmacytic infiltrate. No goblet cell is seen.
• 2023-08-30 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A-
    • R/O eosinophilic esophagitis, lower esophagus, s/p biopsy (A) and (B)
    • Superficial gastritis, s/p CLO test
    • Gastric erosions, antrum
  • CLO test: Negative

[MedRec]

• 2023-08-29 ~ 2023-09-22 POMR Oral and Maxillofacial Surgery Xia YiRan
  • Discharge diagnosis
    • Squamous cell carcinoma of right submandibular gland with neck lymph nodes metastasis cT4bN3M0 stage IVB in progress induction chemotherapy
    • local infection of right neck and parotid gland tail area
    • Chronic viral hepatitis, unspecified
    • Encounter for antineoplastic chemotherapy
    • Chemotherapy related anemia
  • CC
    • He was admitted for futher treatment due to A MALIGNANT TUMOR AT HIS right neck.
  • Present illness
    • This is 46y/o male without underlying history was admitted due to A MALIGNANT TUMOR AT HIS right neck.
    • Accroding to the STATEMENT OF PATIENT’S HIMSELF, THE PRESENT ILLNESS SHOULD BE TRACED BACK TO LAST MONTH.
    • Discharge note from YangMing JiaoTong Univ Hospital, CT scan showed a 4.7x3.8cm tumor at right neck, biopsy showed squamous cell carcinoma.
    • PET scan showed a FDG-avid mass at right neck level II with central necrosis and abutting the right submandibular gland.
    • The possibility of metastatic LAP or submandibular gland cancer are considered. pre-op C/T with PFL twice at onco OPD in 2023/07, but no response was noted by clinical picture even P16+.
    • PFL was switched to TPF and TPF C1 (Q3W) was on 8/9-8/11. (5-FU reduced to 3 days dose since unrecovered thrombocytopenia 75000/ul due to PFL).
    • After TPF, no marked tumor regression was noticed. R/T from 8/21-25,28; x6 times was done.
    • Under the impression of head and neck tumor, he was admitted for futher treatment.
  • Course of inpatient treatment
    • After admission, his Larynx MRI revelaed squamous cell carcinoma of right submandibular gland with neck lymph nodes metastasis cT4N3M0 stage IVB on 2023-08-31. After consulted Hematologist for further treatment of the right neck tumor, and was suggested to consult OS Dr. for surgical intervention directly first, and we was arranged for insertion of PORT-A scheduled by CVS doctor. He transferred to OS ward for prepare pre-chemotherapy survery on 2023-09-04.
    • At OS ward, we had arrange physcial examination was done for pre-chemotherapy. He under received left clavicle port-A insertion on 2023-09-07.
    • Then he received the 1st session of the 1st cycle of induction chemotherapy with #1a TPF (Taxotere 40mg/M2, cisplatin 40mg/M2, 5-fu 1000mg/M2 plus Leucovorin 100mg/M2) + Methotrexate 30mg/M2 on 2023/09/11 to 2023/09/13.
    • And the 2nd session of the 1st cycle of induction chemotherapy with #1b TPF (Taxotere 40mg/M2, cisplatin 40mg/M2, 5-fu 1000mg/M2 plus Leucovorin 100mg/M2) + Methotrexate 30mg/M2 on 2023/09/18 to 2023/09/20.
    • Local heat with red facial skin over the right mandibular angle and parotid gland tail are noted. No shrinkage of the malignant tumor was noted on 2023-09-21.
    • Currently, it is measured about 11*10 cm over postauricular area with induration, extending to right submandibular area and upper neck (One week ago, this malignant tumor was reduced its size). Analegsic agent with Neurotin 1tab PO TID was prescribed. Oral under full liquid diet with high protein diet. Mouth gargling with Parmason solution Q3HPRN. Pay attention chemotherapy-related side effeects and general condition for him. We follow-up Lab. data on today morning showed all data within normal limit. As his condition was stable after chemotherapy was delivered, the patient was discharged on 2023-09-22 and next cycle of induction chemotherapy was arranged for him on 2023-10-02.
  • Discharge prescription
    • Eurodin (estazolam 2mg) 1# PRNHS if insomnia
    • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC if nausea or vomit
    • loperamide 2mg 2# PRNQ8H if diarrhea > 4 times per day
    • Neurontin (gabapentin 100mg) 1# TID
    • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# Q12H
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
    • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC

[immunochemotherapy]

• 2024-05-02 - cetuximab 250mg/m2 400mg 1hr + nivolumab 100mg NS 100mL 1hr (Erbitux + Opdivo)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2024-04-09 - cetuximab 250mg/m2 450mg 1hr + nivolumab 100mg NS 100mL 1hr + methotrexate 24mg/m2 40mg NS 100mL 30min (Erbitux + Opdivo + MTX)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2024-03-27 - docetaxel 28mg/m2 50mg NS 100mL 1hr + cisplatin 28mg/m2 50mg NS 500mL 3hr + fluorouracil 700mg/m2 1200mg leucovorin 70mg/m2 120mg NS 1000mL 22hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2024-03-01
• 2024-01-22
• 2024-01-02
• 2023-12-12
• 2023-12-06
• 2023-11-16
• 2023-11-06
• 2023-10-20
• 2023-10-02
• 2023-09-18
• 2023-09-11

==========

2024-06-04

[Patient Experiences Severe Symptoms of Anorexia, Cough, and Dyspnea]

The patient is reported to have symptoms of loss of appetite (anorexia), cough, and difficulty breathing (dyspnea), all of which are classified as Grade 3 (severe). It is noted that the patient’s weight reached a recorded high of 78.8 kg on 2023-11-06, but then fluctuated with more decreases than increases, reaching a low of 60.5 kg on 2024-04-12. Recently, on 2024-05-24, the weight has risen slightly to 66.1 kg. These weight changes during this period may be influenced by the patient’s swallowing difficulties, which could be a possible cause for the reported loss of appetite. Additionally, a chest X-ray (CXR) performed on 2024-05-14, showed increased infiltration in both lower lungs, which could be an active infection.

While chemotherapy (TPF), targeted therapy (cetuximab: cough incidence 30%, dyspnea 49%, pharyngitis 26%), and immunotherapy (nivolumab: immune-mediated pneumonitis has occurred less frequently, mechanism non-dose-related, immunological. Onset varied; ranging from 2 to 24 months with a median onset of ~3 months) cannot be completely ruled out, it is suspected that these symptoms are more closely related to the patient’s underlying disease progression and the suspected pulmonary infection.

700171113

240603

[exam findings]

• 2024-05-17 RAS + BRAF
  • Cellblock No. S2024-09222
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2024-05-08 Patho - colon biopsy
  • Colorectum, sigmoid colon 25 cm above anal verge, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
• 2024-05-08 Patho - stomach biopsy
  • Stomach, prepyloric antrum, biopsy — Chronic gastritis with intestinal metaplasia, H pylori NOT present
  • Section shows benign gastric mucosal tissue with chronic inflammation and intestinal metaplasia.
• 2024-05-08 CT - abdomen
  • Findings:
    • There is segmental circumferential asymmetrical wall thickening at the sigmoid colon, 5 cm in size, with lumen narrowing that is c/w adenocarcinoma of the sigmoid colon (T3) with partial obstruction.
    • There are six enlarged nodes in the adjacent mesocolon that are c/w regional metastatic nodes (N2a).
    • There are multiple poor enhancing masses on both hepatic lobes (up to 3.3 cm in S5) that are c/w multiple liver metastases (M1a).
    • There are several gallstones.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
• 2024-05-08 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis, s/p CLO test
    • Gastric erosions, prepyloric antrum, s/p biopsy
    • Gastric polyps, fundus and body
  • CLO test: Negative
• 2024-05-08 Colonoscopy
  • Findings
    • The scope reach the sigmoid colon, 25cm AAV, and the scope could not further insertion due to luminal stenosis and large resistence.
    • One cicumferential fugative tumor with luminal stenosis was found at 25cm AAV and biopsy x6 was done.
    • Internal hemorrhoid was noted.
  • Diagnosis:
    • Sigmoid tumor with luminal stenosis, suspect malignancy, s/p biopsy
    • Internal hemorrhoid
    • incomplete study due to luminal stenosis
  • Suggestion:
    • F/U pathology report
    • Arrange CT scan for further survey and refer to CRS
• 2024-05-02 SONO - abdomen
  • Indication: RUQ pain
  • Symptoms: RUQ pain
  • Findings
    • Liver:
      • Smooth surface and fine echotexture of liver was noted.
      • Several hypoechoic lesions with bull’s eye sign up to 3.5cm were noted at right lobe.
      • Several anechoic lesions up to 0.7cm were noted at bilateral lobes.
    • Bile duct and gallbladder
      • Several hyperechoic lesions with PAS were noted in GB.
      • CBD and bilateral IHD were not dilated.
    • Portal veins and blood vessels:
      • Patent portal vein.
    • Kidney:
      • No definite stone or hydronephrosis.
    • Pancreas:
      • Some parts of pancreas blocked by bowel gas, especially tail
    • Spleen:
      • No splenomegaly
    • Ascites:
      • No ascites
  • Diagnosis:
    • Hepatic tumors, right lobe, r/o metastases
    • Hepatic cysts, bilateral lobes
    • GB stones

[immunochemotherapy]

• 2024-05-31 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400m/mg2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-06-03

[reconciliation]

No discrepancies were identified in the medication list, and all laboratory values obtained on 2024-05-31 met criteria to initiate the planned Avastin + FOLFIRI regimen.

700926055

240603

[exam findings]

• 2024-05-31 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (86.3 - 23) / 86.3 = 73.35%
    • M-mode (Teichholz) = 73.6
  • Conclusion:
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Poor echo window
• 2024-04-25 Tc-99m MDP bone scan
  • The scintigraphic findings suggest multiple bone metastases.
• 2024-04-18 Patho - liver biopsy needle/wedge
  • Liver, EUS FNB — Adenocarcinoma, poorly differentiated
  • The specimen submitted consists of multiple small strips of yellow gray soft tissue, labeled liver, measuring up to 0.9 x 0.1 x 0.1 cm. All for section.
  • The sections show adenocarcinoma, poorly differentiated, composed of nests of large pleomorphic neoplastic cells, arranged in solid and subtle glandular patterns, embedded in fibrous stroma.
  • IHC, tumor cells reveal: CK7(+), CK20(-), p40(-), TTF1(-), and Hepa-1(-). According to morphology and immunophenotypes, cholangiocarcinoma cannot be excluded and metastatic pulmonary carcinoma is less likely. Suggest clinic and radiologic correlation.
• 2024-04-17 Endoscopic Ultrasound, EUS
  • Indication:
    • liver tumor
  • Endoscopic findings：
    • Short mucosal breaks noticed at the lower esophagus just above the E-C junction.
  • EUS findings：
    • Using EUS-UCT 260 showed
      • Numerous hypoechoic lesions at both lobe of liver.
      • Two enlarged lymph nodes at mediastium,
      • Minimal ascites is also noticed.
      • One hyperechoic lesion with posterior acoustic shadow in the GB.
      • The size of MPD and CBD are within normal limit.
      • Enlargement of the pancreas tail, size: 21 mm.
  • Management：
    • CH-EUS with Sonazoid 0.6 cc is injected into to the IV line. After 13 sec, ring hyperenhancement pattern is seen at the tumors. EUS-FNB is done with Acquire needle 22G, total two passes performed at Seg 4and some whitish core tissue is obtained. The tissue is sent for histology, and cytology evaluation.
  • Diagnosis：
    • Hepatic tumors Prob. metastasis, s/p CH-EUS FNB
    • Mediastinal lymphadenopathy
    • Ascites
    • GB stones
    • Enlarged pancreas tail
    • Reflux esophagitits, LA grade A-
• 2024-04-16 Patho - colon biopsy
  • Intestine, large, transverse colon, polypectomy — hyperplastic polyp
• 2024-04-15 EGD
  • Superfical gastritis, antrum, s/p CLO test
  • Gastric ulcer, multiple, body, antrum
  • CLO test: Negative
• 2024-04-15 Colonoscopy
  • Colon polyp, transverse colon, s/p polypectomy
  • Internal hemorrhoid
• 2024-04-11 CT - abdomen
  • History and indication: Elevated CA19-9 and anemia. Body weight loss also noted.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Multiple poor enhancing tumors (up to 2.9cm) in both hepatic lobes with middle/ right hepatic vein/ IVC invasion.
    • Renal cysts (up to 1.0cm).
    • Some LNs at hepatic hilar region and retroperitoneum.
    • Enlargement of pancreatic tail.
    • A nodule (1.3cm) at RUL.
    • Minimal ascites.
    • Gallbladder stone (1.3cm).
    • Atherosclerosis of aorta, iliac arteries.
    • Compression fracture of T11. Multiple bony destructions.
  • Imaging Report Form for Cholangiocarcinoma
    • Impression (Imaging stage) : T:T2(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)
• 2024-04-08 SONO - abdomen
  • Diagnosis:
    • Hepatic tumors, r/o metastatic tumors
    • P-duct dilatation
    • Gallstone
    • r/o accessory spleen or lymphadenopathy
  • Suggestion:
    • Arrange admission for primary malignancy survey.
• 2024-03-20 ENT Hearing Test
  • ETF bil POOR (ETF ? Eustachian Tube Function)
  • PTA:
    • Reliability FAIR
    • Average RE 44 dB HL; LE 41 dB HL
    • bil normal to severe SNHL
• 2024-02-21 Nasopharyngoscopy
  • smooth NPx, oropharynx, hypopharynx, sticky post nasal drip

[MedRec]

• 2024-04-10 ~ 2024-04-18 POMR Gastroenterology Zheng KuenLin
  • Discharge diagnosis
    • Hepatic tumors, favor metastasis, status post endoscopic ultrasound guided fine needle biopsy on 2024-04-17.
    • Mediastinal lymphadenopathy
    • Ascites
    • Gallbladder stones
    • Enlarged pancreas tail
    • Reflux esophagitits
    • Anemia
  • CC
    • for anemia survey from OPD admission and body weight loss 6-8 kilograms in 6 months
  • Present illness
    • This is a 73 year-old male, who had the past history of
      • Chronic urticara after COVID-19 vaccine about Moderna
      • Chronic allergic rhinitis, and she was regular follow-up in our OPD and plaquenil used.
    • This time, due to rheumatology and immunology noticed anemia and body weight less 6-8 kilograms in 6 months with no reason, so she was referred to GI man OPD for anemia survey.
    • At GI OPD, abdominal sonography was performed that showed hepatic tumors, r/o metastatic tumors; P-duct dilatation; gallstone and r/o accessory spleen or lymphadenopathy.
    • Follwo up tumor marker with CA 199 that showed 50.45 U/mL. Explained this condition to himself, he understood.
    • Under the impression of Hepatic tumors, r/o metastatic tumors. He was admitted to our GI ward for primary malignancy survey.
  • Course of inpatient treatment
    • After admission, Liver + lung CT with/without contrast was performed which revealed multiple poor enhancing tumors (up to 2.9cm) in both hepatic lobes; some LNs at retroperitoneum. Enlargement of pancreatic tail; a nodule (1.3cm) at RUL; compression fracture of T11 and Multiple bony destructions.
    • Hepatitis markers with HBsAg, Anti HCV were checked that all showed negative finding. Tumor marker with AFP showed 87.9 ng/mL.
    • Painkiller with Scanol 1# po BID was given for symptoms relief.
    • Upper GI endoscopy and colonscopy were all performed which revealed colon polyp, transverse colon, s/p polypectomy Internal hemorrhoid on CFS; superfical gastritis, antrum, s/p CLO test and gastric ulcer, multiple, body, antrum on EGD.
    • In addition, oral form PPI with Pariet 1# po QDAC was given. Oncologist was consulted for management of bilateral liver tumor who suggested do tissue proof. Explained this condition to himself, he understood and agreed do EUS-FNB for further survey.
    • EUS-FNB was done on 4/17 without complications that revealed 1. Hepatic tumors Prob. metastasis, s/p CH-EUS FNB 2. Mediastinal lymphadenopathy 3. Ascites 4. GB stones 5. Enlarged pancreas tail 6. Reflux esophagitits, LA grade A-. There was no abdominal pain found after procedure and medical treatment. Under a stable condition, he was discharged on 4/18 and further GI OPD was arranged later.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNBID if still abdominal pain VAS > 3

[consultation]

• 2024-06-01 Infectious Disease
  • Q
    • Rear-line controlled antibiotics empiric therapy is required. Consultation with an infectious disease specialist is necessary.
  • A
    • This is a case of
      • Hepatic tumors, favor metastasis, status post endoscopic ultrasound guided fine needle biopsy on 2024-04-17.
      • Mediastinal lymphadenopathy
      • Ascites
    • 2024-05-31 WBC 1.24 x10^3/uL
    • Agree with your use with mepem and targocid for the neutropenic patient.
    • Please adjust antibiotic according to culture results and clinical conditions.
• 2024-04-16 Hemato-Oncology
  • Q
    • At GI OPD, abdominal sonography was performed that showed hepatic tumors, r/o metastatic tumors; P-duct dilatation; gallstone and r/o accessory spleen or lymphadenopathy. Under the impression of Hepatic tumors, r/o metastatic tumors. He was admitted to our GI ward for primary malignancy survey.
      
    • Due to Hepatic tumors, r/o metastatic tumors, we need your further advise Thanks~
  • A
    • This 73-year-old man is a case of bilateral liver tumors suspected to be intrahepatic cholangiocarcinoma or pancreatic cancer with liver metastasis. We have been consulted.
    • Please arrange for an EUS-guided biopsy for the liver tumor and pancreatic lesion if possible, or a CT-guided biopsy for the liver tumor.

[chemotherapy]

• 2024-05-16 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + NS 500mL 30min (before CDDP) + cisplatin 50mg/m2 70mg NS 500mL 2hr + NS 500mL 30min (after CDDP) (Gemzar + Kemoplat. QrW)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-05-08 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + NS 500mL 30min (before CDDP) + cisplatin 50mg/m2 80mg NS 500mL 2hr + NS 500mL 30min (after CDDP) (Gemzar + Kemoplat. QrW)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-06-03

[dose adjustments for moderate liver impairment]

Hypoalbuminemia (2 points) and hyperbilirubinemia (1 point), ascites (4/17 EUS, at least 2 points), no PT and encephalopathy data available (2 points), added up total at least 7 points for Child-Pugh class B.

• 2024-06-03 Albumin (BCG) 2.9 g/dL
  
• 2024-06-03 Bilirubin total 1.58 mg/dL
  
• 2024-06-03 Bilirubin direct 0.88 mg/dL
  
• 2024-06-03 Alkaline phosphatase 955 U/L

No dose adjustment is required for the current Gemzar (gemcitabine) and Kemoplat (cisplatin) regimen. However, Celebrex (celecoxib) is recommended to be reduced by 50% for moderate liver impairment (Child-Pugh class B), and the use of Tramacet (tramadol, acetaminophen) is not recommended as both drugs undergo extensive hepatic metabolism.

701168751

240603

[exam findings]

• 2024-05-14 Patho - stomach biopsy
  • Stomach, high body, biopsy — Non-atrophic chronic active gastritis
  • The sections show gastric body mucosal tissue with congestion, edema, mild chronic inflammatory cell infiltration, moderate neutrophil infiltration, no intestinal metaplasia, no gastric atrophy, and no Helicobacter pylori colonization.
• 2024-05-14 EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A-
    • Superficial gastritis, s/p CLO test
    • Gastric mucosal lesion, high body, PW, s/p biopsy
  • CLO test: Negative
• 2024-05-13 Tc-99m MDP bone scan
  • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, and knees.
• 2024-05-11 CT - chest
  • Indication: Faint nodules in right lower lung, r/o lung metastasis
  • Chest CT with and without IV contrast ehnancement shows:
    • Partial atelectatic change at right lower lobe is found.
    • Right mild pleural effusion is found.
    • Perifissural nodule at right middle lobe measuring 0.4cm is found. (Se8 Im66), the nature of the lesion should be further investigated.
    • Heterogeneous tumor at right lobe liver measuring 11.1cm with rupture into peritoneal space is found.
    • Lobulated soft tissue scattered at peritoneal space is found. Cancerous peritonitis is considered.
  • Imp:
    • Huge hepatic tumor at right lobe measuring 11.1cm with tumor rupture and cancerous peritonitis.
    • Right middle lobe tiny nodule. 0.4cm, nature to be determined.
• 2024-05-10 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma
  • The specimen submitted consists of two strips of yellow gray soft tissue, labeled liver, measuring up to 0.7 x 0.1 x 0.1 cm. All for section.
  • The sections show a picture of adenocarcinoma, poorly differentiated, composed of nests, cords, and single pleomorphic neoplastic cells in fibrous stroma. Subtle glandular differentiation and focal tumor necrosis are present.
  • IHC shows: CK7(+), CK20(-), CA19-9(focal +), Arginase-1(-), and Hepatocyte(-). The finding is compatible with cholangiocarcinoma.
• 2024-05-08 SONO - abdomen
  • Indication: Cancer evaluation
  • Symptoms:
    • Liver:
      • one mixed echoic lesion > 10cm with irregular margin was noted at right lobe.
      • Poor echo window of subcostal view.
    • Bile duct and gallbladder:
      • CBD was masked.
      • Gallbladder was not seen.
    • Portal veins and blood vessels:
      • Patent portal vein.
    • Kidney:
      • Hyperechoic lesion was noted in the left kidney
    • Pancreas:
      • masked.
    • Spleen:
      • No splenomegaly
    • Ascites:
      • No ascites
  • Diagnosis:
    • Liver tumor, no liquefaction, still could not r/o malignancy
    • Poor echo window of subcostal view (part of liver, CBD and pancreas were masked)
    • Post cholecystectomy
    • renal calcification, LK
  • Suggestion:
    • dynamic MRI study
    • Liver biopsy if clinical indicated
• 2024-05-07 CT - abdomen
  • With and without contrast enhancement CT of abdomen:
    • S/P cholecystectomy.
    • Large poor enhancing lesion in right lobe liver, up to 12.5cm with subphrenic extension, r/o malignancy (cholangiocarcinoma?) suggest further study.
    • There are soft tissue tumors, up to 5.7cm in right peritoneum and subphrenic region, r/o carcinomatosis.
    • Post-op at left kidney.
    • Outpouching lesions in ascending and descending colon, suggesting colon diverticula.
    • Faint nodular densities in right lower lung, r/o lung metastasis.
    • Focal radiolucent density in right aspect of L3 body, r/o bone metastasis.
  • Impression:
    • Peritoneal tumors, r/o peritoneal carcinomatosis.
    • Large liver poor enhancing lesions with subphrenic extension, r/o malignancy (cholangiocarcinoma?), suggest further study
    • Faint nodules in right lower lung, r/o lung metastasis.
    • Radiolucent density in L3 body, r/o bone metastasis.
    • S/P cholecystectomy.
  • Imaging Report Form for Cholangiocarcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV__(Stage_value)
• 2024-05-07 CXR erect
  • elevation of Rt hemidiaphragm may be due to expiratory phase or abdominal process?
  • marginal spurs of multiple vertebral bodies
  • enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad /supine position
• 2023-11-21 Patho - hemorrhoids
  • Anorectum, hemorrhoidectomy — Hemorrhoid
  • Specimen submitted in formalin consists of multiple pieces of tan, irregular tissue measuring 4.7 x 3.0 x 2.0 cm. On cut, the cut surfaces show many dilated congested vessels. Representative tissue for sections in 2 cassettes.
  • Sections show fragments of cutaneous-colonic junctional tissue with hemorrhage, edema, plexus of markedly dilated congested and focally thrombosed veins.
• 2019-03-07 Surgical pathology Level III
  • Clinical diagnosis
    • Calculus of gallbladder without mention of cholecystitis without mention of obstruction;
  • DIAGNOSIS:
    • Gallbladder, cholecystectomy
      • chronic cholecystitis
        
      • cholesterolosis
        
      • cholelithiasis (by clinical description)
  • GROSS DESCRIPTION:
    • Specimen submitted in formalin consists of a gallbladder measuring 6.2 x 3.4 x 0.7 cm. On opening, there are several small yellow mucosal polyps measuring up to 0.1 x 0.1 x 0.1 cm. No stone is found. Representative sections are taken in 2 cassettes A1-2.
  • MICROSCOPIC DESCRIPTION:
    • Sections show gallbladder with chronic inflammatory cell infiltration, submucosal fibrosis, and some Rokitansky-Aschoff sinus formation. Foamy histiocyte aggregates are noted in the lamina propria of the mucosal polyps.
• 2019-02-22 SONO - abdomen
  • Multiple GB stones with chronic inflammation.
  • Left renal tumor, R/O angiolipoma.

[MedRec]

• 2024-05-08 ~ 2024-05-21 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma with bone and peritoneal metastases, T3N1M1, stage IV
    • Unspecified viral hepatitis C without hepatic coma; Anti-HCV: positive
  • CC
    • Poor appetite, general weakness, body weight loss 3-4 Kg in 2 months and fever with chills about one month.
  • Present illness
    • This 66-year-old male had history of
      • Hypertension
      • Hyperlipidemia
      • Gout
      • Benign prostate hyperplasia
      • Left kidney lipoma status post robotic surgery in 2021
      • Gallbladder stones status post laparoscopic cholecystectomy 2019/03/07
      • Fourth degree hemorrhoids status post hemorrhoidectomy on 2023/11/21
      • HCV carrier s/p DAA treatment(2017/06 ~ 09). HCV eradicated.
    • This time, he sufferred from poor appetite, general weakness, body weight loss 3-4 Kg in 2 months and intermittent fever with chills (fever up to 39’C) about one month. About this week, tea color urine and jaundice were also noted. He visited to LMD for help.
    • At GI OPD, abdominal sonography was performed that showed liver mass, R/O HCC or abscess. Thus, he was refer to our ER for management. At our ER, blood test revealed leukocytosis with left shift found. Influenza screening was also checked that showed negative finding.
    • Abdominal CT with/without contrast was done that showed:
      • Peritoneal tumors, r/o peritoneal carcinomatosis.
      • Large liver poor enhancing lesions with subphrenic extension, r/o malignancy (cholangiocarcinoma?), suggest further study.
      • Faint nodules in right lower lung, r/o lung metastasis.
      • Radiolucent density in L3 body, r/o bone metastasis.
    • Antibiotic with Brosym was treatment. Explained this condition, he understood.
    • Under the impression of 1.) Suspect liver abscess; 2.) Suspect carcinoma of unknown primary (Peritoneal tumors, r/o peritoneal carcinomatosis; Large liver poor enhancing lesions with subphrenic extension, r/o malignancy (cholangiocarcinoma?) with lung and bone metastasis. 3.) Hypertension. He was admitted to our GI ward for management and further survey.
  • Course of inpatient treatment
    • After admission, the chest CT (5/15 24) revealed huge hepatic tumor at right lobe measuring 11.1cm with tumor rupture and cancerous peritonitis. Right middle lobe tiny nodule. 0.4cm, nature to be determined. Liver, CT-guided biopsy (5/14 24) proved Adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma.Abdominal CT (5/17 24) showed Peritoneal tumors, r/o peritoneal carcinomatosis. Large liver poor enhancing lesions with subphrenic extension, r/o malignancy (cholangiocarcinoma?), Faint nodules in right lower lung, r/o lung metastasis. Radiolucent density in L3 body, r/o bone metastasis. S/P cholecystectomy. Bone scan (5/13 24) showed negative for mets. Port-Ａ was inserted on 5/17 24, smoothly. Chemotherapy with Durvalumab (1440mg, self-paid)/Gemzar (1000mg/m2 D1 & D8)/Cisplatin (25mg/m2 D1 & D8) on 5/20 24, smoothly without obvious side effect. He was discharged on 5/21 24 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • MgO 250mg 1# TID
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Actein (acetylcysteine 200mg) 1# TID
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# HS
• 2023-11-21 ~ 2023-11-22 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Fourth degree hemorrhoids status post hemorrhoidectomy on 2023/11/21
    • Hypertension
    • Hyperlipidemia
    • Benign prostate hyperplasia
    • Gout
  • CC
    • Anal protruding mass for years, anal itchy, swelling and pain developed recently        
  • Present illness
    • This 65-year-old male had history of
      • Hypertension
      • Hyperlipidemia
      • Gout
      • Benign prostate hyperplasia
      • Left kidney lipoma status post robotic surgery in 2021
      • Gallbladder stones status post laparoscopic cholecystectomy 2019/03/07
    • This time, he sufferred from anal protruding mass for years, anal itchy, swelling and pain developed recently. Then he came to our OPD for help. At OPD, digital rectal examination showed no blood on the finger nor palpable mass in the distance of finger length. Anoscopy revealed normal color stool, normal rectal mucosa, and prolapsed mixed hemorrhoids. After discussing with the patient, hemorrhoidectomy was arranged. The surgical risks, such as post operative hemorrhage and wound infection were explained to the patient and he understood the risks. Then hemorrhoidectomy was arranged and he was admitted after hemorrhoidectomy for post-op care and further management.
  • Course of inpatient treatment
    • After admission, pre-op and anesthesia assessment was done. Hemorrhoidectomy was performed smoothly on 2023/11/21. After operation, no specific complain except for mild wound pain. Wound was clean and no ozzing. Under relative stable condition, we arranged his discharge on 2023/11/22 and OPD follow up.    
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • MgO 250mg 2# BID
    • Meitifen (diclofenac 75mg) 1# PRNQD
    • Trand (tranexamic acid 250mg) 1# BID
    • Ulstop (famotidine 20mg) 1# PRNQD for Meitifen
    • Biomycin Ointment (neomycin, tyrothricin) BID TOPI
    • Metrozole (metronidazole 250mg) 1# QID
• 2019-03-06 ~ 2019-03-09 POMR General and Gastroenterological Surgery Wu ChaoQun
  • Discharge diagnosis
    • [K80.20] Gallbladder stone status post laparoscopic cholecystectomy on 2019-03-07
  • CC
    • RUQ abdominal pain for months
  • Present illness
    • This 61-year-old male with histories of hypertension, cured HCV and gout was admited to our ward via OPD due to RUQ abdominal pain for months.
    • According to the patient, he had HCV about 3 years ago. He received medication treatment and HCV was cured. He then regular follow up at LMD. This time, gallbladder stone was noted by abdominal echo at LMD about 2 years ago. Due to no significent symptoms, closely follow up was suggested. He suffered from RUQ abdominal fullness and mild pain (VAS:3) in recent months. The symptoms may exacerbate after eating. He then came to our OPD for medical attention.
    • Abdominal echo was arranged and showed: 1. Multiple GB stones with chronic inflammation. 2.Left renal tumor, R/O angiolipoma. During the whole course, there is no dizziness, no nausea, no vomiting, no fever.
    • Under the impression of gallbladder stone with chronic inflammation, he was admited to our ward for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, the patient received operation of laparoscopic cholecystectomy on 2019/03/07. The whole course was smooth. After operation, he recoved well. The wound was clean, no discharge, no erythematous change.
    • Pathology of the specimen showed gallbladder with chronic inflammatory cell infiltration, submucosal fibrosis, and some Rokitansky-Aschoff sinus formation.
    • With his stable vital sign and good condition, he then discharged. We suggested him follow up at our OPD next week.
  • Discharge prescription
    • MgO 250 mg 1# QID 7D
    • Lactam (acetaminophen 500mg) 1# QID 7D

[surgical operation]

[chemotherapy]

• 2024-05-28 - ………………………….. gemcitabine 1000mg/m2 1800mg NS 100mL 30min + cisplatin 25mg/m2 45mg NS 250mL 2hr (C1D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-20 - durvalumab 1440mg NS 100mL 1hr + gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 25mg/m2 40mg NS 250mL 2hr (C1D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

700128624

240531

[exam findings]

• 2024-05-28 CXR
  • Increase bilateral lung markings.
  • Mild cardiomegaly.
  • Thoracic spondylosis.
  • Presence of metallic clips in RUQ, could be due to post cholecystectomy.
• 2024-04-30 SONO - nephrology
  • Parenchymal renal disease, c/w diabetic kidney disease
  • Renal cysts, left kidney
• 2024-04-20 CXR erect
  • Increase bilateral lung markings.
  • Mild cardiomegaly.
  • Thoracic spondylosis.
  • Presence of metallic clips in RUQ, could be due to post cholecystectomy.
• 2024-04-20 EGD
  • Diagnosis:
    • Hiatal hernia
    • Reflux esophagitis, Gr B
    • Superficial gastritis, antrum
    • Shallow GUs, antrum and llow body
    • S/p CLO test
  • CLO test: Negative
  • Suggestion:
    • PPI Tx and OPD f/u
    • EGD was suggested for GUs f/u 3 months later
    • EGD was suggested annually for GERD and propable Barret’s esophagus f/u
• 2024-04-19 ECG
  • Sinus rhythm with 1st degree A-V block
  • Low voltage QRS
  • Borderline ECG

[MedRec]

• 2024-05-28 SOAP Nephrology Lin DingYun
  • Prescription x3
    • Pentop (pentoxifylline 400mg) 1# QD
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
• 2024-04-22 SOAP Gastroenterology Li ZhongXian
  • Prescription x3
    • Pariet (rabeprazole 20mg) 1# QDAC

==========

2024-05-31

[assessing anemia causes and ESA criteria]

Normocytic anemia was observed. Given that TSH and Free T4 levels are WNL, hypothyroidism can likely be ruled out, suggesting CKD as the more probable cause.

• 2024-05-30 MCV 85.8 fL
  

• 2024-05-30 HGB 6.6 g/dL
  

• 2024-05-14 HGB 6.9 g/dL
  

• 2024-05-09 HGB 6.7 g/dL
  

• 2024-04-30 HGB 8.0 g/dL
  

• 2024-04-20 HGB 8.4 g/dL
  

• 2024-04-19 HGB 8.1 g/dL
  

• 2024-04-19 HGB 6.5 g/dL

• 2024-05-28 TSH 1.337 uIU/mL
  

• 2024-05-28 Free-T4 1.05 ng/dL

Oral iron supplementation has been prescribed by our nephrologist on 2024-05-28 for repeat refills. Prior to this supplementation, lab results showed normal iron levels: Ferritin 237 ng/mL and TSAT = 104 ug/dL / 437 ug/dL = 23.8%.

• 2024-04-30 Ferritin 237.0 ng/mL
  
• 2024-04-30 Fe (Iron-bound) 104 ug/dL
  
• 2024-04-30 TIBC 437 ug/dL
  
• 2024-04-30 UIBC 333 ug/dL

It is recommended to initiate erythropoiesis-stimulating agent (ESA) therapy when the following conditions are met: - Hemoglobin consistently lower than 11g/dL, i.e., at least two recordings more than two weeks apart (met). - Adequate iron stores: ferritin > 100µg/L (met), transferrin saturation (TSAT) > 20% (met), reticulocyte hemoglobin content (CHr) > 29pg (not available). - Other causes of anemia excluded (further investigation might be needed, for instance, acquired pure red cell aplasia or monoclonal gammopathies.)

Ref: https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Erythropoieses%20Stimulating%20Agents%20(ESAs)%20in%20Renal%20Failure%20UHL%20Renal%20Guideline.pdf

700504699

240531

[lab data]

2023-10-04 HBsAg Nonreactive
2023-10-04 HBsAg (Value) 0.39 S/CO
2023-10-04 Anti-HBc Reactive
2023-10-04 Anti-HBc-Value 5.48 S/CO
2023-10-04 Anti-HCV Nonreactive
2023-10-04 Anti-HCV Value 0.05 S/CO

[exam findings]

• 2024-05-30 CXR
  • A mass left left chest wall.
  • Multiple bony metastases.
  • Ground glass opacity in RLL.
• 2024-05-03 Nasopharyngoscopy
  • smooth nasopharynx, oropharynx, hypopharynx
  • remove Merocel x2, some blood clots and erosion, no active bleeder noted
• 2024-04-29 CXR erect
  • A mass with adjacent bony destruction at left chest wall.
  • Left pleural effusion.
  • Fracture of left 8th rib.
  • Atherosclerosis of the aorta.
  • Osteoporotic change with some destructive lesions in bony structures.
• 2024-04-29 CT - brain
  • Osteoporotic change with some destructive lesion of bony structures r/o multiple myeloma.
  • Swelling of left parietal scalp. Partial opacification of paranasal sinuses. Brain atrophy.
• 2024-04-29, -03-01 ECG
  • Sinus tachycardia
  • Left axis deviation
  • Abnormal ECG
• 2023-10-10 Knee bilat.
  • Osteoarthritis of the bilateral knee with osteophytes formation and joint space narrowing of the lateral femorotibial joint.
  • There is osteolytic lesion right distal femur.
• 2023-10-02 CXR (erect)
  • Patchy opacity projecting at left upper lateral lung or pleura area is noted. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Linear infiltration over left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2023-07-18 Shoulder Rt and Humerus Rt
  • Osteoporotic or osteolytic change of right humerus, right clavicle and right scapular is noted that may be multiple myeloma? please correlate with clinical condition or CT.
• 2023-05-09 Humerus Bilat
  • Osteoporotic or osteolytic change of left clavicle and left humerus are noted that may be multiple myeloma? please correlate with clinical condition or CT.
  • Fracture of left humeral neck is noted.
• 2023-04-24 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — myeloma.
  • Section shows piece(s) of bone marrow with 50 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes and increased plasmacytoid subpopulation. Megakaryocytes are adequate in number.
  • IHC stains: CD117: <2%; MPO: 25-30%, CD138: 25-30 %; (of the nucleated cells). Kappa and Lambda light chains show a predominant kappa sub-population.
• 2023-01-08 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Linear infiltration over left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2023-01-06 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2023-01-06 ECG
  • Normal sinus rhythm
  • Right superior axis deviation
  • Pulmonary disease pattern
  • Cannot rule out Inferior infarct, age undetermined
  • Abnormal ECG
• 2022-10-24 CXR
  • Normal sinus rhythm
  • Left axis deviation
  • Incomplete right bundle branch block
• 2022-10-24 CXR
  • Tortuosity of the aorta with atherosclerotic change.
  • Increased lung markings over both lungs.
  • Degenerative joint disease of T-spine with marginal osteophytes.
  • Osteopenic change.
• 2022-07-13 Mini-mental state examination, MMSE
  • Score 10
    • Score Level of impairment

    • = 27 None

    • 21-26 Mild
    • 11-20 Moderate
    • <= 10 Severe
• 2022-07-13 Clinical Dementia Rating, CDR
  • Score 2
    • Composite Rating Symptoms
    • 0 none
    • 0.5 very mild
    • 1 mild
    • 2 moderate
    • 3 severe
• 2022-07-01 CT - brain
  • Brain atrophy and leukoaraiosis.
  • Diffuse osteolytic bone change with some area of cortical destruction. Suggest further workup.
• 2021-11-12 ENT Hearing Test
  • PTA
  • Reliability FAIR
  • Average R’t 89 dB HL; L’t 70 dB HL
  • R’t moderately severe to profound mixed type HL
  • L’t moderate to profound mixed type HL.
  • (masking dilemma)
• 2021-11-12 Auditory brainstem evoked response, ABR
  • ABR show response at 60 dB nHL in both ears.
• 2021-10-15 ENT Hearing Test
  • PTA:
    • Reliability FAIR
    • Average R’t 85 dB HL; L’t 73 dB HL
    • R’t moderately severe to profound mixed type HL
    • L’t moderate to profound mixed type HL.
    • (masking dilemma)
  • Tymp: R’t type C; L’t type A.
  • ART: Bil absent.
• 2021-04-02 ENT Hearing Test
  • PTA:
  • Reliability FAIR
  • Average RE 89 dB HL; LE 60 dB HL
  • RE severe to profound MHL (mixed hearing loss)
  • LE moderate to profound SNHL (sensory neural hearing loss)
• 2021-02-19 ENT Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 85 dB HL, severe to profound mixed type HL
    • L’t : 61 dB HL, moderate to severe SNHL
  • Tymp
    • R’t : Type C
    • L’t : Type A
  • ART
    • Bil absent.
• 2021-01-19 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 2020/03/31, the previous bone lesions in the left humeral head, right pubic bone and bilateral knees are a little less evident.
  • The lesions in the upper portions of bilateral S-I joints and greater trochanter of left femur are new. The nature is to be determined (post-traumatic change? other nature?). Please correlate with other clinical findings for further evaluation.
  • Other bone lesions are either stationary or a little less evident.
• 2021-01-18 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Plasma cell myeloma
    
  • The sections show normocellular marrow (30%). The M/E ratio about 3:1. The myeloid cells show good maturation. The megakaryocytes are unremarkable. Sheets and isolated CD138+ mature and immature plasma cells in interstitium, constitue 50% of marrow cells are noted. The plasma cells also reveal kappa light chain restriction and negative for lambda light chain.
• 2020-03-31 Tc-99m MDP bone scan with SPECT
  • Prominently increased activity in the left humeral head, right pubic bone and bilateral knees. Multiple myeloma involving these bones should be watched out. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Increased activity in the middle and lower C-spines, some middle to lower T-spines, some L-spines and sacrum. Either degenerative change or multiple myeloma may show this picture.
  • Some faint hot spots in bilateral rib cages and increased activity in the sternum. The nature is to be determined (post-traumatic change? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Mildly iuncreased activity in the right shoulder. Arthritis may show this picture.
• 2019-05-30 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (57.8 - 11.6) / 57.8 = 79.93%
    • M-mode (Teichholz) = 79
  • Normal chamber size
  • Adequate LV and RV performance
  • Possibly impaired LV relaxation
  • AV sclerosis with trivial AR ; mild MR, TR and PR
  • No regional wall motion abnormalities
• 2019-05-14 Myocardial perfusion SPECT with persanti
  • Probably mild to moderate myocardial ischemia with possible a small portion of severe ischemia at the apical lateral wall and mild myocardial ischemia at the apical anteroseptal wall.
  • Mild reverse redistribution of radioactivity to the inferolateral wall and posterior wall, either normal variant or myocardial ischemia may show this picture.
• 2017-07-10 Nerve Conduction Velocity, NCV
  • The NCV study showed
    • Prolonged distal motor latency and slowing of motor and sensory nerve conduction velocity in bilateral median nerves.
    • Decreased CMAP and SAP amplitude in left median nerve.
    • Decreased CMAP amplitude in bilateral peroneal nerves.
    • Decreased SAP amplitude in right ulnar and left sural nerves.
    • The F wave and H reflex were normal.
    • The above findings suggest entrapment neuropathy of bilateral median nerves at the wrist(left side was severer) with superimposed bilateral peroneal neuropathy.
    • Advise careful clinical correlation.
• 2019-05-30 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 32) / 120 = 73.33%
    • M-mode (Teichholz) = 73
  • Adequate LV systolic function with normal resting wall motion
  • Dilated LA, septal hypertrophy, LV diastolic dysfunction, Gr 1
  • Trivial MR and trivial TR
  • Preserved RV systolic function
• 2017-01-23 Pulmonary Tc-99m perfusion and ventilation scan
  • The Tc-99m MAA perfusion lung scan was obtained 5-10 minutes after injection of Tc-99m MAA 5 mCi. The scintigraphy revealed several smalll subsegmental or nonsegmental defects in perfusion in the upper lobe and the superior segment of the lower lobe of both the right lung and the left lung.
  • The Tc-99m DTPA aerosol lung ventilation lung scan, which was obtained immediaely after inhalation of the radioagent 30 mCi, revealed that there were deficient ventilation in the upper lobe of the superior segment of the lower lobe of both the right lung and left lung, in an extent much larger than were the defects shown on perfusion scan.
  • The scintigraphy revealed several small subsegmental or non-segmental ventilation-perfusion matched defects in the upper lobe and the superior segment of the lower lobe of both the right and left lung, indicating that the probability of pulmonary embolism was low (reported risk of lower than 20%, by revised PIOPED Criteria for Pulmonary Embolus Diagnosis). Please correlate with clinical findings for further evaluation.
• 2017-01-19 ECG
  • Sinus rhythm with Premature atrial complexes
  • Left axis deviation
  • S1-S2-S3 pattern, consider pulmonary disease, RVH, or normal variant
  • Abnormal ECG
• 2017-01-12 CXR
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • Mild cardiomegaly
  • Osteoporotic compression fracture of multiple vertebral bodies
  • osteolytic change in visible bones.

[MedRec]

• 2024-05-30, -03-01, 2023-11-10, -08-18, -05-26, -03-03 SOAP Cardiology Xie JianAn
  • Prescription x3
    • Licodin (ticlopidine 100mg) 1# QD
    • Urosin (atenolol 100mg) 0.25# QD
    • Zulitor (pitavastatin 4mg) 0.5# QN
    • Diovan (valsartan 160mg) 0.5# QD
    • Ulstop (famotidine 20mg) 1# QD
• 2024-02-23 ~ 2024-02-24 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Multiple myeloma, IgA type, ISS stage 3, bone marrow (4/26 23)showed myeloma with a predominant kappa sub-population post VTd with progression
    • Chronic viral hepatitis B without delta-agent anti-Hbc positive
    • Essential (primary) hypertension
    • Dementia without behavioral disturbance
  • CC
    • for C7D1 daratuzumab (Q3W) / Dexa treatment
  • Present illness
    • She started to receive DVd for progressive myeloma with 1q21 (CKS1B) amplification post IRd. C1D1 chemotherapy with Darzalex (16mg/kg, total 876mg) plus Velcade (1.3mg/m2, total 1.9mg) and Limeson 4mg total 20mg D1-D2 were given on 10/4 23, C1D8 on 10/11 23, C1D15 on 10/17 23, C2D1 on 10/24 23. C2D8 on 11/1 23, C2D15 on 11/14 23, C3D1 on 11/22 23, C3D8 on 11/29 23, C3D15 on 2023/12/5, C4D1 on 12/23 23. (C4D8, C4D15 not given at OPD due to leukocytopenia and thrombocytopenia). C5D1 daratuzumab (Q3W) /Velcade /Dexa on 2024/01/03, C5D8 on 2024/01/09, C5D15 on 2024/01/16, C6D1 on 2024/01/24, C6D8 on 2024/01/30, C6D15 on 2024/02/06.
    • Anti-Hbc showed positive and Entecavir was given.
    • Today, she was admitted for C7D1 daratuzumab (Q3W) / Dexa on 2024/02/23.
  • Course of inpatient treatment
    • After admission, chemotherapy with Darzalex (16mg/kg, total 840mg) and Dexa (4mg) given 10mg D1-D2 due to > 75years were given on 2/23 24, smoothly without obvious side effect. She was discharged on 2/24 24 under stable condition and will follow-up OPD on 3/1 24
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# HS
    • MgO 250mg 1# TID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# TID
    • Through (sennoside 12mg) 1# HS
• 2023-10-02 ~ 2023-10-05 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Multiple myeloma, IgA type, ISS stage 3, bone marrow (2023-04-26) showed myeloma. IHC stains: CD117: <2%; MPO: 25-30%, CD138: 25-30 %; (of the nucleated cells). Kappa and Lambda light chains show a predominant kappa sub-population.
    • Essential (primary) hypertension
    • Chronic viral hepatitis B without delta-agent anti-Hbc positive
  • CC
    • for elevated IgA index progression & first daratuzumab/Velcade/Dexa treatment
  • Present illness
    • This 82 year-old woman had medical history of (1) HTN (2) Hyperlipidemia (3) Osteoarthritis knee (5) multiple myeloma, IgA type, ISS stage 3 under Velcade on 2016/5-2017/1 (total 21 times) and Thalidomide since 2019/1-2019/12. She was regular followed up at our OPD with normal IgA level in Mar 2020. According to her and son, right shoulder soreness with pain were noted for one week. She denied fall down, traumatic recently; there was no local heating nor inflammation situation. She comes to our Oncology OPD for help, the x-ray showed no fracture lesion. Under the impression of osteolysis of right shoulder, she was admitted for further management on March 2020. Orthopedist was consulted and they suggested to arrange bone scan or MRI.
    • Bone scan was performed on 2020/03/31 which revealed some faint hot spots in bilateral rib cages and increased activity in the middle and lower C-spines, some middle to lower T-spines, some L-spines, sacrum, sternum, left humeral head, right pubic bone, right shoulder and bilateral knees in whole body survey.
    • Then she was regularly followed up at ONC OPD for Xegeva. Bone marrow on 2020/10/06 showed Hypocellularity, hypocellular marrow (<10%) with almost hemorrhage. Some plasma cells show about 10-20% of hematopoietic cells. Immunohistochemistry of CD34 and CD117 show no increase of blast, CD138 highlights plasma cell, Kappa/lambda light chain: no convincing kappa restriction.
    • Her bone morrow aspiration and biopsy were done and report showed bone marrow with fat and blood only, but MM FISH studies with CD138 selection resulted 1q21 (CKS1B) amplification at ChangHua Christian Hospital (outsourced) on 2020/12/30. Bone marrow showed plasma cell myeloma and IgA level 3373 on 2021/01/18. Bone scan was done on 2021/01/19 showed no evidence of bone lesions. Apply ixazomib on 2021/01/19, under IRd treatment started 2021/01/29 {Ninlaro 3 mg d1, d8, d18 q28d、lenalido 25mg d1-d21 and dexa 40 mg d1, d8, d15, d22} at ONC OPD.
    • The bone marrow, iliac, biopsy (2023/04/26) proved myeloma. IHC stains: CD117: <2%; MPO: 25-30%, CD138: 25-30 %; (of the nucleated cells). Kappa and Lambda light chains show a predominant kappa sub-population.
    • She received Revlimid 1# po qod & Ninlaro 1# po QWAC was given since 2021/05/25 to 2023/04/07. Limeson 5# po QW was given since 2023/05/09 to 2023/09/26. Xgeva 120mg sc was given on 2023/05/02 & 2023/06/06.
    • The elevate IgA showed 527 mg/dL on 2022/12/23, 1020 mg/dL on 2023/1/20, 968 mg/dL on 2023/2/24, 1213 mg/dL on 2023/3/24, 1683 mg/dL on 2023/4/21, 2477 mg/dL on 2023/5/23, 2817 mg/dL on 2023/6/6, 3161 mg/dL on 2023/6/20, 3443 mg/dL on 2023/7/18, 4893 mg/dL on 2023/8/15, 5331 mg/dL on 2023/9/12, 4568 mg/dL on 2023/9/26.
    • She complained of bilateral shoulder for days and Humerus Bilat/Shoulder RT (2023/05/09 & 2023/07/18) showed osteoporotic or osteolytic change of right humerus, right clavicle and right scapular is noted that may be multiple myeloma?
    • This time, owing to elevate IgA idex progression was noted and will given first daratuzumab/Velcade/Dexa treatment on 2023/10/02.
  • Course of inpatient treatment
    • After admission, cehmotherapy with Darzalex (16mg/kg, total 876mg) plus Velcade (1.3mg/m2, total 1.9mg) and Limeson 4mg total 20mg D1-D2 were given on 10/4 23, smoothly without obvious side effect. Anti-Hbc showed positive and Entecavir was added. She was discharged on 10/5 23 under stable condition and will next admission on 10/10 23.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# HS
    • MgO 250mg 1# TID
    • Through (sennoside 12mg) 2# HS
    • Xyzal (levocetirizine 5mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
• 2023-07-26 SOAP Neurology Xiao ZhenLun
  • Prescription x3
    • Syntam (piracetam 1200mg) 1# BID

[consultation]

• 2023-12-13 Psychosomatic Medicine
  • Q
    • Cancer inpatient suicide ideation score >= 2.
  • A
    • This 80 y/o woman was admitted for multiple myeloma. She has suffered from cognitive impairment (taking Syntam in NEU OPD), hearing loss (eardrum rupture), and partially dependent ADL. At home, she can walk slowly with a cane and go out for walks. She mostly can bathe and dress herself but needs her son to watch over her. Dependent IADL, often confused about time and space, and also unclear about her illness and treatment. 2022/7 MMSE 10, CDR 2; She has a fine drive and sleep, but often complained of weakness and pain, with negative thinking and rumination, sometimes expressed death thought (getting old, better to leave early). Denied concrete suicide plan.
    • Brain CT: 2022/7
      • Brain atrophy and leukoaraiosis.
      • Diffuse osteolytic bone change with some areas of cortical destruction.
    • IMP:
      • Depressive disorder
      • Senile dementia, moderate
      • r/o mood and neurocognitive problem related to multiple myeloma
    • Suggestion:
      • zoloft 50mg 0.5# HS.
      • Check TSH, fT4, Folic acid, Vit B12.
      • Arrange PSY OPD follow up.
• 2020-03-28 Orthopedics
  • Q
    • This 82 year-old woman had medical history of 1) Hypertensive heart disease without heart failure 2) Cardiac arrhythmia 3) Hyperlipidemia 4) Osteoarthritis knee 5) multiple myeloma, IgA type, ISS stage 3 under Thado control. she was regular OPD follow up since Jun. 2006.
    • According to her and son, she had right shoulder soreness with pain since few weeks ago. She denied fall down, traumatic recently; there was no local heating nor inflammation situation. She comes to our Oncology OPD for help, the x-ray showed no fracture lesion. We need your expertise for further management, thanks
  • A
    • This 82-year-old woman suffered from right shoulder soreness and pain weeks ago.
    • local findings:
      • no local heat
      • near full ROM of shoulder
      • supraspinatus test: -
    • X-ray:
      • OA change of right shoulder joint, supscious osteolytic lesion in right humerus
    • Suggestion:
      • the pain in right shoulder may caused by Multiple myeloma, further evaluation (MRI, bone scan)
      • OA of the joint also resulted in shoulder pain
      • Please prescribe NSAID (Arcoxia or Celebrex) for symptom relieve.

[chemotherapy]

• 2024-03-21 - daratumumab 16mg/m2 840mg NS 500mL 4hr (DVd C8D1)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2024-02-23 - daratumumab 16mg/m2 840mg NS 500mL 4hr (DVd C7D1)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2024-02-06 - ………………………………….. bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C6D14)
• 2024-01-30 - ………………………………….. bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C6D7)
• 2024-01-24 - daratumumab 16mg/m2 840mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C6D1)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2024-01-16 - ………………………………….. bortezomib 1.3mg/m2 1.9mg SC 1min (DVd C5D14)
• 2024-01-09 - ………………………………….. bortezomib 1.3mg/m2 1.9mg SC 1min (DVd C5D7)
• 2024-01-03 - daratumumab 16mg/m2 849mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C5D1)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2023-12-13 - daratumumab 16mg/m2 843mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C4D1)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2023-12-06 - daratumumab 16mg/m2 854mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C3D15)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2023-11-29 - daratumumab 16mg/m2 860mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C3D8)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2023-11-22 - daratumumab 16mg/m2 864mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C3D1)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2023-11-15 - daratumumab 16mg/m2 856mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C2D15)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2023-11-01 - daratumumab 16mg/m2 880mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C2D8)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2023-10-25 - daratumumab 16mg/m2 880mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C2D1)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2023-10-17 - daratumumab 16mg/m2 880mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C1D15)
  • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2023-10-11 - daratumumab 16mg/m2 867mg NS 500mL 6hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C1D8)
  • dexamethasone 4mg 5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
• 2023-10-04 - daratumumab 16mg/m2 876mg NS 1000mL 8hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C1D1)
  • dexamethasone 4mg 5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL

Treatment Name: DVd (Daratumumab + Velcade® (bortezomib) + dexamethasone) - 2023-10-18 - https://www.chemoexperts.com/dvd-daratumumab-velcade-bortezomib-dexamethasone.html

• DVd (Daratumumab + Velcade® (bortezomib) + dexametha­sone) is a Chemotherapy Regimen for Multiple Myeloma (MM)
  • D - Daratumumab (Darzalex®)
  • V - Velcade® (bortezomib)
  • d - dexamethasone (dex)
• Goals of therapy:
  • DVd is not given to cure multiple myeloma, but rather to slow the progression of the disease and to decrease symptoms.
• Schedule
  • Daratumumab intravenous (I.V.) infusion or subcutaneous (SubQ) injection (Darzalex Faspro®) on Days 1, 8, and 15 of Cycles 1, 2, and 3; then Day 1 only of Cycles 4, 5, 6, 7, and 8, then once monthly (every 28 days) thereafter. The time of infusion varies depending upon the tolerability and number of previous infusions
  • Bortezomib subcutaneous (S.Q.) injection on Days 1, 4, 8 and 11 of Cycles 1, 2, 3, 4, 5, 6, 7, and 8
  • Dexamethasone 20 mg (five 4 mg tablets) by mouth on Days 1, 2, then Days 4, 5, then Days 8, 9, then Days 11, 12 of Cycles 1 through 8.
  • Cycles 1 through 8 are repeated every 21 days.
• Estimated total infusion time for this treatment:
  • For daratumumab, Cycle 1 Day 1 may take up to 8 hours because of the possibility of experiencing infusion reactions. If you do not experience any with the first infusion, Cycle 1 Day 8 may be reduced to 6 hours. If you do not experience any infusion reactions during the first two daratumumab doses, it may only take up to 4 hours after that. There is also a 90-minute rapid infusion option if it is well tolerated
  • If daratumumab is given by subcutaneous injection (Darzalex Faspro®), there may be an observation time of up to 6 hours after the first dose to observe for reactions. If no reactions are seen, the observation times for future doses may be much shorter or not needed at all
  • On days that only bortezomib and dexamethasone are given, infusion time may be as little as 1 hour
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time
  • DVd is usually given in an outpatient infusion center, allowing the person to go home afterwards. It is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated up to eight times and then ONLY daratumumab is given (no Velcade or dexamethasone) until daratumumab no longer works or until unacceptable side effects occur.
• Common DVd Starting Doses
  • Daratumumab 16 mg/kg intravenous (I.V.) infusion on Days 1, 8, and 15 of Cycles 1, 2, and 3; then Day 1 only of Cycles 4 through 8, then once monthly (every 28 days) thereafter
  • Bortezomib 1.3 mg/m2 subcutaneous (S.Q.) injection on Days 1, 4, 8 and 11 of Cycles 1 through 8
  • Dexamethasone 20 mg (five 4 mg tablets) by mouth on Days 1, 2, then Days 4, 5, then Days 8, 9, then Days 11, 12 of Cycles 1 through 8
  • Cycles 1 through 8 are 21 days in duration.

Major toxicities of selected treatment regimens used for relapsed multiple myeloma - 2024-01-24 - https://www.uptodate.com/contents/image?imageKey=HEME%2F108257

• Options for initial relapse
  • Daratumumab, lenalidomide, dexamethasone (DRd)
    • Major toxicities: Acute or delayed hypersensitivity reaction, opportunistic infections, diarrhea, fatigue.
    • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis.
    • Clinical use: Preferred for patients relapsing off therapy or while on small doses of single agent lenalidomide or on bortezomib maintenance.
    • Other: Can interfere with cross-matching and red blood cell antibody screening.
  • Daratumumab, bortezomib, dexamethasone (DVd)
    • Major toxicities: Peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, nausea.
    • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis.
    • Clinical use: Preferred if refractory to full doses of lenalidomide or refractory to a lenalidomide containing triplet.
    • Other: Can interfere with cross-matching and red blood cell antibody screening.
  • Daratumumab, carfilzomib, dexamethasone (DKd)
    • Major toxicities: Hypersensitivity reaction, transient cytopenias, fatigue, diarrhea, hypokalemia, hypertension, dyspnea, serious cardiac dysfunction (approximately 5%).
    • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis.
    • Clinical use: Option for patients refractory to both bortezomib and lenalidomide.
    • Other: Can interfere with cross-matching and red blood cell antibody screening.
  • Isatuximab, carfilzomib, dexamethasone
    • Major toxicities: Hypersensitivity reaction, transient cytopenias, respiratory infections, fatigue, diarrhea, hypertension, serious cardiac dysfunction.
    • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis.
    • Clinical use: Option for patients refractory to both bortezomib and lenalidomide.
    • Other: Can interfere with cross-matching and red blood cell antibody screening.
  • Bortezomib, lenalidomide, dexamethasone (VRd)
    • Major toxicities: Peripheral neuropathy, transient cytopenias, fatigue, gastrointestinal distress.
    • Adjunctives: Thromboprophylaxis; antiviral prophylaxis.
    • Clinical use: May be preferred for patients relapsing off therapy or on lenalidomide maintenance.
    • Other: Subcutaneous, once-weekly dosing of bortezomib decreases toxicity.
  • Bortezomib, cyclophosphamide, dexamethasone (VCD)
    • Major toxicities: Peripheral neuropathy, transient cytopenias.
    • Adjunctives: Antiviral prophylaxis; PCP prophylaxis.
    • Clinical use: May be preferred for patients relapsing while off therapy or on lenalidomide maintenance.
    • Other: Subcutaneous, once-weekly dosing of bortezomib decreases toxicity.
  • Carfilzomib, lenalidomide, dexamethasone (KRd)
    • Major toxicities: Gastrointestinal distress, transient cytopenias, fatigue, hypokalemia, hypertension, dyspnea, serious cardiac dysfunction (approximately 5%).
    • Adjunctives: Thromboprophylaxis; antiviral prophylaxis.
    • Clinical use: May be preferred for more aggressive relapse in fit patients.
    • Other: More cumbersome than weekly schedule of bortezomib- or ixazomib-based regimens.
  • Carfilzomib, pomalidomide, dexamethasone (off-label)
    • Major toxicities: Transient cytopenias, fatigue, hypokalemia, hypertension, dyspnea, potentially severe diarrhea, serious cardiac dysfunction (approximately 5%).
    • Adjunctives: Thromboprophylaxis; antiviral prophylaxis.
    • Clinical use: May be preferred for patients with aggressive disease relapsing on standard dose lenalidomide.
      
  • Bortezomib, pomalidomide, dexamethasone (off-label)
    • Major toxicities: Peripheral neuropathy, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue, peripheral neuropathy.
    • Adjunctives: Thromboprophylaxis; antiviral prophylaxis.
    • Clinical use: May be preferred for patients relapsing on standard dose lenalidomide.
      
  • Ixazomib, lenalidomide, dexamethasone (IRd)
    • Major toxicities: Diarrhea, constipation, nausea, vomiting, thrombocytopenia, peripheral neuropathy, peripheral edema, and back pain.
    • Adjunctives: Thromboprophylaxis; antiviral prophylaxis.
    • Clinical use: May be preferred for frail patients or those with a clinically indolent relapse.
    • Other: Oral regimen.
  • Elotuzumab, lenalidomide, dexamethasone
    • Major toxicities: Acute or delayed hypersensitivity reaction, opportunistic infections, hepatic dysfunction, fatigue.
    • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis.
    • Clinical use: May be preferred for frail patients or those with a clinically indolent relapse.
• Options for multiply relapsed disease: Includes regimens above that have not yet been used
  • Daratumumab, pomalidomide, dexamethasone
    • Major toxicities: Hypersensitivity reaction, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue, peripheral neuropathy.
    • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis.
    • Clinical use: Reserved for patients who have had at least two prior regimens, including lenalidomide and a proteasome inhibitor.
    • Other: Can interfere with cross-matching and red blood cell antibody screening.
  • Isatuximab, pomalidomide, dexamethasone
    • Major toxicities: Hypersensitivity reaction, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue, peripheral neuropathy.
    • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis.
    • Clinical use: Reserved for patients who have had at least two prior regimens, including lenalidomide and a proteasome inhibitor.
    • Other: Can interfere with cross-matching and red blood cell antibody screening.
  • Elotuzumab, pomalidomide, dexamethasone
    • Major toxicities: Acute or delayed hypersensitivity reaction, opportunistic infections, hepatic dysfunction, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue.
    • Adjunctives: Prophylaxis for infusion reactions; thromboprophylaxis.
    • Clinical use: Reserved for patients who have had at least two prior regimens, including lenalidomide and a proteasome inhibitor.
      
  • Selinexor, bortezomib, dexamethasone
    • Major toxicities: Thrombocytopenia, neutropenia, and hyponatremia. Neurologic toxicity (eg, dizziness, confusion).
    • Adjunctives: Antiviral prophylaxis; antiemetic prophylaxis.
    • Clinical use: Reserved for patients with disease refractory to a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.
    • Other: Must monitor sodium.
  • Selinexor plus dexamethasone
    • Major toxicities: Thrombocytopenia, neutropenia, and hyponatremia. Neurologic toxicity (eg, peripheral neuropathy, dizziness, confusion).
    • Adjunctives: Antiemetic prophylaxis.
    • Clinical use: Reserved for patients who have had at least four prior regimens, including at least two proteasome inhibitors, at least two immunomodulatory agents, and an anti-CD38 monoclonal antibody.
    • Other: Oral regimen. Must monitor sodium.

[medication]

• Ninlaro (ixazomib) KNINL01, KNINL01A
  • 2021-01-29 ~ 2023-04-21 3mg/cap QWAC
• Revlimid (lenalidomide) KREVL01
  • 2022-02-04 ~ 2023-03-31 25mg QD PO
  • 2021-01-29 ~ 2022-02-01 25mg QOD PO
• Thado (thalidomide) KTHAD01
  • 2019-01-18 ~ 2020-01-02 50mg HS PO
  • 2017-01-05 ~ 2017-11-16 100mg HS PO
• Velcade (bortezomib) CVELC01
  • 2017-01-26 1.9mg ST SC
  • 2017-01-05 1.9mg ST SC
• Licodin (ticlopidine) KLICO01
  • 2019-05-30 ~ 2024-01-24 ongoing 100mg BID PO
• Xgeva (denosumab) CXGEV01
  • 2022-01-18 120mg Q1M SC
  • 2021-12-07 120mg Q1M SC
  • 2021-11-09 120mg Q1M SC
  • 2021-10-12 120mg Q1M SC
  • 2021-01-14 120mg Q1M SC
  • 2020-12-10 120mg Q1M SC
  • 2020-11-13 120mg Q1M SC
  • 2020-10-16 120mg Q1M SC
  • 2020-09-08 120mg Q1M SC
  • 2020-08-11 120mg Q1M SC
  • 2020-07-14 120mg Q1M SC

==========

2024-05-31

[extensive bony metastases identified

, osteoclast inhibitor recommended]

Imaging studies revealed multiple bone metastases:

• A mass with adjacent destruction of bone in the left chest wall.
• A fracture of the left 8th rib.
• Osteoporotic changes and destructive lesions in bones on brain CT.

Due to the extensive nature of these lesions, further pathological evaluation might be necessary.

Osteoclast Inhibitors Considered:

• Osteoclast inhibitors are a crucial element in managing skeletal complications in patients with multiple myeloma (MM).
• While they cannot repair existing bone damage, they do prevent the formation of new lesions.

Denosumab as a Potential Option:

• Adding denosumab, an osteoclast inhibitor, could be a treatment consideration.

2024-03-21

[sustained FKLC & IgA elevation: potential loss of disease control]

The long-term (4-year) FKLC and short-term (3-month) IgA levels have been exhibiting a sustained increase, which may indicate that the disease is gradually becoming refractory to treatment.

• 2024-03-21 IgA 4882 mg/dL
  

• 2024-01-30 IgA 3310 mg/dL

• 2024-01-09 IgA 2947 mg/dL

• 2023-12-19 IgA 2685 mg/dL

• 2023-11-22 IgA 3460 mg/dL

• 2023-09-26 IgA 4568 mg/dL

• 2023-09-12 IgA 5331 mg/dL

• 2023-11-27 FKLC 139.0 mg/L

• 2021-02-05 FKLC 26.8 mg/L

• 2019-10-11 FKLC 25.4 mg/L

2024-01-24

[evaluating osteoporotic changes after Xgeva discontinuation]

Bortezomib was administered on 2024-01-03, 2024-01-09, and 2024-01-16 (days 1, 7, and 14), deviating from the typical days 1, 4, 8, and 11 schedule in cycle 5 of the DVd regimen. The patient was admitted for Cycle 6 Day 1 treatment. Lab results on 2024-01-23 showed pancytopenia, a decreased eGFR of 53 mL/min/1.73m2, low serum albumin at 2.8 g/dL, and elevated total bilirubin at 0.73 mg/dL. However, these findings should not contraindicate treatment continuation.

The patient had previously been treated with several doses of Xgeva in the first half of 2023. Following this, multiple bone X-rays indicated osteoporotic or osteolytic changes. Therefore, reintroducing Xgeva to address the bone condition could be considered.

2024-01-03

[macrocytic anemia]

The lab results indicate the presence of macrocytic anemia, which could be attributed to deficiencies in vitamin B12, folate, or copper. To alleviate the anemia, it may be advantageous to consider supplementation with vitamin B12 and/or folate.

• 2024-01-02 HGB 8.6 g/dL
• 2024-01-02 MCV 103.6 fL

Additionally, daratumumab and bortezomib in DVd regimen are associated with anemia.

2023-12-13

[DVd Regimen: deviation from original schedule]

The patient was admitted for C4D1 of her daratumumab treatment, which is part of the DVd regimen in combination with bortezomib. The administration schedule for this regimen involves daratumumab on Days 1, 8, and 15 for Cycles 1, 2, and 3; then only on Day 1 for Cycles 4 through 8, followed by a monthly administration (every 28 days) thereafter.

This hospitalization marks the beginning of Cycle 4, and according to the regimen design, daratumumab should only be administered on Day 1 up to Cycle 8. Additionally, as per the regimen’s design, bortezomib is scheduled on Days 1, 4, 8, and 11 for Cycles 1 to 8, and in practice, it is administered concurrently with daratumumab.

Ref: https://www.darzalexhcp.com/pdfs/cp-142382v4-darzalex-maia-cassio-apollo-dosing-admin-guide.pdf

[to reassess bone health]

It is common practice to administer a single dose of a potent bisphosphonate (ie, zoledronic acid at 4 or 5 mg for a single dose) after stopping denosumab therapy to prevent rebound bone loss and fractures. Markers of bone resorption rebound and increase rapidly after denosumab discontinuation, and this can lead to increased loss of bone mineral density and the development of vertebral fractures, particularly in patients with baseline osteoporosis, with a history of prior fracture, or on continued aromatase inhibitor therapy.

The last 3 doses of Xgeva (denosumab 120mg) were administered on 2023-03-24, 2023-05-02, and 2023-06-06. Since it has been over 6 months since the last dose, and there are no hospital records of bisphosphonate use since then, it is recommended to reassess the patient’s bone health.

2023-12-06

[reconciliation]

Currently, access to the PharmaCloud database is unavailable.

There has been a downward trend in eGFR readings over the past 2-3 weeks. Despite this, the patient’s current renal function does not necessitate any dose adjustments at this time.

• 2023-12-05 eGFR 62.30 ml/min/1.73m^2
  
• 2023-11-28 eGFR 73.34 ml/min/1.73m^2
  
• 2023-11-21 eGFR 81.63 ml/min/1.73m^2

No discrepancies have been identified in the active medication list.

2023-11-29

The DVd regimen, which began on 2023-10-04, might have led to a decrease in IgA levels, yet they remain elevated along with FKLC and B2-Microglobulin.

• 2023-11-27 FKLC 139.0 mg/L
  

• 2023-11-27 FLLC 5.9 mg/L
  

• 2023-11-27 FK/FL ratio 23.56 ratio

• 2023-11-23 B2-Microglobulin 5746 ng/mL

• 2023-11-22 IgA 3460 mg/dL
  

• 2023-09-26 IgA 4568 mg/dL
  

• 2023-09-12 IgA 5331 mg/dL

Based on the lab results from 2023-11-28, the patient’s liver and kidney functions are grossly normal, indicating no need for dosage adjustments due to liver or renal concerns for now.

2023-11-01

[pancytopenia after 2023-10-25 C2D1 DVd]

On 2023-10-25, DVd (C2D1) was administered, which resulted in the onset of pancytopenia. Appropriate measures, including the administration of G-CSF and blood transfusion, were promptly undertaken.

• 2023-11-01 WBC 2.70 x10^3/uL

• 2023-10-31 WBC 2.55 x10^3/uL

• 2023-10-25 WBC 2.57 x10^3/uL

• 2023-11-01 HGB 7.6 g/dL

• 2023-10-31 HGB 8.6 g/dL

• 2023-10-25 HGB 8.6 g/dL

• 2023-11-01 PLT 128 *10^3/uL

• 2023-10-31 PLT 42 *10^3/uL

• 2023-10-25 PLT 170 *10^3/uL

[withhold Diovan temporarily]

The latest blood pressure measurement, taken on 2023-11-01 at 12:59, was 100/52. Given the absence of current hypertension, it is advisable to temporarily withhold Diovan (valsartan) to reduce the potential for hypotension.

2023-10-18

[DVd regimen]

This patient received lenalidomide from 2021 to 2023Q1 (and thalidomide prior to that). The DVd regimen is preferred for patients who are refractory to full doses of lenalidomide or to a lenalidomide-containing triplet regimen.

The patient started the DVd regimen in early Oct 2023, with the first dose (C1D1) administered on 2023-10-04, the second dose (C1D8) administered on 2023-10-11, and the third dose (C1D15) administered on 2023-11-17. This hospitalization is for the end of cycle 1.

These three daratumumab infusions were administered over 8 hours, 6 hours, and 4 hours, respectively, which effectively reduced the risk of infusion reactions.

The major toxicities of the DVd regimen include peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, and nausea. Please continue to monitor the patient for these toxicities.

2023-10-11

This patient received repeat prescriptions from our cardiology department for Licodin (ticlopidine), Urosin (atenolol), Zulitor (pitavastatin), Diovan (valsartan), and Ulstop (famotidine) on 2023-08-18, and from our neurology department for Syntam (piracetam) on 2023-07-26. There are no discrepancies, and all these medications are currently being used as prescribed.

[rising IgA levels in 2023]

Since the beginning of this year (2023), IgA levels have risen from the triple digits to the mid-four digits by August, suggesting that the disease may still be progressing.

• 2023-09-26 IgA 4568 mg/dL
• 2023-09-12 IgA 5331 mg/dL
• 2023-08-15 IgA 4893 mg/dL
• 2023-07-18 IgA 3443 mg/dL
• 2023-06-20 IgA 3161 mg/dL
• 2023-06-06 IgA 2817 mg/dL
• 2023-05-23 IgA 2477 mg/dL
• 2023-05-09 IgA 2054 mg/dL
• 2023-05-02 IgA 1923 mg/dL
• 2023-04-21 IgA 1683 mg/dL
• 2023-04-07 IgA 1475 mg/dL
• 2023-03-24 IgA 1213 mg/dL
• 2023-03-10 IgA 1058 mg/dL
• 2023-02-24 IgA 968 mg/dL
• 2023-02-10 IgA 1016 mg/dL
• 2023-01-27 IgA 1063 mg/dL
• 2023-01-20 IgA 1020 mg/dL
• 2023-01-06 IgA 515 mg/dL

2023-01-09

• Neutropenia has be mitigated with filgrastim (G-CSF)

  • 2023-01-09 WBC 2.94 *10^3/uL
  • 2023-01-07 WBC 0.96 *10^3/uL
  • 2023-01-06 WBC 0.94 *10^3/uL
  • 2022-12-23 WBC 4.61 *10^3/uL

• Over the past three months, the IgA levels have been around 500 +- 50 mg/dL, relatively stable, but showing a slowly upward trend.

  • 2023-01-06 IgA515 mg/dL
  • 2022-12-23 IgA527 mg/dL
  • 2022-12-09 IgA473 mg/dL
  • 2022-11-25 IgA534 mg/dL
  • 2022-11-11 IgA460 mg/dL
  • 2022-10-28 IgA451 mg/dL
  • 2022-10-14 IgA410 mg/dL
  • 2022-09-30 IgA390 mg/dL

• Revlimid (lenalidomide) has demonstrated a significantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with multiple myeloma who were treated with lenalidomide and dexamethasone therapy. Please monitor for and advise patients about the signs and symptoms of thromboembolism as always.

• Ninlaro (ixazomib) has been prescribed as a self-paid item and is not listed on PharmaCloud nor in the active prescriptions. Please make sure that the patient’s ANC be greater than 1000/mm3, platelets be greater than 75,000/mm3, and nonhematologic toxicities be at baseline or less than grade 1 (per prescriber discretion) prior to initiating a new cycle of therapy. It is recommended that patients who are seropositive for Varicella zoster virus (VZV) and herpes simplex virus (HSV) receive an antiviral prophylaxis with acyclovir or valacyclovir prior to receiving a proteasome inhibitor (bortezomib, carfilzomib, ixazomib), as there is an increased risk of reactivation if the proteasome inhibitor is used.

700766819

240530

[exam findings]

• 2024-05-03 CT - abdomen
  • History: Rt ovarian clear cell carcinoma, pStage IA, pT1aN0 (if cM0), FIGO Stage IA. s/p debulking surgery on 2024/01/12. Adjuvant chemotherapy from 2024/01/25.
  • Findings:
    • There is a cystic lesion in left pelvis side wall, 6.2 cm in size (the largest dimension). Lymphocele is highly suspected. please correlate with clinical condition.
    • S/P hysterectomy and debulking surgery.
    • Prior CT identified Right liver hemangioma (2.6cm) is noted again, stationary.
  • Impression:
    • Lymphocele in left pelvic sidewall is highly suspected. please correlate with clinical condition.
• 2024-03-09 MRI - abdomen
  • History and indication: Right ovarian clear cell carcinoma
  • With and without contrast MRI of liver revealed:
    • Right liver hemangioma (2.6cm) and cyst (4mm).
    • Left renal cyst (5mm).
  • IMP:
    • Right liver hemangioma (2.6cm) and cyst (4mm).
    • Left renal cyst (5mm).
• 2024-02-29 SONO - abdomen
  • Diagnosis:
    • Propable liver hemangiomas, right
    • Suspected fatty infiltration of pancreas
  • Suggestion:
    • OPD f/u
    • Please correlate with other image
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2024-02-05 SONO - nephrology
  • Interpretation:
    • Parenchymal renal disease
    • Suspect liver tumor (2.1cm)
  • Suggestion:
    • GI opd f/u
• 2024-01-24 CXR
  • S/P port-A implantation.
  • Enlargement of cardiac silhouette.
  • Increased lung markings on both lower lungs are noted. Please correlate with clinical condition.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-01-24 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 18 dB HL; LE 13 dB HL.
  • RE normal to mild SNHL but have A-B gap at 1k Hz.
  • LE WNL.
• 2024-01-16 Patho - ovary (tumor)
  • Diagnosis:
    • Ovary, right, oophorectomy —- Clear cell carcinoma, AJCC 8th edition: pStage IA, pT1aN0(if cM0) , FIGO Stage IA, at least
    • Ovary, left, oophorectomy —- Negative for malignancy
    • Fallopian tube, right, salpingectomy —- Negative for malignancy
    • Fallopian tube, left, salpingectomy —- Negative for malignancy       - —- Hydrosalpinx       - —- Endometriosis
    • Uterus, corpus, abdominal total hysterectomy —- Negative for malignancy       - —- Leiomyoma
    • Uterus, cervix, abdominal total hysterectomy —- Negative for malignancy
    • Uterus, endometrium, abdominal total hysterectomy —- Negative for malignancy       - —- Endometrial polyp
    • Omentum, omentectomy —- Negative for malignancy
    • Lymph node, right pelvic, dissection —- Negative for malignancy (0/14)
    • Lymph node, left pelvic, dissection —- Negative for malignancy (0/12)
    • Lymph node, para-aortic, dissection —- Negative for malignancy (0/6)
  • Gross description:
    • Procedure (select all that apply): Debulking surgery (ATH + BSO + BPLND + para-arotic lymph node dissection + omentectomy)
    • Specimen size:
      • F2024-00015:
        • right ovary: 16.5 x 7.5 x 4.3 cm, 310 g;
        • right tube: 6.0 cm in length and 0.3 cm in diameter;
      • S2024-00966:
        • left ovary:  3.0 x 2.2 x 0.7 cm;  
        • left tube: 7.0 cm in length and 1.0 cm in diameter;
        • uterus: 16.5 x 9.5 x 8.0 cm, 547 g;
        • Cervix: 4.1 x 3.8 x 3.5 cm;
        • Endometrial cavity: 5.7 x 4.0 x 0.5 cm with a polyp, measuring 2.0 x 1.4 x 0.4 cm;
        • Several leiomyomas, measuring up to 4.2 x 3.8 x 3.5 cm  
    • Specimen Integrity
      • Specimen Integrity of Right Ovary (if applicable): Capsule intact, intra-operation rupture (-)
      • Specimen Integrity of Left Ovary (if applicable): Capsule intact
      • Specimen Integrity of Right Fallopian Tube (if applicable):Serosa intact
      • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
    • Tumor Site: Right ovary
    • Ovarian Surface Involvement (required only if applicable): Absent
    • Fallopian Tube Surface Involvement (required only if applicable): Absent
    • Tumor Size: Greatest dimension (centimeters): 16.5 cm
    • Additional dimensions (centimeters): 7.5 x 4.3 cm
    • Sections are taken and labeled as:
      • F2024-00015: Representative sections are taken and labeled as: FsA1-2, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: fallopian tube; X2: adnexa; X3-8: tumor.
      • S2024-00966: Representative sections are taken and labeled as: A1-3: lymph node, right pelvic; B1-3: lymph node, left pelvic; C: lymph node, para-aortic; D1: cervix; D2: endometrium; D3: endometrial polyp; D4-5: leiomyoma; D6: corpus; D7: posterior wall; E1-2: left ovary and fallopian tube; F1-2: oemntum.  
  • Microscopic Description:
    • Histologic Type: Clear cell carcinoma; The immunohistochemical stains reveal CK(+), PAX8(+), Napsin A(+), p53(wild type), PR(-), WT-1(-), SALL4(-), and alpha-inhibin(-).  
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors): not applicable
      • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.
    • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
    • Other Tissue/ Organ Involvement (select all that apply): Not identified
    • Largest Extrapelvic Peritoneal Focus (required only if applicable): Not identified  
    • Peritoneal/Ascitic Fluid: N2024-188
    • Regional Lymph Nodes: Negative for metastasis: right pelvic: 0/14; left pelvic: 0/12; para-aortic: 0/6
    • Additional Pathologic Findings: Endometrial polyp, leiomyomas, and left hydrosalpinx and endometriosis are seen.
• 2024-01-12 ECG
  • Normal sinus rhythm
  • Low voltage QRS
  • Borderline ECG
• 2024-01-12 CT - abdomen
  • History and indication: abdominal pain
  • IMP:
    • A cystic lesion (13cm) at right abdomen with some solid parts r/o ovary tumor.
    • Some tumors (up to 5.6cm) at uterus r/o myomas.
    • Right liver hemangioma (2.6cm) and cyst (4mm).
• 2024-01-12 Gynecologic Ultrasonography
  • IMP:
    • R/O RT adnexa mass
    • Multiple myomas

[MedRec]

• 2024-05-02 ~ 2024-05-04 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Right ovarian clear cell carcinoma, AJCC 8th edition: pStage IA, pT1aN0 (if cM0) , FIGO Stage IA. s/p debulking surgery on 2024/01/12. Adjuvant chemotherapy with TP [paclitaxel (175mg/m2) + carboplatin (AUC 6)] from 2024/01/25.
    • Major depressive disorder, recurrent, moderate
    • Iron deficiency anemia, unspecified
    • Encounter for antineoplastic chemotherapy
    • Chronic viral hepatitis B without delta-agent
  • CC
    • for adjuvant chemotherapy with TP (C5)
  • Present illness
    • This 51 years old female without underlying systemic disease, G0P0, SEX(+), had received open myomectomy 20+ years ago. According to the patient, she had gradually irregular menstral cycle. Hypermenorrhea and dyesmenorrhea also complained for years. Her last menstrual period was 2024/01/05.
    • Initial symptom, she complained progressive abdominal pain and shifted to right lower abdomen in 2024/01/12.
    • The abdominal CT was done on 2024/01/12 showed a cystic lesion (13cm) at right abdomen with some solid parts r/o ovarIAN tumor. The GYN doctor was consulted for further evaluation.
    • The echogram showed a huge right adnexa mass, r/o torsion or malignancy.
    • Under impression of huge right adnexa mass, r/o torsion, she was admitted for emergent underwent debulking surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para aortic lymph note sampling + infracolic omentectomy) on 2024/01/12.
    • The frozen section initial diagnosis revealed malignant tumor (carcinoma) and pending immunohistochemical stains for final diagnosis.
    • Postoperative recovery was smooth. Final pathology report showed right ovarian clear cell carcinoma, AJCC 8th edition: pStage IA, pT1aN0 (if cM0), FIGO Stage IA.
    • The GYN tumor board conference on 2024/01/18 suggested the patient to received chemotherapy. She received adjuvant chemotherapy with TP (Paclitaxel 175mg/m2 plus Carboplatin AUC 6) on 2024/01/02(C1), due to leukopenia, decrease of paclitaxel dose on 2024/02/16(C2), 2024/03/12(C3), 2024/04/09(C4).
    • This time, she was admitted for adjuvant chemotherapy with TP (Paclitaxel 175mg/m2 plus Carboplatin AUC 6) on 2024/05/03(C5).
  • Course of inpatient treatment
    • After admission, Limeson 4mg/tab 5# (20mg) po and ULSTOP F.C 20mg/tab 1# po before chemotherapy with Taxol 12 hrs on 2024/05/02 at 23:00 and before chemotherapy with Taxol 6 hrs on 2024/05/03 at 05:00.
    • She receive adjuvant chemotherapy with TP (Paclitaxel 175mg/m2 / Carboplatin AUC 6) (C5) on 2024/05/03.
    • Primperan 1# po TIDAC and Primperan 1 amp IVD PRNTID was given for nausea and vomiting.
    • Major depressive disorder with Lexapro 10mg/tab 1# PO HS.
    • Iron deficiency anemia with iron supplements by yourself.
    • Chronic viral hepatitis B without delta-agent with Baraclude 0.5mg/tab 1# PO QDAC.
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, she was discharged on 2024/05/04 and OPD followed up later.
  • Discharge prescription
    • Granocyte (lenograstim 250ug) SC 3D on 5/7, 5/8, 5/9
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Emend (aprepitant 125mg) 1# QD 1D on 5/5
• 2024-01-23 SOAP Obstetrics and Gynecology Shao ZhiXuan
  • P: Multidisciplinary Cancer Conference Conclusion, Meeting Date: 2023-01-18
    • Treatment Plan: Postoperative adjuvant chemotherapy is recommended for clear cell carcinoma.
  • Prescription
    • Meififen (diclofenac Na 75mg) 1# QD
    • MgO 250mg 1# TID
• 2024-01-12 ~ 2024-01-19 POMR Obstetrics and Gynecology Shao ZhiXuan
  • Discharge diagnosis
    • Right ovarian clear cell carcinoma with torsion, pT1aN0M0, FIGO stage IA, s/p debulking surgery on 2024/01/12
    • Abdominal pain
    • Anemia
  • CC
    • abdominal pain with cold sweating since yesterday
    • heavy bleeding noted a palpable mass above the umbilicus for 2 years.        
  • Present illness
    • This 50 years old female without underlying systemic disease, G0P0, SEX(+), had received open myomectomy 20+ years ago. According to the patient, she had gradually irregular menstral cycle. Hypermenorrhea and dyesmenorrhea also complained for years. Her last menstrual period was 2024/01/05.
    • This time she complained progress IVE abdominal pain since yesterday and shifted to right lower abdomen in this afternoon. Cold sweating also noted. She denied fever, chills, nausea. vomiting, dysuria or constipation. She came to our ER for help.
    • At ER, her vital signs were stable and lab datas showed anemia with Hb 8.0. The abdominal CT was arranged and showed a cystic lesion (13cm) at right abdomen with some solid parts r/o ovarian tumor. The GYN doctor was consulted for further evaluation. The echogram showed a huge right adnexa mass, r/o torsion or malignancy.
    • Under impression of huge right adnexa mass, r/o torsion, she was admitted for emergent laparotomy right salping-oophrectomy. If consider malignancy, the right adnexa mass would send frozen section and change to debulking surgery when proved malignancy. The pRBC was transfused. The laparotomy right salping-oophrectomy was done on 2024/01/12 and the MALIGNANCY was told by frozen section. The debulking surgery was done and she was admitted for post-operation care and further treatment plan.
  • Course of inpatient treatment
    • The patient was admitted from ER on 01/13/2024 due to abdominal pain suspected right ovarian tumor with torsion. She underwent debulking surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para aortic lymph note sampling + infracolic omentectomy). The frozen section initial diagnosis revealed malignant tumor (carcinoma) and pending immunohistochemical stains for final diagnosis. Postoperative recovery was smooth. Final pathology report showed right ovarian clear cell carcinoma, AJCC 8th edition: pStage IA, pT1aN0 (if cM0) , FIGO Stage IA.
    • The GYN tumor board conference on 2024/01/18 suggested the patient to receive chemotherapy. Her postoperative course was uneventful. Self voiding was smooth. JP drain with serosaguinous fluid and removed smoothly. She was discharged on 2024/01/19. Her follow up appointment is scheduled on 2024/01/24.
  • Discharge prescription
    • Meififen (diclofenac Na 75mg) 1# QD
    • MgO 250mg 1# QID
    • Through (sennoside 12mg) 1# HS
    • Miyarisan BM (clostridium butyricum miyairi 40mg) 1# TID

[consultation]

• 2024-03-11 Psychosomatic Medicine
  • Q
    • for depressive follow up
    • This 51 years old female without underlying systemic disease, G0P0, SEX(+), had received open myomectomy 20+ years ago. According to the patient, she had gradually irregular menstral cycle. Hypermenorrhea and dyesmenorrhea also complained for years. Her last menstrual period was 2024/01/05. Initial symptom, she complained progressive abdominal pain and shifted to right lower abdomen in 2024/01/12.
    • The abdominal CT was done on 2024/01/12 showed a cystic lesion (13cm) at right abdomen with some solid parts r/o ovarian tumor. The GYN doctor was consulted for further evaluation.
    • The echogram showed a huge right adnexa mass, r/o torsion or malignancy. Under impression of huge right adnexa mass, r/o torsion, she was admitted for emergent underwent debulking surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para aortic lymph note sampling + infracolic omentectomy) on 2024/01/12.
    • The frozen section initial diagnosis revealed malignant tumor (carcinoma) and pending immunohistochemical stains for final diagnosis. Postoperative recovery was smooth.
    • Final pathology report showed right ovarian clear cell carcinoma, AJCC 8th edition: pStage IA, pT1aN0(if cM0) , FIGO Stage IA. The GYN tumor board conference on 2024/01/18 suggested the patient to received chemotherapy.
    • She received adjuvant chemotherapy with TP (Paclitaxel 175mg/m2 plus Carboplatin AUC 6) on 2024/01/02(C1). This time, she was admitted for adjuvant chemotherapy with TP (Paclitaxel 175mg/m2 plus Carboplatin AUC 6) on 2024/03/12(C3).
  • A
    • Impression:
      • appointment consultation
    • S/O:
      • give explanation for medication use within the ward and continue OPD follow-up.
    • Plan:
      • keep current psychiatric medications
      • the patient will arrange another appointment by herself
• 2024-01-12 Obstetrics and Gynecology
  • Q
    • 2024-01-12 1 a.m. periumbilical abdominal pain with sweating
    • pain transfer to rt lower abdominal now
    • Deny fever, dizzines, nausea, vomiting, constipation ,diarrhea, chest pain, urinary problem
    • MC just finished
    • Allergy: AKDA
    • Fx: nil
    • Dx: myoma s/p surgery
  • A
    • This 50 y/o female without underlying systemic disease
      • came to ER for abdominal pain since yesterday, and progressed to Rt lower abd this afternoon
      • with cold sweating
      • denied fever, dizzines, nausea, vomiting, constipation ,diarrhea, chest pain, urinary problem
    • OBGYN:
      • G0, sex experience (+)
      • LMP 01/05
      • dysmenorrhea (+), irregular menstral cycle in recent years
      • s/p open myomectomy
    • Lab:
      • WBC 8480, Hb 8.0, PLT 405000, CRP <0.1
      • UA pregnancy negative, mild UTI
    • Abd CT:
      • a huge mass (14cm*11cm )at rt abd, r/o ovarian torsion
      • Multiple uterine myomas
    • TAS:
      • suspected Rt adnexa mass 13*11cm with solid component
      • multiple uterine myoma
      • CDS no fluid
    • Impression:
      • r/o rt adnexa mass with torsion
    • Suggestion:
      • arranged laparotomy RSO, consider frozen section exam if susp. malignancy, if prove malignancy, change to debulking surgery
      • please pre-OP prepare and prepare pRBC 2U and check tumor marker (CEA, CA 125)
      • post-OP OA GYN Dr. Shao

[surgical operation]

• 2024-01-12 - Op Method:
  • Diagnosis:
    • Right huge ovarian mass with torsion, frozen section: malignancy
  • Operation:
    • Debulking surgery (ATH + BSO + BPLND + para-arotic lymph node dissection + omentectomy)   - Finding:
  • Supraumbilical midline vertical skin incision
  • Uterus: hypertrophic and disfigured by multiple myomas, tense adhesion with bladder
  • Adnexa:
    • LOV: 322cm, grossly normal, capsule intact, smooth surface.
    • ROV: 141310cm, with fallopian tube torsion, capsule intact, some necrotic and soft tissue mass and 700cc bloody jelly like fluid noted inside the tumor, intra-operation rupture (-)
    • Frozen section: malignancy
  • CDS: free from adhesion and ascites
  • Ascites: minimal, wash with diswater 20cc and sent cytology analysis
  • Bilateralpelvic lymph nodes and para-arotic LNs: normal (+), enlarged (-), indurated (-)
  • Omentum: grossly normal.
  • Liver: grossly normal & smooth
  • Subdiaphragmatic surface: grossly normal
  • Appendix: grossly normal
  • Estimated blood loss: 600ml
  • Blood transfusion: pRBC 2U
  • Complication: nil

[chemotherapy]

• 2024-05-30 - paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AU5 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-05-03 - paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AU5 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-04-09 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + carboplatin AU5 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-03-12 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + carboplatin AU5 4 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-02-16 - paclitaxel 175mg/m2 250mg NS 500mL 3hr + carboplatin AUC 6 900mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-2 + NS 250mL
• 2024-01-25 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 6 900mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-05-30

[lab results clear for TP regimen]

The 2024-05-28 lab results showed no contraindications for the new session of TP regimen chemotherapy.

A CT scan on 2024-05-03 revealed that the right liver hemangioma is stable. Additionally, a 6.2 cm cystic lesion in the left pelvic sidewall, highly suspected to be a lymphocele, was observed. This condition is most commonly a complication following surgery. If it becomes symptomatic, further treatment may be necessary.

2024-03-11

[paclitaxel-carboplatin & anemia: lab suggests alternative cause]

The paclitaxel-carboplatin regimen was initiated on 2024-01-25. Anemia episodes are observed in all available data points within HIS5. While chemotherapy can theoretically contribute to anemia, lab results suggest it’s likely not the primary cause.

• 2024-03-11 HGB 9.0 g/dL
• 2024-03-07 HGB 9.8 g/dL
• 2024-02-29 HGB 9.8 g/dL
• 2024-02-15 HGB 10.5 g/dL
• 2024-02-01 HGB 8.7 g/dL
• 2024-01-24 HGB 8.6 g/dL
• 2024-01-13 HGB 7.6 g/dL
• 2024-01-12 HGB 8.0 g/dL
• 2023-08-16 HGB 8.3 g/dL
• 2022-12-01 HGB 8.4 g/dL
• 2021-11-15 HGB 7.3 g/dL
• 2020-07-28 HGB 8.8 g/dL

701257674

240530

[lab data]

2023-09-20 HBsAg Nonreactive
2023-09-20 HBsAg (Value) 0.36 S/CO
2023-09-20 Anti-HBc Reactive
2023-09-20 Anti-HBc-Value 5.86 S/CO
2023-09-20 Anti-HCV Nonreactive
2023-09-20 Anti-HCV Value 0.06 S/CO

[exam findings]

• 2024-03-26 CT - chest
  • Indication: Squamous cell carcinoma of lower third of esophagus, ypStage IIIB, ypT3N1M0, status post 3 dimensions video-assisted thoracoscopic surgery esophagectomy and gastric tube reconstruction on 2023/12/11
  • MDCT of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows: comoarison made with CT on 2023/12/04
    • Lungs: mild reticular opacities at Rt apical lung may be due fibrotic change. linear band subsegmental atelectasis at RLL.
    • Mediastinum and hila: post gastric tube reconstruction in middle mediastinum with a long staple line along its anterior margin.no enlarged LN. mild or moderate coronary arterial calcification.
    • Heart: normal size of cardiac chambers.
    • Pleura: minimal effusion.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: s/p jejunostomy. no dilated bowel loops.
    • unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
  • Impression:
    • L/3 esophageal cancer, esophagectomy and gastric tube reconstruction, in good condiition. no locoregional recurrent tumor.
• 2023-12-12 Patho - esophagus subtotal/total resection
  • Diagnosis
    • Esophagus, lower third, VATS esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
    • Stomach, cardia, EG junction, partial gastrectomy —- Squamous cell carcinoma, by direct invasion
    • Azygos vein, right, excision —- Negative for malignancy
    • Resection margin: Negative for malignancy; proximal cutend of esophagus: Negative for malignancy
    • Lymph node, upper paraesophageal, specimen 1, dissection —- Negative for malignancy (0/1)
      
    • Lymph node, middle paraesophageal, specimen 1, dissection —- Negative for malignancy (0/0)
      
    • Lymph node, lower paraesophageal, specimen 1, dissection —- Negative for malignancy (0/6)
    • Lymph node, peri-gastric, specimen 1, dissection — metastatic squamous cell carcinoma (1/12)
    • Lymph node, right, group 2+4, dissection —- Negative for malignancy (0/7)
    • Lymph node, left, group 5, dissection —- Negative for malignancy (0/0)
    • Lymph node, right, group 7, dissection —- Negative for malignancy (0/6)
      
    • Lymph node, left, group 4, dissection —- Negative for malignancy (0/0)
      
    • Lymph node, left, group 9, dissection —- Negative for malignancy (0/1)
    • Lymph node, right, upper paraesophageal, dissection —- Negative for malignancy (0/4)
      
    • AJCC 8 th edition pT N M Pathology stage: ypStage IIIB, ypT3N1(if cM0)
  • Gross Description:
    • Procedure: VATS esophagectomy and gastric tube reconstruction; Size: Esophagus: 11.0 cm in length with a portion of gastric tissue measuring 3.5 cm in length.
      • Azygos vein: 1.2 x 1.0 x 0.4 cm
    • Tumor Site: Distal esophagus (low thoracic esophagus)
      
    • Relationship of Tumor to Esophagogastric Junction: Tumor midpoint lies in the distal esophagus and tumor involves the esophagogastric junction
    • Tumor Size: 2.0 x 1.7 cm
      
    • Sections are taken and labeled as:
      • A1-2: Distal gastric resection margin; A3: esophagus; A4: stomach; A5-9: tumor; A10: lymph node, upper paraesophageal; A11: lymph node, middle paraesophageal; A12: lymph node, lower paraesophageal; A13: lymph node, perigastric; B: proximal cutend of esophagus; C: lymph node, right group 2+4; D: lymph node, left group 5; E: lymph node, right group 7; F: lymph node, left group 4; G: lymph node, left, group 9; H: right upper paraesophageal; I: azygos vein.
  • Microscopic Description:
    • Histologic Type: Squamous cell carcinoma; The immunohistochemical stains reveal p40(+) and CD56(-).
      
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades adventitia
    • Margins: All margins are uninvolved by invasive carcinoma, dysplasia, and intestinal metaplasia
      • Distance of invasive carcinoma from closest margin (millimeters or centimeters): 1 mm
      • Specify closest margin: circumferential
      • Proximal resection margin: 8.7 cm
      • Distal resection margin: 3.2 cm
    • Treatment Effect: Present, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response, score 2)
      
    • Lymphovascular Invasion: Not identified
    • Perineural Invasion: Not identified
    • Regional Lymph Nodes: please see diagnosis
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors: y (posttreatment)
      • Primary Tumor (pT): pT3: Tumor invades adventitia
      • Regional Lymph Nodes (pN): pN1: Metastasis in one or two regional lymph nodes
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
        
    • Additional Pathologic Findings: None identified
• 2023-12-08 MRI - brain
  • IMP: No evidence of intracranial lesion.
• 2023-12-08 Exercise Cardiopulmonary Function Test
  • Conclusion
    • low exercise capacity (VO2max 72%, WR 82%) (normal VO2max > 85%)
    • spirometry: normal (FVC 97%, FEV1 106%)
      
    • respiratory muscle strength: normal inspiratory muscle strength (MIP 108%, MEP 77%)
    • Breathing reserve normal
    • SpO2 Saturation during exercise: 98%
    • cardiac response (LCWI) during exercise: low response during exercise
    • HR response during exercise: high response slope during exercise
    • work efficiency: normal
    • anaerobic threshold: normal
    • oxygen pulse: normal
    • BP response: normal response during exercise
    • EKG: nonspecific findings
      
    • Health-related quality of life (HRQL), CAT= 4, OK (> 10 indicates poor HRQL),
      
  • Impression:
    • Deconditioning with low exercise capacity
      
    • Impaired cardiovascular response with high HR response
  • Suggestions:
    • Treat underlying disease and symptoms
    • Exercise training for low exercise capacity
    • For low cardiac response, suggest adequate fluid intake to keep adequate preload, may Survey cardiac function such as cardiac echo
• 2023-12-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (96 - 28) / 96 = 70.83%
    • M-mode (Teichholz) = 70
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Mild MR
• 2023-12-07 Miniprobe Endoscopic Ultrasound
  • Diagnosis: Esophageal cancer, at least cT1bN1. s/p magnification endoscopy and biopsy
• 2023-12-06 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in bilateral rib cages, maxilla, some C-spine, lower L-spine, L5-sacrum junction, lesser trochanter of left femur, bilateral shoulders, sternoclavicular junctions, S-I joints, hips, and knees.
• 2023-12-05 PET
  • In comparison with the previous study on 2023/09/14, the previous glucose hypermetabolic lesion in the lower portion of the esophagus is much less evident. Besides, the previous glucose hypermetabolic lesion in the left upper paratracheal lymph node disappeared.
  • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
  • Increased FDG accumulation in the muscles of bilateral forearm, colon, both kidneys and right ureter. Physiological FDG accumulation is more likely.
• 2023-12-04 CT - chest
  • Indication: Esophageal cancer re-staging
  • Findings
    • Lungs: mild reticular opacities at Rt apical lung may be due fibrotic change.
    • Mediastinum and hila: interval significaant regression of circumferential wall thickening of distal third of thoracic esophagus and E-G junction.
      • resoltuion of enlarged LN at left upper paratracheal space.
      • the vascular markings and great vessels in the hila and mediastinum are normal in distribution and appearance.
  • Impression:
    • L/3 esophageal cancer, significant in regression as compared with previous CT study.
• 2023-09-20 Pure Tone Audiometry
  • Reliabilty Fair
  • PTA
    • R’t : 45 dB HL, mild to moderately severe conductive HL
    • L’t : 19 dB HL, WNL.
• 2023-09-16 MRI - brain
  • No evidence of brain metastasis.
• 2023-09-15 Tc-99m MDP bone scan
  • Increased activity in some C-spines, lower L-spines and L5-sacrum junction. Degenerative change is more likely.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • Some faint hot spots in bilateral rib cages and mildly increased activity in the lesser trochanter of left femur. The nature is to be determined. Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2023-09-14 Whole body PET scan
  • A glucose hypermetabolic lesion involving the lower portion of the esophagus, compatible with primary esophageal malignancy.
  • Glucose hypermetabolism in a left upper paratracheal lymph node. A metastatic lymph node may show this picture.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
• 2023-09-14 Patho - esophageal biopsy
  • Esophagus, lower, 33 cm below incisors, biopsy — Squamous cell carcinoma, moderately differentiated
  • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.
• 2023-09-13 Miniprobe Endoscopic Ultrasound
  • Endoscopic findings
    • One circumferencial fungated lesion was noted from 33cm below incisors. Panendoscopy was not able to pass through the esophagus at 35 cm below incisors. Biopsy was done.
  • EUS findings
    • EUS showed a mucosal lesion invading into the adventitia of esophageal wall at the lesion site. At least 1 lymph node was noted.
  • Diagnosis
    • Esophageal cancer, at least cT3N1, 33cm below incisor. s/p chromoendoscopy and biopsy
• 2023-09-12 CT - chest
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N1 or N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • Findings
    • Lungs: mild reticular opacities at Rt apical lung may be due fibrotic change.
    • Mediastinum and hila: circumferential wall thickening of distal third of thoracic esophagus, causing severe luminal narrowing, and preserved periesophageal fat plane, possibly involving E-G junction.
      • enlarged LN at left upper paratracheal space.
      • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance. Heart: normal size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
      • small lymph nodes along celiac axis.
  • Impression: L/3 esophageal cancer T3N1 or N2Mx (E1)

[MedRec]

• 2024-03-06 SOAP Hemato-Oncology Xia HeXiong
  • P: Admission for perioperative (adjuvant part) C/T with PF x 4
• 2023-12-03 ~ 2023-12-28 POMR Thoracic Surgery Xie MinXiao
  • Discharge diagnosis
    • Squamous cell carcinoma of lower third of esophagus, ypStage IIIB, ypT3N1M0, status post 3 dimensions video-assisted thoracoscopic surgery esophagectomy and gastric tube reconstruction on 2023/12/11
    • Chronic viral hepatitis B without delta-agent
    • Dysthymic disorder
    • Hypokalemia
  • CC
    • Admitted for cancer restaging under the impression of Squamous cell carcinoma of lower third of esophagus, T3N2M0 stage III.  
  • Present illness
    • This 59-year-old man, had past history of chronic viral hepatitis B and dysthymic disorder under control. His activities of daily living was independent.
    • According to his statement, he started to felt difficult swallowing of solid food in 2023/08. The symptom had got worse even liquid diet could not be swallowed. There was no exacerbating and relieving factor noted. Weight loss about 4kg in recent one month was noticed. There was no vomiting, abdominal pain, abdominal bloating, diarrhea, epigastric pain, easy choking, dysphonia, hoarseness, chest pain, dyspnea, or hemoptysis. The patient denied trauma or esophageal injury history. He visited General medicine out-patient department for help.
    • He underwent upper endoscopic examination on 2023/09/07 and found middle third esophageal tumor that highly suspicious of malignancy. Biopsy was done and showed squamous cell carcinoma of esophagus. He was admitted for esophageal cancer staging on 2023/09/12.
    • Further cancer survey such as chest CT, brain MRI, and whole-body PET scan were done. Chest CT revealed L/3 esophageal cancer T3N1or N2Mx(E1). Brain MRI did not found metastatic lesion. Whole-body PET scan showed Some faint hot spots in bilateral rib cages and mildly increased activity in the lesser trochanter of left femur. Under the impression of squamous cell carcinoma of upper third of esophagus, cT3N1M0, stage IIIA, he had undergone neoadjuvant concurrent chemoradiotherapy since 2023-09.
    • He visited our oncologist out-patient department for regular follow-ups. Due to completed neoadjuvant concurrent chemoradiotherapy with tumor that decreased in size, he visited our chest surgery out-patient department for cancer restaging and evaluation of surgical treatment.
    • Physical examination showed clear breathing sound, regular heart beats, and soft abdomen with no tenderness. There was no palpable tumor over neck. Then he was admitted for cancer restaging under the impression of squamous cell carcinoma of upper third of esophagus, cT3N1M0, stage IIIA.
  • Course of inpatient treatment
    • After admission, for further cancer survey such as chest CT, brain MRI, and whole-body PET scan were done. Chest CT revealed L/3 esophageal cancer, significant in regression as compared with previous CT study. Brain MRI did not found metastatic lesion. Whole-body PET scan showed in comparison with the previous study on 2023/09/14, the previous glucose hypermetabolic lesion in the lower portion of the esophagus is much less evident. Besides, the previous glucose hypermetabolic lesion in the left upper paratracheal lymph node disappeared. Whole body bone scan showed No strong evidence of bone metastasis. EUS showed esophageal cancer, at least cT1bN1. s/p magnification endoscopy and biopsy. Cardiac echogram showed 1.Preserved LV and RV systolic function with normal wall motion, 2.Normal chamber size, 3.Mild MR. CPET showed low exercise capacity (VO2max 72%, WR 82%) (FVC 97%, FEV1 106%).
    • Under the impression of squamous cell carcinoma of lower third of esophagus, cT1bN1M0 stage I. Nutrision support with PPN and done colon prepare.
    • He was done video-assisted thoracoscopic surgery (VATS) esophagectomy and gastric tube reconstruction on 2023-12-11. He was transferred to SICU for post operation care.
    • At SICU, due to low grade fever and high CPR, we changed antibiotic to Brosym on 12/13 and collected culture, and also added Vancomycin on 12/14. Extubation was successful and smooth on 12/13. Feeding from jejunostomy with D5W 20ml/hr for 16 hours on 12/12, elemental diet 20ml/hr on 12/13 and general NG diet 40ml/hr on 12/14. The surgical wound were clear, neck penrose drain discharge was serous fluid, hence we removed penrose on 12/14. Right chest tube discharge color was also clean. Therefore, he was transferred to general ward for further care on 2023/12/14.
    • 0.298 KCL/ NS 2Bot IVD QD and Taita NO.5 500ml 2bot IVD stat on 2023/12/14 for hypokalemia. Follow up CXR stable lung condition then remove chest tube on 2023/12/18. Remove NG tube and try oral water on 2023/12/19 then on clear liquid diet on 2023/12/20. Remove of neck and abdominal suture on 2023/12/25. No chills or fever was noted. Wound care was educated. He was discharged under stable condition and OPD followed up will be arranged.
  • Discharge prescription
    • Actein (acetylcysteine 200mg) 1# TID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Takepron (lansoprazole 30mg) 1# QDAC
    • Sindine (povidone iodine aq soln) QD EXT
    • Through (sennoside 12mg) 2# PRNHS
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Eurodin (estazolam 2mg) 1# HS
    • Alpraline (alprazolam 0.5mg) 1# HS
• 2023-10-05 SOAP Hemato-Oncology Xia HeXiong
  • O: Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 2023-09-26
    • Diagnosis: Squamous cell carcinoma of the lower third of the esophagus, cT3N2M0, stage III
    • Treatment Plan: Concurrent chemoradiotherapy (CCRT) followed by re-evaluation for surgery

[consultation]

• 2023-09-15 Hemato-Oncology
  • Q (same as the Q for Radiation Oncology)
  • A1
    • This 59-year-old man is a newly diagnosed SCC of L/3 Esophageal cancer, cT3N2 (at least, pending brain MRI). We are consulted for neoadjuvant CCRT.
    • We will discuss with the patient about CCRT with PF. Please check HBsAg, Anti HBc, Anti HBs, Anti HCV, and port A insertion before chemotherapy. Please arrange 24 urine CCR and an auditory examination. Thanks for your consultation.
  • A2 Additional reply 2023-09-18 15:30:13
    • We had see patient (he lives in ZhongLi and is a member of TzuChi). Paitent received port A insertion and jejunostomy today. We had well explaint to patient about neoajuvant CCRT. We may take over this case (Please book 11A or 10B) if you agree.
• 2023-09-15 Radiation Oncology
  • Q
    • A 59-year-old man denied any past systemic disease. His operation history was Pterygium OU post operation in 2019 at HuaLien TzuChi Hospital.
      
    • According to his statement, he started to felt difficult swallowing of solid food in mid-August, because the condition didn’t improve, he went to local clinic for examination. He under upper endoscopic examination on 2023/09/07 and found middle third esophageal tumor that highly suspicious of malignancy. Therefore he was transferred to this hospital for further studies. At ward, he was good ambuation, no nausea and vomitus, cigarette smoking and alcohol drinking were quit for at least 10 years. He used to drink hot soup years ago. Weight loss about 4kg in recent one month was told and he denied chest pain and burning. This times, under the impression of esophageal cancer he was admitted for cancer staging and treatment.
    • Lab exam
      • 9/12 CT: L/3 esophageal cancer T3N1 or N2Mx(E1)
      • 9/13 EUS: Esophageal cancer, at least cT3N1, 33cm below incisor, One circumferencial fungated lesion, panendoscopy wasn’t able to pass through the esophagus at 35 cm below incisors, post biopsy, the biopsy is pending
      • 9/14 PET A glucose hypermetabolic lesion in the lower portion of the esophagus and left upper paratracheal lymph node
      • 9/15 bone scan: pending
      • 9/16 brain MRI: pending
    • Due to the lower third esophageal cancer cT3N2Mx
    • We need your expertise to arranged further treatment, neoadjuvant CCRT
    • Thank you very much
  • A
    • Neoadjuvant CCRT is indicated. He will have port-A and jejunostomy done on 9/18.
    • CT-simulation will be arranged on 9/19. Plan to deliver 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area. Then boost the L/3 esophageal tumor and upper mediastinal LAP to 50.4 Gy/ 28 fx.
    • RT will start around 9/22. We will check the brain MRI result on 9/18. Thank you very much.
• 2023-09-12 Gastroenterology
  • Q
    • A 59-year-old man present with middle thired esophageal tomor which found during a upper endoscopy examination on 2023-09-07 at a clinic in ZhongLi, the biopsy was pending.
    • He is dysphagia of solid food for about a month.
    • PH: denied past systemic disease
    • This times, he was admitted for esophageal cancer examination.
    • We have arranged several studies as below
      • 9/14 PET
      • 9/15 Bone scan
      • 9/16 MRI
    • We need you to help us to perfromed EUS with biopsy if possible on 9/13.
    • He wanted and agreeded to receive painless EUS
    • We need your expertise to arrange EUS and abdominal sonography for cancer studies on 9/13.
    • Thank you very much
  • A
    • We are consulted for EUS with biopsy on 9/13.
    • Patient was not at bedside.
    • Lab
      • 2023-09-12 HGB 15.4 g/dL
        
      • 2023-09-12 PLT 324 *10^3/uL
        
      • 2023-09-12 APTT 28.8 sec
        
      • 2023-09-12 PT 10.9 sec
        
      • 2023-09-12 INR 1.06
        
    • CT revealed suspect cancer at lower third of thoracic segment.
    • A: middle thired esophageal tomor
    • P:
      • EUS for esophageal SCC staging is indicated.
      • Already arrange EUS on 9/12 PM on call.
      • Please prescribe J CROWS Lugols solution (self-paid TWD 1500) and bring it to the exam room.

[surgical operation]

• 2023-12-11 - Op Method:
  • 3D VATS esophagectomy + gastric tube reconstruction.
  • Finding:
    • Esophageal cancer, L/3, s/p CCRT. Fibrotic mucosa over L/3 of esophagus.
    • One 10 mm Penrose drain was inserted over the anastomosis site of esophagogastrostomy.
    • One 24 Fr. straigth chest tube was inserted via right 9th ICS.

[radiotherapy]

• 2023-09-12 ~ 2023-11-02 - completed RT to the esohpagus and adjacent lymphatic drainage area: 45 Gy/ 25 fx. the L/3 esophageal tumor and upper mediastinal LAP to 50.4 Gy/ 28 fx.

[chemotherapy]

• 2024-05-29 - cisplatin 75mg/m2 120mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4 (PF4)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-26 - cisplatin 75mg/m2 120mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4 (PF4)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-26 - cisplatin 75mg/m2 120mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4 (PF4)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-30 - cisplatin 60mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 30min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4 (PF Q4W CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-25 - cisplatin 60mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 30min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4 (PF Q4W CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-05-30

[potential causes of macrocytic anemia]

Mild macrocytic anemia was observed. Since there is no evidence of increased reticulocytes, further investigation for vitamin B12 or folate deficiency might be warranted.

• 2024-05-29 HGB 10.5 g/dL
• 2024-05-29 MCV 100.7 fL

2024-04-29

[reconciliation]

A chest CT conducted on 2024-03-26 showed that the esophagectomy and gastric tube reconstruction are in good condition with no evidence of locoregional recurrence. Lab results from 2024-04-26 were grossly within normal limits, and no discrepancies in medication were identified.2024-04-26 were unremarkable. No medication discrepancy found.

2024-03-26

[labs & vitals clear - PF4 chemo likely suitable]

The review of lab results from 2024-03-25 revealed grossly normal values. Additionally, vital signs have remained stable throughout the patient’s hospital stay. Based on this information, there appears to be no contraindication to proceeding with the planned adjuvant chemotherapy regimen PF4.

2023-10-31

A potassium supplement was prescribed due to hypokalemia (K level of 3.3 mmol/L on 2023-10-30). Currently, no medication discrepancies have been identified.

2023-10-30

[tube feeding]

All oral medications on the active drug list can be tube-fed.

[trend towards anemia]

The lab data indicates a trend towards anemia. HGB levels during CCRT have been consistently decreasing. Please continue to monitor the levels and determine if a blood transfusion is necessary.

• 2023-10-30 HGB 11.9 g/dL
• 2023-10-18 HGB 13.2 g/dL
• 2023-10-05 HGB 14.3 g/dL
• 2023-09-12 HGB 15.4 g/dL

2023-09-25

All of the oral medications on the list of active medications can be administered by tube feeding.

2023-09-20 Anti-HBc Reactive indicates tenofovir or entecavir as preventive therapy for potential hepatitis B virus reactivation prior to planned CCRT.

701521262

240530

[lab data]

2024-04-25 HBsAg Nonreactive
2024-04-25 HBsAg Value 0.49 S/CO
2024-04-25 Anti-HBc Reactive
2024-04-25 Anti-HBc Value 5.73 S/CO
2024-04-25 Anti-HBs 2.11 mIU/mL

2024-04-25 Anti-HCV Nonreactive
2024-04-25 Anti-HCV Value 0.13 S/CO

[exam findings]

• 2024-05-25 Neck soft tissue
  • Degenerative change of the bony structure with marginal osteophyte formation is identified.
• 2024-05-25 KUB
  • S/p Total hip replacement over right side
  • Sclerotic change at left femoral head is found.
• 2024-05-14 CXR erect
  • Cardiomegaly is noted.
  • S/p port-A placement with its tip at Superior vena cava
  • Faint aveolar opacity over RIGHT LOWER LOBE is found.
• 2024-05-06 CXR erect
  • Atherosclerotic change of aortic arch
• 2024-04-22 Surgical pathology Level IV
  • DIAGNOSIS:
    • A: Esophagus, 35 cm below incisor, biopsy — Congestion
    • B: Esophagus, 22 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
    • C: Esophagus, 18 cm below incisor, biopsy — Congestion and chronic inflammation
  • GROSS DESCRIPTION:
    • A: Specimen submitted in formalin consists of 2 pieces of tan, irregular tissue measuring up to 0.3 x 0.2 x 0.1 cm. All for section in one cassette A.
    • B: Specimen submitted in formalin consists of 2 pieces of tan, irregular tissue measuring up to 0.4 x 0.1 x 0.1 cm. All for section in one cassette B.
    • C: Specimen submitted in formalin consists of a piece of tan, irregular tissue measuring 0.5 x 0.1 x 0.1 cm. All for section in one cassette C.
  • MICROSCOPIC DESCRIPTION:
    • A: Section shows 2 pieces of squamous mucosa with congestion.
    • B: Section shows 3 pieces of squamous mucosa with infiltration of nests of neoplastic squamous cells. The immunohistochemical stains reveal CK5/6(+), and p40(+).
      
    • C: Section shows a piece of squamous mucosa with congestion and chronic inflammation.
• 2024-04-22 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 15) / 87 = 82.76%
    • M-mode (Teichholz) = 83
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 1.
    • Normal RV systolic function.
    • Mild to moderate MR; mild TR; mild PR.
• 2024-04-22 SONO - abdomen
  • Cirrhosis of liver
  • Splenomegaly, mild
  • Ascites, minimal
  • Cholecystopathy
  • Renal cyst, Lt
• 2024-04-20 MIR - brain
  • Indication: Esophageal cancer staging
  • Imp:
    • No brain nodule or metastasis
    • Old infarct or ICH in left posterior basal ganglia
    • C1 level spinal stenosis with cord compression.
    • Old left eyeball insult, post OP?
• 2024-04-20 MRI - spine
  • C-spine:
    • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression.
    • Widened pre-odontoid space.
    • C1 level spinal canal stenosis with cord compression.
    • Presence of abnormal bright up signal intensity in the central cord seen on sagittal T2WI indicating edema or myelomalacia.
  • TL-spine:
    • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression at L-spine.
    • No evident bony destructive lesion.
• 2024-04-19 Tc-99m MDP bone scan
  • Mildly increased activity in the upper C-spine and lower L-spines. Degenerative change may show this picture.
  • Some faint hot spots in the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, elbows, wrists and knees, compatible with benign joint lesions.
• 2024-04-18 CardioPulmonary Exercise Testing, CPET
  • Diagnosis: esophageal cancer
  • Purpose: Pre-op evaluation
  • Results:
    • Ergometer protocol: incrementa
    • Ergometer type: cycle ergometer, work rate:12 watt/min
    • Load time: 7.1 min
    • ΔVO2/ΔWR (Normal > 8.6 ~ 10.3): 8.5
    • AT: 787 / 1973 = 40
    • Predict
      • MIP: 143 - (0.55 * 59) = 110.55
      • MEP: 268 - (1.03 * 59) = 207.23
    • Meas
      • MIP: 42 / 110.55 = 38
      • MEP: 79 / 207.23 = 38
    • Cause of stop:
    • Rest BP: 147/71 mmHg
    • Max BP: 219/70 mmHg
    • Max Exercise: 86 watts
    • Dyspnea: 4 min
    • leg fatigue: 4 min
    • CAT: 11143251 = 18
  • Conclusion
    • low exercise capacity (VO2max 60%, WR 83%) (normal VO2max > 85%)
    • spirometry: mild obstructive ventilatory impairment (FEV1/FVC 63%, FVC 101%, FEV1 86% )
      
    • respiratory muscle strength: low (MIP 38%, MEP 38%)
    • Breathing reserve: normal
    • SpO2 desaturation during exercise: 95 -> 90%
    • cardiac response (LCWI) during exercise: normal response during exercise
    • HR response during exercise: normal HR response slope during exercise
    • work efficiency: low, 8.5 (cut off 8.6)
    • anaerobic threshold: normal, 40% (cut off 40%)
    • oxygen pulse: low
    • BP response: high BP at rest and during exercise
      
    • EKG: ICRBBB
    • Health-related quality of life (HRQL), CAT = 18 (>10 indicates poor HRQL), dyspnea 4, poor outdoor activity 3, poor sleep 5
  • Impression:
    • low exercise capacity
    • mild obstructive ventilatory impairment
    • poor respiratory muscle strength
    • EKG with ICRBBB
    • High BP at rest and exercise
  • Suggestions:
    • Treat underlying disease and symptoms
      
    • Give bronchodilator
    • Control BP and ICRBBB
    • Limbs exercise and breathing exercise training
• 2024-04-18 Bronchoscopy
  • Bronchoscopic diagnosis:
    • Left vocal cord tumor, favor malignancy
    • LUL chronic bronchitis with some mucus pluggs
    • No endobronchial tumors, foreign bodies.
• 2024-04-18 Nasopharyngoscopy
  • Findings:
    • smooth nasopharynx, oropharynx
    • mild saliva accumulation over left pyriform sinus
    • small bulging over L pyriform sinus anterior wall
    • fair vocal fold movement, a small mass lesion below L vocal fold (subglottis)
  • Conclusion:
    • left pyriform sinus lesion
    • left laryngeal lesion
• 2024-04-17 ECG
  • Normal sinus rhythm
  • Right bundle branch block
  • Abnormal ECG
• 2024-04-17 CXR PA
  • mild enlarged cardiac silhouttedue to dilated left atrium and prominent cardiophrenic angle fat pad
  • marginal spurs of multiple vertebral bodies
• 2024-03-25 CT - chest
  • Findings
    • Known to have tissue-verified middle thoracic esophageal cancer.
    • No overt focal wall thickening or space occupying lesion in the esophagus.
    • Mild fibrotic change in RUL and LLL.
    • Otherwise, no visible active or space occupying lesion in the lung.
    • Hepatic cyst.
    • Portal hypertension & presence of collateral vessels.
  • Esophageal Cancer Staging Form
    • Imaging modality - Imaging by [+] CT scan [ ] MRI
    • Tumor location / size - Location: [+] Middle third of thoracic segment (azygos vein to inferior pulmonary vein) - Size: [+] Non-measurable
    • Tumor invasion [+] No or Equivocal
    • Regional nodal metastasis [+] No or Equivocal
    • Distant metastasis (In this study) [+] No or Equivocal
    • Other findings
  • AJCC Cancer Staging System, 8th edition For Esophageal Carcinoma
    • 20. PRIMARY TUMOR: Tx : Primary tumor cannot be assessed
    • 14. REGIONAL LYMPH NODES: N0 : No regional lymph node metastasis
    • 13. DISTANT METASTASIS: M0 : No distant metastasis (in this study)
    • AJCC 8th edition Staging status: TxN0M0
• 2024-03-20 PET:
  • Brief History and Major Clinical Finding:
    • The 59 y/o man has been diagnosed to have middle thoracic esophageal cancer (endoscopic biopsy done at 25 cm from the incisor on 2024-03-01 showed SqCC), for staging.
  • Findings:
    • There were two focal areas of mildly increased FDG uptake in the right submandibular and right axillary (level I) regions. Otherwise, no other abnormal FDG uptake was demonstrated in the whole body FDG PET scan.
• 2024-03-01 PES
  • The scope was inserted to duodenal 2nd portion.
  • Duodenum: negative to 2nd portion
  • Stomach: Some shalow ulcers were noted at the antrum.
  • Esophagus: There was one 2.5cm reddish plat lesion at 25cm from incisor, biospy was taken.
  • There were three F2 varices at the lower esophagus, we have done one shot of band ligation at red-colored sign.
  • No accidental events and complications occurred during and after the endoscopic examination.

[MedRec]

• 2024-05-24 SOAP Radiation Oncology Wang YuNong
  • P
    • Plan to deliver 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area.
    • Then boost the M/3 esophgeal tumor and LAP to 50.4 Gy/ 28 fx.
• 2024-04-17 ~ 2024-05-17 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Squamous cell carcinoma of upper to middl third of esophagus, cT1bN1M0, stage II status post CCRT with PF1 weekly
    • Essential (primary) hypertension
    • Cirrhosis of liver, child A
    • Chronic obstructive pulmonary disease with (acute) exacerbation
    • Left vocal cord tumor, favor malignancy
    • Cervical-1 level spinal canal stenosis with cord compression
    • Hyperammonemia
    • port-A implantation at left cephalic vein on 2024/04/24
    • Hypomagnesemia
  • CC
    • Newly diagnosed esophageal cancer
  • Present illness
    • This 59-year-old male patient presented to our Thoracic Surgery on 2024/04/16 with a newly diagnosed esophageal cancer at Hualian Tzu Chi Hospital.
    • He had previously underwent a esophagogastroduodenoscopy, which incidentaly revealed the presence of a 2.5cm reddish plat lesion in the esophagus. The pathology report showed squamous cell carcinoma.
    • A computed tomography of the chest showed no overt focal wall thickening or space occupying lesion in the esophagus.
    • Positron emission tomography showed two focal areas of mildly increased uptake in the right submandibular and right axillary regions.
    • He had been experiencing numbness and decreased dexterity on the right hand for three months.
    • His vital signs were stable and within normal limits. Blood labs revealed elevations in aspartate transaminase, total bilirubin, and alkaline phosphatase. There was also a reduced level of albumin. Urine analysis was unremarkable.
    • Under the impression of newly diagnosed esophageal cancer, he was admitted to our Thoracic Surgery ward for cancer survey and surgical evaluation.        
  • Course of inpatient treatment
    • After admission, we performed a comprehensive cancer and pre-operative survey. Bronchoscope on 2024/04/18 revealed Left vocal cord tumor, favor malignancy.
    • We consulted an expert in Ear-Nose-Throat Medicine, who performed a nasopharyngoscopy. The presence of a small mass lesion below left vocal fold. Out-patient department follow up was suggested.
    • Whole-body bone scan and brain MRI showed no definite evidence of bone and brain metastasis.
    • Owing to his bilateral upper limb numbness, weakness, and decreased dexterity, we performed a C-spine MRI. Imaging revealed C1 level spinal canal stenosis with cord compression. Neurosurgery was consulted, who recommended surgical intervention as soon as appropriate with his cancer treatment. In the meantime, he was advised to wear a SOMI brace.
    • Abdominal ultrasound showed suspected liver cirrhosis, mild splenomegaly, minimal ascites, cholecystopathy.
    • EUS revealed esophageal cancer, estimated EUS stage T1bN1, the pathology report showed Squamous cell carcinoma, moderately differentiated. Esophageal varice, lower esophagus.
    • CPET revealed low exercise capacity (VO2max 60%, WR 83%). Cardiac echogram showed LVEF:83%. Mild to moderate MR; mild TR; mild PR.
    • After all examinations, the cancer staging revealed squamous cell carcinoma of upper to middle third of esophagus cT1bN1M0, stage II. We had well explained with the patient and his family about further treatment.
    • Hema-Oncology and Radio-Oncologist were consulted who suggest neoadjuvant CCRT will be arranged. Operation of port-A implantation was done on 2024/04/24.
    • Gastroenterology was contacted again for hyperammonemia who suggested keep Lactulose use.
    • Consulted Oral and Maxillofacial Surgery was consulted for loose tooth assessment, then gave oral hygiene instruction, no dental extraction is needed.
    • MgSO4, MgO for Hypomagnesemia.
    • After treatment, the lab of Ammonia levere was drop, and conscious clear, so he received CCRT with PF1 (Cisplatin 30mg/m2, 5-FU 1000mg/m2) due to liver cirrhosis, child A, #1 on 2024/05/03, #2 on 2024/05/10, #3 on 2024/05/16 (the dose decreased due to ANC: 1231).
    • Baraclude for Anti-HBc: reactive.
    • The radiotherapy was started on 2024/05/02~.
    • After chemotherapy, he denied having a fever, vomiting, dyspnea, or any complaints.
    • Consulted dermatology (2024/05/14): NO active scabies lesions currently.
    • He can be discharged on 2024/05/17, the OPD follow-up will be arranged.
  • Discharge prescription
    • Sinpharderm Cream (urea) BID TOPI
    • Trimbow (beclometasone 100ug, formoterol 6ug, glycopyrronium 12.5ug; per dose) 2 puff BID INHL
    • Takepron (lansoprazole 30mg) 1# QDAC
    • Lactul (lactulose 666mg/mL) 15mL TID
    • Blopress (candesartan 8mg) 1# QD
    • BaoGan (silymarin 150mg) 1# BID
    • Berotec-N Metered Aerosol (fenoterol 0.1mg per dose) 2 puff PRNTID INHL
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • MgO 250mg 1# TID
    • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# TID
    • Eurodin (estazolam 2mg) 1# PRNHS
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2024-04-16 SOAP Thoracic Surgery Xie MinXiao
  • S
    • New diagnosed eso. ca.
    • The 59 y/o man has been diagnosed to have middle thoracic esophageal cancer (endoscopic biopsy done at 25 cm from the incisor on 2024-03-01 showed SqCC)
    • referred from HuaLian
  • O
    • Past history: Liver chirrhosis, diagnosed recently.
    • quit alchol, smoking.
    • smoking, 40 years, 2PPD, quit recently.
  • P
    • arrange admission on 2024-04-16.
    • arrange WBBS, brain MRI, abd. sono, EUS, bronchoscope, CPET, cardioecho.

==========

2024-05-30

[recommended voriconazole TDM for impaired liver function]

No CRE or VRE culture positives were found, but Aspergillus antigen was confirmed.

• 2024-05-28 Aspergillus Ag Positive
• 2024-05-28 Aspergillus Ag Value 0.55 Ratio

For invasive Aspergillosis, voriconazole is usually recommended at a dosage of 6 mg/kg IV/PO Q12H on day 1, followed by 4 mg/kg IV/PO Q12H. However, according to the package insert, in patients with mild to moderate liver impairment (Child-Pugh Class A and B), the standard loading dose should be used, but the maintenance dose should be halved. There are no recommendations for patients with severe liver impairment (Child-Pugh Class C) (Ref: Sanford Guide).

This patient weighs 73 kg. According to the Sanford Guide, the dosing should be 438 mg Q12H on day 1 and then 292 mg Q12H from day 2. Given the patient’s poor liver function, voriconazole therapeutic drug monitoring (TDM) is highly recommended to adjust the maintenance dose.

To order a voriconazole trough level test: - Order Code: L72-166 - Test Name: Antifungal Drugs (Azole) Concentration - Instructions: - Collect the sample within 30 minutes before the next dose. Note the administration time. - Send samples from Monday to Thursday before 14:00. Do not collect samples on national holidays or other times. - Use a purple-top tube and draw 2 to 3 mL. The sample should be centrifuged at 3000 rpm for 10 minutes within 8 hours, and the plasma should be separated into a large test tube. - The sample will be sent to Chang Gung Memorial Hospital by United Medical Laboratories for testing. Draw blood within 30 minutes before administering Vfend (voriconazole).

2024-05-27

[hyperammonemia management and lactulose dose consideration]

Lactul (lactulose) has effectively controlled the hyperammonemia. If serum ammonia levels remain within the normal range for these days, a reduction in the lactulose dosage or even discontinuation may be considered.

• 2024-05-26 Blood ammonia 70 umol/L
• 2024-05-25 Blood ammonia 149 umol/L

[liver cirrhosis Child-Pugh B classified & Medication Review]

The patient’s discharge diagnoses on 2024-05-17 included cirrhosis of the liver, classified as Child-Pugh Class A.

However, recent lab results indicate a revised classification to Child-Pugh Class B. This is based on updated values: Alb 2.9 g/dL (2 points), PT 13.7 seconds (3 points), and BilT 2.15 mg/dL (3 points). Even encephalopathy and ascites were not counted, these scores total at least 8 points, should be classfied as Class B.

The currently used medications have been reviewed for this Child-Pugh Class B patient, no other medications except Tramacet should be dose adjusted. Use of Tramacet is not recommended as acetaminophen and tramadol undergo extensive hepatic metabolism.

• 2024-05-25 Albumin (BCG) 2.9 g/dL
• 2024-05-25 PT 13.7 sec
• 2024-05-25 Bilirubin total 2.15 mg/dL
• 2024-05-15 Bilirubin total 1.01 mg/dL
• 2024-05-15 Bilirubin direct 0.29 mg/dL
• 2024-05-13 Bilirubin total 1.53 mg/dL
• 2024-05-13 Bilirubin direct 0.54 mg/dL

700322331

240529

[lab data]

2023-12-26 BCR/abl qualitative Undetectable
2023-12-21 FLT3-D835 (BM) Undetectable
2023-12-21 FLT3/ITD (BM) Undetectable
2023-12-20 HBsAg Nonreactive
2023-12-20 HBsAg Value 0.43 S/CO
2023-12-20 Anti-HBc Reactive
2023-12-20 Anti-HBc Value 7.15 S/CO
2023-12-20 Anti-HCV Nonreactive
2023-12-20 Anti-HCV Value 0.16 S/CO
2023-12-20 NPM1 qualitative (BM) Undetectable

[exam findings]

• 2024-05-29 SONO - chest
  • Symptom: dyspnea
  • Indication: r/o pleural effusion
  • Clinical diagnosis
    • Acute lymphoblastic leukemia
    • Left breast cancer, cT3N1M1 (lung), stage IV
    • congestive heart failure
  • Echo diagnosis
    • Consolidation, RLL
• 2024-05-28 ECG
  • Atrial flutter with variable A-V block with premature ventricular or aberrantly conducted complexes
  • Nonspecific T wave abnormality
• 2024-05-27 KUB
  • Degeneration of T-L spine.
  • Radiopaque spots at pelvic region.
• 2024-05-27 CXR
  • A consolidation or mass lesion in right lower lung zone
  • Right pleural effusion
  • Enlargement of cardiac sihoutte
• 2024-05-22 ECG
  • Atrial flutter with variable A-V block with premature ventricular or aberrantly conducted complexes
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2024-05-07 CXR erect
  • ill-defined large consolidation in lateral aspect of RLL
  • moderate enlarged cardiac silhoutte due to dilated cardiac chambers (LAD,RAD) and prominent pericardial fat /prominent cardiophrenic angle fat pad
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
  • marginal spurs of multiple vertebral bodies due to spondylosis.
• 2024-05-07 CXR
  • focal consolidation in laterobasal region of Rt lower lobe
• 2024-03-29 CXR erect
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • Faint aveolar opacity over right lower lobe is found.
  • Increased pulmonary vasculature is found.
• 2024-03-29 ECG
  • Atrial flutter with variable A-V block with premature ventricular or aberrantly conducted complexes
  • ST & T wave abnormality, consider anterolateral ischemia
  • Prolonged QT
  • Abnormal ECG
• 2024-03-11 CXR AP
  • appropriately positioned gastric tube
  • Rt pleural effusion
  • increased opacity and volume reduce over Rt lower lung
  • enlarged cardiac silhoutte due to dilated left atrium/prominent cardiophrenic angle fat pad /supine position
• 2024-03-11 SONO - chest
  • Echo diagnosis
    • Right thorax: small amount pleural effusion; thoracocentesis was not performed due to high risk of complications. Lung collapse was noted.
    • Left thorax: no pleural effusion.
• 2024-03-04 CTA - chest
  • CTA of chest revealed:
    • Bil. pleural effusions with adjacent lung collapse. GGO of bil. lungs. Some LNs at mediastinum and bil. axillary region. A nodule (1.9cm) at left breast.
    • Retroversion of uterus with calcifications.
    • Liver cysts (up to 1.3cm).
• 2024-02-07 Nerve Conduction Velocity, NCV
  • Findings
    • Prolonged distal latencies and decreased amplitudesin bilateral medial CMAPs. Slowed NCVs in bilateral ulnar CMAPs above elbow.
    • Slowed NCVs in bilateral medial and ulnar SNAPs.
    • Normal F-wave latencies followed bilateral medial and ulnar nerve stimulations.
  • Conclusion
    • This abnormla NCV study suggested distal neuropathy in bilateral medial and ulnar nerves and bilateralulnar neuropathy acrossed elbow.
• 2024-01-26 Bronchodilator Test
  • r/o severe restrictive ventilatory defect
  • negative BDT
• 2023-12-15 Patho - bone marrow biopsy
  • Bone marrow, biopsy — B-cell lymphoproliferative disorder
  • The specimen submitted consists of two pieces of gray-brown and hard bony tissue, measuring 1.5 x 0.3 x 0.3 cm. All for section after decalcification.
  • The sections show normocellular marrow (25%). The M/E ratio about 3:1. The megakaryocytes are slightly increased in number with occasional small megakaryocytes. Small aggregates and scattered small to medium-sized immature lymphoid cells, account 40% of marrow cells are present.
  • IHC, the immature lymphoid cells show: CD79a(+), CD3(-), CD20(-), CD34(-), CD117(-), TdT(-), and MPO(-). B-lymphoblastic leukemia/lymphoma should be considered in differential diagnosis. Suggest bone marrow smear evaluation, cytogenetic study, and clinic correlation.
• 2023-12-14 CT - chest
  • Indication: Left breast cancer
  • Chest CT without IV contrast ehnancement shows:
    • Soft tissue mass at left breast with size reduction as compared with previous CT on 2023-06-12. Regional lymphadenopathy is also found at left axillary and bilateral paratracheal region.
    • Consolidation of right upper lobe and right lower lobe is found. Right pleural effusion is also found. Lung meta with superimposed pneumonia is considered.
    • Calcified coronary arteries is found.
    • Cardiomegaly is noted.
  • Imp:
    • Left breast cancer with axillary and mediastinal lymphadenopathy. In regression but pneumonic patch with pleural effusion at right hemithorax
• 2023-12-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 42.8) / 126 = 66.03%
    • M-mode (Teichholz) = 66
  • Conclusion:
    • Dilated LA
    • Adequate LV and RV systolic function
    • Moderate MR, mild TR and PR , trivial AR
    • Possibly mild to moderate pulmonary HTN
    • No regional wall motion abnormalities
• 2023-10-31 Patho - stomach biopsy
  • Stomach, high body, GC, biopsy— fundic gland polyp. No H.pylori present
• 2023-10-30 EGD
  • Reflux esophagitis LA Classification grade A-
  • Superficial gastritis
  • Gastric polyps, body, s/p biopsy
• 2023-08-07 CT - brain
  • Mild cortical brain atrophy. Chronic mastoiditis.
• 2023-07-11 Tc-99m MDP bone scan with SPECT
  • Increased activity in the lower C- and lower T-spines and L3-5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the mandible. Dental problem may show this picture.
  • Increased activity in bilateral shoulders, knees and feet, compatible with benign joint lesions.
• 2023-06-27 Her-2/neu DISH
  • RESULT OF HER2 IN SITU HYBRIDIZATION:
    • HER-2 (by in situ hybridization) — Negative (NOT amplified)
  • METHOD AND DETAILS:
    • Number of observers: 1
    • Number of invasive tumor cells counted: 20
    • Average number of HER2 signals per cell: 3.55
    • Average number of CEP17 signals per cell: 2.25
    • HER2/CEP17 ratio: 1.58
    • Heterogeneous signals: Absent
    • Origin slide and block number: S2023-12716
    • Specimen: Formalin-fixed paraffin embedded tissue
    • Adequacy of sample for evaluation: Yes
    • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
  • APPENDIX:
    • ASCO/CAP scoring criteria (2018):
      • Group 1 = HER2/CEP17 ratio >=2.0; >=4.0 HER2 signals/cell
      • Group 2 = HER2/CEP17 ratio >=2.0; <4.0 HER2 signals/cell
      • Group 3 = HER2/CEP17 ratio <2.0; >=6.0 HER2 signals/cell
      • Group 4 = HER2/CEP17 ratio <2.0; >=4.0 and <6.0 HER2 signals/cell
      • Group 5 = HER2/CEP17 ratio <2.0; <4.0 HER2 signals/cell
    • Negative:
      • Group 5
      • Group 2 and concurrent IHC 0-1+ or 2+
      • Group 3 and concurrent IHC 0-1+
      • Group 4 and concurrent IHC 0-1+ or 2+
    • Positive:
      • Group 2 and concurrent IHC 3+
      • Group 3 and concurrent IHC 2+ or 3+
      • Group 4 and concurrent IHC 3+
      • Group 1
• 2023-06-27 Patho - breast biopsy (no margin)
  • DIAGNOSIS: Breast, left, core needle biopsy — Invasive carcinoma of no special type
    
  • GROSS DESCRIPTION: The specimen submitted consisted of 5 strips of tan irregular tissue measuring up to 1.5 x 0.1 x 0.1 cm. All for section in one cassette.
  • MICROSCOPIC DESCRIPTION: Section shows cores of breast tissue with irregular neoplastic glands infiltration and focal tumor necrosis. The immunohistochemical stain of CK5/6 is negative.
  • IMMUNOHISTOCHEMICAL STUDY
    • ER (Ab): Positive (> 95%, strong)
    • PR (Ab): Positive (30%, moderate)
    • Her-2/neu (Ab): Equivocal (2+)
    • Ki-67: 15%
• 2023-06-13 Mammography
  • Impression: Dense breast. Left breast malignancy with bilateral axillary lymph nodes, r/o malignancy with lymph nodes metastasis.
  • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
• 2023-06-12 CT - chest
  • Findings
    • Lungs: a spiculated tumor with pleural tails at RLL (35mm in longest dimension), an ill-defined part solid nodule (25mm) at posterior RUL, tethering on the major fissure.
      • multiple small nodules and centrilobular nodular opacities at Rt lung, a 16mm ground glass nodule at RUL, and mild centrilobular nodular opacities at LUL too.
    • chest wall: a large soft-tissue mass in Lt breast (polylobular borders at least 60mm in longest dimension) involving overlying skin.
      • extensive lymphadenopathy at both axillary regions.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels: mild calcified plaques of the LAD, and LCX, and right coronary arteries.
    • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: dilated LA.
    • Pleura: reace Rt-sided effusion
    • Visible abdominal contents: normal appearance of gall bladder
      • several hepatic cysts measuring up to 12mm.
      • unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
      • Extensive atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis. no destructive lytic or blastic lesion.
  • Impression:
    • Lt breast cancer with bilateral axillary LNs metastasis. RUL and RLL synchronous cancer with ipsilateral lung metastasis? or r/o breast ca with lung metastasis and inflammatory bronchiolitis and Rt lung and LUL.
• 2023-06-12 SONO - breast
  • Findings
    • Parenchymal pattem: Homogeneously sonodense
    • Focal sonographic lesion: Yes
  • Diagnosis
    • Highly suspicious of malignancy, with sonographic positive axillary LAP
  • Treatment
    • Sono-guided biopsy,Core-needle biopsy,Open biopsy
  • Suggestion
    • Arrange mammography, Arrange breast MRI, Arrange excisional biopsy, Admission for surgical intervention
  • BI-RADS:
    • 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken

[MedRec]

• 2024-02-05, -01-08 SOAP General and Gastrointestinal Wang ShengLin
  • Prescription
    • Femara (letrozole 2.5mg) 1# QD 28D
    • Ibrance (palbociclib 100mg) 1# QD 21D
    • diphenidol 25mg 1# TID 28D
• 2023-12-06 ~ 2023-12-21 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Pneumonia over right lung
    • Left breast cancer, of left breast, stage unknow
    • Gastro-esophageal reflux disease with esophagitis
    • Leukocytosis and blast
    • Anemia
    • mild to moderate pulmonary hypertension
  • CC
    • Fever off and on, general malaise and SOB in recently 3days
  • Present illness
    • This 83 years old female has history of
      • Lt breast cancer on hormone therapy & Palbociclib, RUL and RLL synchronous cancer with ipsilateral lung metastasis? or r/o breast ca with lung metastasis and inflammatory bronchiolitis and Rt lung and LUL
      • GERD
      • Leukocytosis and Anemia cause ?
    • She regullar followed up in our GS OPD
    • Three days prior to this admission, fever off and on, SOB with chest tightness and general malaise was noted, she was went to our ER for aid. The TOCC with COVID-19 (son).
    • At MER, the vital sign : BP:116/56; HR:73; BT:36.6’C; RR:18; Con’s:E4V5M6.
    • The laboratory studies disclosed WBC 20800 , N.seg/Lym 16/69 %, HB 6.3 g/dL, Na/K 127/3.5 mmol/L, Glucose 129 mg/dL, BUN/ Cre 26/1.32 mg/dL, Alt 19 mg/dL, and CRP 15.3 mg/dL.
    • The influenza and COVID-19 survey yield negative.
    • The CXR showed consolidations in right lung.
    • Under the impression of Pneumonia and r/o asthma AE, she was admitted to CM ward for management.
  • Course of inpatient treatment
    • After admission, empiric antibiotic with Cravit IV and Colimycin inhalation were used for pneumonia control.
    • Antitussive, mucolytic agents and other palliative treatment were given for symptomatic relief.
    • Bronchodilator with Atrovent plus with Butanyl inhalation was also prescribed for dyspnea with wheezing.
    • Do sputum culture, urine culture and blood culture evalution to identify pathogen.
    • Atypical infection profile (Streptococcus pneumoniae Antigen, Legionella pneumophila urine antigen test, M.Pneu. Ab ) were checked and all revealed negative findings.
    • VS explaint condition for her son and she received bone marrow was done, pending report.
    • Follow up CXR, her pneumonia condition got significant regression.
    • Sudden onset, fever without chills was noted, negtive of PCT and fever subside later.
    • Under the stable condition, she can be discharged on 2023/12/21. OPD follow up is arranged.
  • Prescription
    • Morcasin (sulfamethoxazole 400mg, trimethoprim 80mg) 1# Q12H 6D
    • Mecater (procaterol 25ug) 1# BID 6D
    • Rivotril (clonazepam 0.5mg) 1# HS 6D
    • Through (sennoside 12mg) 2# HS 6D
    • Trand (traxenamic acid 250mg) 1# BID 6D
    • Actein Effervescent (acetylcysteine 600mg) 1# BID 6D
• 2023-11-15 SOAP General and Gastrointestinal Wang ShengLin
  • S: poor appetite
  • Prescription
    • Femara (letrozole 2.5mg) 1# QD 28D
    • Ibrance (palbociclib 100mg) 1# QD 21D
    • diphenidol 25mg 1# TID 28D
    • Biofermin-R (antibiotics-resistant lactic acid bacteriae 1g) 1# TID 7D
• 2023-10-18 SOAP General and Gastrointestinal Wang ShengLin
  • S: no adverse effect
  • Prescription
    • Femara (letrozole 2.5mg) 1# QD 28D
    • Ibrance (palbociclib 100mg) 1# QD 21D
    • diphenidol 25mg 1# 28D
• 2023-09-20 SOAP General and Gastrointestinal Wang ShengLin
  • O
    • sensory neuropathy grade 1
    • hand-foot syndrome grade 1
  • Prescription
    • Femara (letrozole 2.5mg) 1# QD 28D
    • Ibrance (palbociclib 100mg) 1# QD 21D
    • diphenidol 25mg 1# 28D
    • Parmason Gargle Soln (chlorhexidine) BID GAR 7D
• 2023-08-30 SOAP General and Gastrointestinal Wang ShengLin
  • S/O:
    • Hormone therapy: Femera
    • CDK 4/6 inhibitor: Ibrance
    • Mild dizziness, no significant brain metastasis: diphenidol
  • A: Luminla B:
    • ER (Ab): Positive (> 95%, strong)
    • PR (Ab): Positive (30%, moderate)
    • Her-2/neu (Ab): Equivocal (2+)
    • Ki-67: 15%
  • P:
    • Oral hormone therapy: Femera
    • Oral CDK 4/6 inhibitor: Ibrance
    • regular OPD follow up
  • Prescription
    • Ibrance (palbociclib 100mg) 1# QD 21D
    • diphenidol 25mg 1# TID
• 2023-08-23 SOAP General and Gastrointestinal Wang ShengLin
  • S/O:
    • Mild dizziness: no significant brain metastasis => add diphenidol
    • Brain CT: Mild cortical brain atrophy. Chronic mastoiditis.
  • A/P:
    • Oral hormone chemotherapy
    • Oral CDK 4/6 inhibitor
    • regular OPD follow up
  • Prescription
    • Femara (letrozole 2.5mg) 1# QD 28D
    • Ibrance (palbociclib 100mg) 1# QDAC 7D
    • diphenidol 25mg 1# TID 7D
• 2023-07-24 SOAP General and Gastrointestinal Wang ShengLin
  • S:
    • Abdominal distension improved
    • no significant side effects
  • A: Luminla B:
    • ER (Ab): Positive (> 95%, strong)
    • PR (Ab): Positive (30%, moderate)
    • Her-2/neu (Ab): Equivocal (2+)
    • Ki-67: 15%
  • P:
    • Oral hormone chemotherapy
  • Prescription
    • Femara (letrozole 2.5mg) 1# QD 28D
• 2023-07-10 SOAP General and Gastrointestinal Wang ShengLin
  • S: Abdominal distension with constipation
  • O: Pathology
    • Breast, left, core needle biopsy — Invasive carcinoma of no special type
      
    • IMMUNOHISTOCHEMICAL STUDY
      • ER (Ab): Positive (> 95%, strong)
      • PR (Ab): Positive (30%, moderate)
      • Her-2/neu (Ab): Equivocal (2+)
      • Ki-67: 15%
  • Prescription
    • MgO 250mg 1# TID 14D
    • Femara (letrozole 2.5mg) 1# QD 14D
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 14D
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID 14D
• 2023-06-27 SOAP General and Gastrointestinal Wang ShengLin
  • S/O: irregular tumor, 6.7cm in UOQ of left breast
  • A/P: arrange left breast core needle biopsy
  • Prescription
    • fusidic acid 20mg/gm BID EXT 3D
    • Acetal (acetaminophen 500mg) 1# QID 3D
    • cephalexin 500mg 1# Q6H 3D
• 2023-06-12 SOAP General and Gastrointestinal Wang ShengLin
  • S/O: Left breast palpable tumor noted for several days
  • A/P:
    • Breast echo
    • Chest X-ray
    • Chest CT
    • Mammography

[consultation]

• 2023-12-28 Chest Medicine
• 2023-12-25 Family Medicine
• 2023-12-25 Dermatology
• 2023-12-20 Infectious Disease
• 2023-12-11 Hemato-Oncology
• 2023-12-08 Psychosomatic Medicine

==========

2024-05-29

[ALT elevation and Ibrance management]

ALT is rising. Please note that Ibrance (palbociclib) is associated with hepatic incidences, including increased serum alanine aminotransferase (6% to 43%) and increased serum aspartate aminotransferase (8% to 52%). Addition of BaoGan (silymarin) might be considered. And if more severe liver symptoms develop, consider reducing the dose or discontinuing the medication.

• 2024-05-29 ALT 105 U/L
• 2024-05-27 ALT 73 U/L
• 2024-05-22 ALT 56 U/L
• 2024-05-07 ALT 16 U/L

2024-03-13

[monitoring for ILD and pneumonitis before considering resumption of Ibrance]

Ibrance (palbociclib 100mg), administered once daily for 21 days in a 28-day cycle, might be resumed if there has been no induction of ILD and/or pneumonitis. The patient last received this medication on 2024-02-05, and more than a month has passed since then, leading to a delay in the current treatment cycle.

[temporarily purchase Blincyto or Besponsa if needed]

If Ph- B-ALL is confirmed, Blincyto (blinatumomab) and Besponsa (inotuzumab ozogamicin) were temporarily purchased and listed in the database but are currently out of stock at this hospital (file closed). Given this patient’s condition, it may not be possible to secure NHI coverage for these medications. Should there be a need, a request for temporary procurement can be made. (Ref: https://www.nccn.org/professionals/physician_gls/pdf/all_blocks.pdf)

2023-12-25

[tube feeding]

Concor 5mg administration via Simple Suspension Method (SSM):

For patients requiring enteral nutrition, dissolve the Concor 5mg tablet using the SSM. This efficient method involves:

• Dissolving: Crush the tablet and add it to a container of warm drinking water.
• Soaking: Allow the mixture to stand for 5-10 minutes, allowing the tablet to fully dissolve.
• Stirring/Shaking (optional): Gently stir or shake the container at intervals to facilitate dissolving.
• Administration: Once completely dissolved, administer the suspension directly through a feeding tube.

Benefits of SSM:

• Dissolution in warm water: SSM effectively dissolves tablets and capsules even in lukewarm water, suitable for both suspension and feeding tube administration.
• Improved compliance: This method simplifies medication administration for patients with swallowing difficulties, potentially enhancing adherence to treatment.

701526323

240529

[exam findings]

• 2024-05-27 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • S/p port-A placement with its tip at right atrium is found.
  • Nodular lesions are found at both lungs is found.
  • Osteopenia of the bony structure is noted.

[MedRec]

• 2024-05-29 MultiTeam Palliative Care
  • Multidisciplinary Recommendations - Palliative Care
    • Consultation Date: 2024-05-28
    • Response:
      • The patient’s National Health Insurance card indicates a pre-determined wish for palliative care. Diagnosed with cutaneous squamous cell carcinoma in June 2022, treatment has been ongoing at National Taiwan University Hospital. The patient, feeling weak and debilitated, came to our hospital seeking palliative care. During the co-care nurse visit, the patient was using N/C and complained of pain in the left thigh, immobility, and numbness in both hands. The patient expressed a desire for palliative care after being informed by NTU doctors of brain metastases, leading to a decision to cease further treatment.
      • Living alone without caregivers, the patient wishes to stay in our palliative ward. The co-care nurse explained the concept of palliative care and the differences between the palliative ward and general wards, emphasizing that symptom control is the primary focus, and discharge is still possible if conditions stabilize. The patient’s weak family support system and financial difficulties were noted, and the social worker has been informed for assistance.
    • Conclusion and Recommendations:
      • Palliative co-care recommended
      • Suggest consultation with social worker and discharge planning nurse
  • Responder: Chen Hui
  • Response Date: 2024-05-28 17:02
  • Physician’s Reply: 05/29 08:59 Xia HeXiong: Proceed as suggested. Understood.
• 2024-05-27 SOAP Medical Emergency Lin BoZhen
  • S
    • Triage: 3 Limb weakness > Symptom onset time more than 4.5 hours or relieved. The patient’s friend complained that the patient started to feel weak in both lower limbs two days ago. He could still walk with a walker before.
    • F/S:107
    • PH: Lt neck squamous cell ca? under C/T, diffuse spine metastatis(+), Lt clavicular Fr and Rt humerus Fr S/P ORIF NKDA
    • 2024/04/12 Discharge from NTUH:
      • Unknown primary cancer, left neck mass, poorly differentiated carcinoma, p16(+), p40 (focal +) with the parotid, mediastinum, para-caval and para-aortic and abdominal involved
      • PD-L1 (Dako22C3), TPS: 10%; CPS: 15, TC 5~10%
    • status post Cisplatin/HDFL (C1D1 on 2022/08/03- C5D8 on 2022/11/17), with partial response;
    • status post Erbitux based radiotherapy (50cGy/20 fractions, 2022/12/1-2023/01/06);
    • status post maintenance Erbitux (-2023/04/27), with progressive disease
    • status post Erbitux + MTX (C22, 2023/05/04-2023/07/06)
    • status post weekly MTX (C1D1-C10D8 = 2023/07/13-2024/01/26), left neck multiple lymphadenopathies and progression fungating wound in 2023/11
    • status post Endoxan (2023/11/16-2024/02/07)
    • status post palliative radiotherapy to left neck tumor (12Gy/20 fractions, 2023/12/13-2024/01/10), with disease progression
    • status post Carboplatin/ 5-FU (C3, 2024/02/15-2024/04/08), oral UFUR (2024/02/22-2024/02/29)
    • Cancer cachexia.
  • O
    • Vital signs: BP 151/79; HR 120; BT 37.3’C; RR 18;
    • Con’s E4V5M6
    • SpO2 94%
    • chronic ill
    • anicteric, mild anemic
    • Lt neck skin ca. with eschar
    • clear BS, Rt subclavian port A (+)
    • ABD soft and flat, nontender
    • EXT symmetric weakness, edema (+)
  • Plan
    • Preliminary impression C44.92 Squamous cell carcinoma of skin, unspecified
    • Lethargy, WBC 11K, Hb 9.4, Na 130, AST/ALT 198/22, hsT 34.5 > 36.4, Unknown primary cancer, left neck mass, poorly differentiated carcinoma, hospice no bed, OA ONC

==========

2024-05-29

[consider BaoGan for elevated AST after non-liver causes have been ruled out]

Lab results on 2024-05-27 showed elevated AST (198 U/L) and normal ALT (22 U/L). Some of the possible causes could be investigated further:

• Muscle Injury or Disease: AST is present in several tissues, including liver, heart, muscle, and kidneys. An elevated AST with normal ALT might suggest muscle damage rather than liver damage. Conditions such as myopathy, rhabdomyolysis, or after intense exercise can elevate AST levels.
• Cardiac Conditions: AST can also be elevated in the context of a heart attack or other heart damage. If a patient has had recent cardiac trauma or a myocardial infarction, this could cause elevated AST levels (hs-Troponin I 36.4 pg/mL).
• Hemolysis: Hemolysis, or the breakdown of red blood cells, can cause an apparent elevation in AST due to the release from red blood cells.
• Acute Pancreatitis: Although more typically associated with changes in amylase and lipase, acute pancreatitis can sometimes elevate AST levels without affecting ALT significantly.
• Liver Conditions with Preferential AST Elevation: Certain liver conditions might preferentially elevate AST over ALT. Chronic alcohol use, for example.

If liver condition is suspected, the addition of BaoGan (silymarin) may be considered.

701273730

240528

[exam findings]

• 2024-04-02 L-spine flex & ext (including sacrum)
  • Degeneration and spondylosis of L-S spine.
• 2024-04-02 C-spine AP + Lat
  • Degeneration and spondylosis of C-spine.
• 2024-03-21 CXR erect
  • Borderline cardiomegaly
  • Spondylosis of the T-spine
• 2024-01-21 KUB
  • Radiopaque spots at pelvic region.
  • Degeneration and spondylosis of L-S spine.
  • Stool retention in the bowel.
• 2024-01-10 CT - chest
  • Comparison: prior CT dated on 2023/07/13
    • Lungs:
      • plate atelectasis at inferior lingular segment.
      • minimal fibrosis in inferior paravertebral region of RLL, related to osteophytes of spine.
      • subtle mosaic attenuation at LLL.
    • Mediastinum and hila:
      • extensive lymph nodes enlargement at left anterior prevascular space and visceral (middle compartment) space and left hilum, a central low density at Rt pretracheal node.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no effusion or nodule
    • Chest wall and visible lower neck: extensive lymph nodes enlargement at the supracular fossae.
  • Impression:
    • extensive supraclavular-mediastinal-hilar lymphadenopathy
    • in progression compared with CT on 2023/07/13
• 2023-09-23 MRI - L-spine
  • Indication: progressive for distal limbs numbness with pain, more on right foot with left finger
  • Without-contrast MRI of lumbar spine reveals:
    • General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and effacement of bilateral lateral recesses at L4-5.
    • General bulging disc with central focal protrusion and annular tear, and enlarged facets causing mild spinal canal stenosis at L5-S1.
    • No intramedullary lesion.
    • Two oval-shaped nodular lesions, about 15 mm at long axis, at right para-aortic region of L2 level. R/O lymphadenopathy.
  • IMP:
    • Mild lumbar spondylosis, esp L5-S1 (with central HIVD). Para-aortic lymph nodes at L2 level. Suggest further evaluation.
• 2023-09-15 Nerve Conduction Velocity, NCV
  • Findings
    • The NCV study showed (1) Prolonged distal motor latency in right median and right peroneal nerves. (2) Decreased SAP amplitude in all sampled nerves. (3) Slowing sensory conduction velocity in most sampled nerves.
    • The F wave study showed prolonged latency in right peroneal nerve.
    • The H reflex study showed prolonged both sides.
    • The QST study showed abnormal warm sensation in upper limb and abnormal warm and cold sensation in lower limb.
  • Conclusion
    • The above findings suggest sensory predominant polyneuropathy and bilateral lumbosacral radiculopathy. Compare with the previous study on 2022/8/8. Advise clinical correlation.
• 2023-07-13 CT - chest
  • Indication: Malignant (primary) neoplasm, unspecified; Secondary malignant neoplasm of unspecified site
  • Chest CT without IV contrast ehnancement shows:
    • Lymphadenopathy at AP window of the mediastinum is found. In comparison with CT dated on 2023-03-11, the lesion is stationary.
  • Imp:
    • Mediastinal lymphadenopathy, stationary.
• 2023-03-11 CT - chest
  • Chest CT without IV contrast ehnancement shows:
    • Lymphadenopathy at mediastinum is found including AP window and superior medistinum. In comparison with CT dated on 2022-10-26, the lesions enlarged.
    • Marked fatty liver is found.
  • Imp:
    • Mediastinal lymphadenopathy, in enlargement.
• 2022-10-26 CT - chest
  • Indication: Metastatic undifferentiated carcinoma, unknown primary with neck and mediastinal LN metastases CCRT (20211022) ended (20211112)
  • Comparison was made with previous CT dated on 2022/06/30
    • Lungs:
      • plate atelectasis at inferior lingular segment.
      • mild ground-glass opacity at paraspinal region of RLL.
      • minimal fibrosis in inferior paravertebral region of RLL, related to osteophytes of spine.
      • subtle mosaic attenuation at LLL.
    • Mediastinum and hila: enlarged LNs at left anterior prevascular space.
      • the trachea and main bronchi are normallly identified without endobronchial lesion.
    • Vessels:
      • the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: no enlarged LN or soft-tissue nodule.
  • Impression:
    • mediastinal lymphadenopathy at left anterior prevascular space,
    • in progression compared with CT on 2022/06/30.
    • newly developed mild ground-glass opacity in paraspinal region of RLL, nature to be determined, suggest follow up.
• 2022-08-08 Nerve Conduction Velocity, NCV
  • Findings
    • The NCV study showed (1) Prolonged distal motor latency in right median nerve. (2) Decreased SAP amplitude in all sampled nerves. (3) Slowing sensory conduction velocity in right median and right ulnar nerves.
    • The F wave was normal.
    • The H reflex showed prolonged latency in both sides.
    • The QST study showed abnormal warm sensation in upper and lower limbs.
    • There were abnormal cold sensation in lower limb.
  • Conclusion
    • The above findings suggest sensory predominant polyneuropathy and small fiber disease. Compared with previous study on 2021/11/08, there were similar condition.
• 2022-06-30 CT - chest
  • Indication: metastatic undifferentiated carcinoma with paraneoplastic syndrome with polyneuropathyover neck LN and mediastinal LN metastases
  • Chest CT without IV contrast ehnancement shows:
    • Small lymph nodes are found at AP window and paratracheal region. In comparison with CT dated on 2022-03-04, these lymph nodes enlarged slightly.
    • Llinear atelectatic change at left lingula lobe is found.
    • Severe fatty liver is found.
  • Imp:
    • Non-specific lymph nodes in the mediastinum with mild enlargement. Suggest follow up.
    • Fatty liver, severe.
• 2022-04-11 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in bilateral rib cages, maxilla, mandible, middle and lower T-spine, lower L-spine, sacrum, right sternoclavicular junction, both shoulders, S-I joints, knees, and feet.
• 2022-03-04 CT - neck
  • Without contrast Neck CT showed
    • small lymph nodes in the bilateral neck, esp. left supraclavicular fossa. As compared with previous study on 20211203, the sizes were decreased.
  • IMP:
    • small bilateral neck lymph nodes
• 2021-12-03 CT - neck
  • Indication: Neck metastases with unknown primary. follow up tumor status.
  • Comparison: Neck CT done on 20210820 - Neck and chest CT without/with contrast enhancement shows:
    • grossly symmetric bilateral pharyngeal mucosa.
    • multiple enlarged lymph nodes at left supraclavicular region and lower neck (level IV, Vb), with increased adjacent fat stranding. Those lymph nodes has been stationary in size, with the largest one about 1.3cm in level IV.
    • decreased size of bilateral level Ib lymph nodes (about 0.8cm in size).
    • subsegmental atelectasis at lingular segment of LUL; no evidence of pulmonary nodules.
  • Impression:
    • Multiple enlarged lymph nodes at left level IV, Vbm size stationary.
• 2021-11-08 Nerve Conduction Velocity, NCV
  • Findings:
    • The NCV study showed (1) Prolonged distal motor latency in right meidan and right peroneal nerves. (2) Decreased CMAP amplitude in rihgt median, and right peroneal nerves. (3) Decreased SAP amplitude in all sampled nerves. (4) Slowing sensory conduction velocity in right median and right ulnar nerves.
    • The F wave study was within normal limit.
    • The H reflex study showed right side absent.
    • The QST study showed abnormal warm sensation in upper and lower limbs.
  • Conclusion
    • The above finding suggest sensory predominant polynueropathy and small fiber disease.
    • Improve than previous study. Advise clinical correlation.
• 2021-05-20 CT - neck
  • Indication: neck metastases with unknown primaryfollow up tumor status
  • With and Without contrast Neck CT showed
    • multiple enlarged lymph nodes at the left supraclavicular fossa and left lower neck;
    • multiple small lymph nodes in the bilateral neck space.
  • IMP:
    • enlarged lymph nodes at the left supraclavicular fossa and left lower neck.
• 2021-05-26 PET scan
  • Glucose-hypermetabolism in the left lower lung, a primary (priority) or secondary lung cancer should be considered, suggesting biopsy for further investigation.
    
  • Glucose-hypermetabolism in the left pulmonary hilar lymph nodes, bilateral mediastinal lymph nodes, and left supraclavicular fossa lymph nodes, probably lung cancer with regional lymph nodes involvement.
    
  • Glucose-hypermetabolism in the left level V cervical lymph nodes, compatible with cancer with distant metastases.
    
  • Increased FDG uptake at bilateral shoulders and colon, probably benign in nature.
  • Left lower lung cancer (if proved), cTxN3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2021-05-25 Patho - stomach biopsy
  • Stomach, cardia, biopsy — Helicobacter-associated non-atrophic chronic gastritis
• 2021-05-25 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Atrophic gastritis, antrum, s/p CLO test
    • Gastric polyp, cardia, s/p biopsy
    • R/o gastric xanthoma, antrum, PW
  • CLO test: Positive
• 2021-05-20 Tc-99m MDP bone scan
  • Increased activity in the middle and lower T-spines and lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2021-05-19 MRI - nasopharynx
  • Indication: matestasis primay unknown, suspect NPC cancer
  • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck and showed:
    • multiple enlarged lymph nodes in the left supraclavicular fossa
    • unremarkable change in the nasopharynx, oropharynx, and hypopharynx.
    • metallic artifacts in the oral cavity
    • unremarkable change at the skull base
  • IMP:
    • no image evidence of NPC tumor; enlarged lymph nodes in the left supraclavicular fossa.
• 2021-04-22 Patho - lymphnode biopsy
  • Lymph node, level V, neck, excisional biopsy — Metastatic undifferentiated carcinoma, suggest check NP
    
  • The specimen submitted consists of a piece of gray-tan nodularmass, labeled neck level V lymph node, measuring 1.8 x 1.0 x 0.8 cm. All for section.
    
  • The sections show a picture of metastatic undifferentiated carcinoma, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern, embedded within lymphoid tissue. Necrotizing granuloma is found also. Suggest check nasopharyngeal condition.
  • IHC: CK7(-), CK20(-), p40(+), TTF1(-), and EBV(-)
    
  • Comment: The IHC finding is consistent with metastatic squamous cell carcinoma, non-keratinizing
• 2021-04-19 Nerve Conduction Velocity, NCV
  • Findings:
    • The NCV study showed (1) Prolonged distal motor latency in right median nerve. (2) Decreased SAP amplitude and slowing sensory conduction velocity in most sampled nerves.
    • The F wave study showed prolonged latency in right peroneal nerve.
    • The H reflex showed absent right side response.
      
  • Conclusion
    • The above findings suggest probable sensorimotor polyneuropathy. As compare with previous study on 2021/03/26, it was stationary. Advise clinical correlation.
• 2021-04-19 Motor-Evoked Potentials, MEP
  • Findings: Normal waveforms, amplitudes, peak latencies, interpeak intervals following each stimulation.
  • Conclusion: This is a normal MEP study.
• 2021-04-19 SomatoSensory-Evoked Potentials, SSEP
  • Findings: The SSEP study showed absent or prolonged latency in most sampled nerves.
  • Conclusion: The above findings suggest severe sensory system disease. Advise clinical correlation.
• 2021-04-15 CT - abdomen
  • History and indication: elevated CA15-3 with polyneuropathy, need to rule out malignancy
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Enlarged LNs at mediastinum.
    • Some tiny nodules in peritoneal cavity. Colonic diverticula.
    • Small gallbladder stones (3-4mm).
  • IMP:
    • Enlarged LNs at mediastinum.
    • Some tiny nodules in peritoneal cavity.
• 2021-03-26 Nerve Conduction Velocity, NCV
  • Findings
    • The NCV study showed
      • Prolonged distal motor latency in right median nerve.
      • Decreased SAP amplitude and slowing sensory conduction velocity in most sampled nerves.
      • Slowing motor conduction velocity in right median and right peroneal nerve.
    • The F wave study showed prolonged latency in right median nerve.
    • The H reflex was normal.
    • The QST study showed abnormal warm sensation in upper limb.
  • Conclusion
    • The above findings suggest probable sensorimotor polyneuropathy. Advise clinical correlation.

[MedRec]

• 2024-02-15 ~ 2024-02-17 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Malignant (primary) neoplasm, unspecified
    • Metastatic undifferentiated carcinoma, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern, embedded within lymphoid tissue, stage IV. Extensive supraclavular-mediastinal-hilar lymphadenopathy in progression.  
    • Chronic viral hepatitis B without delta-agent, anti-Hbc: positive
    • Hyperuricemia
    • Chronic inflammatory demyelinating polyneuritis
  • CC
    • for regular chemotherapy
  • Present illness
    • This 57 years old, a patient of metastatic undifferentiated carcinoma, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern, embedded within lymphoid tissue, stage IV S/P CCRT and chemotherapy with PF, she developed had bilateral leg numbness (the sensation of ants crawling on the outer side of the right calf and both soles for 4 months ago), but 1 months ago left distal thumb with index finger numbness occured and worsed symptom with pain complainted after regular follow up at Cardinal Tien Hospital, she became unable to walking and bilateral foot pain with leg numbness, she came to our hospital for help on 2021/03/20.
    • Arranged NCV study and the above findings suggest probable sensorimotor polyneuropathy. Nephrologist was consulted for plasma exchange on 2021/04/02, 04/05 and 04/07.
    • She received plasma change for 5 times (until 2021/04/12).
    • Chest to abdominal CT was arranged to rule out malignancy and revealed some tiny nodules in peritoneal cavity, enlarged LNs at mediastinum and left lower neck. Lymph node excision biopsy was done on 2021/04/22.
    • Pathology report revealed metastatic undifferentiated carcinoma, suggest check NP (The sections show a picture of metastatic undifferentiated carcinoma, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern, embedded within lymphoid tissue. Necrotizing granuloma is found also. Suggest check nasopharyngeal condition.)
    • The skull to chest MRI showed no image evidence of NPC tumor, enlarged lymph nodes in the left supraclavicular fossa.
    • Bone scan showed no evidence of bony mets and EBV DNA showed negtive.
    • Check CK and TTF-1, but he told us her CK 7and CK 20 showed negtive.
    • PET by selfpay, report showed Left lower lung cancer (if proved), cTxN3M1c, stage IVB (AJCC 8th ed.).
    • Under the diagnosis of Metastatic undifferentiated carcinoma, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern, embedded within lymphoid tissue. unknown primary, stage IV s/p chemotherapy with PF4 on 2021/05-2021/09, and CCRT since 2021/10/01-2021/11/12 (Treatment target and volume: involved nodal lesions including left low neck, SCF, probably to upper mediastinum area. 6000cGy/30 fractions).
    • Follow up neck CT on 2021/12/03, report showed 1. Multiple enlarged lymph nodes at left level IV, Vbm size stationary and 2. Decreased size of bilateral level Ib lymph nodes.
    • She received C5-C8 PF on 2021/12/13-2022/04/05.
      • Chest CT (2022/06/30) showed non-specific lymph nodes in the mediastinum with mild enlargement.
      • Chest CT (2022/10/26) revealed mediastinal lymphadenopathy at left anterior prevascular space,　in progression compared with CT on 6/30. newly developed mild ground-glass opacity in paraspinal region of RLL
      • Chest CT (2023/03/11) revealed Mediastinal lymphadenopathy, in enlargement.
      • Chest CT (2023/07/11) showed Mediastinal lymphadenopathy, stationary.
      • Chest CT (2024/01/10) showed proved extensive supraclavular-mediastinal-hilar lymphadenopathy in progression compared with CT on 2023/7/13.
    • Last time, she presented to the ER with left chest wall pain noted for 3 days accompanied with extremities numbness, pain control with Ultracet 1# po q12h was added for pain control.
    • C1 chemotherapy with Taxotere (75mg/m2, self-paid) on 2024/01/26.
    • This time, she denied fullness this week, but severe knee pain after chemotherapy around 4 days, so she was brought to our ED on 2024/01/31.
    • Under the impression of Metastatic undifferentiated carcinoma, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern, embedded within lymphoid tissue, stage IV and extensive supraclavular-mediastinal-hilar lymphadenopathy in progression, so she was admitted for C2 Taxotere on 2024/02/15.
  • Course of inpatient treatment
    • After admission, she received Limeson 2# po bid on 2/15-2/17 24 and C2 chemotherapy with Taxotere on 2/16 24.
    • Under the stable condition, she can be discharged today.
  • Discharge diagnosis
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Feburic (febuxostat 80mg) 1# QD
    • Limeson (dexamethasone 4mg) 2# BID
    • Meitifen (diclofenac Na 75mg) 1# PRNQD
    • Ulstop (famotidine 20mg) 1# QD
    • Through (sennoside 12mg) 2# PRNHS

[consultation]

• 2024-04-01 Neurosurgery

  • Q
    • The 57 y/o woman has Metastatic undifferentiated carcinoma, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern, embedded within lymphoid tissue, stage IV.  Extensive supraclavular-mediastinal-hilar lymphadenopathy in progression. - Due to right thigh to foot soreness and right knee swelling, so we need your help for management. Thanks!

• 2022-01-11 Nutrition

• 2021-05-28 Gastroenterology

• 2021-05-18 General and Gastroenterological Surgery

• 2021-05-17 Radiation Oncology

  • Q
    • The 54 y/o woman has lymph node pathology revealed metastatic undifferentiated carcinoma, suggest check NP (The sections show a picture of metastatic undifferentiated carcinoma, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern, embedded within lymphoid tissue. Necrotizing granuloma is found also. Suggest check nasopharyngeal condition.)
    • We need your help for management. Thanks!
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For evaluation due to metastatic undifferentiated carcinoma of the left level V area, with unknown pimary site.
      • PI: According to the patient statement, she suffered from polyneuropathy with sensory dysfunction of upper and lower extremities about several months ago. Abnormal left low neck to SCF nodal lesion was noted during work-up. Pathology (S2021-06275, 2021-4-23) showed lymph node, level V, neck, excisional biopsy — metastatic undifferentiated carcinoma, suggest check NP.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM(-); HTN(+)
      • Previous RT Hx: (-)
    • O:
      • ECOG: 1
      • PE: neck and bil SCF: nodal lesions over left low neck to SCF s/p biopsy; numbness of both upper limbs, poor sensory function over both low limbs.
      • CXR (2021-03-30): neg.
      • CT scan of abdomen (2021-04-15): Enlarged LNs at mediastinum. Some tiny nodules in peritoneal cavity.
      • Pathology (S2021-06275, 2021-04-23): Lymph node, level V, neck, excisional biopsy — Metastatic undifferentiated carcinoma, suggest check NP.
        
      • Tumor marker (2021-05-05): CA153(27.443), CEA(1.102), CA199(41.483), CA125(38.17)
    • A:
      • Metastatic undifferentiated carcinoma of the left level V with unknown primary.
    • P:
      • Because of unknown primary, further work-up including ENT consultation (nasopharyngeal fiberoptic examination), EBV DNA testing, MRI (from skull base to clavicle) .., is recommended for confirmation.
      • Please notify me for further evaluation and management after completion of work-up and if indicated.

• 2021-04-20 Ear Nose Throat

  • Q
    • Mrs. Lin is a 55-year-old woman with HTN.
    • This time, she was admitted to ward due to sensory predominant chronic inflammatory demyelinating polyneuropathy s/p plasmapheresis and pulse steroid therapy.
    • Due to elevated CA15-3 with polyneuropathy, chest to abdominal contrast CT was arranged to rule out malignancy.
    • CT revealed enlarged lymph nodes in left lower neck and mediastinum. PE revealed an about 2*1cm rubbery to hard, fixed lesion over left lower neck.
    • Oncologist was consulted and suggested consutl ENT for LN biopsy.
    • We need you expertise for left lower neck lymph nodes excisional biopsy. Thank you very much!
  • A
    • Arrange excisional biopsy under LA on 2021-04-22 1200-1230

• 2021-04-19 Hemato-Oncology

  • Q
    • Mrs. Lin is a 55-year-old woman with HTN.
    • This time, she was admitted to ward due to sensory predominant chronic inflammatory demyelinating polyneuropathy s/p plasmapheresis and pulse steroid therapy.
    • Due to elevated CA15-3 with polyneuropathy, chest to abdominal contrast CT was arranged to rule out malignancy.
    • CT revealed enlarged nodules in mediastinum and peritoneal cavity. No obvious B symptoms (fever, night sweating, body weight loss) were noted.
    • We need your expertise for further evaluation about possibility of lymphoma or other malignancies.
  • A
    • Patient examined and Chart reviewed. A case of CIDP with enlarged LN. I am consulted for the further evaluation.
    • My suggestions:
      • Based on the CT imaging, LN enalrgement could be found in the areas of mediastinum and left lower neck. Pleaes consult ENT for LN biopsy.
      • Please check LDH and Beta2-microgloculoin.
      • If the data is coming out, pleae let me know.

• 2021-04-13 Rehabilitation

• 2021-04-02 Nephrology

  • Q
    • For plasmapheresis
    • Mrs. Lin is a 55-year-old woman with HTN. This time, she was admitted to ward due to bilateral leg numbness for 4 months.
    • Due to sensory ataxia with chronic inflammatory demyelinating polyneuropathy, we need your expertise for arrangement of plasmapheresis since 2021/04/02 at SICU.
  • A
    • We will arrange FVC insertion and plasma exchange after her admission to ICU
    • Under the indication of CIDP
    • Please prepare 24U before each plasma exchange
    • The TPE will be scheduled since 2021-04-02 with frequency of QW135
    • Premedications: Solucortef 100mg iv , Vena 1Amp iv, Ca gluconate 1Amp iv.

[chemotherapy]

• 2024-04-26 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-03-08 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-02-16 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-01-26 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-04-06 - carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 1800mg NS 500mL D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-02-14 - carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-01-10 - carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-12-13 - carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-11-12 - NS 500mL 1hr (before CDDP) + cisplatin 30mg/m2 48mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
• 2021-11-05 - NS 500mL 1hr (before CDDP) + cisplatin 30mg/m2 48mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
• 2021-10-29 - NS 500mL 1hr (before CDDP) + cisplatin 30mg/m2 48mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
• 2021-10-22 - NS 500mL 1hr (before CDDP) + cisplatin 30mg/m2 48mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
• 2021-10-15 - NS 500mL 1hr (before CDDP) + cisplatin 30mg/m2 48mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
• 2021-10-08 - NS 500mL 1hr (before CDDP) + cisplatin 30mg/m2 48mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
• 2021-10-01 - NS 500mL 1hr (before CDDP) + cisplatin 30mg/m2 48mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
• 2021-09-01 - carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 1650mg NS 500mL D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-07-30 - carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 1640mg NS 500mL D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-07-02 - carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 1600mg NS 500mL D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL (before CDDP <- ??)
• 2021-05-27 - NS 500mL 2hr (before CDDP) + cisplatin 75mg/m2 110mg NS 250mL + NS 500mL 2hr (after CDDP) + fluorouracil 1000mg/m2 1550mg NS 500mL D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[Note]

Cancer of Unknown Primary - 2022-01-10

• Cancer of Unknown Primary: A Review on Clinical Guidelines in the Development and Targeted Management of Patients with the Unknown Primary Site - source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820325/pdf/cureus-0011-00000005552.pdf
• NCCN Clinical Practice Guideline - Occult Primary (Cancer of Unknown Primary [CUP]) - source: https://www.nccn.org/professionals/physician_gls/pdf/occult_blocks.pdf
• Cancer of Unknown Primary Site: Real Entity or Misdiagnosed Disease? - source: https://sci-hub.se/10.7150/jca.42880
• Cancer of Unknown Primary Sites: What Radiologists Need to Know and What Oncologists Want to Know - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603700/pdf/nihms449402.pdf

==========

2024-05-28

Total bilirubin > ULN or AST and/or ALT > 1.5 times ULN concomitant with alkaline phosphatase > 2.5 times ULN: Avoid docetaxel use. Chemotherapy suspended.

• 2024-05-27 AST 125 U/L
• 2024-05-27 Bilirubin total 1.50 mg/dL

2024-04-01

[monitoring hemoglobin: a 6-month decline in HGB levels]

The lab results indicate anemia with a hemoglobin level of 8.0 g/dL. If the patient is experiencing symptoms related to this low hemoglobin level, a transfusion of LPRBC may be necessary.

Additionally, please note that over the last six months, the HGB levels have slowly decreased from above 12 to 8, indicating a clear long-term downward trend.

• 2024-04-01 HGB 8.0 g/dL
• 2024-03-21 HGB 8.3 g/dL
• 2024-03-14 HGB 9.1 g/dL
• 2024-03-07 HGB 8.9 g/dL
• 2024-02-27 HGB 9.2 g/dL
• 2024-02-23 HGB 9.3 g/dL
• 2024-02-15 HGB 9.1 g/dL
• 2024-02-06 HGB 10.4 g/dL
• 2024-02-02 HGB 10.5 g/dL
• 2024-01-25 HGB 10.4 g/dL
• 2024-01-21 HGB 10.9 g/dL
• 2024-01-08 HGB 10.5 g/dL
• 2023-12-12 HGB 10.9 g/dL
• 2023-10-17 HGB 11.9 g/dL
• 2023-09-11 HGB 12.4 g/dL

[bedside visit: routine medication check-up yields no issues]

I visited the patient around 14:20 on 2024-04-01, accompanied by a relative, possibly her husband. I inquired about any medication-related concerns, and they indicated there were no adverse effects or issues noted at present.

Given the absence of further medication queries, I reminded the family to promptly report any discomfort or unusual symptoms.

700112535

240527

[exam findings]

• 2024-04-25, -04-24 CXR
  • approriately positioned endotracheal tube in place
  • marked enlarged cardiomediastinal silhoutte due to a huge
  • mediastinal tumor
  • consolidation in Rt middle to lower lung zone
  • Rt subpulmonary effusion
• 2024-04-24 Patho - lymph node region resection
  • Labeled as “right neck lymph node”, biopsy — T cell lymphoma.
  • Section shows lymph node with infiltration of atypical lymphoid cells.
  • IHC stains: CD3 and CD20: a predominant T cell sub-population. TdT (+).
• 2024-04-23 CXR
  • marked enlarged cardiomediastinal silhoutte due to a huge mediastinal tumor, which narroing the trachea
  • small Rt subpulmonary effusion
  • Consolidation and volume reduce over RML
  • endotracheal tube in place, with the tube tip over C6 vertebra?
• 2024-04-23 PET
  • Increased FDG uptake in multiple lymph nodes on both sides of the diaphragm as mentioned above, in the spleen and bone marrow. Lymphoma should be considered. Please correlate with other clinical findings for further evaluation.
• 2024-04-22 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — acute lymphocytic leukemia/lymphoma.
  • Section shows piece(s) of bone marrow with 95% cellularity and M:E ratio of approximately 5:1. Three cell lineages are present with left shift of leukocytes. Megakaryocytes are reduced in number.
  • IHC stains: CD3 and CD20: a predominant T cell subpopulation. CK (-), Ki-67 (90%). (of the nucleated cells). CD10 (equivocal). TdT (+).
• 2024-04-19 CXR erect
  • Egorged mediastinum is found. Lymphadenopathy is considered.
• 2024-04-19 ECG
  • Sinus tachycardia
  • Rightward axis
  • Borderline ECG
• 2024-04-12 CT 1131010011 at FEMH
  • Before and after IV contrast enhanced CT scan of whole abdomen were performed, revealing:
    • Soft-tissue lesion 13.8x8.2x15.3cm at anterior upper mediastinum with internal small calcification and encasing great vessels, nature to be determined.
      • DDx: lymhoma, germ cell tumor, Castleman disease.
    • Left brachialcephalic vein was markedly compressed. Suggest clinical correlation to r/o .
    • An enlarged lymph nodes at subcarina, nature to be determined.
    • Right side small amount pleural effusion.
    • Several round poor-enhancing nodules at left kidney, nature to be determined.
      • DDx: atypical cysts, inflammatory/infectious process. Suggest clinical correlation and following up.
    • Normal appearance of bilateral adrenal glands.
    • No definite CT evidence of osteolytic or osteoblastic bony lesion is noted in visible bony structures.

[MedRec]

• 2024-05-09 ~ 2024-05-23 POMR Hemato-Oncology Gao WeiYao
  • Course of inpatient treatment
    • This week, chemotherapy with vincritin 2mg on 5/10, L-asparaginase 6000IU on 5/10,12,14(hold) were given, smoothly without obvious side effect. GS was consulted for port-A installation evaluation. Port-A was inserted on 2024-05-17. Blood transfusion with LPRBC 2U & LRP 2PH were given on 2024/05/09 & 2024/05/16.
    • Owing to leukopenia was noted and hold C/T on 2024/05/18 and 05/19. G-CSF 300mg sc qd was added.
    • Daunoblastin 30mg/m2 on 05/20 ~ 05/21, Vincristin 2mg on 05/20, Endoxan 750mg/m2 on 05/20 ~ 05/21.
    • F/U WBC up to 40000/uL on 2024/5/20. Port-a change to left subclavicle was smooth. Under the stable condition, he can be discharged on 2024/05/23. Re-admission on 5/26.
• 2024-04-20 ~ 2024-05-06 POMR Hemato-Oncology Gao WeiYao
  • Admission diagnosis
    • Thrombocytopenia, unspecified
    • Leukemia, unspecified not having achieved remission
    • Fever, unspecified
    • Attention-deficit hyperactivity disorder, combined type
  • Discharge diagnosis
    • Acute lymphoblastic leukemia, T cell phenotype with marked mediastinal LN enlargement / Lymphoblastic T-cell lymphoma, stage IV
    • Thrombocytopenia
    • Attention-deficit hyperactivity disorder, combined type
    • Anxiety disorder
    • Port-a insertion on 2024/04/23
  • CC
    • Cough with intermittd fever off and on >10 day and was brough to Far Eastern Hospital for help and leukemia was favor.
  • Present illness
    • This 18 years old boy patient had history of ADHD under methylphenidate at SanZhong Hospital (only use in school) and asthma. This times, he suffere from cough with fever off and on > 10 days and was brough to FEMH for help on 2024/04/07. 2024/04/11 ~ 04/12 admission to hemology ward and ALL was favor. He denied bone marrow in FEMH. Abdomen CT (+C,-C) showed Soft-tissue lesion 13.8x8.2x15.3cm at anterior upper mediastinum with internal small calcification and encasing great vessels, nature to be determined. For personal reason he was discharged then and brought to our ER for help on 2024/04/20.
  • Course of inpatient treatment
    • After admission, he received bone marrow at first and refered from Dr Xia, report showed acute lymphocytic leukemia/lymphoma.
    • Critical care needs for a large tumor burden in the mediastinum with SOB. Higher uric acid levels of 12 and LDH level > 10,000, Feburic 1# daily and one vial of Rasburicase on 2024-04-22 and 23. PET scan was done on 2024/04/23, it report showed in multiple lymph nodes on both sides of the diaphragm as mentioned above, in the spleen and bone marrow. Lymphoma should be considered. CS was consulted for a right neck lymph node dissection and right femoral port-A catheter insertion on 2024/04/23. Following the surgery, he was transferred to the SICU for postoperative intensive care.
    • LN pathology showed T cell lymphoma. IHC stains: CD3 and CD20: a predominant T cell sub-population. TdT (+). During in the SICU, we closely monitored his vital signs and neurologic status. The patient was smoothly weaned from the ventilator, showing a weaning profile RSBI of 59.2 and Pi/Pe Max of -40/30, and tolerated room air on postoperative day 1. We noted decreased hemoglobin and platelet levels and addressed these with 2 units of LPRBC and 1 unit of LRP transfusion on the morning of 2024/04/25. Due to his stable hemodynamic and neurologic status, he was transferred to the oncology ward for further chemotherapy treatment on 2024/04/25.
    • At ONC ward. he received Triple IT chemo as 2024/04/30. CXR showed mediastinal wide size decrease and can be taper oxygen to room air. Chemo as GRAALL-2003 protocal, he received Daunoblastina/Vincritin/Endoxan on 2024/05/04-05/06. Under the stable condition, he can be discharged on 2024/05/06, re-admission is arranged on 2024/05/09.
  • Discharge prescription
    • Feburic (febuxostat 80mg) 1# QD
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Stogamet (cimetidine 300mg) 1# TID
    • Compesolon (prednisolone 5mg) 7# TID 12D (to be brought when you arranged hospitalization during 2024/05/04 ~ 2024/05/17)
• 2024-04-19 SOAP Medical Emergency
  • S
    • Triage: 2 Fever/chill > Insufficient hemodynamic circulation. Family members said fever for 10 days, cough with sputum, shortness of breath, general weakness, NO GUM BLEEDING, R/O leukemia in Far Eastern Hospital, TOCC denied
    • cough and fever since 2024-04-08
    • leg weakness
    • admitted to Far Eastern Hospital
    • schedule bone marrow biopsy (because the schedule change the biopsy has not been completed yet and MBD)
    • s/p Fasturtec (rasburicase) injection at FEMH
    • PH: asthma, ADHD
    • NKDA
  • O
    • Vital signs: BP 135/76; HR 123; BT 38.6’C; RR 20;
    • Con’s E4V5M6
    • SpO2 96%
    • AC ON CHRONIC ILL
    • Anicteric, Ananemic
    • Multiple petechia over neck
    • Clear BS, RHB
    • ABD soft and flat, nontender
    • EXT no edema
    • pupura over extremity and trunk
  • A
    • Preliminary impression: D69.6 Thrombocytopenia, unspecified
    • 2024/04/19 18:17 WBC = 54.83 x10^3/uL; HGB = 9.8 g/dL; PLT = 24 x10^3/uL; Blast = 61.0 %;
    • 2024/04/19 17:47 ALT = 32 U/L;
    • 2024/04/19 17:47 AST = 242 U/L;
    • 2024/04/19 17:47 Creatinine = 0.98 mg/dL;

[Surgical operation]

• 2024-04-23 - Op Method:
  • right neck LN dissection + right femoral port-A insertion.
  • Finding:
    • Right neck LN enlargement.
    • 8.0 Fr. Polysite, right femoral vein, puncture method.

[chemotherapy]

• 2024-05-27 - Oncoginase (L-asparaginase) 6000 unit NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-05-20 - daunorubicin 30mg/m2 50mg NS 250mL 1hr + vincristine 2mg NS 100mL 30min + cyclophosphamide 750mg/m2 1345mg NS 500mL 2hr D1-2
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
• 2024-05-10 - vincristine 2mg NS 50mL 10min + Oncoginase (L-asparaginase) 6000 unit NS 250mL 1hr QOD D1,3,5
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-5
• 2024-05-04 - daurorubicin 50mg/m2 90mg NS 250mL 1hr D1-3 + vincristine 2mg NS 100mL 30min + cyclophosphamide 750mg/m2 1386mg NS 500mL 2hr
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
• 2024-04-30 - methotrexate 15mg IT 3min + cytarabine 40mg IT 3min + methylprednisolone 40mg IT

==========

2024-05-27

[Neutropenia: Determining Cause and Treatment Options]

The patient has developed neutropenia recently. While the Oncoginase package insert doesn’t emphasize neutropenia as an important side effect, the medications administered on 2024-05-20 - daunorubicin, vincristine, and cyclophosphamide - are known to be more likey to cause neutropenia.

If a further decrease in WBC count is anticipated, the use of G-CSF could be considered as a proper measure.

• 2024-05-26 WBC 1.85 x10^3/uL
• 2024-05-23 WBC 7.59 x10^3/uL
• 2024-05-20 WBC 40.95 x10^3/uL
• 2024-05-17 WBC 0.45 x10^3/uL
• 2024-05-16 WBC 0.27 x10^3/uL
• 2024-05-13 WBC 0.32 x10^3/uL
• 2024-05-09 WBC 2.81 x10^3/uL
• 2024-05-06 WBC 3.22 x10^3/uL
• 2024-05-03 WBC 1.52 x10^3/uL
• 2024-05-01 WBC 1.45 x10^3/uL
• 2024-04-29 WBC 1.81 x10^3/uL
• 2024-04-26 WBC 1.44 x10^3/uL
• 2024-04-25 WBC 4.12 x10^3/uL
• 2024-04-24 WBC 18.04 x10^3/uL
• 2024-04-23 WBC 31.62 x10^3/uL
• 2024-04-22 WBC 36.97 x10^3/uL
• 2024-04-21 WBC 42.57 x10^3/uL
• 2024-04-19 WBC 54.83 x10^3/uL

700350234

240527

[exam findings]

• 2024-05-27 ECG
  • Normal sinus rhythm
  • Low voltage QRS
  • Septal infarct, age undetermined
  • T wave abnormality, consider anterolateral ischemia
  • Abnormal ECG

[MedRec]

[Consultation]

• 2024-05-24
  • Q
    • Triage: 2 Shortness of breath > Mild respiratory distress (92-94%) Dizziness, shortness of breath, confirmed COVID-19 WITHOUT ANTIVIRAL TX last week.
    • PH; HTN, DM, Heart DX,
    • Medication: Plavix, Lipitor, Monkast, Urief, Allegra, bisoprolol, Eurodin, Ambroxol.
    • 2024-03-29 at ShuangHe Hospital: PLT 195K, Cr 1.60, uric acid 7.7, HbA1C 6.2%
  • A
    • The major pathophysiologic mechanisms of thrombocytopenia include decreased platelet production in the bone marrow, peripheral platelet destruction by antibodies, consumption in thrombi, dilution from fluid resuscitation or massive transfusion, and sequestration (pooling) of platelets in the spleen in individuals with portal hypertension and/or splenomegaly.
    • Please check ADAMTS-13, RBC morphology, LDH, haptoglobin, total/direct bilirubin, autoimmune profile (C3, C4, ANA, Anti-DsDNA, Anti-Ro/La, Anti-Sm/RNP, RF), IgG, IgA, IgM, total protein/albumin, serum EP, serum light chain, HIV (EIA), EB-VCA IgM, Helicobacter pylori, HCV, APS profile, DIC profile, ferritin, Fe/TIBC, B12, and folic acid. Arrange an abdominal echo to survey splenomegaly.
    • For ITP with platelet count < 30k, consider trying steroids if there are no contraindications. Arrange for our OPD follow-up after discharge. Thank you!

==========

2024-05-27

[thrombocytopenia and anemia improvement]

Following leukocyte-reduced platelet (LRP) and leukocyte-poor red blood cell (LPRBC) transfusions, the patient’s thrombocytopenia and anemia have shown improvement, although not yet reaching normal ranges. No medication discrepancies were identified after review of HIS5 and PharmaCloud database.

• 2024-05-27 PLT 105 x10^3/uL

• 2024-05-25 PLT 1 x10^3/uL

• 2024-05-24 PLT 54 x10^3/uL

• 2024-05-24 PLT 1 x10^3/uL

• 2024-05-24 PLT 1 x10^3/uL

• 2024-05-23 PLT 1 x10^3/uL

• 2024-05-27 HGB 10.4 g/dL

• 2024-05-25 HGB 7.6 g/dL

• 2024-05-24 HGB 8.5 g/dL

• 2024-05-24 HGB 9.5 g/dL

• 2024-05-24 HGB 8.3 g/dL

• 2024-05-23 HGB 9.5 g/dL

700049597

240524

[exam findings] (not completed)

• 2024-04-25 Patho - bronchus biopsy

  • Lung, LLL, endobronchial tumor, bronchoscopic biopsy — Consistent with metastatic colorectal adenocarcinoma, poorly differentiated
  • Specimen submitted in formalin consists of several tissue fragments measuring up to 0.8 x 0.1 x 0.1 cm. All for section in one cassette.
  • Sections show pleomorphic and glandular tumor cells infiltrating in the bronchial wall with lymphatic invasion.
  • The immunohistochemical stains reveal CDX2(+) and TTF-1(-). The results are consistent with metastatic colorectal adenocarcinoma. Please correlate with the clinical presentation.

• 2024-04-22 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (58 - 11) / 58 = 81.03%
    • M-mode (Teichholz) = 81
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR.
    • Moderate pericardial effusion with nonspecific cardiac tamponade sign, please correlate with clinical presentations.
    • Right pleural effusion.

• 2024-04-19 CT - chest

  • Indication: Pericardial effusionAdenocarcinoma of rectum, cT3N2aM1b, stage IVB
  • Chest CT without IV contrast ehnancement shows:
    • Massive left pleural effusion and mild right pleural effusion is found.
    • Severe Emphysematous change over both lungs.
    • Consolidation of left lower lobe with low density lesion impacted at left lower lobe bronchus is found.
    • Lymphadenopathy at bilateral paratracheal and left hilar region.
    • Mild pericardial effusion is noted.
    • Calcified mass at right adrenal gland measuring 3.35cm in largest dimension is found. (Se301 Im68).
    • Mild ascites formation is found.
  • Imp:
    • Left lung cancer with obstructive pneumonitis. The tumor extension is hard to evaluate due to only non-contrast CT was done.
    • Adrenal meta. Stable.
    • Severe COPD.
    • Bilateral pleural effusio more on left hemithorax and mild right pleural effusion.

• 2024-04-16 ECG

  • Sinus rhythm with Premature atrial complexes
  • Prolonged QT

• 2024-03-23 CT - brain

  • Non-contrast brain CT revealed:
    • Swelling of left temporal scalp. A hypodense lesion at right caudate nucleus.

• 2024-01-26 CT - chest

  • Chest CT with and without IV contrast ehnancement shows:
    • Fibrocalcified lesions are noted at right upper lobe and left upper lobe.
    • Marke Emphysematous change over both lungs is noted.
    • Spiculated nodules at left lower lobe measuring 2.54cm and 2.19cm in largest dimension. Lung meta is compatible. In comparison with CT dated on 2023-12-15, the lesion regressed.
    • Another nodule at left upper lobe attaching interlobar fissure with size about 1.29cm in largest dimension. (Se304 Im36). The lesion regressed markedly.
    • Confluet and dense lymph nodes are found at both sides of the mediastinum. In regression.
    • Enlarged right adrenal gland up to 3.42cm in largest dimension is found. The tumor decreased in size.
  • Imp:
    • Left upper lobe and left lower lobe lung meta. Right adrenal meta and mediastinal lymphadenopathy, in regression.

• ….-..-..

• 2022-12-01 CT - abdomen

  • History and indication: Rectal cancer with stationary left lung metastases bur increase in size of adrenal metastases stage IV
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum.
    • Tumors (1.7cm, 3.7cm) at bil. adrenal regions.
    • Several nodules (up to 1.3cm) at left lung. Emphysema at bil. lungs.
    • Left renal cyst (0.5cm).
    • Atherosclerosis of aorta, iliac arteries.
    • S/P left femoral operation.
  • IMP:
    • Rectal cancer with lung and adrenal metastases.

• 2022-09-09 CT - abdomen

  • Findings:
    • Prior CT identified three metastases in LUL and LLL of the lung are noted again, decreasing in size (the maximal one 2.3 cm in prior CT and 1.6 cm at current CT) that are c/w lung metastases S/P C/T with partial response.
      • In addition, focal fibrotic change at RUL and emphysema of both lungs show stationary.
    • Prior CT identified metastases in right and left adrenal gland (4 cm and 2.2 cm) are noted again, stable in size that are c/w adrenal metastases S/P C/T with stable disease.
    • Prior CT identified several enlarged LNs at the mediastinum are noted again, decreasing in size that are c/w mediastinum LNs metastases S/P C/T with partial response.
    • Colostomy at right transverse colon is noted.
    • Left renal cyst (0.5cm).
  • Impression:
    • Lung metastases S/P C/T show partial response.
    • Bilateral adrenal metastases S/P C/T show stable disease.
    • Mediastinum LNs metastases S/P C/T show partial response.

• 2022-06-29 CT - chest

  • rectal cancer with stationary left lung metastases but increase in size of adrenal metastases compared with CT on 20220224.

• 2022-03-16 Patho - adrenal gland resection

  • Labeled as “right adrenal tumor”, core needle biopsy — metastatic adenocarcinoma.
  • IHC stains: CK 20 (+), CDX-2 (+), compatible with colonic origin.
  • Specimen submitted in formalin consists of 1 piece(s) of tissue measuring 2.4 x 0.3 x 0.3 cm. All for section(s) in one cassette(s).

• 2022-03-07 Patho - lung transbronchial biopsy

  • Lung, LUL, CT-guide biopsy — consistent with metastatic colonic adenocarcinoma
  • Specimen submitted in formalin consists of 4 strips of tan, irregular tissue measuring up to 1.0 x 0.1 x 0.1 cm. All for section in one cassette.
  • Sections show acinar and cribriform glandular cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal CDX2(+), TTF-1(-), and Napsin A(-). The results are consistent with metastatic colonic adenocarcinoma.

• 2022-02-24 CT - abdomen, pelvis

  • Mild regression of recal cancer.
  • Progression of lung and adrenal tumors.

• 2021-11-15 CT - abdomen, pelvis

  • Imaging Report Form for Colorectal Carcinoma
  • Impression (Imaging stage): T3N2aM1a, stage IVA

• 2021-11-12 Patho - colorectal polyp

  • Rectum, biopsy — Adenocarcinoma.
  • IHC stains: EGFR (+); PMS2 (weak +), MSH6 (+), MSH2(+), MLH1 (+).
    
  • Specimen submitted in formalin consists of 5 pieces of tan, irregular tissue measuring 0.2 x 0.2 x 0.1 cm each. All for section in one cassette.
    
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.

• 2020-08-13 CT - lung/mediastinum/pleura

  • Imp: Severe COPD.
  • Bilateral apical lung fibrotic change.

• 2019-06-04 Bronchodilator test

  • Flow-volum curve: Mild airway obstruction with significant response to bronchodilator.

• 2018-09-18 Bronchodilator test

  • Flow-volum curve: Mild airway obstruction without significant response to bronchodilator.

• 2017-10-17 Bronchodilator test

  • Flow-volum curve: Suspected small airway obstruction with significant response to bronchodilator.

• 2017-01-24 Lung volume with function

  • Small airway obstruction with partial response to BD
  • Low IC, no HI, but air-trapping
  • Normal DLCO and normal raw favor smoking related small airway disease

[consultation]

• 2021-11-15 Colorectal Surgery
  • This is a 66-year-old male with a known history of
    • 1. COPD for 10+year under medical control
    • 2. s/p left femoral fracture
  • This time, he experienced constipation for 2 days and dark brownish stool after colonscopy on 2021-11-11, which showed ulcerative mass above 10cm AV s/p multiple boipsy. Besides, lower abdominal pain was accompanied with constipation. So he came to our ER for help. At ER, vital signs were stable. And lab revealed normal liver and kidney function but elevated CRP without leukocytosis and stool OB 4+. CT showed colorectal cancer T3N2aM1a.
  • Lab
    • PE: RLQ tenderness, no rebounding pain, no muscle guarding, no bilateral knocking pain
    • Hb 16 -> 14.6
    • PT 10.7 INR 1.03
    • PLT 198000
  • Colorectal Carcinoma, T3N2aM1a
  • Constipation for 2 days
  • Dark brownish stool after colonscopy on 2021-11-11
  • Assessment
    • Rectal cancer, cT3N2aM1a (Left lung mets)
  • Plan
    • please arrange admission on CRS VS
    • supportive care
    • contact us if still have any CRS problems

[surgical operation]

• 2021-11-17
  • Surgery
    • T-loop colostomy        
  • Finding
    • T-loop colostomy with stent was created at RUQ area   

[radiotherapy]

• 2021-11-29 ~ 2022-01 - deliver 43.2 Gy/ 24 fx to the pelvis, then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx.

[immunochemotherapy]

• 2024-01-30 - RMC-6291 100mg 3# BID 21D 6# (Q3W) (OPD)

• 2024-01-09 - RMC-6291 100mg 3# BID 21D 6# (Q3W) (OPD)

• 2023-12-19 - RMC-6291 100mg 3# BID 21D 6# (Q3W) (OPD)

• 2023-11-28 - RMC-6291 100mg 3# BID 23D 6# (Q3W) (OPD)

• 2023-11-07 - RMC-6291 100mg 3# BID 14D 6# (Q3W) (IPD)

• 2023-08-14 - (FOLFOXIRI)

• 2023-07-24 - (FOLFOXIRI)

• 2023-07-03 - (FOLFOXIRI)

• 2023-06-12 - (FOLFOXIRI)

• 2023-05-22 - (FOLFOXIRI)

• 2023-05-02 - (FOLFOXIRI)

• 2023-04-10 - (FOLFOXIRI)

• 2023-03-17 - (FOLFOXIRI)

• 2023-02-23 - (FOLFOXIRI)

• 2023-01-09 - ………………………….. oxaliplatin 85mg/m2 130mg 2hr . + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4230mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

• 2022-12-19 - bevacizumab 5mg/kg 100mg 90min + oxaliplatin 85mg/m2 130mg 2hr . + leucovorin 400mg/m2 610mg 2hr + fluorouracil 2800mg/m2 4300mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

• 2022-11-28 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 125mg 2hr . + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4220mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

• 2022-11-09 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 125mg 2hr . + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4240mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

• 2022-10-17 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 125mg 2hr . + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4240mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

• 2022-09-19 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr . + leucovorin 400mg/m2 590mg 2hr + fluorouracil 2800mg/m2 4150mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

• 2022-09-06 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr . + leucovorin 400mg/m2 590mg 2hr + fluorouracil 2800mg/m2 4180mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

• 2022-08-23 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr . + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4200mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

• 2022-08-09 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr . + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4200mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

• 2022-07-26 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 70mg/m2 100mg 2hr . + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4200mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

• 2022-07-07 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4250mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD

• 2022-06-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4250mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD

• 2022-06-02 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4270mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD

• 2022-05-18 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4290mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD

• 2022-04-28 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 260mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4300mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD

• 2022-04-15 - ………………………….. irinotecan 170mg/m2 260mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4380mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD

• 2022-03-28 - ………………………….. irinotecan 170mg/m2 260mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4400mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD

• 2022-01-05 - fluorouracil 225mg/m2 350mg 24hr …. (CCRT)

• 2021-12-20 - fluorouracil 225mg/m2 350mg 24hr D1-5 (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

• 2021-12-13 - fluorouracil 225mg/m2 350mg 24hr D1-5 (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

• 2021-12-09 - fluorouracil 225mg/m2 350mg 24hr D1-2 (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

==========

2024-05-24

[potential drug interaction with Smecta (dioctahedral smectite) - tube feeding]

Smecta (dioctahedral smectite) possesses adsorptive properties that may interfere with the absorption of other medications.

To prevent potential interactions, it is recommended to administer Smecta at least two hours apart from other drugs.

2022-05-19

The patient was diagnosed with colorectal carcinoma T3N2aM1a stage IVA, had a T-loop colostomy performed in November 2021, received CCRT from December 2021 to January 2022, and then began receiving palliative FOLFIRI in March (plus bevacizumab in April).

The most recent CT (2022-02-24) revealed a mild regression in colon cancer and a progression of lung and adrenal tumors. In March 2022, biopsies subsequently confirmed that the lung and adrenal tumors were metastatic colonic adenocarcinomas.

According to lab data reported on 2022-05-18, there were generally normal results. His underlying COPD is followed up in our office of thoracic medicine with refillable prescriptions.

700354357

240524

[diagnosis] - 2023-03-10 admission note

• Malignant neoplasm of other parts of pancreas
• Encounter for antineoplastic chemotherapy
• Type 2 diabetes mellitus without complications
• Malignant neoplasm of other parts of pancreas
• Chronic viral hepatitis B without delta-agent
• Chronic viral hepatitis C
• Status post Liver transplantation
• Cachexia

[past history]

• Medical Hx:
  • Prostate cancer s/p R/T 37 times in 2009.
  • DM for more than 10 years
  • HCV related liver cirrhosis, liver transplantation in 2007 in China.

[allergy]

• NKDA

[family history]

• Family history is unremarkable.
• There is no family history of hypertension, mental diseases or asthma.
• No members of the family with diabetes.  
• Mother has lung cancer

[exam findings]

• 2024-05-22 SONO - abdomen
  • Post cholecystectomy
  • Pneumobilia
  • Splenomegaly, mild
• 2024-03-31 CT - abdomen
  • With and without contrast enhancement CT of abdomen shows:
    • Pancreatic neck cancer with duodenal bulb and portal vein invasion. Partial thrombosis of SMV.
    • s/p CBD stent. Dilatation of P-duct.
  • Impression
    • Pancreatic neck cancer, stationary
• 2024-03-31 ECG
  • Sinus rhythm with frequent Premature ventricular complexes
  • Right bundle branch block
• 2024-02-08 ECG
  • Normal sinus rhythm
  • Right bundle branch block
• 2024-02-08 CT - abdomen
  • History and indication:
    • Adenocarcinoma of pancreatic neck
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Stationary condition of pancreatic neck cancer with adjacent vascular invasion and SMV partial thrombosis. S/P CBD stenting.
    • Liver and renal cysts (up to 2.4cm).
    • Minimal ascites.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • Stationary condition of pancreatic neck cancer with adjacent vascular invasion and SMV partial thrombosis. S/P CBD stenting.
• 2024-02-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (94 - 30) / 94 = 68.09%
    • M-mode (Teichholz) = 68
  • Conclusion:
    • Mild septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; moderately dilated LA.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; mild MR.
• 2023-11-07 CT - abdomen
  • Findings
    • S/P biliary stenting.
    • Infiltrative soft tissue tumor in the pancreastic neck with P-duct dilatation, vascular invasion.
    • SMV thrombosis, progression.
    • Liver cyst, 1.1cm in S2.
    • Bilateral renal cysts, up to 2.4cm in right kidney.
    • Presence of ascites.
  • Impression:
    • S/P biliary stenting.
    • Pancreastic neck malignancy with vascular invasion and P-duct dilatation. Stationary.
    • SMV thrombosis, progression.
• 2023-10-30 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (128 - 44.1) / 128 = 65.55%
    • M-mode (Teichholz) = 65.5
    • 2D (M-Simpson) = 57.7
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, trivial TR, normal IVC size
• 2023-10-05 MRI - upper abdomen
  • Indication: Pancreatic cancer
  • Abdominal MRI with and without IV contrast enhancement shows:
    • Moderate Splenomegaly is found.
    • Mild ascites in the abdominal cavity is also noted.
    • There is ill defined pancreatic neck lesion measuring 1.8cm in largest dimension and regional vascular invasion and infiltration with obliterating distal pancreatic duct is found. In comparison with CT dated on 2023-08-11, the lesion decreased in size.
    • Dilated CBD and IHDs is also noted.
    • Bilateral renal cysts are found.
    • MRCP shows dilated CBD and IHDs and distal pancreatic duct is found.
  • Imp:
    • Pancretic neck cancer with vascular invasion and distal pancreatic duct obsctruction s/p C/T with tumor decreased in size.
    • Bililary obstruction without soft tissue at distal CBD
• 2023-08-21 ECG
  • Sinus rhythm with occasional Premature ventricular complexes RSR’’ or QR pattern in V1 suggests right ventricular conduction delay
• 2023-08-21 Endoscopic Retrograde Cholangiopancreatography, ERCP
  • Diagnosis:
    • Malignant distal biliary stricture s/p EST & FCSEMS
    • Chronic cholangitis
    • shallow duodenal ulcers
    • GB invisible
  • Suggestion:
    • f/u amylase & lipase
• 2023-08-11 CT - abdomen
  • Findings: Comparison: prior CT dated 2023/04/28.
    • Prior CT identified ascites in the abdomen and pelvis is noted again, decreasing in amount (only in the pelvis).
    • Prior CT identified an ill-defined poor enhancing mass lesion in the pancreatic neck is noted again, mild increasing in size and poor margination.
      • In addition, Prior CT identified tumor seeding and encasement in the celiac trunk and common hepatic artery and the distal splenic vein, (beyond the trifurcation) is noted again, mild increasing in size.
      • Prior CT identified dilatation of the upstream pancreatic duct is noted again, stationary.
    • Prior CT identified metastatic nodes in the hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified tumor direct invasion the stomach antrum or duodenum 1st portion is noted again, mild increasing in size.
    • A cystic lesion 1 cm in the pancreatic head is noted.
    • There is mild wall thickening at the gastric antrum.
      • Please correlate with gastroscopy.
    • S/P cadaveric liver transplantation and S/P cholecystectomy.
      • A hepatic cyst measuring 0.6 cm in S2 is noted.
        
    • A renal cyst measuring 2.1 cm in right middle pole is noted.
    • The spleen shows prominence in size (long axis: 12 cm).
  • IMP:
    • Prior CT identified ascites in the abdomen and pelvis is noted again, decreasing in amount (only in the pelvis).
    • Adenocarcinoma of the pancreatic neck S/P C/T show stable disease or mild progressive disease.
    • Follow up CT and tumor marker 3 months later is indicated.
• 2023-04-28 CT - abdomen
  • Indication
    • 20230113 CC: wight loss from 70 to 52 Kgs in the past 2 months.
      • Anorexia since Sep 2022. Low abdominal pain since 6 Dec 2022.
      • Chronic diarrhea since 3 months ago.
        
      • He had undergone liver transplantation in 2007 in China.
    • 20230113 CT: Adenocarcinoma of pancreatic neck, cT4N1M0, stage III
    • 20230113 CA199: 53.89 U/mL (<35).
    • 20230117 EUS biopsy: adenocarcinoma
    • 20230202 s/p chemotherapy with FOLFIRINOX
  • Past history: Ca of prostate s/p R/T in 2009. D.M > 10 years.
  • Findings comparison prior CT dated 2023/01/13.
    • There is newly developed ascites in the abdomen and pelvis. please correlate with clinical condition.
    • Prior CT identified an ill-defined poor enhancing mass-like lesion in the pancreatic neck is noted again, mild decreasing in size and poor margination.
      • Prior CT identified dilatation of the upstream pancreatic duct is noted again, stationary.
      • In addition, Prior CT identified tumor seeding and encasement in the celiac trunk and common hepatic artery and the distal splenic vein, (beyond the trifurcation) is noted again, stationary.
    • Prior CT identified metastatic nodes in the hepatoduodenal ligament are noted again, mild decreasing in size.
      • Prior CT identified tumor direct invasion the stomach antrum or duodenum 1st portion is noted again, mild decreasing in size.
    • A cystic lesion 1 cm in the pancreatic head is noted.
    • There is mild wall thickening at the gastric antrum. Please correlate with gastroscopy.
    • S/P cadavertic liver transplantation and S/P cholecystectomy.
      • A hepatic cyst measuring 0.6 cm in S2 is noted.
    • A renal cyst measuring 2.1 cm in right middle pole is noted.
      • The spleen shows prominence in size (long axis: 12 cm).
    • Others
      • There is no focal abnormality in the biliary system.
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • IMP:
    • Newly developed ascites. please correlate with clinical condition.
    • Adenocarcinoma of the pancreatic neck S/P C/T show partial response.
• 2023-01-17 Patho - pancreas biopsy
  • Labeled as “pancreas, neck”, EUS fine needle biopsy — pancreatic adenocarcinoma.
  • IHC stains: CA19-9 (+), CK19 (+), CD56 (-), CK7 (+), CK20 (focal +).
  • Section shows few loosely cohesive neoplastic glands. IHC stains: CA19-9 (+), CK19 (+), CD56 (-), CK7 (+), CK20 (focal +).
• 2023-01-17 ECG
  • Sinus rhythm with 1st degree A-V block
  • Right bundle branch block
• 2023-01-13 Endoscopic Ultrasonography, EUS
  • Pancreatic neck tumor T4NxMx s/p CEH-EUS & EUS/FNB
  • Pancreatic cystic lesion, head portion
• 2023-01-13 CT - abdomen
  • CC: wight loss from 70 to 52 Kgs in the past 2 months.
    • Anorexia since Sep 2022.
    • Low abdominal pain since 6 Dec 2022.
    • Chronic diarrhea since 3 months ago. Colon polyp was removed on 29 Nov 2022.
    • He had undergone liver transplantation in 2007 in China.
  • Past history: Ca of prostate s/p R/T in 2009. D.M > 10 years.
  • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is an ill-defined poor enhancing mass-like lesion in the pancreatic neck (Srs:601 Img:24), 3.7 x 2 cm in size, causing dilatation of the upstream pancreatic duct 9 mm in diameter.
      • In addition, There are soft tissue lesions in the celiac trunk and common hepatic artery surrounding area that may be tumor encasement. The distal splenic vein, beyond the trifurcation, shows small size that also may be tumor encasement.
      • Adenocarcinoma of the pancreatic neck (T4) is highly suspected.
      • Please correlate with CA199 and MRI.
    • There are soft tissue lesions in the hepatoduodenal ligament that may be metastatic nodes (N1).
    • There is fat plane obliteration between the pancreatic neck mass and the stomach antrum or duodenum 1st portion that may be tumor direct invasion.
    • A cystic lesion 1 cm in the pancreatic head is noted.
    • There is mild wall thickening at the gastric antrum.
      • Please correlate with gastroscopy.
    • S/P cadavertic liver transplantation and S/P cholecystectomy.
      • A hepatic cyst measuring 0.6 cm in S2 is noted.
        
    • A renal cyst measuring 2.1 cm in right middle pole is noted.
    • Others
      • There is no focal abnormality in the liver, biliary system, spleen & left kidney.
      • There is no ascites.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion over the mesentery and omentum.
  • IMP:
    • Adenocarcinoma of the pancreatic neck is highly suspected. Please correlate with CA199 and MRI.
    • If pancreatic cancer is finally proved by pathology. According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for pancreatic cancer: T4 N1 M0, Stage:III

[MedRec]

• 2023-11-14 ~ 2023-11-15 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Adenocarcinoma of pancreatic neck, cT4N1M0, stage III, s/p chemotherapy with FOLFIRINOX from 2023/02/02~2023/10/18(C7D1), under chemotherapy with Abraxane plus Gemzar from 2023/11/15~
    • Malignant distal biliary stricture caused by panreatic cancer s/p EST & FCSEMS
    • Status post Liver transplantation
    • Type 2 diabetes mellitus without complications
    • Chronic viral hepatitis B without delta-agent
    • Essential (primary) hypertension
    • Cachexia
  • CC
    • For chemotherapy
  • Present illness
    • This is a 74-year-old male with underlying disease of
      • Cancer of prostate s/p R/T 37 times in 2009
      • D.M for more than 10 years
      • liver transplantation in 2007 in China.
    • He suffred from weight loss from 70 to 52 Kgs in the past 2 months. Thus, he came to our GI OPD for further medical help. Associated symptom included anorexia, low abdominal pain and chronic diarrhea. Tarry stool, constipation, jaundice, and vomiting were not mentioned.
    • Abdominal CT was done on 2023/01/13 revealed adenocarcinoma of the pancreatic neck is highly suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for pancreatic cancer: T4N1M0, Stage:III.
    • EUS-FNB for pancreas was done on 2023/01/17 showed
      • Pancreatic neck tumor T4NxMx s/p CEH-EUS & EUS/FNB
      • Pancreatic cystic lesion, head portion.
    • Pathology showed show enlarged and hypochromatic nuclei, suspicious for adenocarcinoma and pancreas, neck, EUS fine needle biopsy — pancreatic adenocarcinoma.
      • IHC stains: CA19-9 (+), CK19 (+), CD56 (-), CK7 (+), CK20 (focal +).
    • Port-A implantation on 2023/02/01, he receive chemotherapy with Chemotherapy with FOLFIRINOX (Oxlaip 65mg/m2-self pay, Campto 90mg/m2-self pay, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) on 2023/02/02(C1D1), 2023/02/23(1D15), 2023/03/10(C2D1), 2023/03/29(C2D15), 2023/04/11(C3D1), 2023/04/25(C3D15), 2023/05/10(C4D1), 2023/05/31(C4D15), 2023/06/21(C5D1), 2023/08/29(C6D1), 2023/09/19(C6D15), 2023/10/18(C7D1).
    • Fllow up Abdominal CT on 2023/04/28 showed
      • Newly developed ascites. please correlate with clinical condition
      • Adenocarcinoma of the pancreatic neck S/P C/T show partial response.
    • Follow up Abdominal CT on 2023/08/11 showed
      • Prior CT identified ascites in the abdomen and pelvis is noted again, decreasing in amount (only in the pelvis)
      • Adenocarcinoma of the pancreatic neck S/P C/T show stable disease or mild progressive disease.
    • Tumor marker on 2023/08/22 with CA199:48.96 U/mL, CEA:5.85 ng/mL.
    • He had clay color stool and tea color urine for 4-5 days, and he came to GI OPD for survey. The lab test showed obstructive jaundice and mild elevated of liver enzymes.
    • ERCP on 2023/08/21 showed
      • Malignant distal biliary stricture s/p EST & FCSEMS
      • Chronic cholangitis
      • shallow duodenal ulcers
      • GB invisible.
    • Tumor marker on 2023/09/12 with CA199:21.48 U/mL, CEA:4.24 ng/mL.
    • Upper abdominal MRI on 2023/10/05 showed pancretic neck cancer with vascular invasion and distal pancreatic duct obsctruction s/p C/T with tumor decreased in size and bililary obstruction without soft tissue at distal CBD.
    • Tumor marker on 2023/10/03 with CA199:23.14 U/mL, CEA:4.56 ng/mL.
    • Follow up Abdominal CT on 2023/11/07 showed
      • S/P biliary stenting
      • Pancreastic neck malignancy with vascular invasion and P-duct dilatation. Stationary
      • SMV thrombosis, progression.
    • He visited to GS OPD for surgery evaluation, no indication for operation, suggest further chemotherapy, consider to 2024/03.
    • Now, he was admitted for chemotherapy, will change regimen with Abraxane plus Gemzar.
  • Course of inpatient treatment
    • After admission, he received chemotherapy with Abraxane/Gemzar (Abraxane 100mg/m2 /Gemzar 1000mg/m2) on 2023/11/14(C1D1) smoothly, consider added TS-1, if stable condition.
    • Mopride 5mg/tab 1# PO TIDAC for nausea and vomiting.
    • Tramacet 37.5 & 325mg/tab 0.5# PO Q6H for pain control.
    • Status post Liver transplantation was treated with Certican (everolimus) 0.5mg/cap 2# PO QD.
    • Diet control an dcheck finger sugar, Type 2 diabetes mellitus with Trajenta 5mg/tab 1# PO QD.
    • Diovan F.C. 160mg/tab 1# PO QD was given for Hypertension.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for Anti-HBc:reactive.
    • Cachexia with Megest 40mg/mL,120mL/bot 10ml PO QD.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/11/15 and OPD followed up later.
• 2023-03-28 Hemato-Oncology
  • O: AE Gr 3 Neutropenia -> Improved to Gr 1
• 2023-02-22 Hemato-Oncology
  • O: AE Gr 3 Neutropenia -> Improved
• 2023-02-15 Hemato-Oncology
  • Now on Induction FOLFIRINOX, C1D1 on 2023-02-02
  • Already mention treatment strategy
    • Induction chemotherapy with FOLFIRINOX
    • If OP is feasible, go to OP; if OP is not feasible, go to CCRT.
• 2023-02-14 SOAP Radiation Oncology
  • S
    • For radiotherapy due to pancreatic neck adenocarcinoma.
    • PI: The patient transferred from TSGH (Dr. Chao) for CCRT due to pancreatic carcinoma. He was a case of prostate cancer s/p radiotherapy at TSGH.
    • Chemotherapy: 2023-02-02
    • Family history: (mother: lung cancer)
    • Cancer site specific factors: Alcohol (quit); Smoking (-); Betel nut (-).
    • Personal Hx: DM(-); HTN(+); s/p liver transplantation at China.
    • Allergy(-)
    • Previous RT Hx: radiotherapy of the prostate at TSGH.
  • P
    • Preliminary planning dose: 4500cGy/25 fractions of the pancreatic neck tumor, peripheral involved, and regional lymphatic area.
• 2023-01-13 SOAP Gastroenterology
  • S
    • He came because of weight loss from 70 to 52 Kgs in the past 2 months.
    • Anorexia since Sep 2022.
    • Low abdominal pain since 6 Dec 2022.
    • Chronic diarrhea since 3 months ago. Colon polyp was removed on 29 Nov 2022.
    • He had undergone liver transplantation in 2007 in China.
    • Past history: Ca of prostate s/p R/T 37 times in 2009. D.M for more than 10 years.
  • O
    • P.E.: No icteric sclera, soft abdomen, no leg pitting edema.
    • 2023-01-13: Ca-19-9: 53.89. CT of abdomen: R/O Pancreatic Ca.

[consultation]

• 2023-01-19 Hemato-Oncology
  • Q
    • This is a 73-year-old female with underlying disease of
      • Ca of prostate s/p R/T 37 times in 2009.
      • Liver transplantation in 2007 in China.
      • D.M for more than 10 years.
    • This time, he suffured from left upper abdominal dullness pain and weight loss (70 -> 58kg in 2 months). Associated symptom included nausea and poor appetite but denied Icterus, and back pain. Due to above reason, he came to our GI OPD for further survey.
    • Abdominal CT done on 2023/01/13 revealed suspected pancreatic Ca and blood test showed Ca-19-9: 53.89.
    • Under the impression of pancreatic cancer, he was admitted for further survey. EUS-FNB for pancreas was arranged on 2023/01/17. Thus, we request your expertise for aseessment of the administration of chemotherpy.
  • A
    • This 73 year old man is a case of suspect pancrease cancer cT4N1M0, stage III. We are consulted for further evaluation.
    • Pending EUS pathology and arrange our OPD after discharge. For unresectable pancrease cancer, systemic chemotherapy is indicated (consult GS for further operation evaluation). If pancrease cancer is proven, may check HbsAg, Anti Hbc, and anti HCV. Then, consult GS for port A insertion and complete pancrease cancer work up including chest CT (+/-contrast).

[chemotherapy]

• 2024-05-02 - gemcitabine 0800mg/m2 1400mg NS 250mL 30min + nab-paclitaxel 100mg/m2 140mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2024-04-23 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 100mg/m2 130mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2024-03-26 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 100mg/m2 130mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2024-03-12 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 100mg/m2 130mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2024-03-05 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2024-02-08 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2024-01-16 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 100mg/m2 135mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2024-01-10 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-12-29 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-12-12 - gemcitabine 1000mg/m2 1500mg NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-11-30 - gemcitabine 1000mg/m2 1500mg NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-11-14 - gemcitabine 1000mg/m2 1500mg NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-10-18 - (FOLFIRINOX)

• 2023-09-19 - (FOLFIRINOX)

• 2023-08-29 - (FOLFIRINOX)

• 2023-07-11 - (FOLFIRINOX)

• 2023-06-21 - (FOLFIRINOX)

• 2023-05-31 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3

• 2023-05-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3

• 2023-04-25 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3

• 2023-04-11 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3

• 2023-03-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX, Covorin NS 500 -> 250mL)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC (before Irino) + aprepitant 125mg D1-3

• 2023-02-23 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC (before Irino) + aprepitant 125mg D1-3

• 2023-02-02 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC (before Irino) + aprepitant 125mg D1-3

Granocyte (lenograstim 250ug) CGRAN01

• 2023-05-24 3 days (OPD)
• 2023-05-16 3 days (IPD)
• 2023-05-02 3 days (IPD)
• 2023-04-17 3 days (IPD)
• 2023-04-04 3 days (IPD)
• 2023-03-28 3 days (IPD)
• 2023-03-23 3 days (OPD)
• 2023-03-15 3 days (IPD)
• 2023-03-01 3 days (IPD)
• 2023-02-15 3 days (OPD)

WBC

• 2023-05-31 WBC 3.55 x10^3/uL
  
• 2023-05-24 WBC 2.32 x10^3/uL
  
• 2023-05-10 WBC 3.01 x10^3/uL
  
• 2023-04-25 WBC 2.71 x10^3/uL
  
• 2023-04-11 WBC 4.08 x10^3/uL
  
• 2023-03-28 WBC 3.47 x10^3/uL
  
• 2023-03-23 WBC 2.43 x10^3/uL
  
• 2023-03-09 WBC 4.31 x10^3/uL
  
• 2023-02-22 WBC 5.90 x10^3/uL
  
• 2023-02-15 WBC 2.08 x10^3/uL
  
• 2023-01-30 WBC 4.75 x10^3/uL
  
• 2023-01-13 WBC 6.05 x10^3/uL

==========

2024-05-24

[Certican (everolimus) blood level monitoring]

Background:

• The patient received two doses of Certican (everolimus) 1.5mg during this hospitalization: on 2024-05-23 at 04:55 and May 24, 2024-05-24 at 04:59, according to HIS5 records.
• A blood sample was drawn for Certican level monitoring on 2024-05-22 at 10:25.

Interpretation:

• The blood sample was drawn after only one dose of Certican. Therefore, the measured level of 6.0 ng/mL does not represent the steady-state concentration, peak concentration, or trough concentration.
• While the measured level falls within the liver transplant reference range of 3 to 8 ng/mL, it is possible that the peak or trough concentration could exceed this range.

Recommendation:

• If the intent of the blood test was to assess whether the Certican level exceeded the reference range and potentially contributed to adverse reactions, it is recommended to repeat the blood test 1-2 hours after the fourth or fifth dose of the medication. This would provide a more accurate representation of the peak concentration.

2023-10-19

[reconcilation]

The patient had an appointment at Tri-Service General Hospital on 2023-09-23 and received prescriptions for Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem), with the latter not currently being utilized. Please verify if the discontinuation of Stilnox is intentional.

As an additional note, the patient received an injection of Zoladex (goserelin acetate) at TSGH on 2023-10-06, with the previous injection administered on 2023-07-28.

2023-07-12

This patient had an appointment at the Tri-Service General Hospital on 2023-06-24 where he was prescribed Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem). These medications have been correctly incorporated into the patient’s active medication list. No discrepancies were found during the medication reconciliation process.

2023-06-01

• This patient had an appointment at the Tri-Service General Hospital on 2023-05-05, during which he was prescribed a single dose of Zoladex (goserelin acetate 10.8mg). As the suggested administration interval for this medication is every 12 weeks, the next scheduled dose should be on 2023-07-28. No issues were discovered during the medication reconciliation process.

• The patient seems to be showing signs of anemia with an increasing trend towards macrocytosis. As the bilirubin level is still within the normal range, hemolytic anemia may be less likely. A single intramuscular dose of B-Red (hydroxocobalamin 1mg) is scheduled for 2023-06-02, and folate is already included in the current FOLFIRINOX regimen. At this time, there is no concrete evidence indicating a rapid progression in the severity of anemia, so please continue monitoring.

  • 2023-05-31 RBC 3.27 x10^6/uL
    
  • 2023-05-31 HGB 10.5 g/dL
    
  • 2023-05-31 HCT 33.5 %
    
  • 2023-05-31 MCV 102.4 fL
    
  • 2023-05-24 MCV 100.0 fL
    
  • 2023-05-10 MCV 101.5 fL
    
  • 2023-04-25 MCV 102.2 fL
    
  • 2023-04-11 MCV 102.1 fL
    
  • 2023-03-28 MCV 103.6 fL
    
  • 2023-03-23 MCV 99.7 fL
    
  • 2023-03-09 MCV 97.4 fL
    
  • 2023-02-22 MCV 95.0 fL
    
  • 2023-02-15 MCV 91.8 fL
    
  • 2023-01-30 MCV 94.1 fL
    
  • 2023-01-13 MCV 93.6 fL

2023-05-11

• Zoladex (goserelin acetate) 10.8mg was administered Q3M, with the most recent administration occurring on 2023-05-05, at TSGH for the management of the patient’s prostate cancer. Furthermore, antiglycemic, antihypertensive, and anti-rejection medications prescribed at TSGH are correctly reflected in the current active medication list, presenting no issues with medication reconciliation.

• Please be aware, there is a slow yet noticeable upward trend in both AST and ALT lab results. This should be closely monitored for possible potential liver function impairment.

  • 2023-05-10 S-GOT/AST 35 U/L

  • 2023-04-25 S-GOT/AST 42 U/L

  • 2023-04-11 S-GOT/AST 30 U/L

  • 2023-03-28 S-GOT/AST 25 U/L

  • 2023-03-23 S-GOT/AST 30 U/L

  • 2023-03-09 S-GOT/AST 23 U/L

  • 2023-02-22 S-GOT/AST 17 U/L

  • 2023-02-15 S-GOT/AST 16 U/L

  • 2023-01-30 S-GOT/AST 14 U/L

  • 2023-01-13 S-GOT/AST 19 U/L

  • 2023-05-10 S-GPT/ALT 44 U/L

  • 2023-04-25 S-GPT/ALT 55 U/L

  • 2023-04-11 S-GPT/ALT 36 U/L

  • 2023-03-28 S-GPT/ALT 32 U/L

  • 2023-03-23 S-GPT/ALT 35 U/L

  • 2023-03-09 S-GPT/ALT 27 U/L

  • 2023-02-22 S-GPT/ALT 21 U/L

  • 2023-02-15 S-GPT/ALT 22 U/L

  • 2023-01-30 S-GPT/ALT 20 U/L

  • 2023-01-13 S-GPT/ALT 20 U/L

2023-04-26

• Certican (everolimus) has been added to the list of active medications for the patient’s post-liver transplant status without a reconciliation issue.
• 2023-04-25 WBC 2.71K/uL, Granocyte (lenograstim) might be prepared in advance for approximately 1 week after chemotherapy.

2023-03-13

• The patient has been receiving FOLFIRINOX since 2023-02-02, with a reduced dosage of oxaliplatin (85 -> 65mg/m2) and irinotecan (180 -> 90mg/m2) to prevent adverse reactions. Approximately 2 weeks after the first chemotherapy treatment, the patient experienced leukopenia, with a WBC count of 2.08K/uL on 2023-02-15. Following this event, prophylactic G-CSF was administered around 1 week after each subsequent chemotherapy treatment, and no further episodes of leukopenia were observed.
• The previous 84-day refillable prescription of tacrolimus at TSGH on 2022-12-10 was changed to everolimus on 2023-03-04. To manage the trough concentration target range of 3 to 8 ng/mL, patients taking everolimus are recommended to undergo TDM.
• If the patient develops neutropenia again, the dose of everolimus is recommended to be adjusted as follows:
  • For Grade 3 neutropenia (ANC >=500 to <1,000/uL), everolimus treatment will be temporarily interrupted until the condition improves to <= grade 2. Treatment will then be reinitiated at the same dose.
  • For Grade 4 neutropenia (ANC <500/uL), everolimus treatment will be temporarily interrupted until the condition improves to <= grade 2. Treatment will then be reinitiated at 50% of the previous dose. If the reduced dose is lower than the lowest strength available, dosing will be changed to every other day.

2023-01-31

• Although there are case reports of pancreatic adenocarcinoma in liver transplant recipients, there are no systematic review articles on chemotherapy for pancreatic cancer in liver transplant patients found in the public domain.
• If the patient’s performance is evaluated as ECOG 0/1, FOLFIRINOX or modified FOLFIRINOX might be considered as possible regimens for treatment.
• The patient is taking Advagraf (tarcolimus). Tacrolimus is an immunosuppressant, in combination with chemotherapy, it is likely to have an increased immunosuppressive effect, therefore, there may result in potential opportunistic infections which should be closely monitored.

701022889

240523

[MedRec]

• 2022-12-01 ~ 2022-12-03 POMR General and Gastroenterological Surgery Zhang YaoRen
  • Discharge diagnosis
    • Right breast invasive carcinoma with lymph node and bone metastatic status post port-A insertion. cT4bN2M1, stage IV. ER (+, 90%), PR(-, 0%), Her2/neu:(2+), Ki-67:60%. ECOG:0.
    • For neoadjuvant chemotherapy
  • CC
    • noted a palpable mass at right breast about 2 months. But she didn’t pay attention to it. Due to mass was enlarge recently.
  • Present illness
    • This 50-year-old female patient denied any past history including DM, HTN, HBV, heart disease or cancer. She denied any TOCC histories in recent 3 months.
    • She noted a palpable mass at right breast about 2 months. But she didn’t pay attention to it. Due to mass was enlarge recently. She came to our OPD for help.
    • Mammography showed 1). right breast malignancy with skin thickening, rule out malignancy; 2). Enlarged axillary lymph nodes. 3). Left breast tumor, suggest sonographic correlation.
    • Breast sono showed 1). Right 10/2.33 cm, Size: 2.69x1.98 cmand enlarged axillary lymph nodes rule out malignancy with lymph nodes metastasis, suggest biopsy; 2). Left 5/0.13cm, Size: 4.23x1.37 cm rule out hamartoma. Breast MRI showed 1). Right breast malignancy with skin invasion and axillary lymph nodes metastasis. 2). Left breast 3’region irregular tumor, 1.3cm, may consider biopsy. 3). Left breast 5-6’region oval shaped tumor, rule out hamartoma. Right breast core needle biopsy showed invasive carcinoma, ER (+, 90%), PR(-, 0%), Her2/neu:negative(1+), Ki-67:60%. Right axillary lymph node core needle biopsy showed ER (+, 90%), PR(-, 0%), Her2/neu:(2+), Ki-67:60%. FISH report of Her2/neu negative. Left breast core needle biopsy report was pending.
    • Bone scan revealed increased activity in multiple C-, T- and L-spines, sternum, bilateral multiple ribs, sacrum, bilateral pelvic bones and bilateral S-I joints. The scintigraphic findings suggest multiple bone metastatic. CA-153 : 673.965 U/ml, CEA : 104.096 ng/ml. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
    • PE: symmetrical of bilateral breasts. 1). a hard, nontender, movable mass and irregular margin at right breast around 6.56 cm without discharge. 2).a hard, nontender, movable mass and irregular margin at left breast around 22cm without discharge. The bilateral nipple was no dimping without exudative nor bloody discharge and no retraction. The bilateral breast skin had no cellulite change. 3).a hard, nontender, movable mass and irregular margin at right axillary around 3*2cm.
    • ** Neoadjuvent chemotherapy with Lipo-dox and Endoxan for 4 cycles, and Taxotere for 4 cycles then operation and radiotherapy ** were suggest.
    • Under the impression of right breast invasive carcinoma with lymph node and bone metastatic, she was admitted for surgery of port-A insertion and 1st neoadjuvant chemotherpy with Lipo-dox and Endoxan on 2022/12/03.
  • Course of inpatient treatment
    • After admission, port A insertion was performed on 2022/12/02. 1st adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 were given. The wound is clean and dry. No discomfort after chemotherapy. Under the stable condition, she was discharged today, wound will be follow up at OPD. And arrange next admission three weeks later.

[chemotherapy]

• 2024-05-22 - eribulin mesylate 1.4mg/m2 2.5mg NS 100mL 10min (Halaven QW)
  • diphenhydramine 30mg + NS 250mL
• 2024-04-19 - trastuzumab deruxtecan 5.4mg/m2 300mg D5W 100mL 90min (Enhertu)
  • betamethasone 8mg + diphenhydramine 30mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + NS 250mL
• 2024-03-29 - trastuzumab deruxtecan 5.4mg/m2 300mg D5W 100mL 90min (Enhertu)
  • betamethasone 8mg + diphenhydramine 30mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + NS 250mL
• 2024-03-08 - trastuzumab deruxtecan 5.4mg/m2 375mg D5W 100mL 90min (Enhertu)
  • betamethasone 8mg + diphenhydramine 30mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + NS 250mL
• 2024-02-16 - trastuzumab deruxtecan 5.4mg/m2 375mg D5W 100mL 90min (Enhertu)
  • betamethasone 8mg + diphenhydramine 30mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + NS 250mL
• 2024-01-26 - trastuzumab deruxtecan 5.4mg/m2 385mg D5W 100mL 90min (Enhertu)
  • betamethasone 8mg + diphenhydramine 30mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + NS 250mL
• 2024-01-05 - trastuzumab deruxtecan 5.4mg/m2 350mg D5W 100mL 90min (Enhertu)
  • betamethasone 8mg + diphenhydramine 30mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + NS 250mL
• 2023-12-15 - trastuzumab deruxtecan 5.4mg/m2 347mg D5W 100mL 90min (Enhertu)
  • betamethasone 8mg + diphenhydramine 30mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + NS 250mL
• 2023-11-24 - trastuzumab deruxtecan 5.4mg/m2 360mg D5W 100mL 90min (Enhertu)
  • betamethasone 8mg + diphenhydramine 30mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + NS 250mL
• 2023-11-15 - paclitaxel 80mg/m2 137mg NS 250mL 90min + gemcitabine 800mg/m2 1375mg NS 100mL 30min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-04-28 - docetaxel 75mg/m2 135mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-04-07 - docetaxel 75mg/m2 133mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-03-17 - docetaxel 75mg/m2 130mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-02-24 - docetaxel 75mg/m2 127mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-02-03 - liposome doxorubicin 35mg/m2 59mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1014mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-01-13 - liposome doxorubicin 35mg/m2 59mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 999mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-12-23 - liposome doxorubicin 35mg/m2 59mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1004mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-12-03 - liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 994mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2024-05-23

[History of Elevated ALT Levels and Treatment Considerations]

Elevated ALT: - A review of historical laboratory results revealed two instances of elevated ALT levels: November 2023 and currently, in April and May 2024.

Treatment Regimen and Consistency: - The patient has been receiving Enhertu at a standard dose of 5.4mg/m2 since late November 2023. The dosing interval has remained consistent at every 3 weeks (Q3W) throughout this period, including during the current ALT elevation.

Potential Link to Enhertu: - Enhertu is known to cause elevated liver enzymes, including increased serum alanine aminotransferase (ALT) (34% to 53%), alkaline phosphatase (ALP) (22% to 54%), and aspartate aminotransferase (AST) (35% to 67%). Additionally, increased bilirubin (15% to 24%) has been reported with Enhertu, with no clear timeframe for onset identified. Due to this association, Enhertu cannot be ruled out as a potential cause of the current ALT elevation.

Mitigation Strategies: - BaoGan (silymarin) has been prescribed to potentially alleviate these liver enzyme elevations associated with Enhertu.

Treatment Switch and Continued Monitoring: - As of 2024-05-22, the treatment regimen has been switched to Halaven (eribulin mesylate). - It’s important to note that Halaven has also been reported to cause elevated ALT (43%) and AST (36%). Therefore, close monitoring of liver function tests remains necessary.

ALT data: - 2024-05-20 ALT 279 U/L - 2024-05-17 ALT 262 U/L - 2024-04-19 ALT 151 U/L - 2024-03-29 ALT 114 U/L - 2024-03-08 ALT 66 U/L - 2024-02-15 ALT 59 U/L - 2024-02-08 ALT 73 U/L - 2024-01-26 ALT 73 U/L - 2024-01-05 ALT 54 U/L - 2023-12-27 ALT 89 U/L - 2023-12-15 ALT 83 U/L - 2023-12-08 ALT 97 U/L - 2023-12-01 ALT 215 U/L - 2023-11-27 ALT 276 U/L - 2023-11-22 ALT 186 U/L - 2023-11-22 ALT 186 U/L - 2023-11-14 ALT 154 U/L - 2023-11-11 ALT 133 U/L - 2023-08-24 ALT 59 U/L - 2023-07-31 ALT 84 U/L - 2023-06-28 ALT 23 U/L - 2023-06-19 ALT 24 U/L

701493510

240523

[exam findings]

• 2024-05-16 Visceral Angiography over 2 vessels
  • Findings
    • Patency of portal vein, SMV and IMV.
    • Occlusion of superior rectal artery with collateral circulation. No evidence of active bleeding.
    • No procedure-related complication during the whole procedure.
  • IMP:
    • Occlusion of superior rectal artery with collateral circulation. No evidence of active bleeding.
• 2024-04-29, -04-25 KUB
  • S/P colostomy over right abdomen
  • Small bowel obstruction is highly suspected. Please correlate with CT.
• 2024-04-22 ECG
  • Normal sinus rhythm
  • ST & T wave abnormality, consider inferior ischemia
  • ST & T wave abnormality, consider anterolateral ischemia
  • Prolonged QT
• 2024-04-22 KUB
  • S/P colostomy over right abdomen
  • increased air in nondistended loops of small bowel and colonic segments air with no visualized of rectal gas
  • Atherosclerosis of abdominal aorta and bilateral iliac arteries.
  • Enlargement of both kidneys
• 2024-04-22 CXR
  • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
  • Multiple nodules of variable sizes throughout both lungs due to metastasis.
  • Thoracic aortic arch calcified atheriosclerotic plaque
• 2024-01-11 CT - abdomen
  • History and indication: Colon cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colostomy. R-S colon cancer with adjacent structures invasion (uterus, left lower ureter, adjacent bowel loop, posterior pelvic wall), LNs, liver, spleen and lung metastases (progression).
    • Left hydronephrosis.
    • Gallbladder stones (up to 5mm).
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • R-S colon cancer with adjacent structures invasion (uterus, left lower ureter, adjacent bowel loop, posterior pelvic wall), LNs, liver, spleen and lung metastases (progression).
• 2023-10-21 MRI - brain
  • Indication: colon cancer with lung mets; dizziness, nausea with vomiting and unsteady gait
  • Findings:
    • Two heterogeneously enhancing tumors (35 mm and 20 mm) associating with perifocal edema in left cerebellar hemisphere, causing mass effect on brain parenchyma and CSF spaces. Resultant hydrocephalus also noted.
    • An enhancing nodule (5 mm) in posterior part of right mesial temporal lobe.
  • IMP:
    • C/W Brain metastases.
• 2023-09-15 All-RAS + BRAF gene mutation analysis
  • Cell block no. S2023-015925
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 12 GGT>TGT, p.G12C)
    • BRAF: There was no variant detect in the BRAF gene
• 2023-09-15 CXR (erect)
  • S/P port-A implantation.
  • Lung metastases.
  • Atherosclerotic change of aortic arch
• 2023-08-22 CT - abdomen
  • PHx: Rectosigmoid junction cancer near total obstruction with lung metastases stage IV
  • Without contrast enhancement CT of abdomen shows:
    • Rectosigmoid colon CA with adjacent structure invasion.
    • s/p T-loop colostomy. Fecal material in proximal colon.
    • Left hydronephrosis.
    • Peritoneal stranding and minimal ascites.
    • Nodular lesions in both lung fields.
    • No bony destructive lesion on these images.
  • Impression
    • Rectosigmoid colon CA with lung metastasis
    • s/p T-loop colostomy.
    • r/o obstruction or stool impaction.
    • Left hydronephrosis.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:M1(M_value) STAGE:____(Stage_value)
• 2023-08-22 KUB
  • s/p Rorximal T-loop colostomy with soft-tissue mass like structure, colonic segment bulging from the colostomy
  • fecal material filled nondilated D-colon and cecum
  • Atherosclerosis of abdominal aorta and bilateral common and external iliac arteries.
• 2023-08-18 CXR (erect)
  • Presence of ileus.
  • S/P Port-A infusion catheter insertion.
  • Multiple nodules at bil. lungs.
• 2023-08-11 Patho - colon biopsy
  • Rectum, biopsy — Adenocarcinoma, well differentiated
  • The sections show a picture of adenocarcinoma, well differentiated, composed of columnar neoplastic cells arranged in glandular pattern with desmoplastic stromal reaction.
  • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
• 2023-08-09 CT scan (patient carried)
  • CC: Difficult defecation for 1-2 years. Poor appetite, nausea with vomiting after meal, and general weakness for weeks.
    • No passage flatus and stool about 10 days.
    • Colonoscopy showed an ulcerative mass at sigmoid about 30 cm from AV, partial obstructed. Biopsy and pathology proved adenocarcinoma.
    • 20230810 sigmoidoscopy: One mass was noted in the rectum (6 cm AAV)
  • Indication: rectal cancer with obstruction
  • Findings:
    • There is segmental wall thickening at the rectosigmoid junction, measuring 7.5 cm in size, with suggestive tumor necrosis and left L3 ureter invasion (moderate left hydroureteronephrosis and delayed contrast excretion of left kidney) that is c/w adenocarcinoma (mucinous type?) of the rectosigmoid junction (T4b).
    • There are seven enlarged nodes in the sigmoid mesocolon that are c/w metastatic nodes (N2b).
    • There are multiple variable sized soft tissue lesions in both lung and the largest one in RUL, measuring 4.1 cm that are c/w multiple lung metastases (M1a).
    • The differential diagnosis includes primary lung cancer at RUL with lung-to-lung metastases. CT-guided biopsy of RUL lesion is indicated.
    • In addition, there are several enlarged nodes in the paratracheal space that may be metastatic nodes.
    • There is ascites and suggestive fatty stranding in the omentum that may be normal variation secondary to ascites and carcinomatosis M1C). Please correlate with ascites cytology.
    • There are few gallstones.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)

[MedRec]

• 2023-09-15 ~ 2023-09-18 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Rectosigmoid junction cancer near total obstruction with lung metastases stage IV
    • Chronic viral hepatitis B without delta-agentanti-Hbc positive
  • CC
    • for C1D1 palliative chemotherapy with FOLFIRI
  • Present illness
    • This 66-year-old woman, a patient of rectosigmoid junction cancer near total obstruction with lung metastases stage IV status post T-loop colostomy was diagnosed on 2023/08/09, had dysuria with fever and then went to Wan Fang Hospital emergent room for help last month on 2023/07/14. Abdominal CT (2023/7/14) revealed colorectal cancer with multiple lung metastasis. However she suffered from no passage flatus and stool about 10 days since 2023/08/07, poor appetite, nausea with vomiting after meal, and general weakness for 2 weeks.
    • Image study with sigmoidscopy (2023/8/10) showed Rectal cancer with obstruction s/p biopsy and rectum, biopsy (2023/8/11) proved adenocarcinoma, well differentiated, IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+). Repeat abdominal CT (2023/8/22) revealed rectosigmoid colon CA with lung metastasis, s/p T-loop colostomy. r/o obstruction or stool impaction. Left hydronephrosis.
    • The tumor marker showed CA-199 = 912.700, CEA = 256.480 on 2023/8/15. Hepatitis marker revealed HBsAg:negative, Anti-Hbc: positive and anti-HCV:negative. Port-A was inserted on 2023/8/18.
    • Today, she was admitted for C1D1 palliative chemotherapy with FOLFIRI on 2023/9/15.
  • Course of inpatient treatment
    • After admission, chemotherapy with Campto (180mg/m2) plus Leucovorin (400mg/m2)and 5-FU (2800mg/m2) were given on 9/15-9/17 23, smoothly without obvious side effect.
    • All-RAS + BRAF was checked on 9/15 23.
    • Entecavir was added for anti-Hbc positive.
    • She was discharged on 9/18 23 under stable condition and will follow-up at OPD.
  • Discharge diagnosis
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2023-08-23 ~ 2023-08-30 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Rectosigmoid junction cancer near total obstruction with lung metastases stage IV status post T-loop colostomy on 2023/08/09, complicated with marked prolaspe of distal limb of loop-T colostomy
  • CC
    • No stool from T-loop colostomy for two days
  • Present illness
    • This 66 years old female patient had a history of Rectosigmoid junction cancer near total obstruction with lung metastases stage IV status post T-loop colostomy on 2023/08/09.
    • According to patient and her families statement, had dysuria with fever and then went to Wan Fang Hospital emergent room for help last month (2023/07/14). Abdominal CT revealed colorectal cancer with multiple lung metastasis, and admission for further management was suggested, but patient refused.
    • However she suffered from no passage flatus and stool about 10 days since 2023/08/07, poor appetite, nausea with vomiting after meal, and general weakness for 2 weeks. She was sent to our hospital for further evaluation on 2023/08/07, physical examination showed abdomen distension, hyperactive bowel sound. KUB revealed ileus, and CXR revealed multiple nodules at bilateral lungs. Consult CRS was performed and operation of T-loop colostomy under general anesthesia was performed on 2023/08/09.
    • This time, the patient was suffered from colon became bulging from the colostomy for two days. Constipation with poor apeptite was noted. The patient dnied nause or vomiting. Due to above symptom, the patient came to our ER for help. At ER, PE showed fair respiratory patterm, no abdominal pain; Lab data showed no infection sign. Under the impression of suspect T-loop obstruction, the patient was admitted.
  • Course of inpatient treatment
    • After admission, Lifoxitin as empirical antibiotic was used. Antibiotic change to Brosym due to fever onset and lab data on 08/25 revealed persistent infection sign.
    • Fever relief after medicine used and fair appetite after Megest was used. Fiar T-loop colon bag function was noted during hospitation. After fair respiratory patterm and appetite, stable T-loop bag function, the patient was discharged on 08/30 and OPD follow-up was suggested.
  • Discharge prescription
    • MgO 250mg 1# TID
    • Ceficin (cefixime 100mg) 2# BID
• 2023-08-07 ~ 2023-08-11 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Rectosigmoid junction cancer near total obstruction with lung metastases stage IV status post T-loop colostomy on 2023/08/09
    • Cachexia
  • CC
    • Difficult defecation for 1-2 years.
    • Poor appetite, nausea with vomiting after meal, and general weakness for weeks.
    • No passage flatus and stool about 10 days.
  • Present illness
    • This 66 years old female patient denied any history of systemic disease.
    • According to patient and her families statement, has dysuria with fever and then came to Wan Fang Hospital emergent room for help last month (2023/07/14). Abdominal CT revealed colorectal cancer with multiple lung metastasis, and admission for further management was suggested, but patient refused.
    • However she suffered from no passage flatus and stool about 10 days, poor appetite, nausea with vomiting after meal, and general weakness for 2 weeks. She was sent to our hospital for further evaluation on 2023/08/07, physical examination showed abdomen distension, hyperactive bowel sound. KUB revealed ileus, and CXR revealed multiple nodules at bilateral lungs. Consult our CRS and then she was admitted for further treatment and management.
  • Course of inpatient treatment
    • After admission with ward routine and blood examination were done. Operation of T-loop colostomy under general anesthesia was performed on 2023/08/09. NPO and IV fluids support. The colostomy wound healing well and no erythema change. Chewing cookies, toast, rice with gum was started at post-op day 1. No nausea and no vomiting, flatus passage. On low residual diet was started at post-op day 2. Well bowel movement and stools passage (+) with diet well tolerated. No fever and no complication. Discharged in general condition stable on 2023/08/11 and will follow up in our out-patient department next week.
  • Prescription
    • none

[consultation]

• 2023-12-05 Radiation Oncology
  • Q
    • for pelvic cavity tumor compression and radiotherapy evaluation
    • This 66-year-old woman, a patient of rectosigmoid junction cancer near total obstruction with lung & brain metastases stage IV status post T-loop colostomy by Dr Xiao GuangHong was diagnosed on 2023/08/09 S/P C/T with FOLFIRI one time on 9/15 23. She complained of severe anal pain for days. Dr. Xiao GuangHong, a colorectal surgeon, diagnosed the pain as being caused by a tumor pressing on the pelvic cavity. We need expertise to evaluate her condition thanks!
  • A
    • O
      • RT (2023-10-27 ~ 2023-11-23): 1250cGy/5 fractions (6MV photon) of the whole brain, and 3000cGy/12 frcations (6MV photon) of the metastatic brain tumors.
    • A:
      • Adenocarcinoma of the RS colon, stage cT4bN2bM1a, stage IVA, s/p chemotherapy, with brain metastases, s/p radiotherapy.
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: Pain of the pelvic to sacral area.
      • Goal: palliation
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0930, 2023-12-11.
• 2023-10-24 Radiation Oncology
  • Q
    • The 66 y/o woman has RS colon with lung and brain mets, we need your help for RT assessment. Thanks!
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For radiotherapy due to adenocarcinoma of the rectum with multiple including brain metastases.
      • PI: The patient suffered from unstable gait and dizziness, MRI of brain showed metastases. Referred for radiotherapy of the brain.
      • Family history: (father: adenocarcinoma of the prostate)
      • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
      • Previous RT Hx: (-)
    • O: ECOG: 2
      • PE: neck and bil SCF: neg; left hand showed abnormal cerebellar test.
      • Operation (2023-08-09): T-loop colostomy.
      • CT scan (2023-08-09):
        • There is segmental wall thickening at the rectosigmoid junction, measuring 7.5 cm in size, with suggestive tumor necrosis and left L3 ureter invasion (moderate left hydroureteronephrosis and delayed contrast excretion of left kidney) that is c/w adenocarcinoma (mucinous type?) of the rectosigmoid junction (T4b).
        • There are seven enlarged nodes in the sigmoid mesocolon that are c/w metastatic nodes (N2b).
        • There are multiple variable sized soft tissue lesions in both lung and the largest one in RUL, measuring 4.1 cm that are c/w multiple lung metastases (M1a).
        • The differential diagnosis includes primary lung cancer at RUL with lung-to-lung metastases. CT-guided biopsy of RUL lesion is indicated.
        • In addition, there are several enlarged nodes in the paratracheal space that may be metastatic nodes.
        • There is ascites and suggestive fatty stranding in the omentum that may be normal variation secondary to ascites and carcinomatosis (M1c). Please correlate with ascites cytology.
        • There are few gallstones. Stage cT4bN2bM1a, stage IVA.
      • Sigmoidscopy (2023-08-10): One mass was noted in the rectum (6 cm from anal verge). Diagnosis: Rectal cancer with obstruction s/p biopsy.
      • Pathology (S2023-15925, 2023-08-15): Rectum, biopsy — Adenocarcinoma, well differentiated
      • MRI of brain (2023-10-21):
        • Two heterogeneously enhancing tumors (35 mm and 20 mm) associating with perifocal edema in left cerebellar hemisphere, causing mass effect on brain parenchyma and CSF spaces. Resultant hydrocephalus also noted.
        • An enhancing nodule (5 mm) in posterior part of right mesial temporal lobe. Imp: C/W Brain metastases.
    • A:
      • Adenocarcinoma of the RS colon, stage cT4bN2bM1a, stage IVA, status during chemotherapy, with brain metastases.
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: brain metastases
      • Goal: palliation
      • Treatment target and volume: brain
      • Technique: VMAT/IGRT and 2D
      • Preliminary planning dose: 1250cGy/5 fractions of the whole brain, and 3000cGy/12 fractions of the metastatic brain tumors.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family. She understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-10-26.

[surgical operation]

• 2023-08-09
  • Surgery
    • T-loop colostomy        
  • Finding
    • T-loop colostomy was created at RUQ area        
  • Procedure
    • Patient was put on supine position under ETGA
    • Sterized and drapped as routine
    • RUQ skin incision and muscular layer was splitted, fasia and peritoneum was opened
    • Iluem was identified and externalization, looped with a rubber tube
    • Colostomy was opened and matured by suturing with 3-0 monopril
    • Covered with stoma bag   

[radiotherapy]

[chemotherapy]

• 2024-04-13 - ………………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4065mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-03-29 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-03-04 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-02-16 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-19 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-01 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-15 - irinotecan 180mg/m2 265mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4120mg NS 500mL 46hr (FOLFIRI)
  • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

==========

2024-02-01

[reconciliation]

Lab results showed hypokalemia (2.8 mmol/L), hypomagnesemia (1.5 mg/dL), injectable KCl + NaCl, injectable MgSO4 were applied. Smecta (dioctahedral smectite) and loperamide were prescribed for diarrhea. No drug discrepancy identified

2023-12-15

Elevated levels of CRP and PCT were detected.

• 2023-12-14 Procalcitonin (PCT) 26.95 ng/mL
  
• 2023-12-13 CRP 7.6 mg/dL
  
• 2023-12-13 CRP 7.0 mg/dL

Cefepime 2g Q8H started on 2023-12-14. The patient’s body temperature has shown a preliminary downward trend since its peak of 37.8’C on the morning of 2023-12-15.

700030422

240522

[lab data]

• 2024-03-09 HBsAg Reactive
  

• 2024-03-09 HBsAg Value 4493.77 S/CO
  

• 2024-03-09 Anti-HBc Reactive
  

• 2024-03-09 Anti-HBc-Value 7.01 S/CO
  

• 2024-03-09 Anti-HBs 0.00 mIU/mL

• 2024-03-09 Anti-HCV Nonreactive
  

• 2024-03-09 Anti-HCV Value 0.09 S/CO

[exam findings]

• 2024-04-24 CT - abdomen
  • Findings: Comparison prior CT dated 2024/01/12.
    • Prior CT identified several metastases on both hepatic lobes are noted again, marked decreasing in size that are c/w liver metastases S/P C/T with partial response.
    • Prior CT identified segmental asymmetrical wall thickening of the sigmoid colon is noted again, mild increasing in size.
    • There is a newly developed soft tissue nodule in RML of the lung, 5 mm in size at lung window setting. Follow up is indicated.
    • Diverticulum in right lateral wall of the urinary bladder is noted.
  • Impression:
    • Liver metastases S/P C/T show partial response.
    • Prior CT identified segmental asymmetrical wall thickening of the sigmoid colon is noted again, mild increasing in size. Please correlate with colonoscopy.
      
    • There is a newly developed soft tissue nodule in RML of the lung, 5 mm in size at lung window setting. Follow up is indicated.
• 2024-02-08 Patho - skin cyst/tag/debridement
  • Skin, back, excision — Epidermal inclusion cyst
  • Sections show piece(s) of skin with one intradermal cyst lined by squamous epithelium. The cystic cavity is full of keratin material.
• 2024-01-12 CT - abdomen
  • Findings: Comparison prior CT dated 2023/10/16.
    • Prior CT identified segmental asymmetrical wall thickening of the sigmoid colon is noted again, mild decreasing in size and enhancement.
      • Prior CT identified two enlarged nodes in the adjacent mesocolon are not noted again.
    • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size that are c/w liver metastases S/P C/T with progressive disease.
    • Prior CT identified two ovoid-shaped enlarged nodes in right inguinal area are noted again, stationary.
      • Benign reactive nodes are highly suspected.
    • Diverticulum in right lateral wall of the urinary bladder is noted.
  • Impression:
    • Liver metastases S/P C/T show progressive disease.
• 2023-10-16 CT - abdomen
  • History and indication: Sigmoid cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Stable of S-colon cancer but mild progression of bil. liver metastases.
    • Left minimal pleural effusion.
    • Some calcifications in prostate.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Stable of S-colon cancer but mild progression of bil. liver metastases.
• 2023-07-20 MRA - brain
  • Clinical information: r/o brain metastasis or recent stroke
  • Findings:
    • Known a case of sigmoid colon cancer with brain metastasis. NO evidence of brain metastasis.
    • Presence of hydrocephalus with trans-ependymal CSF shift.
    • Moderate periventricular small vessel disease. NO acute ischemic infarct.
    • Suspect one arachnoid cyst over posterior fossa, causing compression of both cerebellar lobes.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
• 2023-05-05 CT - abdomen
  • Findings: Comparison: prior CT dated 2022/08/16.
    • Prior CT identified segmental asymmetrical wall thickening of the sigmoid colon is noted again, mild decreasing in size and enhancement.
      • Prior CT identified two enlarged nodes in the adjacent mesocolon are not noted again.
    • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size that are c/w liver metastases S/P C/T with progressive disease.
    • Prior CT identified two ovoid-shaped enlarged nodes in right inguinal area are noted again, stationary.
      • Benign reactive nodes are highly suspected.
    • The urinary bladder shows diffuse wall thickening and small size that may be chronic cystitis.
  • Impression:
    • Liver metastases S/P C/T show progressive disease.
• 2023-02-11 CT - abdomen
  • Findings
    • Sigmoid colon, s/p operation. No local recurrent tumor.
    • No enlarged lymph nodes in para-aortic and pelvic regions.
    • Several liver metastasis, mild in progression.
    • No ascites, nor extraluminal free air.
    • No bony destructive lesion on these images.
  • Impression
    • Sigmoid colon, s/p operation
    • Liver metastasis, mild in progression
    • Suggest clinical correlation and follow up evaluation
• 2022-11-09 MRI - brain
  • General brain atrophy. Leukoaraiosis. Mild intracranial artherosclerosis.
• 2022-08-16 CT - abdomen
  • Findings
    • Mild regression of S-colon cancer and bil. liver metastases (up to 4.0cm).
    • A small nodule (3.6mm) at RLL.
    • Some calcifications in prostate.
    • A nodule (1.9cm) at left buttock.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • Mild regression of S-colon cancer and bil. liver metastases (up to 4.0cm).
• 2022-08-03 All-RAS + BRAF
  • There was no variant detected in the KRAS/NRAS gene.
  • There was no variant detected in the BRAF gene.
• 2022-05-24 CT - abdomen
  • Findings
    • Much regression of S-colon cancer and bil. liver metastases (up to 5.2cm).
    • A bullae (2.8cm) at LUL.
    • Some calcifications in prostate.
    • Some tiny nodules in bil. lungs.
    • A nodule (1.9cm) at left buttock.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • Much regression of S-colon cancer and bil. liver metastases (up to 5.2cm).
    • A bullae (2.8cm) at LUL.
    • Some tiny nodules in bil. lungs.
• 2022-03-03 CT - chest
  • Indication: colon cancer with liver meta, favor lung meta
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Pneumatocele at left upper lobe up to 2.48cm in largest dimension is found.
      • Diffuse centrilobular Emphysematous change over both lungs is found.
      • Minimal atelectatic change at right middle lobe and left lingula lobe is found.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • No evidence of bilateral pleural effusion.
      • Calcified coronary arteries is found.
    • Visible abdomen:
      • Target like hepatic tumors are found at both lobes of liver up to 9.6cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-02-25, the lesion is stationary.
        
      • The spleen, pancreas, both kidneys and adrenals are intact.
  • Imp:
    • No evidence of pulmonary meta.
    • Diffuse centrilobular Emphysematous change over both lungs.
    • Liver meta. stationary as previous CT on 2022-02-25.
• 2022-02-25 Patho - colon biopsy (Y1)
  • Colon, sigmoid colon, 30cm from AV, s/p biopsy x6 — Adenocarcinoma.
  • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2022-02-25 CT - abdomen
  • History: 20220224 sono: Two huge 8.68x7.07cm and 7.68x6.43cm ill-defined hyperechoic lesion with scattered hyperechoic spot at left lobe and S5, Two 2.13cm and 1.5cm hyperechoic lesions with hypoechoic rim was noted at S5 and S6
  • Indication: Suspected HCCs or metastases
  • Findings:
    • There is segmental asymmetrical wall thickening of the sigmoid colon measuring 5 x 2.5 cm in size that may be adenocarcinoma.
      • In addition, there are two enlarged nodes in the adjacent mesocolon that may be metastatic nodes.
    • There are several lobulated well-defined poor enhancing masses on both hepatic lobes, the largest one measuring 9.2 cm in S2-3 of the liver. During dynamic study, all masses show poor enhancement in arterial phase, portal venous phase, and delayed phase images.
      • Metastases are highly suspected.
    • There is a well-defined enlarged node measuring 2.2 x 1.4 cm in hepatoduodenal ligament that may be benign reactive node.
      • The differential diagnosis include metastatic node.
    • There are two ovoid-shaped enlarged nodes in right inguinal area that may be benign reactice nodes.
    • There are two small soft tissue nodule in RML and RLL of the lung at lung window setting, nature? Please correlate with chest CT.
    • The urinary bladder shows diffuse wall thickening and small size that may be chronic cystitis.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M1 (M_value) STAGE:IVA(Stage_value)

[MedRec]

• 2022-11-08 SOAP Psychosomatic medicine
  • S
    • Recently found to have increasingly deteriorating memory, depressive symptoms, anxiety symptoms, fear symptoms, delusional symptoms (being stolen, being harmed, jealousy, being intruded, misidentification), hallucinations, behavioral disorders (irritability, aggression, wandering, gluttony, changes in eating, repetitive behavior, bizarre behavior, poor personal hygiene, inappropriate disorganization).
    • Screen dementia positive in the community by (elderly health check, care points, community health centers) with AD-8 test.
    • Past history of hypertension (+, -), DM (+, -), hyperlipidemia (+;-), arrhythmia (+,-), alcohol drink habit (+,-), head injury (+,-).
    • 1st time visiting comes with TZ volunteer, family (couple, son, daughter) due to poor memory, frequently showing forgetfulness for years.
    • Community memory screening AD8 > 2
    • Dementia warning signs assessment > 2
    • In the past few months, have family members mentioned (or have you discovered) that you seem to have the following conditions? Please mark (V) for yes and (X) for no.
      • ( v ) Memory decline affecting life:
      • ( v ) Difficulty planning or solving problems:
      • ( v ) Unable to handle familiar tasks
      • ( v ) Confusion about time and place:
      • ( v ) Difficulty understanding the relationship between visual images and space:
      • ( v ) Difficulty in verbal expression or writing:
      • ( v ) Things are misplaced and lose the ability to retrace steps:
      • ( v ) Poor or weakened judgment:
      • ( v ) Withdrawal from work or social activities:
      • ( v ) Changes in mood and personality:
      • Result: Mark (V) for a total of OO items.
  • O
    • Repeating the same questions, stories, and statements. Difficulty learning how to use tools, equipment, and small appliances. Forgetting the correct month and year. Difficulty remembering appointment times. Persistent problems with thinking and memory.
    • Result explanation:
      • Please check the items below according to the actual scores on the previous page (single choice):
        • AD8 total score >= 2 points
        • GDS total score >= 2 points
    • Patient meets the criteria for Alzheimer’s disorder
      • A: Multiple cognitive developmental impairments combined with the following A-1 and A-2 impairments:
        • A-1: Memory impairment (unable to learn new things or unable to recall previously learned things)
        • A-2: At least one of the following cognitive impairments:
          • Aphasia
          • Apraxia
          • Agnosia
    • Disturbance in executive functioning
      • B: Causing social or occupational difficulties, and a significant decline from the previous level of functioning
      • C: Cognitive decline is gradual and persistent
    • PSP: poor social function, disorientation to time and place, easily lost orientation to home
    • O: Vital sign: relatively stable
      • Physical and neurological examination: no significant abnormal findings were noticed during outpatient visiting
    • Mental Status Examination:
      • JOMAC: poor orientation, memory, and abstract thinking.
      • Insight: partial
      • Impression: Mild Cognitive Impairment
    • Plan to do:
      • Examinations for CBC, VDRL, BUN, Creatinine, GOT, GPT, T4, TSH, B12, and Folic acid.
      • MMSE or CDR cognitive test report.
      • Arrange brain CT or MRI if indicated
  • Diagnosis
    • Mild cognitive impairment of uncertain or unknown etiology G31.84
• 2022-08-31 SOAP Hemato-Oncology
  • S: 2022-08-03 All-RAS: Wildtype
  • O: 2022/08/16 CT: ABD - Mild regression of S-colon cancer and bil. liver metastases (up to 4.0cm).
• 2022-08-03 SOAP Hemato-Oncology
  • O: AE: anorexia - staionary
  • P: Avastin 10 - 2 = 8 on 2022-08-03
• 2022-07-20 SOAP Hemato-Oncology
  • O: AE: anorexia
• 2022-05-25 SOAP Hemato-Oncology
  • O: AE: Gr 1 constipation -> diarrhea
• 2022-04-27 SOAP Hemato-Oncology
  • O: AE Gr 1 constipation -> not improved
  • A/P:
    • Avastin 24 - 2 = 22
    • Already explain HTN, proteinuria, hollow organ perforation etc
    • Arrange Abd/Pelvis/Chest CT Q3M, next on 2022-05-24
• 2022-04-13 SOAP Hemato-Oncology
  • O: AE Gr 1 constipation
  • Prescription
    • Norvasc (amlodipine 5mg) 1# QD
    • Takepron (lansoprazole 30mg) 1# QDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Through (sennoside 12mg) 2# HS
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • MgO 250mg 1# TID
    • Hepac Lock Flush (heparin sodium 100 USP units/mL 10mL) 10# ST IRRI (irrigation)
• 2022-03-31 SOAP Hemato-Oncology
  • O: Now on FOLFIRI, C1D1 on 2022-03-07
• 2022-03-17 SOAP Hemato-Oncology
  • S: Hx of sigmoid cancer s/p C/T, T3bN1aM1a, Stage IVA
• 2022-03-10 ~ 2022-03-10 POMR Hemato-Oncology
  • Discharge diagnosis
    • Sigmoid colon cancer with liver metastases, T3N1bM1a, stage IVA
    • Reflux esophagitis LA grade A
    • Gastric erosions, antrum and low body
    • Chronic viral hepatitis B without delta-agent
    • Constipation, unspecified
  • CC
    • anorexia, epigastric paresthesia, and tea color urine for days
  • Prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Takepron (lansoprazole 30mg) 1# QDAC
• 2022-02-23 ~ 2022-03-10 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Sigmoid colon cancer with liver metastases, T3N1bM1a, stage IVA
    • Reflux esophagitis LA grade A
    • Gastric erosions, antrum and low body
    • Chronic viral hepatitis B without delta-agent
    • Constipation, unspecified
  • CC
    • anorexia, epigastric paresthesia, and tea color urine for days
  • Present illness
    • This 74 year-old male patient has the histories of 1) HBV but loss follow-up, 2) inguinal hernia s/p operation, 3) upper GI bleeging s/p micro invasive surgery. He denied any allergey, and family history. He smoke 0.5 PPD for 60 years and no alcholism.
    • He had body weight lost 8 Kgs (60 to 52 Kgs) and severe anorexia in the past 3 months. He visited Postal Hospital for help. Hepatitis markers were checked and HBeAg, Anti-HBs, Anti-HBe, Anti-HBc, Anti-HCV were all negative, and HBsAg 3048.14 IU/mL. Tumor maker was checked and showed AFP 3.9 ng/mL; CEA 1993 ng/mL; CA-199 555 ng/mL. Abdominal sonography was arranged on 2022/02/09 and revealed multiple liver tumors.
    • He transferred to our GI OPD for help. He sufferred from anorexia, epigastric paresthesia, and tea color urine for days. He denied chillness or fever, nausea or vomiting, dizziness, headache, chest tightness or pain, diarrhea or constipation, dysuria or frequency found. No TOCC history was noted. COVID19 rapid test showed Negative. Lab data showed no leukocytosis and normal AST, ALT, bilirubin, r-GT. Elevated ALP 122 U/L.
    • Under the impression of Liver tumor, R/O HCC or metastasis tumor, he was admitted to GI ward for cancer survey and further management.
  • Course of inpatient treatment
    • After admitted, Abdominal echo on 2022/02/24 showed parenchymal liver disease and liver tumors, bilateral lobes, r/o HCC or metastasis tumor.
    • Tumor maker was checked and showed 2022-02-25 AFP 3.6 ng/mL; CA199 592.71 U/mL; CEA 2204.47 ng/mL.
    • Abdominal CT on 2022/02/25 showed colon cancer with liver metastasis, T3 N1b M1a, Stage: IVA.
    • Colonoscopy on 2022/02/25 showed colon polyp, ascending colon, s/p hot snare polypectomy and EZ clip x2. (A), colon polyp, descending colon, s/p biopsy removal. (B), colon polyp, sigmoid colon, colon cancer, Paris classification 0-Isp,12mm, was noted at sigmoid colon, 30cm from AV, s/p biopsy*6. (C) and internal hemorrhoid. Colon, sigmoid colon, 30cm from AV, s/p biopsy showed Adenocarcinoma; IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Chest CT on 2022/03/03 showed no evidence of pulmonary meta, diffuse centrilobular Emphysematous change over both lungs and liver metastasis.
    • Applying Major Illness on 2022/03/03. Port-A catheter insertion on 2022/03/04.
    • Chemotherapy with FOLFIRI(Campto 90mg/m2, L 400mg/m2, 5FU 400mg/m2 and 2400mg/m2)(C1D1) from 2022/03/07~2022/03/09.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • EGD on 2022/02/25 showed reflux esophagitis LA grade A, superficial gastritis, s/p CLO test, gastric erosions, antrum and low body, suspected gastric intestinal metaplasia, antrum, angle, and low body, s/p biopsy and deformed bulb.
    • Reflux esophagitis with Takepron 1# po QDAC.
    • Hepatitis markers were checked and HBeAg, Anti-HBs, Anti-HBe, Anti-HBc, Anti-HCV were all negative, and HBsAg 3048.14 IU/mL.
    • Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC.
    • Sennoside 2# po HS for Constipation.
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, he was discharged on 2022/03/10 and OPD followed up later.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Takepron (lansoprazole 30mg) 1# QDAC
• 2022-02-23 SOAP Gastroenterology
  • S
    • Loss 8 Kgs (60 to 52 Kgs) and anorexia in the past 3 months.
    • Metastatic lesions were found in the liver with sky high tumor markers at a LMC on 2022-02-08.
    • So, he was referred to our hospital for evaluation.
  • O
    • PE: No icteric sclera, soft abdomen, no leg pitting edema.
    • 2022-02-07 CEA: 1993 (<5).
    • 2022-02-07 Ca19-9: 555. (at a LMC).
    • 2022-02-09 Abdo sono: Multiple liver tumors. (at a LMC).

[consultation]

• 2024-04-23 Dermatology
  • Q
    • for redness, swelling of the feet, paronychia of right big toe for 2~3 days
  • A
    • CC: Nail lesions over right big toenail
    • Skin findings:
      • Periungual erythema and swelling with some pus discharge over right big toenail
      • Subungual hyperkeratosis, nail discoloration, nail dystrophy over toenails
    • Imp:
      • Acute paronychia (Right big toe) with chronic onychomycosis
    • Plan:
      • Keep systemic antibiotic use
      • Topical biomycin BID for right big toe nail lesions
      • Educated that the big toe of the right foot should not touch the water
      • Topical exelderm soln BID for other toenails
      • Arrange Derm OPD follow up after discharge
• 2024-02-03 Plastic and Reconstructive Surgery
  • Q
    • This 76-year-old man patient is a case of Sgmoid colon cancer with liver metastases, T3N1bM1a, stage IVA under chemotherapy. He was admitted for chemotherapy with Erbitux plus FOLFIRI.
    • This time, he presented back wound with discharge for least 2 days. we need your further evaluation and management.
  • A
    • Excision of the epidermal cyst can be done under local anesthesia in the afternoon of 2024/02/07 (Wed). Thanks.
• 2023-11-07 Plastic and Reconstructive Surgery
  • Q
    • This 76-year-old man patient is a case of Sgmoid colon cancer with liver metastases, T3N1bM1a, stage IVA s/p chemotherapy with FOLFIRI from 2022/03/07~2023/06/01(15 cycles) and Avastin from 2022/04/27~, progressive disease of liver tumor, palliative chemotherapy with FOLFOX from 2023/06/19~. He was admitted for chemotherapy.
    • This time, he presented with fall down today, left back laceration was noted. we need your further evaluation and management.
  • A
    • I will let the patient get into the OR for wound debridement and suture in the afternoon of 11/8. Thanks.
• 2023-08-31 Rehabilitation
  • Q
    • This 76-year-old man patient is a case of Sgmoid colon cancer with liver metastases, T3N1bM1a, stage IVA s/p chemotherapy with FOLFIRI from 2022/03/07~2023/06/01(15 cycles) and Avastin from 2022/04/27~, progressive disease of liver tumor, palliative chemotherapy with FOLFOX from 2023/06/19~. He was admitted for prepare chemotherapy.
    • This time, for bilateral lower limbs weakness with action remains unchanged. Now, for evaluate rehabilitation exercises. Thank you.
  • A
    • Due to deconditioning, we were consulted for bedside PT rehabilitation programs.
    • Premorbid status
      • Walk slowly ID; use walker sometimes indoor to walk faster / BADL ID
      • Sedentary lifestyle
    • Physical examination
      • 2023/08/31 14:17 T/P/R: 36.5’C / 85bpm / 18bpm BP:130/78mmHg
      • Body weight: 48.2
      • Consciousness: E4V5M6
      • Cognition: intact
      • Sphincter: urinary and stool continence
      • Muscle power:
        • RUE/RLE 4+/4
        • LUE/LLE 4+/4
      • Functional status: could walk to toilet slowly ID
      • BADL: under supervision
    • Assessment
      • Sgmoid colon cancer with liver metastases, T3N1bM1a, stage IVA s/p chemotherapy with FOLFIRI from 2022/03/07 to 2023/06/01(15 cycles) and Avastin from 2022/04/27, progressive disease of liver tumor, palliative chemotherapy with FOLFOX from 2023/06/19, with deconditioning
      • Chronic viral hepatitis B without delta-agent
      • Anemia due to antineoplastic chemotherapy
      • Hypertension
    • Plan
      • Rehabilitation programs: arrange bedside PT rehabilitation programs.
      • Goal: recondition; improve endurance and muscle strength; improve ambulation.
• 2023-07-17 Neurology
  • Q
    • for evaluation early dementia
    • This 76-year-old man, a patient of Sigmoid colon cancer with liver metastases, T3N1bM1a, stage IVA s/p chemotherapy with FOLFIRI from 2022/03/07~2023/06/01(15 cycles) and Avastin from 2022/04/27~, progressive disease of liver tumor, palliative chemotherapy with FOLFOX from 2023/06/19~. He was admitted for chemotherapy.
    • Because patients tend to forget things was found at home for days. We need expertise to evaluate his condition thanks!
  • A
    • Assessment
      • Acute short-term memory decline for days, r/o secondary cause of cognitive decline
    • Suggestion
      • Arrange brain MRA with/without contrast to r/o brain metastasis or recent stroke
      • Check TSH, free T4, vitamin B12, folic acid, VDRL, cortisol (8AM), ACTH (8AM), ammonia.
• 2022-03-02 Hemato-Oncology
  • A
    • Impression:
      • Sigmoid colon cancer with liver metastases, at least cT3N1bM1a, stage IVA, patho: Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Suggestion:
      • Already make appointment for family meeting in the morning on 2022-03-03
      • arrange chest CT with/without contrast r/o lung meta
      • consult CRS for operation evaluation
      • may add FOLFIRI +/- avastin
        
      • We wound like to take over this case, thanks for your consultation. If there is any problem, please feel free to let us known.
• 2022-03-02 Colorectal Surgery
  • A
    • S
      • This 74 year-old male patient was consulted CRS for colon cancer with liver metastases. he has the histories of 1) HBV but loss follow-up, 2) inguinal hernia s/p operation, 3) upper GI bleeging s/p micro invasive surgery. He denied any allergey, and family history.
      • He smoke 0.5 PPD for 60 years and no alcholism. He had body weight lost 8 Kgs (60 to 52 Kgs) and severe anorexia in the past 3 months.
      • He visited Postal Hospital for help. Hepatitis markers were checked and HBeAg, Anti-HBs, Anti-HBe, Anti-HBc, Anti-HCV were all negative, and HBsAg 3048.14 IU/mL. Tumor maker was checked and showed AFP 3.9 ng/mL; CEA 1993 ng/mL ; CA-199 555 ng/mL. Abdominal sonography was arranged on 2022/02/09 and revealed multiple liver tumors. He transferred to our GI OPD for help. He sufferred from anorexia, epigastric paresthesia, and tea color urine for days. He denied chillness or fever, nausea or vomiting, dizziness, headache, chest tightness or pain, diarrhea or constipation, dysuria or frequency found. No TOCC history was noted. COVID19 rapid test showed Negative. Lab data showed no leukocytosis and normal AST, ALT, bilirubin, r-GT. Elevated ALP 122 U/L. Under the impression of Liver tumor, R/O HCC or metastasis tumor, he was admitted to GI ward for cancer survey and further management.
      • After admission, colonscopy was done and the pathlogy showed adenocarcinoma
      • Abdominal CT with contrast was done that showed colon cancer with liver metastasis, T3N1bM1a, stage IVA..
      • Abdomen: soft, no distended, no tenderness
      • pass stool(+)
    • A: S-colon cancer with multiple liver metastases, T3N1bM1a, stage IVA.
    • P:
      • We will discuss with the patient and his son this afternoon
      • Suggest chemotherapy with target therapy first, then re-evaluate for possible colectomy+/-liver surgery
      • Check RAS gene status
      • We would like to follow this patient

[chemoimmunotherapy]

• 2024-03-08 - cetuximab 500mg/m2 700mg 2hr + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + atropine 0.5mg SC + NS 250mL
• 2024-02-19 - cetuximab 500mg/m2 700mg 2hr + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 400mg/m2 560mg NS 100mL 10min + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + atropine 0.5mg SC + NS 250mL
• 2024-02-02 - cetuximab 500mg/m2 700mg 2hr + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 400mg/m2 560mg NS 100mL 10min + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + atropine 0.5mg SC + NS 250mL
• 2024-01-12 - ………………………… irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 400mg/m2 560mg NS 100mL 10min + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + atropine 0.5mg SC + NS 250mL
• 2023-12-26 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-07 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-13 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-16 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-22 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-04 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-09 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-24 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-07 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-19 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-05 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-22 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-18 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-04 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-14 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-23 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-02 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-09-21 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-09-07 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-08-24 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-08-03 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-07-20 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-07-06 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-06-22 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 120mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-06-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-05-25 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-05-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-04-27 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-04-13 - ………………………………….. irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-04-01 - ………………………………….. irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-03-18 - ………………………………….. irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-03-07 - ………………………………….. irinotecan 90mg/m2 135mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-05-22

[Electrolyte Management and Tumor Marker Monitoring]

Electrolyte Balance:

• Hypokalemia (low potassium) and hypomagnesemia (low magnesium) are currently being effectively managed with appropriate supplementation (Const-K and MgSO4).

• 2024-05-21 K (Potassium) 3.1 mmol/L

  • 2024-05-21 Mg (Magnesium) 1.7 mg/dL

Tumor Marker Trend:

• The tumor marker CEA, which had been declining for several months, showed a slight increase in the past month. While it’s too early to determine if this is a new upward trend, close monitoring is recommended.
  • 2024-05-22 CEA 60.65 ng/mL
  • 2024-04-23 CEA 55.27 ng/mL
  • 2024-04-15 CEA 55.57 ng/mL
  • 2024-03-28 CEA 100.23 ng/mL
  • 2024-02-20 CEA 1531.85 ng/mL
  • 2024-01-12 CEA 2483.63 ng/mL

2024-03-29

[assessing chemotherapy timing with low ANC level]

The decreasing levels of both CEA and CA199 markers may suggest that the Erbitux + FOLFIRI regimen remains effective.

However, given that the ANC was 881/uL yesterday, administering chemotherapy immediately might not be advisable. It’s recommended to wait a few days for the G-CSF to take effect before considering further chemotherapy.

• 2024-03-28 CEA 100.23 ng/mL

• 2024-02-20 CEA 1531.85 ng/mL

• 2024-01-12 CEA 2483.63 ng/mL

• 2024-03-28 CA199 18.58 U/mL

• 2024-02-20 CA199 74.53 U/mL

• 2024-01-12 CA199 267.11 U/mL

• 2024-03-28 WBC 2.67 x10^3/uL

• 2024-03-28 Neutrophil 30.3 %

2024-02-20

After initiation of FOLFIRI regimen on 2024-01-12 from prior FOLFOX, both CEA as well as CA199 have dropped dramatically. Lab results other than these tumor markers were unremarkable. No drug discrepancies were noted.

• 2024-02-20 CEA 1531.85 ng/mL

• 2024-01-12 CEA 2483.63 ng/mL

• 2024-02-20 CA199 74.53 U/mL

• 2024-01-12 CA199 267.11 U/mL

2024-02-05

Given the rising CEA and CA199 levels in recent lab results and liver metastases progression identified on the abdominal CT scan dated 2024-01-12, the treatment was switched back to FOLFIRI from FOLFOX in Jan 2024, with the addition of cetuximab starting Feb 2024.

• 2024-01-12 CEA 2483.63 ng/mL

• 2023-12-08 CEA 1122.86 ng/mL

• 2023-11-08 CEA 703.93 ng/mL

• 2023-10-04 CEA 400.12 ng/mL

• 2024-01-12 CA199 267.11 U/mL

• 2023-12-08 CA199 198.46 U/mL

• 2023-11-08 CA199 88.48 U/mL

• 2023-10-04 CA199 34.70 U/mL

Other lab parameters, including blood cell counts, electrolytes, and liver and kidney functions, remained largely normal, presenting no contraindications to the commencement of the new chemotherapy session. The patient’s back wound has been evaluated by our plastic and reconstructive surgeon, recommending an excision of the epidermal cyst under local anesthesia scheduled for the afternoon of 2024-02-07 (Wednesday). No discrepancies in medication were noted.

2023-12-25

[tube feeding]

Potassium Supplementation Options:

• This hospital currently offers only one oral potassium supplement: Const-K 750mg extended-release tablets, providing 10 mEq of potassium per tablet.
• For patients requiring oral potassium but struggling to swallow the large Const-K tablets, crushing them into fine particles and mixing with water is permissible.

Dulcolax (bisacodyl 5mg):

• Since Dulcolax tablets have an enteric coating meant to dissolve in the intestine, splitting or crushing it is not recommended. Fortunately, Bisacodyl suppositories (10mg) offer a similar alternative with the same active ingredient. Additionally, the patient is currently taking Through (sennoside 12mg) twice daily at bedtime.

2023-12-08

[tube feeding]

Const-K 750mg, an extended-release tablet, delivers 10 mEq of potassium per tablet. It is the sole oral potassium supplement available in this hospital. In comparison, a single banana provides more potassium, approximately 2.2 mEq per inch or 0.9 mEq per cm. If injectable potassium supplementation is not preferred, the Const-K tablet can be crushed into fine particles for easier swallowing with water.

Dulcolax, containing bisacodyl 5mg, is an enteric-coated formulation and should not be split or ground. As an alternative, Bisadyl supp pills, which contain bisacodyl 10mg, can be used. Currently, the patient is also taking Through (sennoside 12mg) 2# HS.

2023-11-08

[tube feeding]

Tube feeding is available for all oral medications on the active drug list.

[reconciliation]

Based on the PharmaCloud and HIS5 documentation, there is no evidence of the patient attending any external medical facilities within the last 90 days, and within our institution, the patient’s consultations have been exclusively with the Hemato-Oncology department. A review of the patient’s medication records has not revealed any inconsistencies.

[evaluating A-FOLFIRI to A-FOLFOX switch through temporal CEA changes]

A CT scan dated 2023-10-16 showed stable disease in the sigmoid colon but indicated a mild progression of bilateral liver metastases, which aligns with the trend observed in CEA levels.

• The peak CEA level within this timeline is on 2023-06-19, at 497.14 ng/mL.

• After the chemotherapy regimen changed from A-FOLFIRI to A-FOLFOX on the same date (2023-06-19), the CEA levels decreased, reaching a low of 321.79 ng/mL by 2023-09-14, suggesting an initial response to the new treatment.

• However, there was an increase in the CEA level to 400.12 ng/mL by 2023-10-04, which could potentially indicate a worsening condition or resistance to the current therapy.

CEA lab readings:

• 2023-10-04 CEA 400.12 ng/mL
• 2023-09-14 CEA 321.79 ng/mL
• 2023-08-08 CEA 339.37 ng/mL
• 2023-07-05 CEA 419.60 ng/mL
• 2023-06-19 CEA 497.14 ng/mL
• 2023-05-16 CEA 409.91 ng/mL
• 2023-05-03 CEA 414.57 ng/mL
• 2023-04-11 CEA 337.63 ng/mL
• 2023-03-01 CEA 193.51 ng/mL
• 2023-02-11 CEA 213.84 ng/mL
• 2023-02-08 CEA 193.49 ng/mL

2023-10-16

According to PharmaCloud and HIS5 records, the patient has no records of visits to other hospitals in the past three months, nor are there any records from departments other than Hemato-Oncology at our hospital. No medication discrepancy issues were found.

2023-06-20

• Based on the information retrieved from the PharmaCloud database, the patient visited a local clinic for nausea and vomiting on 2023-06-09. The last chemotherapy treatment took place from 2023-06-01 to 2023-06-03. Delayed nausea and vomiting, a common side effect of chemotherapy, usually begins more than 24 hours after treatment and may continue for several days after completion of therapy. Please monitor to see if the nausea and vomiting resolves.
• During this hospitalization, the patient started a new regimen of FOLFOX (previously on FOLFIRI). As oxaliplatin is a new component for the patient, a patient education visit was conducted at approximately 15:00 on 2023-06-20. However, at the time of the visit, the patient was resting with his eyes closed. In order not to disturb the patient’s rest, the oxaliplatin medication guide including information on side effects, precautions, and pharmacy contact information was left on the bedside table for the patient to review upon awakening.

2023-06-02

• The patient had appointments at a local clinic for chronic pharyngitis on 2023-04-03 and 2023-05-02. The medications prescribed during these visits have now expired. No issues were identified during the medication reconciliation process, provided the patient no longer has symptoms of pharyngitis.

2023-05-08

On 2023-05-03, lab data showed essentially normal results except for an elevated tumor marker CEA. CEA initially decreased from 2204ng/mL on 2022-02-25 to 50ng/mL on 2022-10-12 after starting bevacizumab plus FOLFIRI treatment on 2022-03-07. However, during the course of treatment, the CEA level has then increased in an apparent trend and has reached 414ng/dL to date. During the same period, another tumor marker, CA199, has also increased, but at a slower rate. This might indicate that the disease has become more heterogeneous with increased resistance and/or that the current regimen may not be as effective as it was initially. Comparing the results of the two most recent CT scans (2023-05-05 and 2023-02-11), it is evident that the liver metastases are showing progressive disease.

• 2023-05-03 CEA 414.57 ng/mL
• 2023-04-11 CEA 337.63 ng/mL
• 2023-03-01 CEA 193.51 ng/mL
• 2023-02-11 CEA 213.84 ng/mL
• 2023-02-08 CEA 193.49 ng/mL
• 2022-11-02 CEA 78.00 ng/mL
• 2022-10-12 CEA 50.71 ng/mL
• 2022-09-21 CEA 52.31 ng/mL
• 2022-08-17 CEA 60.72 ng/mL
• 2022-07-20 CEA 94.15 ng/mL
• 2022-06-22 CEA 146.05 ng/mL
• 2022-06-08 CEA 176.80 ng/mL
• 2022-05-25 CEA 265.53 ng/mL
• 2022-05-11 CEA 419.31 ng/mL
• 2022-04-27 CEA 448.30 ng/mL
• 2022-04-01 CEA 1395.98 ng/mL
• 2022-02-25 CEA 2204.47 ng/mL
• 2023-05-03 CA199 21.68 U/mL
• 2023-04-11 CA199 18.12 U/mL
• 2023-03-01 CA199 16.28 U/mL
• 2023-02-11 CA199 20.05 U/mL
• 2023-02-08 CA199 14.93 U/mL
• 2022-11-02 CA199 10.66 U/mL
• 2022-10-12 CA199 12.81 U/mL
• 2022-09-21 CA199 10.02 U/mL
• 2022-08-17 CA199 10.98 U/mL
• 2022-07-20 CA199 11.93 U/mL
• 2022-06-22 CA199 12.26 U/mL
• 2022-06-08 CA199 15.92 U/mL
• 2022-05-25 CA199 19.70 U/mL
• 2022-05-11 CA199 33.04 U/mL
• 2022-04-27 CA199 36.93 U/mL
• 2022-04-01 CA199 131.87 U/mL
• 2022-02-25 CA199 592.71 U/mL

No medication reconciliation issues have been identified for this patient.

701119388

240522

[lab data]

• 2024-05-06 Anti-HBc Nonreactive
  
• 2024-05-06 Anti-HBc-Value 0.20 S/CO
  
• 2024-05-06 HBsAg Nonreactive
  
• 2024-05-06 HBsAg (Value) 0.45 S/CO
  
• 2024-05-06 Anti-HBs 65.80 mIU/mL
  
• 2024-05-06 Anti-HCV Nonreactive
  
• 2024-05-06 Anti-HCV Value 0.13 S/CO

[exam findings]

• 2024-05-06, -04-15 CXR erect
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
• 2024-04-11 ECG
  • Normal sinus rhythm
  • Right bundle branch block
• 2024-03-27 MRI - pelvis
  • There is no focal lesion in the rectum, near anal verge.
• 2024-03-25 CT - abdomen
  • History and indication:
    • Anus, hemorrhoidectomy — squamous cell carcinoma, moderately differentiated
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Mild wall thickening of anus.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • Mild wall thickening of anus c/w anal cancer (T1N0M0, I).
• 2024-03-19 Patho - hemorrhoids
  • Anus, hemorrhoidectomy — squamous cell carcinoma, moderately differentiated
  • Section shows fragments of cutaneous-colonic junctional tissue with papillary and invasive squamous cell carcinoma.
  • The immunohistochemical stains reveal CK(+), p40(+), and p16(+).

[MedRec]

• 2024-04-11 ~ 2024-04-19 POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • Squamous cell carcinoma of anus, cT1N0M0, stage I
    • Essential (primary) hypertension
    • Type 2 diabetes mellitus without complications
    • Encounter for antineoplastic chemotherapy
    • Encounter for antineoplastic radiation therapy
  • CC
    • For CCRT with 5-fu plus mitomycin
  • Present illness
    • This 65 years old female patient with medical history of hypertension and arrhythmia. She had squamous cell carcinoma, T1N0M0, stage I.
    • Tracing back the past history, she present to our CRS OPD with anal protruding mass, mild anal bleeding for a year. She visited our outpatient department for help. Digital rectal examination showed no blood over the gloves and no palpable mass in the distance of finger length. Anoscopy showed normal color stool, normal rectal mucosa, and prolapsed mixed hemorrhoids at right lateral with induration. After fully explaination, she was admitted for elective complete hemorrhoidectomy under impression of mixed hemorrhoids. s/p hemorrhoidectomy on 2024/03/19.    
    • This time, she admitted for CCRT with 5-fu plus mitomycin.
  • Course of inpatient treatment
    • After admission, HPV vaccine with garasil 0.5mg/syringe IM stat by self-payment on 2024/04/11. Consult GS for port-a insertion.
    • Kept OPD medication with candesartan 8mg/tab 0.5# hs, rosuvastatin 10mg/tab 1# hs.
    • CCRT with 5-Fu plus mitomycin (5-fu 1000mg/m2 x 4days, mitomycin 10mg/m2) since 2024/04/15 to 2024/04/19.
    • CT-simulation was arranged on 2024/04/16. Plan to deliver 45 Gy/ 25 fx to the pelvis including bil. inguinal LNs. Then boost the anal tumor to 54 Gy/ 30 fx. RT will start around 2024/04/19 or 22. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2024/04/19 and OPD followed up later.
  • Discharge prescription
    • Romicon-A (dextromethorpahn 20mg, cresolsulfonate 90mg, lysozyme 20mg) 1# BID
    • Actein (acetylcysteine 200mg) 1# BID
    • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC if nausea or vomiting
    • Antica Syrup (orciprenaline, bromhexine, doxylamine) 10mL HS
• 2024-04-08 SOAP Colorectal Surgery Xiao GuangHong
  • A/P
    • Oncology Multidisciplinary Team Meeting Conclusion,

Meeting Date: 2023-03-26 -

Reassess TNM stage using MRT (magnetic resonance tomography). - Proceed with CCRT (Concurrent Chemoradiotherapy).

• 2024-03-19 ~ 2024-03-20 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Fourth degree hemorrhoids status post hemorrhoidectomy on 2014/03/19
    • Hypertension
    • Arrhythmia
  • CC
    • anal protruding mass, mild anal bleeding for a year.
  • Present illness
    • This 65 years old female patient with medical history of hypertension and arrhythmia.
    • She suffered from anal protruding mass, mild anal bleeding for a year. She visited our outpatient department for help. Digital rectal examination showed no blood over the gloves and no palpable mass in the distance of finger length. Anoscopy showed normal color stool, normal rectal mucosa, and prolapsed mixed hemorrhoids at right lateral with induration. After fully explaination, she was admitted for elective complete hemorrhoidectomy under impression of mixed hemorrhoids. 
  • Course of inpatient treatment
    • This 65 years old female patient was a case of hemorrhoids. She admitted on 2024/03/19 and hemorrhoidectomy was performed on the days of admission.
    • The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable.
    • She was discharged on 2024/03/20 and will follow up in our out-patient department next week.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • MgO 250mg 2# BID
    • Meitifen (diclofenac Na 75mg) 1# PRNQ12H
    • Trand (tranexamic acid 250mg) 1# BID
    • Ulstop (famotidine 20mg) 1# PRNQ12H (with Meitifen)
    • Biomycin Ointment (neomycin, tyrothricin) 1# BID TOPI
• 2023-06-19 SOAP Gastroenterology Li XianZhong
  • Prescription x3
    • Pariet (rabeprazole 20mg) 1# QDAC

[surgical operation]

• 2024-03-19
  • Op Method: Hemorrhoidectomy         
  • Finding: Prolasped hemorrhoids at 3,7,11 o’clock        

[radiotherapy]

[chemotherapy]

• 2024-05-22 - mitomycin-C 10mg/m2 16mg NS 100mL 30min + fluorouracil 1000mg/m2 1600mg D5W 500mL 24hr D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-04-15 - mitomycin-C 10mg/m2 16mg NS 100mL 30min + fluorouracil 1000mg/m2 1600mg D5W 500mL 24hr D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-05-22

[stable hypertension post-anal SCC surgery with no recent hyperglycemia evidence]

The stage I anal SCC was surgically treated on 2024-03-19, and the second session of mitomycin-C and 5-FU therapy began on 2024-05-22. The patient’s underlying hypertension has remained stable, as indicated by generally normal blood pressure readings, and there is no recent evidence of hyperglycemia. No medication discrepancies were found.

701493707

240522

[exam findings]

• 2024-04-30 CT - chest
  • without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • lungs:
      • extensive ground glass opacity with bronchiectasis at RUL.
      • patchy consolidation, fine reticular opacities, and areas of faint ground glass opacity and bronchiectasis at RLL.
      • fine reticular opacities, areas of faint ground glass opacity and bronchiectasis at RML.
      • mild mixed ground glass opacity and consolidation in medial LLL.
    • small Lt pleural effusion. inhomgeneous density of moderate Rt pleural effusion. Rt apical pleural thickening.
    • s/p esophagectomy and partial gastrectomy and gastric tube reconstruction.
    • Chest wall and visible lower neck: no visible enlarged LN.
    • Visible abdomen: unremarkable of liver, spleen, both kidneys, adrenal glands, GB, and pancreas. s/p jejunostomy. no enlarged LN.
  • Impression:
    • post CCRT change in Rt lung and LLL.
    • exxudative Rt pleural effusion.
• 2024-04-17, -03-26, -02-29 CXR erect
  • Peri-bronchial wall thickening of the right lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2024-02-04 CXR erect
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2024-01-22 Patho - gallbladder (benign lesion)
  • Gallbladder, laparoscopic cholecystectomy —- Chronic cholecystitis
  • Section(s) show(s) gallbladder mucosal tissue with invaginated sinus mucosa, marked chronic inflammation.
• 2024-01-18 SONO - abdomen
  • Suspected GB stones and sludge
• 2024-01-16 Esophagography
  • Esophagography revealed:
    • s/p esophagectomy + gastric tube reconstruction.
    • Dilatation with some contrast stasis in reconstructed gastric tube.
    • A few contrast medium passaged from reconstructed gastric tube to duodenum.
  • Impression
    • Post-OP change
    • No contrast leakage
    • Some contrast stasis in reconstructed gastric tube
• 2024-01-16 KUB
  • a drain over Rt lower abdomen, jejunostomy
• 2024-01-15 CXR erect
  • regression of Rt pleural effusion replaced with air s/p pigtail drain placement
  • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
  • s/p esophagectomy and gastric tube reconstruction.
• 2024-01-08 SONO - chest
  • right side small amount of pleural effusion, pig-tail drainage via right 7th ICS posterior mid-axillary line was performed and milk-like fluid was drained out smoothly.
• 2024-01-07 CT - abdomen
  • S/P operation. Right pleural effusion. GGO at right lung.
• 2023-11-28 Patho - esophagus subtotal/total resection
  • Diagnosis
    • Esophagus, middle to lower third, VATS esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
      • Stomach, cardia, partial gastrectomy —- Negative for malignancy
      • Azygos vein, right, excision —- Negative for malignancy
    • Resection margin: Negative for malignancy; proximal cutend of esophagus: Negative for malignancy
      • Lymph node, upper paraesophageal, specimen 1, dissection —- Negative for malignancy (0/1)
        
      • Lymph node, middle paraesophageal, specimen 1, dissection —- Negative for malignancy (0/0)
        
      • Lymph node, lower paraesophageal, specimen 1, dissection —- Negative for malignancy (0/1)
      • Lymph node, peri-gastric, specimen 1, dissection — Negative for malignancy (0/4)
      • Lymph node, right, group 2+4, dissection —- Negative for malignancy (0/11)
      • Lymph node, left, group 5, dissection —- Negative for malignancy (0/5)
      • Lymph node, right, group 7, dissection —- Negative for malignancy (0/4)
        
      • Lymph node, left, group 2+4, dissection —- Negative for malignancy (0/2)
        
      • Lymph node, right, upper paraesophageal, dissection —- Negative for malignancy (0/1)
      • Lymph node, left, neck, level IV, dissection —- Metastatic squamous cell carcinoma (4/5)
      • AJCC 8 th edition pT N M Pathology stage: ypStage IVB, ypT1bN0M1
  • Gross Description:
    • Procedure: VATS esophagectomy and gastric tube reconstruction;
    • Size:
      • Esophagus: 9.5 cm in length with a portion of gastric tissue measuring 3.3 cm in length.
        
      • Azygos vein: 1.2 x 0.7 cm
      • Left level IV neck lymph node: measuring up to 1.8 x 1.7 x 1.5 cm
    • Tumor Site: Middle to lower esophagus,
      
    • Relationship of Tumor to Esophagogastric Junction: Tumor is entirely located within the tubular esophagus and does not involve the esophagogastric junction
    • Tumor Size: Grossly, an ulcer, measuring 2.4 x 1.1 cm, is seen. Microscopically, 2 foci, measuring 0.2 x 0.15 cm and 0.15 x 0.05 cm, are seen.
      
    • Sections are taken and labeled as: A1-2: Distal gastric resection margin; A3: esophagus; A4: EG junction; A5: stomach; A6-11: tumor; A12: lymph node, upper paraesophageal; A13: lymph node, middle paraesophageal; A14: lymph node, lower paraesophageal; A15: lymph node, perigastric; B: proximal cutend of esophagus; C1-2: lymph node, right group 2+4; D: lymph node, left group 5; E: lymph node, right group 7; F: lymph node, left group 2+4; G: lymph node, right upper paraesophageal; H: azygos vein; I1-2: lymph node, left level IV neck.
  • Microscopic Description:
    • Histologic Type: Squamous cell carcinoma, s/p CCRT; The immunohistochemical stains reveal CK5/6(+) and p40(+).
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades the submucosa
    • Margins: All margins are uninvolved by invasive carcinoma, dysplasia, and intestinal metaplasia
      • Distance of invasive carcinoma from closest margin (millimeters or centimeters): 4 mm, Specify closest margin: circumferential
      • Proximal resection margin: 4.8 cm
      • Distal resection margin: 5.6 cm
    • Treatment Effect: Present, Single cells or rare small groups of cancer cells (near complete response, score 1)
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Not identified
    • Regional Lymph Nodes: please see diagnosis
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      
    • TNM Descriptors: y (posttreatment)
      • Primary Tumor (pT): pT1b: Tumor invades the submucosa
      • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case)
      • pM1: Distant metastasis, Specify site(s), if known: left level IV neck lymph node; The immunohistochemical stains reveal CK5/6(+) and p40(+).
    • Additional Pathologic Findings: NO extracapsular spread (ECS) is seen in metastatic lymph nodes.
• 2023-11-17 PET scan
  • Glucose hypermetabolism in the lower portion of the esophagus and in some left left supraclavicular lymph nodes, compatible with residual esophageal malignancy and residual metastatic lymph nodes.
  • Glucose hypermetabolism in a right precarinal lymph node, in the proxomal portion of the esophagus and EG junction. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in bilateral pulmonary hilar lymph nodes and around the Port-A line. Inflammation is more likely.
    
  • Glucose hypermetabolism in the upper and lower lobes of bilateral lungs and in the bone marrow of bilateral femurs. Post treatment related pneumonitis and bone marrow hyperplasia may show this picture.
• 2023-11-17 Spirometry:
  • Normal baseline study without significant bronchodilator response
    • Lung volume: Normal SVC, TLC, RV and RV/TLC, no air-trapping
    • Mild decrease DLco and increase airway resistance
  • Conclusion:
    • Normal ventilation without bronchodilator response or air-trapping
    • Mild decrease DLco and increase airway resistance
• 2023-11-16 Patho - stomach biopsy
  • A. Stomach, GC side of body, biopsy (A) — Chronic gastritis, H pylori NOT present
  • B. Stomach, GC side of body, biopsy (B) — Hyperplastic polyp
• 2023-11-15 Tc-99m MDP bone scan
  • In comparison with the previous study on 2023/08/14, the previous lesions of increased radioactivity at bilateral S-I joints are more evident, and the nature is to be determined. Please correlate with other clinical findings and follow up bone scan in 3 months for further evaluation.
  • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, L5-S junction, bilateral shoulders, hips, and knees.
• 2023-11-14 MRI - brain
  • Known a case of esophageal cancer. No evidence of brain metastasis.
  • One old lacuna infarct over left putamen.
• 2023-11-13 CT - chest
  • Indication: esophageal cancer, restaging
  • Comparison made with CT on 2023/08/16
    • Lungs: patchy consolidations and ground-glass opacities at RLL.
      • several patchy ground-glass opacities at RUL and LLL.
      • subpleural lines at both lower lobes.
    • Mediastinum and hila: interval decrease in size an enhancing submucosal mass at posterior wall of lower third of thoracic esopahgus. decrease in szie of multiple small LNs in visceral space.
      • the vascular markings and great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Chest wall and visible lower neck: interval decrease in size and number of discrete enlarged LNs at left supraclavicular fossa and posterior triangle of the lower neck.
    • Visible abdominal-pelvic contents: significant decrease in size of an enlarged lymph node at retroperitoneum (behind the neck of thepancreas aand anterior diaphgramtic crura) and at upper para-aortic region.
      • unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys. bile ducts: No dilatation.Mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
  • Impression:
    • L/3 esophageal cancer T2N3, in regression as compared with previous chest CT on 2023/08/16,
    • post treatment related pneumonitis in RLL, LLL, and RUL.
• 2023-11-13 Exercise Cardiopulmonary Function Test
  • Conclusion
    • low exercise capacity ( VO2max 43%, WR 69%) ( normal VO2max > 85%)
    • spirometry: normal (FVC 102%, FEV1 108% )
      
    • respiratory muscle strength: normal ( MIP 89%, MEP 73%)
    • Breathing reserve normal
    • Desaturation during exercise: nil
    • cardiac response (LCWI) during exercise: low response during exercise
    • HR response during exercise: high slope during exercise
    • work efficiency: low
    • anaerobic threshold: low
    • oxygen pulse: low
    • BP response: normal response during exercise
    • EKG: nonspecific findings
      
    • Health-related quality of life (HRQL), CAT= 18, poor (>10 indicates poor HRQL), cough 3, sputum 3, dyspnea 3
  • Impression:
    • Deconditioning with low exercise capacity
    • Poor Health-related quality of life (HRQL), CAT= 18
    • Poor cardiac response and rapid HR response during exercise
  • suggestion:
    • treat underlying disease and symptoms
      
    • perform limbs exercise training
    • survey rapid HR response, such as drug or thyroid function and etc
    • for low cardiac response, suggest adequate fluid intake to keep adequate preload, may Survey cardiac function such as cardiac echo
• 2023-10-18 Nasopharyngoscopy
  • Findings:
    • smooth NPx, oropharynx, hypopharynx, edematous change of bilateral arytenoid mucosa, sticky saliva
  • Conclusion:
    • edematous change of bilateral arytenoid mucosa, sticky saliva
• 2023-08-19 Pure Tone Audiometry
  • PTA Reliability FAIR
  • Average RE 18 dB HL; LE 23 dB HL.
    • RE WNL.
    • LE normal to moderate SNHL.
• 2023-08-17 Patho - esophageal biopsy
  • Labeled as “middle esophagus”, biopsy — squamous cell carcinoma.
  • Section shows squamous cell carcinoma.
• 2023-08-16 Patho - esophageal biopsy
  • Esophagus, 25-30 cm below incisor, biopsy — squamous cell carcinoma
  • Microscopically, it shows squamous cell carcinoma consisting of non-keratinized epidermoid neoplastic nests in downward infitrating growth fasion. The tumor cells have eosinophilic cytoplasm, pleomorhic round nuclei and nuclear hyperchromasia.
  • Immunohistochemical stain reveals P40(+), P63(+), CK(+), CEA(-).
• 2023-08-16 CT - chest
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • Findings
    • Lungs: normal appearance of bilateral lungs.
    • Mediastinum and hila: an enhancing submucosal mass (11mm thick, 30mm in length) at posterior wall of lower third of thoracic esopahgus, causing luminal narrowing and no adjacent structures invasion. a small periesophageal LN is foundmultiple small LNs in visceral space. the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
    • Heart: normal size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: multiple discrete enlarged LNs at left supraclavicular fossa and posterior triangle of the lower neck.
    • Visible abdominal-pelvic contents:
      • an enlarged lymph node at retroperitoneum, behind the neck of thepancreas aand anterior diaphgramtic crura. several enlarged LNs at upper para-aortic region.
      • unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
      • bile ducts: No dilatation.
      • Mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
    • Visualized bones: unremarkable.
  • Impression: L/3 esophageal cancer T2N3Mx(E1)

[MedRec]

• 2024-03-13 SOAP Hemato-Oncology He JingLiang
  • Prescription x3
    • Alpraline (alprazolam 0.5mg) 1# PRNHS
    • Norvasc (amlodipine 5mg) 1# QD
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 90mg, lysozyme 20mg) 1# TID
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-09-12 SOAP Dermatology Zhou WeiTing
  • S: severe itchy papules and plaques erupition over trunk after medication.
  • O:
    • 1. urticaria/angioedema type
    • 2. maculopapular type
    • 3. urticaria-purpura type
         
    • 4. erythema multiforme SJS/TEM
    • 5. fixed drug eruption or AGEP rapid onset type
    • 6. drug hypersensitivity syndrome as DRESS
    • 7. lichenoid chronic progressive type
    • Suspect related medication: chemotherapy.
  • Plan:
    • education about drug side effec and explain
    • strongly suggested OPD f/u
  • Prescription
    • Compesolon (prednisolone 5mg) 2# PRNQD
    • Asthan (ketotifen 1mg) 1# BID
    • Sinpharderm Cream (urea) QN TOPI
    • Topsym Cream (0.05% fluocinonide) BID EXT
• 2023-09-07 SOAP Hemato-Oncology Xia HeXiong
  • Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 2023-08-22
    • L/3 Esophageal cancer SCC, cT2N3M0, stage IVA.
    • Initially, concurrent chemoradiotherapy (CCRT) will be administered, followed by an evaluation to determine whether surgery is feasible.
• 2023-09-01 SOAP Radiation Oncology Wan YuNong
  • Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, whole esopahgus, and adjacent lymphatic drainage area. Then boost the gross tumor and LAPs to 50.4 Gy/ 28 fx.
• 2023-08-13 ~ 2023-08-30 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Middle third of thoracic esophagus squamous cell carcinoma with multiple enlarged lymph node, cT2N3M0, stage IVA
    • Eczema herpeticum
    • Essential (primary) hypertension
    • Hyperlipidemia, unspecified
    • Chronic viral hepatitis B without delta-agent, Anti-HBc: reactive
    • Insomnia
    • Intertrigo friction wound with tinea infestation
  • CC
    • PET showed L/3 esophageal tumor in 2023/08. The patient suffer from chocking easily for 2-3 years.
  • Present illness
    • This 56-year-old man, had past history of hypertension and hyperlipidemia under controlled.
    • According to his statement, he noticed a small nodule at his left neck about 2 years ago, the tumor keep existing and got bigger, so he went to pohai hospital for examination, where biopsy was done, and the result showed metastatic squamous cell carcinoma. Then he was done PET showed L/3 esophageal tumor in 2023/08. He had suffered from chocking easily for 2-3 years, without dysphagia or body weight loss or other discomfort.
    • There was no exacerbating factor and no relieving factor notes. Left neck mass had also been noted for 2-3 years. There was no vomiting, abdominal pain, abdominal bloating, diarrhea, epigastric pain, body weight loss, easy choking, dysphonia, hoarseness, chest pain, dyspnea, or hemoptysis. The patient denied trauma or esophageal injury history.
    • He visited our chest surgery out-patient department for cancer restaging and evaluation of surgical treatment. Physical examination showed clear breathing sound, regular heart beats, and soft abdomen with no tenderness. There was one mass with irregular margin over left neck with tenderness, not mobile, hard. Then he was admitted for cancer restaging under the impression of lower third esophageal cancer.
  • Course of inpatient treatment
    • After admission, he was done Brain MRI and abdominal echogram showed no metastasis, PES showed Esophageal tumor, 25-30 cm from incisor, M/3 of esophagus s/p Bx complicated with intra-luminal narrowing on 2023/08/15, chest CT showed L/3 esophageal cancer on 2023/08/16, EUS showed Esophageal tumor, probably submucosal lesion, middle esophagus, status post biopsy Para-esophageal lymphadenopathy, T3N3M0 on 2023/08/17. Arrange on Port-A catheter implantation on 2023/8/21.
    • Due to esophaheal cancer T3N3M0, consult Hematology Oncology and Radiology for arrange CCRT then tranferred to hematology oncology ward for future treatment on 2023/8/18. Before chemotherapy survey, PTA on 2023/08/19 showed Reliability FAIR, Average RE 18 dB HL; LE 23 dB HL, RE WNL, LE normal to moderate SNHL. 24hrs CCr. on 2023/08/19 showed 70.1mL/min.
    • Tramacet 37.5 & 325mg/tab 1# PO Q12H, Limadol 100mg/2mL/amp 50mg IVD PRNQ6H for pain control.
    • CT-simulation on 2023/08/22(+). Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, whole esopahgus, and adjacent lymphatic drainage area. Then boost the gross tumor and LAPs to 50.4 Gy/ 28 fx. RT start on 2023/08/25.
    • He received radiochemotherapy with PF (Cisplatin 75mg/m2 D1, 5-Fu 1000mg D1-D4, (MgSO4 1amp and Lasix 1amp after Cisplatin)) from 2023/08/25~2023/08/29 smoothly. Adequate IVF was given.
    • For chemotherapy, Vemlidy 25 mg/tab 1# PO QD was given for Anti-HBc: reactive. Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting. Hypertension was treated with Sevikar F.C. 5 & 20mg/tab 1# PO QD. Hyperlipidemia with Zulitor F.C 4mg/tab 0.5# PO QN, Bokey 100mg/cap 1# PO QD. Insomnia with Alpraline 0.5mg/tab 1# PO PRNHS if insomnia. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/08/30 and OPD followed up later.
  • Discharge prescription
    • Zalain Cream (sertaconazole nitrate 2%) BID TOPI (over large area of peripheral annular lesions)
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) PRNBID TOPI (if itchy)
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Siliverzine (silver sulfadiazine) BID EXT (over maceration wound)
    • Through (sennoside 12mg) 2# HS
    • Alpraline (alprazolam 0.5mg) 1# PRNHS
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Limeson (dexamethasone 4mg) 1# QD
    • Stogamet (cimetidine 300mg) 1# QD
    • Zyprexa (olanzapine 5mg) 1# PRNHS
• 2023-09-07 SOAP Hemato-Oncology Xia Hexiong
  • O: Multi-disciplinary Cancer Team Meeting Conclusion, Meeting Date: 2023-08-22
    • L/3 Esophageal cancer SCC, cT2N3M0, stage IVA.
    • Plan to start with CCRT then assess the possibility for surgery.

[consultation]

• 2024-01-19 General and Gastrointestinal Surgery Chen JiaHui
  • Q
    • He try to have oil-free diet since 2024/01/12. But abdominal pain and nausea, vomit was noted after meal. So he didn’t eat anymore.
    • We follow up KUB and esophagography revealed no esophageal obstruction or ileus. But nausea and vomiting was not improved.
    • Follow up abdominal echogram revealed Suspected GB stones and sludge on 2024/01/18.
    • Thus we need your professional evaluation and suggestion. Thank you very much.
  • A
    • S: The patient suffered from abdominal pain and nausea and vomting since 20240107. Due to suspected GB stones with acute cholecystitis, surgical evaluation is consulted.
    • O: vital signs: BP:178/102; HR:107; BT:36.7’C; RR:17; SpO2:96%
      • abdomen: old surgical scar 15 cm over upper midldine, feeding jejunostomy over L’t abdomen, soft, ovoid, decrease bowel sound, mild RUQ tenderness, no Murphy’s sign
        
      • lab data: see chart
        
      • Abdominal sonography: gall stones and sludged
    • A: Gall stones with acute cholecystitis
    • P: SDM
      • If he agrees with surgical treatment, emergent LC is suggested.
        
      • If not, NPO, adequate hydration, antibiotics treatment, & closely observation is suggested.
• 2024-01-17 Gastroenterology Cai PeiZhan
  • Q
    • This 57-year-old man has middle third of esophagus squamous cell carcinoma with multiple enlarged lymph node, ypT1bN0M1, ypStage IVB status post 3D VATS esophagectomy, gastric tube reconstruction and left neck lymph node dissection on 2023/11/27.
    • According to his statement, he suffer from vomit and severe abdominal pain for 4 days. Orthopnea and dyspnea was also associated with chest tightness. He went to our emergency department for help. His chest film showed right pleural effusion. Under the impression of right pleural effusion, the patient was admitted for further evaluation and management.    
    • After admission, chest echogram was preformed and right pigtail catheter was inserted on 2024/01/08. Chylous fluid was drained. NPO with PPN support was prescribed. He try to have clear liquid since 2024/01/10.
    • Due to right pigtail drain become clean serosanguinous fluid. He try to have oil-free diet since 2024/01/12. But abdominal pain and nausea, vomit was noted after meal. So he didn’t eat anymore.
    • We follow up KUB and esophagography revealed no esophageal obstruction or ileus. He had bowel gas and stool passed.
    • Imperan and Novamin were used. But nausea and vomiting was not improved. Thus we need your professional evaluation and suggestion. Thank you very much.
  • A
    • the patient with history of esophagus cancer, s/p CCRT. However, due to persistent nausea, and abdominal pain, we are consulted.
      • conscious: clear
      • chest: smooth with right chest pigtail
      • abdomen: right abdominal tenderness, soft
    • Lab
      • 2024-01-15 ALT 27 U/L
        
      • 2024-01-15 AST 23 U/L
        
      • 2024-01-15 K (Potassium) 3.8 mmol/L
        
      • 2024-01-15 Ca (Calcium) 2.35 mmol/L
        
      • 2024-01-15 Albumin (BCG) 3.4 g/dL
        
      • 2024-01-15 HGB 12.1 g/dL
        
      • 2024-01-15 PLT 243 *10^3/uL
        
    • 2024/01/07 abdominal CT IMP: S/P operation. Right pleural effusion. GGO at right lung.
    • 2024/01/16 KUB
      • a drain over Rt lower abdomen, jejunostomy
      • No abnormal small bowel and colonic gas pattern.
      • The size & contour of kidneys,spleen,liver, & psoas shadows, properitoneal & pelvis fat lines are unremarkable.
    • 2024/01/16 ESOPHAGRAPHY
      • Post-OP change
      • No contrast leakage
      • Some contrast stasis in reconstructed gastric tube
    • impression
      • nausea with abodminal tenderness
    • suggestion
      • Give medication with gascon and prokinetic agent such as mosapride or domperidone; keep PPI
      • Give medication such as sennoside (BID), dulcolax (ST and QD), EVAC to keep stool passage if constipation improve, taper these medication
      • Follow up KUB to see if symptoms improved
      • Correct hypoalbuminemia to improve bowel edema.
      • Arrange abdominal echo
• 2023-09-28 Dermatology Zhou WeiTing
  • Q
    • This 65-year-old man patient is a case of Middle third of thoracic esophagus squamous cell carcinoma with multiple enlarged lymph node, cT2N3M0, stage IVA s/p concurrent chemoradiotherapy with PF (Cisplatin 75mg/m2, 5-Fu 1000mg) from 2023/08/25~. He was admitted for CCRT with PF (C2) from 2023/09/26~2023/09/30.
    • This time, for bilateral foot skin redness rash with itch. Now, for evaluate bilateral foot skin redness rash with itch therapy. Thank you.
  • A
    • Under the impression of
      • tinea cruris et intertrigo over genital area
      • alleregic dermatitis over bilstera lower limbs.
    • The following suggestion:
      • Exelderm cream 1 tubetopical bid use over genital area and Topysm cream 1 tube topical bid use over bilateral thigh.
        
      • consider Ketotifen and Allegra 1# bid po use first.
      • If still poor response, consider compresolone 2# PRNQD po use for 5 days.
• 2023-08-29 Dermatology Zhou WeiTing
  • Q
    • The patient is an 56-year-old male with a history of Middle third of thoracic esophagus squamous cell carcinoma with multiple enlarged lymph node, cT2N3M0, stage IVA
    • He presented with itch and skin rash at bilateral inguinal for few days, under Mycomb, no improving. We need your further evaluation and management.
  • A
    • The patient had sufferred from firctional excoriative wound with fuluremt dischagre and annular lesion with active borders on the gerion.
      
    • Under the impression of intertrigo fricitonal wound with tinea infestation.
    • The following sugeetion:
      • Sliverzine cream 1 tube topical bid use over maceration wound first.
      • Zalaine cream 1 tube topical bid use over large area of peripheral annular lesions.
        • If itchy or other symptoms, maintain Mycomb cream 1 tube topical PRN use over these lesions.
• 2023-08-18 Radiation Oncology
  • Q (same as 2023-08-17 HemaOnco)
  • A
    • Biopsy at LuoDong BoAi H. showed metastatic squamous cell carcinoma.
    • If the pathology report showed submucosal SCC, neoadjuvant CCRT is indicated. CT-simulation will be arranged on 8/22.
    • Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, whole esopahgus, and adjacent lymphatic drainage area.
    • Then boost the gross tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 8/24 or 25. Thank you very much.
• 2023-08-17 Hemato-Oncology
  • Q
    • This 56-year-old man. He noticed a small nodule at his left neck about 2 years ago, biopsy showed metastatic squamous cell carcinoma. Then he was done PET showed L/3 esophageal tumor in 2023/08. He visited our CS OPD and admission for cancer staging.
    • He was done EUS on 8/17 showed Esophageal tumor, probably submucosal lesion, middle esophagus, Para-esophageal lymphadenopathy, T3N3M0.
    • We would like to consult for arrange CCRT. Thank you. Sincerely request your help to evaluate and manage this patient.
  • A
    • This 56 year old man is a case of nodal positive esophageal SCC. We are consulted for CCRT.
    • Please check Anti HBc, Anti HBs, HBsAg, Anti HCV, 24 urine CCr. Audiometry. We will discuss with patient about CCRT with PF and take over this case.
    • Please arrange port A insertion and book 11A ward.
• 2023-08-14 Gastroenterology
  • Q
    • This 56-year-old male was admitted for further examination due to esopheal tumor was noted.
    • According to the patient, he noticed a small nodule at his left neck about 2 years ago, but he didn’t mild it. But the tumor keep existing, so he went to OPD for eamination, where biopsy was done, and the result showed metastatic squamous cell carcinoma. PET showed L/3 esophageal tumor in 2023/08. The patient stated that he had mild dysphagia and sometimes choking.
    • So, this time, he was admitted for esophageal tumor further exmination.
      • 8/14 WBBS
      • 8/15 09:00 chest CT + 12:40 Brain MRI
      • 8/16 09:30 CPET
      • 8/17 EUS + abdominal sona
    • We would like to consult for arrange EUS and abdominal sona on 8/17.
  • A
    • 56M
    • Phx: HTN under medication, Old CVA.
    • S+O:
      • Mild dysphagia and sometimes choking
      • Left neck palpable mass
      • The patient said he had EGD 2 years ago at other hospital.
      • Biopsy at left neck mass showed metastatic squamous cell carcinoma (other hospital)
    • A: Suspicious lower esophageal SCC
    • P:
      • Please arrange EGD before EUS examination
      • EUS for esophageal SCC staging already arrange on 8/17
      • Please prescribe J CROWS Lugols solution (self-paid TWD 1500) and bring it to the exam room.

[radiotherapy]

[chemotherapy]

• 2024-05-21 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 2hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-2 (PF CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250ml + aprepitant 125mg PO
• 2024-04-18 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 2hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-2 (PF CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250ml + aprepitant 125mg PO
• 2024-03-26 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 2hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-2 (PF CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250ml + aprepitant 125mg PO
• 2024-02-29 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 2hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-2 (PF CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250ml + aprepitant 125mg PO
• 2023-09-26 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D2-4 (PF CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-25 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1800mg NS 500mL 24hr D2-4 (PF CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-04-19

[tracking scc reductions under current treatment]

SCC level is decreasing, which may indicate disease response to current therapy. No medication discrepancy detected.

• 2024-04-18 SCC 2.10 ng/mL
  
• 2024-04-12 SCC (NM) 3.85 ng/mL
  
• 2024-03-15 SCC (NM) 4.46 ng/mL
  
• 2024-02-23 SCC (NM) 4.41 ng/mL

2024-03-27

[Salagen therapy: from BID to TID for better efficacy]

Salagen (pilocarpine) can be used to treat dry mouth associated with head and neck cancer, starting at 5 mg TID. The dose can be adjusted based on how well it’s tolerated and its effectiveness, with a typical daily range between 15 and 30 mg, and no single dose exceeding 10 mg.

If the current prescription of 5 mg BID doesn’t yield the expected results, increasing the frequency to TID could be considered.

Note: Evoxac (cevimeline) can be used to treat xerostomia (associated with Sjögren disease)

2024-03-01

[prior dermatological reaction to PF regimen: close monitoring for skin changes]

The PF regimen was re-administered for CCRT on 2024-02-29. It is noteworthy that the patient experienced dermatological adverse reactions when the same regimen was used in 2023-08 to 2023-09. Therefore, it is advisable to closely monitor the patient for any signs of skin changes following the current administration.

2023-09-27

[reconciliation]

The patient consistently refills his repeat prescription from LuoDong BoAi Hospital for Bokey (aspirin), Sevikar (amlodipine, olmesartan), and Livalo (pitavastatin). These drugs are currently being used with no discrepancies identified.

[dermatologic adverse reactions (5-FU)]

HIS5 records indicate that the patient visited our dermatologist on 2023-09-12 for suspected chemotherapy-related dermatopathy.

It has been reported that fluorouracil (administered initially on 2023-08-26 at a dose of 1800mg for 3 days) is associated with various dermatologic side effects, including alopecia, nail changes (including nail loss), dermatitis, hyperpigmentation (around veins), maculopapular rash (pruritic), palmar-plantar erythrodysesthesia, skin fissures, skin photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis, and xeroderma. Since the second dose was administered on 2023-09-27 at a lower dose of 1500mg for 3 days, it is advisable to monitor the patient closely for any recurrence of dermatopathy.

700910204

240520

[exam findings]

• 2024-04-12 CT - chest
  • Indication: Endometroid adenocarcinoma, FIGO grade 2, of the uterine endometrium, AJCC 8th edition pathology stage:pT3aN0(cM0); FIGO stage IIIA, s/p laparotomy gynecologic oncology staging surgery (ATH + BSO + infracolic omentectomy + BPLND), with vaginal stump recurrence, and lung metastases.
  • Chest CT with and without IV contrast ehnancement shows:
    • Right upper lobe soft tissue nodule measuring 2.68cm is found. (Se301 Im31). In comparison with CT dated on 2023-11-07, the lesion enlarged markedly. Another nodule at left upper lobe measuring 0.3cm is noted. (Se202 Im73).
    • Another nodule at left upper lobe measuring
  • Imp:
    • Metastatic nodules at right upper lobe and left upper lobe. The right upper lobe nodule enlarged.
• 2024-01-10 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Borderline ECG
• 2024-01-10 CXR supine
  • There are few nodular opacities projecting in both lung that are c/w lung metastases after correlate with CT.
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2023-11-17 ECG
  • Sinus rhythm with 1st degree A-V block
• 2023-11-14 Ocular Fundus Photography
  • Left - NPDR, moderate
  • Right - NDR
• 2023-11-07 CT - chest
  • Findings: Comparison was made with CT on 2023/07/29
    • Lungs: interval increase number and size of nodules of variable sizes in both upper lobes (up to 10mm at RUL) due to metastases as compared with previous chest CT on 2023-07-29
    • Mediastinum and hila: a well-defined soft-tissue nodule at left prevascular space, at the level of thoracic inlet 9srs/img11/8.
      • extensive coronary arterial calcification
    • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Pleura: trace Lt-sided effusion .
    • Visible abdominal contents: Hyperplasia of bilateral adrenal glands.
      • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • endometrial ca of uterus with lung metastasis.
    • enlarged left thyroid lobe or metastatic LAP in thoracic inlet of upper mediastinum.
    • extensive 3V-CAD.
• 2023-10-11 CT - abdomen
  • 2023/07/24 Endometroid adenocarcinoma, pT3aN0(if cM0); stage IIIA
    • vaginal bleeding. she did not have R/T or C/T
  • Findings:
    • There are three kissing soft tissue masses in the uterine fossa, the largest one measuring 4.7 cm in size (the largest dimension), that may be recurrent adenocarcinomas.
    • There are two kissing small soft tissue nodules in left adnexa that may be metastatic nodes.
    • There is a cystic-like lesion 3.4 cm in the cul-de-sac that also may be recurrent tumor.
    • There is a cystic lesion in right adnexa, 4.3 cm in size (the largest dimension), that may be lymphocele.
      • The differential diagnosis includes recurrent tumor.
    • Hyperplasia of bilateral adrenal gland are noted.
  • Impression:
    • There are three kissing soft tissue masses in the uterine fossa, the largest one measuring 4.7 cm in size (the largest dimension), that may be recurrent adenocarcinomas.
• 2023-08-02 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 34) / 122 = 72.13%
    • M-mode (Teichholz) = 72
  • Conclusion:
    • Concentric LV hypertrophy and mild RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis.
    • Prominent epicardial and pericardial fat.
• 2023-08-02 SONO - vein
  • No evidence of DVT, bilateral lower legs
  • Right CFV trivial reflux
  • Right LSV trivial reflux, involved right sphenofemoral junction (SFJ) with proximal GSV 0.8 cm,
  • Right low leg soft tissue mild edema.
• 2023-07-29 CTA - chest
  • Right upper lobe tiny nodule. 0.3cm
  • Pulmonary embolism is found at branching pulmonary artery over left side. (Se305 IM24).
  • Cardiomegaly and Calcified coronary arteries is found.
• 2023-07-24 Patho - uterus (with or without SO) neoplastic
  • Diagnosis:
    • Uterus, endometrium, staging surgery — Endometroid adenocarcinoma, FIGO grade 2
    • Uterus, myometrium, staging surgery — Tumor involving srosa and > 1/2 myometrial thickness. Intramural leiomyoma
    • Cervix, staging surgery — Tumor involving cervical stromal connective tissue
    • Ovary, bilateral, staging surgery — Negative for malignancy
    • Fallopain tube, bilateral, staging surgery — Negative for malignancy
    • Omentum, staging surgery — Negative for malignancy
    • Lymph node, left iliac, dissection — Negative for malignancy
      
    • Lymph node, left obturator, dissection — Negative for malignancy
    • Lymph node, right iliac, dissection — Negative for malignancy
    • Lymph node, right obturator, dissection — Negative for malignancy
      
    • AJCC 8th edition pathology stage:pT3aN0 (if cM0); FIGO stage IIIA
  • Gross description:
    • Procedure (select all that apply)
      • laparotomy gynecologic oncology staging surgery (ATH + BSO + infracolic omentectomy + BPLND)    
      • Note: For information about lymph node sampling, please refer to the Regional Lymph Nod section.
    • Tumor Site (select all that apply)
      • Endometrium
    • Tumor Size:
      • Greatest dimension: 6 cm
      • Additional dimensions (centimeters): 5 x 1.5 cm
    • Sections are taken and labeled as:A1-2: left ilia LN, B1-2:left obturator LN, C1-2: right iliac LN,D1-2:right obturator LN, E1-2:right adnexae, E3-4:left adnexae, E5:cervix and margin, E6-9:tumor, E10:myoma, F:omentum
  • Microscopic Description:
    • Histologic Type:Endometrioid carcinoma with focal squamous differentiation
    • Histologic Grade: (required only if applicable) FIGO grade 2 (low-grade)
    • Myometrial Invasion: present (>= 1/2 whole thickness)
    • Uterine Serosa Involvement: Present
    • Cervical Stromal Involvement: Present
    • Other Tissue/ Organ Involvement (select all that apply): Not identified
    • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
      • Ectocervical/Vaginal Cuff Margin: Free ( 8 mm of closest margin distance)
      • Parametrial/Paracervical Margin: Free
        
    • Lymphovascular Invasion: Present
    • Regional Lymph Nodes:
      • Right Pelvic Node: 0 / 9
      • Left Pelvic Node: 0 / 6
      • Para-aortic Node: Not included
    • Greatest dimension of largest nodal metastatic deposit (required only if macrometastasis or micrometastasis present): Not applicable
    • Isolated tumor cells (0.2 mm or less and not more than 200 cells) (required only in the absence of macrometastasis or micrometastasis in other lymph nodes): Absent
      • Note: Number of lymph nodes with macrometastasis, lymph nodes with micrometastasis, and lymph nodes with isolated tumor cells may be reported separately but this is not mandatory.
    • Additional Pathologic Findings: None identified
    • Immunostain — p16 (focal patchy+, 30%), p53: wild-type, Napsian A (-).
• 2023-07-12 MRI - pelvis
  • Clinical history: 62 y/o female patient with Uterus, endometrium, endometrial aspiration — Endometroid adenocarcinoma, well differentiated.
  • With and without contrast enhancement MRI: Pelvis
    • Diffuse soft tissue tumors in the uterine cavity (from fundus and lower body), c/w endometrial malignancy. With extension to right parametrium.
    • Small lymph nodes in bilateral obturator regions.
    • Non-enhancing nodules, up to 1.8cm in left kidney, r/o bilateral renal cyst.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T3a(T_value) N:N0(N_value) M:M0(M_value) STAGE:_IIIA__(Stage_value)
      
  • Impression:
    • Endometrial malignancy, cstage T3aN0M0.
    • Bilateral renal cysts.
• 2023-06-30 Patho - endometrium curretage/biopsy
  • Uterus, endometrium, endometrial aspiration — Endometroid adenocarcinoma, well differentiated
  • The specimen submitted consists of multiple small pieces of gray-brown soft tissue, measuring up to 0.3 x 0.3 x 0.2 cm and totally weighing 2 gm. All for section in one cassette.
  • The sections show endometroid adenocarcinoma, well differentiated, composed of endometrial tissue with densely packed glands, confluent glands, cribrifrom glands, and focal papillary architecture. Nuclear atypia is mild to moderate. Prominent squamous differentiation is present.
• 2023-06-23 Gynecologic ultrasonography
  • Endometrial thickening, EM 14.3mm
  • R/O Uterine myoma
• 2023-04-13 SONO - neck (lymph node)
  • Sonography of neck revealed some LNs in bil. neck.
  • R/O a lipoma (0.49x1.65cm) at submental region.
• 2022-12-06 SONO - nephrology
  • Bilateral parenchymal renal disease, c/w diabetic kidney disease
  • Single renal cyst, left kidney

[MedRec]

• 2023-07-23 ~ 2023-08-03 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of endometrium post laparotomy gynecologic oncology staging surgery on 2023/07/24
    • Endometroid adenocarcinoma, pathology stage:pT3aN0(if cM0); FIGO stage IIIA,FIGO grade 2
    • Postmenopausal bleeding
    • Endometrial hyperplasia
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Pulmonary embolism is found at branching pulmonary artery over left side.
  • CC
    • Abnormal vaginal bleeding for one month
  • Present illness
    • This 63 y/o woman with menopause, P2 (C/S, NSD), with past history of HTN, DM, dyslipidemia. She came to our hospital this time due to abnormal vaginal bleeding for one month.
    • According to the patient, she had regular menstral cycle with duration/interval of 5-6/28-30 days, with menorrhagia, no dysmenorria. She had menopause 13 years ago, at the age of 50 y/o. However, heavy bleeding was noted by patient one month ago. She must wear diapers whole day long, and needs to change per hour. She also noted decreased body weight (88kg-83kg), abdominal distension, malaise and exertional dyspnea. She denied abdominal pain, no nausea or vomiting, no tarry/bloody stoool, no constipation, no urinary freqency.
    • Due to above symptoms, she turned to our GYN OPD for help. The transvaginal sono on 2023.06.23 revealed uterine myoma in size of 45 x 32mm, endometrium: 1.43cm, otherwise normal. Endometrial aspiration showed endometriod adenocarcinoma, well differentiated. Tumor marker showed CA125 = 11.7 U/mL; CA199 = 15.73 U/mL; CEA = 1.86 ng/mL, Hb: 10.2 g/dL. Abdominal MRI was also done on 2023.07.17 and revealed diffuse soft tissue tumors in the uterine cavity (from fundus and lower body), c/w endometrial malignancy, with extension to right parametrium, cT3aN0M0. And the Hb showed 8.0 g/dL.
    • Under the impression of endometriod adenocarcinoma, cT3aN0M0, she was admitted on 2023.07.23 for laparoscopic staging surgery and post operative care.
  • Course of inpatient treatment
    • This is a 62 y/o woman with HTN, DM and dyslipidemia under medical control. She received laparoscopic staging surgery for endometrial cancer on 2023/07/24. Her postoperative status has been stable; however, elevated D-dimer > 10000 ng/mL was noted on 07/28 and 07/29. Chest CTA on 07/29 revealed pulmonary embolism (filling defect) over the left pulmonary branch.
    • The cardiologist was consulted. Clexane 60mg SC QD was administered since 07/28, titrated to 80mg Q12H on 07/29. Component therapy was given to keep Hb > 10 g/dL.
    • Under the impression of pulmonary embolism, she was transferred to MICU on 07/29.
    • After admission to MICU, CV suggest check protein C, protein S, anti-thrombin III, lupus anticogulant and clexane 80mg q12h s, then blood transfusion LPRBC 1u st to keep Hb > 10mg/dL.
    • Hypoglycemia, hold OHA for hypoglycemia.
    • Precirbed Lixana 30mg QD since 7/31. Due to relative codition, she will transfer to ward for further care on 2023/07/31, Eating and urination by self voiding, as well as defecation were smooth. The vital sign was stable after surgery.
    • The surgical pathology revealed endometrioid adenocarcinoma stage:pT3aN0(if cM0); FIGO stage IIIA,FIGO grade 2. The Gyn tumor conference suggest further radiotherapy and chemotherapy. chest CTA show right upper lobe tiny nodule 0.3cm.
    • She is discharged on 08/03/2023 afternoon and her followup appointment is scheduled on next week.
  • Discharge prescription
    • Pradaxa (dabigatran 110mg) 1# BID
    • Biomycin (neomycin, tyrothricin) BID TOPI for hip lesion
    • cephalexin 500mg 1# QID
    • MgO 250mg QID
    • naproxen 250mg 1# TID

[consultation]

• 2023-07-31 Psychosomatic Medicine
  • Q
    • Cancer inpatient with suicidal thoughts scoring >= 2 points.
  • A
    • Psychiatric impression:
      • adjustment reaction
      • r/o depressive disorder
    • Psychiatric history:
      • This 62-year-old woman without any psychiatric history.
      • She was admitted to OBGYN for endometriod adenocarcinoma, cT3aN0M0, for laparoscopic staging surgery.
      • She expected to go home after the operation, but a pulmonary embolism occurred after the operation and she needed to be treated in the intensive care unit.
      • This change of the condition had a great impact on her mood. She felt depression and negative thinking during admission in MICU.
      • However, her depression much improved today because of she could transfer to general ward under stable condition.
    • MSE:
      • consious alert, fair attention, coherent and relevnet speech, fair spontaneious speech, residual low mood, but no lack of intrest for pleasure; poor appetite and sleep at night in ICU.
      • there was no psyhomotor agitation or retardation, less fatigue, less negative thinking and denied current suicide ideation, denied anxiuos dissdtress
    • Suggestion:
      • psychoeducation
      • discussed psychiatric treatment about the patient, she refused psychotropic medication
      • arrange psychiatric OPD follow up
• 2023-07-29 Cardiology
  • Q
    • This is a 62 y/o woman with HTN, DM and dyslipidemia. She received laparoscopic staging surgery for endometrial cancer on 2023/07/24. Her postoperative status has been stable; however, elevated D-dimer > 10000 ng/mL was noted on 07/28 and 07/29. Clexane 60mg SC QD was administered, titrated to 90mg Q12H on 07/29. Chest CTA on 07/29 revealed pulmonary embolism (filling defect) over the left pulmonary branch. We will arrange ICU transfer a.s.a.p. and we hope you could help evaluate the patient as your expertise. Thank you.
  • A
    • I was consulted for acute pulmonary embolism
    • Endometrial cancer status post laparoscopic staging surgery on 2023/07/24
    • No dyspnea under Nasal cannula
    • Lab
      • 2023-07-29 D-dimer > 10000.00 ng/mL(FEU)
        
      • 2023-07-28 CRP 2.6 mg/dL
        
      • 2023-07-28 D-dimer > 10000.00 ng/mL(FEU)
        
      • 2023-07-25 WBC 8.17 x10^3/uL
        
      • 2023-07-25 HGB 8.9 g/dL
        
      • 2023-07-25 PLT 227 x10^3/uL
        
      • 2023-07-23 BUN 21 mg/dL
        
      • 2023-07-23 Creatinine 0.87 mg/dL
        
    • Chest CTA: Right upper lobe tiny nodule. 0.3cm
      • Pulmonary embolism is found at branching pulmonary artery over left side.
      • Cardiomegaly and Calcified coronary arteries is found.
    • EKG: NSR
    • Impression:
      • Acute pulmonary embolismi, left, non-massive type
      • Endometrial cancer status post laparoscopic staging surgery on 2023/07/24
      • Anemia
    • Suggestion:
      • Please give Enoxaparin 80mg Q12H SC. (BW: 83kg)
      • PRBC transfusion, keep Hb > 10g/dl.
      • Admit to CV ICU
      • The family was well explained about the treatment strategy, including catheter-directed thrombectomy if failure to medical treatment.
      • Please check protein C, protein S, anti-thrombin III, lupus anticogulant.
    • Thanks for your consultation and F/U on call.
  • A 2023-08-01 08:54:54
    • Suggest Dabigatran 110mg BID PO (full dose) despite Edxoaban (30mg) 1# QD (lose dose strategy) according to obesity status and consideration of antidote availablity.
    • Arrange cardiac echo and vein echo for further study.
    • Thanks for your consultation and F/U on call.

[consultation]

• 2024-05-20 Dermatology
  • Q
    • for Due to corns and blisters on soles of left feet progression
    • The 63 y/o woman has recurrent endometroid cancer with lung mets, stage IV. Due to corns and blisters on soles of left feet pain for days, so we need your help for management.
  • A
    • This patient suffered from erytehamtous papulesiplaques on bil soles
    • Imp: Dyshidrotic dermatitis
    • Suggestion:
      • Sinpharderm * 1 tubes/bid
      • Clobetasol * 4 tubes/bid
• 2024-04-12 Dermatology
  • Q
    • The 63 y/o woman has recurrent endometroid cancer with lung mets, stage IV. Due to corns and blisters on soles of left feet pain for 4 days, so we need your help for management.
  • A
    • This patient suffered from multiple vesicles on L’t foot for days.
    • Imp: Dyshidrotic dermatitis
    • Suggestion:
      • Predinislon 1 / Bid
      • Doxyclin * 1 /bid
      • Rinderon eyeoilment * 1 tube/bid
      • Mycomb * 1 tube/bid
• 2023-07-31 Psychosomatic Medicine
  • Q
    • Cancer inpatient has suicidal ideation score of >=2.
  • A
    • Psychiatric impression:
      • adjustment reaction
      • r/o depressive disorder
    • Psychiatric history:
      • This 62-year-old woman without any psychiatric history.
      • She was admitted to OBGYN for endometriod adenocarcinoma, cT3aN0M0, for laparoscopic staging surgery.
      • She expected to go home after the operation, but a pulmonary embolism occurred after the operation and she needed to be treated in the intensive care unit.
      • This change of the condition had a great impact on her mood. She felt depression and negative thinking during admission in MICU.
      • However, her depression much improved today because of she could transfer to general ward under stable condition.
      • MSE: consious alert, fair attention, coherent and relevnet speech, fair spontaneious speech, residual low mood, but no lack of intrest for pleasure; poor appetite and sleep at night in ICU.
      • there was no psyhomotor agitation or retardation, less fatigue, less negative thinking and denied current suicide ideation, denied anxiuos dissdtress
    • Suggestion:
      • psychoeducation
      • discussed psychiatric treatment about the patient, she refused psychotropic medication
      • arrange psychiatric OPD follow up
• 2023-07-29 Cardiology
  • Q
    • This is a 62 y/o woman with HTN, DM and dyslipidemia. She received laparoscopic staging surgery for endometrial cancer on 2023/07/24.
    • Her postoperative status has been stable; however, elevated D-dimer > 10000 ng/mL was noted on 07/28 and 07/29.
    • Clexane 60mg SC QD was administered, titrated to 90mg Q12H on 07/29.
    • Chest CTA on 07/29 revealed pulmonary embolism (filling defect) over the left pulmonary branch.
    • We will arrange ICU transfer a.s.a.p. and we hope you could help evaluate the patient as your expertise. Thank you.
  • A
    • I was consulted for acute pulmonary embolism
      • Endometrial cancer status post laparoscopic staging surgery on 2023/07/24
      • No dyspnea under Nasal cannula
    • Lab
      • 2023-07-29 D-dimer > 10000.00 ng/mL(FEU)
        
      • 2023-07-28 CRP 2.6 mg/dL
        
      • 2023-07-28 D-dimer > 10000.00 ng/mL(FEU)
        
      • 2023-07-25 WBC 8.17 x10^3/uL
        
      • 2023-07-25 HGB 8.9 g/dL
        
      • 2023-07-25 PLT 227 *10^3/uL
        
      • 2023-07-23 BUN 21 mg/dL
        
      • 2023-07-23 Creatinine 0.87 mg/dL
        
    • Chest CTA:
      • Right upper lobe tiny nodule. 0.3cm
      • Pulmonary embolism is found at branching pulmonary artery over left side. (Se305 IM24).
      • Cardiomegaly and Calcified coronary arteries is found.
    • EKG:
      • NSR
    • Impression:
      • Acute pulmonary embolismi, left, non-massive type
      • Endometrial cancer status post laparoscopic staging surgery on 2023/07/24
      • Anemia
    • Suggestion:
      • Please give Enoxaparin 80mg Q12H SC. (BW: 83kg)
      • PRBC transfusion, keep Hb > 10g/dl.
      • Admit to CV ICU
      • The family was well explained about the treatment strategy, including catheter-directed thrombectomy if failure to medical treatment.
      • Please check protein C, protein S, anti-thrombin III, lupus anticogulant.
      • Thanks for your consultation and F/U on call.
  • A 2023-08-01 08:54:54
    • Dear doctor:
      • Suggest Dabigatran 110mg BID PO (full dose) despite Edxoaban (30mg) 1# QD (lose dose strategy) according to obesity status and consideration of antidote availablity.
      • Arrange cardiac echo and vein echo for further study.

[surgical operation]

• 2023-07-24
  • Surgery
    • Diagnosis: Endometrial cancer
    • Operation: Laparascopy -> shift to laparotomy gynecologic oncology staging surgery (ATH + BSO + infracolic omentectomy + BPLND)       
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus:
      • disfigured due to tumor mass occupying, papillary mass in uterus cavity with extention to the cervix, intraoperative rupture (+)
      • severe adhesion to the bowel and cul de sac
      • Adnexa: grossly normal
      • CDS: ascites (-), adhesion (+)
      • Bilateralpelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: grossly normal, infracolic omentectomy was done
      • Estimated blood loss: 550 mL
      • Blood transfusion: nil
      • Complication: nil

[radiotherapy]

• 2023-10-24 ~ 2023-12-13 - 4500cGy/25 fraction sof the pelvic, and 5940cGy/33 fractions of the vaginal stump recurrent tumor area.

[chemotherapy]

• 2024-04-13 - paclitaxel 175mg/m2 325mg NS 300mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-03-21 - paclitaxel 175mg/m2 325mg NS 300mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-02-16 - paclitaxel 175mg/m2 317mg NS 300mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-01-11 - paclitaxel 175mg/m2 315mg NS 300mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-12-12 - cisplatin 40mg/m2 70mg NS 250mL 2hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-05 - cisplatin 40mg/m2 70mg NS 250mL 2hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-28 - cisplatin 40mg/m2 70mg NS 250mL 2hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-20 - cisplatin 40mg/m2 70mg NS 250mL 2hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-05-20

[hyperuricemia managed with febuxostat; clobetasol for dermatitis; mid-term renal function decline noted, potential carboplatin adjustment]

Our dermatologist recommended using clobetasol propionate ointment for her dyshidrotic dermatitis (first consultation on 2024-04-12, just one month ago). Except for elevated BUN (33 mg/dL) and uric acid (8.7 mg/dL), other lab results on 2024-05-17 were relatively unremarkable. Hyperuricemia is managed with Feburic (febuxostat). TPR readings are stable, and blood sugar levels are acceptable. No current medication issues were found.

Over the past 10 months, the patient’s eGFR has decreased by approximately 20 to 30 mL/min/1.73m2, with the latest value being 51.7. The current regimen uses the less nephrotoxic carboplatin, but if renal function declines further, it may be necessary to reduce the carboplatin dose.

If the CrCl falls below 30 mL/min, the current use of Pradaxa (dabigatran) should be reduced.

2024-03-20

[lab results affirm safety for continued chemotherapy sessions]

Cisplatin combined with radiotherapy was administered from 2023-11 to 2023-12, followed by a regimen of carboplatin and paclitaxel starting in 2024-01 as part of the systemic therapy.

Medications prescribed by the nephrologist on 2024-01-30, the cardiologist on 2024-02-29, and the general surgeon on 2024-03-13 have been included in the active medication list.

The patient’s vital signs are currently stable, and lab results on 2024-03-19 revealed no significant abnormalities, indicating no contraindications to continuing with a new chemotherapy session. No medication discrepancies were identified.

2024-01-11

[hyperuricemia]

During this hospitalization, the patient experienced a significant increase in serum uric acid levels. Feburic (febuxostat) 80mg QD was initiated to address this.

• 2024-01-10 Uric Acid 8.2 mg/dL
• 2023-11-17 Uric Acid 6.8 mg/dL
• 2023-07-31 Uric Acid 6.8 mg/dL
• 2022-04-19 Uric Acid 6.9 mg/dL

If the elevated uric acid levels persist despite Feburic therapy, the addition of benzbromarone may be considered for further urate reduction.

701396053

240517

[exam findings] (not completed)

[MedRec]

• 2023-09-13 SOAP Dermatology Zhou WeiTing
  • S: severe itchy papules and plaques erupition over trunk after medication.
  • O: Height: 161.3 cm; Weight: 62.4 kg; BMI: 24
    • 1. urticaria/angioedema type
    • 2. maculopapular type
    • 3. urticaria-purpura type
         
    • 4. erythema multiforme SJS/TEM
    • 5. fixed drug eruption or AGEP rapid onset type
    • 6. drug hypersensitivity syndrome as DRESS
    • 7. lichenoid chronic progressive type
    • Suspect related medication.
  • P:
    • education about drug side effect and explain
    • Strongly suggested OPD f/u
  • Prescription
    • Topsym Cream (fluocinonide 0.05%) BID EXT
    • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# PRNTID
    • Asthan (ketotifen 1mg) 1# BID
    • Compesolon (prednisolone 5mg) 2# PRNQD
    • C.B. Ointment (chlorpheniramine, lidocaine, methy salicylate, menthol, camphor) PRNBID TOPI (for pain management)
• 2023-09-06 SOAP Hemato-Oncology Xia HeXiong
  • A/P: Due to overall SD of liver, pancreatic tail, omentum and scalp but increasing CEA, the regimen will shift to GASL Q2/3W (TS-1 two weeks on and one week off),s o TS-1 will be given on Week 1 and Week 2, then off on Week 3
  • Prescription
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNQ8H
    • BaoGan (silymarin 150mg) 1# TID
    • TS-1 (tegafur, gimeracil, oteracil; 25mg) 2# BID
    • Folina (folinate 15mg) 2# BID
    • Hepac Lock Flush ST IRRI
• 2023-08-17 SOAP Gastroenterology Chen JiangHua
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
• 2023-07-12 SOAP Hemato-Oncology Xia HeXiong
  • S: All-RAS G12V
  • A/P: On 2023-06-21, already explain Stage 4 (Scalp, invasion to spleen, R/O lung and liver) Based on PET and CT to the patient and her daughter. =>> If not working of Abraxane / Gem, may consider electron beam for scalp
• 2023-06-21 SOAP Hemato-Oncology Xia HeXiong
  • A/P: On 2023-06-21, already explain Stage 4 (Scalp, invasion to spleen, R/O lung and liver) Based on PET and CT to the patient and her daughter.
• 2023-06-07 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • complete C/T x 12
    • refer to the Dr. Wu for possible of resection of the tumor
    • Due to new lesion (2023/05/31 Whole body PET scan), need to consider shift regimen to Abraxane/Gemcitabine after scalp biopsy.
• 2023-03-01 SOAP Hemato-Oncology Wan XiangLin
  • Prescription
    • Emend (aprepitant 125mg) 1# QD 3D
    • Stilnox (zolpidem 10mg) 1# HS
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Hepac Lock Flush ST IRRI
• 2023-02-14 SOAP Hemato-Oncology Zhang ShouYi
  • S
    • #1 palliative C/T wt palliative C/T wt FOLFIRINOX IV Q2W x 12 on 10/12 22.
    • #2 on 10/25 22. #3 on 11/8 22. #4 on 11/29 22. #5 on 12/13 22. #6 on 12/27 22. #7 on1/31 23. #8 on 2/14 23.
• 2022-10-11 SOAP Gastroenterology Chen JiangHua
  • S: for NUC due to anti-HBc Ab (+) and intended to do C/T
  • Prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
• 2022-10-11 SOAP Hemato-Oncology Zhang ShouYi
  • A: pancreatic tail CA wt liver & lung & peritoneal mets Dx in Sep 2022 s/p EGD biopsy showing adenoCA at LMD in Sep 2022.
• 2022-10-04 SOAP Hemato-Oncology Zhang ShouYi
  • S
    • 59 y/o female, a pt of pancreatic tail CA wt liver & lung & peritoneal mets Dx in Sep 2022 s/p EGD biopsy showing adenoCA at LMD in Sep 2022.
    • suffered from initial presentation of epigastric distended with mild pain for 1-2 week in Sep 2022. s/p UGI scope revealed gastric fundus tumor at LMD.
    • c/o back pain for days in Sep 2022.
      • no cough, no dyspnea
      • no bloody rhinorrhea, no nasal stuffness, no epistaxis
      • no dysphagia, no odynophagia, no epigastralgia
      • no fever, no weight loss, no night sweats
    • referred to our hemato-oncologic clinic on 10/4 22 by Dr Wu ChaoCun
    • pancreatic tail CA wt liver & lung & peritoneal mets.
  • P
    • will do EGD for biopsy (10/4 22).
    • explain to pt & his daughter about the indication & risk / benefit of palliative C/T wt FOLFIRINOX IV Q2W x 12 (10/4 22).
    • will do HBsAg, anti-HBc, anti-HCV (10/4 22)
    • will consult Dr Wu ChaoCun for Port-A installation (10/4 22).
    • will do chest CT (10/4 22).
    • will give palliative C/T wt FOLFIRINOX IV Q2W x 12 (10/4 22).
    • Adm on 10/11 22 for #1 palliative C/T wt palliative C/T wt FOLFIRINOX IV Q2W x 12.
    • RTC 1 wk later on 5/4 20 for CBC & DC, CXR, abd no report.
• 2022-09-16 SOAP General and Gastrointestinal Surgery Wu ChaoCun
  • S
    • epigastric distended with mild pain for 1-2 week
    • UGI scope revealed gastric funus tumor path ADC
  • O
    • BP: 132/86; HR: 84;
    • suggest CT scan
    • DM -
    • H/T -
    • cancer staging
    • clo test ++
  • Diagnosis
    • C16. 9 Malignant neoplasm of stomach, unspecified
  • Prescription
    • Scrat (sucralfate 1g) 1# BIDAC
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Metrozole (metronidazole 250mg) 1# QID
    • Klaricid (clarithromycin 500mg) 1# BID

[chemotherapy]

• 2023-10-12 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-05 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-20 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-06 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-23 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-16 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-02 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-19 - gemcitabine 1000mg/m2 1500g NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-12 - gemcitabine 1000mg/m2 1500g NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-28 - gemcitabine 1000mg/m2 1500g NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-14 - gemcitabine 1000mg/m2 1700g NS 250mL 30min + nab-paclitaxel 100mg/m2 170mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-12 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 500mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2023-03-29 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 500mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2023-03-15 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 500mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2023-03-01 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3900mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2023-02-14 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3900mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2023-01-31 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2022-12-27 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2022-12-13 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2022-11-29 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2022-11-08 - oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2022-10-25 - oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
• 2022-10-12 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL

FOLFIRINOX chemotherapy for metastatic pancreatic cancer - 2023-10-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

• Cycle length: 14 days.
• Regimen
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 180 mg/m2 IV
    • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 400 mg/m2 IV bolus
    • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
    • Day 1
  • FU
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2023-10-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

• Cycle length: 14 days.
• Regimen
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 150 mg/m2 IV
    • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

==========

2024-05-17

[tube feeding]

Dulcolax, containing 5 mg of bisacodyl, is an enteric-coated formulation that should not be split or crushed. As an alternative, Bisadyl suppositories with 10 mg of bisacodyl can be used. The patient is also prescribed sennoside 12 mg, 2 tablets at bedtime.

If these medications are not sufficiently effective, the addition of lactulose may be considered.

2023-10-20

According to PharmaCloud records, the patient has not visited any other hospitals in the past three months, and no discrepancies in medication have been identified.

A general urine test conducted on 2023-10-19 revealed sediment RBC 50-99/HPF and Bacteria 1+, potentially indicating the presence of urinary tract infections (UTIs) that may require further intervention.

The patient underwent a total of 12 cycles of a modified FOLFIRINOX regimen for her pancreatic tail cancer from 2022-10 to 2023-04. A new treatment protocol of gemcitabine + nab-paclitaxel was initiated on 2023-06-14, with TS-1 added to the regimen on 2023-09-06. A dermatologic adverse reaction was noted on 2023-09-13. Per today’s progress note, the patient has developed oral mucositis, and there is a plan to administer Difflam (benzydamine) spray and/or Nincort (triamcinolone acetonide) oral gel. Given that triamcinolone is a synthetic corticosteroid, its prolonged use can lead to side effects, including oral fungal infections (thrush), taste alterations, and, in rare instances, adrenal suppression. Therefore, it’s recommended to employ the lowest effective dose.

701038432

240516

[exam findings]

• 2024-05-15 SONO - chest
  • Symptom: dyspnea
  • Indication: r/o pleural effusion
  • Clinical diagnosis: Adenocarcinoma of S-colon with obstruction with multiple liver metastases, cT3N2M1a, stage IVa, status post T-loop colostomy on 2023/04/15 s/p chemotherapy
  • Findings
    • Left-side of thorax:
      • There was minimal loculated pleural effusion. Rapid LLL movement with respiration was found.
      • irregularly atelectasis of LLL
    • Right-side of thorax:
      • There was no pleural effusion. The right hemidiaphragm was nearly fixed with respiration
      • Mildly irregular pleurae was found. Heteroechoic liver tumors and hepatomegaly was found
    • Special Procedure
      • high risk of peumothorax if thoracentesis of left loculated pleural effusion
  • Echo diagnosis
    • Pleural effusion, minimal, left
    • Atelectasis, LLL
    • Pleural thickening, right
    • multiple hepatic turmors
• 2024-04-20 CT - brain
  • no acute intracranial hemorrhage
• 2024-04-17, -04-15 CXR erect
  • Pleura effusion of right and left costal-phrenic angle.
  • Increased lung markings on both lower lungs are noted. Please correlate with clinical condition.
  • Hypo-inflation of both lung is noted.
• 2024-04-09 SONO - abdomen
  • c/w liver metastasis
  • suspect LN metastasis
  • Renal cyst
  • Ascites
• 2024-04-03 ECG
  • Normal sinus rhythm
  • T wave abnormality, consider anterior ischemia
• 2024-04-03 CXR
  • Blunted left costophrenic angle.
  • S/P Port-A infusion catheter insertion.
  • A linear density a right lower lung.
• 2024-03-13 SONO - abdomen
  • Liver tumors, bilatreal lobes
  • Renal cysts, both kidney
  • Renal stones, right kidney
• 2024-02-08 CT - abdomen
  • History and indication: sigmoid cancer obstruction with multiple liver metastases, cT3N2M1a, stage IVa, status post T-loop colostomy on 2023/04/15
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Mild progression of S-colon cancer and liver metastases.
    • Right renal stone (2mm). Bil. renal cysts (up to 2.4cm).
    • A calcification at pelvic cavity.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Mild progression of S-colon cancer and liver metastases.
• 2023-11-06, -08-02 CT - abodomen
  • Findings
    • Mild regression of S-colon cancer and liver metastases.
    • Right renal stone (2mm). Bil. renal cysts (up to 2.4cm).
    • A calcification at pelvic cavity.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • Mild regression of S-colon cancer and liver metastases.
• 2023-05-31 CT - brain
  • No evidence of intracranial lesion. Cervical spondylosis.
• 2023-05-29 24hr portable ECG
  • Baseline was sinus rhythm
  • Very frequent isolated VPCs / VPC couplets (one morphology dominant, burden 26%) (inferior axis, LBBB, lead I: R, aVL: qS, r/o RV high septum origin, near His)
  • 1 episode of VPC salvo ( 3 beats, multi-form, 84bpm)
  • A few isolated APCs / APC couplets
  • 6 episodes of short-run AT, max 9 beats (with RBBB intermittently)
  • No long pause
• 2023-05-29 ECG
  • Sinus rhythm with frequent Premature ventricular complexes
  • Abnormal ECG
• 2023-05-28 ECG
  • Sinus bradycardia with frequent Premature ventricular complexes
• 2023-05-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (74.2 - 28.5) / 74.2 = 61.59%
    • M-mode (Teichholz) = 75.2
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, mild TR, normal IVC size
• 2023-05-26 Abdomen - Standing (Diaphragm)
  • S/P colostomy at right middle abdomen.
  • Wedge deformity of T12 and L2 vertebral body is noted. Please correlate with clinical condition.
• 2023-05-03 All-RAS + BRAF mutation
  • Cellblock No. S2023-07776
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-04-24 Patho - colon biopsy
  • Colon, sigmoid, 30 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    
  • Section shows pieces of colonic tissue with invasive cribriform glands in submucosa.
  • The immunohistochemical stains reveal CDX2(+), CD56(-), EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2023-04-24 Sigmoidoscopy
  • A tumor lesion is located at S-colon (30cm AAV) just behind a sharp angle with lumen narrowing and obstruction
• 2023-04-15 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
• 2023-04-14 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Long segmental wall thickening at sigmoid colon measuring 5.6cm in largest dimension is found. Sigmoid colon cancer is considered. Several lymph nodes (n > 8) are found around the main mass.
    • The intestines are markedly dilated due to sigmoid colon obstruciton.
    • Huge hepatic tumors are found at both lobes of liver up to 8.4cm in largest dimension. Liver meta is considered.
    • Minimal ascites at subphrenic region and minimal right pleural effusion is found.
    • Deformed bilateral femoral head is found. AVN is considered.
    • Increased pulmonary vasculature is found.
  • Imp:
    • Sigmoid colon cancer with regional lymph nodes and liver meta.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)

[MedRec]

• 2023-07-25 SOAP Cardiology Liu ZhiRen
  • Prescription x3
    • Meletin (mexiletine 100mg) 1# BID
• 2023-05-02 SOAP Hemato-Oncology He JingLiang
  • A: Adenocarcinoma of S-colon with obstruction with multiple liver metastases, cT3N2M1a, stage IVa, status post T-loop colostomy on 2023/04/15
  • P: suggest palliative chemotherapy with FOLFIRI + target therapy with avastin x 12 cycles
• 2023-04-15 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Sigmoid cancer obstruction with multiple liver metastases, cT3N2M1a, stage IVa, status post T-loop colostomy on 2023/04/15
    • Bilateral avascular necrosis
  • CC
    • abdominal fullness WITH OBSTIPATION for one week. Accompanied with nausea and poor appetite.
  • Present illness
    • This is a 74-year-old female without any underlying diseases. This time, she visited our emergency room due to abdominal fullness WITH OBSTIPATION for one week. Accompanied with nausea and poor appetite. SHE ALSO EXPERIENCED CHANGE IN BOWEL HABIT WITH DIFFICULT PASSAGE OF STOOL IN RECENT WEEKS. There was no fever, no chills, no chest pain, no tarry stool, no constipation, no diarrhea. She also denied body weight loss in the recent half year.
    • At our ER, her vital signs were BP:150/86; HR:91; BT:36.6; RR:18; Con’s:E4V5M6, SpO2:96%. PE showed soft and oviod abdomen with hypoactive bowel sound. Lab data showed hyponatremia, elevcated of CRP level and leukocytosis. KUB revealed ileus AND MARKED DILATED COLON. Abdomen CT showed long segmental wall thickening at sigmoid colon measuring 5.6cm in largest dimension, sigmoid colon cancer WITH OBSTRUCTION is considered. Several lymph nodes (n>8) are found around the main mass. The intestines are markedly dilated due to sigmoid colon obstruciton. Huge hepatic tumors are found at both lobes of liver up t 8.4cm in largest dimension. Liver meta is considered. Also, minimal ascites at subphrenic region and minimal right pleural effusion are found.
    • Under the impression of tumor of S-colon with obstruction and liver metastases, she was admitted for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, operation of T-loop colostomy under general anesthesia were performed on 2023/04/14. Op finding: marked colon and small bowel dilatation and bowel wall edema. The whole procedure was smooth. NPO and adequate IV fluid supplement. Antibiotic treatment with Sintrix was prescribed on 04/15~4/24. Early activity is encouraged. She had flatus and stool passage via ostomy. Her abdominal wound pain subsided. Oral intake program was adjusted and there was no abdominal discomfort after trying oral intake, IV fluid supplement was tapered and discontinued later.
    • She had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. Her abdominal wound pain had got much better. In stable condition, she was discharged on 2023/04/25 and will receive OPD follow up next week.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H

[surgical operation]

• 2023-04-15 - Op Method: T-loop colostomy         
  • Finding:
    • Marked colon and small bowel dilatation and bowel wall edema.            - T-loop colostomy was carried out at RUQ abdomen. The whole procedure was smooth.    

[immunochemotherapy]

• 2024-04-12 - cetuximab 400mg/m2 300mg 2hr + irinotecan 180mg/m2 150mg D5W 90min + leucovorin 400mg/m2 350mg NS 250mL 2hr + fluorouracil 2800mg/m2 2500mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-03-14 - cetuximab 400mg/m2 300mg 2hr + irinotecan 180mg/m2 150mg D5W 90min + leucovorin 400mg/m2 340mg NS 250mL 2hr + fluorouracil 2800mg/m2 2400mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-02-15 - bevacizumab + … (Avastin + FOLFOX)
• 2024-01-29 - bevacizumab + … (Avastin + FOLFOX)
• 2024-01-05 - bevacizumab + … (Avastin + FOLFOX)
• 2023-12-07 - bevacizumab + … (Avastin + FOLFOX)
• 2023-12-06 - bevacizumab + … (Avastin + FOLFIRI)
• 2023-11-06 - bevacizumab + … (Avastin + FOLFIRI)
• 2023-10-20 - bevacizumab + … (Avastin + FOLFIRI)
• 2023-09-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-06 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-17 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-31 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-11 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr
• 2023-05-09 - ………………………………….. irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 45hr
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

==========

2024-05-16

Stool OB 4+ was observed on 2024-05-15, and a PPI is currently being administered. Feburic (febuxostat) is also being used to lower serum uric acid. Sintrix (ceftriaxone) was empirically administered for PCT 1.55 ng/mL and CRP 17 mg/dL.

Prolonged PT with normal aPTT could indicate acute DIC, liver disease, mild vitamin K deficiency, or warfarin use. There are no records of warfarin in the PharmaCloud database.

• 2024-05-15 OB 4+
  
• 2024-05-15 PT 17.6 sec
  
• 2024-05-15 APTT 34.1 sec
  
• 2024-05-15 D-dimer 6631.00 ng/mL(FEU)
  
• 2024-05-15 Procalcitonin (PCT) 1.55 ng/mL
  
• 2024-05-15 CRP 17.0 mg/dL

No medication discrepancies have been identified.

2024-04-08

Targocid (teicoplanin) and Mepem (meropenem) are being administered for elevated PCT and CRP levels, while BaoGan (silymarin), Uliden (ursodeoxycholic acid), potassium and magnesium supplements Const-K, KCl and MgSO4 are addressing elevated liver enzymes (AST, ALT), bilirubin, and instances of hypokalemia and hypomagnesemia.

The current dosages for these medications do not require adjustment despite the patient’s impaired liver function.

700870154

240514

[exam findings]

• 2024-04-12 SONO - gynecology
  • EM:8.9mm, minimal fluid
• 2024-03-19 CT - chest
  • Diffuse large B-cell lymphoma, intra-abdominal lymph nodes, stage III, chemotherapy with RCDOP Q3W for 6cycles (Lipodox by self-payment) (First time only RCOP) from 2024/01/03~
  • Comparison: prior CT dated on 2023/12/16
    • Lungs: no interval change of a small solid nodule without calcification or fat density in Rt apical lung (about 4 mm srs/img202/27). normal appearance of RML, RLL, and left.
    • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
    • Visible abdominal-pelvic contents: small LNs at para-aortic region.several small gall bladder stones.
  • Impression:
    • RUL solid nodule 4 mm, favor a benign nodule (stable)
    • no evidence of LAP in the chest, abdomen, and visible neck
• 2024-01-02 PET
  • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm as mentioned above.
  • Mildly inhomogenous FDG distribution in the enlarged spleen was noted.
  • Mildly increased FDG uptake in a ocal area in the right apical lung. Inflammation is more likely. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2023-12-27 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with 40% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
• 2023-12-22 Patho - lymph node region resection
  • Labeled as “left neck tumor”, excisional biopsy — diffuse large B cell lymphoma. High grade. Double expressor, genimal center type.
  • Section shows lymph nodes diffusely infiltrated by large round blue cells, effacing lymphoid architecture. Occasional mitoses are present.
  • IHC stains: CD3 and CD20: a predominant B cell sub-population. CD10 (+) c-myc (+, > 70%), bcl-2 (+, > 70%), bcl-6 (+, > 70%), CK (-), MUM-1 (+, > 70%), Ki-67 (90%), cyclin-D1 (-).
• 2023-12-18 SONO - abdomen
  • Retroperitoneal tumors, near aorta and IVC, r/o malignancy such as lymphoma or metastases
  • Splenomegaly, mild
  • Pleural effusion, bilateral
• 2023-12-16 CT - chest
  • Lymphadenopathy at bilateral abdominal paraaortic region and bilateral lower neck, r/o lymphoma or others.
  • Consolidation of right lower lobe and left lower lobe with bilateral massive pleural effusion and mild pericardial effusion.
• 2023-12-15 SONO - vein
  • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
  • Pulsatile venous flow patterns bilaterally, considering elevated right heart pressure
• 2023-12-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (90 - 16) / 90 = 82.22%
    • M-mode (Teichholz) = 82
  • Conclusion:
    • Indeterminated LV filling pressure; mildly dilated LA.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial MR; moderate TR.
    • Mild to moderate pulmonary hypertension (the estimated systolic PA pressure 60 mmHg), possibly due to lung parenchymal disease + pleural effusions.
    • Minimal amount pericardial effusion ( < 50ml); Bilateral pleural effusions.
• 2023-12-12 EGD
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
  • Gastric ulcer, Forrest classification III, angle, s/p biopsy
  • Gastric polyp, middle body, GC
• 2023-12-11 CT - brain
  • No evidence of intracranial hemorrhage.
• 2023-11-16 Bladder sonography
  • PVR: 44.82ml
• 2023-11-16 Uroflowmetry
  • Q max : low
  • flow pattern : obstructive

[MedRec]

• 2023-12-13 ~ 2024-01-10 POMR Hemato-Oncology Yang MuJun
  • Discharge diagnosis
    • Diffuse large B-cell lymphoma, intra-abdominal lymph nodes, stage III, chemotherapy with RCDOP Q3W for 6 cycles (Lipodox by self-payment) (First time only RCOP) from 2024/01/03~
    • Encounter for antineoplastic chemotherapy
    • Acute gastric ulcer without hemorrhage or perforation
    • Heart failure, unspecified
    • Anemia, unspecified
    • Thrombocytopenia, unspecified
    • Unspecified sequelae of cerebral infarction
    • Dyspnea
    • Cerebral infarction, unspecified
  • CC
    • tarry stool for one week
  • Present illness
    • This is a 72 year-old female who has following underlying diseases:
      • CVA
      • Heart failure
    • Patient had upper abdominal discomfort since August, started to feel dyspnea since September, edema since the end of October.
    • She had tarry stool since last week, and it happened everyday.
    • Patient also had left chest stuffy pain but not exacerbated by inspiration.
    • At the ER, patient conscious is clear. Patient had normal skin tugor, clear breathing sounds, and regular heart beat. Lab data: Neutrophil 83%. Lymphocyte 7.7%. HGB 6.6 g/dL. After blood transfusion during ER, HGB had come to 9.4 g/dL.
    • PA/ AP chest film shows: Ground glass opacity in RLL. Upper GI endoscopy: mucosa break<5mm was noted at EC junction. Erythenatous change of gastric mucosa wash found. One 3mm clean-based, Forrest classification III ucler, with surrounding mucosal swelling was noted at the angle. One 2mm sessile polyp was noted at middle body. No bleeding was noted.
    • Under impression of anemia caused by gastric ulcer, she was admitted to our ward for further evaluation.
  • Course of inpatient treatment
    • After adimission we checked her lab dat on 12/14 and showed anemia and thrombocytopenia, with platelets initially low at 24,000 and increased to 50,000 after the transfusion of 4 units of blood.
    • Thus, we consulted Hematologist for her, surgical lymphnode biopsy and further hematology studies were suggested.
    • We also consulted Cardiovascular Specialist and Chest Specialest for her edema to rule out heart failure or pulmonary embolism.
    • 2-D echo showed normal LV systolic function and chest echo showed pleural uffsion but hold fine needle aspiration due to coagulopathy pending corrected.
    • Diurectics and albumin were prescribed for lower limbs edema and pleural effusion.
    • We consulted General Surgeon for her lymphnode excission biopsy and was arranged on 12/21.
    • Pathology report on 12/25 revealed Diffuse-type B cell lymphoma.
    • Thus, the patient was reffered to Oncology ward for further treatment.
    • After Oncology ward, consult surgical for port-a insertion and well done on 12/29.
    • PET scan on 2024/01/02 initially shows Upper and lower mediastinal cavity metastasis.
    • Chemotherapy with First-line for diffuse large B-cell lymphoma, RCDOP Q3W for 6 cycles (Lipodox by self-payment) (First time only RCOP) from 2024/01/03(C1).
    • Additionally, we continued blood transfusion for anemia and thrombocytopenia.
    • PPI iv form for 2024/01/01 stool OB shows 4+. Follow CxR no significantly abnormal on 2024/01/05.
    • For sore throat intermittent, follow rapid test of COVID and influenza A+B were negative.
    • Repeated laboratory data was WBC 4180/uL, HGB 8.5mg/dl, PLT 57000/uL on 2024/01/10.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/01/10 and OPD followed up later.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H if pain or fever > 38’C
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Folacin (folic acid 5mg) 1# QD
    • Fudecough (dextromethorphan 15mg) 1# TID
    • Smecta (dioctahedral smectite 3mg) 1# PRNTIDAC if watery stool
    • Uretropic (furosemide 40mg) 0.5# QD
    • Nincort Oral Gel (triamcinolone 1mg/gm) BID TOPI
    • Cravit (levofloxacin 500mg) 1.5# QDAC
    • lysozyme 90mg 1# TID
    • Pariet (rabeprazole 20mg) 1# QDAC
• 2017-02-23 SOAP Neurology Xiao ZhenLun
  • Diagnosis
    • Unspecified late effect of cerebrovascular disease [I69.30]
    • Fasciitis,unspecified [M72.9]
  • Prescription x3
    • MgO 250mg 1# QD
    • Bokey (aspirin 100mg) 1# QD

[consultation]

[immunochemotherapy]

• 2024-05-13 - rituximab 375mg/m2 540mg NS 500mL 7hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 85mg QD PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-04-12 - rituximab 375mg/m2 540mg NS 500mL 7hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 85mg QD PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-03-22 - rituximab 375mg/m2 540mg NS 500mL 7hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 85mg QD PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-02-19 - rituximab 375mg/m2 540mg NS 500mL 7hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 85mg QD PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-29 - rituximab 375mg/m2 540mg NS 500mL 7hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + liposome doxorubicin 30mg/m2 20mg D5W 250mL 2hr + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 85mg QD PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-03 - rituximab 375mg/m2 540mg NS 500mL 7hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min …………………………………………. + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 85mg QD PO D1-5 (R-CVP or R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-05-14

[neutropenia follow-up]

Neutropenia resolved after Granocyte (lenograstim) administration for 3 consecutive days beginning on 2024-05-09.

• 2024-05-13 WBC 6.96 x10^3/uL
  
• 2024-05-13 Neutrophil 54.7 %

2024-05-10

[grade 3 neutropenia developed]

Lab results indicated an ANC of 728/uL. Caution is advised when administering a new session of R-CHOP.

Treatment should ideally be started only after the ANC has risen at least above 1000/uL.

• 2024-05-09 Neutrophil 41.4 %
  
• 2024-05-09 WBC 1.76 x10^3/uL

2024-04-15

[reconciliation]

Hypocalcemia was observed with a calcium level of 1.87 mmol/L on 2024-04-15, for which a dose of IVD Calglon (calcium gluconate) was administered, followed by a prescription for oral calcium carbonate. All other lab parameters recorded on that date were grossly within normal limits, and there were no discrepancies in medication management.

2024-02-20

[immunochemo with graded doxorubicin addition & electrolyte management]

Liposomal doxorubicin was incorporated into the existing immunochemotherapy regimen on a gradual basis. The initial dose of 20mg was administered on 2024-01-29, followed by an escalation to 40mg on 2024-02-19.

Concomitantly, Const-K and calcium carbonate were used to manage hypokalemia (3.2mmol/L) and hypocalcemia (1.99mmol/L), respectively. No medication discrepancies were identified.

2024-01-26

[managing low platelet counts during cancer treatment]

Since Dec 2023, this patient has exhibited persistent thrombocytopenia, well before starting the R-COP regimen on 2024-01-03. While R-COP may contribute to this condition, it should not be considered the sole cause. Thrombocytopenia could also be a manifestation of the patient’s underlying DLBCL.

• 2024-01-26 PLT 39 *10^3/uL
• 2024-01-15 PLT 35 *10^3/uL
• 2024-01-10 PLT 57 *10^3/uL
• 2024-01-08 PLT 52 *10^3/uL
• 2024-01-07 PLT 53 *10^3/uL
• 2024-01-06 PLT 19 *10^3/uL
• 2024-01-05 PLT 30 *10^3/uL
• 2024-01-04 PLT 11 *10^3/uL
• 2024-01-03 PLT 16 *10^3/uL
• 2023-12-31 PLT 20 *10^3/uL
• 2023-12-30 PLT 32 *10^3/uL
• 2023-12-28 PLT 25 *10^3/uL
• 2023-12-26 PLT 29 *10^3/uL
• 2023-12-25 PLT 29 *10^3/uL
• 2023-12-20 PLT 33 *10^3/uL
• 2023-12-18 PLT 19 *10^3/uL
• 2023-12-14 PLT 42 *10^3/uL
• 2023-12-12 PLT 50 *10^3/uL
• 2023-12-12 PLT 67 *10^3/uL
• 2023-12-11 PLT 58 *10^3/uL
• 2023-12-11 PLT 24 *10^3/uL
• 2023-11-19 PLT 170 *10^3/uL

Patients being treated with cytotoxic chemotherapy have a suppressed bone marrow that often cannot produce adequate platelets. It is recommended to use prophylactic platelet transfusion in these settings, assuming the patient is hospitalized, afebrile, and without active infection. A threshold platelet count of 10K/uL (transfuse for a platelet count < 10K/uL) is generally used. If fever, sepsis, or coagulopathy is present, or if the patient is not hospitalized and/or cannot be closely monitored, higher thresholds may be needed. (Ref: https://www.uptodate.com/contents/platelet-transfusion-indications-ordering-and-associated-risks)

701338812

240509

[lab data]

2023-08-29 Anti-HBc Reactive
2023-08-29 Anti-HBc-Value 6.12 S/CO
2023-08-29 Anti-HBs 85.60 mIU/mL
2023-08-29 HBsAg Nonreactive
2023-08-29 HBsAg (Value) 0.35 S/CO

2023-08-29 Anti-HCV Nonreactive
2023-08-29 Anti-HCV Value 0.10 S/CO

[exam findings]

• 2024-04-23 CT - chest
  • Findings
    • Lungs: s/p RUL wedge resection with staple line and reticular opacities at apical lung region. minimal paraspinal fibrosis of RLL, related to irritation of adjacent osteophytes of spine
      • normal appearance of RML and left lung.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels:
      • Thoracic aorta: normal caliber, Central pulmonary arteries: normal caliber.
    • Heart: normal size of cardiac chambers. minimal calcified aortic valves
    • Chest wall and visible lower neck: marginal spurs of multiple vertebral bodies due to spondylosis
    • Visible abdominal contents: massive ascites is visible
  • Impression:
    • post op change in RUL. no new lung nodule.
• 2024-03-08 Patho - stomach subtotal/total (tumor)
  • Diagnosis
    • Stomach, prepyloris, s/p neoadjuvant chemotherapy followed by radical subtotal gastrectomy (S2024-4551) — intestinal metaplasia, many intramural mucinous pools, post chemotherapy effect. No residual tumor.
    • Lymph node, LN, 1,3, 4, 5, 6, 7, 8, 9, 10, 11, 12, LND2 resection (S2024-4551) — focal foreign body reaction, focal mucinous pools, focal nodal fibrosis; post chemotherapy effect. No residual tumor (0/66).
    • Pancreas capsule, excision (S2024-4551) — negative for malignancy.
    • Transverse colon, partial resection (S2024-4551) — ischemic change. No tumor.
    • Tissue labeled as “abdomen wall tumor”, excision and frozen section (F2024-81FS) — foreign body giant cell reaction. No malignancy.
    • ypT0 ypN0 (if cM0)
  • Gross Description:
    • Procedure - radical subtotal gastrectomy with LN D2 dissection + GJ anastomosis take down + T-colon partial resection : Stomach: lessuser curvature: 8 cm; greater curvature: 13 cm; duodenal cuff: 1.5 cm; mucosal erosion: 2 x 1.5 cm. anastomosis bowel: 5 cm
    • Tumor Site - prepyloris
    • Tumor Size - no residual tumor.
    • Gross configuration: no residual tumor.
    • Sections are taken and labeled as:
      • Tissue for frozen section: F2024-81FS: Tissue labeled as “abdomen wall tumor”.
      • Tissue for formalin fixation: (S2024-4551): A1: distal margin of the stomach; A2: proximal margin of the stomach; A3-9: erosion/tumor site; A10-12: non-tumor site; A13: anastomosis; A14: LN1; A15-17: LN3; A18-21: LN4; A22: LN5; A26-24: LN6; A25-27: LN (7, 8, 9, 10, 11, 12); A28: pancreas capsule; A29: bilateral cut ends of the transverse colon; A30: ischemic change site of the colon; A31: mesentery.
  • Microscopic Description:
    • Histologic Type - No residual tumor.
    • Histologic Grade - No residual tumor.
    • Tumor Extension - No residual tumor.
      • Margins
        • Proximal margin: uninvolved by invasive carcinoma
        • Distal margin: uninvolved by invasive carcinoma
        • Radial margin: uninvolved by invasive carcinoma
      • Lymphovascular Invasion: not identified
        
      • Perineural Invasion: not identified
        
      • Regional Lymph Nodes
        • Number of lymph nodes examined/involved: 0 / 66 = A14: LN1 (0/0); A15-17: LN3 (0/10); A18-21: LN4 (0/11); A22: LN5 (0/2); A23-24: LN6 (0/10) ; A25-27: LN (7, 8, 9, 10, 11, 12) (0/31); A28: pancreas capsule (0/2). .
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition): no residual tumor.
        • TNM Descriptors (required only if applicable) (select all that apply)
        • y (posttreatment)
        • Primary Tumor (pT) - ypT0: No residual tumor
        • Regional Lymph Nodes (pN) - ypN0: No regional lymph node metastasis
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case) If cM0
      • Additional Pathologic Findings
        • Intestinal metaplasia
        • Other (specify): mucinous pools, foreign body giant cell reaction.
      • Ancillary Studies - none
        
      • Comment(s) - none.
• 2024-03-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 37) / 122 = 69.67%
    • M-mode (Teichholz) = 69.4
  • Conclusion:
    • Adequate LV,RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild MR, TR, AR, PR
• 2024-03-05 Flow Volume Chart
  • Mild obstructive ventilatory impairment
• 2024-02-01 MRI - upper adbomen
  • Indication: epigastric pain for recent one months.
  • Abdominal MRI with and without IV contrast enhancement shows:
    • status post gastrojejunostomy bypass
    • Gastric wall thickneing at antrum is found. In comparison with CT dated on 2023-12-15, the lesion is stationary.
    • Small lymph nodes are found at periantral region. However, the lesions are non-specific
    • Tiny hepatic cyst measuring 0.8cm in largest dimension is found at S7/8 (Se13 Im10).
• 2024-01-16 Tc-99m MDP bone scan
  • Increased activity in the middle and lower T-spines and L4-5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2024-01-15 MRI - brain
  • Indication: Adenocarcinoma of right upper lobe lung post operation 3 dimensions video-assisted thoracoscopic surgery right upper lobe wedge resection and radical lymph node dissection 2023/12/29.
  • Findings:
    • Mild degree of general enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
    • Ossification of posterior longitudinal ligament causing spinal canal stenosis at visible C1-2 levels.
  • IMP:
    • Mild general brain atrophy. OPLL at C-spine. No evidence of brain metastasis.
• 2024-01-12 PET scan
  • Mild glucose hypermetabolism in the stomach around the previous operative area and in two focal areas in the peripyloric area. The nature is to be determined (residual or recurrent malignancy? inflammation?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the upper lobe of right lung and in the right lateral chest wall. Post-operative inflammation may show this picture.
  • Mild glucose hypermetabolism in bilateral pulmonary regions. Inflammatory process may show this picture.
• 2024-01-01 CXR erect
  • s/p right chest tube in place, its tip directed superomedially, projecting over 3rd rib
  • Port-A catheter inserted into SVC via left subclavian vein.
  • s/p RUL wedge resection
  • Rt pneumothorax in regression
  • Subcutaneous emphysema in the right neck and chest wall.
• 2023-12-29 Patho - lung wedge biopsy
  • Diagnosis
    • Lung, right, upper lobe, VATS wedge resection (S2023-26261A) and biopsy with frozen section (F2023-583FS) —- adenocarcinoma.
      • IHC stains: Napsin-A (+), TTF-1 (+), CK5/6 (-), p40 (-), CD56 (-).
    • Lymph node, ipsilateral (group No. 2+4), lymphadenectomy (S2023-26261B) —– free
    • pT1b pN0 (if cM 0); Pathology stage: IA2, at least
  • Gross Description
    • Specimen received:
      • Lung, size:_biopsy specimen: 0.6 x 0.3 x 0.2 cm; wedge resection specimen: 10 x 5 x 4 cm
        
      • Lymph nodes, 1bottle, maximal size: 1.0 x 0.4 x 0.3 cm
    • Tumor Site: Peribronchial
    • Gross Tumor Size:
      • Solitary : 1.1 x 1.0 x 1.0 cm
    • Gross tumor patterns: Well defined
      • Representative sections are taken and labeled as:
        • Tissue for frozen section: F2023-583FS: RUL biopsy.
        • Tissue for formalin fixation: S2023-26261A RUL wedge resection specimen: A1-3: tumor; A4-8: non-tumor; B: LN2+4.
  • Microscopic Description
    • Tumor Size - 1.1 x 1.0 x 1.0 cm.
    • Tumor Focality - Single tumor
      • Note: Required elements that differ among the tumor nodules (eg, tumor size, histologic type) should be reported for each tumor nodule.
    • Histologic Type (select all that apply) - Invasive adenocarcinoma, acinar predominant (100 %)
    • Histologic Grade (according to the main histological type) - G1: Well differentiated
    • Spread Through Air Spaces (STAS) - Not identified
    • Visceral Pleura Invasion - Not identified
    • Lymphovascular Invasion (select all that apply) - Not identified
    • Direct Invasion of Adjacent Structures (select all that apply) - No adjacent structures present
    • Margins (select all that apply) - All margins are uninvolved by carcinoma
    • Distance of invasive carcinoma from closest margin (centimeters): 2.5 cm
    • Specify closest margin: resection stapled margin.
    • Treatment Effect - No known presurgical therapy
    • Lymph Node Examination (required only if the lymph nodes present in the specimen) - free (right group 2+4: 0/10
    • Extranodal Extension - Not identified
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition) – IA2, at least
      • Note: Reporting of pT, pN, and (when applicable) pM categories is based on information available to the pathologist at the time the report is issued. Only the applicable T, N, or M category is required for reporting; their definitions need not be included in the report. The categories (with modifiers when applicable) can be listed on 1 line or more than 1 line.
    • TNM Descriptors (required only if applicable) (select all that apply) - N/A.
      • Primary Tumor (pT) - pT1b: Tumor >1 cm, but <=2 cm in greatest dimension
        • Note: Tumors with these features are classified as T2a if <=4 cm or if the size cannot be determined and T2b if >4 cm but <=5 cm.
      • Regional Lymph Nodes (pN) - pN0: No regional lymph node metastasis
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case) - if cM0
    • Additional Pathologic Findings (select all that apply) - None identified
    • Ancillary Studies - IHC stains: Napsin-A (+), TTF-1 (+), CK5/6 (-), p40 (-), CD56 (-).
      • Note: For reporting cancer biomarker testing results, the CAP Lung Biomarker Template should be used. Pending biomarker studies should be listed in the Comments section of this report.
• 2023-12-28 ECG
  • Normal sinus rhythm
  • Possible Septal infarct, age undetermined
  • Abnormal ECG
• 2023-12-28 CXR
  • Subtle nodular increased opacity over peripheral of RUL
  • Marginal spurs of multiple vertebral bodies of T-spine due to spondylosis.
  • Port-A catheter inserted into SVC via left subclavian vein.
• 2023-12-15 CT - abdomen
  • History: Gastric cancer of antrum with pancreatic neck invasion, cT4bN2M0 stage IVA status post gastrojejunostomy bypass on 2023/08/28
  • Findings:
    • There is a newly developed small ground-glass opacity 1 cm at RUL of the lung (Srs:301 Img:10). Primary lung cancer is highly suspected.
      • In addition, there are few lymph nodes in para-tracheal space.
      • Follow up is indicated.
    • Prior CT identified wall thickening at gastric antrum is noted again, marked decreasing in wall thickness. Please correlate with gastroscopy.
    • Prior CT identified peri-gastric lymph nodes are noted again, decreasing in size.
    • A liver cyst 0.6cm in S8.
    • status post gastrojejunostomy bypass
  • Impression:
    • Primary lung cancer 1 cm in RUL is highly suspected.
    • Prior CT identified wall thickening at gastric antrum is noted again, marked decreasing in wall thickness. Please correlate with gastroscopy.
    • Prior CT identified peri-gastric lymph nodes are noted again, decreasing in size.
• 2023-11-21 ECG
  • Marked sinus bradycardia
• 2023-08-29 Body fluid cytology - ascites
  • Negative
• 2023-08-22 CT - abdomen
  • Clinical history: 72 y/o male patient with gastric ulcer r/o cancer.
  • Findings
    • Wall thickening at gastric antrum with ulceration, r/o gastric malignancy.
    • Presence of perigastric lymph nodes.
    • R/O liver cyst, 0.6cm in S8 liver.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:IVA__(Stage_value)
  • Impression:
    • Gastric antrum tumor with ulceration with perigastric lymph nodes, r/o gastric malignancy, if proven malignancy, cstage T4bN2M.
    • R/O liver cyst.
• 2023-08-22 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 30.6) / 120 = 74.5%
    • M-mode (Teichholz) = 74.5
    • 2D (M-Simpson) = 53.9
  • Conclusion:
    • Thickened AV with moderate AR
    • Normal MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
• 2023-08-10 Patho - stomach biopsy
  • Stomach, antrum, biopsy — Ulcer with high-grade gastric dysplasia, and H.pylori present
    • note: If clinical suspicion of malignant tumor persists, re-biopsy is recommended.
  • Microscopically, it shows ulcer with necrotic debris, hemorrhage, leukocytic infiltrate and high-grade dysplasia of gastric mcuosa with nuclear hyperchromasia and plemorphism. Helicobacter-like bacilli are seen.
  • Immunohistochemical stain of CK is negative for invasive lesion.
• 2023-08-10 EGD
  • Reflux esophagitis, lower esophagus, LA classification, grade A
  • Gastric ulcerative lesion, rule out advanced gastric cancer type III, antrum, s/p biopsy
  • Rule out gastric outlet obstruction related to the antral lesion
  • Incomplete study, food in stomach and failed to enter duodenum

[MedRec]

• 2024-03-04 ~ 2024-03-15 POMR General and Gastroenterological Surgery Wu ChaoQun
  • Discharge diagnosis
    • Gastric cancer of antrum with pancreatic neck invasion, cT4bN2M0 stage IVA post neoadjuvant chemotherapy status post radical subtotal gastrectomy with D2 lymph node dissection + T-colon partial resection on 2024/03/07. ECOG:1, ypT0ypN0(cM0).
    • Essential (primary) hypertension
  • CC
    • For gastrectomy +/- pancreatectomy
  • Present illness
    • This 74 year-old man patient has past history of 1. Gastric cancer of antrum with pancreatic neck invasion, cT4bN2M0 stage IVA status post gastrojejunostomy bypass on 2023/08/28 s/p chemotherapy with biweekly FLOT (Docetaxel 50mg/m2, Oxalip 85mg/m2, LV 200mg/m2, 5FU 2600mg/m2) plus Nivolumab (3mg/kg, 200mg –> self pay) on 2023/09/22~; 2. Adenocarcinoma of right upper lobe lung post operation 3 dimensions video-assisted thoracoscopic surgery right upper lobe wedge resection and radical lymph node dissection 2023/12/29.
    • Initial, he sufferred from poor intake with postprandial fullness and poor appetite with body weight loss 10kg in recent half years. Then he came to LMD for help. UGI scope showed gastric ulcer with moderate dysplasia. Then he referred to our hospital for further management. Repet PES on 2023/08/10 showed reflux esophagitis, lower esophagus, LA classification, grade A, gastric ulcerative lesion, rule out advanced gastric cancer type III, antrum, s/p biopsy, rule out gastric outlet obstruction related to the antral lesion and incomplete study, food in stomach and failed to enter duodenum. Stomach, antrum, biopsy pathology showed ulcer with high-grade gastric dysplasia, and H.pylori present.
    • Tumor marker on 2023/07/18 of CEA:2.25ng/ml CA199:385.56 U/ml.
    • 2D echo on 2023/08/22 showed M-mode (Teichholz) = 74.5, 1. Thickened AV with moderate AR 2. Normal MV with mild MR 3. Normal LV chamber size and wall thickness 4. Preserved LV and RV systolic function 5. Mild PR, mild TR, normal IVC size.
    • Abdominal CT on 2023/08/22 showed 1. Gastric antrum tumor with ulceration with perigastric lymph nodes, r/o gastric malignancy, if proven malignancy, cstage T4bN2M, stage IVA. 2. R/O liver cyst. GJ bypass and Port-A catheter insertion on 2023/08/28. Perioperative chemotherapy with biweekly FLOT(Docetaxel 50mg/m2, Oxalip 85mg/m2, LV 200mg/m2, 5FU 2600mg/m2) plus Nivolumab (3mg/kg, 200mg –> self pay (buy 5 free 1) #1) on 2023/09/22 (C1D1), on 2023/10/17 (C1D15, Nivolumab 3mg/kg, 200mg 贈), on 2023/11/04 (C2D1, 3mg/kg, 200mg, self-paid #2), on 2023/11/18 (C2D15, 3mg/kg, 200mg, self-paid #3), on 2023/12/14 (C3D1, 3mg/kg, 200mg, self-paid #4), on 2024/01/17 (C3D15, 3mg/kg, 200mg, self-paid #5).
    • Followed-up Abdomen CT on 2023/12/15 revealed 1. Primary lung cancer 1 cm in RUL is highly suspected. 2. Prior CT identified wall thickening at gastric antrum is noted again, marked decreasing in wall thickness. Please correlate with gastroscopy. 3. Prior CT identified peri-gastric lymph nodes are noted again, decreasing in size. Due to suspected primary lung cancer in RUL, he visited to CS OPD and be hospitalized, then received operation of 3 dimensions video-assisted thoracoscopic surgery right upper lobe wedge resection and radical lymph node dissection was performed smoothly on 2023/12/29.
    • He denied poor appetite, body weight loss, abdominal pain or abdominal fullness. At OPD, upper abdomen MRI revealed (2) Gastric wall thickneing at antrum is found. In comparison with CT dated on 2023-12-15, the lesion is stationary. (3) Small lymph nodes are found at periantral region. However, the lesions are non-specific. After discussiing with Dr. Wu, he was admitted to ward for nutrition support and gastrectomy +/- pancreatectomy.
  • Course of inpatient treatment
    • After admission, radical subtotal gastrectomy with LN D2 dissection + T-colon partial resection was processed successfully on 2024/03/04. Pathologic report was pending The post-operative course was relatively smooth without complication.
    • During the hospitalization, the empiric antibiotic, stool softener and analgesic agent were administered and the wound management was performed. There were no nosocomial infection and other complications. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. In a relatively stable condition, the patient was discharged, and an OPD follow-up will be arranged.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID 7D
    • Mosapin (mosapride citrate 5mg) 1# TID 7D
    • Takepron (lansoprazole 30mg) 1# QDAC 7D
    • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# Q12H 3D
• 2023-09-20 ~ 2023-09-25 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Gastric cancer of antrum with pancreatic neck invasion, cT4bN2M0 stage IVA status post gastrojejunostomy bypass on 2023/08/28 s/p chemotherapy with biweekly FLOT (Docetaxel 50mg/m2, Oxalip 85mg/m2, LV 200mg/m2, 5FU 2600mg/m2) plus Nivolumab (3mg/kg, 200mg, self pay) on 2023/09/22~
    • Chronic viral hepatitis B without delta-agent
    • Essential (primary) hypertension
  • CC
    • For perioperative chemotherapy with FLOT plus Nivolumab (C1D1).
  • Present illness
    • This 72 year old man patient sufferred from poor intake with postprandial fullness and poor appetite with body weight loss 10kg in recent half years. Then he came to LMD for help. UGI scope showed gastric ulcer with moderate dysplasia. Then he referred to our hospital for further management. Repeat PES on 2023/08/10 showed reflux esophagitis, lower esophagus, LA classification, grade A, gastric ulcerative lesion, rule out advanced gastric cancer type III, antrum, s/p biopsy, rule out gastric outlet obstruction related to the antral lesion and incomplete study, food in stomach and failed to enter duodenum. Stomach, antrum, biopsy pathology showed ulcer with high-grade gastric dysplasia, and H.pylori present. Tumor marker on 2023/07/18 of CEA:2.25ng/ml CA199:385.56 U/ml. 2D echo on 2023/08/22 showed M-mode(Teichholz) = 74.5, 1. Thickened AV with moderate AR 2. Normal MV with mild MR 3. Normal LV chamber size and wall thickness 4. Preserved LV and RV systolic function 5. Mild PR, mild TR, normal IVC size. - Abdominal CT on 2023/08/22 showed 1. Gastric antrum tumor with ulceration with perigastric lymph nodes, r/o gastric malignancy, if proven malignancy, cstage T4bN2M, stage IVA. 2. R/O liver cyst. GJ bypass and Port-A catheter insertion on 2023/08/28. Now, he was admitted to ward for perioperative chemotherapy with biweekly FLOT (Docetaxel 50mg/m2, Oxalip 85mg/m2, LV 200mg/m2, 5FU 2600mg/m2) plus Nivolumab (3mg/kg, 200mg, self pay) (C1D1) on 2023/09/22.
  • Course of inpatient treatment
    • After admitted, Dorison 1# po BID and Famotidine 1# po BID D1~D3 from 2023/09/21~2023/09/23.
    • Perioperative chemotherapy with biweekly FLOT (Docetaxel 50mg/m2, Oxalip 85mg/m2, LV 200mg/m2, 5FU 2600mg/m2) plus Nivolumab (3mg/kg, 200mg, self pay, buy 5 and get 1 free) (C1D1) on 2023/09/22~2023/09/23.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • Chronic viral hepatitis B without delta-agent(Anti-HBc(+)) with Vemlidy 1# po QD.
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, he was discharged on 2023/09/25 and OPD followed up later.       
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2023-09-12 SOAP Hemato-Oncology Xia HeXiong
  • P: Admission for Perioperative C/T with FLOT or FOLFOX plus Nivolumab
• 2023-08-21 POMR General and Gastrointestinal Surgery Wu ChaoQun
  • Discharge diagnosis
    • Gastric cancer of antrum with pancreatic neck invasion, cT4bN2M0 stage IVA status post gastrojejunostomy bypass on 2023/08/28. ECOG:1
    • Essential (primary) hypertension
  • CC
    • Poor intake with postprandial fullness and poor appetite with body weight loss 10kg in recent half years.
  • Present illness
    • This 72 year old male with past history of hypertension without regular follow up. This time, he sufferred from poor intake with postprandial fullness and poor appetite with body weight loss 10kg in recent half years. Then he came to LMD for help. UGI scope showed gastric ulcer with moderate dysplasia. Then he referred to our hospital for further management.
    • Repeat UGI scope also revealed gastric ulcerative lesion, rule out advanced gastric cancer type III, antrum, status post biopsy. Pathology showed ulcer with high-grade gastric dysplasia, and H.pylori present. Tumor marker of CEA:2.25ng/ml CA199:385.56 U/ml. He denied of fever, chills, dizzness, vomiting or tarry stool.
    • Under impressed of gastric ulcer with high grade dysplasia and suspect of malignancy, he was admitted for nutrition support first and further surgical intervention.
  • Course of inpatient treatment
    • After admission, pre-operation survey was done and no abnormality. TPN was also given for pre-operation nutrition support. He received operation on 8/28 then operation finging showed distal pylroic tumor with direct invasion to posterior pancreas neck and multiple LN at peripyloric area were noted.
    • Due to above of the finding and poor nutrtion with this case, GJ bypass was performed first. Post operaively, we observed patient recovery and keep empiric antibiotic, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed. He try to introduced liquid diet with step by step and until to semi-liquid diet was tolerate well. His generally well beings and relativley stable.
    • We consulted Oncology for further chemotherapy with immunotherapy, then the regimen will be arrange at OPD. There were no nosocomial infection and other complications and vital signs were stable after the surgery. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Abdomen wound clean and removal JP tube was done smoothly on 9/2.
    • Under improved general condition, he was allowed to discharge today and GS and Oncology OPD follow up was arranged.
  • Discharge prescription
    • Olmetec (olmesartan medoxomil 20mg) 1# QD
    • Acetal (acetaminophen 500mg) 1# QID
    • Rich (lansoprazole 30mg) 1# QDAC
    • Mopride (mosapride citrate 5mg) 1# TID

[consultation]

• 2023-08-31 Hemato-Oncology
  • Q
    • for neoadjuvant chemotherapy with immunotherapy, we will planning for further operation after 3 months later
    • This 72 y/o male with past history hypertension without regular follow up. This time, he diagnosis for gastric ulcerative with high grade dysplasia and suspect of malignancy then was admitted on 8/21. He received operation on 8/28 then operation finging showed distal pylroic tumor with direct invasion to posterior pancreas neck and multiple LN at peripyloric area were noted. Due to above of the finding and poor nutrtion with this case, GJ bypass was performed first. After operation, we need your help for neoadjuvant systemic chemotherapy + immunotherapy for 3 months first, then we will planning for further tumor resection procedure after 3 moths later.
  • A
    • Patient examined and Chart reviewed. A case of locally far advanced gastric cancer is ntoed. I am consulted for the further management with neoadjuvant treament.
    • My suggestiolns:
      • Already discuss with patient and family regarding chemotehrapy (FOLFOX or FLOT) plus immune checkpoint inhibitor
      • Please arrange my OPD if discharge
    • Thanks for your consultation. Any problem, please let me know.
• 2023-08-22 Gastroenterology
  • Q
    • nutrition support with TPN
    • This 72 y/o male with past history of hypertension without regular follow up. This time, he sufferred from poor intake with postprandial fullness and poor appetite with BW loss 10kg in recent half years. Then he came to LMD for help. UGI scope showed gastric ulcer with moderate dysplasia. Then he referred to our hospital for further management. Repeat UGI scope also revealed gastric ulcerative lesion, rule out advanced gastric cancer type III, antrum, s/p biopsy. Pathology showed ulcer with high-grade gastric dysplasia,and H.pylori present. Under impressed of gastric ulcer with high grade dysplasia and suspect of malignancy, he was admitted on 8/21, then further operation with subtotal gastrectomy will be arrange. Pre-operative nutrition support with TPN is planning. Thanks for your time!!
  • A
    • A case of suspect gastric cancer who request pre-op nutrition support.
      • General appearance: ill looking
      • GI tract: Dysphagia (-), Abd pain (-), Abd distension (-), Nausea (-), Vomiting (-), Diarrhea (-), Poor appetite (-), Poor digestion (+), BW loss (+, 10kg/6M) , stool (+), Bowel sound (-)
        
      • Feeding: Full liquid diet as tolerance
      • Allergy: NKA
    • Nutrition assessment:
      • BH 164cm BW 51.5kg
      • IBW 59kg 87%IBW BMI 19.2
        
      • BEE (calculated based on IBW) 1211kcal TEE 1890kcal
    • Lab data: Alb 4.0 TP 6.8 Na 138 K 3.5 BS 100
    • According to the patient`s present conditions, parenteral nutrition plus enteral feeding (as tolerance) will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
    • PN use recommendation:
      • DC SMOFkabiven peri 1440ml QD
      • SMOFkabiven central 1477ml QD, 61.5ml/hr
      • Lyo-Povigent 4ml/QD (add in TPN) (if not availabe, then swift to B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
      • Addaven 10ml/QD (add in TPN)
    • Items to be monitored when PN use
      • TPN is for single route, do not mix with other drugs except TPN drugs.
      • Check BW QW5 and record I/O Q8H
      • Check one touch Q6H x 2 days, if stable QD check
      • Please control BS <200 mg/dl with RI sliding scale
      • QW1 check CBC/DC
      • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
      • When TPN is insufficient, replace with YF5 or D10W.

[surgical operation]

• 2024-03-07
  • Surgery
    • radical subtotal gastrectomy with LN D2 dissection
    • GJ anastomosis take down
    • T-colon partial resection due to ischemia
  • Finding
    • prepyloris gastric tumor with outlet obstruction
    • pancreas neck capsule fibrosis without tumor invasion
    • no tumor seeding or ascite
  • Procedure
    • ETGA
    • upper midline laparotomy
    • resection peritoneal lesion and frozen shows foreign body reaction without tumor
    • subtotal gastrectomy with GJ anastomosis take down
    • LN1,3,4,5,6,7,8,9,11p,12a resection
    • T-colon segmental resection with side to side anastomosis
    • Roux-en-Y GJ anastomosis
    • peritoneal lavage
    • two J-vac inserted
    • wound closed
• 2023-12-29
  • Surgery
    • 3D VATS RUL wedge resection + LND.
  • Finding
    • One GGO lesion was noted over RUL, size about 1.0cm in diameter.
    • Frozen section: adenocarcinoma.
    • One 20 Fr. straight chest tube was inserted via right 4th ICS.
• 2023-08-28
  • Surgery
    • GJ bypass
    • port A insertion
  • Finding
    • distal pylroic tumor with direct invasion to posterior pancreas neck
    • multiple LN at peripyloric area
    • no ascite
    • no liver mets
    • no peritoneal seeding
    • patient’s daugther decide GJ bypass and Port-A insertion

[immunochemotherapy]

• 2024-05-09 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 65mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (Opdivo + FLOT)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-03-07 (radical subtotal gastrectomy)

• 2024-02-05 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 65mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (Opdivo + FLOT)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-01-18 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 65mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (Opdivo + FLOT)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

• 2023-12-14 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 65mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (Opdivo + FLOT)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

• 2023-11-17 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 60mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 240mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (Opdivo + FLOT)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-11-03 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 60mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 350mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3000mg NS 500mL 24hr (Opdivo + FLOT)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-10-17 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 60mg D5W 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 4000mg NS 500mL 24hr (Opdivo + FLOT)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-09-21 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 60mg D5W 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 4000mg NS 500mL 24hr (Opdivo + FLOT)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-02-05

[no more leukopenia now, checking WBC left shifts]

A leukopenia episode was observed with a notably low WBC count of 1.82K/uL on 2024-02-02, following approximately two weeks after the last Opdivo + FLOT treatment on 2024-01-18. The timely administration of Granocyte (lenograstim) has effectively resolved the leukopenia as of the current date.

• 2024-02-05 Metamyelocyte 1.9 %
  

• 2024-02-05 Promyelocyte 1.0 %

• 2024-02-05 WBC 13.12 x10^3/uL 2024-02-05 Opdivo + FLOT

• 2024-02-02 WBC 1.82 x10^3/uL ***

• 2024-01-23 WBC 4.40 x10^3/uL

• 2024-01-17 WBC 3.72 x10^3/uL 2024-01-18 Opdivo + FLOT

• 2024-01-10 WBC 6.61 x10^3/uL

• 2023-12-28 WBC 15.72 x10^3/uL

• 2023-12-26 WBC 2.01 x10^3/uL **

• 2023-12-14 WBC 6.16 x10^3/uL 2023-12-14 Opdivo + FLOT

• 2023-11-28 WBC 2.84 x10^3/uL *

• 2023-11-21 WBC 4.20 x10^3/uL

• 2023-11-17 WBC 2.54 x10^3/uL * 2023-11-17 Opdivo + FLOT

• 2023-11-03 WBC 2.26 x10^3/uL ** 2023-11-03 Opdivo + FLOT

• 2023-11-01 WBC 2.17 x10^3/uL **

• 2023-10-11 WBC 3.22 x10^3/uL 2023-10-17 Opdivo + FLOT

• 2023-10-04 WBC 2.82 x10^3/uL *

• 2023-09-21 WBC 4.21 x10^3/uL 2023-09-21 Opdivo + FLOT

• 2023-09-01 WBC 5.35 x10^3/uL

The differential WBC count continues to exhibit a left shift, warranting an investigation to exclude the presence of an infection.

2023-12-15

The lab data from 2023-12-14, as well as TPR readings, appear generally normal. After reviewing the PharmaCloud and HIS5 records, no discrepancies were found in the active medication list.

2023-10-17

No discrepancy in the medication is found after a review of the PharmaCloud and HIS5 records.

701519553

240509

[exam findings]

• 2024-04-08 Patho - stomach biopsy
  • PATHOLOGIC DIAGNOSIS
    • Stomach, antrum, exploratory laparotomy with excision of ulcer and repair
      • — Malignant B-cell lymphoma
        
      • — Ulcer with perforation
  • MACROSCOPIC DESCRIPTION
    • Operation procedure: exploratory laparotomy with excision of ulcer and repair
    • Topology: gastric antrum
    • Specimen size and number: one small piece measured 5.3 x 2.4 x 0.3 cm in size with inflammatory exudate coated at serosal fat. Representatively embedded for section in two cassettes.
  • MICROSCOPIC EXAMINATION
    • Histology type: B-cell lymphoma, compatible with diffuse large B-cell lymphoma shows large atypical lymphoid cells with nucleoli. Please refered to S2024-06146 for detailed description. Besides, ulcer with transmural inflammation and acute suppurative serositis with foreign body and abscess, compatible with perforation
    • Immunohistochemistry: CK(-), CD3(-) and CD20(+) for atypical lymphoid cell
• 2024-04-08 KUB
  • S/P operation.
  • S/P NG tube indwelling.
  • Presence of ileus.
  • Radiopaque spots at pelvic region.
• 2024-04-03 CT - abdomen
  • Non-contrast CT of abdomen-pelvis revealed:
    • Pneumoperitoneum.
    • Distention of stomach.
    • Atherosclerosis of aorta, iliac arteries.
    • A calcification (5.7mm) at LLL.
  • IMP:
    • Pneumoperitoneum.
    • Distention of stomach.
• 2024-04-03 ECG
  • Normal sinus rhythm
  • Nonspecific T wave abnormality
  • Prolonged QT
• 2024-04-01 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (85 - 28) / 85 = 67.06%
    • M-mode (Teichholz) = 67
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Trivial MR, mild to moderate TR and trivial PR
    • Mild pulmonary hypertension
    • Preserved RV systolic function
• 2024-03-29 PET
  • Glucose hypermetabolism in the body and antrum of the stomach, compatible with lymphoma.
    
  • Mild glucose hypermetabolism in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation may show this picture.
    
  • Increased FDG accumulation in a focal area in the region about the middle portion of the transverse colon. The nature is to be determined (physiological FDG accumulation? other nature?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in a focal area in the left aspect of maxilla. Dental problem may show this picture.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
• 2024-03-27 CT - chest
  • Without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Lungs: a 6mm LLL perifissural granuloma, a 4mm RML perifissural granuloma, and a 3mm anterior RUL perifissural nodule, and a 4mm granuloma at posterior RUL (srs/img 202/123,101,104,52).
      • posterior fine reticular at LLL and RLL, likely fibrosis
    • Mediastinum and hila: many small LNs at A-P window, insignificant based on CT exam.
      • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance. no coronary arterial calcificatiion.
    • Heart: normal size of cardiac chambers.
    • Pleura: no effusion.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal-pelvic contents: a large infiltrative tumor with a large ulceration, causing asymmetic wall thickening of lower body and antral part of the stomach.
      • mild hyperplasia of both adrenal glands.
      • mild atherosclerosis of abdominal aorta and bilateral CIAs.
  • Impression:
    • large gastric with a large ulceration, lymphoma.
    • several small granulomas in the lungs. no LAP in chest and visible neck.
• 2024-03-27 Patho - stomach biopsy
  • Stomach, lower body and distal antrum, biopsy — Diffuse large B-cell lymphoma, non-GCB subtype
  • Section shows fragments of gastric tissue ulcer and infiltration of large lymphoid cells.
  • The immunohistochemical stains reveal CD3(-), CD20(+), CD10(-), CD5(-). CD30(-), BCL2(+), BCL6(+), cMYC(-), MUM1(+), Cyclin D1(-), and CK(-). The Ki-67 is > 80%.
• 2024-03-26 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Free of lymphoma involvement
    • Immunohistochemical stains:
      • MPO: positive for myeloid series
      • CD71: positive for erythroid series
      • CD61: positive for megakaryocytes
      • CD34: positive for blast
      • CD117: positive for blast
      • CD20: positive for B-cell
      • CD3: positive for T-cell
  • Microscopically, the section shows pictures as follows:
    • Normocellularity for his age, 30%
    • M/E ratio about 2/1, normal matureation of myeloid series and erythroid series
    • Adequate megakaryocytes with focal mononucleation and hyposegmentation
    • No increase of blast
    • Scatter T lymphocytes
    • Scatter B lymphocytes. It is free of lymphoma involvement
• 2024-03-26 EGD
  • Diagnosis:
    • Gastric large ulcerative fungated tumor, lower body and distal antrum, suspect lymphoma and adenocarcinoma, s/p biopsy
    • Superficial gastritis, s/p CLO test
    • Suboptimal study due to food residue
  • CLO test: Positive
  • Suggestion:
    • No active bleeding
    • Suboptimal study due to food residue
    • pursue pathology and CLO test
    • PPI therapy

[MedRec]

• 2024-04-22 SOAP Hemato-Oncology Yang MuJun
  • S
    • refill entecavir
    • add three-in-one for H.P eradication (2 weeks)
    • admit on 2024-05-06 for C2 R-CDOP (Day1 R, Day 2 C, Day 3 D, Day 4 O, D1-D5 P) BW:52kg
  • A
    • Gastric DLBCL
  • P
    • Amoxicillin (1 gram) Twice daily x14 days
    • Clarithromycin (500 mg) Twice daily x14 days
    • Esomeprazole 40 mg Twice daily x14 days
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Klaricid (clarithromycin 500mg) 1# BID
    • ammoxicillin 250mg 4# BID
    • Nexium (esomeprazole 40mg) 1# BIDAC
• 2024-03-25 ~ 2024-04-03 POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • Diffuse large B-cell lymphoma of Stomach, lower body and distal antrum, biopsy, stage IE, IPI:1
    • Encounter for antineoplastic chemotherapy
  • CC
    • tarry stool for 2days.
  • Present illness
    • This is a 71yrs old male, history of Diffuse large B-cell lymphoma, gastric lymphoma just diagnosis at MOHW TaoYuan Hospital.
    • This time, he suffered from tarry stool for 2days. He visited our Hematology and Oncology OPD for help today then referred to ER for admission. He also accompany body weight loss 3~4 kg in a half-year.
    • At MER, the vital sign: blood pressure 108/56mmHg; pulse 89 rate/min; temperature 36.1’C; respiratory rate 20 rate/min; Con’s E4V5M6; saturation 99%. The laboratory data disclosed WBC 7.95*10^3/uL, N.seg 78.2%, Glucose 148mg/dL, PLT 266K/uL, HGB 10mg/dl. The chest film showed no active lung lesion. The EKG shows normal sinus rhythm. Under the impression of Diffuse large B-cell lymphoma, gastric lymphoma, he was admitted to Hematology and Oncology ward for management.
  • Course of inpatient treatment
    • After admission, arrange PES for tarry stool on 2024/03/26 and diagnosis: Gastric large ulcerative fungated tumor, lower body and distal antrum, suspect lymphoma and adenocarcinoma, s/p biopsy. Arrange Bone marrow on 2024/03/26 was done smoothly, pending of report.
    • PPI with pantoprazole 40mg IVD Q12H for tarry stool.
    • Antifibrinolytics with transamin 500mg IV Q12H.
    • IVF with N/S 500ml plus b-complex 1amp QD.
    • Constipation with sennoside 2# HS.
    • Hypocalcemia with calcium gluconate 10ML qd.
    • CT image on 2024/03/27 and revealed impression: large gastric with a large ulceration, lymphoma. several small granulomas in the lungs. no LAP in chest and visible neck. Consult GS for port-a insertion on 2024/03/28.
    • PET scan shows glucose hypermetabolism in the body and antrum of the stomach, compatible with lymphoma. 2D echo shows EF 67%, Conclusion: 1. Adequate LV systolic function with normal resting wall motion 2. Septal hypertrophy 3. Trivial MR, mild to moderate TR and trivial PR 4. Mild pulmonary hypertension 5. Preserved RV systolic function.
    • 2024-03-29 17:21 PATHO-bone marrow biopsy revealed free of lymphoma involvement. 2024-04-01 16:45 PATHO-stomach biopsy of lower body and distal antrum, biopsy shows Diffuse large B-cell lymphoma, non-GCB subtype. Thus, adjuvent chemotherapy with RCOP (Mebthra 375mg/m2, endoxan 750mg/m2, vincristine 1.4mg/m2) from 2024/04/01 (C1).
    • Steroid with Compesolon 17# po qd on 2024/04/01~2024/04/05. PPI shift to oral from to back. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2024/04/03 and OPD followed up later.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Const-K (KCl 750mg/10mEq) 1# TID
    • Through (sennoside 12mg) 2# HS
    • Compesolon (prednisolone 5mg) 17# QD for 2024-04-04 and 2024-04-05
    • Nexium (esomeprazole 40mg) 1# QDAC

[consultation]

• 2024-04-03 General and Gastroenterological Surgery
  • Q
    • CC bil. ribs pain while breathing since this morning
    • no dyspnea, no chest tightness, no abdominal pain, no dysuria, no URI symptom
    • PH: Diffuse large B-cell lymphoma
    • NKDA
  • A
    • A case of acute epigastric pain for one day
      • no chills. no fever
      • no passage of tarry stools
    • P.E showed diffuse local tenderness over whole abdomen with muscle guarding
    • Lab and Computed Tomography of Abdomen disclosed pneumoperitonmeum by hollow organ perforation
    • Emergency op is indicated, however, anethesia risk is very high!

[surgical operation]

• 2024-04-03
  • Surgery
    • Exploratory laparotomy with excision of ulcer, primary repair and multiple darinage
  • Finding
    • A gastric ulcer with perforation, antrum, ant. wall, 2cm in size - possible malignancy
    • A lot of purulent fluid over whole abdominal spaces, 100ml in amount
    • No liver or mesentary metastasis

[immunochemotherapy]

• 2024-05-09 - rituximab 375mg/m2 540mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 20mg D5W 250mL 2hr D3 + vincristine 1.4mg/m2 2mg NS 50mL 10min D4 + prednisolone 60mg/m2 90mg PO D1-5 (R-CDOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-01 - rituximab 375mg/m2 540mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D1 ……………………………………………. + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + prednisolone 60mg/m2 85mg PO D1-5 (R-COP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + acetaminophen 500mg PO

==========

2024-05-09

This patient received R-COP on 2024-04-01 during his last hospital stay and admitted to receive R-CDOP on 2024-05-09 during this hospitalization. Lab results on 2024-05-08 showed no significant abnormalities, and no medication discrepancies were identified.

700382293

240508

[exam findings]

• 2024-05-06 Nasopharyngoscopy
  • severe R otalgia+ wet ear and unable to sleep, NP tumor+
• 2024-04-15 Nasopharyngoscopy
  • R wet ear+ R lat NP tumor+ necrotic tissue
• 2024-04-01 MRI - nasopharynx
  • for NPC and PET showed mild glucose hypermetabolism in the right nasopharynx.
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows: comparison: 2024/01/26 MRI
    • A case of NPC S/P indction C/T. Residual tumor at nasopharyngeal space with invasion of right parapharyngeal space, masticator space, cavernous sinus, PPF, and paranasal sinuses were noted. S/P treatment, seems stationary or with slight regression.
      
    • Right otitis media and Right mastoiditis.
    • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
    • Anterior and bil. lateral posterior neck soft tissue swelling, post R/T change.
    • No evident abnormal enlarged lymph node in the visible neck.
• 2024-03-14 PET scan
  • Mild glucose hypermetabolism in the right nasopharynx. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    
  • Glucose hypermetabolism in the right buccal region and in the middle portion of the tongue. The nature is also to be determined. Please also correlate with other clinical findings for further evaluation
  • Mildly increased FDG uptake in bilateral pulmonary hilar lymph nodes and in the lower portion of the esophagus. Inflammation is more likely.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
• 2024-03-11 Nasopharyngoscopy
  • no visible L NP tumor as discribed by MRI report, PET staging indicated
• 2024-01-26 MRI - nasopharynx
  • Findings:
    • The current study was compared to the prior one obtained on 2023/09/28.
    • Known a case of NPC S/P indction C/T. Last time, large residual tumor (＞6.0cm) at nasopharyngeal space with invasion of right parapharyngeal space, masticator space, cavernous sinus, PPF, and paranasal sinuses. Marked shrinkage of this tumor S/P treatment. One small residual tumor (2.1cm) over left NP roof at this study.
    • Right otitis media.
    • Right mastoiditis.
• 2024-01-22 Nasopharyngoscopy
  • R otorrhea + pus, R nasal pus, NER
• 2023-12-25 Nasopharyngoscopy
  • R mucopus, nasal + CN 12 palsy (R), R/T completed, C/T = 1/2, BW = 54kg
• 2023-12-04 Nasopharyngoscopy
  • NP crust s/p local treatment
  • smooth oropharynx, larynx, hypopharynx
  • no vocal palsy, adequate upper airway
• 2023-11-20 Nasopharyngoscopy
  • NP tumor gone, sticky sputum, gr 2 mucositis, R otorrhea,
  • RT = 6 frx left, BWL 8kg (65 to 57kg now)
• 2023-11-13 Nasopharyngoscopy
  • Right EAC otorrhea with pus, s/p L/T, Right TM intact but redness
• 2023-10-16 ENT Hearing Test
  • PTA
    • Reliabilty Fair
    • R’t : 43 dB HL, normal to severe mixed type HL
    • L’t : 21 dB HL, normal to moderate SNHL
  • Tymp
    • R’t : Type C
    • L’t : Type A
  • ART
    • R’t : absent
    • L’t : contra absent.
• 2023-10-02 Nasopharyngoscopy
  • NPC undergoing CCRT
  • MRI validation done
  • will receive further C/T
  • grossly smooth NP
• 2023-09-28 MRI - nasopharynx
  • The current study was compared to the prior one obtained on 2023/06/27.
  • Known a case of NPC S/P indction C/T. Shrinkage of this tumor, but still large residual tumor (>6.0cm) at nasopharyngeal space with invasion of right parapharyngeal space, masticator space, cavernous sinus, PPF, and paranasal sinuses.
  • Right otitis media.
  • Right mastoiditis.
• 2023-09-22 ENT Hearing Test
  • Tymp:
    • Bil type A.
  • ART:
    • Bil reduced and absent.
  • E-tube function test:
    • Bil Poor.
  • PTA:
    • Reliability FAIR
    • Average RE 44 dB HL; LE 21 dB HL.
    • RE normal to moderately severe SNHL.
    • LE normal to mild SNHL.
• 2023-09-18 Nasopharyngoscopy
  • 9/18 fiber = s/p induction C/T*3 (smooth NP now), then MRI validatiaon + then CCRT
  • R MEE+ tinnitus, PTA =
  • 2023/6/19 NPC, R= NK, diff ca (cT4N2M0, stage IVA) [RT Wang + CT Gao]
• 2023-07-10 KUB
  • S/P double J catheter insertion, left side urinary tract.
  • Fecal material store in the colon.
• 2023-07-10 SONO - kidney
  • Diagnosis: Bilateral renal stones
  • Suggestion:
    • L’t Kidney :
      • Size: 10 x 4.9 cm
      • Cortex: 1.2 cm
      • Calculus:(Max) Lower calyx 0.5 cm 0.3 cm
    • R’t Kidney :
      • Size: 11 x 5.8 cm
      • Cortex: 2.1 cm
      • Calculus:(Max) Lower calyx 0.3 cm 0.1 cm
• 2023-07-04 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
• 2023-07-01 CT - abdomen
  • Clinical history: 52 y/o male patient with NPC cT4N2M0, left hydronephrosis r/o maligancy or stone.
  • With and without contrast enhancement CT of abdomen–whole:
    • Dilatation of left pelvicaliceal system and upper ureter due to left upper ureteral stone (2.4cm).
    • Small bilateral renal caliceal stones.
    • Right renal cyst, 1.3cm.
    • Liver cysts, up to 1.7cm in liver dome.
    • Presence of gallbladder sludge.
    • R/O atelectasis in right lower near diaphragm, suggest follow up study.
  • Impression:
    • Left upper ureteral stone with hydronephrosis.
    • Small bilateral renal caliceal stones.
    • Right renal cyst.
    • R/O liver cysts.
    • R/O atelectasis in right lower near diaphragm, suggest follow up study.
    • Gallbladder sludge.
• 2023-06-29 PET scan
  • A large glucose hypermetabolic lesion involving the nasopharynx, right parapharyngeal space, right oropharynx, right maxillary sinus, right pterygoid muscles, skull base, sphenoid sinus and invasion to the right temporal lobe of the brain, compatible with advanced nasopharyngeal malignancy with intracranial invasion.
  • Glucose hypermetabolism in the left retropharyngeal and multiple bilateral neck level II to III lymph nodes. Multiple metastatic lymph nodes may show this picture.
  • Increased FDG accumulation in both kidneys. Physiological FDG accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2023-06-28 SONO - abdomen
  • Diagnosis:
    • Fatty liver, moderate
    • Liver cysts, both lobes
    • Hydronephrosis, left kidney
    • Pancreatic calcified lesions
  • Suggestion:
    • Urology for hydronephrosis survey
    • Regular abdominal ultrasound follow up
• 2023-06-27 MRI - nasopharynx
  • Indication: nasopharyngeal carcinoma, for cancer work up
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
    • A larage lobulated mass lesion (> 12 cm in largest dimension), mainly at right nasopharygeal space, with invasion of oropharynx, paranasal sinuses, both cavernous sinuses, right temporal fossa, right medial pterygoid muscle, right PPF and right parapharyngeal space.
      
    • Tumor also invasion to right posterior fossa, CP angle.
    • Multiple enlarged necrotic nodes (max: 4.1 cm) over both level II and III of neck and left retropharyngeal space. All above the low border of cricoid cartilage.
      
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor and LNs.
  • IMP: Right NPC, T4N2Mx, stage IVA.
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:4(T_value) N:N2(N_value) M:0(M_value) STAGE:IVA (Stage_value)
• 2023-06-27 ENT Hearing Test
  • Tymp:
    • RE type C; LE type A.
  • ART:
    • Bil absent.
  • PTA
    • Reliability FAIR
    • Average RE 29 dB HL; LE 21 dB HL.
    • RE normal to moderate SNHL with 4k Hz A-B gap.
    • LE normal to mild SNHL.
• 2023-06-20 CT - neck
  • One huge lobulated mass lesion (> 8cm in largest dimension), mainly at right nasopharygeal space, with invasion of paranasal sinuses, both cavernous sinuses, right temporal fossa, right medial pterygoid muscle, right PPF and right parapharyngeal space. Suggest tissue proof to rule out malignancy.
  • Multiple enlarged necrotic nodes (max: 4.5cm) over both level II and III of neck, favor malignant nodes.
• 2023-06-19 Patho - nasopharyngeal/oropharyngeal biopsy
  • DIAGNOSIS:
    • Nasopahrynx, punch biopsy — Non-keratinizing squamous cell carcinoma, differentiated (WHO-2A)
  • GROSS DESCRIPTION:
    • Specimen submitted in formalin consists of several pieces of tan, irregular tissue measuring up to 1.2 x 0.7 x 0.3 cm. All for section in one cassette.
  • MICROSCOPIC DESCRIPTION:
    • Histologic Type: Non-keratinizing carcinoma, differentiated (WHO-2A); The immunohistochemical stains reveal CK(+) and p63(+).
    • Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy): patient not received
      
    • Additional Pathologic Findings (select all that apply): None identified
    • Ancillary Studies: patient not received
      
    • Clinical History (select all that apply): absent
• 2023-06-19 Nasopharyngoscopy
  • smooth OPx, HPx
  • crust with mild bulging over right upper adenoid pad
  • fair inf. turbinate, mucopus over left superior meatus

[MedRec]

• 2023-10-06 SOAP Radiation Oncology Wang YuNong
  • Plan
    • The bil. neck: 50 Gy/ 25 fx. The preC/T NP tumor and LAPs involved area: 70 Gy/ 35 fx.
• 2023-08-15 SOAP Radiation Oncology Wang YuNong
  • Plan
    • Arrange MRI and EBV DNA test in Sep 2023 (after induction C/T completes). Refer to ENT Dr. Su for NP response assessment.
    • CT-simulation will be arranged on 9/26.
    • The RT regimen: The NP, oropharynx, bil. neck lymphatic drainage area: 50 Gy/ 25 fx. The gross NP tumor and LAPs: 70 Gy/ 35 fxs. RT will start around 10/2.
    • RTC: 9/26.
• 2023-06-26 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Right nasopharyngeal carcinoma, cT4N2M0, stage IVA, EBV DNA: 4460
    • Left ureter stone with left hydronephrosis s/p Flexible ureteroscopic lithotripsy & double J stenting, left side on 7/4
    • Localized swelling, mass and lump, neck
    • Chronic sinusitis, unspecified
    • Personal history of COVID-19
    • Calculus of ureter
  • CC
    • Right progressive painless neck mass for a year
  • Present illness
    • This is a 52-year-old man with past history of Inguinal hernia status post operation
    • A(+, seldom)/B(-)/C(+, 1 PPD for 30 +years)
    • He was brought to our outpatient department with chief complaint of right progressive painless neck mass for a year. Accompanying symptoms included trismus and intermittent epistaxis. No facial palsy, odynophagia, dysphagia, easy chocking, hemoptysis, otalgia, voice change, dyspnea, diplopia, recent body weight loss, fever were noticed. Physical exam showed a 6*4 cm firm and unmovable mass over right neck level II region. Fiberscopic exam showed bulging over right upper adenoid pad and right posterior oropharyngeal wall. Biopsy of the nasopharyngeal tumor was done, and the pathology report prooved malignancy. Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, the patient was admitted for cancer work-up.
  • Course of inpatient treatment
    • After admission, serial tests were arranged for tumor staging work up. MRI showed nasopharyngeal carcinoma, cT4N2Mx, stage IVA. Abdominal sonography showed negative for malignancy but left hydronephrosis. Whole body PET scan showed advanced nasopharyngeal malignancy with multiple metastatic lymph nodes over bilateral level II/III and intracranial invasion.Tooth extraction was unnescessary after consulting OS doctor. After consulting with oncologist and radiation oncologist, induction chemotherapy first and then concurrent chemoradiotherapy was favored. Under relative stable condition, the patient will be transferred to oncology ward for further systemic treatment arrangement.
    • After transfer to oncology ward, we consult CVS for port A insertion and check anti-HBc for chemotherapy preparation. Additionally, we arrange abdominal CT for left hydronephrpsis survey. Abdominal CT show Left upper ureteral stone (2.4cm)with hydronephrosis. Consult GU doctor and arrange lexible ureteroscopic lithotripsy & double J stenting, left side on 7/4. In addiiton, due to urine routein show pyuria, add cefuroxime noted.
    • Remove foley on 7/5 morning and voiding smoothly. Under relative stable condition, he was discharge with oral form antibiotic.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQID
    • Mefno (mephenoxalone 200mg) 1# Q12H
    • Ulstop (famotidine 20mg) 1# BID
    • Meitifen (diclofenac Na 75mg) 1# Q12H
    • Allegra (fexofenadine 60mg) 1# BID
    • Ceficin (cefixime 100mg) 2# Q12H

[consultation]

• 2023-12-04 Ear Nose Throat
  • Q
    • This is a 52-year-old man, a patient of right nasopharyngeal carcinoma, cT4N2M0, stage IVA, EBV DNA: 4460.
    • Image study with nasopharyngoscopy (2023/06/19) showed smooth OPx, HPx, crust with mild bulging over right upper adenoid pad, fair inf. turbinate, mucopus over left superior meatus and neck CT (2023/06/21) showed One huge lobulated mass lesion (> 8cm in largest dimension), mainly at right nasopharygeal space, with invasion of paranasal sinuses, both cavernous sinuses, right temporal fossa, right medial pterygoid muscle, right PPF and right parapharyngeal space. 2. Multiple enlarged necrotic nodes (max: 4.5cm) over both level II and III of neck, favor malignant nodes.
    • Nasopharynx MRI (2023/06/27) revealed right NPC, T4N2Mx, stage IVA.
    • He underwent C1 induction chemotherapy with TPF on 2023/07/10, C2 on 2023/08/02, C3 on 2023/09/07.
    • Radiotherapy started since 2023/10/03 to 2023/11/27 for Rt to the bil. neck, NP, Rt parapharygeal space, and masticator space and CCRT with Cisplatin (40mg/m2, weekly) was given on 2023/10/03, 2023/10/09, 2023/10/17, 2023/10/24.
    • He complaint about restricted tongue movement and easy choking for two weeks after radiotherapy. We need your help for further evaluation and treatment suggestion. Thank you.
  • A
    • S:
      • restricted tongue movement and choking sometimes for 2 weeks
      • odynophagia-, dysphagia-
    • O:
      • Oral cavity: no palpable oral tumor, limited tongue motion (right side)+
      • Scope: NP crust s/p local treatment
      • smooth oropharynx, larynx, hypopharynx
      • no vocal palsy, adequate upper airway
    • A:
      • restricted tongue movement, may due to RT
    • Plan:
      • Nasal and NP crust s/p L/T
      • ENT OPD f/u
• 2023-11-13 Ear Nose Throat
  • Q
    • for right ear pus discharge
    • This 52-year-old man, a patient of right nasopharyngeal carcinoma, cT4N2M0, stage IVA, EBV DNA: 4460 was diagnosed on 2023/06/21. He suffered from right progressive painless neck mass for a year.
    • He was admitted due to cachexia and right ear pus discharged for days. The righr ear pus culture: Pseudomonas aeruginosa. We need expertise to evaluate his condition thanks!
  • A
    • S:
      • right ear pus discharge for days
      • hearing loss-, aural fullness+
      • pus culture: Pseudomonas aeruginosa
    • O:
      • Right EAC otorrhea with pus, s/p L/T, Right TM intact but redness
      • Scope: NP crust
    • A:
      • Right otitis externa and myringitis
      • NPC under treatment
    • Plan:
      • Local treatment done
      • Keep Cravit and Earflo
      • ENT OPD f/u
• 2023-07-03 Urology
  • Q
    • This 52 year old man is a case of NPC cT4N2M0, stage IVA. He will receive induction chemotherpy follow by CCRT. During staging, left ureter stone (2.4cm) with left hydronephrosis was noted. We need your help before we begin chemotherapy.
  • A
    • This 52 year old man is a case of NPC cT4N2M0, stage IVA. We were consulted for left ureteral stone with hydronephrosis.
    • He will receive induction chemotherpy follow by CCRT.
    • Left URSL will be arranged on 2023/07/04 morning on call.
    • Please collect U/A today
• 2023-06-30 Hemato-Oncology
  • Q
    • for concurrent chemoradiotherapy arrangement
    • This is a 52-year-old man with past history of inguinal hernia status post operation A(+, seldom)/B(-)/C(+, 1 PPD for 30 +years)
    • This time, he was admitted to our ward for NPC cancer work up.
      • Pathology: Non-keratinizing squamous cell carcinoma, differentiated (WHO-2A)
      • 6/27 MRI: cT4N2Mx, stage IVA
      • 6/28 Abdominal echogram: negative for malignancy
      • 6/29 Whole body PET scan: local regional disease. No distant metastases.
      • EBV DNA: 4460.
    • Under the impression of NPC, cT4N2Mx, stage IVA , we need your expertise for postoperative concurrent chemoradiotherapy arrangement.
  • A
    • This 52 year old man is a case of NPC, cT4N2M0 stage IVA, EBV DNA 4460. We are consulted for further evaluation.
    • For advanced NPC, induction chemotherapy [TPF: three cycles of intravenous docetaxel (60 mg/m2 on day 1), intravenous cisplatin (60 mg/m2 on day 1), and continuous intravenous fluorouracil (600 mg/m2 per day from day 1 to day 5) every 3 weeks] followed by CCRT [weekly cisplatin] is suggested.
    • We will discuss with patient about further systemic chemotherapy. Please arrange port A insertion and check anti HBc. Additionally, please arrange abdominal CT for hydronephrosis survey. We will take over this case if you agree.
• 2023-06-30 Radiation Oncology
  • Q
    • (same as consulting Hemato-Oncology on the same day)
  • A
    • Under the impression of NPC, cT4N2Mx, stage IVA, according to the current NCCN guideline, induction chemotherapy followed by CCRT is the category 1 choice.
    • After induction C/T finishs, please refer back for CCRT arrangement by then.
    • The RT regimen: The NP, oropharynx, bil. neck lymphatic drainage area: 50 Gy/ 25 fx. The gross NP tumor and LAPs: 70 Gy/ 35 fxs. Thank you very much.

[radiotherapy]

• 2023-10-03 ~ 2023-11-27 - completed RT to the bil. neck: 50 Gy/ 25 fx. The NP, Rt parapharygeal space, and masticator space: 70 Gy/ 35 fx.

[chemotherapy]

• 2024-04-23 - nivolumab 3mg/kg 140mg NS 100mL 1hr + gemcitabine 1250mg/m2 1800mg NS 100mL 30min (Opdivo + Gemzar)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-01-02 - carboplatin AUC 5 400mg + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-12-05 - carboplatin AUC 5 380mg + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-10-25 - cisplatin 40mg/m2 68mg NS 500mL 2hr (CDDP QW CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP) + NS 500mL 1hr (after CDDP)
• 2023-10-18 - cisplatin 40mg/m2 68mg NS 500mL 2hr (CDDP QW CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP) + NS 500mL 1hr (after CDDP)
• 2023-10-11 - cisplatin 40mg/m2 68mg NS 500mL 2hr (CDDP QW CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP) + NS 500mL 1hr (after CDDP)
• 2023-10-04 - cisplatin 40mg/m2 68mg NS 500mL 2hr (CDDP QW CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP) + NS 500mL 1hr (after CDDP)
• 2023-09-08 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 60mg/m2 100mg NS 500mL 2hr D1 + fluorouracil 600mg/m2 1000mg NS 500mL 24hr D1-5 (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-08-03 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 60mg/m2 100mg NS 500mL 2hr D1 + fluorouracil 600mg/m2 1000mg NS 500mL 24hr D1-5 (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-07-10 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 60mg/m2 100mg NS 500mL 2hr D1 + fluorouracil 600mg/m2 1000mg NS 500mL 24hr D1-5 (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-05-08

[Otitis Media, Acute, Empiric Therapy]

The nurse practitioner has advised the patient increasing dietary salt intake to manage his hyponatremia (serum sodium 128 mmol/L).

Normal liver and kidney function were confirmed by the lab results on 2024-05-07. Currently, the administration of Soonmelt (amoxicillin 500mg, clavulanic acid 100mg) at 2 vials (1200mg) Q8H is appropriate as there are no contraindications.

Supplementary references: Otitis Media, Acute, Empiric Therapy - Empiric therapy, acute otitis media, acute otorrhea, recurrent otitis media, tympanostomy - Ref: https://web.sanfordguide.com/en/sanford-guide-online/disease-clinical-condition/otitis-media

• Clinical Setting
  • Initial empiric therapy for acute otitis media (AOM) in infants, children and adults.
    • Diagnosis of AOM in children is based on presence of moderate to severe bulging of the TM or new onset otorrhea. May diagnose with mild bulging and recent (<48 hours) onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal child) or intense erythema of the TM.
    • Pneumatic otoscopy demonstrating immobile tympanic membrane establishes presence of effusion but does not discriminate acute otitis media from non infected effusion. That is why symptoms are an important criterion
• Etiologies
  • Commonly detected bacteria
    • Streptococcus pneumoniae
    • Haemophilus influenzae
    • Moraxella catarrhalis
    • Staphylococcus aureus
  • Commonly detected viruses
    • Influenza
    • Parainfluenza
    • RSV
    • Human metapneumonvirus
    • Adenovirus
    • Enterovirus/rhinovirus
• Primary Regimens
  • Adult Acute AOM
    • If patient has had no antibiotics in the prior month:
      • Amoxicillin high dose 1000 mg tid
      • Amoxicillin-clavulanate 875 /125 mg po bid
    • If patient has had antibiotics in the prior month:
      • Amoxicillin-clavulanate 875/125 mg bid
      • Levofloxacin 750 mg q24h x 5 days
      • Moxifloxacin 400 mg q24h x 5 days
    • Duration of treatment: 10 days (generally, but note that Levofloxacin and moxifloxacin is 5 days)
  • Acute otorrhea with tympanostomy tubes (Med Lett. 2016; 58: 153):
    • Otovel (ciprofloxacin 0.3% + fluocinolone acetonide 0.025% otic solution) for the treatment of acute otitis media with tympanostomy tubes in patients (aged ≥6 months) due to S. aureus, S. pneumoniae, H. influenzae, M. catarrhalis, and P. aeruginosa). The product is available in 0.25 mL single-dose vials and the recommended dose is instillation of the contents of one vial into the affected ear canal twice daily for 7 days
    • Ciprodex (ciprofloxacin 0.3%/dexamethasone 0.1%) 4 drops in affected ear bid x 7 days
    • Ofloxacin 0.3% generic 5 drops in affected ear bid x 10 days

2023-11-08

[leukopenia, thrombocytopenia]

The weekly administrations of cisplatin on 2023-10-04, 2023-10-11, 2023-10-18, and 2023-10-25 are an integral part of the current concurrent chemoradiotherapy (CCRT) treatment. However, the patient’s WBC and PLT recovery appears to be insufficient, resulting in a continued decline in WBC and PLT counts. Consequently, chemotherapy has been temporarily suspended, and a regimen of G-CSF (filgrastim) 300mg SC QD was commenced on 2023-11-07. A platelet transfusion will also be performed today (2023-11-08).

• 2023-11-08 WBC 1.73 x10^3/uL **

• 2023-11-07 WBC 1.30 x10^3/uL **

• 2023-10-31 WBC 2.33 x10^3/uL *

• 2023-10-24 WBC 3.36 x10^3/uL

• 2023-10-17 WBC 4.63 x10^3/uL

• 2023-10-09 WBC 6.55 x10^3/uL

• 2023-10-03 WBC 6.27 x10^3/uL

• 2023-11-08 PLT 34 10^3/uL **

• 2023-11-07 PLT 30 10^3/uL **

• 2023-10-31 PLT 67 *10^3/uL **

• 2023-10-24 PLT 142 10^3/uL

• 2023-10-17 PLT 250 *10^3/uL
  

• 2023-10-09 PLT 299 *10^3/uL
  

• 2023-10-03 PLT 314 *10^3/uL

There is a slight increase in WBC and PLT, according to the preliminary observation today.

[acute otitis media]

Ref: Otitis Media, Acute, Empiric Therapy - https://webedition.sanfordguide.com/en/sanford-guide-online/disease-clinical-condition/otitis-media

In treating adult acute otitis media (AOM) without prior antibiotic exposure in the preceding month, the following therapeutic options can be considered:

• Amoxicillin high dose 1000 mg tid
• Amoxicillin-clavulanate 875 /125 mg po bid
• Cefdinir 300 mg q12h or 600 mg q24h
• Cefpodoxime proxetil 200 mg bid
• Cefprozil 250-500 mg bid

For patients who have received antibiotics in the previous month, alternative treatments include:

• Amoxicillin-clavulanate 875/125 mg bid
• Levofloxacin 750 mg q24h x 5 days
• Moxifloxacin 400 mg q24h

The standard duration for treatment is 10 days, although it is important to note that the course for Levofloxacin is 5 days.

At present, the patient is being treated with Soonmelt (amoxicillin 500mg, clavulanic acid 100mg) 1200mg IVD Q8H, which is considered an appropriate treatment.

[alarming trend: kidney function deteriorates over the past two months]

Kidney function has shown a worsening trend in the last two months.

• 2023-11-07 eGFR 51.44 ml/min/1.73m^2
  
• 2023-10-31 eGFR 49.19 ml/min/1.73m^2
  
• 2023-10-24 eGFR 65.68 ml/min/1.73m^2
  
• 2023-10-17 eGFR 69.58 ml/min/1.73m^2
  
• 2023-10-09 eGFR 60.01 ml/min/1.73m^2
  
• 2023-10-03 eGFR 66.93 ml/min/1.73m^2
  
• 2023-09-22 eGFR 71.70 ml/min/1.73m^2
  
• 2023-09-15 eGFR 85.37 ml/min/1.73m^2
  
• 2023-09-07 eGFR 80.60 ml/min/1.73m^2
  
• 2023-09-03 eGFR 81.52 ml/min/1.73m^2

The current dose of cisplatin used in concurrent chemoradiotherapy (CCRT) is lower than that used in the earlier TPF regimen, and adequate hydration has been provided during administration. To further protect renal function after recovery from the recent leukopenia and thrombocytopenia event, and if CCRT treatment is to continue, additional renal protective options include:

• Ethyol (amifostine): A cytoprotective agent that can be administered prior to cisplatin to guard against nephrotoxicity by selectively shielding normal tissues from the harmful effects of chemotherapy. However, this medication is currently not available at our institution.

• Magnesium Supplementation: To counteract the magnesium wasting caused by cisplatin, which can lead to nephrotoxicity, magnesium supplements may be administered to prevent hypomagnesemia.

• Potassium Supplementation: Administered to replenish potassium lost during cisplatin treatment, as cisplatin can cause potassium to be excreted in the urine, potentially leading to hypokalemia.

• N-acetylcysteine (NAC): An antioxidant considered to protect the kidneys from damage induced by cisplatin through the reduction of oxidative stress.

• Diuretics: Agents like mannitol may be used alongside hydration to induce diuresis, which can help prevent the accumulation of cisplatin in the kidneys.

700556380

240507

[exam findings]

• 2024-04-25 KUB
  • Calcifications over right upper abdomen overlaping with renal shadow, could be due to right renal stones.
  • Calcifications in the pelvic cavity, could be due to phleboliths.
  • Lumbar spondylosis.
• 2024-04-08 PD-L1 (28.8)
  • Cellblock No. S2024-03221
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS >=5
    • Combined Positive Score (CPS): 5
• 2024-03-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 28) / 87 = 67.82%
    • M-mode (Teichholz) = 68
  • Conclusion:
    • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis and mild aortic root calcificiation; trivial MR.
• 2024-03-04 CT - abdomen
  • History and indication: gastric cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of gastric antrum with reginal LAP. Several LNs at retroperitoneum.
    • Bil. renal stones (up to 2.1cm). Tiny renal cysts.
    • S/P left humeral operation.
    • Atherosclerosis of aorta, iliac arteries.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N3a(N_value) M:M1(M_value) STAGE:IVB(Stage_value)
• 2024-02-21 Patho - stomach biopsy
  • Stomach, angularis to antrum, biopsy — Adenocarcinoma.
  • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
  • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score = 1+).
• 2024-02-21 Patho - colon biopsy
  • Colorectum, sigmoid colon, s/p cold snare polypectomy — Tubular adenoma with low grade dysplasia
  • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with low grade dysplasia.
• 2024-02-20 EGD
  • Diagnosis:
    • Suboptimal study, due to much food residuals
    • Gastric malignancy, if gasctric cancer approved, then borrmann classification type III was impressed, from angularis to antrum, LC, s/p biopsy.
    • Superficial gastritis, antrum, s/p CLO test.
    • Reflux esophagitis LA Classification grade A-
  • CLO test: Positive
  • Suggestion:
    • Pursue CLO test and pathology report
    • Consider to arrange further evaluation for malignancy staging
• 2024-02-20 Colonoscopy
  • Colon polyp, Paris classification 0-Is, sigmoid colon, s/p cold snare polypectomy.
  • Diverticulum, ascending colon and sigmoid colon.
  • Mixed hemorrhoid

[MedRec]

• 2024-04-23 Hemato-Oncology SOAP Yang MuJun
  • Prescription
    • B-Red (hydroxocobalamin 1mg/mL/amp) 1# ST IM
    • Smecta (dioctahedral Smectite 3gm/pk) 1# PRNTIDAC
    • Megest (megestrol 40mg/mL) 10mL QD
    • MgO 250mg 1# QD
• 2024-04-15 ~ 2024-04-20 POMR Integrative Medicine Yang MuJun
  • Present illness
    • Diagnosis was Gastric adenocarcinoma with impending obstruction, cT3N3aM1, stage:IVB, status post GJ bypass on 2024/03/22.
    • This time, she was admitted for palliative chemotherapy with FLOT plus Nivolumab (self pay).
  • Course of inpatient treatment
    • After admission, Limeson 4mg/tab 1# PO BID and Famotidine 20mg/tab 1# PO BID x3 day for prevention chemotherapy allergy on 2024/04/15~2024/04/18.
    • She received Q2W palliative chemotherapy with Nivolumab (3mg/kg, 200mg self pay) plus FLOT(Docetaxel 50mg/m2, Oxalip 85mg/m2, LV 200mg/m2, 5-Fu 2600mg/m2, 1st all 70%) on 2024/04/16 (C1).
    • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
    • Helicobacter pylori was treated with Pariet F.C 20mg/tab 1# PO BIDAC, Scrat 1g/10mL/pk 1pk PO QIDAC.
    • Hypomagnesemia and Hypokalemia were noted, Magnesium Sulfate 10%, 20mL/amp 1amp IVD QD and Const-K Extended-Release Tablets 750mg/10mEq/tab 1# PO QD for supportive.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/04/20 and OPD followed up later.   
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# PRNBIDAC
    • Megejohn (megestrol acetate 160mg) 1# QD
• 2024-03-13 ~ 2024-03-31 POMR General and Gastroenterological Surgery Chen YanZhi
  • Discharge diagnosis
    • Malignant neoplasm of stomach cT3N3aM1, stage IVB
  • CC
    • decreased body weight for 20% in one month
  • Present illness
    • This 64 yo female, with a past history of
      • Renal stone s/p and urosepsis in 2011, 2016,
      • newly diagnosed on 20240221 Stomach cancer: angularis to antrum, biopsy — Adenocarcinoma. IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+).
    • was admitted due to decreased body weight for 20% in one month.
    • According to the patient. she had epigastric pain for 1 month and had stomachache on 2024/02/06 accompanied with decreased appetite, abdominal fullness, nausea sensation, and OB (+). The pain was exacerbated by eating and ameliorated by fasting. She had taken NSAID due to right elbow dislocation. On 2024/02/16, she went to Dr. Cai PeiShan’s OPD for help. PE showed mild epigastric tenderness. Symptomatic treatment was given, and colonscopy and upper GI endoscopy were arranged on 20240220.
    • The result showed gastric malignancy, GERD, and CLO test: Positive. Pathologic result of stomach showed stomach adenocarcinoma. IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+). Colonscopy showed Colon polyp, at sigmoid colon and diverticulum at ascending colon and sigmoid colon.Polyp showed tubular adenoma with low grade dysplasia. Due to above, she was transfered to Dr. Chen YanZhi’s OPD, where abdominl CT was arranged, clinical stage showed cT3N3aM1, stage:IVB. Because of CLO (+), she underwent clarithromycin, metronidazole, amoxicillin therapy, but she had side effect of severe anorexia, so stopped on 2024/03/04.
    • She also mentioned body weight loss from 2024/02/06: 56kg to 2024/03/13: 47kg. Lab data showed anemia, Hb:7.9. normal liver function, CRP:1.7, GFR:74
    • Under the impression of gastric cancer, she was admited for operation and nutrition supplement.
  • Course of inpatient treatment
    • After admission, LPRBC 4U was transfused due to anemia, Hb eleveated from 7.9 -> 9.6. Lyo-povigent, Oliclinomel, Addaven were given for nutrition supplement; however, she felt stinging after nutrition infusion. So we changed to SMOFlipid 250ml QD, the infusion process was smooth, so we then added to SmofKabiven 1448ml QD till now.
    • Operation was arranged on 2024/03/22. Pre-op evaluation including cardiac echo and Spirometry were arranged. Cardiac echo showed IVS thicking, others are relative normal. After operation, she was under NPO, analgestics was prescribed as pain control. Gas passage and stool passage were noticed, and ambulation was good. She practiced Tri-flow everyday, average: 900-1200ml. NG was clamped on 2024/03/25, she denied abdominal pain, diarrhea, abdominal distention. Water 100ml was tried on the next day, and then clear liquid was tried. She underwent Port-A insertion on 2024/03/27 and will take chemotherapy under Dr. Yang MuJun. Then full liquid diet, soft diet were tried, the process was smooth. Due to relative stable condition, she discharged and will be followed up at Oncologist Dr. Yang MuJun’ OPD and will be admited at 2024/04/15 for first dose chemotherapy.
  • Discharge prescription
    • Takepron (lansoprazole 30mg) 1# QDAC
    • Acetal (acetaminophen 500mg) 1# QID

[consultation]

• 2024-04-16 Rehabilitation
  • Q
    • For bed side rehabilitation, we need your consultation for evaluation.
  • A
    • Assessment
      • Gastric adenocarcinoma with impending obstruction, cT3N3aM1, stage IVB, status post GJ bypass on 2024/03/22
    • Plan
      • Since the patient can walk independently and perform BADLs without assistance, rehabilitation programs will not be scheduled at this time.
      • If there is a decline in muscle strength or limb dexterity, please contact CR Luo YuanTing, and we will arrange rehabilitation programs.
• 2024-03-25 Integrative Medicine
  • Q
    • This is a consultation for chemotherapy
    • This is a 64 -year-old female, with a past history of
      • Renal stone s/p and urosepsis in 2011, 2016,
      • newly diagnosed on 20240221 Stomach cancer: angularis to antrum, biopsy — Adenocarcinoma. IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+). was admitted due to decreased body weight for 20% in one month.
    • After admission, Lyo-povigent, Oliclinomel, Addaven were given for nutrition supplement; however, she felt stinging after nutrition infusion. So we changed to SMOFlipid 250ml QD, the infusion process was smooth, so we then added to SmofKabiven 1448ml QD.
    • Operation was arranged on 3/22. OP result showed locally advanced gastric cancer at prepyloric region, at least T4a, pending obstruction. Small LAP over paraaorta and IVC region, distant metastasis cannot be r/o.
    • Status Post: laparoscopic GJ bypass
    • Biweekly neoadjuvant FLOT chemotherapy with Nivlumab use were considered
    • NG: Clamped on 3/25
    • NPO, gas passage(+), stool passage(+)
    • We would like to consult your expertise for chemotherapy
    • Please feel free to contact with me if any problems, thanks!
  • A
    • This 64 year old woman is a case of newly diagnosis gastric adenocarcinoma with impending obstruction, s/p GJ bypass on 3/22. We are consulted for perioperative Biweekly neoadjuvant FLOT chemotherapy with Nivlumab. We will discuss with patient. Thank you!

[surgical operation]

• 2024-03-22
  • Surgery
    • laparoscopic GJ bypass
  • Finding
    • locally advanced gastric cancer at prepyloric region, at least T4a, pending obstruction
    • small LAP over paraaorta and IVC region, distant metastasis cannot be r/o

[immunochemotherapy]

• 2024-05-06 - nivolumab 3mg/kg 200mg D5W 100mL 1hr + docetaxel 50mg/m2 56mg D5W 150mL 1hr + oxaliplatin 85mg/m2 100mg D5W 350mL 2hr (Y-sited Covorin) + leucovorin 200mg/m2 220mg D5W 250mL 2hr (Y-sited Oxa) + fluorouracil 2600mg/m2 3600mg D5W 500mL 24hr (Opdivo + FLOT 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-04-16 - nivolumab 3mg/kg 200mg D5W 100mL 1hr + docetaxel 50mg/m2 50mg D5W 150mL 1hr + oxaliplatin 85mg/m2 100mg D5W 350mL 2hr (Y-sited Covorin) + leucovorin 200mg/m2 200mg D5W 250mL 2hr (Y-sited Oxa) + fluorouracil 2600mg/m2 2600mg D5W 500mL 24hr (Opdivo + FLOT 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-05-07

Hypokalemia and hypomagnesemia have been managed with oral Const-K tablets and intravenous MgSO4 supplementation. No medication discrepancies have been identified.

701269031

240506

      

[allergy]

• NKDA         

[Family History]

• Father had DM
• She denied cancer history in her family

[lab data]

• 2023-01-11 Anti-HBc Nonreactive
  
• 2023-01-11 Anti-HBc-Value 0.13 S/CO
  
• 2023-01-11 Anti-HBs 3.73 mIU/mL
  
• 2023-01-11 HBsAg Nonreactive
  
• 2023-01-11 HBsAg (Value) 0.39 S/CO
  
• 2023-01-11 Anti-HCV Nonreactive
  
• 2023-01-11 Anti-HCV Value 0.08 S/CO

[exam findings]

• 2024-03-26 SONO - thyroid gland
  • Sonography of thyroid gland revealed:
    • Enlargement of right thyroid gland.
    • Some nodules (up to 2.67cm) in bil. thyroid gland.
• 2024-02-17 CT - abdomen
  • Indication: Bilateral high grade serous ovarian carcinoma, cT3N1bM1, stage IV s/p bilateral oophorectomy, hysterectomy and chemotherapy, recurrent with peritoneal seeding s/p chemotherapy with Taxol/Carboplatin 2023/2/10, 3/3, 3/25, 4/18, progression (2023-05-03 CT: multiple metastatic nodes in the mediastinum and abdominal para-aortic space and para-cava space show progressive disease.) s/p lipodox + carboplatin 2023/5/9, 5/30, 6/27, 7/25, HER-2 negative (1+), s/p Enhertu 2023/8/22, 9/12, 10/3, 10/31, 11/21, 12/12
  • With and without contrast enhancement CT of abdomen shows:
    • s/p hystero-oophorectomy .
    • Progression of lymph nodes in left laxillary, mediastinal, and para-aortic regions.
    • A mass lesion with heterogeneous enhancement, 2.2cm, in S8 of liver.
  • Impression
    • Ovarian carcinoma, s/p operation
    • Metastatic lymph nodes, in progression
    • Liver metastasis
• 2024-02-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (76 - 24) / 76 = 68.42%
    • M-mode (Teichholz) = 69
  • Conclusion:
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Trivial MR; trivial TR.
• 2023-11-07 CT - abdomen
  • S/P hysterectomy.
  • GB stones.
  • Regression size of metastatic lymph nodes in paraaortic, mediastinum and left axillary regions.
• 2023-08-17 - abdomen
  • S/P hysterectomy.
  • Some LNs (up to 2.8cm, progression) at mediastinum, left axillary region and retroperitoneum.
  • Right thyroid nodule (8mm).
• 2023-08-17 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 24) / 93 = 74.19%
    • M-mode (Teichholz) = 74.1
  • Conclusion:
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Trivial MR
• 2023-07-26 Her-2/neu DISH
  • RESULT OF HER2/NEU IN SITU HYBRIDIZATION
    • There is NO amplification of HER2 gene is detected
  • METHOD AND DETAILS:
    • Number of observers: 1
    • Number of invasive tumor cells counted: 20
    • Average number of HER2 gene copy signal per cell: 1.9
    • Average number of CEP17 gene copy signal per cell: 1.9
    • HER2/CEP17 ratio: 1
    • Heterogeneous signals: Absent
    • Origin slide and block number:S2023-14060
    • Specimen: Formalin-fixed paraffin embedded metastatic ovary serous carcinoma
    • Adequacy of sample for evaluation: Yes
    • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
  • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
    • Amplified:
      • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
      • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=6.0 signals/cell
    • Not amplified:
      • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number <4.0
      • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=4.0 and <6.0 signals/cell
      • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number <4.0
• 2023-07-17 Patho - lymphnode biopsy
  • Lymph node, left axillary, sono-guide biopsy — Compatible with metastatic ovarian serous carcinoma
  • Microscopically, the sections show a picture of metastatic adenocarcinoma characterized by tumor cells arranged in cribriform pattern infiltrating in parenchyma.
  • Immunohistochemistry of PAX-8(+), CK7(+, scatter), CK20(-), WT-1(+) and P53(scant +, aberrant expression), compatible with metastatic ovarian serous carcinoma.
  • 2023-07-28 Immunohistochemistry of Her-2/neu show negative, Dako score 1+
• 2023-05-10 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (64 - 14) / 64 = 78.13%
    • M-mode (Teichholz) = 79
  • Conclusion:
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Degenerative changes of mitral valve with trivial mitral regurgitation; trivial tricuspid regurgitation; mild pulmonary regurgitation.
• 2023-05-03 CT - abdomen
  • Findings:
    • There is a newly developed soft tissue mass in mediastinum para-aortic space, measuring 1.9 x 1.1 cm (Srs:302 Img:24).
      • Metastasis is suspected.
    • Prior CT identified multiple metastatic nodes in abdominal para-aortic space and para-cava space are noted again, increasing in size (Srs:302 Img:61-68).
    • Prior CT identified soft tissue lesions in right anterior subphrenic space is noted again, mild increasing in size (Srs:302 Img:55) that may be tumor seeding.
    • Prior CT identified a poor enhancing lesion 0.7 cm in S4/8 of the liver dome is noted again, stationary but poor margination.
    • Prior CT identified soft tissue lesions in bilateral cardiac-phrenic angle (Srs:302 Img:53,55) are noted again, mild increasing in size.
    • Soft tissue mass-like lesions in bilateral adnexa (Srs:302 Img:110) are suspected that may be tumor recurrence.
      • The differential diagnosis includes post-operative change.
      • Please correlate with GYN. sonography or MRI.
    • S/P hysterectomy and oophorectomy.
    • Presence of gallbladder stone.
  • Impression:
    • Multiple metastatic nodes in the mediastinum and abdominal para-aortic space and para-cava space show progressive disease.
• 2023-02-09 Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 16 dB HL
    • L’t : 15 dB HL
    • Bil WNL except 8k Hz.
• 2023-01-20 MRI - brain
  • Indication: Ovarian cancer s/p OP and chemotherapy, with recurrence over peritoneum seeding
  • IMP: No evidence of intracranial lesion.
• 2023-01-19 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the nasal bone, L3-4 spines, bilateral shoulders, left elbow and bilateral hips in whole body survey.
  • IMPRESSION:
    • Mildly increased activity in the L3-4 spines. Degenerative change may show this picture.
      
    • Increased activity in the nasal bone. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, left elbow and bilateral hips, compatible with benign joint lesions.
• 2023-01-18 PET scan
  • There was increased FDG uptake in the surface of the right lobe of liver (SUVmax early: 7.24, delay: 7.37), in the surface or sub-diaphragm of the left lobe of liver (SUVmax early: 10.73, delay: 11.82), celiac lymph nodes (SUVmax early: 5.60, delay: 7.06), left para-aortic space lymph nodes (SUVmax early: 10.31, delay: 11.92), lymph nodes in the LLQ (SUVmax early: 11.90, delay: 12.74) and RLQ (SUVmax early: 10.59, delay: 11.47) of abdomen, and spleen (SUVmax early: 4.63, delay: 4.89). In addition, increased FDG uptake was also noted in several left mediastinal lymph nodes (SUVmax early: 7.27, delay: 6.51), and bilateral pulmonary hilar lymph nodes (SUVmax early: 3.74, delay: 6.05).
  • IMPRESSION:
    • Glucose hypermetabolism lesions in n the surface of the right lobe of liver, in the surface or sub-diaphragm of the left lobe of liver, celiac lymph nodes, left para-aortic space lymph nodes, lymph nodes in the LLQ and RLQ of abdomen, and spleen, highly suspected recurrent tumor with peritoneal seeding, suggesting further investigation and follow-up.
      
    • Glucose hypermetabolism in the left mediastinal lymph nodes, the nature is to be determined (reactive or metastatic lymph nodes or other nature ?), suggesting further investigation.
      
    • Glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, probably reactive nodes.
    • Ovarian cancer s/p treatment with tumor recurrence and peritoneal seeding, rc-stage IVB, by this F-18 FDG PET scan.
• 2023-01-17 CT - abdomen
  • S/P hysterectomy and oophorectomy.
  • GB stone.
  • Hypodense nodule, 0.68cm in the liver dome, suspected liver metastasis. DDx: subphirenic seeding.

[MedRec]

• 2024-02-21 SOAP Hemato-Oncology Xia HeXiong
  • O:
    • s/p paclitaxel and carboplatin, C1D1 on 2023-02-10 to 2023-04-18, PD
      • AE: Stiffness of hand joint; Neutropenia Gr 3 -> Improved
    • s/p Lipo-Dox +/- Carboplatin, C1D1 on 2023-05-09 to 2024-07-25, PD
      • AE: Gr 1 Leukopenia.
    • s/p Enhertu, C1D1 on 2023-08-22 to 2024-01-23 best response PR
  • P
    • Thyroid function Q3M, next on 2024-03
    • Arrange CT Q3M, next on 2024-02-17
  • Prescription
    • Dulcolax (bisacodyl 5mg) 1# QN
    • Through (sennoside 12mg) 1# HS

[immunochemotherapy]

• 2024-05-03 - topotecan 1.5 mg/m2 2.2mg NS 60mL 30min D1-5
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-5
• 2024-04-11 - topotecan 1.5 mg/m2 2.0mg NS 60mL 30min D1-5
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-5
• 2024-03-21 - topotecan 1.25mg/m2 1.8mg NS 70mL 30min D1-5
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-5
• 2024-02-28 - topotecan 1.5 mg/m2 2.1mg NS 70mL 30min D1-5
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-5
• 2024-01-23 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
  • dexamethasone 8mg + palonosetron 250ug + NS 250mL + MgSO4 10% 20mL
• 2024-01-02 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
  • dexamethasone 8mg + palonosetron 250ug + NS 250mL + MgSO4 10% 20mL
• 2023-12-12 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
  • dexamethasone 8mg + palonosetron 250ug + NS 250mL
• 2023-11-21 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
  • dexamethasone 8mg + palonosetron 250ug + NS 250mL
• 2023-10-31 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
  • dexamethasone 8mg + palonosetron 250ug + NS 250mL
• 2023-10-03 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
  • dexamethasone 8mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-12 - trastuzumab deruxtecan 5.4mg/kg 200mg D5W 100mL 90min (Enhertu)
  • dexamethasone 8mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-22 - trastuzumab deruxtecan 5.4mg/kg 200mg D5W 100mL 90min (Enhertu)
  • dexamethasone 8mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-25 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr + carboplatin AUC 4 540mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-27 - liposome doxorubicin 40mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 4 500mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-30 - liposome doxorubicin 40mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 4 500mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-09 - liposome doxorubicin 50mg/m2 60mg D5W 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-18 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-03-25 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-03-02 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-02-10 - paclitaxel 140mg/m2 200mg NS 250mL 3hr + carboplatin AUC 4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

Topotecan - 2024-02-29 - https://www.uptodate.com/contents/topotecan-drug-information

• Ovarian cancer, metastatic: IV:
  • 1.5 mg/m2/day for 5 consecutive days every 21 days, continue until disease progression or unacceptable toxicity or
  • (off-label dosing) 1.25 mg/m2/day for 5 days every 21 days until disease progression or unacceptable toxicity or a maximum of 12 months or
  • (weekly administration; off-label dosing) 4 mg/m2 on days 1, 8, and 15 every 28 days until disease progression or unacceptable toxicity or a maximum of 12 months.

==========

2024-05-06

Topotecan was initiated in late Feb 2024 following a CT scan on 2024-02-17 that showed progressing abdominal metastatic lymph nodes. This regimen will have been in use for three months by the end of this month. An updated imaging study may be arranged to evaluate the treatment effect, especially since the CA125 levels reached a record high on 2024-05-02.

• 2024-05-02 CA125 2517.9 U/mL <- record high
• 2024-04-23 CA125 1779.3 U/mL
• 2024-04-09 CA125 2451.5 U/mL
• 2024-04-02 CA125 1787.5 U/mL
• 2024-03-12 CA125 1441.3 U/mL
• 2024-02-20 CA125 1482.3 U/mL
• 2024-01-22 CA125 714.9 U/mL
• 2024-01-02 CA125 696.1 U/mL

Review of the patient’s medication regimen did not reveal any discrepancies

2024-03-22

[irinotecan cycle 2: tolerated 1st session, labs clear]

The patient is admitted for the 2nd session of irinotecan therapy. This patient tolerated the 1st session well, and lab results from 2024-03-21, showed no contraindications for administration.

2024-02-29

[disease progression after multiple regimens: Enhertu partial response & topotecan consideration]

The patient’s disease progressed after receiving paclitaxel and carboplatin, followed by liposomal doxorubicin and carboplatin. However, a partial response was observed with Enhertu (fam-trastuzumab deruxtecan-nxki. There was NO amplification of HER2 gene detected on 2023-07-26).

Enhertu is an antibody-drug conjugate (ADC) that delivers the topoisomerase I inhibitor payload deruxtecan (DXd). Topotecan, which is currently being used, is also a topoisomerase I inhibitor. Therefore, it is expected that there may still be a response, but with potentially higher adverse reactions.

Neutropenia was observed when Enhertu was previously administered, so close monitoring is recommended.

2023-03-03

• Although most patients with high-grade serous carcinoma (HGSC) initially respond to platinum-based chemotherapy, the large majority of patients will relapse. ref: ESMO-ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease†. Ann Oncol. 2019;30(5):672-705. doi:10.1093/annonc/mdz062
  • There are no validated predictive markers of primary platinum refractory or resistant disease.
  • Defects in HR repair are associated with improved outcome/PFS following platinum-based chemotherapy.
  • The time elapsed since last platinum chemotherapy represents a continuum of probability of response to further chemotherapy.
• In potentially platinum-responsive patients previously exposed to bevacizumab, platinum-based rechallenge followed by PARPi maintenance therapy is effective irrespective of BRCA mutation and HRD status. Olaparib, niraparib and rucaparib can also be considered for use as monotherapy in patients with recurrent disease who have received several previous lines of treatment. ref: How to sequence treatment in relapsed ovarian cancer. Future Oncol. 2021;17(3s):1-8. doi:10.2217/fon-2020-1122
  • The patient initiated a new series of cycles with paclitaxel and carboplatin from 2023-02-10.
• According to the National Health Insurance drug reimbursement regulations, PARP inhibitors (olaparib, niraparib) can be used for maintenance therapy in patients with ovarian, tubal, or primary peritoneal cancer who meet all of the following conditions for up to two years:
  • Used after responding to first-line platinum-based chemotherapy.
  • Patients have germline or somatic BRCA1/2 pathogenic or suspected pathogenic mutations.
  • FIGO stage III or IV disease.
• According to the National Health Insurance drug reimbursement regulations, patients with malignancies who have experienced leukopenia with a white blood cell count less than 1000/uL or neutrophil count (ANC) less than 500/uL after receiving chemotherapy, can use short-acting injection of granulocyte colony-stimulating factor (G-CSF) such as filgrastim or lenograstim.
  • It has been planned to administer Granocyte (lenograstim) once daily for 3 consecutive days, starting from 2023-03-03.

2023-03-02

• The condition of leukopenia has been resolved after administering lenograstim for 3 consecutive days (2023-02-21 ~ 2023-02-23)
  • 2023-03-01 WBC 4.19 x10^3/uL
    
  • 2023-02-20 WBC 1.48 x10^3/uL

701522425

240506

[exam findings]

• 2024-04-25 Transrectal Ultrasound of Prostate, TRUSP
  • Diagnosis: Benign prostatic hyperplasia
  • Prostate
    • Size of prostate: 5.01 (T) cm x 2.09 (L) cm x 4.18 (AP) cm = 22.9 cc
    • Size of adenoma: 2.43 (T) cm x 1.52 (L) cm x 2.83 (AP) cm = 5.45 cc
  • Seminal vesicles
    • Symmetricity:
      • Size: L’t 1.65 x 0.44 cm
      • Size: R’t 1.59 x 0.555 cm

[MedRec]

• 2024-04-30 SOAP Hemato-Oncology He JingLiang
  • S
    • 2024-04-30 ca of colon with LN mets
    • SOB was noted
  • O
    • 20240430: BP:149/97; HR:94 beats/min
  • P
    • admission for pain control
  • Prescription
    • OxyNorm (oxycodone 5mg) 1# Q6H
    • Durogesic (fentanyl 12ug/h 2.1mg/patch) 1# Q3D EXT
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 90mg, lysozyme 20mg) 1# TID
• 2024-04-25 SOAP Urology Yu ZhiQin
  • S:
    • lower abdominal pain, difficult uriantion, for three months
    • colon cancer, s/p op, with para-aortic LNs? s/p C/T
    • cough, chest pain, flank pain
  • O:
    • 20240425: BH:165 cm; BW:50 kg; BMI:18.4
    • U/A: no pyuria,
    • no improved after abx for two weeks
    • bladder pain syndrome?
  • Prescription
    • Harnalidge (tamsulosin 0.4mg) 1# QDAC
    • Wecoli (bethanechol 25mg) 1# TIDAC

==========

2024-05-06

This patient was admitted on 2024-05-04 and is continuing to receive UFT for the treatment of colon cancer.

Morphine and Tramacet are currently being used for pain management. According to the nursing record at 07:15 on 2024-05-06, the patient reported no pain, with a VAS score of 0, indicating effective pain control. No medication discrepancies have been found.

700512587

240503

[exam findings]

• 2024-04-30 MRI - brain
  • Multifocal abnormal subcortical white matter change over both cerebral and cerebellar hemispheres. Suggest check enhanced MRI to rule out occult lesions.
  • Severe periventricular small vessel disease. NO acute ischemic infarct.
  • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
  • MR angiography of the brain shows normal intracranial vessel including circle of willis.
• 2024-04-30 SONO - nephrology
  • Interpretation:
    • Renal tumor, right, suspect malignancy? 10.8*8.5cm
    • Hydronephrosis, left, s/p DBJ
    • Parenchymal renal disease
• 2024-04-22 KUB
  • S/P double J catheter insertion, right and left side urinary tract.
  • Spondylosis with scoliosis of the L-spine with convex to left side
• 2024-04-18 Patho - kidney biopsy
  • Labeled as “right renal tumor”, biopsy — carcinoma with squamous differentiation.
  • Section shows renal tissue with carcinoma and squamous differentiation.
  • IHC stains: CK5/6 (+), p40 (+), CK7 (focal+), CK20 (focal +), GATA-3 (equivocal).
• 2024-04-16 CT - chest
  • Comparison was made with CT on 2023 2024
    • Lungs: posterior subpleural recticular opacities and ground-glass opacity at both lower and both upper lobes
      • septal thickening at biapical lung regions.
    • Mediastinum and hila: no enlarged LN or mass.
    • Thoracic aorta: normal caliber, Central pulmonary arteries: normal caliber. Heart: normal size of cardiac chambers.
    • Pleura: small Lt-sided effusion
    • Chest wall and visible lower neck: a well-defined soft-tissue mass (3cm) at left lower neck (level IV, lateral to thyroid gland) due to an enlarged lymph node. a few tiny calcifications in Lt breast.
    • Visible abdominal contents: extensive lymphadenopathy in the paraaortic region and retroperitoneum
      • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • mild fibrosis in both lungs, cause? Lt lower neck and retroperitoneal neoplastic LAP. no lung tumor.
• 2024-04-15 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 33 dB HL; LE 30 dB HL
  • RE mild to moderate SNHL, 4000 Hz had AB gap
  • LE normal to mild SNHL
• 2024-04-12 CXR erect
  • Scoliosis of the T-spine with convex to right side.
  • Atherosclerotic change of aortic arch
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2024-04-10 SONO - gynecology
  • Left ovarian cyst, 2.34x1.95cm, flow(-)
  • Ascites(+)
• 2024-04-09 Patho - lymphnode biopsy
  • Soft tissue, retroperitoneum, CT-guide biopsy — Compatible with metastatic squamous cell carcinoma, moderately differentiated, origin?
  • The specimen submitted consisted of several strips of tan, irregular tissue measuring up to 0.3 x 0.1 x 0.1 cm in size, fixed in formalin. All for section in a cassette.
  • Sections show solid sheets of hyperchromatic tumor cells infiltrating in a fibrotic stroma. Focal keratinization is seen.
  • The immunohistochemical stains reveal CK7(focal +), CK20(focal +), CK5/6(focal +), p40(+), and GATA3(focal +). Invasive urothelial carcinoma may show focal or pure squamous cell carcinoma. Please correlate with the clinical presentation and image study.
• 2024-04-03 PET scan
  • Glucose hypermetabolic lesions in the left lower neck, left supra-clavicular fossa, left infra-clavicular fossa, and in soft tissue of abdomen and plevis, highly suspected lymphoma with involvement of lymph node regions.
    
  • Increased FDG uptake in the right kidney, highly suspected lymphoma with involvement of extralymphatic organ.
  • Increased FDG uptake in bilateral pulmonary hilar regions, bilateral mediastinal spaces, and in bilateral femurs, lymphoma with involvement of lymph node regions and bone marrow may be considered, suggesting follow-up with PET scan for investigation.
    
  • Highly suspected diffuse large B-cell lymphoma, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2024-04-03 Patho - lymphnode biopsy
  • Lymph node, left neck level 4, FNA — Compatible with metastatic squamous cell carcinoma, poorly differentiated
  • The specimen submitted consisted of five tiny pieces of lymph node tissue measuring up to 0.1 x 0.1 x 0.1 cm in size, fixed in formalin. Grossly, they were gray in color and soft in consistence. All embedded for section.
  • Microscopically, the section shows a picture compatible with metastatic squamous cell carcinoma, poorly differentiated characterized by solid tumor nests infiltration with focal dyskeratosis and focal tumor necrosis.
  • Immunohistochemistry shows CK(+), P63(+), CK7(+, focal), GATA-3(+, focal) and PAX-8(-). Clinical correlation is advised.
• 2024-04-02 CT - abdomen
  • With and without contrast enhancement CT: ABD — Liver, Spleen, Biliary duct, Pancreas:
    • Infiltrative tumor in right kidney with dilatation of right pelvicaliceal system, right renal malignancy?
      
    • Dilatation of left ureter due to compression at upper ureter.
    • Unremarkable change of the liver, spleen, pancreas.
    • There are diffuse multiple enlarged lymph nodes in the paraaortic, aortocaval and bilateral iliac regions.
    • No ascites.
  • Impression:
    • Infiltrative tumor in right kidney with hydronephrosis, r/o right renal malignancy.
    • Diffuse enlarged lymph nodes (paraaortic, aortocaval and bilateral iliac regions), metastasis or lymphoma?
    • Left hydroureter.
  • Imaging Report Form for Renal Cell Carcinoma
    • Impression (Imaging stage) : T:T4(T_value) N:N1(N_value) M:M1(M_value) STAGE:_IV__(Stage_value)
• 2024-04-02 CT - neck
  • Findings:
    • One large necrotic mass (2.8cm) over left level IV of neck, highly suspect malignant node. Suggest tissue proof.
    • The oral cavity shows no evidence of focal lesion.
    • The mouth floor and submandibular regions are normal. No focal lesion is identified.
    • The salivary and submandibular gland remain intact.
    • The thyroid appears normal in size and enhancement.
• 2024-03-22 EGD
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
  • Gastric polyps, high body and fundus, suspect fundic gland polyps
  • Duodenal subepithelial lesion, the inlet of SDA, suspected external compression
• 2024-03-22 SONO - abdomen
  • Renal tumor, right
  • para-aortic lymphadenopathy.
• 2023-05-24 Bone densitometry - spine (self-paid)
  • L-spines BMD (AP view) performed by DXA revealed:
    • AP L-spines, BMD of L1-4 0.755 gms/cm2, about 2.7 SD below the peak bone mass (72 %) and 0.3 SD above the mean of age-matched people (106%).
  • IMP:
    • osteoporosis.

[MedRec]

[consultation]

• 2024-05-01 Nephrology
  • Q
    • This is a 76 year old woman with the history of pre-diabetes and hyperlipidemia without medication. This time, she was admitted due to abdominal fullness for 1-2 months.
      • Abdominal CT was further arranged, with the results of diffuse enlarged lymph nodes at paraaortic, aortocaval and bilateral iliac regions, infiltrative tumor in right kidney with hydronephrosis, and left hydroureter. Lymphoma or metastasis was suspected. pathology showed Labeled as “right renal tumor”, biopsy — carcinoma with squamous differentiation. IHC stains: CK5/6 (+), p40 (+), CK7 (focal+), CK20 (focal +), GATA-3 (equivocal).
      • Neck CT showed a large necrotic mass (2.8cm) over left level IV of neck, highly suspect malignant node, pathology showed Lymph node, left neck level 4, FNA — Compatible with metastatic squamous cell carcinoma, poorly differentiated.
      • Whole body PET scan showed highly suspected diffuse large B-cell lymphoma, stage IV (AJCC 8th ed.), highly suspected lymphoma with involvement of extralymphatic organ. pathology showed Soft tissue, retroperitoneum, CT-guide biopsy — Compatible with metastatic squamous cell carcinoma, moderately differentiated, origin?.
    • Due to the above reasons, she was admitted for bilateral tumor stent insertion and further treatment.
    • Paclitaxel (80mg/m2) + Carboplatin (AUC:2, 150mg ) C1 on 2024/04/25
    • Due to renal function suddenly deteriorates (Bun:75mg/dl, Cr:3.55mg/dl), we need your consultation for evaluation. Thanks a lot!!!
  • A
    • We visited the patient at the bedside and evaluated her condition. Her consciousness was clear, and showed no signs of respiratory distress. However, she complained of severe nausea and vomit whenever she tries to ingest anything. As such she had not had sufficient oral fluid intake over the past few weeks.
    • Lab
      • 2024-04-30 Na (Sodium) 128 mmol/L
        
      • 2024-04-30 BUN 75 mg/dL
        
      • 2024-04-30 K(Potassium) 5.5 mmol/L
        
      • 2024-04-30 Creatinine 3.55 mg/dL
        
      • 2024-04-22 Creatinine 0.76 mg/dL
        
    • Our impressions are as follows:
      • Acute kidney injury (stage 3) with pre-renal azotemia due to prolonged dehydration, but also need to rule out post renal obstruction
      • Hyperkalemia due to reduced urinary K excretion and recent use of K supplement (KCl in TPN and const-K)
      • Hypovolemic hypotonic hyponatremia
    • Our advices are as follows:
      • Record daily I/O and BW
      • Arrange renal sonogram for assessment of chronic kidney changes and to rule out post renal obstructions
      • Administer adequate IV fluid hydration, but be wary of fluid overload
      • Consider IV Furosemide 40mg Q6H~Q8H if oliguria persists after adequate IV fluid hydration
      • Avoid all nephrotoxic agents until AKI resolves
    • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance.
• 2024-04-11 Obstetrics and Gynecology
  • Q
    • This is a 76 year old woman with the history of pre-diabetes and hyperlipidemia without medication. This time, she was admitted due to abdominal fullness for 1-2 months. According to the patient, she started to have abdominal fullness for 1-2 months. The fullness persisted and progressed to a dull painful sensation, which could not relieve under any position. She also noticed hiccups, fatigue, and decreased appetite. She could eat only one meal per day ever since. Her body weight dropped significantly during the last 2 months and stated that she looked thinner than before. She also had worsened back soreness and pain especially at lower back. Due to the above reasons, she went to our GI OPD on 2024/03/21 for help.
    • At GI OPD, physical exam showed soft abdomen, and a lymph node at left lower neck. Blood test showed elevated CA199 302.76 U/mL. She underwent upper endoscopy and showed duodenal subepithelial lesion at the inlet of superior duodenal angle, suspected external compression. Abdominal CT was further arranged, with the results of diffuse enlarged lymph nodes at paraaortic, aortocaval and bilateral iliac regions, infiltrative tumor in right kidney with hydronephrosis, and left hydroureter. Lymphoma or metastasis was suspected.
    • She was referred to ENT OPD on 04/01 for her left lower neck mass, and malignancy was also suspected. Neck CT showed a large necrotic mass (2.8cm) over left level IV of neck, highly suspect malignant node. Lymphnode biopsy was conducted for tissue proof.
    • Whole body PET scan showed highly suspected diffuse large B-cell lymphoma, stage IV (AJCC 8th ed.), highly suspected lymphoma with involvement of extralymphatic organ. Due to the above reasons, she was admitted for bilateral tumor stent insertion and further treatment.
    • For CT showed Diffuse enlarged lymph nodes (paraaortic, aortocaval and bilateral iliac regions), metastasis or lymphoma?
    • R/O GYN malignant, for survey, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • 76 y/o menopaused woman, G2P2(NSD) was admitted for
      • Diffuse enlarged lymph nodes (paraaortic, aortocaval and bilateral iliac regions), metastasis or lymphoma?
      • Left neck level IV hard mass, highly suspect malignant node.(GI, GYN, GU, breast, lung) origin to be determined; s/p CT-guided biopsy (pathology: SCC, poorly differentiated)
      • Multiple enlarged lymph nodes in the paraaortic, aortocaval and bilateral iliac regions, s/p CT- guided biopsy on 2024/04/09, pending pathology report
      • Right renal tumor with hydronephrosis r/o right renal malignancy, s/p right ureterorenoscopic examination & bilateral tumor stent insertion on 2024-04-08
    • PHx: Pre-diabetes and hyperlipidemia without medication.
    • Lab data: elevated CA199 302.76 U/mL
    • Abdominal CT scan on 2024/04/02:
      • Infiltrative tumor in right kidney with hydronephrosis, r/o right renal malignancy.
      • Diffuse enlarged lymph nodes (paraaortic, aortocaval and bilateral iliac regions), metastasis or lymphoma?
      • Left hydroureter.
    • Neck CT scan on 2024/04/02: a large necrotic mass (2.8cm) over left level IV of neck, highly suspect malignant node.
    • Whole body PET scan on 2024/04/09: highly suspected diffuse large B-cell lymphoma, stage IV (AJCC 8th ed.), highly suspected lymphoma with involvement of extralymphatic organ.
    • Transvaginal sonography:
      • Uterus: atrophy, EM = 4.2 mm
      • LOV: one cystic mass lesion, 2.34x1.95cm, flow(-)
      • Rt adnexa: free
      • CDS: with ascites, little
    • IMP:
      • GYN malignancy was not likely
    • Suggestion:
      • Check CA125, CEA level
      • Well explained to patient about current condition.
      • Feel free to contact us for any new/other GYN findings

[chemotherapy]

• 2024-04-25 - paclitaxel 80mg/m2 120mg NS 250mL 3hr + carboplatin AUC 2 150mg NS 250mL (CrCl 50 AUC 2)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-05-03

[using Micafungin in candidemia with renal impairment]

For patients with candidemia, UpToDate [1] suggests initial therapy with one of the following echinocandins:

• Anidulafungin: 200 mg loading dose, then 100 mg intravenously (IV) daily
• Caspofungin: 70 mg loading dose, then 50 mg IV daily
• Micafungin: 100 mg IV daily

Micafungin 100mg IVD QD is currently in use and meets the guideline proposal. This patient has impaired renal function, however no dosage adjustment necessary for any degree of kidney dysfunction [2].

Ref: - [1] https://www.uptodate.com/contents/management-of-candidemia-and-invasive-candidiasis-in-adults - [2] Pharmacokinetics of micafungin in healthy volunteers, volunteers with moderate liver disease, and volunteers with renal dysfunction. J Clin Pharmacol. 2005;45(10):1145-1152.

[culture results: urine - Candida albicans 80000 CFU/cc; blood and port A - yeast-like]

Candida albicans - Sanford guide

Clinical Setting

• Candidemia, disseminated candidiasis: non-neutropenic, neutropenic patients
• Most common cause of mucosal and cutaneous candidaisis
• Normal human flora
• Risk factors: Antibiotic use, GI surgery, immunocompromised state
• Positive blood culture for yeast, suspected catheter-related bloodstream infection

Classification

• Candida albicans - most common cause of invasive candida infections, forms germ tube

Primary Regimens

• Empiric Therapy:
  • Caspofungin 70 mg IV loading dose, then 50 mg IV qd
  • Micafungin 100 mg IV qd
  • Anidulafungin 200 mg IV loading dose, then 100 mg IV qd
  • Rezafungin 400 mg x 1 loading dose, then 200 mg IV once weekly
• Directed Therapy (species identified)
  • Fluconazole 800 mg (12 mg/kg) loading dose, then 400 mg IV/po qd once blood cultures have cleared and clinically stable

Alternative Regimens

• Empiric Therapy Non-Neutropenic Patients:
  • Fluconazole 800 mg (12 mg/kg) loading dose, then 400 mg IV/po qd (in cases of mild-to-moderate illness and no prior azole therapy)
  • Lipid-based Amphotericin B 3-5 mg/kg IV qd
  • Amphotericin B 0.7 mg/kg IV qd
  • Voriconazole 6 mg/kg bid x 2 doses, then 4 mg/kg bid

Antimicrobial Stewardship

• Duration of therapy for candidemia without persistent fungemia or metastatic complications is for 2 weeks after documented clearance of Candida from the bloodstream, resolution of symptoms attributable to candidemia, and resolution of neutropenia.
• Repeat blood cultures to confirm clearance of fungemia.

2024-05-02

[evaluating cardiac output and metabolic acidosis in clinical settings, considerations for albumin supplementation in hypoalbuminemia]

According to the TPR panel in HIS5, the patient’s net fluid input has consistently been positive over the past week, theoretically corresponding to an increase in body weight, although weight measurements have only been recorded in the TPR panel since 2024-05-01. During this period, the patient’s heart rate has increased from under 100 to 130 beats per minute. Since hypovolemia should have been addressed, and given a PCT level of 4.30 ng/mL and D-dimer > 10000 ng/mL (FEU) on 2024-05-01 suggesting a possible infection, further investigation into infectious signs is warranted. Could the increased heart rate be a compensatory mechanism to enhance cardiac output or to counteract metabolic acidosis due to impaired kidney function? A 2D cardiac echocardiogram might be considered.

Additionally, with hypoalbuminemia noted at 2.5 g/dL on 2024-05-01, albumin supplementation could also be considered.

701473497

240503

[exam findings]

• 2024-04-12 CT - abdomen
  • History: Sigmoid colon cancer recurrence with bladder wall invasion, T4bN2aM0, stage IIIC
  • Findings: Comparison: prior CT dated 2024/02/01.
    • Prior CT identified rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion is noted again, stationary. Some LNs at pelvic cavity. S/P colostomy at right transverse colon.
    • Prior CT identified some metastases in both lungs are noted again, mild decreasing in size.
    • S/P Percutaneous nephrostomy of right and left kidney.
    • Delayed contrast excretion of left kidney and patchy poor enhancement in the posterior medial aspect of right kidney middle pole is noted. Please correlate with urine routine.
    • Some calcifications in bil. scrotum.
  • Impression:
    • Prior CT identified rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion is noted again, stationary.
    • Prior CT identified some metastases in both lungs are noted again, mild decreasing in size.
• 2024-03-27 CT - brain
  • no acute intracranial hemorrhage
• 2024-03-27 ECG
  • Sinus tachycardia
  • Right atrial enlargement
  • Rightward axis
  • Borderline ECG
• 2024-03-21 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Hiatal hernia
    • Superficial gastritis
  • CLO test: not done
  • Conclusion:
    • No active bleeders were noted in this study
• 2024-03-01 Patho - skin cyst/tag/debridement
  • Labeled as “left forearm”, biopsy — benign skin with fibrosis, hematoma, and mild chronic inflammation.
• 2024-02-01 CT - abdomen
  • History and indication: Colon cancer with bladder invasion s/p op; stage III
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion. Some LNs at pelvic cavity. S/P colostomy.
    • Some nodules in bil. lungs. A small calcificaiton at RLL.
    • Some calcifications in bil. scrotum. Mild right hydronephrosis.
    • Atherosclerosis of aorta.
    • S/P left side double J catheter insertion. Some stones (up to 1.5cm) in urinary bladder. Still dilatation of left renal pelvis.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion, LNs and lung metastases.
• 2023-10-31 CT - abdomen
  • Clinical history: 46 y/o male patient with Sigmoid colon cancer recurrence with bladder wall invasion, T4bN2aM0, stage IIIC, status post T-loop colostomy on 2023/03/08, status post FOLFIRI from 2023/06/10 ~ from pelvis to chest.
  • With and without contrast enhancement CT of abdomen – whole:
    • S/P double J catheter drainage, left side.
    • S/P colostomy in right abdomen.
    • Rectal malignancy with urinary bladder and left distal ureteral invasion
    • Dilatation of left pelvicaliceal system and ureter.
    • Bilateral lung tumors, r/o lung metastasis, progression.
  • Impression:
    • S/P double J catheter drainage, left side. S/P colostomy in right abdomen.
    • Rectal malignancy with urinary bladder and distal ureteral invasion. Progression.
    • Multiple lung metastasis, progression.
• 2023-05-28 CXR
  • Normal sinus rhythm
  • Right atrial enlargement
  • Rightward axis
  • Pulmonary disease pattern
  • Abnormal ECG
• 2023-05-25 CT - abdomen
  • History and indication: Colon cancer with bladder invasion s/p op; stage III
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion. Some LNs at pelvic cavity. S/P colostomy.
    • Some nodules in bil. lungs. A small calcificaiton at RLL.
    • Some calcifications in bil. scrotum.
    • Atherosclerosis of aorta.
    • S/P left side double J catheter insertion and the lower end in urethra. Still dilatation of left renal pelvis.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion, LNs and lung metastases. Left hydronephrosis.
• 2023-04-15 Urology SONO - kidney
  • CC
    • Colon cancer s/p colectomy and partial cystectomy in 2021/05 at Cathay GH
    • Followed by R/T and C/T
    • Fecaluria noted on 2023/02/28
    • Obstructive uropathy s/p URS and DBJ before colostomy
    • Right side colostomy performed in 2023/03
• 2023-04-15 Bladder sonography
  • PVR 11.55 ml
• 2023-03-10 Patho - colon biopsy
  • Colon tumor, sigmoid (15 cm from anal verge), biopsy — Compatible with adenocarcinoma, recurrent
  • Microscopically, the sections show a picture of mainly benign mucosa with focal ulcer, necrotic debris and few tumor cells show subtle cribriform pattern, compatible with recurrent adenocarcinoma.
• 2023-03-09 Signoidoscopy
  • Sigmoid cancer recurrence with lumen narroing at 15 cm from AV, biopsy was done
• 2023-03-02 CT - abdomen
  • History and indication: Colon cancer with bladder invasion s/p op; stage III
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion. Some LNs at pelvic cavity.
    • Some calcifications in bil. scrotum.
    • Atherosclerosis of aorta.
    • S/P left side double J catheter insertion and the lower end in urethra.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)

[MedRec]

• 2023-05-04 SOAP Hemato-Oncology
  • P
    • Urologist: C/T goes first and then repair fistula
    • Port-A flush Q3M on 2023-05-04
• 2023-04-15 SOAP Urology
  • S
    • Colon cancer s/p colectomy and partial cystectomy in 2021/05 at Cathay GH
    • Followed by R/T and C/T
    • Fecaluria noted on 2023/02/28
    • Obstructive uropathy s/p URS and DBJ before colostomy
    • Right side colostomy performed in 2023-03
  • O
    • 2023/04/14 Renal sona: no hydronephrosis, bladder sona: thick bladder wall, small PVR, adviuse hydration and follow-up
  • Diagnosis
    • Dysuria R30.0
  • Prescription
    • Urief (silodosin 8mg) 1# QD
• 2023-04-13 SOAP Hemato-Oncology
  • S
    • CCRT with CapOx (2- cycles) -> Avstin plus Oxaliplatin x 10 cyces -> shift to Avastin plus irinotecan due to oxaliplatin-induced neuropathy -> Hold avastin for 5-6 months plus irinotecan due to ulcer over anastomic site by avastin -> due to left hydronephrosis, fistula between tumor and posterior wall of bladder was noted. D-J was done and PD was confirmed -> Shift to regorafenib (taken for 2 weeks) since 2023-01. For avoiding infection over fistula, colostomy was conducted on 2023-03-08.
  • P
    • Consider FOLFIRI with or without Anti-EGFR dependent on RAS.
    • Waiting for infection under control and RAS data
• 2023-03-16 SOAP Hemato-Oncology
  • P: Request to visit Urologist for manage the fistula between bladdner and tumor
• 2023-03-02 ~ 2023-03-10 POMR Colorectal Surgery
  • Discharge diagnosis
    • Sigmoid colon cancer recurrence with bladder wall invasion, T4bN2aM0, STAGE:IIIC, status post T-loop colostomy on 2023/03/08
    • Enterovesical fistula with urinary tract infection
  • CC
    • Urination with stool content for weeks
  • Present illness
    • This is a 46-year-old male with past history of
      • 1. Moderate differentiated adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C
        • s/p anterior reseection with radical lymph node dissection on 2021/05/18
        • s/p radiotherapy with 5400 cGy/30 Fx (2021/06/21 - 2021/08/03, s/p oxaliptin + capecitabine (C1D1 - C2D1 -2022/11/29, 2021/06/22 ~ 07/13)
        • s/p mFOLFOX + Avastin (CIDI ~ C11D1 = 2021/08/10 ~2022/01/12)
        • s/p FOLFIRI (CID1 = 2022/01/25)
        • s/p Strivaga (2023/2/18-3/2)
      • 2. Right lower lung atypical adenomatous hyperplasia, s/p Video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis on 2022/02/10
      • 3. Cystoscopy + left ureteroenoscopy (URS) revealed bladder papillary tumor at posterior wall (S-colon invasion?), left UVI stricture, left middle ureter severe toturous & dilation
      • 4. HBV carrier, on tenofovir
    • Tracing back to his previous medical history initially he suffered from periumbilical pain then intermittent LLQ abdomen pain for 3 months. The pain sustained more than one hour, described as cramping and severe. He had visited Xindian Cardinal Tien Hospital on 12/07 and then transferred to Taipei Medical University Hospital.
      • Due to above symptoms, he went to Cathay General Hospital GI Dr. Li JiaLong OPD. There was no tenesmus. Body weight lost 7 kg (from 57 to 50）was noted. 2021/05/04 coloscopy was proceeded up to tumor location. It is about 4cm luminal colon tumor mass with nearly total occlusion 40 cm from anal verge s/p biopsy. Pathology report revealed adenocarcinoma. The whole abdomen CT scan performed and finding: Irregular annular thickening of sigmoid colon nearly 6.8 x 3.3cm in size, with perfocal fat stranding.
      • Anterior resection with radical lymph node dissection + partial cystectomy and bladder wall repair was performed on 2021/05/18.
      • After operation , he received CRT of radiotherapy with 5400 cGy/30 fractions during 2021/06/21 - 2021/08/03 and chemotherapy with oxaliptin + capecitabine (CID1 ~ C2D1 = 2021/06/22 ~ 07/13）then mFOLFOx + Avastin (C1D1 ~ C11D1 = 2021/08/10 ~ 2022/01/12). Follow-up Chest CT on 2021/12/31 revealed two new subpleural nodules (5. 5mm and 3mm at RLL of lungs, suspected lung metastasis. so video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis was performed on 2022/02/10 and the pathology revealed atypical adenomatous hyperplasia.
      • Chemotherapy regimen was shifted to FOLFIRI cycle 1 - cycle 4 on 2022/01/25-2022/04/13.
      • He received FOLFIRI(46) & avastin on 20220413 cycle 4 but nausea, change in bowel habit (stool passage turn less and thin), mild periumbilical pain and tenderness were noted. There were no other symptoms such as fever with chills headache, dizziness, vomiting, diarrhea, constipation, cough with sputum production, dysuria, gross hematuria, diaphoresis (cold sweating) or dyspnea.
    • This time, ever since the AR on 2021/05/18, dirty urine was noted, but recently more stool content has been found. Therefore, he transferred from Cathay General Hospital to our OPD due to recommendation by his father-in-law.
    • Therefore, under the impression of adhesion of bladder and colon he was admitted for further investigation of cancer invasion or possible colonstomy evaluation.
  • Course of inpatient treatment
    • After admission with ward routine and blood examination were done. Operation of T-loop colostomy under general anesthesia were performed on 2023/03/08. NPO and IV fluids support. The wound healing well and no erythema change. Chewing cookies, toast, rice with gum was started at op day. No nausea and no vomiting, flatus passage. On low residual diet was started at post-op day 1. Patient education with colostomy care was done. Normoactive bowel movement and stools passage with diet better tolerated. There wrew no fever and no complication. So he was arranged for discharge for hisstable general condition on 2023/03/10 and will be followed up in ONCOLOGY for further chemotherapy.
  • Discharge prescription
    • Uroprin (phenazopyridine 100mg) 1# TID
    • Morcasin (sulfamethoxazole 400mg, trimethoprim 80mg) 2# BID
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Defram-K (diclofenac 25mg) 1# PRNQ8H
• 2023-03-02 SOAP Colorectal Surgery
  • S
    • Colon cancer with bladder invasion s/p op; stage III, 2021-05-19
    • post-OP chemotherapy + target therapy ; DJ insertion
    • Stool passage from urine for one week
    • Septicemia 2023-01

[consultation]

• 2024-04-30 Dermatology

• 2024-03-21 Reconstructive and Plastic Surgery

• 2024-03-05 Dermatology

• 2024-02-25 Infectious Disease

• 2024-02-23 Dermatology

• 2024-02-22 Ear Nose Throat

• 2024-02-22 Urology

• 2024-02-01 Urology

• 2024-01-12 Psychosomatic Medicine

• 2023-11-22 Urology

• 2023-06-29 Colorectal Surgery

  • Q
    • This is a 46-year-old male with past history of
      • 1. Moderate differentiated adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C
        • s/p anterior reseection with radical lymph node dissection on 2021/05/18
        • s/p radiotherapy with 5400 cGy/30 Fx (2021/06/21 - 2021/08/03, s/p oxaliptin + capecitabine (C1D1 - C2D1 - 2022/11/29, 2021/06/22 ~ 07/13)
        • s/p mFOLFOX + Avastin (CIDI ~ C11D1 = 2021/08/10 ~2022/01/12) - s/p FOLFIRI (CID1 = 2022/01/25)
        • s/p Strivaga (regorafenib) (2023/2/18-3/2),
      • 2. Right lower lung atypical adenomatous hyperplasia, s/p Video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis on 2022/02/10,
      • 3. Cystoscopy + left ureteroenoscopy (URS) revealed bladder papillary tumor at posterior wall (S-colon invasion?), left UVI stricture, left middle ureter severe toturous & dilation,
      • 4. HBV carrier, on tenofovir.
    • since the AR on 2021/05/18, dirty urine was noted, but recently more stool content has been found, CT showed Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion, s/p T-loop colostomy on 2023/03/08.
    • He presented anal pain when sit, we need your further evaluation and management.
  • A
    • this is a 46-year old man with adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C - s/p anterior reseection with radical lymph node dissection on 2021/05/18
      • and anal pain was told for 8 days
    • DRE: no obvious hemorrhoid but firm mass over ant rectum region about 5cm aav region, possible progress of rectal cancer
    • P:
      • add alcos anal and posuline for supp use
      • warm water sitz bath

• 2023-06-29 Urology

  • Q
    • He received Left double J catheter replacement on 2023/05/31, he presented with scrotal pain when urination, we need your further evaluation and management.
  • A1
    • After change DBJ last month, urinary incontinence disappeared
    • Drainage effect of stent will be followed (he insist NOT tumor stent for fear of pain )
    • He said he had left scrotal discomfort since last week
    • Physical examination showed no obvious swelling or heating
    • Scrotal ultrasound will be arranged
  • A2 2023-06-30 09:55:48
    • little fluid around testis (malnutriotion may be related)
      • the pain is related to voiding
    • try doxaben HS may be beneficial for voiding

• 2023-03-06 Gastroenterology

  • Q
    • For HBV medication, tenofovir use
    • This is a 46-year-old male with past history of
      • 1. Moderate differentiated adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C
        • s/p anterior reseection with radical lymph node dissection on 2021/05/18
        • s/p radiotherapy with 5400 cGy/30 Fx (2021/06/21 ~ 2021/08/03),
        • s/p oxaliptin + capecitabine (C1D1 - C2D1 -2022/11/29, 2021/06/22 ~ 07/13)
        • s/p mFOLFOX + Avastin (CIDI ~ C11D1 = 2021/08/10 ~ 2022/01/12) - s/p FOLFIRI (CID1 = 2022/01/25)
        • s/p Regorafenib (Strivaga, 2/18-3/2)
      • 2. Right lower lung atypical adenomatous hyperplasia, s/p Video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis on 2022/02/10
      • 3. Cystoscopy + left ureteroenoscopy (URS) revealed bladder papillary tumor at posterior wall (S-colon invasion?), left UVI stricture, left middle ureter severe toturous & dilation
      • 4. HBV carrier, on tenofovir
    • Under the impression of adhesion of bladder and colon he was admitted to our CRS ward for further investigation of cancer invasion or possible colostomy evaluation. During hospitalization, Tenofovir has been used up. We need your expertise for medication use.
  • A
    • 46 years old man has sigmoid cancer, s/p CCRT, chemotherapy, Target therapy, HBV carrier under tenofovir. He has admitted for adhesion of bladder and colon. Therefore, we are consulted for tenofovir.
    • PE
      • conscious: clear
      • chest: smooth breath pattern
      • abdomen: soft and flat
    • Impression
      • Sigmoid cancer, s/p CCRT, target therapy
      • HBV carrirer under Tenofovir
    • Suggestion
      • If the PharmaCloud database indicates that the patient has been prescribed Tenofovir at an outside hospital, the issuing institution should be changed to our hospital (pending confirmation).

[surgical operation]

• 2023-03-08
  • Surgery: T-loop colostomy        
  • Finding: T-loop colostomy was created at RUQ area        
  • Procedure
    • Patient was put on supine position under ETGA
    • Sterized and drapped as routine
    • RUQ skin incision and muscular layer was splitted, fasia and peritoneum was opened
    • Iluem was identified and externalization, looped with a rubber tube
    • Colostomy was opened and matured by suturing with 3-0 monopril
    • Covered with stoma bag  

[radiotherapy]

[chemotherapy]

• 2024-04-29 - nivolumab 3mg/kg 100mg NS 100mL 1hr (Opdivo + Stivarga (regorafenib))

• 2024-04-10 - nivolumab 3mg/kg 100mg NS 100mL 1hr (Opdivo + Stivarga (regorafenib))

• 2024-03-22 - nivolumab 3mg/kg 100mg NS 100mL 1hr (Opdivo + Stivarga (regorafenib))

• 2024-03-07 - nivolumab 3mg/kg 100mg NS 100mL 1hr (Opdivo + Stivarga (regorafenib))

• 2024-02-22 - nivolumab 3mg/kg 100mg NS 100mL 1hr (Opdivo + Stivarga (regorafenib))

• 2024-02-05 - nivolumab 3mg/kg 100mg NS 100mL 1hr (Opdivo + Stivarga (regorafenib))

• 2024-01-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min (Avastin + Lonsurf (trifluridine, tipiracil))

• 2023-12-23 - bevacizumab 5mg/kg 200mg NS 100mL 90min (Avastin + Lonsurf (trifluridine, tipiracil))

• 2023-11-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min (Avastin + Lonsurf (trifluridine, tipiracil))

• 2023-10-09 - FOLFIRI

• 2023-09-12 - FOLFIRI

• 2023-08-15 - FOLFIRI

• 2023-07-25 - FOLFIRI

• 2023-07-05 - irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL

• 2023-06-09 - irinotecan 120mg/m2 160mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

• 2024-02-05 ~ undergoing (2024-02-23) - Stivarga (regorafenib 40mg)

• 2023-10-30 ~ 2024-02-02 - Lonsurf (trifluridine 15mg, tipiracil 7.065mg) 3# BID

Systemic therapy for nonoperable metastatic colorectal cancer: Approach to later lines of systemic therapy - 2024-02-23 - https://www.uptodate.com/contents/systemic-therapy-for-nonoperable-metastatic-colorectal-cancer-approach-to-later-lines-of-systemic-therapy

• Microsatellite unstable/deficient mismatch repair tumors - For patients who have high microsatellite instability (MSI-H)/deficient mismatch repair (dMMR) tumors who did not receive an immune checkpoint inhibitor for initial first-line therapy, we suggest immune checkpoint inhibitor immunotherapy rather than another form of systemic therapy. Two options are available:
  • Monotherapy with an immune checkpoint inhibitor that targets the programmed cell death 1 (PD-1) receptor, ie, either nivolumab or pembrolizumab, is one option. In clinical trials, objective response rates (ORRs) with these two PD-1 inhibitors are 30 to 50 percent, and some responses are durable. Both drugs have been approved by the US Food and Drug Administration (FDA) for this indication in the United States, and the choice of one agent over the other is empiric. Patients who experience disease progression on either of these drugs should not be offered the other.
  • Another option is the combination of nivolumab plus ipilimumab, a monoclonal antibody directed against a different immune checkpoint, cytotoxic T lymphocyte antigen 4 (CTLA-4). Although there are no randomized trials directly comparing dual therapy with monotherapy with either nivolumab or pembrolizumab alone, indirect comparisons from the multicohort phase II CheckMate 142 trial suggest that combined immunotherapy provides improved efficacy over anti-PD-1 monotherapy and has a favorable risk-benefit ratio. Updated analyses with long-term follow-up of the two second-line cohorts reported four-year progression-free survival (PFS) of 52 percent in the combination nivolumab-ipilimumab arm and 36 percent with single-agent nivolumab. The combination has received FDA approval in the United States for patients with MSI-H or dMMR mCRC that has progressed despite other treatments. It is currently not known in which patients with MSI-H mCRC to use combined nivolumab plus ipilimumab, or whether this combination is active in patients who relapse or progress on single-agent checkpoint inhibitor immunotherapy.
• Trifluridine-tipiracil with or without bevacizumab - Trifluridine-tipiracil plus bevacizumab is an option for patients with mCRC who have been previously treated with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy, an anti-VEGF agent, and an EGFR inhibitor (if RAS wild-type). Trifluridine-tipiracil monotherapy may be offered to patients who are unable to tolerate or have contraindications to bevacizumab.
  • Trifluridine-tipiracil (TAS-102) is an oral cytotoxic agent that consists the nucleoside analog trifluridine (trifluorothymidine, a cytotoxic antimetabolite that, after modification within tumor cells, is incorporated into DNA causing strand breaks) and tipiracil, a potent thymidine phosphorylase inhibitor, which inhibits trifluridine metabolism and has antiangiogenic properties as well.
  • Trifluridine-tipiracil is administered twice daily on days 1 to 5 and 8 to 12 of a 28-day cycle, and bevacizumab is administered at 5 mg/kg on days 1 and 15 of a 28-day cycle. Other studies suggest that an every-two-weeks schedule of administration of trifluridine-tipiracil (twice daily on days 1 to 5 of a 14-day cycle) with bevacizumab (5 mg/kg on day 1 of a 14-day cycle) is associated with less toxicity, especially neutropenia. This schedule is a reasonable alternative for patients who have difficulty tolerating the standard dosing of this combination.

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2024-05-03

Stivarga (regorafenib) is known to cause anemia in 79% of cases, with severe anemia (grade 3) occurring in 5% and critical anemia (grade 4) in 1% of patients.

Severe anemia was previously addressed in the pharmacist’s notes on 2024-04-30. The most recent HGB lab value, recorded on 2024-04-29, was 7.6 g/dL. Since the last LPRBC transfusion, no further updates on the lab values have been recorded.

2024-04-30

The biopsy of the left forearm conducted in early March did not pathologically confirm skin metastasis.

Grade 3 severe anemia, with a hemoglobin level of 7.6 g/dL recorded on 2024-04-29, was addressed with a LPRBC transfusion.

No discrepancies in medication have been identified at this time.

2024-02-23

[regorafenib and nivolumab: evaluating adverse skin reactions]

Stivarga (regorafenib) has been associated with skin rash occurrences in 26% to 30% of cases. Given that this medication has been administered since 2024-02-05 and the onset of skin rash was noted on 2024-02-18, a causal relationship cannot be ruled out.

Dermatologic toxicities, such as immune-mediated rashes including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN, some instances fatal), exfoliative dermatitis, and bullous pemphigoid, may be induced by nivolumab. The mechanism is not dose-related and remains unclear. Typically, dermatologic toxicity presents early in the course of treatment with nivolumab, with a median onset time ranging from 2.8 to 6.1 weeks post-treatment initiation, and can affect patients with any type of tumor. The median onset time for symptoms resembling Sjögren’s disease is approximately 70 days. Therefore, considering the skin rash appeared merely two weeks after starting nivolumab, it is improbable that nivolumab is the cause.

2024-02-01

[strategies for weight management during chemotherapy]

The patient, undergoing treatment with Avastin and Lonsurf, has maintained a body weight of approximately 40kg since Mar 2023, experiencing a decline to 38kg in the last week.

Lonsurf is known to contribute to decreased appetite (reported in 34% to 39% of cases) and diarrhea (reported in 23% to 32% of cases, with grades 3/4 severity in 3%).

Considering these side effects, the introduction of megestrol may be beneficial in addressing the patient’s weight loss.

2023-07-05

[UTI follow-up]

• Urine culture results from 2023-06-28 identified Escherichia coli > 100K CFU/cc. The patient has been administered Brosym (cefoperazone, sulbactam) 4g IVD Q12H since that day. Lab results of urine analysis showed a decrease in bacteria from 3+ on 2023-06-28 to 1+ on 2023-07-04. Similarly, leukocyte esterase decreased from 2+ on 2023-06-28 to 1+ on 2023-07-04, sediment WBC dropped from > 50/HPF on 2023-06-28 to < 10/HPF on 2023-07-04, and urine color improved from turbid yellow on 2023-06-28 to clear light yellow on 2023-07-04. These results indicate that the antimicrobial agent is effective and the urinary tract infection is improving.
• Kidney and liver functions appeared normal according to lab data on 2023-07-03, so no drug dose adjustment is required.

701497658

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[exam findings]

• 2024-04-18 CXR erect
  • A nodular opacity projecting in the right upper lung is noted that is c/w lung cancer after correlate with CT.
  • S/P port-A implantation.
  • S/P nasogastric tube insertion.
  • S/P tracheostomy
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2024-03-28 Tc-99m MDP bone scan
  • In comparison with the previous study on 2023/12/13, the lesions in the L3-5 spines are a little more evident. Degenerative change in a little more severe status may show this picture. However, please follow up bone scan for further evaluation and to rule out other possibilities.
  • No prominent change is noted in other bone lesions, possibly more benign in nature.
• 2024-03-27 MRI - brain
  • Findings:
    • moderate intraventricular and extraventricular CSF spaces
    • moderate to severe bilateral periventricular leukoaraiosis.
    • unremarkable change in the skull base
    • unremarkable change in the intracranial vessels
    • right mastoiditis; dural sinus thrombosis in the left sigmoid sinus.
    • multiple heterogeneous enhancing nodular lesions in the supratentorial and infratentorial brain, incrrease in sizes, except the one in the right temporal lobe.
  • IMP:
    • multiple brain metastasis, increase in size, except the one in the right temporal lobe.
• 2024-03-26 CT - chest
  • Indication: Right upper lobe lung cancer, adenocarcinoma, cT4N3M1c, stage IVB, multiple brain meta, with IICP, epilepsy, lung to lung metastases, EGFR(-), ROS(-), ALK(-), PD-L1: 2%, ECOG:3 status post radiotherapy and chemotherapy
  • Comparison was made with CT on 2023/12/09
    • Lungs: RUL spiculated tumor with pleural tails measuring 2.7cm (axial dimension, srs/img202/39).
      • posterior large consolidation with reticular opacities at both lower lobes. increasing in size of nodules at LUL, RUL, and RLL..
      • moderate bilateral upper lobes centrilobular emphysema and substantial subpleural paraseptal emphysema.
    • Mediastinum and hila: enlarged LNs in both sides of visceral space. mild coronary arterial calcification
    • Thoracic aorta: normal caliber, extensive atherosclerotic change.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal size of cardiac chambers. midseptal hypertrophy of IVS.
    • Pleura: Rt greater thanLt, small bilateral effusions.
    • Chest wall and visible lower neck: small LNs at Lt supraclavicular fossa.
    • Visible abdominal-pelvic contents: many renal cysts.
      • numerous hepatic cysts measuring up to 12cm.
      • unremarkable of the GB, spleen, both adrenal glands, pancreas, and no enlarged lymph node.
      • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • RUL cancer with lung to lung and mediastinal LNs metastases, in progression in size of lung to lung metastaatic lesions and new consolidative process in lower lobes of lungs (pneumonia?) as compared with CT on 2023/12/09
• 2024-02-27 EEG
  • Abnormal, continuing generalized slowing with theta waves 5-6Hz, indicated moderate cortical dysfunction bilaterally, suggest clinical correlation.
• 2024-02-16 EEG
  • Borderline, mild intermittent diffuse cortical dysfunction. no focal cortical dysfunction or e[pileptic form discharges were recorded.
• 2023-12-28 EEG
  • Abnormal, continuing generalized slowing with theta waves, sporadic & multi-focal phase reversal over bilateral P and left T (P3, P4, T5) areas, indicated moderate to severe cortical dysfunction bilaterally, suggest clinical correlation and AEDs control.
• 2023-12-13 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in both rib cages, mandible, some L-spine, bilateral shoulders, left S-I joint, hips, knees, and left ankle.
• 2023-12-11 MRI - brain
  • Indication: RUL adenocarcinoma, cT4N3M1c, stage IVB, multiple brain meta, with IICP, epilepsy, lung to lung meta, EGFR(-), ROS(-), ALK(-), PD-L1 2%, ECOG 3, status post radiotherapy
  • Imp: Multiple brain metastases, a large one at right temporal lobe as mentioned above.
• 2023-12-09 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lymphadenopathy at bilateral paratracheal region is found. In regression.
      • S/p port-A placement with its tip at Superior vena cava
      • Minimal opacities over right lower lobe and left lower lobe is found.
      • S/p tracheal tube placement with its tip in place.
      • No evidence of bilateral pleural effusion.
      • Spiculated nodule at right upper lobe measuring 3.67cm is found. In comparison with CT dated on 2023-09-13, the lesion is stationary.
      • Moderate Centrilobular Emphysematous change over both lungs is found.
    • Visible abdomen:
      • Multiple hepatic cysts at both lobes of liver measuring 11.5cm at right lobe are found.
      • The spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Right upper lobe lung cancer with mediastinal lymphadenopathy. The primary tumor is stationary but the mediastinal lymph nodes regressed.
• 2023-11-20 EEG
  • Abnormal EEG.
  • This EEG featured continuous periodic spike-and-wave complexes at 1-1.5 Hz in right hemisphere with frequent spreading to the left side. This EEG suggests periodic lateralized epileptiform discharges in right hemisphere with spreading to the left side. Advise clinical correlation and adjustment of anti-epileptic drugs.
• 2023-10-31 EEG
  • This is an abnormal EEG suggesting moderate cortical dysfunctions like metabolic encephalopathy.
  • Background: alpha 7-8 Hz
  • intermittent diffuse delta slow waves at bilateral central and temporal area
  • No epileptiform discharge during this recording
  • Please correlate clinially
• 2023-10-24 EEG
  • This is an abnormal EEG suggesting moderate to severe cortical dysfunctions like metabolic encephalopathy or hypoxic encephalopathy.
  • Background: Theta 6-7 Hz
  • intermittent diffuse delta slow waves at bilateral central and temporal area
  • No epileptiform discharge during this recording
  • Please correlate clinially
• 2023-10-19 SONO - chest
  • Pleural tapping 16 #-needle Right side 60 ml serosanguineous
  • Insertion of pig-tail catheter Right side 14 fr. through the 7 ICS
  • Insertion of pig-tail catheter Left side 14 fr. through the 7 ICS
• 2023-10-17 EEG
  • This is an abnormal EEG suggesting moderate to severe cortical dysfunctions like metabolic encephalopathy or hypoxic encephalopathy.
  • Background: Theta 6-7 Hz
  • intermittent diffuse delta slow waves at bilateral central and temporal area
  • No epileptiform discharge during this recording
  • Please correlate clinially
• 2023-10-11 EEG
  • Abnormal, continuing generalized slowing with theta (4-5Hz) and delta (2-3Hz) waves bilaterally, indicated severe cortical dysfunction bilaterally, no epileptic discharges were found, suggest clinical correlation.
• 2023-10-09 ROS1 IHC
  • Cellblock No. S2022-19306
  • RESULT: Negative
• 2023-10-09 ALK IHC
  • Cellblock No. S2022-19306
  • RESULT: Negative
• 2023-10-07 CT - brain
  • Brain metastasis
  • Ventriculomegaly
  • Minimal midline shift
• 2023-09-27 EGFR mutation
  • Cellblock No. S2023-19306
  • RESULTS
    • No mutation was detected at exons 18,19,20,21 of EGFR gene in this specimen.
• 2023-09-27 PD-L1 (22C3)
  • Cellblock No. S2023-19306
  • RESULTS
    • Tumor Proportion Score (TPS) assessment: TPS >= 1% and <50%
    • Tumor Proportion Score (TPS): 2%
• 2023-09-26 Patho - lung transbronchial biopsy
  • Lung, RUL, CT-guide biopsy—adenocarcinoma, moderately differentiated
  • Sections show acinar glandular cells and solid tumor nests infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal CK7(+), CK20(-), TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
• 2023-09-26 ECG
  • This is an abnormal EEG suggesting right central focal moderate to severe epileptogenic activities.
  • Background: theta 7-8 Hz
  • continuous focal sharp and spiky waves over right central area
  • Advise AEDs used
  • Please correlate clinically.
• 2023-09-26 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (96 - 24) / 96 = 75.00%
    • LVEF (%) = 75
    • M-mode (Teichholz) = 75
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH; LV diastolic dysfunction Gr 3 (restrictive pattern).
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR; aortic valve sclerosis.
    • Possible mild pulmonary hypertension, estimated PASP: 41 mmHg.
• 2023-09-18 EEG
  • This EEG featured nearly continuous periodic spikes or spike-and-wave complexes in right hemisphere with phase reversals at P4 and T6, and with occasional spreading to the left side. The background activity were composed by rare alpha rhythm at 8-9 Hz, 20-40 uV in left posterior head area and beta rhythm at 13-15 Hz,10-20 uV in left anterior head area.
  • This EEG suggests periodic lateralized epileptiform discharges in right hemisphere. Advise clinical correlation and adjustment of anti-epileptic drugs.
  • Conclusion: Abnormal EEG.
• 2023-09-15 CT - brain for navigator
  • Findings
    • Several intra-axial enhancing tumors associating with extensive perifocal edema involving right frontal lobe, bilateral temporal lobes, right basal ganglion and vermis, with the largest one about 32 mm in right temporal lobe, Metastases are first considered.
    • No bony abnormality.
  • IMP:
    • Multiple brain metastases.
• 2023-09-15 CT - brain
  • Findings
    • decreased Intraventricular and extraventricular CSF spaces, more on the right side; 7.5mm midline shift to the left side
    • multiple brain tumors in the bilateral supratentorial brain and the verebellar vermis, more on the right side with severe perifocal edema in the right basal ganglion, right thalamus, right temporal lobe and right parietal lobe.
    • unremarkable change in the skull base
    • low density change in the right pons. r/o recent infarction.
  • IMP:
    • multiple brain metastais with 7.5mm midlins shift to the left side.
    • low density change in the right pons. r/o recent infarction.
• 2023-09-13 CT - chest
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:M1c(M_value) STAGE:____(Stage_value)
  • Findings
    • lungs: a spiculated tumor with pleural tails over RUL (24mm) consistent with a primary lung cancer.
      • additional small nodules in both lungs.
      • moderate, bilateral, upper lobes predominant, centrilobular emphysema, in lungs.
      • substantial subpleural paraseptal emphysema in upper lobes.
    • Mediastinum and hila: metastatic lymphadenopathy in both sides of the visceral space.
    • Thoracic aorta: normal caliber, mild atherosclerotic change.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal size of cardiac chambers.
    • Pleura: minimal Rt-sided effusion.
    • Chest wall and visible lower neck: small LN at Rt supraclavicular fossa.
    • Visible abdominal-pelvic contents:
      • multiple small bilateral renal cysts.
      • numerous hepatic cysts measuring up to 11.2cm.
      • unremarkable of the GB, spleen, both adrenal glands, pancreas
    • Visualized bones: unremarkable.
  • Impression:
    • RUL cancer T4N3M1c(E1)
• 2023-09-12 MRA - brain
  • Findings:
    • Several enhancing mass lesions over both temporal lobes, left thalamus, the cerebellar vermis and right corona radiata. The largest one (3.4cm) at right temporal lobe with prominent peritumoral edema. Favor metastatic lesions.
    • Compressed right lateral ventricle.
    • MR angiography of the brain shows normal intracranial vessel including circle of willis.
    • Suspect one acute ischemic lacuna infarct or tiny metastasis over right cerebellar lobe.
• 2023-09-12 CT - brain
  • Focal hyperdense mass-like lesion over right temporal lobe. Prominent subcortical edema over right fronto-temporal lobes. Suggest check enhanced MRI to rule out occult tumor.
    
  • Compressed right lateral ventricle.
  • R/O minimal acute SAH over right pre-central sulcus.
• 2023-09-12 CXR
  • a spiculated tumor at Rt apical lung consistent with primary lung cancer
• 2023-09-12 ECG
  • Sinus rhythm with Premature atrial complexes

[MedRec]

• 2023-09-12 ~ 2023-11-07 POMR Integrative Medicine Duan WeiLun
  • Discharge diagnosis
    • Right upper lung adenocarcinoma, cT4N3M1c, stage IVB, with multiple cerebral and cerebellar meta, with increasing intracranial pressure, s/p operation and insertion port-A on 10/18.
    • Essential (primary) hypertension, poorly controlled
    • hypernatremia and hypokalemia
    • Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
    • Pneumonia due to Klebsiella pneumoniae (2023.09.25)
    • Pneumonia due to Pseudomonas (2023.09.25)
    • Chronic viral hepatitis B without delta-agent
    • Pulmonary candidiasis (2023.09.21)
    • Dependence on respirator [ventilator] status s/p tracheostomy on 10/18
    • Pneumonia due to 10/16 sputum/c：CR-Acinetobacter, CRPA (P.aeruginosa)
  • CC
    • Left side limb weakness for 3 days
  • Present illness
    • This individual is a 71-year-old man with a pre-existing condition of hypertension, which is currently being managed with medication. Recently, he experienced a three-day episode of weakness in his left limbs.
    • As reported by the patient’s family, this weakness, accompanied by a headache, began three days ago. There is no history of trauma or prior stroke episodes in the patient’s medical records.
    • Due to the worsening nature of his symptoms, the patient was brought to our Emergency Room for medical assistance.
    • Upon arrival at the Emergency Room, the patient displayed stable vital signs and was fully conscious (E4V5M6). A neurological examination revealed central facial palsy on the left side and reduced muscle strength on the left side (muscle power 4).
    • A brain CT scan was conducted, revealing a hyperdense mass-like lesion in the right temporal lobe, as well as significant subcortical edema in the right fronto-temporal lobe.
    • Subsequently, an MRA (Magnetic Resonance Angiography) was performed, which detected several enhancing mass lesions in both temporal lobes, the left thalamus, the cerebellar vermis, and the right corona radiata.
    • Upon consultation with a neurosurgeon, it was strongly recommended that the patient be admitted for further treatment. Given the clinical impression of a brain tumor with associated brain edema, the patient was admitted to our ward for further evaluation and management.
  • Course of inpatient treatment
    • This individual, a 71-year-old man, has a preexisting medical condition of hypertension that is currently managed with medication. Recently, he experienced a three-day episode of left limb weakness accompanied by a headache. These symptoms began three days ago, and there is no history of trauma or prior strokes in his medical records. Due to the worsening nature of his symptoms, the patient was brought to our Emergency Room for medical assistance.
    • Upon arrival at the Emergency Room, the patient had stable vital signs and was fully conscious (E4V5M6). A neurological examination revealed central facial palsy on the left side and reduced muscle strength on the left side (muscle power 4).
    • A brain CT scan revealed a hyperdense mass-like lesion in the right temporal lobe, along with significant subcortical edema in the right fronto-temporal lobe.
    • Subsequently, an MRA (Magnetic Resonance Angiography) detected several enhancing mass lesions in both temporal lobes, the left thalamus, the cerebellar vermis, and the right corona radiata.
    • Following consultation with a neurosurgeon, admission for further treatment was strongly recommended.
    • Given the clinical impression of a brain tumor with associated brain edema, the patient was admitted for further evaluation and management. Monitoring of the neurological condition will continue during the ward stay.
      • Treatment includes Mannitol 75ml every 8 hours and Medason 40mg every 8 hours for brain edema control.
      • The anticonvulsant agent Keppra 500mg every 12 hours has been prescribed for seizure prevention.
    • A whole-body CT scan revealed right upper lung cancer, staged as T4N3M1c(E1). However, a seizure occurred on the morning of 9/15, around 3 am, characterized by bilateral eye deviation and right leg twitching.
      • Anxicam 2mg was administered twice, after which the patient’s level of consciousness dropped to E1V1M4.
    • A brain CT scan revealed multiple brain metastases with a 7.5mm midline shift to the left side.
      • Consequently, the Keppra dosage was adjusted to 1000mg every 12 hours for seizure control.
    • The patient exhibited breathing sounds with rales and poor cough ability.
    • Chest x-rays showed increased infiltration, leading to chest percussion and suction as needed, with the addition of tapimycin for suspected aspiration pneumonia.
    • Oxygen support was provided with a 10L/min mask to maintain oxygen saturation at 100%.
    • The patient underwent nasogastric tube feeding and had a Foley catheter in place due to the brain tumor diagnosis.
    • The patient’s son and family were fully informed of the situation.
    • On 2023/09/16, the patient underwent a left temporal craniotomy and removal of a metastatic tumor and sent biopsy (9/20 Brain boipsy showed: left temporal craniotomy and removal of tumor; No metastatic carcinoma can be identified in cytokeratin immunostain), after which he was transferred to the Surgical Intensive Care Unit (SICU) for post-operative care.
    • During SICU, the patient received oxygenation with ventilator assistance and H2 blockers for preventing stress ulcers.
      • Steroids, particularly Solu-medure, continued to be administered.
      • An anti-brain swelling agent, mannitol, was used.
      • Empirical antibiotic treatment with tapimycin initiated on 2023/09/15 continued.
      • Hypernatremia was noted, leading to a gradual shift in intravenous fluids to half saline and the provision of free water with meals.
    • Arrange EEG on 9/18 showd periodic lateralized epileptiform discharges in right hemisphere.
    • On 2023/09/20, a right-side eyelid seizure attack occurred. A neurologist was consulted, suggesting the addition of Vimpat and Topamax for epilepsy management.
    • The patient’s current conscious state is E3M5-6VE, and efforts are being made to wean him off the ventilator using the psv mode. Neurologic monitoring is ongoing and closely followed.
    • On 2023/09/25, consult chest men and hematology and oncology for lung cancer. He will be take over to chest men for interventional treatment.
    • After transfer to ICU, ventialtor supply and tapper to off sedation titration. steroid with solu-medrol iv injection and bronchodialtor inhalation.
    • Precribed Ciprofloxacine(09/26-09/30) and Fluconazole(09/26-10/01) for infection control.
    • AED as Depakine, Keppra, Vimpat and Topamax were given for epilepsy agent.
    • Adjust Mannital dose and anti-hypertension agent for BP control.
    • Echocardiography was arranged for heart function survey, and which showed EF 75%, aortic valve sclerosis.
    • Conscult chest surgiest for considor prot-A placement for further invassive chemotherapy.
    • Collect cortisol/thyroid, HbA1C, HIV and HBV.
    • Considor CT quide biopsy for evaluation lung cancer survey and disclosed adenocarcinoma, moderately differentiated “stage IVB,T4N3M1c”.
    • Arrange EEG on 2023/09/26 showed continuous focal sharp and spiky waves over right central area.
    • Arrange family meeting and Well explain to his son and little sister about the critical condition, side effect for cancer treatment, they understood that.
      • Decan 1amp Q8H and mannitol for brain metastasis.
      • PPI wtih self-carried Lansoprazole to prevent Cushing’s ulcers.
    • 2023/09/28 positioning for radiotherapy.
    • Sent Genetic Test/ PD-L1, EGFR(2023/09/27) for lung cancer.
    • Adjust Deparkin to max dose (2023/09/28 valproic acid 48) for intermittent ssizure.
    • However, septic shock and AKI with oliguria, and metabolic acidosis were noticed on 2023/10/01. Mannitol and anti-hypertensive agents were stopped. IV fluid challenge with N/S, Plasbumin infusion, Blood transfusion with FFP 4unit for 3 days (10/01-10/03), and Vasopressor with Norepinephrine titration were administered to correct shock status. Rolikan was given to correct metabolic acidosis. Culture samples inculding sputum and blood were repeated. Foley catheter was changed and urine routine was obtained, suspecision of UTI. We stopped antibiotic with Ciprofloxacin and changed to Brosym (10/1-10/5) + Targocid (10/1-10/14) for infection control. Besides, antifungal with Fluconazole was stopped and changed to Mycamine (10/01-10/14) for infection control. The patient was relieved from shock status and renal function improving soon after treatments.
    • As a result of sepsis, we canceled port-A insertion and chemotherapy was hold due to poor conditions. We well explained to the patient’s family (son) about his critical conditions and he could understand.
    • Self-payment target therapy with Tagrisso 1# PO QD was prescribed (10/2-10/6) as his family’s wish and we kept tracing for the report of Genetic Test/ PD-L1, EGFR. On 10/2, IICP signs were noticed and we resumed Mannitol regularly used. However, polyuria (6300ml/day) was noticed after Mannitol given, suspecision of central DI.
    • Radiation to metastatic brain tumors since 10/3 x 12fx. Another blood transfusion with FFP 4unit for 3 days (10/4-10/6) and adequate IV fluid with 0.298% N/S were prescribed for polyuria and hydration.
    • We consulted Nephrologist for polyuria, who replied 1) Check urine Na, K, Osm (random urine), 2) Follow up on serum electrolyte to avoid severe urinary loss during diuresis, 3) Reduce the solute in IV fluid and try NG enteral fluid replacement for polyuria if possible, 4) Consider decreasing the dose of Mannitol if osmotic diuresis does not resolve.
    • The brain radiotherapy QD was arranged since 2023/10/03. On 2023/10/05, we discontinued Brosym (10/01-10/05) and changed to Sintum (10/05-10/14) due to sputum culture yielded Pseudomonas.
    • On 10/06, the EGFR gene mutation test showed no mutation was detected at exons 18,19,20,21 of EGFR gene in this specimen. We well explained the report of EGFR gene mutation test to his family (son) by telephone and he can understand.
    • Self-payment target therapy with Tagrisso was discontinued for EGFR negative.
    • BT with LRP for thrombocytopenia. Taper Rivotril and lorazepam dose.
    • DC mannitol for large amount urine output.
    • Adjust dexamathasone dosage.
    • Control infection change Targocid (teicoplanin 10/17~), Mepem (meropenem 10/17~), Mycamine (micafungin 10/18~) and Baktar po (sulphamethoxazole + trimethoprim, 10/17~) treatment.
    • Correct thrombocytopenia and anemia given transfusion. Consult surgy perpare insertion port-A and Tracheostomy on 10/18.
    • Bilatory pleural effusion try given FFP with Lasix annx insertion pig-tail daring.
    • Arranged C/T with carboplatin 70% + alimta full (D1) on 10/20. FFP 4U QD x 3 days (10/23-10/25) for volume restored and IV fluid hydration for polyuria and hyponatremia.
    • Discontinued Morcasin po (10/17~10/25) due to negative of PjP, Ganciclovior was prescribed for CMV infection (viral load assay: 10000 IU/mL), also consult INF for CMV infection and persist fever, and consulted Ophthamology for exclude CMV retinitis.
    • We changed antibiotic with Amikacin/INHL (10/19-10/27) to Colimycin/INHL (10/27-) due to sputun culture yielded CRPA.
    • precribed G-CSF (10/30-11/3) for neutropenia. Adeqaute fluid supply for dehydration.
    • Go on weaning and try T-mask overnight since 11/2 as tolerance. Arrange bedside rehabillation.
    • DC Ganciclovir, taper to Valcyte for CMV viral load 2950 on 11/6.
    • Precribed antibiotic with Ceficin (11/7-) for infection control. He will transfer to ward for further care.
    • Under improve condition, he was transfer to gemeral ward for further care. His consciousness clear to confused under Tr mask supply. After his family discuss with Dr Yang MeiZhen. He is prepare discharge today then transfer to nursing home for further care and management on 2023/11/07. Remove CVP on 2023/11/07. And OPD follow up is arranged.
  • Discharge prescription
    • Ceficin (cefixime 100mg) 2# BID since 2023-11-07
    • Cordaraone (amiodarone 200mg) 1# BID hold if HR < 70bpm
    • Folacin (folic acid 5mg) 1# QD
    • Keppra Oral Soln (levetiracetam 100mg/mL) 5mL BID
    • Rivotril (clonazepam 0.5mg) 1# PRNHS if insomnia
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# HS
    • Valcyte (valganciclovir 450mg) 2# QD since 2023-11-07
    • Biomycin Ointment (neomycin, tyrothricin) BID TOPI for posterior buttock wound
    • Acetal (acetaminophen 500mg) 1# Q6H
    • Depakine Oral Soln (valproate Na 200mg/mL) 400mg Q12H
    • hydralazine 50mg 1# Q8H hold if BP < 130/90mmHg
    • Norvasc (amlodipine 5mg) 1# Q12H hold if BP < 120/70mmHg
    • Cortisone (cortisone acetate 25mg) 1# QD
    • Ulstop (famotidine 20mg) 1# BID
    • Bisadyl Supp (bisacodyl 10mg) 2# PRNQOD if constipation
    • Foster Evohaler (beclomethasone 100ug, formoterol 6ug; per dose; 120 doses/bot) 2# BID INHL
    • Spiriva Respimat (tiotropium 2.5ug/puff) 2# HS INHL
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Const-K (KCl 10mEq) 1# QD
    • Nexium (esomeprazole 40mg) 1# QDAC

[chemotherapy]

• 2024-04-05 - Imfinzi (durvalumab) 240mg NS 100mL 1hr (Li Zhong)
  • diphenhydramine 30mg + NS 250mL
• 2024-04-04 - docetaxel 75mg/m2 100mg NS 200mL 1hr (Li Zhong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-02-19 - Imfinzi (durvalumab) 240mg NS 100mL 1hr (Li Zhong)
  • diphenhydramine 30mg + NS 250mL
• 2024-02-16 - pemetrexed 500mg/m2 800mg NS 100mL 10min + NS 250mL (before carboplatin) + carboplatin AUC 6 400mg NS 250mL 2hr + NS 250mL (after carboplatin) (Li Zhong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 100mL
• 2023-12-28 - pemetrexed 500mg/m2 800mg NS 100mL 10min + NS 250mL (before carboplatin) + carboplatin AUC 6 400mg NS 250mL 2hr + NS 250mL (after carboplatin) (Li Zhong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 100mL
• 2023-11-29 - pemetrexed 500mg/m2 800mg NS 100mL 10min ………………………… + carboplatin AUC 5 400mg NS 250mL 2hr (Li Zhong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 100mL
• 2023-10-20 - pemetrexed 500mg/m2 800mg NS 100mL 10min ………………………… + carboplatin AUC 5 300mg NS 250mL 2hr (Yang MeiZhen)
  • dexamethasone 4mg + hydroxocobalamin 1mg IM + NS 100mL 10min + KCl inj 15% 5mL NS 500mL 2hr + KCl inj 15% 5mL D5W 500mL 2hr + mannitol 20% 150mL (before carboplatin) + lorazepam 0.5mg PO (before carboplatin) + granisetron 3mg NS 100mL 30min (before carboplatin) + KCl inj 15% 5mL NS 500mL 2hr (after carboplatin) + KCl inj 15% 5mL D5W 500mL 2hr (after carboplatin)

==========

2024-05-03

[Sevatrim preparation and administration]

Sevatrim (sulfamethoxazole 400mg, trimethoprim 80mg; 5mL per ampoule) for Adults:

• Dosage:
  • Standard Dosage: 10mL twice daily, once in the morning and once in the evening.
  • Severe Infection: 15mL twice daily, once in the morning and once in the evening.
• Administration:
  • Sevatrim should only be administered intravenously and must be diluted before use as follows:
    • For one ampoule (5mL): Dilute in 125mL of infusion solution.
    • For two ampoules (10mL): Dilute in 250mL of infusion solution.
    • For three ampoules (15mL): Dilute in 500mL of infusion solution.
• Preparation:
  • Dilute immediately before use.
  • Shake the mixture well after adding Sevatrim to the infusion solution to ensure complete mixing.
  • Discard the injection if any visible turbidity or crystals are observed at any time during or before mixing.
• Compatible Diluents:
  • When diluted as described above, Sevatrim can be mixed with the following solutions:
    • Glucose Intravenous Infusion BP 5% and 10%
    • Sodium Chloride Intravenous Infusion BP (0.9%)
• Incompatible Substances:
  • Sevatrim should not be mixed with any other substances.
• Infusion Rate:
  • The recommended infusion time is approximately 1.5 hours, but this can be adjusted as needed to achieve a balance.
• Storage and Handling:
  • Discard any unused diluted solution.

2024-04-22

[balancing efficacy and side effects in lung cancer chemotherapy]

CT and MRI imaging in Mar 2024 confirmed disease progression, prompting a shift in treatment to a regimen of docetaxel plus durvalumab starting on 2024-04-04.

Pancyclopenia subsequently developed with a nadir observed on the 10th day following docetaxel administration.

Currently, leukopenia has resolved, and both anemia and thrombocytopenia have significantly improved.

• 2024-04-21 WBC 9.01 x10^3/uL
  

• 2024-04-18 WBC 23.51 x10^3/uL
  

• 2024-04-14 WBC 2.16 x10^3/uL
  

• 2024-04-12 WBC 0.57 x10^3/uL nadir
  

• 2024-04-08 WBC 2.80 x10^3/uL
  

• 2024-04-03 WBC 5.31 x10^3/uL docetaxel (2024/04/04)

• 2024-04-21 Neutrophil 63.5 %

• 2024-04-18 Neutrophil 80.4 %

• 2024-04-14 Neutrophil 22.3 %

• 2024-04-12 Neutrophil 8.0 % nadir
  

• 2024-04-08 Neutrophil 65.7 %

• 2024-04-03 Neutrophil 67.4 % docetaxel (2024/04/04)

• 2024-04-21 HGB 9.8 g/dL
  

• 2024-04-18 HGB 11.5 g/dL
  

• 2024-04-14 HGB 10.6 g/dL
  

• 2024-04-12 HGB 6.6 g/dL nadir
  

• 2024-04-08 HGB 8.4 g/dL
  

• 2024-04-03 HGB 8.1 g/dL docetaxel (2024/04/04)

• 2024-04-21 PLT 97 *10^3/uL
  

• 2024-04-18 PLT 46 *10^3/uL
  

• 2024-04-14 PLT 105 *10^3/uL
  

• 2024-04-12 PLT 32 *10^3/uL nadir
  

• 2024-04-08 PLT 44 *10^3/uL
  

• 2024-04-03 PLT 46 *10^3/uL docetaxel (2024/04/04)

The standard docetaxel dose for NSCLC is 75 mg/m². For this patient, with a body surface area (BSA) of 1.52 m² based on his weight of 52 kg and height of 159 cm, the calculated dose would be 114 mg. However, given the patient’s ECOG performance status of 3, a reduced dose of 100 mg (with no platin in the regimen) was administered.

If pancytopenia cannot be effectively managed with blood transfusions or G-CSF, further dose reductions or extending the dosing interval might be considered, although this could potentially impact treatment efficacy.

2024-03-12

[durvalumab: lymphocytopenia more common than leukopenia]

The patient’s historical data shows that leukopenia often occurs one to two weeks after chemotherapy. According to the literature, 2024-02-19 administered durvalumab is less likely to cause leukopenia, and lymphocytopenia is more common. The latest data shows that the WBC level is now normal.

• 2024-03-07 WBC 3.23 x10^3/uL
• 2024-03-05 WBC 3.43 x10^3/uL
• 2024-03-01 WBC 7.73 x10^3/uL
• 2024-02-27 WBC 1.82 x10^3/uL *
• 2024-02-23 WBC 1.06 x10^3/uL *
• 2024-02-20 WBC 1.30 x10^3/uL * durvalumab (2024/02/19)
• 2024-02-15 WBC 2.53 x10^3/uL pemetrexed + carboplatin (2024/02/16)
• 2024-01-23 WBC 5.38 x10^3/uL
• 2024-01-19 WBC 4.21 x10^3/uL
• 2024-01-15 WBC 20.07 x10^3/uL
• 2024-01-11 WBC 1.54 x10^3/uL *
• 2024-01-08 WBC 1.01 x10^3/uL *
• 2024-01-02 WBC 4.65 x10^3/uL
• 2023-12-27 WBC 5.20 x10^3/uL pemetrexed + carboplatin (2023/12/28)
• 2023-12-13 WBC 5.24 x10^3/uL
• 2023-12-11 WBC 5.89 x10^3/uL
• 2023-12-08 WBC 2.45 x10^3/uL
• 2023-12-05 WBC 1.56 x10^3/uL *
• 2023-12-04 WBC 1.45 x10^3/uL *
• 2023-11-29 WBC 2.09 x10^3/uL pemetrexed + carboplatin (2023/11/29)
• 2023-11-27 WBC 2.81 x10^3/uL
• 2023-11-20 WBC 4.96 x10^3/uL

2024-01-24

[recovery patterns of WBC and PLT after chemotherapy]

The last administration of pemetrexed plus carboplatin for this patient occurred on 2023-12-28.

The nadir for both WBC and PLT counts was observed on 2024-01-08, which aligns with the expected timeline for these side effects.

According to UpToDate, carboplatin tends to have a higher incidence of leukopenia and thrombocytopenia compared to pemetrexed.

Currently, both WBC and PLT levels are in the process of recovery.

• 2024-01-23 WBC 5.38 x10^3/uL

• 2024-01-19 WBC 4.21 x10^3/uL

• 2024-01-15 WBC 20.07 x10^3/uL

• 2024-01-11 WBC 1.54 x10^3/uL **

• 2024-01-08 WBC 1.01 x10^3/uL ***

• 2024-01-02 WBC 4.65 x10^3/uL

• 2023-12-27 WBC 5.20 x10^3/uL

• 2024-01-23 PLT 174 *10^3/uL

• 2024-01-19 PLT 97 10^3/uL

• 2024-01-15 PLT 42 *10^3/uL **

• 2024-01-11 PLT 137 *10^3/uL

• 2024-01-08 PLT 17 10^3/uL **

• 2024-01-02 PLT 108 *10^3/uL

• 2023-12-27 PLT 110 *10^3/uL

700402171

240502

[exam findings]

• 2024-03-16 CT - abdomen
  • Indication: Sigmoid cancer obstruction status post sigmoid colectomy, pT3N2aM0(4/16), pStage: IIIB, G2, LV(+), Perineural(+) for twelfth mFOLFOX6 aduvant chemotherapy, with local recurrence for FOLFOX neoadjuvant chemotherapy
  • With and without contrast enhancement CT of abdomen shows:
    • Sigmoid colon CA, s/p operation.
    • A mass lesion, 2.2cm, in left seminal vesicle.
    • A lymph node in para-aortic region.
    • Two nodular lesions, 0.3cm, in RLL of lung.
  • Impression
    • Sigmoid colon CA, s/p operation
    • Left seminal vesicle recurrent tumor, stationary
    • RLL nodules, r/o lung metastasis
• 2023-12-11, -12-06 ECG
  • Normal sinus rhythm
  • Minimal voltage criteria for LVH, may be normal variant
• 2023-11-10 Patho - colon resection (non tumor) (Y1)
  • Tissue, left plevic cavity, CT- guide biopsy — metastatic adenocarcinoma, compatible with colorectal origin
  • Microscopically, it shows adenocarcinoma composed of invasive tumor glands and stromal fibrosis.
  • Immunohistochemical stain reveals CK20(+), CDX-2(+), PSA(-), CK7(-) at tumor.
• 2023-11-09 PET scan
  • A glucose hypermetabolic lesion in the left pelvic cavity. Malignancy with local recurrence should be considered. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar and bilateral axillary lymph nodes. Inflammatory process may show this picture.
  • Increased FDG accumulation in both kidneys, bilateral ureters and colon. Physiological accumulation of FDG is more likely.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2023-11-04 CT - abdomen
  • History and indication: A case of advanced sigmoid cancer obstruction s∕p op, pT3N2aM0
  • With and without-contrast CT of abdomen revealed:
    • S/P operation. A soft tissue lesion (1.7cm, srs7, img116) at left pelvic cavity r/o tumor recurrence.
  • Impression:
    • S/P operation. A soft tissue lesion (1.7cm, srs7, img116) at left pelvic cavity r/o tumor recurrence.
• 2023-09-28 Colonoscopy
  • Colon cancer s/p op
  • No evidence of recurrence
• 2023-09-28 SONO - abdomen
  • Diagnosis:
    • Fatty liver, mild
  • Suggestion:
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2022-09-29 SONO - abdomen
  • Diagnosis:
    • Fatty liver, mild
    • Suspected fatty infiltration of pancreas
  • Suggestion:
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2021-10-05 CT - abdomen
  • Indication: A case of advanced sigmoid cancer obstruction s/p op. pT3N2aM0. Sigmoid colectomy with LNs dissection on 20171020
  • Imp: s/p sigmoid colon cancer LAR and autosuture. No evidence of recurrent/residual tumor in the current study.
• 2021-10-05 Colonoscopy
  • Colon cancer s/p op
  • No evidence of recurrence

[MedRec]

• 2017-10-16 ~ 2017-10-28 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • C18.7 Sigmoid colon cancer with obstruction, cT3N0M0 s/p exploratory laparotomy with sigmoid colectomy, pT3N2aM0, (4/16), G2, LV (+); pStage IIIB
    • S/P Port-A catheter implatation
  • CC
    • Constipation off and on for 2 months.
    • Intermittent low abdominal pain and passage of loose stool more than 10 times/day in recent 2 days.
    • Cold sweating with nausea, without fever were noted for one day.
  • Present illness
    • This 40 years old male patient denied any history of systemic disease. He suffered from constipation off and on for 2 months, without medical treatment. This time, he complained of intermittent low abdominal pain and passage of loose stool more than 10 times/day in recent 2 days. Cold sweating with nausea, without fever were noted for one day. He came to our emergency department for help on 106-10-15 night. Physical examination showed tenderness of low abdominal region, hypo-active bowel sounds. Leukocytosis with WBC 17.43 x10^3/uL, N.band 1.0 %, N.seg. 92.0 %. No elveated CRP 0.22 mg/dL. Abdomen-Standing (Diaphragm) X-ray showed presence of ileus.
    • Abdominal CT revealed in favor of S-colon cancer with obstruction, suggest colonscopy study, cstage T3N0Mx. At ER, EVAC enema and empirical antibiotics treatment by Ceftriaxone Sandoz. CRS was consult and NG decompression first was suggest. After fully explaination, he is admitted to our ward for further evalation and management.
  • Course of inpatient treatment
    • After admission, NPO and NG decompression. Nutrition support by Clinimix N9 and IV fluids support.
    • Antibiotics treatment by Ceftriaxone Sandoz (2017/10/16~10/17).
    • Fever with BT: 38.2~38.8 C and leukocytosis with WBC 15.94 x10^3/uL, N.band 16.0 %, N.seg. 59.0 %, CRP 18.32 mg/dL on 10/17, we consult infectious doctor and antibiotics change to Brosym (10/17~10/25).
    • Leukocytosis and abdominal pain were improved, operation of Exp Lap AR under general anesthesia were performed on 2017/10/20.
    • Foley was removal at post op day 1, voiding smoothly by patient himself.
    • The wound healing well and no erythema change. No nausea and no vomiting, flatus passage. On low residual diet was started at post-op day 3. Bowel movement normal and stools passage (+) with diet well tolerated.
    • Leukocytosis was improved with WBC 6.53 x10^3/uL, N.seg. 55.0 %, CRP 1.26 mg/dL on 10/23. DC Brosym and shift to oral antibiotics by CURAM on 10/25 by infectious doctor suggested.
    • The surgical pathology proved adenocarcinoma of sigmoid colon (4/16), G2, LV (+), pT3N2aM0; pStage: IIIB.
    • Adjuvant chemotherapy was suggested, GS was consulted and Port-A implantation was performed on 10/26.
    • CVP was removal on 10/26. No fever and no complication.
    • Discharged in general condition stable on 106/10/28 and will follow up in our out-patient department next week.
  • Discharge prescription
    • Curan 1# Q12H 3D
    • Meitifen 75mg 1# PRNQ12H 7D

[radiotherapy]

[chemotherapy]

• 2024-05-01 - oxaliplatin 85mg/m2 160mg D5W 250mL 2hr + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 5400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-04-18 - oxaliplatin 85mg/m2 160mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5300mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-04-02 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-03-13 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-01-08 - oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 300mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-12-25 - oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 300mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-12-11 - oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

==========

2024-05-02

The lab results obtained on 2024-05-01, were largely unremarkable, and the patient’s ECOG performance status of 1 indicated no apparent reason to withhold FOLFOX therapy.

2024-01-10

The lab results on 2024-01-07 were grossly normal and ECOG PS 1, no obvious contraindication to the administration of FOLFOX.

700734717

240501

[exam findings]

• 2024-05-01 CT - chest
  • WITHOUT contrast enhancement CT: Lung/Mediastinum/Pleura
    • Presence of some pericardial effusion.
    • Mild bronchiectasis in bilateral lower lungs.
    • Post-op at the stomach.
    • Uneven surface of liver parenchyma, suggesting liver cirrhosis.
    • Massive ascites. Increased soft tissue in the peritoneum, r/o peritoneal carcinomatosis.
  • Impression:
    • Minimal pericardial effusion.
    • Mild bronchiectasis in bilateral lower lungs.
    • Post-op at the stomach.
    • Massive ascites. R/O peritoneal carcinomatosis.
• 2024-05-01 CXR
  • Increase bilateral lung markings.
  • Cardiomegaly.
    
  • Thoracic spondylosis.
  • S/P pacemaker.
• 2024-04-23 KUB
  • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, L-spine.
  • increased air in nondistended loops of small bowel over RUQ, could be paralytic ileus.
  • Bilateral small kidneys and abdominal ascites
• 2024-04-23 CXR
  • s/p transevenous (Lt subclavian vein route) single-chamber pacemaker inserted with pacing lead in RV
  • enlarged cardiac silhoutte due to dilated cardiac chambers (LAD,RAD) and prominent cardiophrenic angle mediastinal fat pad /supine position
  • marginal spurs of multiple vertebral bodies of T-L spine due to spondylosis.
• 2024-04-15 Bladder Sonography
  • PVR 149 mL
• 2024-04-14 CT - abdomen
  • The CT scan of the whole abdomen was performed without IV contrast medium enhancement and revealed that:
    • Pericardial effusion. S/P pacemaker implant.
    • Cirrhosis of liver.
    • Massive amount of ascites.
    • S/P gastroenterotomy.
    • Atrophy of both kidneys.
    • S/P Foley catheter insertion.
• 2024-04-12 Body fluid cytology - ascites
  • Clinical finding: gastric adenocarcinoma, stage IV
  • Report: 15 cc red cloudy ascites - Suspicious for malignancy
• 2024-04-11 SONO - abdomen
  • Thick GB wall.Propable hypoalbuminemia related
  • Moderate ascites
  • Pancreas not shown
  • Suboptimal examination of liver,especially the subcostal view due to poor echo window (disruption of the transmission of US waves by bowel gas and patient’s body habitus)
• 2024-04-11 Ascites tapping
  • 18G needle was inserted at RLQ under echo guided insertion. Dark red color fluid was noted and total 500ml was obtained and sent for analysis.
• 2024-04-02 ECG
  • Atrial fibrillation with occasional ventricular-paced complexes
  • Nonspecific ST and T wave abnormality
• 2024-03-07 ECG
  • Ventricular-paced rhythm with occasional supraventricular complexes
  • Abnormal ECG
• 2024-03-04 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Gastric cancer s/p operation. Increased soft tissues at peritoneal cavity with ascites.
    • Left inguinal hernia.
    • Tiny liver cysts.
    • Some LNs at neck and mediastinum.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P pace-maker implantation.
  • Imp
    • Gastric cancer s/p operation. Increased soft tissues at peritoneal cavity with ascites r/o peritoneal carcinomatosis.
• 2024-03-01 CXR erect
  • Cardiomegaly and tortuosity of the thoracic aorta.
  • Widening of the mediastinum.
  • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
  • S/P pacemaker implant.
• 2023-11-09 ECG
  • Atrial fibrillation with frequent ventricular-paced complexes
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2023-11-09 EGD
  • Diagnosis:
    • Suboptimal study, due to much food residuals
    • Status post Billroth II anastomosis.
    • Reflux esophagitis LA Classification grade A
    • Duodenal ulcer, E-loop
  • CLO test: not done
  • Suggestion: PPI use
• 2023-07-19 CT - abdomen
  • Indication: 91 y/o male, a pt of gastric CA, pT4aN3aM1 (LN14v: positive), stage IV, s/p Op on 1/2 23 by Dr Wu ChaoQun
  • Oral and rectal contrast was not given for bowel opacification.
  • Findings:
    • S/P subtotal gastrectomy
    • There is left inguinal hernia with omentum fat herniation.
      • In addition, there is a mixed calcification and enhancing soft tissue lesion in the distal end of the left inguinal hernia (Srs:301 Img:104).
      • Please correlate with sonography.
    • R/O liver cysts, up to 0.8cm in S2.
    • Minimal pericardial effusion.
  • Impression:
    • S/P subtotal gastrectomy. There is no evidence of tumor recurrence.
      
    • There is left inguinal hernia with omentum fat herniation.
    • In addition, there is a mixed calcification and enhancing soft tissue lesion in the distal end of the left inguinal hernia (Srs:301 Img:104).
    • Please correlate with sonography.
• 2023-06-15 SONO - abdomen
  • Sonography of hepatobiliary system revealed:
    • Left liver cyst (0.41x0.73cm).
    • Wall thickening of gallbladder (0.45cm) with a polyp (0.16cm).
    • Patency of PV, HVs, IVC and aorta in hepatic portion.
  • IMP:
    • Left liver cyst (0.41x0.73cm).
    • Wall thickening of gallbladder (0.45cm) with a polyp (0.16cm).
• 2023-06-08 ECG
  • Atrial fibrillation with frequent ventricular-paced complexes
  • T wave abnormality, consider anterior ischemia
  • Abnormal ECG
• 2023-01-02 Patho - stomach subtotal/total (tumor)
  • Diagnosis:
    • Stomach, open distal subtotal gastrectomy — mixed adenocarcinoma (70% of signet-ring cell carcinoma component + 30% of mucinous adenocarcinoma component), poorly differentiated
    • Lymph node, LN 1, dissection — Negative for LN metastasis ( 0 / 1 ); Positive for tumor seeding
    • Lymph node, LN 3, dissection — Negative for LN metastasis ( 0 / 7 ); Positive for tumor seeding
    • Lymph node, LN 4, dissection — Negative for LN metastasis ( 0 / 3 ); Positive for tumor seeding
    • Lymph node, LN 5, dissection — Positive for tumor seeding (soft tissue only)
    • Lymph node, LN 6, dissection — Positive for LN metastasis ( 2 / 12 ); Positive for tumor seeding
    • Lymph node, LN 7,8,9,11p, dissection — Positive for LN metastasis ( 3 / 15 )
    • Lymph node, LN 12a, dissection — Positive for tumor seeding (soft tissue only)
    • Lymph node, LN 14v, dissection — Positive for LN metastasis ( 2 / 7 ); Positive for tumor seeding
    • Omentum, omentectomy — Negative for malignancy
    • AJCC 8th edition pathology stage: pT4aN3aM1; AJCC stage IV
  • Gross Description:
    • Procedure
      • open distal subtotal gastrectomy + LN dissection + omentectomy
    • Tumor Site
      • Antrum, anterior wall, posterior wall, lesser curvature
    • Tumor Size : 8x 7 cm
    • Gross configuration
      • For advanced carcinoma (Borrmann classification)
      • Type III: Ulcerated with poorly defined infiltrative margins
    • Sections are taken and labeled as: A1:distal cut end, A2:proximal cut end, A3-10:tumor, B:LN1,C1-3:LN3, D1-3:LN4, E:LN5, F1-2:LN6, G1-3: LN 7,8,9,11p, H:12A, I1-2:14v, J:omentum
  • Microscopic Description:
    • Histologic Type
      • Mixed Adenocarcinoma (70% of signet-ring cell carcinoma component + 30% of mucinous adenocarcinoma component)
    • Histologic Grade
      • G3: Poorly differentiated, undifferentiated
    • Tumor Extension
      • Tumor invades the serosa (visceral peritoneum)
    • Margins
      • Proximal margin: uninvolved by invasive carcinoma
      • Distal margin: uninvolved by invasive carcinoma
      • Radial margin: involved by invasive carcinoma
    • Lymphovascular Invasion: present
      
    • Perineural Invasion: not identified
    • Regional Lymph Nodes
      • Number of lymph nodes examined/involved: 7 / 45
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
      • Primary Tumor (pT)
        • pT4a: Tumor invades the serosa (visceral peritoneum)
      • Regional Lymph Nodes (pN)
        • pN3a: Metastasis in seven to 15 regional lymph nodes
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case)
        • pM1: Distant metastasis
      • Specify site(s): soft tissues of LN1~LN6, LN12a and LN14v
    • Additional Pathologic Findings
      • Intestinal metaplasia
      • High-grade dysplasia
      • Helicobacter pylori-type gastritis
    • Ancillary Studies: None
      
    • Comment(s): None
• 2022-12-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (160 - 46) / 160 = 71.25%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Mild septal and RV hypertrophy.
    • Dilated LV with normal LV and RV systolic function.
    • Degenerative changes of mitral valve and chamber dilatation with moderate to severe MR; severe TR; mild PR; aortic valve sclerosis with moderate AR.
    • Minimal amount pericardial effusion ( < 50ml).
    • Dilated proximal ascending aorta ( 38 mm); mild aortic root calcification.
    • S/P permenant pacemaker implanation with pacing leads in RA/RV.
    • Atrial fibrillation; severely dilated LA/RA.
• 2022-12-23 Patho - stomach biopsy
  • Stomach, antrum LC, biopsy — mucinous adenocarcinoma.
  • Specimen submitted in formalin consists of 6 pieces of tan, irregular tissue measuring 0.2 x 0.2 x 0.1 cm. All for section in one cassette.
  • Section shows fragments of gastric tissue with abundant mucin and a few irregular neoplastic glands.
  • IHC stains: Her2/neu: negative (score=0).
• 2022-12-22 CT - abdomen
  • With and without contrast enhancement CT of abdomen - whole:
    • Moderate wall edema/thickening at gastric antrum with mucosal enhancement.
    • Focal wall edema at lower rectum with engorged vessels.
    • R/O liver cysts, up to 0.8cm in S2.
    • Unremarkable change of the spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
    • Minimal pericardial effusion.
    • Presence of left inguinal hernia.
  • Impression:
    • Moderate wall edema/thickening at gastric antrum with mucosal enhancement.
    • Focal wall edema at lower rectum with engorged vessels.
    • Minimal pericardial effusion.
    • Left inguinal hernia.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE:III_(Stage_value)
• 2022-12-22 EGD
  • Diagnosis:
    • suspicious, advanced Gastric cancer, Borrmann type 2, angle to pylorus, s/p biopsy
    • Superficial gastritis, upper body.
    • Pyloric stenosis
  • CLO test: not done
  • Suggestion:
    • IV PPI use and blood transfusion.
    • Arrange CT for cancer staging.

[MedRec]

• 2024-03-26, -02-07, 2023-12-05, -10-12, 08-07, -07-21 SOAP Hemato-Oncology He JingLiang
  • Prescription x2
    • Xeloda (capecitabine 500mg) 1# BID 14D
    • Through (sennoside 12mg) 1# HS 28D
    • Uretropic (furosemide 40mg) 0.5# QD 28D
• 2023-06-30, -06-09, -05-19, -04-28 SOAP Hemato-Oncology He JingLiang & Wan XiangLin
  • Prescription
    • Xeloda (capecitabine 500mg) 1# BID 14D
    • Through (sennoside 12mg) 1# HS 21D
    • Uretropic (furosemide 40mg) 0.5# QD 21D
• 2023-04-07, -03-15, -02-20, -02-04 SOAP Hemato-Oncology Wan XiangLin & Zhang ShouYi
  • Prescription
    • Xeloda (capecitabine 500mg) 1# BID 14D
• 2022-12-22 ~ 2023-01-12 POMR General and Gastroenterological Surgery Wu ChaoQun
  • Discharge diagnosis
    • Mucinous adenocarcinoma of gastric antrum, pT4aN3aM1; stage IV status post distal subtotal gastrectomy with D2 lymph node dissection and Braun’s anastomosis on 2022/12/31
    • Gastrointestinal hemorrhage, unspecified
    • Acute posthemorrhagic anemia
    • Atrioventricular block, complete
    • Presence of cardiac pacemaker
    • Enlarged prostate with lower urinary tract symptoms
    • Hypertensive heart disease without heart failure
  • CC
    • Tarry stool for 3 weeks
  • Present illness
    • This is a 91 y/o male with past histories of BPH, Af and AF s/p pacemaker. He was brought to our ER due to low HGB level noted at CV OPD. He has tarry stool for 3 weeks, and sometimes has shortness of breath. His HGB was noted 5.5 at CV OPD, and was referred to the ER. At ER, 生命徵象: 血壓:121/56; 脈搏:95 次/分; 體溫:34.4 ℃; 呼吸:18 次/分; Con’s:E4V5M6. Conjunctiva: pale Heart: no murmur, regular heart beat. Lab: HGB 5.5. CXR: S/P pace-maker implantation. Cardiomegaly. Abd CT: wall edema/thickening at gastric antrum with mucosal enhancement. EGD: suspect gastric CA. Blood transfusion and IV PPI were given at the ER. Under the impression of r/i advanced gastric ulcer with UGIB and anemia, the patient was admitted to the ward for further care.
  • Course of inpatient treatment
    • After admission, NPO with adequate IV fluid supplement and IV form PPI agent for EGD reported suspicious, advanced Gastric cancer, Borrmann type 2, angle to pylorus, s/p biopsy. Blood transfusion with LPRBC 2 U to correct anemia. Follow up lab showed no sign of rebleeding and stationary Hb (8.3)level. Oral intake trial was administered.
    • Tumor marker of CA199 showed 564.08 U/mL. The Stomach, antrum LC, biopsy pathologic reported mucinous adenocarcinoma. IHC stains:  Her2/neu: negative (score=0). Consulted GS who suggsted cardio-pulmonary function evaluation first. Follow up lab showed sign of progressive anemia, initial NPO with IV fluid support, IV PPI,blood transfusion with LPRBC 2 U BID was given to correct anemia. contact GS for further management who suggested operation for gastric cancer and patient agreed. Hold Edoxaban since 12/30. Open distal subtotal gastrectomy with D2 LN dissection and Braun’s anastomosis was done smoothly on 12/31. After operation, he was transferred to SICU for post-op care.
    • During SICU, on ETT with MV, NPO with NG decompression, Adequate PPN and IVF support, PPI, Self-paid Albumin and Furosemide use, adeqaute pain control was given. Decreased Na 129 was noted, then 3% N/S was given. Successful extubation was done on 01/01. Follow up lab data revealed no decreased Hb and improved imbalanced electrolyte was noted. Wound was clean and no ozzing. No infection sign at NG, CVC, J-vac drainage or A-line. No stool or flatus passage noted on 01/03, Enema once was given. Under relative stable hemodynamics, he was transferred to GS ordinary ward on 2023/01/03.
    • In GS ward, we observed patient recovery and keep empiric antibiotic, stool softener, albumin with lasix therapy, nutrition support with TPN and analgesic agent were administered and the wound management was performed. He try to oral intake with step by step then can tolerate well with semi-liquid diet. After well oral intake, TPN was tapper to off on 1/8. His generally well beings and relativley stable. There were no nosocomial infection and other complications and vital signs were stable after the surgery. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Abdomen wound clean and was removal JP tube was done smoothly on 1/9 & 1/10. Under improved general condition, he was allowed to discharge today and OPD follow up was arranged.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Harnalidge (tamsulosin 0.4mg) 1# QDAC
    • Takepron (lansoprazole 30mg) 1# QDAC
    • Utapine (quetiapine 25mg) 2# HS

[consultation]

• 2024-04-15 Urology
  • Q
    • Chief Complaints:
      • Family members requested to insert urinary catheter.
      • lower abdominal distension
      • aur since this morning.
    • Past History:
      • Mucinous adenocarcinoma of gastric antrum, pT4aN3aM1; stage IV status post distal subtotal gastrectomy with D2 lymph node dissection and Braun’s anastomosis on 2022/12/31, Increased soft tissues at peritoneal cavity with ascites r/o peritoneal carcinomatosis
      • Presence of cardiac pacemaker
      • Hypertensive heart disease without heart failure
    • Surgical history: Denied
    • Drug allergy: Denied
  • A
    • This 92-year-old male patient cut his Foley catheter by himself and came to ER for help. Bedside echo revealed a tube-like structure in the bladder. Abdominal CT confirmed the remaining of the catheter inside the bladder. The bladder seemed not distended. Therefore we suggest observation at ER for one night and we will arrange flexible cystoscope in tomorrow morning to try removing the catheter. Thank you for your consultation !!!
  • A 2024-04-15 09:45:26
    • We have perform the cystoscopy and remove the urethral catheter smoothly. He could void by self with residual urine about 100ml. I suggest oral medications first instead of repeat catheterization first (family also refuse urethral catheter) and follow up self voiding. Please give oral antibiotics, Urief, Avodart and bethanechol. Urology clinic follow up is indicated.
• 2024-04-08 Family Medicine
  • Q
    • For combine hospice care
    • This 92-year-old man, a patient of mucinous adenocarcinoma of gastric antrum, pT4aN3aM1; stage IV status post distal subtotal gastrectomy with D2 lymph node dissection and Braun’s anastomosis on 2022/12/31 S/P Xeloda 1# po bid since 2023/02/04, suffered from initial presentation of anemia & UGI bleeding Dx in 2022-12. He visited to GI OPD for further evaluation and survey.
    • This time, he complained general weakness and abdominal dullness for 2 days and he came to our ER on 2024-04-02. At ER, abdominal tapping about 800ml bloody fluid ascites, Cr:1.57, TBI:1.07. He was admitted for further evaluation and treatment. The patient, and family request to hospice care, so we need your help, thanks a lot!!
  • A
    • S: Cons clear, ECOG 3
    • Patient and his wife wished to discuss about future plan with VS He.
    • Currently, patient has no abdominal fullness and pain, so repeat ascites tapping may not be feasible at this moment.
    • We will follow up under share care.
    • Indication: gastric cancer with peritoneal seeding
• 2023-12-29 Ophthalmology
  • Q
    • Chief Complaints:
    • Rt eye reddness las night
    • Past History: SSS s/p pacemaker, Gastric cancer s/p op
    • Surgical history:Denied
    • Drug allergy: Denied
    • Medication: Edoxaban
  • A
    • S: red eye od since yesterday
      • PH: HTN+, SSS s/p pacemaker, Gastric cancer s/p op
      • Medication: Edoxaban
      • oph hx: -
      • NKA
      • trauma -
      • rubbing eyes +
    • O:
      • EOM full
      • BCVA od 0.3x+1.25/-1.25x60 os 0.5x+2.50/-3.00x90
      • IOP 13/13 mmHg
      • Pupil: 3+/3+, no RAPD
      • Conj: 11-2o’c SCH od, not injected os
      • K: clear ou
      • AC: d&cl ou
      • iris: RIC ou
      • lens: NS++ ou
      • fundus: C/D=0.3 ou
      • Lab
        • 2023-12-29 PT 11.3 sec
          
        • 2023-12-29 INR 1.10
          
    • A:
      • SCH od
      • cataract ou
    • P:
      • explained the assessment to the patient and family
      • OPD f/u on 1/2
      • come back asap if s/s worsen

[surgical operation]

• 2022-12-31
  • Surgery
    • Open distal subtotal gastrectomy witｈ D2 LN dissection
    • Braun’s anastomosis
  • Finding
    • Hugh distal gastric ilcerative mass with multiple ulcer oozing
    • 1000 cc blood inside stomach
    • cT4aN1M0
    • seeding(-)
    • ascite(-)

==========

2024-05-02

[considerations for ursodeoxycholic acid in this elevated bilirubin case]

On 2024-05-01, this patient’s eGFR was recorded at 41 mL/min/1.73m². The patient is currently receiving Loforan (cefotaxime) at a dosage of 2g IVD Q8H, which is at the upper limit of the recommended dosage for patients with a CrCl of 10 to 50 mL/min. The patient’s vital signs are stable at this time.

Previous lab data indicated elevated DBI/TBI percentages. Given the persistently high total bilirubin, the addition of Uliden (ursodeoxycholic acid 100mg) at a dose 1# QD might be considered as an optional treatment to improve this condition.

2024-04-03

[potential Xeloda dose change: low eGFR identified]

Both CEA and CA199 tumor markers have shown a significant increase since 2024. This rise suggests potential disease progression. Additionally, an abdominal CT scan performed on 2024-03-04, revealed increased soft tissue in the peritoneal cavity with ascites, raising suspicion for peritoneal carcinomatosis.

• 2024-03-22 CEA (NM) 23.483 ng/ml
  

• 2023-10-17 CEA (NM) 2.287 ng/ml
  

• 2023-08-11 CEA (NM) 2.751 ng/ml
  

• 2023-07-21 CEA (NM) 2.233 ng/ml
  

• 2023-06-30 CEA (NM) 3.143 ng/ml
  

• 2023-02-07 CEA (NM) 2.343 ng/ml

• 2024-03-22 CA-199 (NM) 1878.950 U/ml
  

• 2024-02-23 CA-199 (NM) 151.353 U/ml
  

• 2023-12-08 CA-199 (NM) 34.657 U/ml
  

• 2023-10-17 CA-199 (NM) 44.405 U/ml
  

• 2023-08-11 CA-199 (NM) 25.447 U/ml
  

• 2023-07-21 CA-199 (NM) 32.308 U/ml
  

• 2023-06-30 CA-199 (NM) 25.255 U/ml
  

• 2023-02-07 CA-199 (NM) 29.598 U/ml

The patient has been taking Xeloda (capecitabine) since 2023-02. His most recent eGFR measured on 2024-04-02 is 44. According to UpToDate, a 75% reduction in the usual daily dose recommended for patients with a CrCl of 30-50 mL/min is advised.

701123943

240430

[exam findings]

[MedRec]

• 2023-07-31 ~ 2023-08-12 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Multiple myeloma IgA kappa type, ISS stage III, with hypercalcemia, renal failure, and osteolytic bone lesions.
    • Pneumonia at right lower lung, sputum culutre: Mixed normal flora Growth 3+
    • Upper Gastrointestinal Bleeding, stool OB:1+
    • Chronic kidney disease, stage 4 (severe)
    • Reflux esophagitis LA Classification grade A
    • Hypercalcemia
    • Anemia, unspecified
    • Essential (primary) hypertension
    • Hypoalbuminemia
    • Hyperuricemia
    • Chronic viral hepatitis B without delta-agent
  • CC
    • fatigue and generalized bone pain for one month
  • Present illness
    • A 68-year-old woman, with a history of hypertension under Norvasc control, was admitted with a chief complaint of progressive fatigue and generalized bone pain for one month. She also complianed of epigastric pain, vomit, anemia, and renal failure were present for one month. She has visted the GI OPD first, where the laboraotry data was checked, showing severe hypercalcemia. Thus, she was informed to visit the ER.
    • At ER, her vitial sign showed BP:104/61 mmHg; HR:75/min; BT:36.5’C; RR:18/min; and SpO2:96%. The Laboratory data showed serum calcium (Ca) 3.47 mmol/dL, albumin 3.4 g/dL, phosphorous (P) 4.8 mg/dL, creatinine 3.35 mg/dL, Hb 8.6 g/dL. Under impression of hypercalcemia, she was admitted for further management on 2023/07/31.
  • Course of inpatient treatment
    • The patient was treated with hydration with iv isotonic saline, iv lasix 20 mg QD, iv Miacalcic 200IU SC 12 hourly. With the therapy serum calcium levels were form 3.84 to 3.2. The patient was then referred to the hemato-oncology division for the treatment of the multiple myeloma on 2023/08/03.
    • Followed-up Esophagogastroduodenoscopy (2023/07/29) showed Reflux esophagitis LA Classification grade A. Gastric erosion, cardia. Gastric shallow ulcers, antrum. Superficial gastritis, s/p CLO test. Duodenal polyp, bulb, s/p biopsy: Chronic duodenitis.
    • The renal echo was done on 2023/08/01, and report showed A circular hyperechoic lesion, 0.69*0.69cm, in the cortex of middle portion, left kidney, c/w angiomyolipoma. Interpretation: Hyperechoic cortex, prominent pyramids and enlarged size of bilateral kidneys, c/w myeloma kidney. An angiomyolipoma, left kidney.
    • Skull PA + Lat.: Diffuse osteolytic lesions in the skull.
    • Due to suspect Multiple myeloma, so consulted hemato-oncology, and followed-up M-peak: positive, IgA: 2470 mg/dL, B2-Microglobulin: 13319 ng/mL, the bone marrow was done on 2023/07/31, and the biopsy showed Plasma cell myeloma, The sections show a picture of plasma cell myeloma composed of hypercellular marrow (80%) with mainly aggregate plasma cells, comprised 90% nucleated cells in CD138 immunostain. The plasam cells also show kappa light chain restriction, lambda light chain negative as well as hypoplasia of both myeloid and erythroid series and hyperplasia of megakaryocyte, highlights by MPO, CD71 and CD61 immunostains. No increase of blast cell (CD34(-)). Free Light Chain κ/λ: FKLC 3730 mg/L.
    • She suffered from fever up to 38, and coffee ground, shortness of breathing noted, and complaints severe cough with light yellowish stick sputum, stool OB: 1+, so gave antibiotic with Cefim, PPI with Pantoloc plus Transamin, and nasal cannula support, antitussives plus expectorant treatment.
    • The lab of CBC/DC showed anemia (Hb:6.6g/dL), gave blood trtansfusion with LPRBC. the lab of BCS showed hypoalbuminemia, hyperuricemia, so gave hydration, Rolikan, and Feburic by self-paid, Albumin 1bot QD * 3days by self-paid. MgSO4 plus MgO for hypomagnesemia treatment.
    • Follow-up heart echo will be arranged. After treatment, the symptom of Hypercalcemia, UGI bleeding improved, but still much sputum noted. Major Illness Application was done on 2023/08/04.
    • Followed-up heart echo (2023/08/07) showed LVEF(%) = 73, 1. Normal LV systolic function with normal wall motion. 2. Concentric LVH, dilated LA; LV diastolic dysfunction Gr 2. 3. Normal RV systolic function. 4. Mild MR; mild to moderate TR; mild PR. 5. Possible mild pulmonary hypertension, estimated PASP: 41 mmHg.
    • Followed-up Bronchodilator Test (03 + 06 kit), Flow Volume Chart Exam (for 03 + 06 use) was done on 2023/08/09, the report showed r/o very severe restrictive ventilatory defect, negative BDT. Extract a tooth was done on 2023/08/08.
    • Under impression of Multiple myeloma IgA kappa type, ISS stage III, with hypercalcemia, renal failure, and osteolytic bone lesions, so she received Compesolon 5mg/tab 1tab BID, Thado 50mg/cap 1cap BID treatment, and Xgeva 120mg SC Q1M was done on 2023/08/11. After treatment, the symptoms improved. She can be discharged on 2023/8/12, the OPD follow-up will be arranged.
  • Discharge prescription
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Compesolon (prednisolone 5mg) 1# BID
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg)
    • Through (sennosides 12mg) 2# HS
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Cough Mixture (platycodon 120mL/bot) 5mL HS
    • Norvasc (amlodipine 5mg) 1# BID
    • Thado (thalidomide 50mg) 1# BID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q12H
    • MgO 250mg 1# TID

[consultation]

• 2024-04-24 Psychosomatic Medicine

• 2024-04-17 Metabolism and Endocrinology

• 2024-04-12 Nephrology

• 2024-04-03 Radiation Oncology

• 2024-04-02 Diagnostic Radiation

• 2024-04-02 Infectious Disease

• 2023-08-02 Maxillofacial Surgery

• 2023-07-31 Hemato-Oncology

[immunochemotherapy]

• 2024-04-23 - Darzalex (daratumumab) 16mg/kg 800mg NS 1000mL 6.5hr
  • dexamethasone 20mg + diphenhydramine 30mg + nontelukast 10mg 1# PO + acetaminophen 500mg 2# PO + NS 250mL
• 2024-04-16 - Darzalex (daratumumab) 16mg/kg 800mg NS 1000mL 6.5hr
  • dexamethasone 20mg + diphenhydramine 30mg + nontelukast 10mg 1# PO + acetaminophen 500mg 2# PO + NS 250mL
• 2024-03-22 - Velcade (bortezomib) 2.2mg SC (VTD)
• 2024-03-19 - Velcade (bortezomib) 2.2mg SC (VTD)
• 2024-03-13 - Velcade (bortezomib) 2.2mg SC (VTD)
• 2024-03-06 - Velcade (bortezomib) 2.2mg SC (VTD)
• 2024-02-29 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2024-02-07 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2024-01-31 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2024-01-24 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2024-01-17 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2024-01-10 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-12-20 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-12-13 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-12-06 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-11-29 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-11-22 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-11-15 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-11-08 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-11-01 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-10-26 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-10-19 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-10-12 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-10-05 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-09-21 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-09-14 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-09-07 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-08-31 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-08-24 - Velcade (bortezomib) 2.0mg SC (VTD)
• 2023-08-17 - Velcade (bortezomib) 2.0mg SC (VTD)

==========

2024-04-30

[combination therapies for oral mucositis]

This patient is currently being treated with Darzalex (daratumumab) and Revlimid (lenalidomide) for multiple myeloma and has developed oral mucositis. Nincord Oral Gel (triamcinolone) has been prescribed to manage this condition. Should this treatment prove insufficiently effective, additional topical therapies might be considered:

• Topical lidocaine solutions can provide pain relief, though they require frequent application to maintain efficacy.

• The topical application of morphine sulfate (0.2%, 2 mg/mL in water), used as a 15 mL rinse held in the mouth for two minutes before expectorating, may reduce both the duration and intensity of mouth pain, even without significant systemic absorption.

Additionally, the oral supplementation of glutamine, which may be available at the WellCare store on B1 level, could also be optionally considered. The updated 2020 guidelines from the MASCC/ISOO for the prevention and treatment of oral mucositis recommend the use of oral glutamine for preventing oral mucositis in individuals with head and neck cancer undergoing chemoradiotherapy, although no recommendation is made for other patient groups. (Ref: MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020 Oct 1;126(19):4423-4431. doi: 10.1002/cncr.33100. Epub 2020 Jul 28. Erratum in: Cancer. 2021 Oct 1;127(19):3700.)

2024-04-29

[recommended daptomycin regimen for decreased renal function]

On 2024-04-29, the patient’s serum creatinine was 2.98 mg/dL, BUN 53 mg/dL, eGFR 16.57 mL/min/1.73m², and body weight 56.8 kg.

Per the Sanford Guide, Cubicin (daptomycin) should be administered at 6 mg/kg every 48 hours. The current dosage of 500 mg daily is recommended to be adjusted to 350 mg every other day.

701488075

240430

[exam findings]

• 2024-04-26 MRA - lower extremity
  • With and without-contrast multiplannar and multisequences MRI of right lower leg revealed:
    • A mass lesion (5.96.39.9cm) in right calf, inside medial head of gastrocnemius muscle. Internal solid and cystic (myxoid) components. Heterogeneous enhancement after contrast administration.
    • Adjacent soft tissue edema.
  • Impression
    • Right calf intramuscular (medial head of gastrocnemius muscle) mass; DDx: sarcoma, metastasis, myxoma
• 2024-04-19 ECG
  • Normal sinus rhythm with sinus arrhythmia
  • Prolonged QT
  • Abnormal ECG
• 2024-04-12 MRI - nasopharynx
  • Indication: Oral cancer with bone, lung liver and lower limbs mets under immunotherapy
  • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed and show:
    • Extensive soft tissue mass with t1-hypointensity, T2-hyperintensity and vivid enhancement involving muscle of left temporalis muscle, masticator space, pterygopalatine fossa, mandible, and oropharyngeal wall, and encasing left ICA. Progressive as compared with MRI on 20231122.
    • No enlarged lymph node.
    • Diffuse swelling with striation appearance of subcutaneous region at left facial region.
    • A well-defined heterogeneous intensity cystic mass, about 36 mm, at right thyroid gland.
  • IMP:
    • Advanced left oral cancer with bony involvement and ICA encasement, progressive as compared with MRI on 20231122.
    • Right thyroid cystic mass (36 mm).
• 2024-04-11 Tc-99m MDP bone scan
  • In comparison with the previous study on 2024/01/15, no prominent change is noted in the lesion in the posterior spect of the right 9th rib. However, multiple new bone lesions are noted in the posterior spect of the left 4th rib, anterior aspect of left 7th rib, left scapula and right humeral shaft. Multiple bone metastases should be watched out.
  • The lesions in the left aspect of maxilla, lower L-spines and sacrum are more evident. Bone metastases can not be ruled out.
• 2024-04-10 CT - chest
  • Indication: Oral cancer with bone, lung liver and lower limbs mets under immunotherapy
  • Finding comparison: prior CT on 2024/1/3
    • lungs: interval significant decrease in size and number of metastatic lesions at the lungs. subsegmental atelectasis ar RML and medial septal thickening at RLL.
      • centrilobular emphysema at both upper lungs.
    • Mediastinum and hila: interval regression of metastatic lymphadenopathy in the visceral space and Rt hilum. mild anterior pericardial effusion.
    • Pleura: minimal Rt-sided effusion.
    • Chest wall and visible lower neck: Rt thyroid low attenuated nodule (29mm). a large metastatic tumor at Rt T7-8 paravertebral
      • region with destruction the 7th rib and adjacent vertebra.
    • Visible abdominal contents: regression of metastatic hepatic tumors but increase in size of metastatic LN at hepatic hulum,
      • metastatic left renal tumor and left adrenal tumor.
  • Impression:
    • oral cancer with regresion of lung and mediastinal-hilar-hepatic metastases, but new Rt T7 paraverteral metastatic tumor and progression of Lt renal and adrenal and hepatic hilar LN metastases as compared with CT on 2024/01/03
• 2024-02-07 CXR
  • Irregular mass shadow at right paratracheal stripe and right infra-hilar region. Please correlate with CT.
  • Lung nodule at left lower lung zone.
• 2024-02-05 CXR
  • There are few nodular opacities projecting in both lung that may be metastases. Please correlate with CT.
  • A mass opacity projecting at right upper mediastinum is highly suspected.
• 2024-02-02 Patho - soft tissue biopsy / simple excision (non lipoma)
  • Soft tissue, right upper calf, CT-guide biopsy — metastatic squamous cell carcinoma
    
  • Section shows cores of solid sheets of hyperchromatic tumor cells infiltrating in fibrotic stroma. Focal keratinization is seen.
  • The immunohistochemical stains reveal CK5/6(+) and p40(+). The results are consistent with metastatic squamous cell carcinoma.
• 2024-01-30 MRI - lower extremity
  • Indication: mouth, poorly differentiated squamous cell carcinoma, pT4bN0M0, stage IV
  • With and without-contrast multiplannar and multisequences MRI of right leg revealed:
    • A mass lesion (4.14.66.8cm), mixed solid and cystic components. over right upper calf, inside medial head of gastrocnemius muscle. Enhancement of tumor wall, as well as internal solid part after contrast administration.
    • Adjacent muscle edema.
    • No enlarged regional lymph node.
    • Unremarkable change of bony structures.
  • Impression
    • An intramuscular mass over right upper calf; DDx: sarcoma, metastasis. Suggest tissue study to clarify.
• 2024-01-16 Chest Lateral RT
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-01-16 CXR
  • Irregular mass shadow at right paratracheal stripe and right infra-hilar region. Please correlate with CT.
  • Lung nodule at left middle lung zone.
• 2024-01-16 PD-L1 IHC
  • Cellblock No. S2024-816
  • RESULTS：
    • Tumor cell (TC) staining assessment: TC >= 50%
    • Percentage of PD-L1 expressing tumor cells (%TC): 95%
• 2024-01-16 PD-L1 (22C3)
  • Cellblock No. S2024-00816
  • RESULTS：
    • Tumor Proportion Score (TPS) assessment: TPS >= 50%
    • Tumor Proportion Score (TPS): 95%
• 2024-01-16 PD-L1 (SP142)
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • S2024-816
    • Tumor type: squamous cell carcinoma
    • Tumor location: lung (in favor of metastasis)
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark XT
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: Pass,
    • Adequate tumor cells present (>= 50 viable tumor cells): Yes
  • Result:
    • Tumor cell (TC) staining assessment:
      • TC category: TC >= 50%
      • Percentage of PD-L1 expressing tumor cells (%TC): 70%
    • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
  • Note:
    • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
    • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2024-01-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 31) / 122 = 74.59%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
• 2024-01-15 Tc-99m MDP bone scan
  • Several hot areas/spots in the left aspect of maxilla, left aspect of the mandible, and post. spect of the right 9th rib, respectively, metastatic bone disease should be considered, suggesting PET scan for investigation and follow-up with bone scna in 3 months.
  • Suspected benign lesions in some T- and L-spine, both rib cages (except the right 9th rib), bilateral sternoclavicular junctions, shoulders, elbows, S-I joints, hips, and knees.
• 2024-01-11 Patho - bronchus biopsy
  • Lung, RB8-10 orifice, bronchoscopic biopsy — squamous cell carcinoma, moderately differentiated, origin ?
  • Sections show bronchial mucosa with invasive solid sheets of hyperchromatic tumor cells. Focal keratinization is seen.
  • The immunohistochemical stains reveal CK5/6(+), p40(+), TTF-1(-), Napsin A(-) and CD56(-). Please correlate with the clinical presentation and image study for tumor origin.
• 2024-01-05 SONO - thyroid gland
  • Enlargement of right thyroid gland.
  • A cystic lesion with mural nodule (1.35x2.32cm) in right thyroid gland.
• 2024-01-03 CT - chest
  • Indication: right lower gum malignancy, s/p surgery and adjuvant CCRT
  • without & with contrast enhancement, coronal and sagittal reconstructed images and axial slab MIP images shows:
    • lungs: multiple nodules of variable sizes at both lower lobes and lingula measuring up to 27mm at RLL.
      • centrilobular nodules and opacification of bronchi at RLL.
      • centrilobular emphysema at both upper lungs.
    • Mediastinum and hila: extensive lymphadenopathy with low attenuation in the Rt visceral space and Rt hilum, that narrowing distal intermediate bronchus and inferior pulmonary artery.
      
    • Thoracic aorta: normal caliber,Heart:
    • Pleura: minimal Rt-sided effusion.
    • Chest wall and visible lower neck: Rt thyroid low attenuated nodule (29mm)
    • Visible abdominal contents: several poor ehancing tumors in the liver up to 55mm.
      • a large soft-tissue mass at hepatic hilum, likely metastatic LAP, 34mm. a suspect tumor at left kidney (22mm).
      • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • oral cancer with lung, mediastinal-hilar-abdominal LNs, hepatic and renal metastases.
    • obstructive RLL bronchopneumonia.
    • Rt thyroid mass, metastatic?
• 2023-12-14 CT - abdomen
  • History and indication: PDSCC of hard palate, s/p wide excision
  • Non-contrast CT of abdomen-pelvis revealed:
    • Some nodules in bil. visible lungs.
    • A hypodense nodule (3.3cm) at left hepatic lobe.
    • Some calcifications at prostate.
  • IMP:
    • Lung and liver metastases.
• 2023-12-12 SONO - abdomen
  • Suspect liver metastasis, S4
• 2023-12-11 Nasopharyngoscopy
  • NER
  • bil stiff free flap
  • trismus
• 2023-11-22 MRI - nasopharynx
  • Findings
    • post-OP change with flap reconstruction in the bilateral head and soft palate without evidence of local recurrence.
    • selling of the left massetor muscles and left pterygoid muscles with a small part, about 12.7mm, in the medial aspect of the left mandible (srs9, img 12 and srs750, img 1).
      
    • low SI change on T1WI in the bome marrow of the left mandible with heterogeneous enhancement.
    • a nodular lesion, about 34mm in the right thyroid gland.
    • mucosal thickening in the left nasopharynx.
    • soft tissue swelling in the oropharyngeal, oral cavity and hypopharyngeal mucosa.
  • IMP:
    • focal abnormal ADC lesion in the left masticator space. r/o tumor. Please f/u.
    • mucosal thickening in the left nasopharyngeal mucosa
    • abnormal SI change in the left mandibular bone marrow. PLease correlate with previous study.
• 2023-10-02 ENT Hearing Test
  • Tymp RE type C, LE type B
  • ART bil absent
  • PTA:
    • Reliability FAIR
    • Average RE 54 dB HL, LE 56 dB HL
    • RE mild to profound HL
    • LE moderate to profound HL
• 2023-07-12 Patho - lip biopsy/wedge resection
  • Diagnosis:
    • neck level III lymph node, right, selective neck dissection — Negative for malignancy
    • neck level IIa lymph node, right, selective neck dissection — Negative for malignancy
    • neck level Ib lymph node, right, selective neck dissection — Negative for malignancy
    • Submandibular gland, right, selective neck dissection — Negative for malignancy
    • neck level III lymph node, left, selective neck dissection — Negative for malignancy
    • neck level IIa lymph node, left, selective neck dissection — Negative for malignancy
    • neck level Ib lymph node, left, selective neck dissection — Negative for malignancy
    • Submandibular gland, left, selective neck dissection — Negative for malignancy
    • neck level Ia lymph node, median, selective neck dissection — Negative for malignancy
    • neck level Ib lymph node, left, selective neck dissection — Negative for malignancy
    • infratemporal fossa, left, wide excision — Negative for malignancy
    • lateral pterygoid muscle and palate, left, wide excision — Negative for malignancy
    • tooth, bilateral (#33, #36, #38, #47), extraction — Confirmed
    • hard paltate, bilateral, wide excision — Negative for malignancy
    • medial pterygoid muscle and palate, left, wide excision — Negative for malignancy
    • anterior hard palate, median (14-24), left, wide excision — Negative for malignancy
    • hard palate tumor with bone erosion, median — Squamous cell carcinoma, moderate to poorly differentiated
    • Bone, maxilla, bilateral, Maxillectomy — Involved by squamous cell carcinoma
  • Microscopic examination
    • Histologic Type — Squamous cell carcinoma
    • Histologic Grade — G3: Poorly differentiated
    • Microscopic Tumor Extension: Maxilla
    • Margins (obtained from the main resection specimen):
      • Margins uninvolved by invasive carcinoma
      • Distance from closest margin: 5 mm
        
    • Lymph-Vascular Invasion: present
    • Perineural Invasion: not identified
• 2023-07-06 PET scan
  • Glucose hypermetabolism involving bilateral soft palate and hard palate, compatible with primary malignancy involving these regions.
  • Mild glucose hypermetabolism in multiple bilateral neck level II and Ib lymph nodes. Either metastatic lymph nodes or inflammation may show this picture. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
• 2023-06-27 CT - neck
  • Oralcavity - Impression (Imaging stage) : T:T4a N:N0 M:M0 STAGE:____
• 2023-06-26 Patho - tongue biopsy
  • Tumor, left soft palate, punch biopsy — Squamous cell carcinoma and candidiasis
  • The specimen submitted consisted of multiple fragments of tumor tissue measuring up to 0.5 x 0.4 x 0.2 cm in size, fixed in formalin. Grossly, they were gray in color and soft in consistence. All embedded for sections.
  • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated characterized by solid tumor nests infiltration with focal keratin formation. Besides, ulcer, bacterial colonies and fungal hyphae and spores, morphology consistent with candidiasis are also included.
  • Immunohistochemistry shows CK(+), P16(-) and P63(+) for tumor, special stain of PAS highlights fungal infection.
• 2023-06-26 Nasopharyngoscopy
  • bil soft palate/hard palate granular tumor
  • recurrent, operated in 2018
  • suspect malignancy
• 2023-06-26 ENT Hearing Test
  • Tymp RE type C, LE type As
  • ART absent
  • PTA:
    • Reliability FAIR
    • Average RE 43 dB HL; LE 51 dB HL
    • RE mild to severe HL, masking dilemma
    • LE moderate to severe MHL

[MedRec]

[surgical operation]

• 2023-07-11
  • Surgery
    • free left anterolateral thigh flap and titanium-plate reconstruction of palate
    • reduction and fixation of fractured mandible
  • Finding
    • missing lower parts of bilateral maxilla, the upper teeth, and the palate owing to ablasion of cancer
    • also missing mucosa of bilateral walls of pharynx, but it was not resurfaced since the wounds can heal gradually by itself
    • free flap: left anterolateral thigh flap
      • dimension of flap: 12cm X 8cm
      • pedicle of flap: descending branches of lateral circumflex artery and veins from left profundus femoris system, 1A2V
      • numbers and type of perforators: 2, inta-muscular
      • recepient vessels: right superior thyroid artery and vein
      • design of flap: an ovale skim paddle, folded posteriorly as 7cm X 8cm and 5cm X 8cm parts, the previous is for resurfacing the oral side of palate, and the later is for the nasal side
      • ischemic time: 1H40M
      • fair prefusion and color of the flap at the end of the operation
      • primary closure of the flap donor wound
    • the bony part of the palate was reconstructed with a titanium plate
    • fractured mandible from its synphysis for fascilitating the cancer ablasion surgery
    • one 10F JP drain over left supra-clavicular region for post-operative drainage   
• 2023-07-11
  • Surgery
    • Wide excision of oral cancer
    • selective neck dissection, bilateral
    • Tracheotomy
    • Maxillectomy, bilateral
    • Bilateral partial glossectomy
    • Extraction of caries (#12, #13#, #15, #21, #22, #24, #33, #36, #38, #47)
  • Finding
    • cT4aN2cM0
    • tumor over bilateral hard palate, soft palate, lateral tongue, with invading of left infratemporal fossa
    • L lateral pterygoid plate and muscle excised, margin may not be adqeuate although grossly free (skull base exposed, pterygoid plexus oozing= hemostasis with bipolar electrocautery)
    • L CN 11 explsed and preserved
    • all upper gum, gingiva, and hard palate excised
    • trismus after prior op (R lower gum fibrosis), 2fB=> mandibulectomy for access of cancer

[radiotherapy]

• 2023-08-10 ~ 2023-09-20 - completed RT to the bil. neck lymphatic drainage area: 50 Gy/ 25 fx. The preOP hard palate tumor bed: 60 Gy/ 30 fx.

[chemotherapy]

• 2024-04-17 - nivolumab 3mg/kg 200mg NS 100mL 60min + D5W 1000mL 2hr (Y-sidted Opdivo)

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2024-04-03 - nivolumab 3mg/kg 200mg NS 100mL 30min

• 2024-03-20 - nivolumab 3mg/kg 200mg NS 100mL 30min

• 2024-03-06 - nivolumab 3mg/kg 200mg NS 100mL 30min

• 2024-02-21 - nivolumab 3mg/kg 200mg NS 100mL 30min

• 2024-02-07 - nivolumab 3mg/kg 200mg NS 100mL 30min

• 2023-09-14 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + metoclopramide 10mg

• 2023-09-07 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-08-31 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-08-24 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-08-17 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-08-10 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-04-30

[tube feeding]

Dulcolax, containing 5mg of bisacodyl, is an enteric-coated formulation that should not be split or ground. An alternative is the use of Bisadyl supp pills with 10mg bisacodyl. The patient is also prescribed sennoside 12mg 2# HS.

If these medications prove not enough effective, the addition of lactulose may be considered.

[safe addition of potassium to Bfluid infusions]

Bfluid 1000 mL contains 20 mEq/L of potassium and can accommodate an additional 40 mEq/L in the same bag. If it is intended to use Y-sited 0.298% KCl 500mL (which contains 20 mEq of potassium), there should be no incompatibilities.

[managing hypercalcemia with hydration and Miacalcic]

On 2024-04-29, hypercalcemia was noted with a calcium level of 3.50 mmol/L.

The patient is currently receiving 0.298% KCl in 0.9% NaCl 500mL IVD Q8H and Bfluid 1000mL QD, totaling 2500mL of daily hydration.

The addition of Miacalcic (calcitonin) might be considered as a subcutaneous injection, starting with an initial dose of 4 units/kg every 12 hours. If calcium reduction is inadequate after 6 to 12 hours, the dose may be increased to 8 units/kg every 6 to 12 hours. It is suggested to monitor for the development of tachyphylaxis after administration.

[fluconazole dosing strategy and alternative treatments for oropharyngeal candidiasis]

For nonpregnant adults with oropharyngeal candidiasis, nystatin suspension is an option. However, based on the patient’s stable renal and liver function from the lab results dated 2024-04-29, fluconazole is recommended, starting with 200 mg orally on the first day followed by 100 to 200 mg daily.

If the candidiasis becomes refractory, the dose may be doubled, up to a maximum of 400 mg per day. Should there be no response after several days, consider switching to an alternative treatment such as:

• Itraconazole oral solution (200 mg daily)
• Posaconazole oral suspension (400 mg twice daily for the first 3 days, then 400 mg daily)
• Voriconazole (200 mg orally twice daily)
• Amphotericin B deoxycholate oral suspension
• Echinocandins or IV amphotericin B for severe refractory cases, although rarely needed

Treatment typically lasts 7 to 14 days for uncomplicated cases and 14 to 28 days for refractory cases.

2024-04-22

Hypokalemia has been noted for several days. It is recommended that the serum potassium level be reassessed to determine whether or not supplementation is needed.

• 2024-04-19 K (Potassium) 3.2 mmol/L
• 2024-04-17 K (Potassium) 3.2 mmol/L

700362726

240429

[exam findings] (not completed)

• 2024-04-15 MRI - nasopharynx
  • Indication: SCC of M/3 esophagus, cT2N0M0, stage II2. Hard palate sqamous cell carcinoma, pT2N0M0 s/p wide excision on 2011/04/21 and completion of radiotherapy in 2011/07. Newly developed Rt upper maxillary tumor, much regressed after RT.
  • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck show:
    • Diffuse T1-hypointensity, T2-hyperintensity and faint enhancement involving muscle of right masticator space, temporalis muscle, lateral wall of right maxillary sinus and upper buccal mucosa.
    • Bony defect at right part of hard palate and inferior wall of right maxillary sinus, with extensive mucosal thickening and fluid accumulation in right maxillary sinus.
      
    • No enlarged lymph node.
    • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
    • Mottled T2-hyperintensity filling in bilateral mastoid air cells, indicating mastoiditis.
    • Kyphoscoliosis of C-spine. Cervical spondylosis, esp C4-5-6 evels.
  • IMP:
    • C/W right maxillary sinus tumor s/p treatment, with residual abnormal intensity. No previous MRI for comparison.
    • D/D: Post-RT inflammatory process, or with residual tumor. Suggest close follow-up.
• 2023-12-19 PET scan
  • In comparison with the previous study on 2023/06/14, the glucose hypermetabolic lesion in the upper to middle third of esophagus is less evident.
  • Glucose hypermetabolism in a focal area in the right upper gum with adjacent bone invasion, compatible with malignancy in this region.
    
  • Glucose hypermetabolism in a focal area in the right submandibular area. A metastatic lymph node can not be ruled out.
  • Glucose hypermetabolism in a focal area in the right parotid region. The nature is to be determined (a metastaitc lesion? some kind of parotid lesion?). Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in the left aspect of mandible. Dental problem may show this pictrure. Please also correlate with other clinical findings for further evaluation.
• 2023-12-05 Patho - gingival/oral mucosa biopsy
  • Gingiva, right maxillary, incisional biopsy — Squamous cell carcinoma, moderately differentiated
  • The specimen submitted consists of a piece of gray-tan soft tissue, labeled gingiva, measuring 0.9 x 0.9 x 0.7 cm. All for section.
  • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.
• 2023-11-10 Ascites tapping
  • Total 1000 cc light orange color fluid drained out.
• 2023-11-02 Ascites tapping
  • 75ml reddish ascites was sent to analyze and 2000ml reddish ascites tapping was performed.
• 2023-11-02 SONO - abdomen
  • Liver cirrhosis
  • Cholecystopathy
  • Massive ascites
• 2023-10-18 CXR
  • Atherosclerotic change of aortic arch
  • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
• 2023-10-18 Nasopharyngoscopy
  • Findings
    • smooth nasopharynx, oropharynx, hypopharynx, hard palate defect with inf T visible, ulcer over R upper gum
  • Diagnosis/conclusion
    • hard palate cancer s/p op + RT
    • oral ulcer
• 2023-10-03 Bronchodilator Test
  • Mild restrictive ventilatory impairment
  • Not significant bronchodilator reversibility
• 2023-09-18 CT - chest
  • Comparison was made with CT on 2018/05/23
    • Lungs: patchy ground-glass opacities superimposed on extensive centrilobular emphysema over bilateral lungs.
    • Mediastinum and hila: multiole small LNs in visceral space of mediastinum. no focal wall thickening along the course of the esophagus.
    • Aorta: normal in caliber, moderate atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal in caliber.
    • Heart: normal in size..
    • Pleura: no effusion.
    • Chest wall and lower neck: unremarkable..
    • Visible abdominal contents: appearance of liver cirrhaosis, moderate splenomegaly,and massive ascites, varices at E-G junction. edematous wall thickening of gall bladder. unremarkable of both kidneys and pancreas.
    • Extensive atherosclerotic change of the abdominal aorta.
    • Mrginal spurs of multiple vertebral bodies.
  • Impression:
    • extensive COPD and lung infection or drug toxicity.
    • liver cirrhosis with portal hypertension,

[MedRec]

• 2023-11-01 ~ 2023-11-03 POMR Gastroenterology Chen JianHua

  • Discharge diagnosis
    • Alcoholic liver cirrhosis with ascties, splenomegaly and pancytopenia, Child-Pugh score B s/p paracentesis
    • Malignant neoplasm of middle third of esophagus
    • Hypokalemia
  • CC
    • Abdomen distension with chills and low grade fever in the evening for few days.
  • Present illness
    • This 68-year-old male had histories of
      • Alcoholic liver cirrhosis with thrombocytopenia noted since 2000 plus esophageal varices bleeding for 3 times s/p ligation in 2004
      • Eczema and chronic urticaria were noted for 10+ years with regular medication
      • Hard palate sqamous cell carcinoma, pT2N0M0 s/p wide excision on 2011/04/21 and completion of radiotherapy in 2011/07
      • Right upper ureteral stone with hydronephrosis s/p extracorporeal shock wave lithotripsy on 2011/05/17.
      • Left total hip replacement on 2017/07/05, right total hip replacement on 2017/11/03)
      • Squamous cell carcinoma of middle third of esophagus, cT2N0M0 stage II status post left port-A implantation on 2023/07/03 status post radiotherapy
    • He complained marked abdominal gradually distended, accompanied with chills and low grade fever in the evening, almost every day. Thus he came to our GI OPD for help. PE showed distended abdomen (ascites). After discussion with the patient, admission for tapping was suggested. Thus this time he was admitted for further treatment.
  • Course of inpatient treatment
    • After admitted, he received paracentesis 2000ml on 2023/11/02.
    • Abdomen echo revealed 1. Liver cirrhosis, 2. Cholecystopathy, 3. Massive ascites and splenomegaly. Ascitic fluid cell count revealed no white blood cells. The abdomen distension was relief.
    • Under stable condition, he can be discharge on 2023/11/03. OPD follow up was arranged.
  • Discharge prescription
    • Const-K (potassium chloride 750mg 10mEq) 1# BID 7D
    • spironolactone 25mg 2# QD 7D

• 2023-07-02 ~ 2023-07-04 POMR Thoracic Surgery Xie MinXiao

  • Discharge diagnosis
    • Squamous cell carcinoma of middle third of esophagus, cT2N0M0 stage II status post left port-A implantation on 2023/07/03
    • Alcoholic liver cirrhosis
    • Esophageal varices
    • Thrombocytopenia
  • CC
    • For esophageal cancer survey
  • Present illness
    • This 68-year-old male had histories of
      • Alcoholic liver cirrhosis with thrombocytopenia noted since 2000 plus esophageal varices bleeding for 3 times s/p ligation in 2004
      • Eczema and chronic urticaria were noted for 10+ years with regular medication
      • Hard palate sqamous cell carcinoma, pT2N0M0 s/p wide excision on 2011/04/21 and completion of radiotherapy in 2011/07
      • Right upper ureteral stone with hydronephrosis s/p extracorporeal shock wave lithotripsy on 2011/05/17.
      • left total hip replacement on 2017/07/05, right total hip replacement on 2017/11/03)
    • He was just discharged from New Taipei City Hospital SanChong Branch on 2023/05/17 due to EV bleeding and had tarry stool passage twice on 2023/05/31, so he was admiited to New Taipei City Hospital SanChong Branch. During hospitalization, repeated bloody stool was noted even after hemostasis, so he was transferred to ICU for repeated PES. PES revealed esophageal tumor at esophagus s/p biopsy. Pahological report disclosed squamous cell carcinoma, moderately differentiated, pT2N2M0. He later signed AAD and was transferred to our ER due to personal issue.
    • Then the patient was admitted to our MICU due to UGI bellding, favor EV or GV bleeding.
    • PES performed on 2023/06/06 disclosed one 8mm whitish mass like lesion wtih exudate coating was noted at 25cm below the incisors. No active bleeding was noted under PPI use then he was transfered to GI ward under stable condition on 2023/06/07.
    • EUS with biopsy for Esophageal lesion will be performed on 2023/06/12 and which disclosed: 1) R/o esophageal cancer, at least cT2N0, 26-28cm below incisor. s/p chromoendoscopy, s/p biopsy. 2) Esophageal varices.
    • Pathological report revealed Squamous cell carcinoma, CK(+) and P16(-), moderately differentiated.
    • CS was consulted for consultation of management of esophageal cancer.
    • PTA showed reliability fair with average RE 31 dB HL; LE 25 dB HL.
    • PET revealed: Increased FDG uptake in the upper to middle third of esophagus, compatible with the primary esophageal cancer.
    • Increased FDG uptake in several lesions in the left upper lung, probably inflammation process, suggesting follow-up with chest CT for investigation.
    • Bronchoscopy disclosed chronic rhinitis, nasal polyp. No visible endobronchial lesions. MTBC PCR was negative.
    • Bone scan showed Increased activity in some L-spines and right hip. Severe degenerative change may show this picture. Some faint hot spots in bilateral rib cages. The nature is to be determined.
    • Brain MRI revealed No evidence of intracranial lesion. The patient was discharged GI ward on 2023/06/16 after all esophageal tumor survey was done.
    • This time, the patient admitted on 2023/07/02 to CS ward for jejunastomy creation and port-A insertion.
  • Course of inpatient treatment
    • After admission, pre-op assessment was done. Operation of left side port-A insertion was performed smoothly on 2023/07/03. No complication was noted.
    • CRS was consulted for GI bleeding and Alcos-anal oint use was suggested.
    • Radiation Oncology was consulted for radiotherapy.
    • ENT was consulted and nasoendoscopy was done on 2023/07/04.
    • He was discharged under stable hemodynamics and OPD follow up will be arranged.

• 2023-06-05 ~ 2023-06-16 POMR Gastroenterology Chen JianHua

• 2022-04-02 ~ 2022-04-08 POMR Gastroenterology Hong YuLong

• 2017-11-02 ~ 2017-11-03 POMR Orthopedics Li YiXuan

• 2017-07-04 ~ 2017-07-11 POMR Orthopedics Li YiXuan

==========

701511248

240429

[lab data]

2024-01-11 HBsAg Nonreactive
2024-01-11 HBsAg Value 0.51 S/CO
2024-01-11 Anti-HBs 22.54 mIU/mL
2024-01-11 Anti-HCV Nonreactive
2024-01-11 Anti-HCV Value 0.18 S/CO
2024-01-11 Anti-HBc Nonreactive
2024-01-11 Anti-HBc Value 0.19 S/CO

[exam findings]

• 2024-04-28 Foot Lt
  • AP and oblique films of left foot shows:
    • A mass at left foot with adjacent bony erosion.
    • Osteoporosis of bony structures.
• 2024-03-12 ECG
  • Sinus tachycardia
  • Possible Inferior infarct, age undetermined
• 2024-02-14 KUB
  • Presence of ileus.
• 2024-01-19 CT - Knee L
  • CT of left knee without/with contrast enhancement shows:
    • irregular enhancing mass (3.1cm) with adjacent fat spiculation at left inguinal region, compatible with left inguinal lymphadenopathy.
    • multiple enhancing nodules at left popliteal region (size from 1.2cm to 2.4cm), and subcutaneous left lower leg (1.8cm) attached to superficial fascia, metastatic tumors are compatible.
    • permeative bone change at left distal femur and proximal tibia, suggest correlation with bone scan to exclude bone metastasis.
  • Impression:
    • Left inguinal lymphadenopathy (3.1cm).
    • Multiple metastatic tumors at left popliteal region (size from 1.2cm to 2.4cm), and subcutaneous left lower leg (1.8cm).
    • Suspect bone metastases, suggest bone scan correlation.
• 2024-01-11 CT - abdomen
  • History and indication: Malignant melanoma of skin
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Left hydronephrosis and hydroureter due to distal ureter lesion.
    • A LN (4.1cm) at left inguinal region.
    • Right adrenal myelolipoma (5.7cm).
  • IMP:
    • A LN (4.1cm) at left inguinal region.
    • Right adrenal myelolipoma (5.7cm).
    • Left hydronephrosis and hydroureter due to distal ureter lesion.

[MedRec]

• 2024-03-12 SOAP Medical Emergency
  • S: left foot melanoma with bleeding+
    • Hx of Malignant melanoma, Lt foot s/p exsisional biopsy on 20231102
• 2024-02-21 SOAP Hemato-Oncology He JingLiang
  • S: pt refuse C/T, pain control
  • Prescription
    • OxyNorm (oxycodone 5mg) 1# PRNQ6H 14D
    • Durogesic (fentanyl 12ug/h, 2.1mg/patch) 1# Q3D EXT 15D
• 2024-02-14 SOAP Medical Emergency
  • S: Complaints of severe diarrhea after chemotherapy last week
    • nausea and watery diarrhea for 1 day
    • frequency+
    • chemotherapy last wk
  • Preliminary Impression: K52.9 Noninfective gastroenteritis and colitis, unspecified
  • Prescription
    • EVAC Enema (sodium biphosphate and sodium phosphate) ST RECT
    • NS 500mL ST IVD (100mL/1hr)
    • Despas (hyoscine-N-butylbromide) 20mg ST IVD
    • Bisadyl supp (bisacodyl 10mg) 1# PRNQOD RECT 3D if no stool passage 2 days
    • Promeran (metoclopramide 3.84mg) 1# PRNTID 3D
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID 3D
    • Stogamet (cimetidine 300mg) 1# TID 3D
    • MgO 250mg 1# TID 3D
    • Cero (cefaclor monohydrate 250mg) 2# Q8H 3D
• 2024-02-08 SOAP Medical Emergency
  • S: Chief Complaints: Malignant melanoma left foot, ankle area oozing
  • Preliminary Impression: C43.9 Malignant melanoma of skin, unspecified
  • Prescription
    • Biomycin ointment (neomycin, tyrothricin) BID TOPI
    • NS Irrigation 3000mL ST EXT
• 2024-02-07 SOAP Hemato-Oncology He JingLiang
  • S: C/T CDDP + Vinblastine
  • Prescription
    • OxyNorm (oxycodone 5mg) 1# PRNQ6H 14D
    • Eurodin (estazolam 2mg) 1# HS 14D
    • Durogesic (fentanyl 12ug/h, 2.1mg/patch 1# Q3D EXT 15D
• 2024-01-31 SOAP Hemato-Oncology He JingLiang
  • S: C/T with CDDP + vinblastin, require BRAF data
  • Prescription
    • OxyNorm (oxycodone 5mg) 1# PRNQ6H 14D
    • Eurodin (estazolam 2mg) 1# HS 7D
    • Durogesic (fentanyl 12ug/h, 2.1mg/patch 1# Q3D EXT
• 2024-01-17 SOAP Hemato-Oncology He JingLiang
  • S: arrange CT knee joint
• 2024-01-17 SOAP General and Gastroenterological Surgery He Fen
  • Prescription
    • Framycin Gause Dressing (fradiomycin 18mg/patch) ST EXT
• 2024-01-10 SOAP General and Gastroenterological Surgery He Fen
  • O
    • wound over left foot: a lot of bleeding
    • cd with compression
  • A/P
    • Survey and treat
    • wound care. tumor bleeding!
    • ER if active bleeding
  • Prescription
    • Biomycin ointment (neomycin, tyrothricin) BID TOPI
• 2024-01-10 SOAP Hemato-Oncology He JingLiang
  • S
    • Malignant melanoma, Lt foot s/p exsisional biopsy on 2013-11-02
    • PET scan: nodal metastases
  • O
    • BP:147/95; HR:98; BH:175cm; BW:90kg

[chemotherapy]

• 2024-02-07 - vinblastine 10mg NS 100mL 1hr + cisplatin 100mg NS 250mL 2hr + NS 500mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-04-29

A fungating wound infection on the left foot was observed, with imaging revealing a mass associated with adjacent bone erosion. Currently, the patient is being treated with Brosym (cefoperazone, sulbactam). No discrepancies in medication were identified. in use. no medication discrepancy identified.

2024-03-13

[navigating pembrolizumab and nivolumab for melanoma under NHI, addressing the gap in BRAF mutation data]

The NHI provides coverage for pembrolizumab and/or nivolumab for patients diagnosed with stage III or IV melanoma, particularly those with unresectable or metastatic tumors who have not responded to at least one prior systemic treatment.

Currently, there are no records of BRAF mutation test results available in the HIS5 system. It is advisable to conduct BRAF mutation testing if it has not been performed previously.

[bedside visit: navigating patient preferences in advanced disease care]

I visited this patient around 13:55 today. The patient shared that he was treated for the disease at TMUH in Apr 2023, including undergoing surgery, and no BRAF mutations were found. He has searched extensively and viewed his medical images to understand the spread and malignancy of the disease. He has also discussed his wish for a peaceful end with his family, who understand and support this preference.

I inquired if the patient’s reluctance to continue chemotherapy was solely due to severe watery diarrhea. I suggested that we could focus more on medications to manage the diarrhea. However, the patient indicated that beyond diarrhea, factors such as difficulty in mobility, the risk of infection from low white blood cell counts due to chemotherapy, taste alterations, and poor appetite contributed to his decision against enduring further treatment.

I then asked if using painkillers still allowed for comfortable bowel movements, mentioning that there are medications available to aid with this symptom. The patient noted he naturally tends towards constipation but currently have bowel movements more than once a week, which are not particularly hard, and find this manageable.

Considering the patient’s understanding, it might be appropriate to consider arranging hospice combined care to align with the patient’s wishes.

700052059

240425

[exam findings]

• 2024-03-14 PD-L1 (SP142)
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • Tumor type: squamous cell carcinoma, moderately differentiated
    • Tumor location: esophagus
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark ULTRA
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: [V] Pass, [] Fail
    • Adequate tumor cells present (>=50 viable tumor cells): [V] Yes, [] No
  • Result:
    • Tumor cell (TC) staining assessment:
      • TC category: TC < 1%
      • Percentage of PD-L1 expressing tumor cells (%TC): < 1% (optional)
    • Tumor-infiltrating immune cell (IC) staining assessment:
      • IC category: [V] IC < 1%
      • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): < 1% (optional)
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2024-03-12 Pure Tone Audiometry
  • Reliabilty Fair
  • PTA
  • R’t : 10 dB HL, WNL
  • L’t : 13 dB HL, normal to mild SNHL.
• 2024-03-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (109 - 42) / 109 = 61.47%
    • M-mode (Teichholz) = 60
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR, mild AR, and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
• 2024-03-09 MRI - brain
  • IMP: no evidence of brain metastasis.
• 2024-03-08 CXR erect
  • Supine chest image shows:
    • Port-A catheter inserted into RA via left subclavian vein.
    • a focal Rt-sided convexity of lower azygoesophageal recess interface, raise suspicious of esophageal tumor
• 2024-03-08 Miniprobe Endoscopic Ultrasound
  • Indication: Cancer staging
  • Symptoms: Pre-EUS diagnosis: Esophageal cancer
  • Endoscopic findings：
    • A 7 cm length esophageal ulcerative tumor mass involving 50% of the circumference with easily touched bleeding noticed at the 30 to 37 cm below the incisors. Using magnifying endoscopy with narrow-band imaging (ME-NBI), the IPCL pattern according to JES was B3, with avascular areas noted.
  • EUS findings：
    • Using EUS-DP 25, mucosal thickening was noted at lower esophagus. The lesion involves beyond the muscular layer. Three enlarged lymph nodes were noted, with the largest measuring 11.9mm.
  • Diagnosis：
    • Esophageal cancer, lower esophagus, T3N2
• 2024-03-07 Exercise ECG
  • Conclusion
    • low exercise capacity ( VO2max 82%, WR 99%) ( normal VO2max >85%)
    • spirometry: normal (FVC 103%, FEV1 109% )
      
    • respiratory muscle strength: normal ( MIP 110%, MEP 96%)
    • Breathing reserve normal
    • SpO2 desaturation during exercise: nil
    • cardiac response (LCWI) during exercise: normal response during exercise
    • HR response during exercise: normal response slope during exercise
    • work efficiency: 9.2, normal (cut off 8.6)
    • anaerobic threshold: 46%, normal ( cut off 40%)
    • oxygen pulse: normal
    • BP response: high response during exercise
      
    • EKG: normal sinus rhythm
    • Health-related quality of life (HRQL), CAT= 9 (>10 indicates poor HRQL), but chest tightness 5
  • Impression:
    • Deconditioning with poor exercise capacity
    • High BP during exercise
    • Low risk for operation for his peak VO2 >17 ml/kg
  • Suggestions:
    • Treat underlying cardiac disease
      
    • exercise training for poor exercise capacity
    • control BP
• 2024-03-06 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, and hips.
• 2024-03-05 PET
  • A glucose hypermetabolic lesion involving the lower portion of the esophagus, compatible with primary esophageal malignancy.
  • Glucose hypermetabolism in two lymph nodes at the EG junction. Metastatic lymph nodes may show this picture.
  • Mild glucose hypermetabolism in other multiple lymph nodes as mentioned above. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
• 2024-03-04 CT - chest
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:____(T_value) N:____(N_value) M:____(M_value) STAGE:____(Stage_value)
  • Findings: Comparison was made with CT on 2024/02/16
    • Lungs: minimal centrilobular nodular opacities at posterior basal segment of LLL.
    • Mediastinum and hila: asymmetric esophageal wall thickeningresulting luminal narrowing at distal third of thoracic esophagus (length about 7cm). no invasion of adjacent organs.
    • Visible abdominal contents: two enlarged lymph nodes at E-G junction.unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
    • Visualized bones: unremarkable.
  • Impression: L/3 esophageal cancer with regional LNs metastasis T3N1Mx.(E1)
• 2024-02-26 Patho - esophagreal biopsy
  • Esophagus, lower, 30-35 cm from incisor — moderately-differentiated squamous cell carcinoma
  • Microscopically, section shows squamous cell carcinoma consisting of irregular squamous epithelial tumor nests with keratin pearls and invasive growth pattern. The tumor cells display nuclear pleomorphis, hyperchromasia, high N/C ratio, prominent nucleoli, intercellular briding, eosinophilic cytoplasma and mitoses.
• 2024-02-26 EGD
  • Diagnosis:
    • advanced esophageal cancer, lower esophagus, s/p biopsy
    • Superficial gastritis, s/p CLO test
    • Gastric shallow ulcer, antrum, PW
    • Duodenal shallow ulcer, bulb
    • Duodenal subepithelial lesion, probably lymphangeal cyst
  • CLO test: Positive
• 2024-02-26 SONO - abdomen
  • Diagnosis:
    • Fatty liver, mild
    • CBD dilatation
  • Suggestion:
    • Lymph node could not be identified due to increased bowel gas
• 2024-02-16 CT - chest
  • Indication: COPD, lung cancer? DOE
  • Chest CT without IV contrast ehnancement shows:
    • Minimal opacity at left upper lobe (Se9 Im95), right lower lobe (Se9 Im124) is found. Recent inflammation is considered.
    • Wall thickening at distal esophagus is found up to 6cm in length. Esophageal cancer is considered. (Se11 Im34)
    • Enlarged lymph nodes are found at cardiac portion of the stomach.
  • Imp:
    • Esophageal cancer at lower third with perigastric lymph nodes (n＝2) is noted. Suggest contrast enhanced study and endoscopy.
• 2023-11-16 Exercise ECG BRUCE
  • Resting ECG:
    • Normal sinsu rhythm with PACs
  • ST Segment Abnormalities:
    • No significant ST-T change during exercise and recovery phases.
  • Arrhythmia:
    • Isolated PACs during recovery phase
  • Conclusion
    • Negative for myocardial ischemia

[MedRec]

[radiotherapy]

[chemotherapy]

• 2024-03-13 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 24hr D1-4 (PF CCRT)

==========

2024-04-25

[administering Nexium via SSM for this tube-fed patient]

Pariet (rabeprazole) tablets are enteric-coated and not recommended to be crushed. An alternative approach for tube feeding patients is to use Nexium (esomeprazole) with the Simple Suspension Method (SSM), which allows the medication to be prepared in a liquid form suitable for administration through a nasogastric (NG) tube.

The Simple Suspension Method involves the following steps:

• Place the medication in a small container.
• Add warm water to cover the medication fully.
• Stir or agitate the solution vigorously until the medication has dissolved or is sufficiently broken down for NG tube administration.
• Use a syringe or feeding pump to administer the medication mixture through the NG tube.

Key considerations for using the Simple Suspension Method include:

• Using warm water can help dissolve the medication more effectively.
• It is important to stir or shake the solution thoroughly to ensure complete dispersion of the medication.
• If the medication is in capsule form, open the capsule and dissolve the contents in water.

700930423

240425

[allergy]

• Omnipaque (iohexol) - skin rash

[lab data]

• 2022-12-13 Anti-HBc Reactive
  
• 2022-12-13 Anti-HBc Value 6.08 S/CO
  
• 2022-12-13 HBsAg Nonreactive
  
• 2022-12-13 HBsAg Value 0.33 S/CO
  
• 2022-12-13 Anti-HCV Reactive
  
• 2022-12-13 Anti-HCV Value 12.14 S/CO

[exam findings]

• 2024-03-14 CT - abdomen
  • History and indication:
    • Adenocarcinoma of descending-sigmoid colon, cT3N1M1, stage IV
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation.
    • Several poor enhancing nodules (up to 1.8cm) at left hepatic lobe.
    • Enlargement of prostate.
    • Emphysema of bil. lungs. A small nodule (5mm) at RML.
    • S/P Port-A infusion catheter insertion.
  • Impression:
    • S/P operation.
    • Several poor enhancing nodules (up to 1.8cm) at left hepatic lobe c/w metastases.
    • A small nodule (5mm) at RML.
• 2023-11-29 All-RAS + BRAF mutation
  • Cellblock No. S2018-12982A4
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-11-29 KUB
  • Spondylosis of the L-spine is noted.
• 2023-11-15 CT - abdomen
  • History: synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer (pT2N0M0) s/p Lt hemicolectomy on 2018-08-14 by Dr Xiao GuangHong
    • 2019/09/12 MRI: two metastases in S8 dome and S7 s/p Op by Dr Wu ChaoQun,
    • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
    • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
    • 2022/01/07 MRI: No focal lesion in the right liver dome
    • 2022/12/02 MRI: Two metastases 4 cm in S2 and 1 cm in S4.
    • 2023/03/17 MRI: Two metastases 2.6 cm in S2 and 1 cm in S4.
  • Findings: Comparison prior MRI dated 2023/03/17.
    • There is a poor enhancing lesion 4.4 x 2.5 cm in S2 of the liver dome. Please correlate with MRI to R/O metastasis S/P treatment?
    • There is a rim enhancing lesion 2 cm in S4 of the liver that is c/w metastasis.
    • S/P partial resection of S8 dome and S6/7 of the liver.
      • There is mild irregular liver contour that may be cirrhosis.
      • There is splenomegaly (long axis: 12 cm) that may be portal hypertension.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidneys.
      • There is no evidence of ascites or lymphadenopathy.
      • The abdominal aorta and IVC are grossly unremarkable.
        
  • IMP:
    • There is a poor enhancing lesion 4.4 x 2.5 cm in S2 of the liver dome. Please correlate with MRI to R/O metastasis S/P treatment?
    • Metastasis 2 cm in S4 of the liver.
• 2023-11-08 EGD
  • Reflux esophagitis LA Classification grade A
  • Esophageal varices F1CbLi.; S/P EVL
  • Superficial gastritis; antrum
• 2023-10-13 PET
  • Two glucose hypermetabolic lesions in the segment 2 and segment 4 of the liver respectively, compatible with liver metastases.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar and some mediastinal lymph nodes. Inflammation is more likely.
    
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulaiton may show this picture.
• 2023-10-03 ECG
  • Sinus rhythm with 1st degree A-V block with frequent Premature ventricular complexes
• 2023-10-03 ECG
  • Sinus bradycardia with 1st degree A-V block
• 2023-08-16 SONO - abdomen
  • Diagnosis:
    • poor echo window due to much bowel gas and unable to detect two lesions, S2 and S4, noted at liver MRI (2023/07/18).
    • Suspcious liver calcified, right posterior segment
    • Liver cirrhosis, mild splenomegaly
    • fatty infiltration of pancreas
  • Suggestion:
    • arrange other image for complete liver survey
• 2023-07-21 Myocardial perfusion SPECT with persantin
  • Probably moderate myocardial ischemia at the inferoposterior wall and mild myocardial ischemia at the anteroapical wall, anteroseptal wall and basal lateral wall.
• 2023-07-18 MRI - upper abdomen
  • History and indication: Liver metastases
  • With and without contrast MRI of liver revealed:
    • Stable size (1.0cm) of S4 lesion. Decreased size (2.2cm) of S2 lesion.
    • Tiny cysts in liver and spleen.
  • IMP:
    • Stable size (1.0cm) of S4 lesion. Decreased size (2.2cm) of S2 lesion.
• 2023-07-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (82 - 38) / 82 = 53.66%
    • 2D (M-Simpson) = 54
  • Conclusion:
    • Hypokinesia of LV inferior wall, posterior wall with preserved LV systolic function.
    • Normal RV systolic function.
    • Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Mild aortic valve sclerosis with mild AR; mild PR; mild posterior mitral annulus calcification.
    • Dilated aortic root and proximal ascending aorta (40 mm) with mild calcification.
• 2023-06-29 ECG
  • Sinus rhythm with 1st degree A-V block with frequent Premature ventricular complexes
  • Abnormal ECG
• 2023-06-29 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2023-06-29 Abdomen - standing (diaphragm)
  • Spondylosis of the L-spine is noted.
  • Splenomegaly.
• 2023-05-18 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Suboptimal study, due to food residuals
    • Reflux esophagitis LA Classification grade A
    • Esophageal varices, F1CbLi. RCS(-) White nipple sign(-). From 32cm to 40cm below incisors.
    • Gastric shallow ulcers, antrum
  • Suggestion
    • Suboptimal study, due to food residuals
    • PPI use
    • Regular follou up
• 2023-03-17 MRI - upper abdomen
  • History and Indication:
    • synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer(pT2N0M0) s/p Lt hemicolectomy on 20180814
    • 2019/09/12 MRI: two metas in S8 dome and S7 s/p Op
    • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
    • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
    • 2022/01/07 MRI: No focal lesion in the right liver dome
    • 2022/12/02 MRI: Two metastases 2.5 cm in S2 and 1 cm in S4.
  • MR Imaging of the abdomen was performed on a 1.5 T superconducting magnet and phase arrayed body coil. Patient kept in supine position with field of view 38 cm, slice thickness 6 mm and gap 1 mm.
    
  • Non-contrast MRI has limitation in diagnosis of solid organ pathology, bowel loop lesion, and vascular system abnormality. We recommend contrast enhanced MRI if patient’s renal function can tolerate Gd-DTPA injection.
    • Prior MRI identified a metastasis 4 cm in S2 of the liver is noted again, decreasing in size to 2.6 cm that is c/w metastasis S/P C/T with partial response.
      • In addition, Prior MRI identified a metastasis 1 cm in S4 of the liver is noted again, stable in size that is c/w metastasis S/P C/T with stable disease.
    • S/P partial resection of S8 dome and S6/7 of the liver.
      • There is mild irregular liver contour that may be cirrhosis.
    • There is splenomegaly (long axis: 12 cm) and small recanalization of paraumbilical vein that is compatible with portal hypertension.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidneys.
      
    • There is no evidence of ascites or lymphadenopathy.
    • The abdominal aorta and IVC are grossly unremarkable.
      
  • IMP:
    • One metastasis in S2 liver S/P C/T shows partial response.
    • One metastasis in S4 liver S/P C/T shows stable disease.
• 2022-12-02 MRI - upper abdomen
  • History and Indication: synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer(pT2N0M0) s/p Lt hemicolectomy on 20180814.
    • 2019/09/12 MRI:two metas in S8 dome and S7 s/p Op
    • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
    • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
    • 2022/01/07 MRI: No focal lesion in the right liver dome
  • Findings
    • There are two mass lesions measuring 4 cm in S2 and 1 cm in S4 of the liver, showing hypointensity on T1WI and mild hyperintensity on both T2WI and DWI.
      • Two metastases 4 cm in S2 and 1 cm in S4 of the liver are suspected.
    • S/P partial resection of S8 dome and S6/7 of the liver.
      • There is mild irregular liver contour that may be cirrhosis.
    • There is splenomegaly (long axis: 12 cm) and small recanalization of paraumbilical vein that is compatible with portal hypertension.
  • IMP:
    • Two metastases 4 cm in S2 and 1 cm in S4 of the liver are suspected.
• 2022-09-15 SONO - abdomen
  • S/P right liver operation. Mild splenomegaly.
• 2022-06-27 MRI - upper abdomen
  • S/P liver operation. Liver cirrhosis with splenomegaly.
• 2022-06-21 Patho - colorectal polyp
  • Colon, descending colon (40 cm from anal verge), Biopsy removal Specimen: A — Hyperplastic polyp
    • Section shows fragment(s) of polypoid colonic mucosal tissue with crowded benign hyperplastic mucinous glands.
  • Colon, sigmoid colon (25 cm from anal verge), Polypectomy (cold snaring) Specimen: B — Tubular adenoma with low grade dysplasia
    • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with low grade dysplasia.
• 2022-06-21 Colonoscopy
  • Colon cancer s/p op
  • No evidence of recurrence
• 2022-06-06 SONO - abdomen
  • poor echo window
  • Liver cirrhosis (incomplete exam of liver), mild splenomegaly
  • fatty infiltration of pancreas
• 2022-03-31 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2022-03-04 SONO - abdomen
  • Liver cirrhosis
  • Splenomegaly
  • Suboptimal examination of liver due to poor echo window
• 2022-01-07 MRI - upper abdomen
  • History and Indication:
    • synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer (pT2N0M0) s/p Lt hemicolectomy on 20180814
    • 2019/09/12 MRI: two metas in S8 dome and S7 s/p Op,
    • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
    • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
    • 2021/07/09 MRI: No focal lesion in the right liver dome
  • Findings:
    • S/P partial resection of S8 dome and S6/7 of the liver. There is no abnormal signal nodule in the residual liver on both T1WI, T2WI, and DWI.
    • There is mild irregular liver contour that may be cirrhosis.
    • There is splenomegaly (long axis: 12 cm) and small recanalization of paraumbilical vein that is compatible with portal hypertension.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidney.
      
    • There is no evidence of ascites or lymphadenopathy.
    • The abdominal aorta and IVC are grossly unremarkable.
      
  • IMP:
    • No focal lesion in the residual liver.
    • Cirrhosis of the liver and portal hypertension.
• 2021-12-03 SONO - abdomen
  • Suspected cirrhosis with splenomegaly, mild
  • Pancreas not shown
  • Suboptimal examination of liver due to poor echo window
• 2021-09-30 SONO - abdomen
  • S/P right liver operation.
• 2021-07-16 Bladder sonography
  • PVR 5.12mL
• 2021-07-16 Uroflowmetry
  • Q max: good
  • flow pattern: obstructive
• 2021-07-09 MRI - upper abdomen
  • No focal lesion in the residual liver.
  • Cirrhosis of the liver and portal hypertension.
• 2021-05-12 Patho - stomach biopsy
  • Stomach, mid body, PW side, s/p biopsy — Chronic gastritis, H pylori NOT present
• 2021-03-02 SONO - abdomen
  • S/P partial resection of right lobe liver.
  • Early cirrhosis of the liver and Splenomegaly.
• 2020-12-07 MRI - upper abdomen
  • S/P liver operation. A small hemangioma (0.8cm) at S7 of liver. Tiny liver cysts. Liver cirrhosis with splenomegaly.
• 2020-10-20 Patho - colorectal polyp
  • Colon polyp, splenic flexure, polypectomy — Tubular adenoma with low grade dysplasia
• 2020-10-20 Colonoscopy
  • Colon cancer s/p op
  • No evidence of recurrence
  • Splenic flexure polyp s/p polypectomy
• 2020-09-16 Neurosonology
  • Mild to moderate atheromatous lesions in L middle CCA; mild atheromatous lesions in bilateral CCA bifurcations.
  • Smaller caliber with decreased flow in L cervical VA, possible L VA hypoplasia.
  • Normal extracranial carotid and R vertebral arterial flows.
• 2020-09-15 MRI - upper abdomen
  • Colon cancer s/p operation.
  • Much regression of right liver nodules (up to 1.2cm).
  • Splenomegaly.
• 2020-08-15 MRA - brain
  • Indication: brain concussion with unsteady gait
  • IMP
    • No definite intracranial hemorrhage
    • Brain atrophy
• 2020-08-15 CT - brain
  • Indication: suspected concussion
  • IMP:
    • No definite intracranial hemorrhage
    • Brain atrophy and intracranial arteriosclerosis
• 2020-05-06 Nerve Conduction Velocity, NCV
  • Findings
    • MNCV: decrease amplitude in left peroneal nerve and right tibial nerve acrros popliteal fossa.
    • SNCV: decrease amplitude in bilateral median, ulnar and sural nerves. slow NCV in bilateral median and left ulnar nerves.
    • F-wave: prolonged latencies in bilateral median, left ulnar, bilateral peroneal+ tibial nerves.
    • H-reflex: prolonged latencies bilaterally.
  • Conclusion
    • This NCV study suggests axonal sensory polyneuropathy, may superimposed polyradiaculopathy.
• 2020-05-06 Quantitative Sensory Threshold, QST
  • Findings: Abnormal warm threshold and normal cold threshold in left extremities.
  • Conclusion: This QST study suggests small fiber neuropathy in left extremities.
• 2020-04-14 PET
  • No prominent FDG uptake was noted in the liver dome tumor delineated in the MRI imaging. However, a metastatic lesion of low FDG uptake can not be ruled out. Please correlate with other imaging modalities for further evaluation.
  • A glucose hypermetabolic lesion in the left supraclavicular fossa. The nature is to be determined (a metastatic lesion? other nature?). Please correlate with other clinical findings for further evaluation.
  • A mild glucose hypermetabolic lesion in the left anterior upper chest region near the Port-A implantation. The nature is to be determined. (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • No prominent glucose hypermetabolism in the lesion in the middle lobe of right lung. Please also correlate with other imaging modalities for further evaluation.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
• 2020-04-07 MRI - liver, spleen
  • History and indication: colon colon cancer with liver & lung mets
  • IMP: Right liver metastases s/p resection. A poor enhancing nodule (2.9cm) in right liver dome suspected metastases.
• 2020-04-07 CT - chest
  • no interval change of a RML perifissural solid nodule as compared with previous CT study on 2019/11/22, more in favor odfan intrapulmonary LN rather metastatic nodule.
  • substantial centrilobular emphysema and subpleural paraseptal emphysema in RUL and LUL.
• 2019-11-22 CT - chest
  • Indication: colon cancer with liver mets
  • Imp: Very tiny nodule at right upper lobe about 0.6cm in largest dimension is found. Nature to be determined.
• 2019-10-02 Surgical pathology Level V
  • Clinical diagnosis: Malignant sigmoid colon neoplasm
  • Pathologic diagnosis
    • Liver, S7, segmental hepatectomy — Metastatic colonic adenocarcinoma
      
    • Liver, S8, partial hepatectomy — Metastatic colonic adenocarcinoma
      
    • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
  • Macroscopic examination
    • Procedures: Segmental hepatectomy of S7 and partial hepatectomy of S8
      
    • Specimen Size: 8.4 x 6.8 x 3.0 cm, 178 gm (S7), 5.5 x 4.7 x 2.1 cm and 24 gm (S8)
      
    • Tumor Focality: Multiple (number: 2)
      
    • Tumor Site: S7 and S8
      
    • Tumor Size: 2.5 x 2.3 x 2.2 cm with satellite nodule, 0.3 cm (S7); and 2.0 x 1.8 x 1.5 cm (S8)
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Cirrhotic
      
    • Sections are taken and labeled as: A1-A2= S7 tumor, A3= S7 satellite nodule + margin, B1-B2= S8 tumor
  • Microscopic examination
    • Diagnosis: Metastatic colonic adenoarcinoma
      
    • Histologic grade: Moderately differentiated
      
    • Tumor growth pattern: Infiltrative
      
    • Tumor pseudocapsule: Absent
      
    • Tumor necrosis: Mild (10%)
      
    • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 1.1 cm (S7) and 1.1 cm (S8), respectively
        
    • Vascular invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
      
    • Non-neoplastic liver parenchyma: Chronic hepatitis C with cirrhosis
      
    • Fatty Change: Present (5%)
• 2019-09-12 MRI - liver, spleen
  • A case of synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer (pT2N0M0) s/p Laparoscopic left hemicolectomy on 2018-08-14.
    • Hard stool passage
    • liver metastasis
    • obvious tumor at right lobe at least two tumor at S8 and S6-7
  • Findings
    • Hypervascular hepatic tumor at S7 of liver up to 2.7cm, and another less enhanced tumor at dome up to 1.6cm is found. Metastasis is considered.
    • Very tiny nodule at right middle lobe up to 0.2cm is found. lung meta is considered.
  • Impression:
    • Compatible with liver and lung meta.
• 2019-09-10 SONO - abdomen
  • Diagnosis
    • Parenchymal liver disease
    • Hepatic tumor, nature to be determinated
  • Suggestion
    • Post tumor biopsy, please pursue pathology report
• 2019-09-09 Surgical pathology level V
  • Indication: Malignant sigmoid colon neoplasm
  • Diagnosis: Liver, clinical history of colorectal carcinoma, CT guided biopsy — Adenocarcinoma.
    • IHC stain CK20 (+), compatible with colorectal adenocarcinoma.
• 2019-08-26 PET
  • Multiple mildly to moderately glucose hypermetabolic lesions in right lobe of liver, hepatic metastases from tumors of lower FDG avidity (e.g., better differentiated tumors) should be considered. Please correlate with other work-up studies for further evaluation.
  • A nodule-like lesion in the middle lobe of right lung without prominent glucose hypermetabolism, the nature is to be determined (pulmonary metastasis, inflammatory lesion, or else). Please correlate with other work-up studies and keep follow-up for further evaluation.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change in response to locoregional inflammation may show such a picture.
• 2019-08-19 CT - abdomen
  • Colon cancer s/p operaiton. In favor of lung and liver metastases.
• 2019-02-14 SONO - abdomen
  • Suspected chronic liver parenchyma disease (Please correlate with liver function)
  • Poor assessment of biliary tract and PV
  • Pancreas not shown
  • Suboptimal examination of liver due to poor echo window
• 2018-11-16 Brainstem auditory evoked potential, BAEP
  • The BAEP study showed no response of left wave I. The above finding suggest left side lesion distal to auditory nerve. Advise clinical correlation.
• 2018-11-06 Colon fiberoscopy
  • Colon cancer s/p op
  • No evidence of cancer recurrence
• 2018-10-13 MRI - L-spine
  • Grade I spondylolisthesis at L4/5 with moderate spinal canal stenosis.
• 2018-08-02 Surgical pathology Level VI
  • pathologic diagnosis
    • Large intestine, descending-sigmoid colon (and sigmoid?), laparoscopic left hemicolectomy?/ Laparoscopic anterior resection and anastomosis-malignant? — Adenocarcinoma, moderately differentiated x2
    • Resection margins: free
    • Lymph node, mesocolic, dissection — Free (0/16)
    • Lymph node, IMA / SMA, dissection — N/A.
    • AJCC 8th edition Pathology stage:
      • Larger one: pT3N0 (if cM0); pStage: IIA.
      • Smaller one: pT2N0 (if cM0); pStage: I.
      • NOTE: cM might be the same or might be upgraded when more clinical and image data are available for evaluation.
  • macroscopic examination
    • Operation procedure: laparoscopic left hemicolectomy?/ Laparoscopic anterior resection and anastomosis-malignant?
    • Specimen site: descending sigmoid colon
    • Specimen size: 11 cm in length
      
    • Tumor size: the larger one 3.5 x 3 x 3 cm at 1.8 cm away from one end and another smaller one 1 x 0.5 x 0.5 cm at 2.0 cm from the other end.
    • Tumor location: 1.8 cm and 2.0 cm away from the two resection margins, respectively.
    • Depth of invasion grossly: the smaller one: muscularis propria; the larger one: mesocolic soft tissue.
      
    • Mucosa elsewhere: Free.
    • Tissue for sections: A1-2: bilateral margins; A3-5: the larger tumor; A6: the smaller tumor; A7-9: lymph nodes.
  • microscopic examination
    • Histology: Adenocarcinoma,
    • Histology Grade: moderately differentiated
    • Depth of invasion: the smaller one: muscularis propria; the larger one: mesocolic soft tissue.
      
    • Angiolymphatic invasion: Not identified.
      
    • Perineural invasion: Not identified.
    • Discontinuous extramural tumor extension: Not identified.
    • Serosal margin status of colon: Uninvolved, 2 mm in distance.
    • Lymph node metastasis, mesocolic: Free (0/16)
    • Lymph node metastasis,, IMA / SMA: N/A.
    • Extranodal involvement: N/A.
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT)
        • Larger one: pT3N0 (if cM0); pStage: IIA.
        • Smaller one: pT2N0 (if cM0); pStage: I.
      • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
      • Distant Metastasis (pM): if cM0
      • NOTE: cM might be the same or might be upgraded when more clinical and image data are available for evaluation.
    • Type of polyp in which invasive carcinoma arose: Not identified
      
    • Additional pathologic findings: None identified.
    • TNM descriptors: N/A.
    • Tumor regression grading S/P CCRT: N/A.
  • REFERENCE:
    • S2018-11971: Colon, splenic flexure 60 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • S2018-11972: Colon, descending 45 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2018-07-17 Surgical pathology Level IV
  • Colon, descending 45 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • Colon, splenic flexure 60 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2018-07-17 Colon fiberoscopy
  • Splenic flexure cancer with partial obstruction s/p biopsy, tattooed and clipped
  • Suspected synchnous D-colon cancer s/p biopsy tattooed and clipped
  • Colon polyp s/p polypectomy
• 2018-04-30 24hrs Holtor’s scan
  • Baseline was sinus rhythm with 1st degree AV block
  • A few isolated APCs
  • A few isolated VPCs (mono-form, burden <1%)
• 2018-04-23 EKG
  • Sinus rhythm with 1st degree A-V block

[MedRec]

• 2024-01-10 SOAP Hemato-Oncology He JingLiang
  • Prescription x3
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Alpraline (alprazolam 0.5mg) 1# QN
• 2023-12-05 SOAP Gastroenterology Xu RongYuan
  • Prescription x3
    • Pariet (rabeprazole 20mg) 1# QDAC
• 2023-11-08 SOAP Neurology Xiao ZhenLun
  • Prescription x3
    • Rivotril (clonazepam 0.5mg) 2# HS
    • Saline (nicametate citrate 50mg) 1# TID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
    • Syntam Granules (piracetam 1200mg) 1# QD
    • Secorin (oxazolam 10mg) 1# HS
• 2023-11-08 SOAP Metabolism and Endocrinology Guo XiWen
  • Prescription x3
    • Zulitor (pitavastatin 4mg) 1# QD
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
    • Relinide (repaglinide 1mg) 1# TIDAC
    • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD

[consultation]

• 2023-02-06 Psychosomatic Medicine
  • Q
    • Cancer inpatient has suicidal ideation score of >=2.
  • A
    • “I am getting more and more worried as I think about it.”, “It has made my temper very bad and hurt the people closest to me.”, “The relapse is so recurrent that it has made me like this. Living is not just helpless, it’s already meaningless.”
    • The patient has long-term generalized disorder and panic disorder, loss of gollow-up in 2019 after the diagnsois of maliganacy. Long-term floating anxiety to apprehensive rumination adverselty influence his quality of life and quality of mood as easy anger and easy dysphoria. Currently, he mainfests depression as low self-esteem, feeling of helplessness and worthlessness, although he recognises the clinical reality. He worries about bad effect of antidepressant on his physical problems; reassurnace.
    • Please reinstate escitalopram 5mg QN, titrate it up to 10mg a couple days later. Alprazolam 0.5mg hs. Psychiatry outpatient follow up, please. Thanks.

[multiteam]

• 2023-02-07 Psycho-Oncology
  • Reason for consultation: Other: Cancer inpatient has suicidal ideation score of >=2
  • Conclusion:
    • 19. 2/7 visit, the patient reported that a psychiatrist had also visited the day before.
      • He has been taking anti-anxiety medication for 6-7 years but has not stopped, only taking it when feeling uncomfortable. He has gone to see a psychiatrist before but did not continue after undergoing liver tumor radiofrequency ablation.
      • He is expected to undergo six rounds of chemotherapy this time, but as there is a liver tumor close to a blood vessel, there is a greater risk. After the chemotherapy, even if he get better, the cancer will likely recur in 1-2 years.
      • This is why he marked the suicide ideation score in the middle - “it’s better to just go, but I don’t have the courage.” After treatment, he will probably feel tired for three days. When anxiety comes on, he cannot control it and have to go to the hospital. He experienced a sudden onset during the Chinese New Year when his child invited them to Hualien. His son went to the pharmacy to buy medication, and after taking it, he felt better.
      • He has been seeing an otolaryngologist for medication, but he does not know why he experience anxiety. He has Arab ancestry and is physically strong.
    • 15. 2018/08 rectosigmoid colon cancer, postoperative concurrent chemoradiotherapy (CCRT), 108/10 recurrence, postoperative liver metastasis, previously visited for suicidal ideation (moderate). 111/12 recurrence, admitted for the fourth round of chemotherapy on 2/6, BSRS = 8 (mild), suicidal ideation score of 2 (moderate).
    • 1. Reviewed their treatment history and anxiety experiences, encouraged them to complete cancer treatment, follow up with the psychiatrist for medication adjustment, and contact the Love Life Adjustment Association (an anxiety support group).
    • (AP) The patient can express themselves through conversation, is willing to cooperate with cancer treatment, and is hesitant to follow up with the psychiatrist. They have been encouraged to take the initiative to make an appointment and will be cared for again during the next chemotherapy session.
• 2023-02-07 Social Services
  • Referral Date: 2023-02-06
  • Reason for Referral: Other: Patient has suicidal ideation with a score of >=2
  • Handling Status: Not opening a case
  • Reason for Not Opening a Case: Meeting with the patient on 2023-02-07:
    • Family Situation: The patient is 75 years old, married with a daughter and a son. The patient lives with his wife and children.
    • Evaluation and Treatment:
      • The patient just finished meeting with the psychologist and the psychiatrist visited the patient yesterday. The patient reported a history of diagnosed panic disorder and currently feels hopeless and depressed due to long-term illness, but he has no actual suicidal thoughts or plans at present due to family and ethical beliefs. During the meeting, the patient’s mood was still stable. The social worker was concerned about the patient’s sleep and the patient reported that his sleep is sometimes good and sometimes bad, and it can be affected by his mood swings. However, the recent birth of his grandchild at home is something that has made him happy recently.
      • The evaluation meeting determined that the patient’s mood is mainly affected by his illness, but he is currently able to cooperate with related medical treatments. The family has a good level of economic support and there are no current issues. Therefore, the social worker will provide emotional support and counseling to the patient.

[chemoimmunotherapy]

• 2024-04-24 - cetuximab 400mg/m2 700mg + irinotecan 180mg/m2 300mg D5W 250mg 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (Erbitux + FOLFIRI. Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-04-01 - cetuximab 400mg/m2 700mg + irinotecan 180mg/m2 300mg D5W 250mg 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (Erbitux + FOLFIRI. Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-03-11 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 80mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFOX. Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-15 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 80mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFOX. Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-01-18 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 80mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFOX. Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 80mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFOX. Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-27 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 80mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFOX. Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-17 - ………………………………….. irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI, dose reduced)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + atropine 0.5mg IVD
• 2023-06-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI, dose reduced)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + atropine 1mg IVD
• 2023-06-01 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 790mg NS 250mL 2hr + fluorouracil 2800mg/m2 5560mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + atropine 1mg IVD
• 2023-05-04 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 795mg NS 250mL 2hr + fluorouracil 2800mg/m2 5580mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2023-04-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5630mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2023-03-15 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5650mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2023-02-22 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2023-02-06 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2023-01-12 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2022-12-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2022-12-12 - ………………………………….. irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5500mg NS 500mL 46hr (FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2020-07-17 - ………………………………….. oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5700mg NS 500mL 46hr (FOLFOX, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• …. .. ..

==========

2024-04-25

[managing high blood glucose during cancer therapy]

During this hospitalization, the patient has maintained stable vital signs and lab results from 2024-04-24 have been grossly normal. There is no contraindication to proceeding with this session of Erbitux plus FOLFIRI.

However, blood glucose levels have been recorded around 200 mg/dL, which remains elevated despite current medications, Relinide (repaglinide) and Galvus Met (vildagliptin, metformin). If these high glucose levels persist, the introduction of additional antihyperglycemic agents may be necessary.

2024-04-02

[reconciliation]

There is no evidence in the lab results on 2024-04-01 to be a contraindication to the administration of chemotherapy.

2024-03-12

[Baraclude (entecavir) dosage for reduced kidney function]

Renal function lab results:

• 2024-03-11 Creatinine 1.52 mg/dL

• 2024-02-27 Creatinine 1.26 mg/dL

• 2024-02-15 Creatinine 1.32 mg/dL

• 2024-01-31 Creatinine 1.03 mg/dL

• 2024-01-18 Creatinine 1.36 mg/dL

• 2024-01-10 Creatinine 1.11 mg/dL

• 2024-03-11 eGFR 47.63 ml/min/1.73m^2

• 2024-02-27 eGFR 59.14 ml/min/1.73m^2

• 2024-02-15 eGFR 56.05 ml/min/1.73m^2

• 2024-01-31 eGFR 74.63 ml/min/1.73m^2

• 2024-01-18 eGFR 54.15 ml/min/1.73m^2

• 2024-01-10 eGFR 68.45 ml/min/1.73m^2

On 2024-03-11, a serum creatinine level of 1.52 mg/dL was measured, indicating a slight decline in kidney function. For patients taking Baraclude (entecavir) with a CrCl between 30 and 50 mL/minute, the following dosage adjustments are recommended:

• Reduce the daily dose to 50% of the usual dose for the specific indication.
• Alternatively, administer the usual dose every other day (QOD).

2024-01-19

Medications prescribed by other departments are incorporated into the current medication list, and no discrepancies have been identified.

2023-07-18

In addition to visiting our hemato-oncology department, the patient also consulted our urologist on 2023-07-07 and our cardiologist on 2023-07-14. The urologist prescribed Urief (silodosin) and the cardiologist prescribed Concor (bisoprolol). These medications were accurately added to the active formulary and no discrepancies were found during reconciliation.

2023-06-29

According to the current PharmaCloud database, the patient refiled his prescription at Taipei City Hospital on 2023-06-21 for Algitab Chewable Tablets (alginic acid), Avamys Nasal Spray (fluticasone furoate), and Engene Eye Drops Patron (flavineadenine dinucleotide), all of which are valid for 28 days and are currently still valid. However, these medications are not yet on the patient’s active formulary at our hospital. This could lead to potential medication reconciliation discrepancies. It’s advisable for the primary care team to confirm whether these medications are still needed for the patient’s current clinical condition. If these medications are needed, they should be added to the patient’s active formulary accordingly.

2023-06-02

Per the PharmaCloud database, this patient recently had an outpatient visit at Taipei City Hospital on 2023-05-24. He was prescribed Algitab, Broen-C, acetaminophen for oral use, and sulfamethoxazole eye drops for a 28-day duration. Most of these medications are intended to manage GI symptoms. Upon examination of the current medication list, equivalent therapeutic drugs have already been prescribed. Consequently, no issues were identified during the medication reconciliation process.

2023-04-11

Based on the serum glucose level range of 288 mg/dL to 230 mg/dL, it appears that the patient’s underlying condition of type 2 DM is not well-controlled despite taking Galvus Met (vildagliptin + metformin) and Relinide (repaglinide). However, since there is no evidence of renal insufficiency (as of 2023-04-10 with Cre at 1.02mg/dL, eGFR at 75.67, and BUN at 21), the addition of Dibose (acarbose 100mg) 0.5# TIDAC is recommended if the high glucose level persists.

2023-02-23

The recurrence of cancer has left the patient feeling helpless, and he has been visited by a psychiatrist, a counseling psychologist, and a social worker in early Feb 2023. He is currently still taking alprazolam, but his emotional state is stable.

The patient’s HbA1c has shown a slow decline trend, blood sugar readings were 145 to 164 mg/dL on 2/22 and 2/23, there is still room for improvement.

• 2023-02-13 HbA1c 6.1%
• 2022-09-15 HbA1c 6.6%
• 2022-06-06 HbA1c 6.4%
• 2022-03-01 HbA1c 6.1%
• 2021-12-22 HbA1c 6.2%
• 2021-09-30 HbA1c 6.8%
• 2021-06-18 HbA1c 6.6%
• 2021-02-22 HbA1c 6.4%
• 2020-11-30 HbA1c 6.5%
• 2020-09-08 HbA1c 6.8%
• 2020-06-15 HbA1c 7.0%
• 2020-03-23 HbA1c 7.2%
• 2019-09-20 HbA1C 6.7%
• 2018-04-12 HbA1C 7.1%

701374610

240425

[exam findings]

• 2024-04-19 CXR
  • Lung markings: nodular lesions in the bilateral lung fields, the largest one about 35mm.
• 2024-04-13 CXR erect
  • Nodular lesions of both lungs, may be metastatic lesions.
  • Tortuosity of the aorta with atherosclerotic change.
• 2024-04-03 CXR erect
  • Multiple nodules at bil. lungs.
• 2024-03-23 CXR erect
  • Bilateral lung nodules, could be due to lung metastasis.
• 2024-02-24 CT - abdomen
  • With and without contrast enhancement CT of abdomen - whole:
    • Post-op at the colon.
    • Presence of gallbladder stone.
    • There are multiple lung tumors, up to cm in left lower lung, could be due to lung metastasis, progression as compare with CXR on 2023-11-06.
    • Left abdominal wall hernia.
  • Impression:
    • Post-op at the colon. Multiple lung metastasis, progression.
    • GB stones.
    • Left abdominal wall hernia.
• 2023-11-06 CT - abdomen
  • Indication: RS colon cancer s/p OP
  • Abdominal CT with and without enhancement revealed:
    • s/p rectal op and colostomy with its orifice at LLQ.
    • Nodlar lesions at left lower lobe measuring 2.25cm and right lower lobe measuring 1.6cm in largest dimension. In comparison with CT dated on 2023-07-24, the lesions enlarged.
  • Imp:
    • Rectal cancer s/p op.
    • Bilateral lung meta. In enlargement.
• 2023-07-24 CT - abdomen
  • Findings
    • S/P operation with post-operative change. Nodules (7.4mm, 8.4mm) at RLL.
    • Gallbladder stone (4mm).
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • S/P operation with post-operative change. Nodules (7.4mm, 8.4mm) at RLL r/o metastases.
• 2023-06-13 All-RAS + BRAF
  • Cellblock No. N2022-07268 A2
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-24 CT - chest
  • Indication: R-S colon cancer with lung and peritoneal mets
  • Findings
    • Lungs: multiple randomly distributed pulmonary nodules of varying sizes in both lungs due to metastases.
    • Mediastinum and hila: old calcified LN in subcarinal space.
  • Impression:
    • R-S colon cancer with lung metastasis in progression as compared with the previous abdominal CT on 2023/04/25
• 2023-05-15 PET scan
  • Glucose hypermetabolic lesion at the R-S junction of colon, highly suspected tumor recurrence.
    
  • Glucose hypermetabolism in lymph nodes in LLQ of abdomen, compatible with cancer with peritoneal surface metastases.
    
  • Increased FDG uptake in bilateral inguinal lymph nodes, in the left upper and lower lungs, in the right lower lung, in bilateral mediastinal and pulmonary hilar lymph nodes, and in a lymph node in the right supraclavicular fossa, highly suspected cancer with distant metastases.
    
  • R-S colon cancer s/p treatment, highly suspected tumor recurrence with peritoneal surface and distant metastases, cTxNxM1c, stage IVC (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-05-11 Patho - peritoneum biopsy
  • Diagnosis
    • Peritoneum, laparoscopic lysis of adhesion + resection of peritoneal tumor — metastatic adenocarcinoma and stitch foreign body reaction. Comaptible with colorectal origin
    • Sigmoid colon, Revision of prolong S colostomy — conformed
    • AJCC 8th edition pathology stage: pTxNxM1c; AJCC stage IVC
  • Gross description:
    • The specimen submitted consists of multiple tissues measuring up to 2.5x 0.3x 0.3 cm in size, fixed in formalin.
      • Grossly, it Is elastic and yellow-brownish.
    • The specimen submitted consists of 1 tissue measuring 5x 2x 1.5 cm in size, fixed in formalin.
      • Grossly, it Is elastic and yellow-brownish.
    • All for sections are taken and labeled as: A:peritoneum, B:colostomy
  • Microscopically, sections A shows nestes of adenocarcomatous tumor cells and foreign body material with stromal fibrosis. Section B shows bland colon tissue and no evidence of tumor.
  • Immunohistochemical stain reveals CK(+) and CK20(+) at tumor.
• 2023-04-25 CT - abdomen
  • History and indication: R-S colon cancer s/p Op and under C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation with post-operative change. Nodules (4.3mm, 10.6mm) at RLL.
    • Gallbladder stone (4mm).
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • S/P operation with post-operative change. Nodules (4.3mm, 10.6mm) at RLL r/o metastases.
• 2023-04-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 28.5) / 112 = 74.55%
    • M-mode (Teichholz) = 74.6
    • 2D (M-Simpson) = 69.4
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with mild MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • No PR, mild TR, normal IVC size
    • Dilated LA
• 2023-01-31 CT - abdomen
  • S/P operation with post-operative change. No evidence of tumor recurrence.
• 2022-10-28 CT - abdomen
  • s/p Hartmann operation and colostomy at left upper pelvis sigmoid colon. There is no evidence of tumor recurrence.
• 2022-10-13 Patho - skin cyst/tag/debridement
  • Skin, chest wall, excision — Epidermal inclusion cyst, ruptured
  • Section shows a piece of skin with one ruptured intradermal cyst lined by squamous epithelium. The cystic cavity is full of keratin material. Foreign body giant cell reaction is present.
• 2022-09-22 Bladder Sonography
  • PVR: 10.4 ml
• 2022-09-15 Cystography
  • Administration of contrast medium, total about 130ml, into the urinary bladder.
  • There is no evidence of contrast medium leakage from the urinary bladder.
• 2022-09-08 Patho - colon resection (non tumor)
  • PATHOLOGIC DIAGNOSIS
    • Large intestine, rectos-gmoid colon, previous Hartmann’s operation at Taipei Mackay Memorial Hospital, s/p adjuvant chemotherapy, now re-do hartmann’s operation —- ulcer, acute inflammation. No residual malignancy, nor dysplasia.
    • Resection margins: free
    • Lymph node, mesocolic, s/p adjuvant chemotherapy, dissection — no lymph node, no malignany.
  • MACROSCOPIC EXAMINATION
    • Operation procedure: re-do hartmann’s operation
    • Specimen site: rectosigmoid colon
      
    • Specimen size: 14.5 cm in length
      
    • Tumor size: Grossly ulcerated tumor-like lesion: 3.5 x 2.5 cm. (NOTE: microscopically, no residual malignancy nor dysplasia.)
    • Tumor location: 1.5 cm and 9.5 cm away from the two resection margins, respectively (or involved).
    • Depth of invasion grossly: no residual malignancy
    • Mucosa elsewhere: free.
    • Tissue for sections: A1: proximal margin; A2: distal margin; A3-9: tumor-like site; A10-15: mesocolic tissue, (possible lymph nodes).
  • MICROSCOPIC EXAMINATION :
    • Histology: No residual malignancy, nor dysplasia.
    • Histology Grade: No residual malignancy, nor dysplasia.
    • Depth of invasion: No residual malignancy, nor dysplasia.
    • Angiolymphatic invasion: No residual malignancy, nor dysplasia.
    • Perineural invasion: No residual malignancy, nor dysplasia.
    • Discontinuous extramural tumor extension: No residual malignancy, nor dysplasia.
    • Serosal margin status of colon: No residual malignancy, nor dyspno lymph node, no malignany.No. Positive / No. Total
      
    • Lymph node metastasis,, IMA / SMA: N/A.
    • Extranodal involvement: no lymph node, no malignany.
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition) : No residual malignancy, nor dysplasia.
      
    • Type of polyp in which invasive carcinoma arose: No residual malignancy, nor dysplasia.
    • Additional pathologic findings: No residual malignancy, nor dysplasia.
    • TNM descriptors: y (Post-treatment).
      
    • Tumor regression grading S/P CCRT: Modified Ryan scheme for Tumor Regression Score: 0: No viable cancer cells (complete response)
• 2022-09-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 28.8) / 102 = 71.76%
    • M-mode (Teichholz) = 71.8-65.3
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with mild MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • No PR, trivial TR, normal IVC size
• 2022-08-30 Colonoscopy
  • Findings
    • Colon:
      • The scope could not insert from stomy due to stricture at opening. Inflammation at opening of stomy was found.
      • The scope reach the closed end site (8cm AAV) from anus.
    • Others:
      • Mixed hemorrhoid was noted.
  • Diagnosis:
    • S/p colostomy at S-colon, with stomy opening stricture and inflammation
    • S/p Hartmann operation
    • Mixed hemorrhoid
    • Incomplete study due to stricture at stomy opening
• 2022-07-19 CT - abdomen
  • Clinical history: 69 y/o male patient with adenocarcinoma of RS-colon s/p Hartmann operation at Taipei Mackay Hospital (Xu ZiQi chief) on 2022-04-01, pT3N2aM0, stage IIIB complicating with post-op ileus and wound infection. and then. and s/p 1st C/T on early May. They want to receive further C/T at our hospital.
  • With and without contrast enhancement CT of abdomen–whole:
    • Post-op at the colon. Prominent soft tissue density in left abdominal wall around the stomy, post-op change? Suggest clinical correlation.
      
  • Impression:
    • Post-op at the colon. Prominent soft tissue density in left abdominal wall around the stomy, post-op change? Suggest clinical correlation and follow up.
• 2022-04-25 CT - brain
  • No evidence of intracranial hemorrhage.

[MedRec]

• 2024-03-15 SOAP Colorectal Surgery Lv ZongRu
  • P: disease progress, suggest CT or hospice care.
  • Prescription x3
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# QID
    • Alpraline (alprazolam 0.5mg) 1# PRNQN
    • Mobic (meloxicam 7.5mg) 1# QD
    • Zanidip (lercanidipine 10mg) 1# QD
    • MgO 250mg 2# BID
    • Through (sennoside 12mg) 2# PRNHS
• 2022-09-05 ~ 2022-09-16 POMR Colorectal Surgery Lv ZongRu
  • Course of inpatient treatment
    • After admission with ward routine and pre-op study were done. After well explain the risk of surgery including heart, lung complications and risk of leakage.
    • Operation of fail of closure of Hartmann’s operation due to severe adhesion of intesinte and S-colon to low abdomen and re-do hartmann’s operation and cystorrhaphy for bladder injury with small defect under general anesthesia were performed on 2022/09/07.
    • NPO and adequate IV fluid supplement.
    • Antibiotic treatment with Soonmelt 1200 mg IVD Q8H was prescribed for bladder injury with small defect on 2022/09-07.
    • His wound pain is acceptable by PCA. Early activity is encouraged. The wound healing well and no erythema change. Antibiotic shifted to oral form Curam since 2022/09/10.
    • He had stool passage and abdominal wound pain subsided. Drain is clear ascites and removal of JP drain on 09/10. Oral intake program was adjusted and there was no abdominal discomfort after trying oral intake, IV fluid supplement was tapered and discontinued later. He had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. His abdominal wound pain had got much better.
    • Cystography was performed via foley catheter and there is no evidence of contrast medium leakage from the urinary bladder. Removal of a Foley catheter on 09/15 and voiding recovery on the day of Foley catheter removal.
    • In stable condition, he was discharged on 2022/09/16 and will receive OPD follow up next week.
  • Discharge prescription
    • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# Q12H
    • Through (sennoside 12mg) 1# HS
    • Acetal (acetaminophen 12mg) 1# PRNQ6H
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2022-06-15 ~ 2022-06-18 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Malignant neoplasm of rectosigmoid junction
    • Adenocarcinoma of RS-colon s/p Hartmann operation at Taipei Mackay (Xu ZiQi chief) on 2022/04/01, pT3N2aM0, stage IIIC complicating with post-op ileus and wound infection
    • Essential (primary) hypertension
    • Chronic viral hepatitis B without delta-agent
    • Constipation, unspecified
  • CC
    • For chemotherapy.
  • Present illness
    • This 69-year-old man patient is a case of Adenocarcinoma of RS-colon s/p Hartmann operation at Taipei Mackay (Xu ZiQi chief) on 2022/04/01, pT3N2aM0, stage IIIC complicating with post-op ileus and wound infection.
    • 1st chemotherapy with Capecitabine and Oxaliplatin in 2022/05. They want to receive further chemotherapy at our hospital for nauasea with vomiting. Port-A catheter insertion on 2022/06/13.
    • Now, he was admitted to ward for chemotherapy with FOLFOX (Oxalip 75mg/m2, LV 300mg/m2, 5FU 300mg/m2 and 2400mg/m2)(C1D1) on 2022/06/15.
  • Course of inpatient treatment
    • After admitted, Chemotherapy with FOLFOX (Oxalip 75mg/m2, LV 300mg/m2, 5FU 300mg/m2 and 2400mg/m2)(C1D1) on 2022/06/15~2022/06/17.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • Hypertension with Zanidip F.C 10mg (Lercanidipine) 1# po QD.
    • Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC.
    • Constipation with MgO 2# po TID and Sennoside 2# po HS.
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, he was discharged on 2022/06/18 and OPD followed up later.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • MgO 250mg 2# TID
    • Through (sennoside 12mg) 2# HS
    • Zandip (lercanidipine 10mg) 1# QD
    • Acetal (acetaminophen 500mg) 1# PRNQ6H if pain or fever

[consultation]

• 2024-04-03 Dermatology
  • A
    • CC: Pain over right big toe nail
    • Skin findings: ingrown nail with mild erythema over right big toe nail
    • Imp: paronychia, ingrown nail
    • Plan:
      • Cryotherapy was done
      • Topical tetracycline BID for nail lesions
• 2024-03-30 General and Gastrointestinal Surgery
  • Q
    • Injury level: 3 Abdominal pain > Acute moderate central pain (4-7) Main complaint: The patient was discharged from the hospital on Tuesday due to intestinal obstruction. He returned to the outpatient department today and said there was some small intestinal obstruction. He is still experiencing stomach distension, pain and discomfort, so He went to the emergency room for treatment.
    • Epigastric intermittent pain and sore saliva
    • had little defecation today
    • denied N/V
    • PHx:
      • colon CA s/p laparoscopic lysis of adhesion + resection of peritoneal tumor + revision of prolong sigmoid-colostomy on 2023/05/10
      • HTN
  • A
    • Lab data:
      • 2024-03-30 Lipase 18 U/L
        
      • 2024-03-30 Bilirubin total 0.89 mg/dL
        
      • 2024-03-30 CRP 1.1 mg/dL
        
      • 2024-03-30 Glucose ( serum ) 130 mg/dL
        
      • 2024-03-30 ALT 41 U/L
        
      • 2024-03-30 Neutrophil 71.8 %
        
      • 2024-03-30 Lymphocyte 21.1 %
        
      • 2024-03-30 WBC 9.48 x10^3/uL
        
      • 2024-03-30 RBC 4.80 x10^6/uL
        
      • 2024-03-30 HGB 15.0 g/dL
        
    • PHx:
      • colon CA s/p laparoscopic lysis of adhesion + resection of peritoneal tumor + revision of prolong sigmoid-colostomy on 2023/05/10
    • PET scan: There was increased FDG uptake in multiple focal areas in the pelvic cavity (SUVmax early: 15.62, delay: 21.07), in multiple focal areas in lower abdominal cavity (SUVmax early: 12.43, delay: 15.99), in bilateral inguinal lymph nodes (SUVmax early: 11.90, delay: 13.27). In addition, there was increased FDG uptake in multiple focal areas in bilateral lungs (SUVmax early: 10.31, delay: 12.65) and in the left mediastinal and left pulmonary hilar lymph nodes (SUVmax early: 14.76, delay: 16.72).
      • IMPRESSION:
        • Glucose hypermetabolism in multiple focal areas in the pelvic cavity, compatible with recurrent malignancy or metastases.
          
        • Glucose hypermetabolism in multiple focal areas in the lower abdominal cavity, compatible with metastatic lesions such as metastatic lymph nodes.
          
    • Impression:
      • ileus due to tumor recurrence
      • adhesion ileus
      • constipation
    • Suggestion:
      • On NG with NG decompression
      • tumor survey for the recurrent colon cancer
      • Prophylactic antibiotic treatment
      • IVF supplement
      • close follow up CBC/DC and BCS
• 2024-03-23 General and Gastrointestinal Surgery
  • Q
    • Injury examination level: 3 Abdominal pain > Blood pressure or heartbeat are different from the patient’s normal values, but hemodynamics is stable. The stoma has not been excreting for 2-3 days. Abdominal pain started yesterday.
    • peri-ostomy pain since yesterday with N/V and acid-reflux sensation
    • No fever
    • The patient is a victim of adenocarcinoma of RS-colon s/p Hartmann operation at Taipei Mackay (Chief Xu ZiQi) on 2022-04-01, pT3N2aM0, stage IIIB complicating with post-op ileus and wound infection. and then. and s/p 1st C/T on early May.
    • Allergy: NKDA
    • Medication: Lercanidipine
    • Past history:
      • Adenocarcinoma of rectosigmoid colon, pT3N2aM0, stage IIIB status post laparoscopic lysis of adhesion + resection of peritoneal tumor + revision of prolong sigmoid-colostomy on 2023/05/10
      • Essential (primary) hypertension
    • Personal history: nil
  • A
    • S:
      • Lung and pevis metastasis was diagnosed in our hospital. He stopped chemotherapy since 2023-06. abdominal pain and no passage stool from colostomy for 3 days.
    • O: vital signs: stable, no fever
      • abdomen: colostomy ovr LLQ, old surgical scar 30 cm over midline, soft, ovoid, increase bowel sound, periumbilical tenderness, tympanic percussion
        　 - lab data: see chart
      • CT: 1. Post-op at the colon. Small bowel ileus, r/o adhesion ileus (at lower abdomen), can’t rule out associated with local recurrence. 2. Left abdominal wall hernia. 3. Multiple lung metastasis, left abdominal wall metastasis. 4. GB stones.
    • A:
      • adenocarcinoma of RS-colon, pT3N2aM0, stage III s/p op with lung and pevis metastases　
      • ileus may be due to cancer related obstruction
    • P:
      • Suggest admission for NG decompression, adequate hydration, and cloesly observation
      • We will arrange small bowel series during hospitalization. If mechanic obstruction is proved, palliative bypass surgery may be considered.
      • If he refused NG decompression, hospice care and palliative treatment may be considered.
• 2023-05-09 Urology
  • Q
    • This time, arrange laparoscopy check adhesion + if can not repair, revision of DS colostomy on 2023/05/10. Due to concerns about bladder adhesion during the operation.
    • We need your for combine surgery. Thank you.
  • A
    • I have review the history and exams. Due to advanced tumor stage and previous operation, tissue fibrosis and adhesion may be severe. Surrounding tissue damage and organ injury may happen in a high chance.
    • In my opinion, the operation has a higher failure rate and may not be effective. Please well explain and discuss with the patient and his family before the operation. We will prepare for the operation if GU tract is involved. Thanks for your consultation.

[chemotherapy]

• 2024-04-24 - …………………………….. irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 600mg NS 250mL 90min (Y-sited Irino) + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 4800mg NS 500mL (FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3

• 2024-04-08 - bevacizumab 5mg/kg 500mg NS 100mL + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 800mg NS 250mL 90min (Y-sited Irino) + fluorouracil 400mg/m2 800mg NS 100mL 10min + fluorouracil 2400mg/m2 4800mg NS 500mL (Avastin + FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3

• 2023-07-11 - (Avastin + FOLFIRI)

• 2023-06-27 - (Avastin + FOLFIRI)

• 2023-06-13 - (Avastin + FOLFIRI)

• 2023-05-30 - (Avastin + FOLFIRI)

• 2023-01-10 - (FOLFOX)

• 2022-12-27 - (FOLFOX)

• 2022-12-13 - (FOLFOX)

• 2022-11-29 - (FOLFOX)

• 2022-11-15 - (FOLFOX)

• 2022-11-01 - (FOLFOX)

• 2022-08-09 - (FOLFOX)

• 2022-07-26 - (FOLFOX)

• 2022-07-12 - (FOLFOX)

• 2022-06-28 - (FOLFOX)

• 2022-06-15 - (FOLFOX)

==========

2024-04-25

[reduced chemotherapy dosage following adverse effects; clinical observations following dose adjustment]

Imaging this year confirmed the presence of lung lesions, and FOLFIRI therapy was reintroduced on 2024-04-08. Subsequent assessments indicate that the patient’s tumor markers, CEA and CA199, as well as liver enzymes ALT and AST, are decreasing, suggesting an improvement in the patient’s condition.

Due to abdominal pain and hiccups experienced after the last chemotherapy session, Avastin has been withheld, and the bolus dose of 5-FU has been reduced to 300 mg/m^2 from the standard 400 mg/m^2. The resolution of symptoms remains under observation, and no discrepancies in medication have been found.

• 2024-04-24 ALT 42 U/L

• 2024-04-19 ALT 88 U/L

• 2024-04-24 AST 23 U/L

• 2024-04-17 AST 57 U/L

• 2024-04-17 CEA 15.80 ng/mL

• 2024-04-08 CEA 25.63 ng/mL

• 2024-04-17 CA199 44.24 U/mL

• 2024-04-08 CA199 62.23 U/mL

701103011

240424

[exam findings]

• 2024-04-10 CT - abdomen
  • History: Gastric cancer s/p C/T with UFUR.
  • Findings:
    • Prior CT identified distended stomach with fluid content is noted again, stationary.
    • Prior CT identified gastric tumor and regional lymph nodes is noted again, stationary. Please correlate with gastroscopy.
    • A renal cyst 1 cm in left middle pole is noted. In addition, there are several renal stones (up to 0.5cm).
• 2024-03-04 PD-L1 (SP142)
  • Pathologic Report for VENTANA PD-L1 (SP142) Assay
    • Tumor type: Adenocarcinoma
    • Tumor location: Stomach
    • Testing assay: SP142 Assay (Ventana)
    • Control slide result: [V]Pass, []Fail
    • Adequate tumor cells present (>=100 viable tumor cells): [V] Yes, [] No
  • Result:
    • Tumor Cell Staining Assessment: PD-L1 Expression: 0% Tumor Cells
    • Tumor Infiltrating Immune Cell Staining Assessment: PD-L1 Expression: 1% Immune cells
  • Note:
    • Percent of PD-L1 expression in tumor cells (TC): The percentage of viable tumor cells with membrane positivity at any intensity
    • Percent of PD-L1 expression in immune cells (IC): The percentage of tumor-infiltrating immune cells with discernible staining of any intensity
• 2024-03-04 PD-L1 IHC
  • Cellblock No. S2023-11514
  • RESULTS：
    • Tumor cell (TC) staining assessment: TC: < 1%
      • Percentage of PD-L1 expressing tumor cells (%TC): <1% (optional)
    • Combined Positive Score (CPS) assessment: CPS >= 5
      • Combined Positive Score (CPS) : 25 (optional)
• 2024-01-11 CT - chest
  • Indication: Malignant neoplasm of stomach, unspecified
  • Chest CT with and without IV contrast ehnancement shows:
    • Spiculated lesion at right upper lobe is found. In comparison with CT dated on 2023-05-20, the lesion is stationary.
    • Mininmal infiltration at right lower lobe and left lower lobe is found.
    • Diffuse wall thickening of the stomach is found. Perigastric lymph nodes is also found.
    • Osteopenia of the bony structure is noted.
  • Imp:
    • Right upper lobe spiculated lesion. Stationary. Suggest regular follow up.
    • Gastric wall thickening and regional lymph nodes. stable.
• 2023-12-27 CT - abdomen
  • History: Gastric cancer s/p C/T with UFUR.
  • Findings:
    • Prior CT identified distended stomach with fluid content is noted again, stationary. Please correlate with gastroscopy to r/o gastric outlet obstruction.
    • Prior CT identified gastric tumor and regional lymph nodes is noted again, stationary. Please correlate with gastroscopy.
    • A renal cyst 1 cm in left middle pole is noted.
      • In addition, there are several renal stones (up to 0.5cm).
• 2023-08-19 CT - abdomen
  • Indication: Gastric cancer with pancreas, spleen and liver metstases, stage IV
  • With and without contrast enhancement CT of abdomen shows:
    • Distended stomach with fluid content. Regression of gastric tumor and regional lymph nodes.
    • Regression of LUL nodules.
  • Impression
    • Gastric cancer, s/p chemotherapy
    • Regression of gastric tumor, regional lymph node and lung metastasis
    • Distended stomach. Suggest clinical correlation to r/o gastric outlet obstruction.
• 2023-06-09 Patho - stomach biopsy
  • Stommach, angularis, AW, biopsy — Adenocarcinoma, moderately differentiated
  • The sections show tubular adenocarcinoma, moderately differentiated, composed of cuboidal neoplastic cells, arranged in focal tubular pattern with desmoplastic stromal reaction. Colonies of Helicobacter pylori are present.
• 2023-05-20 CT - chest
  • Indication: Gastric cancer
  • Chest CT with and without IV contrast ehnancement shows:
    • Calcified coronary arteries is found.
    • S/p port-A placement with its tip at Superior vena cava.
    • Tiny lymph nodes are found at both sides of the mediastnum.
    • Minimal infiltration at right lower lobe and left lower lobe is found. In comparison with CT dated on 2018-01-31, the lesions are stationary.
    • Two nodular lesions are found at right upper lobe measuring 0.7cm and 0.4cm. Nature to be determined.
    • Some lymph nodes are found at perigastric region.
    • Wall thickening at gastric body measuring 1.7cm is found. Gastric cancer is compatible.
    • Tiny calcified dots at both kidneys are found. Renal stone is considered.
  • Imp:
    • Right upper lobe nodules. Nature?
    • Gastric cancer with abdominal lymph nodes
    • Minimal infiltration at both lungs. Stationary.
• 2023-05-02 CXR erect
  • Atherosclerotic change of aortic arch
  • Old fracture of right distal clavicle.
• 2018-02-02 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (70.4 - 18) / 70.4 = 74.43%
    • M-mode (Teichholz) = 74.6
  • Conclusion
    • Dilated LA
    • Adequate LV,RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild TR
    • Mild Pulmonary HTN
• 2018-01-31 CT - abdomen
  • History and indication: Rule out gastric cancer, type III
  • With and without-contrast CT of abdomen revealed:
    • Wall thickening of gastric antrum with regional LAP.
    • Left pleural effusion. Infiltration of bil. lungs.
    • Renal stones (1-2mm).
  • Imaging Report Form for Gastric Carcinoma
    • Tumor location / Size
      • Location: □ Cardia □ Fundus □ Body: Lesser/Greater curvature ■ Antrum □ Pylorus □ Other: __________
      • Size: ■ Non-measurable □ Measurable: __________cm (greatest diameter)
    • Tumor invasion depth: □ Not assessable ■ Assessable, tumor invasion to: ■ Gastric wall □ Perigastric tissue □ Adjacent organs or structures: _________ □ Others: ___________
    • Regional nodal metastasis: □ No or Equivocal ■ Yes, number of suspicious lymph node: 5 and location: around tumor
    • Distant metastasis (In this study): ■ No or Equivocal □ Yes , □ Non-regional lymph nodes or □ distant organ; and location: _________(specify lymph node or organ location)
  • Impression:
    • Gastric cancer (The gold standard of evaluation of lymph node metastases and detailed tumor status is microscopic examination).
    • Cstage T2N2Mx
• 2018-01-30 Surgical pathology Level Iv
  • Clinical diagnosis:
    • Hemorrhage of gastrointestinal tract,unspecified;
  • Diagnosis:
    • Stomach, antrum and body, AW, LC, PW, biopsy — modertaely differentiated adenocarcinoma — candida infection
  • Gross description:
    • The specimen submitted consists of 4 tissue fragments measuring up to 0.2x 0.2x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic.
    • All for section is taken.
  • Microscopically, it shows modertaely differentiated adenocarcinoma composed of proliferation of tumor cells arranged in glandular architecture and infiltrative growth pattern. Fungla hypahe are seen.
• 2018-01-29 Upper G-I panendoscopy
  • Reflux esophagitis, lower esophagus, LA clasification grade B 　- Esoaphageal ulcer, lower esophagus 　- Advanced gastric cancer, type II, body, antrum, AW, LC, PW, s/p biospy

[MedRec]

• 2023-04-19 SOAP Hemato-Oncology
  • S:
    • Hx of gastric cancer s/p C/T with UFUR
  • O:
    • 2018/01/30 Surgical pathology Level IV
      • Stomach, antrum and body, AW, LC, PW, biopsy — modertaely differentiated adenocarcinoma
  • P:
    • Admssion for checking HBV, HCV, CBC/DC, Biomchemistry and AFP/CA125/CA199/CEA, FOLFOX

[chemotherapy]

• 2024-04-23 - (FOLFOX)
• 2024-03-29 - (FOLFOX)
• 2024-03-01 - (FOLFOX)
• 2024-01-10 - (FOLFOX)
• 2024-01-02 - (FOLFOX)
• 2023-10-27 - (FOLFOX)
• 2023-10-03 - (FOLFOX)
• 2023-09-12 - (FOLFOX)
• 2023-08-21 - (FOLFOX)
• 2023-07-25 - (FOLFOX)
• 2023-07-10 - (FOLFOX)
• 2023-06-09 - (FOLFOX)
• 2023-05-03 - oxaliplatin 65mg/m2 90mg D5W 250mL 6hr + leucovorin 400mg/m2 550mg NS 500mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFOX, Oxa long infusion to prevent allergy)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2024-04-24

[considerations for prescribing oral MgO post-discharge]

According to HIS5 lab results, this patient has consistently experienced hypomagnesemia. Although MgSO4 injections were administered during hospitalization, oral MgO may be considered for discharge prescriptions and outpatient care if there are no contraindications.

2023-05-04

• The patient received the FOLFOX regimen on 2023-05-03, with a reduced dose of oxaliplatin (85mg/m2 to 65mg/m2) and an extended infusion time (from 2 hours to 6 hours), as well as the addition of famotidine 20mg as premedication. As of now, no significant adverse reactions have been observed.

700133216

240422

[exam findings]

• 2024-01-12 PET
  • A glucose hypermetabolic lesion in the right breast, compatible with primary breast malignancy.
  • A glucose hypermetabolic lesion in the lower lobe of left lung. Primary lung malignancy should be considered first.
  • Glucose hypermetabolism in some bilateral paratracheal and left subcarinal lymph nodes. Metastatic lymph nodes may show this picture.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes and in bilateral shoulders. Inflammatory process is more likely.
  • Mild glucose hypermetabolism in a focal area in the left maxillary sinus. The nature is to be dertermined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
• 2024-04-01 Patho - breast biopsy (no need margin)
  • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (+, 100%, strong intensity), PR (+, 98%, strong intensity), Her2/neu: negative (score=0), Ki-67 (70%), p63 (-), CK5/6 (-), E-cadherin (+).
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2024-03-19 CT - chest
  • Indication: Rt breast lump for 1-2 wks which grew up (20240315) Past Hx:DM, HTN and dementia
  • Findings:
    • Chest wall and visible lower neck: a spiculated soft-tissue tumor (33.3 x 47mm) at the right breast (subareolar located), with overlying skin thickening. no enlarged LN at Rt axilla.
    • Lungs: a soft tissue mass (spiculated 33mm in longest dimension) over LLL. a peripheral, subsegmental ground glass opacity at lateral aspect of RUL.
      • partial atelectasis of inferior lingular segment and RML.
    • Mediastinum and hila: enlarged LNs in pretracheal and subcarinal spaces.
      • multiple, old calcified LNs in the visceral space and both hila, sequela of previous TB infection
      • extensive coronary arterial calcification.
    • Thoracic aorta: normal caliber,
    • Heart: dilated LA, extensive calcified mitral annulus
    • Pleura: minimal Lt-sided effusion
    • Visible abdominal contents: multiple small gall bladder stones and a Lt renal cyst measuring 24mm.
      • marginal spurs of multiple vertebrae due to spondylosis. .
      • compression fracture of T12 vertebral body.
  • Impression:
    • Rt breast cancer, no regional LAP.
    • LLL tumor 33mm, another primary lung cancer r/o metastasis,
    • extensive 3V-CAD.
    • enlarged mediastinal LAPs, metastasis?

[MedRec]

• 2023-06-15 ~ 2023-06-24 POMR Integrative Medicine Hong BoBin
  • Discharge diagnosis
    • Mild persistent asthma, uncomplicated
    • Hypostatic pneumonia, unspecified organism
    • Type 2 diabetes mellitus without complications
    • Unspecified dementia without behavioral disturbance
    • Cerebral atherosclerosis
    • Allergic rhinitis, unspecified
    • Gastro-esophageal reflux disease without esophagitis
    • Gout, unspecified
    • Mixed hyperlipidemia
    • Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
    • Calculus of gallbladder; ABD sonography, 2023-06-19
    • Renal cyst, left; ABD sonography, 2023-06-19
  • CC
    • Productive cough for near one month.
  • Present illness
    • This is a 97 years old female with underlying disease of 1. HTN 2. type II DM 3. hyperlipidemia 4. gout 5. asthma 6. sennile demensia. She live at home with her family. Her activity of her daily life need assisstance by her cargiver.
    • This time, she present with productive cough for near one month. Associated symptoms include increased cough frequency, occational acid regurgitation, running nose, decreased appetite and activity. According to her family, no fever, chillness ,nausea, vomitting, sorethroat, abdominal pain, diarrhea, constipation, bloody stool, tarry stool, foul or cloudy urine. Her family was diagnosed with covid-19 last month. However, covid screen for patient show negative finding. Patient was not diagnosed with covid-19 before.
    • She was then sent to our ER for help. At ER, vital sign show BP:139/81; HR:81; BT:35.7’C; RR:18; Con’s:E4V4M6, SpO2:96%. PE show bilateral clear breathing sound. Lab data show no leucocytosis or CRP elevation. Liver, renal or eletrolyte also show no abnormal finding. CXR show right middle lung atelectasis and faint aveolar opacity over left lower lobe. Covid and Influenza test show negative finding.
    • Under the impresion of cough, cause need to be ruled out, she is admitted to our ward for furthre survey and treatment.
  • Course of inpatient treatment
    • After admission, we arrnage chest echo and it reveal no evidence of free pleural effusion over both sides. Since fair blood sugar control, we also arrange abdominal echo and it reveal no liver abscess. The patient’s symptoms of cough and sputum relieve after admitted to our ward. No fever, chillness, chocking or agitation were noted.
    • Under the relative stable condition, the patient may be discharged and followed up at OPD for her clinical condition.
  • Discharge prescription
    • Relinide (repaglinide 1mg) 1# TIDAC15
    • Nexium (esopeprazole 40mg) 1# QDAC
    • Genurso (ursodeoxycholic acid 100mg) 1# BID
    • Emetrol (domperidone 10mg) 1# BIDAC
    • Glimet (glimepiride 2mg, metformin 500mg) 1# QDAC

==========

2024-04-22

[hormone receptor positive breast cancer and potential lung mets]

The patient has been diagnosed with a non-special type invasive carcinoma in the right breast, showing positive hormone receptors for both ER and PR through immunohistochemistry, and negative for HER2.

Recent CT scans have identified a suspected primary lung cancer or mets in the left lower lobe, with enlarged mediastinal lymph nodes that might also represent metastatic involvement. A lung biopsy consultation has been arranged.

Lab results as of 2024-04-21 were largely within normal ranges, and a review of the HIS5 and PharmaCloud databases has revealed no discrepancies in medication management to date.

700811991

240422

[lab data]

• 2022-09-09 Anti-HBc Reactive
  
• 2022-09-09 Anti-HBc-Value 4.74 S/CO
  
• 2022-09-09 Anti-HBs 8.30 mIU/mL
  
• 2022-08-25 HBsAg Negative
  
• 2022-08-25 HBsAg Value 0.538
  
• 2022-08-25 Anti-HCV Negative
  
• 2022-08-25 Anti-HCV Value 0.0352

[exam findings]

• 2022-09-16 CXR
  • Multiple nodules at bil. lungs.
• 2022-08-30 All-RAS + BRAF mutations assay
  • All-RAS mutations assay
    • Detection range
      • KRAS codon 12, 13, 59, 61, 117, 146
      • NRAS codon 12, 13, 59, 61, 117, 146
    • Results
      • Detected (KRAS codon 12 GGT>GTT, p.G12V)
    • Interpretation
      • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • BRAF mutations assay
    • Detection range
      • BRAF codon 600
    • Results
      • There was no variant detected in the BRAF gene.
    • Interpretation
      • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
• 2022-08-28 Standing KUB
  • Degeneration and spondylosis of L-S spine.
• 2022-08-25 Patho - colon segmental resection for tumor
  • Diagnosis:
    • Intestine, large, sigmoid colon, left hemicolectomy — Moderately differentiated adenocarcinoma
    • Proximal anastomosis: Negative for malignancy
      
    • Distal anastomosis: Negative for malignancy
      
    • Lymph node, regiona, dissection — Metastatic adenocarcinoma (4/18)
    • AJCC 8th edition pathology stage: T3N2a( cM1); AJCC stage IVA, at least
  • Gross Description:
    • Procedure: Left hemicolectomy
    • Tumor Site: Sigmoid colon
    • Tumor Size: 4.8x 3.5 cm.
      
    • Macroscopic Tumor Perforation: Not identified
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
    • Margins:
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Present
        
      • Perineural Invasion: Not identified
      • Tumor Budding:
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
        • Intermediate score (5-9)
    • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
    • Tumor Deposits: Not identified
      • Specify number of deposits: N/A
    • Regional Lymph Nodes
      • Number of Lymph Nodes Involved/Examined: 4 / 18, with extranodal extension
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition):
      • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
      • Primary Tumor (pT):
        • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
      • Regional Lymph Nodes (pN):
        • pN2a: Four to six regional lymph nodes are positive
      • Distant Metastasis (pM):
        • N/A
• 2022-08-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 33) / 108 = 69.44%
    • M-mode (Teichholz) = 69
  • Conclusion
    • Normal LV systolic function with normal wall motion.
    • LV diastolic dysfunction Gr 2.
    • Normal RV systolic function.
    • Mild MR; mild TR; aortic valve sclerosis.
• 2022-08-23 Flow Volume Curve
  • Mild obstructive pulmonary function impairment
• 2022-08-22 CXR
  • Multiple nodules at bil. lungs.
• 2022-08-22 CT - abdomen
  • History
    • 73 y/o 2022-07-17 abdominal pain off and on for a period of time
    • PI : diarrhea (-) constipation (-) BW loss (-) appetite : good, relieving factor (-)
    • PHx : HTN (+) DM (+) Op. (+) prostate hypertrophy CAD s/p stenting
  • Imp
    • Suspected colon cancer at rectosigmoid colon with lung meta and regional lymph nodes
  • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value)
• 2022-08-11 Patho - colon biopsy
  • R-S junction, 20 cm AAV, biopsy — Adenocarcinoma, moderately differentiated
  • The sections show adenocarcinoma, moderately differentiated, composed of columnar neoplastic cells, arranged in glandular, cribriform, and papillary patterns with desmoplastic stromal reaction.
  • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
• 2022-08-10 Colonoscopy
  • Suspected colon cancer, 20cm AAV, s/p biopsy
  • Internal hemorrhoid

[immunochemotherapy]

• 2022-09-26 - irinotecan 120mg/m2 150mg 90min + leuocovrin 300mg/m2 450mg 2hr + fluorouracil 2400mg/m2 3700mg 46hr

==========

2024-04-22

[initial experiences with reduced-dose Stivarga in clinical setting]

The patient has been undergoing treatment with Stivarga (regorafenib) for metastatic colorectal cancer since 2024-04-18, following a conservative initial dosing strategy of 80 mg daily.

On 2024-04-21, the patient’s lab serum glucose level was recorded at 306 mg/dL. Subsequent measurements taken from the TPR panel on 2024-04-22 morning indicated glucose levels between 131 and 148 mg/dL, suggesting that glucose levels are currently managed.

No discrepancies have been identified in the patient’s medication regimen as per the latest reviews.

2022-09-27

Pathology performed in late August 2022 revealed the disease to be characterized by pMMR, EGFR(+), KRAS codon 12 mutations, without BRAF mutations.

• pMMR => it would be less prominent in the effect of pembrolizumab or nivolumab +- ipilimumab.
• mutated RAS => the effect of anti-EGFR antibody treatment (e.g., panitumumab, cetuximab) might be mitigated.
• lack of BRAF codon 600 mutatation => encorafenib might not be the choice.

The blood pressure appears to be under control (with bisoprolol and nicorandil); however, the blood sugar appears to be a little higher (with metformin and vildagliptin). The addition of a hypoglycemic agent is not urgently required yet.

701394185

240422

[exam findings]

• 2024-03-26 Anoscopy

  • DRE/anoscopy: mixed hemorrhoids with thrombus

• 2024-03-11, -03-06 KUB

  • Hepatomegaly is noted. Please correlate with CT.
  • Fecal material store in the colon.

• 2024-03-11 CXR erect

  • S/P port-A implantation.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?

• 2024-03-11 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 22) / 91 = 75.82%
    • LVEF (%) = 76
    • M-mode (Teichholz) = 76
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR.

• 2024-03-06 All-RAS + BRAF mutation

  • Cellblock No. S2024-03615 A1
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 12 GGT>TGT, p.G12C)
    • BRAF: There was no variant detect in the BRAF gene.

• 2024-02-26 Patho - urinary bladder TUR

  • Urianry bladder, “bladder tumor”, TURBT — Compatible with metastatic colonic adenocarcinoma
  • The specimen submitted consists of multiple small pieces of gray-white soft tissue, labeled “bladder tumor”, measuring up to 1.8 x 0.4 x 0.3 cm and weighing 9.8 gm. All for sections as: A1-A3.
  • The sections show following features:
    • Histologic type: Compatible with metastatic colorectal adenocarcinoma
    • Histologic grade: Moderately differentiated
    • Tumor configuration: Papillary and solid
    • Muscularis propria: Present
    • Lymphovascular invasion: Not identified
    • IHC: CK7(-), CK20(+), CDX2(+), Beta-catenin(cytoplasmic staining only)

• 2024-02-07 CT - abdomen

  • Indication: Adenocarcinoma of sigmoid colon with perforation and left ovarian abscess, pT4bN1bM1c stage IVC, S/P Harman procedure + small bowel segmental resection + partial bilateral salpingo-oophorectomy on 2022/06/09
  • Findings:
    • Prior CT identified liver metastases in both hepatic lobes are noted again, increasing in size and number that is c/w liver metastases with progressive disease.
    • Prior CT identified para-aortic and mesentery lymph nodes are noted again, stationary.
    • S/P LAR with autosuture retention over the rectum.
      • s/p closure of the descending colostomy.
    • There is minimal ascites.
    • The urinary bladder shows diffuse mild wall thickening and S/P Foley’s catheter insertion.
  • Impression:
    • Multiple liver metastases show progressive disease.

• 2024-02-06 Patho - urinary bladder biopsy

  • Urinary bladder, biopsy — intestinal metaplasia
  • Section shows fragments of mucosa with mildly dysplastic columnar epithelial cells. No definite stromal invasion is found.
  • The immunohistochemical stains reveal CK7(-), CK20(+), and CDX2(-).
  • Please correlate with the clinical presentation. If malignancy is suspected, re-biopsy is suggested.

• 2024-02-06 Cystoscopy

  • R/O bladder tumor

• 2024-02-01 SONO - nephrology

  • Parenchymal renal disease.
  • Massive liver tumor.
  • Bladder mass lesion, r/o blood clot , r/o bladder tumor.

• 2023-12-03 SONO - gynecology

  • IMP:
    • EM: 9.6mm, suspect hydrometra
    • Uterine myomas

• 2023-08-19 CT - abdomen

  • Indication: Adenocarcinoma of sigmoid colon with perforation and left ovarian abscess, pT4bN1bM1c stage IVC
  • With and without contrast enhancement CT of abdomen shows:
    • Sigmoid colon CA, s/p operation. s/p descending colostomy.
    • Mild regression of liver metastasis.
    • Mild regression of para-aortic and mesentery lymph nodes.
    • A mass lesion, 2.3cm, in isthmus of thyroid gland.
  • Impression
    • Sigmoid colon CA, s/p operation
    • Liver and lymph node metastasis, mild in regression

• 2023-05-11 CT - abdomen

  • History and indication:
    • Adenocarcinoma of sigmoid colon with perforation and left ovarian abscess, pT4bN1bM1c stage IVC, status post Harman procedure + small bowel segmental resection + partial bilateral salpingo-oophorectomy on 2022/06/09
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon operation. Some LNs (up to 0.9cm) in retroperitoneum and bil. inguinal regions.
    • Mild regression of liver metastases. Bil. liver cysts (up to 1.5cm).
    • A cyst (1.6cm) at uterus.
  • IMP:
    • S/P colon operation. Some LNs (up to 0.9cm) in retroperitoneum and bil. inguinal regions (stable).
    • Mild regression of liver metastases.

• ….-..-..

• 2022-06-10 Patho - colon segmental resection for tumor

  • PATHOLOGIC DIAGNOSIS
    • A
      • Large intestine, sigmoid colon, Hartmann procedure —- Adenocarcinoma, moderately differentiated
        
    • B
      • Small intestine, ileum, segmental resection —- Adenocarcinoma, by direct invasion with colo-ileal fistula formation
    • C
      • Ovary, right, oophorectomy —- Mature cystic teratoma
      • Fallopian tube, right, salpingectomy —- Negative for malignancy
      • Soft tissue, right adnexal, excision —- Abscess formation with tumor seeding, no left ovary or fallopian tube is seen
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection —- Adenocarcinoma, metastatic (3/19)
    • Lymph node, IMA / SMA, dissection —- Not received
    • AJCC 8th edition Pathology stage: pStage IVC, pT4bN1bM1c
  • MACROSCOPIC EXAMINATION
    • Operation procedure: Hartmann procedure, small intestine segmental resection, bilateral salpingo-oophorectomy
      
    • Specimen site: A: sigmoid colon; B: Small intestine; C: right ovary and fallopian tube
      
    • Specimen size: A: sigmoid colon: 17.5 cm, Omentum: 7.5 x 3.0 x 1.3 cm, Peritoneum: 3.0 x 3.2 cm; B: Small intestine: 25.6 cm; C: right ovary: 8.5 x 5.5 x 4.0 cm, fallopian tube: 5.0 x 0.5 cm, and adnexal soft tissue: 2.5 x 1.5 x 1.1 cm
      
    • Tumor size:
      • A: sigmoid colon: 7.0 x 6.0 x 2.2 cm with perforation and acute inflammatory exudate coating on serosa
      • B: Small intestine: perforation, 3.0 x 2.5 cm, tumor 1.0 x 0.8 cm, with acute inflammatory exudate coating on serosa
      • C: Tumor seeding: 0.5 x 0.4 cm; Right ovary: 8.5 x 5.5 x 4.0 cm; Cystic with hair and yellow friable tissue
    • Tumor location:
      • A: sigmoid colon: 8.0 cm and 4.0 cm away from the two resection margins, respectively
      • B: Small intestine: 14.6 cm and 6.5 cm away from the two resection margins, respectively
    • Depth of invasion grossly: invasion to small intestin and colo-ileal fistula formation
    • Mucosa elsewhere: congestion
    • Representative sections are taken and labeled as: A1-2: bilateral resection margin, colon; A3: colon, non-tumor; A4: omentum; A5: tumor with peritoneum; A6: tumor with omentum; A7-9: tumor; A10-13: lymph node, mesocolic; B1-2: bilateral resection margin, small intestine; B3: small intestine, non-tumor; B4-7: tumor with perforation; C1-3: right fallopian tube; C4-8: right ovary; C9-11: right adnexal soft tissue.
  • MICROSCOPIC EXAMINATION
    • Histology: adenocarcinoma
    • Histology Grade: moderately differentiated
    • Depth of invasion: invasion to small intestine and colo-ileal fistula formation
    • Angiolymphatic invasion: Present.
      
    • Perineural invasion: Present.
      
    • Discontinuous extramural tumor extension: Not identified.
    • Serosal margin status of colon: Involved
      
    • Lymph node metastasis, mesocolic: 3/19
    • Lymph node metastasis, IMA / SMA: Not received
    • Extranodal involvement: Not identified.
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): pT4b: Tumor directly invades or adheres to adjacent organs or structures
      • Regional Lymph Nodes (pN): pN1b: Two or three regional lymph nodes are positive
      • Distant Metastasis (pM): pM1c: Metastasis to the peritoneal surface is identified alone or with other site or organ metastases (seeding on right adnexal serosa)
    • Type of polyp in which invasive carcinoma arose: Not identified
    • Additional pathologic findings:
      • The immunohistochemical stains reveal EGFR(+), PMS2(-), MLH1(-), MSH2(+), and MSH6(+).
      • Tumor Budding: Low score (0-4)
      • The right ovary reveals a cystic teratoma lined by squamous and bronchial epithelium with skin appendages. The left ovary and fallopian tube are not found. Abscess formation and tumor seeding are seen in adnexal soft tissue.
      • Acute inflammatory exudate coating on serosa of colon, small intestine, right ovary and fallopian tube is seen.
    • TNM descriptors: unknown
      
    • Tumor regression grading S/P CCRT: patient not received

[MedRec]

• 2023-11-01, -08-10 SOAP Hemato-Oncology He JingLiang
  • Prescription x3
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2023-04-26 SOAP Hemato-Oncology Wan XiangLin
  • Prescription x3
    • Allegra (fexofenadine 60mg) 1# BID
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • ZnO ointment (zinc oxide 200mg/g) BID TOPI
    • Nexium (esomeprazole 40mg) 1# QDAC
• 2023-02-14, 2022-11-22, -09-05 SOAP Hemato-Oncology Zhang ShouYi
  • Prescription x3
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2022-08-08 SOAP Hemato-Oncology Zhang ShouYi
  • S
    • will do HBsAg, anti-HBc, anti-HCV (8/8 22).
    • will consult Dr Wu ChaoQun for Port-A installation (8/8 22).
    • will give #1 palliative C/T wt FOLFIRI / Avastin IV Q2W x 12.
    • will apply Avastin (8/8 22).
    • Adm on 8/15 22 for #1 palliative C/T wt FOLFIRI / Avastin IV Q2W x 12.
  • A
    • Adenocarcinoma of sigmoid colon wt perforation & L ovarian abscess, pT4bN1bM1c stage IVC, s/p Op on 6/9 22
  • Prescription
    • Megejohn (megestrol acetate 160mg) 1# QD
• 2022-06-09 ~ 2022-07-28 POMR General and Gastrointestinal Surgery Wu ChaoQun
  • Discharge diagnosis
    • Adenocarcinoma of sigmoid colon with perforation and left ovarian abscess, pT4bN1bM1c stage IVC, status post Harman procedure + small bowel segmental resection + partial bilateral salpingo-oophorectomy on 2022/06/09; remove previous artifical fascia and closed the abdominal wall and End colostomy revision on 2022/06/16. ECOG:2
    • Adenocarcinoma of sigmoid colon with perforation with septic shock
    • Intraabdomen leakage with skin fistula with intaabdomen infection (CRPA + Stenotroph. maltophilia + Candida)
    • Intraabdomen abscess status post sono-guide with pig-tail drainage on 2022/07/14
    • Hypokalemia
    • Hypophosphatemia (2022/07/18 P:1.0)
    • Hypoalbuminemia
  • CC
    • abdominal distension for half year, bloody stool for a period of time. She felt general weakness and shortness of breath today.
  • Present illness
    • The 49 years old female patient denied any systemic disease, such as hypertension or diabetes mellitus. This time, she presented to our ER for medical attention due to abdominal distension for half year, bloody stool for a period of time. She felt general weakness and shortness of breath today.
  • Course of inpatient treatment
    • At ER, her initial GCS remained E4V5M6, vital signs TPR: 37.1/140/16, BP: 88/49 mmHg. The physical examination showed cold sweating. Abdomen CT revealed extensive peritonitis with hallow viscus perforation, right ovarian teratoma. We gave IVF challenge 3000 ml for hypotension. She was admitted for received emergent Harman procedure, small bowel segmental resection and partial bilateral BSO due to Sigmoid colon tumor with perforation and left ovarian abscess, colo-ileal fistal, right ovarian tumor on 6/9~6/10. After operation, she was transferred to SICU for post-op inetensive care on 2022/06/10.
    • After operation, Levophed and Dopamin for hemodynamic support and antibiotics with vancomycin and Doripenem, SABS. The intraabdomina abscess culture yield E-coli, group F streptococci and P.a. The wound pus culture yield Bacteroides fragilis and sputum culture showed Candida, so antibiotic with Doripenem, Cravit, and Eraxis.
    • We tried NG feeding since 6/20 smoothly. However, elevation CRP and leukocytosis, fever was noted, add SABS for infection control. Due to right pleural effusion, pigtail was insertion. Smoothly extubation after well weaning profile and on BIPAPuse on 6/20. However, stool leakage from lapa wound on 6/24. Reintubation due to respiratory failure on 6/25. Infection doctor was consultion for antibiotic, he suggest shift to DC SABS and cravit, add Targocid and Finibax use. Because abdomen wound high output dischage, VAC suction was done with drainage turbid bile mix stool dischage, amount 200~250ml/day. Laboratory data improved then start try weaning ventilator and extubation on 7/06. However, shallow of breathing and anxity after extubation, under Bi-PAP support and sedation with Utapine + Xanax use. Abdomen wound shift to ostomy bag cover.
    • This week, the pulmonary condition became improved, try weaning Bi-PAP was done, Pulmonary rehabilitation with Aero-Bika and Triflow training. Unfortunately, Spinking fever (>39.5’C) persist everyday. Fever workup with B/C, S/C TB/C(Nagative) and CVP tip/C and removal Foley (PCT>22) was done. Antibiotic with Vancomycin + Erasix + Doripenem use. Try to oral intake with clear liquid diet on 7/12, Abdominal wound with ostomy bag cover, drainage bile and mix stool 50~100ml/day. We arrange Abdominal CT with/without contrast for abdominal condition evaluation on 7/14, it revealed 1. Some fluid collection in peritoneal cavity. Some LNs (up to 1.2cm) in retroperitoneum. 2. Bil. pleural effusion with adjacent lung collapse. We consulted Radiology for on abdominal pig-tail for drainage abdomen fluid on 7/14~7/17 (Fluid clear). IPPB training for lung collapse. after the fever condiotion subside. After laboratory data revealed improved and hemodynamic condition improved, she was transfer to our GS ward on 7/20.
    • In GS ward, we observed patient recovery and keep empiric antibiotic, stool softener, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed. She try to introduced soft diet with step by step and was tolerate well. However, mild fever was noted and suspected of exposure to COVID-19. Isolated was done since 7/24 and we recheck PCR and fast-screening showed negative both. So we kept triflow training and chest care support for lung physiotherapy. Her generally well beings and relativley stable. Abdomen wound with turbid discharge was decreaing and wound is healing. Final wound culture showed Stenotroph and CRPA, so antibiotic shift to oral Cifipne + Cravit support since 7/27. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Under improved general condition, she was allowed to discharge today and OPD follow up was arranged.
  • Discharge prescription
    • Cardiolol (propranolol 10mg) 1# TID
    • Ceficin (cefixime 100mg) 2# Q12H
    • Cravit (levofloxacin 500mg) 1.5# QDAC
    • MgO 250mg 1# TID
    • Ulstop (famotidine 20mg) 1# BID
    • Through (sennoside 12mg) 1# HS

[consultation]

• 2024-02-27 Colorectal Surgery
  • Q
    • A 51 years old woman has sigmoid colon cancer with liver and lymphatic metastasis, pT4bN1bM1c stage IVC, s/p FOLFIRI/ Avastin.
    • She was admitted in our Infection ward due to hematuria and the urinalysis: showed hematuria and pyuria, a renal echo showed 6.5cm mass lesion in the urinary bladder, which suspected blood clot or bladder tumor.
    • The nephrologists thought it looks more like a blood clot, and received bladder irrigation until now.
    • Follow-up abdomen CT revealed multiple liver metastases show progressive disease, s/p FOLFOX (C1D1) on 2024/02/19-02/21.
    • She suffered from dark blood noted from fistula wound since 2024/02/25 until now. So we need your help, thanks a lot!!
  • A
    • Past op hostpry:
      • Adenocarcinoma of sigmoid colon with perforation and left ovarian abscess, pT4bN1bM1c stage IVC, status post Harman procedure + small bowel segmental resection + partial bilateral salpingo-oophorectomy on 2022/06/09; remove previous artifical fascia and closed the abdominal wall and End colostomy revision on 2022/06/16. s/p palliative chemotherapy with FOLFIRI/ Avastin on 2022/08~
      • TURBT + blood clot evacuation on 2024-02-23
      • 2024-02-07: CT:
        • Prior CT identified liver metastases in both hepatic lobes are noted again, increasing in size and number that is c/w liver metastases with progressive disease.
        • Prior CT identified para-aortic and mesentery lymph nodes are noted again, stationary.
        • S/P LAR with autosuture retention over the rectum.
        • closure of the descending colostomy.
        • There is minimal ascites.
        • The urinary bladder shows diffuse mild wall thickening and S/P Foley’s catheter insertion.
      • PE:
        • Abdomen: soft, no distended, no tenderness, no muscle guarding, no peritoneal signs
      • Colostomy: some green formed stool passage
        • Enterocutaneous fistula at low abdomen (+) with ostomy bag cover: some blood passage
        • No fever, no leukocytosis
        • Foley catheter: gross clear urine
    • A:
      • Enterocutaneous fistula at low abdomen with some blood passage
    • P:
      • An enterocutaneous fistula formation without intraperitoneal contamination is favor, thus, no urgent surgury is needed at present
      • Transamine use or blood transfusion if needed, conisder CT-angiography if GI bleeding got worse
      • Inform colostomy NP for care
      • We would like to follow this patient and inform us if any problem
• 2024-02-22 Urology
  • Q
    • Dut to many blood clots noted via foley tube, continue irrigation, and change the Foley tube 20G, still obstruction due to blood clots. So we need your help, thanks a lot!!
  • A
    • Despite bedside irrigation, blood clots evacuation may be arrnaged on 02/23
    • please keep midnight NPO
  • A 2024-02-24 07:26:40
    • 02/23 found bladder tumor with bleeding
    • hard to tell it is endometriosis, colon cancer or bladder cancer. pending pathology report
• 2024-02-06 Urology
  • Q
    • For bladder mass lession
    • A 51 years old woman has sigmoid colon cancer with liver and lymphatic metastasis, pT4bN1bM1c stage IVC, and received chemotherapy of FOLFIRI plus Avastin in your department, she was admitted in our Infection ward due to hematuria and the urinalysis: showed hematuria and pyuria,a renal echo showed 6.5cm mass lesion in the urinary bladder, which suspected blood clot or bladder tumor.
    • The nephrologists thought it looks more like a blood clot, bladder irrigation was arranged.
    • The oncology suggest arranged Abdominal CT and consult GU for evaluation.Thanks!
  • A
    • CYSTSOCOPY and biopsy was made today.
    • Cystoscopic finding: bladder tumor, favor colon cancar with bladder invasion.
    • Please keep bladder irrigation and transamin use.
    • And contact with Oncologist about further treatment managment after the report of biopsy
• 2024-02-02 Hemato-Oncology
  • Q
    • A 51 years old woman has sigmoid colon cancer with liver and lymphatic metastasis, pT4bN1bM1c stage IVC, and received chemotherapy of FOLFIRI plus Avastin in your department, she was admitted in our Infection ward due to hematuria and the urinalysis: showed hematuria and pyuria,a renal echo showed 6.5cm mass lesion in the urinary bladder, which suspected blood clot or bladder tumor.
    • The nephrologists thought it looks more like a blood clot, bladder irrigation was arranged.
    • She is worried that the cancer has metastasized to bladder and wants to discuss future chemotherapy plans with you. Please help her, thank you.
  • A
    • This 51-year-old woman is a case of:
      • Adenocarcinoma of the sigmoid colon with perforation and a left ovarian abscess with tumor seeding, pT4bN1bM1c stage IVC.
        • He underwent the Harman procedure, small bowel segmental resection, and partial bilateral salpingo-oophorectomy on 2022/06/09.
        • Postoperatively, he received palliative chemotherapy with FOLFIRI/Avastin from 2022/08.
      • Viral hepatitis B without hepatic coma, Anti-HBc: positive.
      • History of COVID-19 infection.
    • This time, he was admitted due to UTI. Renal echo shows a 6.5cm mass lesion noted in the urinary bladder. Blood clot or bladder tumor should be ruled out.
    • Please arrange an abdominal CT (+/- contrast). Consult a GU doctor for further evaluation. Keep antibiotic for UTI. Arrange our OPD after discharge.
• 2023-12-03 Obstetrics and Gynecology
  • Q
    • Hematuria > Abnormal coagulation - moderate or mild bleeding. This patient started to resolve hematuria yesterday.
    • denied dysuria, denied micturion pain
    • PH
      • Adenocarcinoma of sigmoid colon with perforation and left ovarian abscess, pT4bN1bM1c stage IVC, status post Harman procedure + small bowel segmental resection + partial bilateral salpingo-oophorectomy on 2022/06/09
      • Unspecified viral hepatitis B without hepatic coma, Anti-HBc: postive
    • For recheck, S/P abdominal C.T
    • S/P C12 chemotherapy with Avastin + FOLFIRI
  • A
    • This is a 51 y/o, P1 woman with advanced sigmoid colon cancer s/p 20 cycles of palliative chemotherapy. According to the patient, her menstrual cycle has become irregular since she started to receive chemotherapy. She noticed active bleeding with blood clots during urination last night, and was uncertain if it was hematuria or vaginal bleeding. Hence, she visited the ER. We were consulted for evaluation.
    • CC
      • Bleeding noted during urination for one day.
    • ObGyn history
      • P1
      • LMP: 2023/10 or 11?
      • s/p partial BSO in 2022/06
      • history of chocolate cyst
    • PV
      • very scanty pinkish discharge
      • no cervical lifting tenderness
    • Sono
      • Uterus: RvF, 74 X 55 mm
      • EM: 9.6mm with suspected hydrometra
      • Uterine myomas: M1 9 X 8 mm, M2 20 X 13 mm
      • ROV: 25 X 18 mm
      • LAD: free
      • CDS: no fluid
    • Impression
      • EM: 9.6mm with suspected hydrometra
      • Uterine myomas: M1 9 X 8 mm, M2 20 X 13 mm
    • Suggestion
      • Please check U/A and evaluate other possible causes for bleeding.
      • Well explanation to the patient: vaginal bleeding is not prominent.
      • Suggest OPD f/u for uterine myomas.
      • Thank you for your consultation. Please feel free to contact us if further GYN findings are noted.

[immunochemotherapy]

• 2024-04-19 - oxaliplatin 85mg/m2 95mg D5W 250mL 2hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3100mg NS 500mL 46hr (FOLFOX 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-04 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-19 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3980mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-14 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4160mg NS 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.25mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-16 - (Avastin + FOLFIRI)
• 2023-09-06 - (Avastin + FOLFIRI)
• 2023-08-17 - (Avastin + FOLFIRI)
• 2023-07-31 - (Avastin + FOLFIRI)
• 2023-06-27 - (Avastin + FOLFIRI)
• 2023-06-05 - (Avastin + FOLFIRI)
• 2023-04-20 - (Avastin + FOLFIRI)
• 2023-03-29 - (Avastin + FOLFIRI)
• 2023-03-13 - (Avastin + FOLFIRI)
• 2023-02-22 - (Avastin + FOLFIRI)
• 2023-02-02 - (Avastin + FOLFIRI)
• 2023-01-13 - (Avastin + FOLFIRI)
• 2022-12-23 - (Avastin + FOLFIRI)
• 2022-12-09 - (Avastin + FOLFIRI)
• 2022-11-24 - (Avastin + FOLFIRI)
• 2022-11-07 - (Avastin + FOLFIRI)
• 2022-10-21 - (Avastin + FOLFIRI)
• 2022-08-29 - (FOLFIRI)

==========

2024-04-22

[liver function abnormalities - FOLFOX dose reduction - consider liver mets]

This patient has exhibited significantly elevated AST and bilirubin levels, with slightly elevated ALT but normal direct to total bilirubin ratios.

It is possible that liver mets are the primary cause of these abnormalities.

FOLFOX is generally not considered heavily hepatotoxic as the metabolism of oxaliplatin is nonenzymatic, occurring rapidly and extensively. And for fluorouracil, the manufacturer’s labeling does not suggest dosage adjustments for severe impairment, it has been recommended not to use under these conditions (“Lancet Oncol. 2019;20(4):e200-e207” and “Semin Oncol. 2006;33(1):50-67”).

The dose of FOLFOX was further reduced to 80% at the last administration on 2024-04-19.

• 2024-04-22 ALT 51 U/L

• 2024-04-22 AST 398 U/L

• 2024-04-19 AST 328 U/L

• 2024-04-17 AST 313 U/L

• 2024-04-15 AST 349 U/L

• 2024-04-11 AST 333 U/L

• 2024-04-08 AST 330 U/L

• 2024-04-02 AST 321 U/L

• 2024-04-01 AST 313 U/L

• 2024-04-22 Bilirubin total 1.56 mg/dL

• 2024-04-19 Bilirubin total 1.77 mg/dL

• 2024-04-17 Bilirubin total 1.76 mg/dL

• 2024-04-15 Bilirubin total 1.51 mg/dL

• 2024-04-11 Bilirubin total 1.38 mg/dL

• 2024-04-08 Bilirubin total 1.03 mg/dL

• 2024-04-02 Bilirubin total 1.43 mg/dL

• 2024-04-01 Bilirubin total 1.07 mg/dL

• 2024-04-22 Bilirubin direct 0.81 mg/dL

• 2024-04-19 Bilirubin direct 0.93 mg/dL

• 2024-04-17 Bilirubin direct 0.95 mg/dL

• 2024-04-15 Bilirubin direct 0.75 mg/dL

• 2024-04-11 Bilirubin direct 0.71 mg/dL

• 2024-04-08 Bilirubin direct 0.49 mg/dL

• 2024-04-02 Bilirubin direct 0.83 mg/dL

• 2024-04-01 Bilirubin direct 0.56 mg/dL

2024-04-02

[medication regimen addressing fever, bilirubin levels, and low albumin]

Sintrix (ceftriaxone) is being administered for fever and chills, while Uliden (ursodeoxycholic acid) and BaoGan (silymarin) are addressing elevated direct bilirubin (DBI/TBI 52%) and AST levels (321 U/L). Albumin supplementation is in place for hypoalbuminemia, with levels at 3.0g/dL. A review of the medication regimen shows no discrepancies.

2024-02-21

[evaluating liver function in the context of metastatic disease]

A CT scan conducted on 2024-02-07 revealed multiple liver metastases indicative of progressive disease. Consequently, the treatment regimen was transitioned to FOLFOX from Avastin + FOLFIRI, the latter having been administered since the third quarter of 2022.

Abnormal LFT results may reflect the metastatic burden. Both Baraclude and GaoGan are currently being administered, with no discrepancies found in the medication regimen.

• 2024-02-19 AST 100 U/L
  
• 2024-02-19 ALT 42 U/L
  
• 2024-02-19 Bilirubin total 1.16 mg/dL
  
• 2024-02-19 Bilirubin direct 0.56 mg/dL
  
• 2024-02-19 Alkaline phosphatase 432 U/L

700554360

240419

[exam findings]

• 2024-03-20 Tc-99m MDP bone scan
  • Several hot/faint hot spots in both rib cages and increased activity at the right S-I joint, cancer with bone metastasis should be considered, suggesting biopsy (the lesion at the right S-I joint) for investigation.
  • Increased activity at the L4-5 spines, the nature is to be determined (post-traumatic change, severe DJD, or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, some T-spine, left knee, and feet.
• 2024-03-16 CT - chest
  • Indication: postmenopausal advanced breast carcinoma, Rt with heavily LN metastases post Rt simple mastectomy plus ALND on 2023/11/09, pT2(2)N3aM0, stage IIIc, post EC chemotherapy
  • Chest CT with and without IV contrast ehnancement shows:
    • S/p port-A placement with its tip at Superior vena cava
    • Minimal infiltration at right upper lobe is found. (Se302 Im88).
    • Calcified coronary arteries is found.
    • S/P mastectomy at right side.
    • Small lymph nodes are found at paraaortic region is found.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
  • Imp:
    • Right breast cancer s/p MRM with minimal infiltration at right upper lobe and bone meta.
• 2024-03-12 SONO - abdomen
  • Fatty liver, moderate
  • Renal cyst, left kidney
• 2024-02-15 KUB + L-spine Lat
  • K.U.B. and lateral views of lumbar spine show:
    • disc space narrowing at L4-5 level and marginal spurs of vertebral bodies at L2-L5 levels due to spondylosis, L-spine.
    • loss of natural lordosis
• 2023-12-06 PET
  • Increased FDG uptake in the right breast, compatible with the right breast cancer s/p surgical reaction.
    
  • Increased FDG uptake in the left breast, the nature is to be determined (benign tumor or other nature ?), suggesting breast sonogram for follow-up.
    
  • Increased FDG uptake in lymph nodes of bilateral neck regions, probably reactive nodes, suggesting follow-up.
    
  • Increased FDG uptake in enlarged lymph nodes at paracaval and para-aortic regions of retroperitoneum, the nature is to be determined also (inflammation/infection process, lymphoma or other nature ?), suggesting biopsy for investigation.
    
  • The right pleural effusion and at the L3 spine lesion shown on the previous chest CT reveal no increased FDG uptake, indicating no evidence of malignancy by this F-18 FDG PET scan.
    
  • Increased FDG uptake at the left shoulder, probably benign in nature.
  • No abnormally increased FDG uptake is evidently delineated elsewhere.
• 2023-12-05 CT - chest
  • Indication: A newly diagnosed postmenopausal advanced breast carcinoma, Rt with heavily LN metastases post Rt simple mastectomy plus ALND on 2023/11/09, pT2(2)N3aM0, stage IIIc, T 4.2 cm, and 3.4 cm, Gr 2, LN (18/18), LVI (+), PNI (+), ER (60%), PR (40%), Her-2: ++ FISH (-), Ki-67:10%. at Taipei City Hospital FuYou Branch
  • Chest and upper abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • small Rt pleural effusion with thickening of parietal pleura.
    • Mediastinum and hila: abnormal soft-tissue at Rt cardiophrenic angel, 23mm.
    • Chest wall and visible lower neck: large region of skin thickening and underlying thick and well-defined homogeneous low attenuation area in the Rt anterior chest wall. no enlarged LN.
    • Visible abdominal contents: extensive enlarged lymph nodes at paracaval and para-aortic regions of retroperitoneum.
    • Visualized bones: a focal blastic change in L3 and L4 vertebral bodies.
  • ImP:
    • post treatment change at Rt anterior chest wall. -small Rt pleural effusion, exudative. Rt cardiophrenic angle and retroperitoneal lymphadenopathy. a focal blastic change in L3 and L4 vertebral bodies.
• 2018-05-07 Knee RT standing
  • Knee Rt standing AP and Lat views:
    • Narrowing of the medial compartment of femorotibial joint
    • Ahlback calcification: grade 2
• 2018-05-07 Knee LT standing
  • Knee Lt standing AP and Lat views:
    • Moderate to severe osteoarthritis of left knee with varus configuration
    • Ahlback calcification: grade 3-4
• 2018-05-07 Merchant view
  • Merchant view (patella 45 0) Bil :
    • No lateral subluxation or lateral tilting of the patella
    • Enthesopathy and spur formation of the patella

[chemotherapy]

• 2024-04-19 - docetaxel 75mg/m2 120mg NS 250mL 3hr (D Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-03-29 - docetaxel 75mg/m2 120mg NS 250mL 3hr (D Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-02-27 - epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (EC(90) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-30 - epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (EC(90) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-09 - epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (EC(90) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-19 - epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (EC(90) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-04-19

700577504

240419

[MedRec]

• 2024-03-15 ~ 2024-03-19 POMR Chest Medicine Huang JunYao
  • Discharge diagnosis
    • Right lower lobe lung cancer (adenocarcinoma) with bone metastases, cT4N3M1C, stage IVB with bone meta, ECOG 1
    • Encounter for antineoplastic immunotherapy
    • Encounter for antineoplastic chemotherapy
    • Chronic viral hepatitis B without delta-agent
    • Chronic rhinitis
    • Insomnia
    • Other specified hypothyroidism
  • CC
    • Admission on 20240311 for C60 Alimta 700mg, C29-4 Nivo 100 (charge), C41-4 Cyramza 400mg (4 vila charge), CEA, Hold C6-3 Ipi 50mg free charge,
  • Present illness
    • This 66-yeAr-old woman is a case of
      • HBV
      • Chronic rhinitis
      • Hypothyroidism
      • Right lower lobe lung cancer (adenocarcinoma) with bone metastases, cT4N3M1a, stage IV, ECOG 1 was diagnosis on 2018/09/11, Iressa was prescribed for the management of lung cancer since 2018/09/26 and start C1 chemotherapy with Alimta and CDDP since 2018/10/04. Check NGS liquid for Garden 360 on 2022/07 and revealed PIK3CA, EGFR G322S.     - The chemotherapy regimen as below:
      • 1st chemotherapy with Alimta since 2018/04/10, C1 CDDP 2018/04/10 to C5 CDDP on 2019/03/27
      • added Avastin since 2019/06/26 and then shifted to Cyramza since 2019/12/04
      • added immunetherapy with Nivo since 2019/12/05 and then shifted to Keyturda since 2019/03/04,
      • and changed to double immumotherapy with Nivo plus Ipilmumab since since 2021/03/31 and 2021/04/01.
    • Track back her history, she suffered from cough with scanty sputum off and on over 1 month. Body weight loss 1.5kg in 1 month was noted. Then she visited our chest OPD. PE showed right neck LN(+).
    • CXR revealed 1). Extensive consolidation in Rt middle and lower lung zones with enlargement of hilum and Rt upper mediastinal widening due to advanced lung cancer with regional lymphadenopathy 2). Mild Rt pleural effusion 3). Borderline cardiomegaly.
    • Chest CT showed RLL lung cancer, T4N3M1a.
    • Bone scan was arranged on 2018/09/11 and showed 1) Three hot spits in the right rib cage and three faint hot spots in the left rib cage, respectively, lung cancer with both rib cages metastasis may be considered, suggesting further investigation (such as PET/CT scan) and follow-up with bone scan in 3 months. 2) Suspected benign lesions in the maxilla, L-spine, bilateral shoulders, elbows, wrists, knees, and ankles.
    • Pleural effusion Cytology showed Immunocytochemistry shows TTF-1(+), Napsin-A(+), CK7(+) and P40(-) for tumor cells, indicates a case of pulmonary adenocarcinoma.
    • Pleura, biopsy on 2018/09/13 revealed Negative for malignancy.
    • We prescribed Iressa for the treatment of lung cancer.
    • Consulted GI for the treatment HBV of before chemotherapy and use of entecavir with OPD follow-up were suggested.
    • Self paid Iressa was prescribed for the management of lung cancer since 2018/09/26.
    • Under the impression of Right lower lobe lung cancer (adenocarcinoma) with bone metastases, cT4N3M1a, stage IV, ECOG 1 was diagnosis on 2018/09/11, Iressa was prescribed for the management of lung cancer, she was admission on schdule for chemotherpay with C60 Alimta 700mg, C29-4 Nivo 100 (charge), C41-4 Cyramza 400mg (4 vila charge), CEA, Hold C6-3 Ipi 50mg free charge.
  • Course of inpatient treatment
    • After admission, under the normal ANC count, angiogenesis inhibitor with C41-4 Cyramza 400mg (charge) was smoothly given on 2024/03/15, chemotherapy with C60 Alimta 700mg added on 2024/03/16, immunetherapy with C29-4 Nivo 100 (charge) will given on 2024/03/18, the side effect with chemotherapy and immunotherpy close monitor.
    • Beside, lung cancer re-staging with Chest CT and Bone scan will be arrange on 2024/03/18 and 2024/03/19 for evaluation. The chest CT report showed stationary. After chemotherapy and immunotherapy, there were no fatigue or nausea or vomiting noted. Under the table conditions, she was discharge on 2024/03/19, CM OPD was arranged for future follow-up and report watching.
  • Discharge prescription
    • none

[immunochemotherapy]

• 2024-04-19 - Alimta (pemetrexed) 700mg NS 100mL 10min + Opdivo (nivolumab) 100mg NS 100mL 1hr

  • B-Red (hydroxocobalamin) 1mg IM

• 2024-04-18 - Cyranza (ramucirumab) 400mg NS 250mL 90min

  • dexamethasone 8mg + diphenhydramine 30mg + NS 250mL

• 2024-03-16 - Alimta (pemetrexed) 700mg NS 100mL 10min + Opdivo (nivolumab) 100mg NS 100mL 1hr D3

  • B-Red (hydroxocobalamin) 1mg IM

• 2024-03-15 - Cyranza (ramucirumab) 400mg NS 250mL 90min

  • dexamethasone 8mg + diphenhydramine 30mg + NS 250mL

• 2024-01-26 - Alimta (pemetrexed) 700mg NS 100mL 10min + Opdivo (nivolumab) 100mg NS 100mL 1hr

  • B-Red (hydroxocobalamin) 1mg IM

• 2024-01-25 - Cyranza (ramucirumab) 400mg NS 250mL 90min

  • dexamethasone 8mg + diphenhydramine 30mg + NS 250mL

• 2023-12-13 - Alimta (pemetrexed) 700mg NS 100mL 10min + Opdivo (nivolumab) 100mg NS 100mL 1hr D2

  • B-Red (hydroxocobalamin) 1mg IM

• 2023-12-12 - Cyranza (ramucirumab) 400mg NS 250mL 90min

  • dexamethasone 8mg + diphenhydramine 30mg + NS 250mL

• 2023-11-08 - Alimta (pemetrexed) 700mg NS 100mL 10min + Opdivo (nivolumab) 100mg NS 100mL 1hr D2

  • B-Red (hydroxocobalamin) 1mg IM

• 2023-11-07 - Cyranza (ramucirumab) 400mg NS 250mL 90min

  • dexamethasone 8mg + diphenhydramine 30mg + NS 250mL

• ….-..-..

• 2020-02-04 - Alimta (pemetrexed) 700mg NS 100mL 10min + Opdivo (nivolumab) 100mg NS 100mL 1hr D2

  • B-Red (hydroxocobalamin) 1mg IM + dexamethasone 4mg + NS 250mL

• 2020-02-03 - Cyranza (ramucirumab) 400mg NS 250mL 90min

  • dexamethasone 8mg + diphenhydramine 30mg + NS 250mL

==========

2024-04-19

[tracking HGB levels post immunochemotherapy]

This patient has been on a treatment regimen including ramucirumab (400mg), pemetrexed (700mg), and nivolumab (100mg) since 2020-02-03. Starting around Jul/Aug 2023, a noticeable decrease in HGB levels was observed, dropping below 10 g/dL.

• 2024-04-18 HGB 7.6 g/dL
• 2024-03-15 HGB 10.0 g/dL
• 2024-01-25 HGB 6.4 g/dL
• 2023-12-12 HGB 9.1 g/dL
• 2023-11-06 HGB 8.4 g/dL
• 2023-10-03 HGB 9.1 g/dL
• 2023-08-22 HGB 9.5 g/dL
• 2023-07-17 HGB 10.7 g/dL
• 2023-05-17 HGB 11.6 g/dL
• 2023-04-17 HGB 12.2 g/dL
• 2023-02-13 HGB 12.0 g/dL
• 2023-01-03 HGB 12.0 g/dL

There is no clear evidence to determine whether the long-term use of these medications or other factors (such as a brief period on Navelbine (vinorelbine) also in Jul/Aug 2023) caused the decline.

Notably, the drugs have varying incidences of anemia: ramucirumab at 4%, pemetrexed between 15%-19% (grades 3/4 3%-5%), and nivolumab between 19%-41% (grades 3/4 <= 3%). Nivolumab has also been linked to rare cases of autoimmune hemolytic anemia (AIHA) (Ref: JAMA Oncol. 2016;2(10):1346-1353. doi:10.1001/jamaoncol.2016.1051).

To manage this anemia, LPRBC transfusions have been effectively used (on 2024-04-18, 2024-01-25, 2023-11-06).

700027907

240418

[MedRec]

• 2023-07-17 ~ 2023-07-27 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Lung adenocarcinoma at right upper lung with mediastinal LAPs, malignant right pleural effusion s/p thoracocentsis on 2023/06/20, multiple bone metastasis; cT4N3M1c, stage IV; ECOG = 2. EGFR mutation L858R, under Afatinib 40mg since 7/05 23.
    • Cachexia
    • hypokalemia
    • hyponatremia
    • Hypocalcemia
    • Hypoalbuminemia
    • xerotic dermatitis
    • irritated contact dermatitis
    • hypomagnesemia
  • CC
    • for fever up to 38.3, and shortness of breathing since the afternoon on 2023/7/16
  • Course of inpatient treatment
    • After admission, he received hydration, the antibiotic with Cefim for infection control first.
    • Then he suffered from watery diarrhea, so Giotrif 1tab QD shifted to Giotrif 1tab QOD for cancer control.
    • And the patient, family request to counsulted Family Medicine for combine hospice care.
    • The patient complaints kin rash, and itchy since radiotherapy, so consulted dermatology for evaluation, and suggested to use lotion first. Mycomb cream 1 tube topical bid use over itchy lesions -> If still unbearable pruritus, consider topysm cream 1 tube topical bid use. Sinphraderm cream 1 tube topical QN use over dry scaling hyperpigmented lesions.
    • The electrolyte imblance due to poor intake, and diarrhea, so gave 0.298% KCL in N/S 500ml, Const-k, Calglon (calcium gluconate), MgSO4 to correct electrolyte.
    • After treatment, the symptom of poor intake, diarrhea and electrolyte imblance improved, and he denied having a fever, vomiting, or any complaints.
    • Xgeva 120mcg QM was done on 2023/07/26. He can be discharged on 2023/07/27, the OPD follow-up will be arranged.
  • Discharge prescription
    • Giotrif (afatinib 40mg) 1# QOD
    • Gaslan (dimethylpolysiloxane 40mg) 2# TID
    • Const-K (KCl 750mg/10mEq/tab) 1# QD
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • spironolactone 25mg 1# QD
    • Suwell (aluminum hydroxide 200mg, magnesium hydroxide 200mg, simethicone 25mg) 1# BID
    • Smecta (dioctahedral smectite 3mg) 1# TIDAC if diarrhea
    • MgO 250mg 1# TID
    • calcium carbonate 500mg 1# TID
• 2023-07-05 SOAP He JingLiang
  • A: EGFR mutation L858R
  • P: Giotrif
  • Prescription
    • Giotrif (afatinib 40mg) 1# QDAC ***
    • Through (sennoside 12mg) 1# HS
    • loperamide 2mg 1# PRNQD
    • Toricam (piroxicam 10mg/gm) BID TOPI
    • Suwell (aluminum hydroxide 200mg, magnesium hydroxide 200mg, simethicone 25mg) 1# BID
    • Doxaben (doxazosin 4mg) 1# QD
    • Anxiedin (lorazepam 0.5mg) 1# PRNHS if insomnia
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
• 2023-06-20 ~ 2023-06-30 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Malignant neoplasm of unspecified part of right bronchus or lung
  • CC
    • lower back pain for months.
  • Present illness
    • This is a 84 male, had past history of
      • HTN,
      • DM,
      • dyslipidemia,
      • BPH,
      • Lower back pain and Rt L5 radiculopathy since 2022.
    • This time, he suffered from back and thigh pain for 1-2 weeks. He firstly came to our ortho OPD for help, where L-spine MRI was arranged. On 05/24 L-spine MRI, Multiple bone tumor were found: multiple bone tumors in the sacrum, bilateral iliac bones, L5, L3, L1 and T12 vertebral bodies. So he was transferred to Hematology & Oncology OPD for help, where blood test and chest CT were arranged.
    • Blood test showed CEA: 1476 and CA199: 274; CT on 06/20 showed a huge mass over RUL and massive pleural effusion which Lung Carcinoma is suspected, cT4N3M1c. He came to our ER on 06/20. At ER, vital sign were BP:173/78; PR:83; BT:36.4; RR:18; Con’s:E4V5M6; SpO2:96%. Patient complained SOB for one week (parrelled to CT with pleural effusion) and dry cough. R’t pleural effusion post thoracocentsis 500ml at ER.
    • Under the impression of newly diagnosed lung cancer with bone invasion, he was admitted for further care.
  • Course of inpatient treatment
    • After admission, cancer suevey was done. CT guided lung biopsy was done on admission day. The procedure went smoothly. The f/u supine CXR showed right pleural effusion (r/o pleural effusion or biopsy-related hemothorax), but no dyspnea was complained after the procedure. Transamin was given for 3 days. The f/u erect CXR on 6/24 showed the same as before.
    • 06/23 brain MRI showed Three enhancing nodular lesions, about 6 mm, at left precentral gyrus, right thalamus and right caudate nucleus, respectively. C/W brain metastases.
    • 06/26 Colonscope showed One sessile polyp was noted in the transverse colon, Size 0.8 cm.
    • Pleural Effusion pathology reported on 6/26, which showed Malignancy.
    • The CT biopsy patho. report showed RUL, CT-guide biopsy — adenocarcinoma, moderately differentiated. EGFR (pending), PD-L1 (Result: (A) Tumor cell (TC) staining assessment: TC category: TC < 1%; (B) Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%) were then examinated.
    • Whole body bone scan will be done on 6/27, the report showed The scintigraphic findings suggest multiple bone metastases.
    • Lower back pain was still complained, XGEVA was given on 6/28. Oral surgery specilalist was consulted, he suggested not to receive tooth extraction recently.
    • Radiotherapy was also indicated for multiple bone meta., the localization has been done on 6/29, and the radiotherapy will begin in next week.
    • SPECT was also arranged on 6/30, the report is pending.    
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H if fever or pain
    • Doxaben (doxazosin 4mg) 1# QD
    • Anxiedin (lorazepam 0.5mg) 1# PRNHS if insomnia
    • Through (senosside 12mg) 1# HS

[surgical operation]

• 2024-04-18
  • Surgery
    • pericardiotomy and right chest tube insertion
  • Finding
    • The pericardial effusion was about 600 cc in amount.       
    • The right pleural effusion was about 600 cc in amount.  
• 2020-11-25
  • Surgery
    • phaco + pciol od    
  • Finding
    • Cataract od    
    • IOL: Cflex +19.0  

==========

2024-04-18

[pericardiotomy and chest tube insertion for effusion]

This patient was diagnosed with lung adenocarcinoma and bone metastases in mid-2023 and has been treated with Giotrif (afatinib) since the diagnosis.

Today (2024-04-18), he underwent a pericardiotomy and had a right chest tube placed to alleviate pericardial effusion. Currently, his vital signs and blood glucose levels are stable, and no discrepancies in medication have been noted.”

700789557

240418

[exam findings]

• 2024-04-08 Nasopharyngoscopy
  • smooth oropharynx, hypopharynx
  • nasopharyngeal mass decreasing size with some sticky post nasal drip
• 2024-03-29 SONO - nephrology
  • Nephrolithiasis, right
  • Renal tumor, left, suspect angiomyolipoma
  • Parenchymal renal disease
• 2024-03-01 Nasopharyngoscopy
  • persistant nasopharyngeal mass, not much change in size, but with much sticky post nasal drip
• 2024-02-29 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 28 dB HL; LE 25 dB HL.
    • RE normal to mild CHL.
    • LE normal to mild SNHL.
• 2024-02-16 Nasopharyngoscopy
  • persistant nasopharyngeal mass
• 2024-02-08 PET
  • Glucose hypermetabolism involving the nasopharynx, compatible with primary nasopharyngeal malignancy.
  • Glucose hypermetabolism in multiple right neck level II to III and left neck level II lymph nodes, suggesting metastatic lymph nodes.
  • Increased FDG accumulation in the colon, both kidneys and right ureter. Physiological FDG accumulation is more likely.
• 2024-02-06 MRI - nasopharynx
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2024-01-31 Patho - polyps, inflammatory - nasal/sinonasal
  • Nasopharynx, biopsy — Non-keratnizing squamous cell carcinoma
  • Section shows pieces of respiratory epithelium lined tissue with infiltration of nests of nonkeratinzing squamous cell carcinoma.
  • The immunohistochemical stains reveal CK5/6(+) and p40(+).
• 2024-01-31 Nasopharyngoscopy
  • Nasopharyngeal mass highly suspect malignancy s/p biopsy, persue report

[MedRec]

• 2024-03-11 SOAP Ear Nose Throat Zheng JingWen
  • A: Non-keratnizing squamous cell carcinoma of nasopharynx, new diagnosed, cT1N2M0, stage III
  • P: Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 2024-02-23
    • Treatment Plan: Induction chemotherapy + CCRT
    • Team Stage Consensus: cT2N2M0, stage: III
• 2024-02-27 ~ 2024-03-11 ~ POMR Integrative Medicine Yang MuJun
  • Discharge diagnosis
    • Non-keratinizing squamous cell carcinoma of the nasopharynx, newly diagnosed as cT2N2M0, stage III. He was admitted for port-A insertion and then induction chemotherapy with TPF (docetaxel 60mg/m2, cisplatin 60mg/m2, 5-Fu 600mg/m2) from 2024/02/29
    • Chronic serous otitis media, right ear
    • Epistaxis
    • Hemoptysis
  • CC
    • for induction with TPF x3 then CCRT
  • Present illness
    • This is a 52years-old male, diagnosis of Non-keratnizing squamous cell carcinoma of nasopharynx, new diagnosed, cT2N2M0, stage III on 2024/02/16.
    • Tracing back the past history, he suffered from blood tingled sputum for 1 month, blood tingled rhinorrhea and nasal bleeding for days and right aural fullness.
    • On 2024-02-03 MRI of nasophyrnx shows Nasopharyngeal Carcinoma.
    • On 2024-02-16 Nasopharyngoscopy reveal smooth oropharynx, hypopharynx, persistant nasopharyngeal mass.
    • After vitited our oncology OPD and add entecavir for anti HBc+, induction C/T TPF x3 first, manage teeth problem before CCRT.
    • This time, admitted for port-A insertion and then induction chemotherapy with TPF.
  • Course of inpatient treatment
    • After admission, consult general surgey for port-A insertion was arrrange on 2024/02/29 and done smoothyl.
    • AntiHBc postive with Baraclude 0.5mg/tab 1# QDAC.
    • Induction chemotherapy with C1 TPF (docetaxel 60mg/m2, cisplatin 60mg/m2, 5-Fu 600mg/m2) was done smoothly on 2024/02/29~2024/03/04.
    • Arrange PTA on 2024/02/29 and revealed Reliability FAIR.
    • Consult Oral Surgery for oral examination before CCRT and Suggest tooth 27 extraction, patient needs consideration.
    • For right ear fluid and consult ENT, Right Grommet insertion arranged on 2024/03/06.
    • Elevated bilrubin with Ursodeoxycholic acid 1# bid.
    • Neurokinin 1 (NK1) receptors Antagonist with Emend for 3days (3/6~3/8) by self-payment.
    • Lekopenia, WBC 950/ul was noted on 2024/03/09 and GCSF with granocyte 250mg/vial SC for 3days (3/9-3/11).
    • Patient tolerated the chemotherapy without vomiting.
    • With the stable condition, he was discharged on 2024/03/11 and OPD followed up later.
  • Discharge prescription
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Allegra (fexofenadine 60mg) 1# BID
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Gasmin (dimethylpolysiloxane 40mg) 1# BID
    • Promeran (metoclopramide 3.84mg) 1# BIDAC
    • Megest (megestrol 40mg/mL) 10mL QD
    • Through (sennoside 12mg) 1# HS
    • Trand (tranexamic acid 250mg) 1# PRNBID
    • Ulstop (famotidine 20mg) 1# QD
    • Smecta (dioctahedral Smectite 3gm) 1# PRNTIDAC if diarrhea
• 2024-02-26 SOAP Hemato-Oncology Yang MuJun
  • S: MultiTeam Meeting: cT2N2M0, stage III,
    • add entecavir for anti HBc+
    • Plan: induction C/T first.
    • Manage teeth problem before CCRT.

[consultation]

• 2024-04-18 Radiation Oncology

  • Q
    • After vitited our oncology OPD and add entecavir for anti HBc+, induction C/T TPF *3 first then CCRT, manage teeth problem before CCRT. Induction chemotherapy with TPF (docetaxel 60mg/m2, cisplatin 60mg/m2, 5-Fu 600mg/m2) from 2024/02/29~2024/03/04(C1), 2024/03/26~2024/03/31(C2).
    • Lekopenia (WBC 950/ul) was noted on 2024/3/9 and GCSF with granocyte 250mg/vial SC for 3days (3/9-3/11).
    • This time, admitted for induction chemotherapy with C3 TPF.
    • After PF C3, plan to receive CCRT, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • This is a 52years-old male with Non-keratnizing squamous cell carcinoma of nasopharynx, cT2N2M0, stage III diagnosed on 2024/02/16, s/p induction C/T TPF *3. Teeth evaluation and extraction have been done.
    • CCRT is indicated. CT-simulation will be arranged on 5/2.
    • Plan to deliver 50 Gy/ 25 fx to the bil. neck and NP. Then boost the nasopharyngeal tumor and LAPs to 70 Gy/ 35 fx.
    • RT will start around 5/7 or 8. Suggest H&N MRI in late Apr.

• 2024-03-28 Nephrology

  • Q
    • for elevated creatinine, suspect cisplatin related
    • This is a 52-year-old male, diagnosis of Non-keratnizing squamous cell carcinoma of nasopharynx, new diagnosed, cT2N2M0, stage III on 2024/02/16.
    • Tracing back the past history, he suffered from blood tingled sputum for 1 month, blood tingled rhinorrhea and nasal bleeding for days and right aural fullness.
    • On 2024-02-03 MRI of nasophyrnx shows Nasopharyngeal Carcinoma.
    • On 2024-02-16 Nasopharyngoscopy reveal smooth oropharynx, hypopharynx, persistant nasopharyngeal mass.
    • After vitited our oncology OPD and add entecavir for anti HBc+, induction C/T TPF *3 first then CCRT, manage teeth problem before CCRT.
    • Induction chemotherapy with TPF (docetaxel 60mg/m2, cisplatin 60mg/m2, 5-Fu 600mg/m2) from 2024/02/29~2024/03/04(C1). Leukopenia (WBC 950/ul) was noted on 2024/03/09 and GCSF with granocyte 250mg/vial SC for 3days (03/09-03/11).
    • This time, admitted for induction chemotherapy with C2 TPF.
    • We sincerely need your professional assistance!!
  • A
    • We are consulted for renal insufficiency induced by cisplatin.
    • a 52years-old male, diagnosis of Non-keratnizing squamous cell carcinoma of nasopharynx, new diagnosed, cT2N2M0, stage III on 2024/02/16 s/p TPF C1(02/29~03/04) creatinine level rised since 03/07
    • Lab
      • 2024-03-26 General urine examination /HPF
        
      • 2024-03-26 NIT -
        
      • 2024-03-26 PRO -
        
      • 2024-03-26 Sediment-RBC 0-2 /HPF
        
      • 2024-03-26 Sediment-WBC 0-5 /HPF
        
      • 2024-03-26 Epithelium 0-5 /HPF
        
      • 2024-03-26 BUN 27 mg/dL
        
      • 2024-03-26 Creatinine 1.32 mg/dL
        
      • 2024-03-26 Albumin (BCG) 3.9 g/dL
        
      • 2024-03-18 BUN 27 mg/dL
        
      • 2024-03-18 Creatinine 1.39 mg/dL
        
      • 2024-03-11 BUN 22 mg/dL
        
      • 2024-03-11 Creatinine 1.59 mg/dL
        
      • 2024-03-09 BUN 21 mg/dL
        
      • 2024-03-09 Creatinine 1.52 mg/dL
        
      • 2024-03-07 BUN 25 mg/dL
        
      • 2024-03-07 Creatinine 1.33 mg/dL —> After 1st C/T with cisplatin
        
      • 2024-03-04 Creatinine 0.84 mg/dL
        
      • 2024-03-04 eGFR 101.99 ml/min/1.73m^2
        
      • 2024-02-27 BUN 16 mg/dL
        
      • 2024-02-27 Creatinine 0.90 mg/dL
        
      • 2024-03-26 Na (Sodium) 133 mmol/L
        
      • 2024-03-26 K (Potassium) 3.8 mmol/L
        
      • 2024-03-26 Ca (Calcium) 2.27 mmol/L
        
      • 2024-03-26 Mg (Magnesium) 1.9 mg/dL
        
      • 2024-03-26 P (Phosphorus) 3.3 mg/dL
        
      • The creatinine level rises around 3 days after TPF regimen and reaches plateau around 1.3 mg/dl, ~ 1.5x baseline
      • The electrolyte imbalance is not significant, but hyponatremia present.
    • Impression:
      • cisplatin induced nephrotoxicity
    • Recommendation:
      • Intravenous saline infusion with Magnesium and KCl might be protective: isotonic saline plus (1 amp of KCL and 2 amps of MgSO4) -> 1000mL prior to cisplatin over 2-3 hrs, and a minimum of 500 mL of the solution over the 2 hrs following the cisplatin administration
        • evidence: A Systematic Review of Strategies to Prevent Cisplatin-Induced Nephrotoxicity. Oncologist. 2017;22(5):609. Epub 2017 Apr 24. - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5423518/
      • Consideration of dose reduction if feasible
      • Monitoring of serum Cr and electrolyte levels (sodium, potassium, magnesium, and phosphorus) following treatment
      • Avoidance of potential nephrotoxins such as NSAIDs.
      • Record U/O, BW
  • A 2024-03-28 14:40:26
    • 1000 mL isotonic saline + (1 amp of KCL and 2 amps of MgSO4) -> 1000mL prior to cisplatin over 2-3 hrs, and a minimum of 500 mL of the solution over the 2 hrs following the cisplatin administration

• 2024-03-01 Ear Nose Throat

• 2024-02-27

[chemotherapy]

• 2024-04-17 - docetaxel 60mg/m2 130mg NS 250mL 1hr + KCl 15% 10mL MgSO4 10% 40mL NS 1000mL 3hr (before CDDP) + cisplatin 60mg/m2 130mg NS 500mL 3hr + KCl 15% 10mL MgSO4 10% 40mL NS 1000mL 3hr (after CDDP) + fluorouracil 600mg/m2 1300mg NS 1000mL 24hr D1-5 (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-26 - docetaxel 60mg/m2 130mg NS 250mL 1hr + cisplatin 60mg/m2 130mg NS 500mL 2hr + fluorouracil 600mg/m2 1300mg NS 1000mL 24hr D1-5 (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-29 - docetaxel 60mg/m2 130mg NS 250mL 1hr + cisplatin 60mg/m2 130mg NS 500mL 2hr + fluorouracil 600mg/m2 1300mg NS 1000mL 24hr D1-5 (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

Treatment protocols for squamous cell carcinoma of the head and neck - 2024-03-11 - https://www.uptodate.com/contents/treatment-protocols-for-squamous-cell-carcinoma-of-the-head-and-neck

• REGIMENS
  • Weekly single-agent docetaxel - https://www.uptodate.com/contents/image?imageKey=ONC%2F139515
    • Cycle length:
      • 7 days.
    • Duration of therapy:
      • Weekly, until disease progression or unacceptable toxicity.*
    • Regimen
      • Docetaxel
      • 40 mg/m2 IV
      • Dilute in 100 or 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
  • Docetaxel, cisplatin, fluorouracil (TAX324) - https://www.uptodate.com/contents/image?imageKey=ONC%2F65438
    • Cycle length:
      • Every 21 days for three cycles.
    • Regimen
      • Docetaxel
        • 75 mg/m2 IV
        • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
        • Day 1
      • Cisplatin
        • 100 mg/m2 IV
        • Dilute in 250 mL NS and administer over 30 minutes to three hours. Do not administer with aluminum needles or IV sets.
        • Day 1
      • Fluorouracil (FU)
        • 1000 mg/m2/day IV
        • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
        • Days 1 through 4
  • Docetaxel, cisplatin, fluorouracil (TAX323) - https://www.uptodate.com/contents/image?imageKey=ONC%2F72461
    • Cycle length:
      • Every 21 days for four cycles.
    • Regimen
      • Docetaxel
        • 75 mg/m2 IV
        • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
        • Day 1
      • Cisplatin
        • 75 mg/m2 IV
        • Dilute in 250 mL NS and administer over 60 minutes. Do not administer with aluminum needles or IV sets.
        • Day 1
      • Fluorouracil (FU)
        • 750 mg/m2/day IV
        • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
        • Days 1 through 5
  • Cetuximab - https://www.uptodate.com/contents/image?imageKey=ONC%2F56253
    • Cycle length:
      • Weekly OR every two weeks.
    • Regimen
      • A
        • Cetuximab (loading dose)
          • 400 mg/m2 IV
          • The appropriate dose should be withdrawn from the vials (supplied in a concentration of 2 mg/mL) and aseptically transferred into an empty sterile IV bag without further dilution. The initial dose should be infused over 120 minutes.
          • Day 1
        • Cetuximab
          • 250 mg/m2 IV
          • If day 1 is tolerated, subsequent doses may be administered over 60 minutes.
          • Weekly, beginning day 8
      • B
        • Cetuximab (loading dose and subsequent)
          • 500 mg/m2 IV
          • The appropriate dose should be withdrawn from the vials (supplied in a concentration of 2 mg/mL) and aseptically transferred into an empty sterile IV bag without further dilution.*¶ When administered every 2 weeks, all doses should be infused over 120 minutes.
          • Every 2 weeks
  • Pembrolizumab - https://www.uptodate.com/contents/image?imageKey=ONC%2F127101
    • Cycle length:
      • Every three weeks, OR every six weeks.
    • Duration of therapy:
      • Until disease progression or unacceptable toxicity.
    • Regimen
      • A
        • Pembrolizumab
          • 200 mg IV
          • Dilute in NS or D5W to a final concentration between 1 and 10 mg/mL and infuse over 30 minutes through an 0.2- to 5-micron sterile, nonpyrogenic, low-protein-binding inline or add-on filter.
          • Day 1, every three weeks
      • B
        • Pembrolizumab
          • 400 mg IV
          • Dilute in NS or D5W to a final concentration between 1 and 10 mg/mL and infuse over 30 minutes through a 0.2- to 5-micron sterile, nonpyrogenic, low-protein-binding inline or add-on filter.
          • Day 1, every six weeks
  • Pembrolizumab plus cisplatin and fluorouracil - https://www.uptodate.com/contents/image?imageKey=ONC%2F139923
    • Cycle length:
      • 21 days.
    • Duration of therapy:
      • 6 cycles (pembrolizumab plus cisplatin and fluorouracil) then pembrolizumab alone to complete up to 35 cycles total or until disease progression or unacceptable toxicity.
    • Regimen
      • Pembrolizumab
        • 200 mg IV
        • Dilute in NS or D5W to a final concentration between 1 and 10 mg/mL and infuse over 30 minutes through an 0.2- to 5-micron sterile, nonpyrogenic, low-protein-binding inline or add-on filter.
        • Day 1
      • Cisplatin
        • 100 mg/m2 IV
          
        • Dilute in 250 mL NS and administer over 60 minutes (or at 1 mg/min). Do not administer with aluminum needles or sets.
        • Alternative: Dilute in 2 L 5% dextrose in one-half or one-third NS containing 37.5 g of mannitol and infuse over a six to eight hour period.[2] Do not administer with aluminum needles or sets.
        • Day 1
      • Fluorouracil (FU)
        • 1000 mg/m2 IV
        • Dilute in 500 to 1000 mL D5W and administer as a continuous infusion over 24 hours per day for four days (96 hours). Begin each course after completion of cisplatin.
        • To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose can be diluted in 100 to 150 mL NS.
        • Days 1 through 4
  • Nivolumab - https://www.uptodate.com/contents/image?imageKey=ONC%2F127100
    • Cycle length:
      • Every two weeks, OR every four weeks.
    • Duration of therapy:
      • Until disease progression or unacceptable toxicity.
    • Regimen
      • A
        • Nivolumab
          • 240 mg IV
          • Dilute with either NS or D5W to a final concentration between 1 and 10 mg/mL; total infusion volume should not exceed 160 mL. Infuse over 30 minutes through an IV line containing a sterile, nonpyrogenic, low-protein binding inline filter (pore size of 0.2 to 1.2 micrometer).
          • Day 1, every two weeks
      • B
        • Nivolumab
          • 480 mg IV
          • Dilute with either NS or D5W to a final concentration between 1 and 10 mg/mL; total infusion volume should not exceed 160 mL. Infuse over 30 minutes through an IV line containing a sterile, nonpyrogenic, low-protein binding inline filter (pore size of 0.2 to 1.2 micrometer).
          • Day 1, every four weeks

==========

2024-04-18

[mitigating creatinine spikes in TPF therapy with KCl and MgSO4]

In late Mar 2024, KCl and MgSO4 supplements were introduced while the patient was undergoing the TPF regimen. Subsequently, there has been no observed trend of increased serum creatinine levels; in fact, there has been a somewhat decrease in these levels.

2024-03-27

[neutropenia & kidney labs up after chemo, monitor closely for cycle 2]

The patient developed neutropenia, along with elevated SCr and BUN levels, following the 1st cycle of docetaxel, cisplatin, and fluorouracil chemotherapy.

The second cycle was nonetheless initiated on 2024-03-26. Close monitoring of these blood values is recommended.

2024-03-11

[TPFL & leukopenia - G-CSF resolved]

TPFL was administered on 2024-02-29, and the WBC nadir was observed on 2024-03-09. The timing suggests that the leukopenia was likely caused by chemotherapy. Granocyte (lenograstim 500mg SC) was administered on 2024-03-09, and leukopenia has not been observed since.

• 2024-03-11 WBC 5.09 x10^3/uL
• 2024-03-09 WBC 0.95 x10^3/uL
• 2024-03-07 WBC 1.93 x10^3/uL
• 2024-03-04 WBC 5.78 x10^3/uL
• 2024-02-27 WBC 5.10 x10^3/uL
• 2024-02-19 WBC 5.41 x10^3/uL

700935943

240412

[exam findings] (not complted)

• 2024-03-30 CT - chest
  • Indication: Bone destruction of T1 right body and transverse process, nature? Nodular lesion over Rt upper and Lt upper nature ?
  • Chest CT with and without IV contrast ehnancement shows:
    • Spiculated nodule at right upper lobe measuring 2.12cm in largest dimension is found. (Se5 Im33).
    • Perifissural nodule at right middle lobe is found.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Lymphadenopathy at both sides of the mediastinum including AP window and paratracheal region.
  • Imp:
    • Right upper lobe lung cancer with bone meta and mediastinal lymphadenopathy
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T1(T_value) N:N3(N_value) M:M1(M_value) STAGE:____(Stage_value)
• 2024-03-28 CXR erect
  • A nodular opacity projecting in the right upper lung is suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch

[MedRec]

• 2024-03-28 SOAP Hemato-Oncology Gao WeiYao
  • O
    • 2024/03/06 IgG4 = 478 mg/dL;
    • 2024/03/05 IgG (blood) = 809 mg/dL;
    • 2024/03/26 MRI: C-spine
      • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression.
      • Bone destruction of T1 right body and transverse process, nature?
    • 2024/03/28 WBC = 12.70 x10^3/uL;
• 2024-03-28 SOAP Orthopedics Zeng XiaoZu
  • O: MRI revealed T1 tumor r/o metastatic lesion, no cord compression; refer to Oncologist for tumor work-up

[consultation]

==========

2024-04-12

[switching from Atozet to separate forms for tube administration]

The combination medication “Atozet (ezetimibe 10mg, atorvastatin 20mg” should not be crushed according to the manufacturer’s instructions and is unsuitable for tube feeding.

Alternatively, our hospital stocks separate formulations of “Ezetrol (ezetimibe 10mg)” and “Atotin (atorvastatin 20mg)”, which can be crushed and administered via tube feeding if necessary.

2024-04-08

Blood sugar and pain levels are currently under control, and no discrepancies in medication have been identified.

700355056

240411

[exam findings]

• 2024-04-10 CT - abdomen
  • Findings:
    • There is a soft tissue lesion 2.3 cm in LUL of the lung (Srs:7 Img:16), directly attached the pleura. Tumor is highly suspected.
      • please correlate with clinical condition.
    • There are few enlarged nodes in the pre-vascular and para-aortic space. In addition, there is massive bilateral Pleura effusion and passive atelectasis in bilateral posterior basal lung.
    • There is splenomegaly (the greatest anterior-posterior dimension: 13.6 cm).
    • Both lobe thyroid show enlarged in size and few ill-defined poor enhancing lesions that may be nodular goiter.
      • Please correlate with sonography.
    • There is biconcave deformity of L3 vertebral body and osteoporotic change of L5 vertebral body. Please correlate with MRI.
    • Aneurysmal dilatation of the ascending thoracic aorta is noted.
    • A hepatic cyst 1 cm in S6/7 is noted.
  • Impression:
    • There is a soft tissue lesion 2.3 cm in LUL of the lung (Srs:7 Img:16), directly attached the pleura. Tumor is highly suspected. please correlate with clinical condition.
• 2024-03-05 ECG
  • Sinus bradycardia
  • Possible Left atrial enlargement
  • Left axis deviation
  • Left bundle branch block
• 2024-02-27 Cardiac Catheterization
  • Past Medical History
    • The patient has a history of ESRD under H/D.
  • Indication
    • The patient was referred with low blood flow. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
  • Approach
    • Percutaneous access was performed through the AV shunt fistula where a 6F sheath was inserted.
  • Procedure
    • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 30cc. The patient was treated with Dormicum (Dosage = 2.5 mg).
  • Finding Summary
    • Lef radiocephalic fistula with outflow juxta-venous limb and middle forearm restenosis
    • s/p PTA with some thrombus inside the vessel s/p catheter thrombosuction
  • Intervention Summary
    • Left Radio cephalic , Pre-DS = 86%, juxta-area
      • MLD/RVD=0.85/6.28 mm → 4.77/6.38 mm, Post-DS = 25%.
      • Guiding catheter: Boston 6F Peripheral MP 55.
      • Guide Wire: Terumo Radifocus 0.035 150cm.
      • Balloon: Medtronic Fortrex. 7 X 40 mm.
      • Balloon2: Brosmed Triwedge Scoring balloon. 5.0 X 40 mm.
    • Left Radio cephalic , Pre-DS = 63%
      • MLD/RVD=2.19/5.99 mm → 4.96/5.79 mm, Post-DS = 14%.
      • Guide Wire: Terumo Radifocus 0.035 150cm.
      • Balloon: Medtronic Fortrex. 7 X 40 mm.
      • Balloon2: Brosmed Triwedge Scoring balloon. 5.0 X 40 mm.
  • In conclusion:
    • left AVF stenosis
  • Recommendation :
    • PTA Intervention treatment: Retrograde PTA
• 2024-02-27 Peropheral Vascular Test - AV fistula
  • Clinical Diagnosis: AVF dysfunction
  • Report:
    • Access type: native
    • Site: left forearm
    • Clinical problem: low blood flow
    • Age of vascular access:
    • Result:
      • Left radiocephalic fistula restenosi at juxta-area, MLD 1.7-1.8 mm, which cause poor flow in this fistula
      • DS is around 70-75%, outflow cephalic veins 5.5-5.6-6.0 mm. very small cephalic vien at upper arm,
      • Larger basilic vien at upper arm Th evessel size is around 6.3-6.5 mm
      • Estiamted volume flow is around 170 ml/min
      • Right side:
        • SVC: 7.3 mmHg ;
        • MVO/SVC: 100 % ;
        • Average MVO/SVC: 100 %
    • Suggestion: PTA
• 2024-01-30 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (76.4 - 25.8) / 76.4 = 66.23%
    • M-mode (Teichholz) = 66.2
  • Conclusion:
    • Severely dilated LV; severe LV systolic dysfunction with wall thinning and akinesia from basal to apical anteroseptum, anterior wall and whole apex; apical aneurysm (+).
    • LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 2.
    • Normal RV systolic function.
    • Aortic valve sclerosis with no AS and AR; mild MR; mild TR; mild PR.
• 2024-01-16 CT - facial bone
  • Focal destruction (2.4cm in length) of right mandible.
  • Obstruction of left nasolacrimal duct.
• 2023-12-08 ECG
  • Sinus rhythm with frequent Premature ventricular complexes
  • Possible Left atrial enlargement
  • Left axis deviation
  • Left bundle branch block
  • Abnormal ECG
• 2023-12-08 CXR erect
  • S/P double lumen insertion, right side.
  • Plate density in left lower lung, could be due to atelectasis.
  • Cardiomegaly.
  • S/P sternostomy with metallic wire retention.
• 2023-11-21 Cardiac Catheterization
  • Finding Summary
    • Left radiocephalic fistula with radial artery , cephalic vein (juxta anastomosis and mid-cephalic vein) s/p PTA
  • Intervention Summary
    • Left Radio cephalic, Pre-DS = 76%
      • MLD/RVD=1.18/4.92 mm → 4.06/5.11 mm, Post-DS = 21%.
      • Guide Wire: Terumo Radifocus 0.035 150cm.
      • Balloon: Biotronik Passeo-35 Xeo. 5.0 X 40 mm.
    • Left Radio cephalic, Pre-DS = 73%
      • MLD/RVD=1.73/6.31 mm → 5.44/6.28 mm, Post-DS = 13%.
      • Guide Wire: Terumo Radifocus 0.035 150cm.
      • Balloon: Boston Mustang. 6.0 X 40 mm.
    • Left Radio cephalic, Pre-DS = 77%
      • MLD/RVD=1.53/6.58 mm → 5.27/6.55 mm, Post-DS = 3%.
      • Guide Wire: Terumo Radifocus 0.035 150cm.
      • Balloon: Boston Mustang. 6.0 X 40 mm.
  • In conclusion: left AVF immature shunt
  • Recommendation:
    • PTA Intervention treatment: Retrograde PTA
• 2023-09-26 Peropheral Vascular Test : AV fistula
  • Clinical Diagnosis: AVF dysfunction
  • Report:
    • Access type: native
    • Site: left forearm
    • Clinical problem: immature shunt
    • Age of vascular access:
    • Result:
      • Left radiocephalic fistual with inadequtae vessel size from juxta-area to upper arm basilic vein
      • The vessel size at midforearm 5.6 mm, 5.3 mm, 4.5 mm, UA basilic vien = 7.1 mm
      • juxta-area lumen narrowing = 33%
      • Estimated volume flow is aorund 330-407 mkl/min
      • Right side:
        • SVC: 12.4 mmHg ;
        • MVO/SVC: 100 % ;
        • suggestion:
          • encourage hot packing and hand gripping exercise, at present the vessel site is too small
          • Avoid hypotension and elevate blood pressure are essentail
      • Suggestion: Clinical follow up
• 2023-08-09 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
  • Possible Left atrial enlargement
  • Left bundle branch block
• 2023-04-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (243 - 153) / 243 = 66.23%
    • M-mode (Teichholz) = 35
    • 2D (M-Simpson) = 35
  • Conclusion:
    • Dilated LA and LV; severely abnromal LV systolic function with anteroseptal and apex akinesia
    • Mild to moderate MR, mild TR
    • LV diastolic dysfunction, Gr II
    • Preserved RV systolic function
• 2023-03-21 Nerve Conduction Velocity, NCV
  • Findings
    • The NCV study showed
      • reduced CMAP amplitude in left tibial nerve,
      • decreased motor nerve conduction velocity in bilateral median, ulnar, peroneal, and right tibial nerves,
      • reduced SAP amplitude and decreased sensory nerve conduction velocity in bilateral median and ulnar nerves,
      • reduced SAP amplitude in right sural nerve,
      • decreased sensory nerve conduction velocity in left sural nerve.
    • The F-wave study showed prolonged minimal F-wave latency in bilateral median, ulnar, peroneal, and tibial nerves.
    • The H-reflex study showed prolonged minimal H-wave latency in bilateral tibial nerves.
    • The theramal QST study showed abnormal warm thershold in the lower limb.
  • Conclusion
    • The above findings sensorimotor polyneuropathy and small fiber neuropathy. Advise clinical correlation.
• 2023-01-12 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Myeloma.
  • Section shows piece(s) of bone marrow with 95% cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is a predominant plasmacytoid cell subpopulation present.
  • IHC stains: CD138: 50-60%, kappa and lambda light chains: a predominant lambda subpopulation. MPO: 30-35 %, CD71: 15-20 % (of the nucleated cells).
• 2022-12-07 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Left ventricular hypertrophy with QRS widening
  • T wave abnormality, consider inferolateral ischemia
• 2022-11-24 Myocardial perfusion SPECT with persantin
  • Probably severe myocardial ischemia with possible a portion of infarction at the apex, septum and adjacent anteroseptal wall and mild myocardial ischemia at the basal inferolateral wall.

700823721

240411

[past history]

• Hypertension for 10 years with regular medication control.
  • Norvasc 1# PRNQD
• Type 2 diabetes mellitus for 15+ years with regular OHA control.
  • Relinide 1mg 0.5# po TIDAC
  • Januvia 100mg 1# po QD
  • Uformin 500mg 1# po TIDCC
• Hyperlipidemia for 15+ years with regular medication control.
  • Crestor 10mg 0.5# po QD
  • Dipyridamole 25mg 1# po BID
• Operation history: PHACO + PCIOL OD on 2015/07/21
  • ChatGPT:
    • “PHACO + PCIOL OD” is a term used in ophthalmology and it refers to a type of eye surgery.
      • PHACO: Stands for “Phacoemulsification,” which is a modern cataract surgery in which the eye’s internal lens is emulsified with an ultrasonic handpiece and aspirated from the eye.
      • PCIOL: Stands for “Posterior Chamber Intraocular Lens,” which is an artificial lens that is implanted in the eye to replace the natural lens that was removed during cataract surgery.
      • OD: Stands for “Oculus Dexter,” which is Latin for “right eye”.
    • So, “PHACO + PCIOL OD” means the patient underwent phacoemulsification cataract surgery with posterior chamber intraocular lens implantation in the right eye.

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2024-03-25 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasocavity, right, punch biopsy — Diffuse large B-cell lymphoma
  • Section shows 2 pieces of respiratory epithelium lined tissue with infiltration of large pleomorphic tumor cells.
  • The immunohistochemical stains reveal CD3(-) and CD20(+). The Ki-67 is > 90%.
• 2024-03-21 Patho - skin non-cyst/tag/debridement/plastic
  • Skin, flank, left, biopsy — Diffuse large B-cell lymphoma
  • The sections show a picture of diffuse large B-cell lymphoma with following features:
    • Specimen: Left flank
    • Procedure: Biopsy
    • Tumor site: Skin
    • Histologic type: Diffuse large B-cell lymphoma
    • Immunophenotyping: CD3(-), CD20(+), PAX 5(+), and CK(-)
• 2024-03-18 Nasopharyngoscopy
  • DLBCL
  • PET+
  • new R NP and nasal lesion
• 2024-03-18 SONO - head and neck soft tissue
  • Clinical Impression/Intent:
    • Sonographic Impression:bil huge goiter with intrathoracic extension
    • Fine needle aspiration:L
  • Content: Thyroid
  • Intelnal echo: Homogeneous
    
  • Lump: Solitary
  • Most Significant site: Bilateral
  • Margin: Smooth/Distinct
  • Echogenicity: Isoechoic
  • Calcification: None
  • Architecture: Solid
• 2024-03-15 PET scan
  • In comparison with the previous study on 2023/10/06, the glucose hypermetabolism in the right nasal cavity is more evident and the lesion in a lymph node in the left anterior upper thigh is new. Residual/recurrent ymphoma may show this picture. However, the previous glucose hypermetabolism in the right N-P region disappeared.
    
  • The glucose hypermetabolism in bilateral mediastinal and pulmonary hilar lymph nodes is a little less evident.
  • Glucose hypermetabolism in a focal area in the skin of the left lateral aspect of the upper abdomen. The nature is to be determine (inflammation/infection? other nature?). Please correlate with other clinical findings for further evaluation.
    
  • Mildly increased FDG uptake in the left adrenal gland, probably a functing or non-functing benign tumor of the left adrenal gland.
  • Mildly increased FDG uptake in the left hip joint. Arhtritis may show this picture.
  • Increased FDG accumulation in the colon, probably physiological accumulation of FDG.
• 2024-03-14 Nasopharyngoscopy
  • fiber = fibrotic NP+ tonsil, neck mass-, less dizziness with Rx, vocal palsy
• 2024-02-27 CT - chest
  • Indication: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
  • Comparison: prior CT 2023/11/10
    • Lungs: minimal fibrosis in paravertebral region at RLL, related to osteophytes of spine. no abnormality in RUL, RML, and left lung.
    • Mediastinum and hila: no enlarged LN.
      • extensive calcified plaques of the coronary arteries.
    • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
    • Heart: dilated LA and mild calcified aortic valves
    • Chest wall and visible lower neck: markedly enlarged thyroid gland with tiny calcifications, extending to tthe superior mediastinum, and with mass effects on the trachea and adjacent vessels.
    • Extensive atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
  • Impression:
    • extensive 3V-CAD. thyroid goiter with mediastinal extension.
    • no recurrent tumor.
• 2023-11-23 ENT Hearing Test
  • Tymp:
    • R’t type B; L’t type As
  • ART:
    • Bil absent.
  • PTA:
    • Reliability FAIR
    • Average RE 65 dB HL; LE 65 dB HL
    • R’t moderately severe to severe SNHL
    • L’t moderately severe SNHL
• 2023-11-23 Cervical Vestibular Evoked Myogenic Potential
  • cVEMP Interaural Amplitude Asymmetry ratio 7%, WNL
• 2023-11-10 CT - chest
  • Indication:
    • Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
    • Localized enlarged lymph nodes
  • Chest and Abdominal CT with and without enhancement revealed:
    • Enlarged thyroid with calcifie dots are found.
    • Small, homogeneous lymph nodes are found in the mediastinum. In comparison with CT dated on 2023-09-06, the lesions are stationary.
    • S/p port-A placement with its tip at Superior vena cava.
    • Calcified coronary arteries is found.
    • Cystic change at pancreatic tail measuring 1.43cm in largest dimension is found.
  • IMp:
    • Small lymph nodes in the mediastinum. Stationary.
    • Calcified coronary arteries is found.
• 2023-11-06 Nasopharyngoscopy
  • NP = diffuse large B-cell lymphoma + bil NM
• 2023-10-06 PET
  • In comparison with the previous study on 2023/02/01, the glucose hypermetabolism in the right N-P region and right nasal cavity is less evident. The previous glucose hypermetabolism in the left N-P region, bilateral neck and supraclavicular lymph nodes, bilateral axillary lymph nodes, and the lymph nodes in the abdomen, pelvis, bilateral inguinal and upper thigh regions all disappeared.
    
  • The glucose hypermetabolism in bilateral mediastinal and pulmonary hilar lymph nodes are more evident. Please correlate with other clinical findings for further evaluation.
    
  • Mildly increased FDG uptake in the left adrenal gland, probably a functing or non-functing benign tumor of the left adrenal gland.
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological accumulation of FDG.
• 2023-10-03 CXR erect
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • Superior mediastinal widening due to inferior extension of an enlarged thyroid gland
• 2023-09-18 MRI - nasopharynx
  • Several enlarged LNs at right supraclavicular fossa, watch out and follow up.
  • Enlarged bil. thyroid glands with multiple nodules or cysts as seen on prior MR scans, seems stationary.
• 2023-09-06 CT - chest
  • Impression:
    • resolution of nodular lesions in LLL of lung,
    • extensive 3V-CAD. thyroid goiter with mediastinal extension.
    • no neoplastic LAP in chest and abdomen.
• 2023-06-21 MRI - nasopharynx
  • C/W lymphoma s/p chemotherapy with complete remission. Suggest regular follow-up.
• 2023-06-05 Nasopharyngoscopy
  • fiber = grossly DFS, lymping and dry throat
• 2023-05-22 CT - chest
  • Indication: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck s/p C/T
  • Comparison was made with previous CT
    • Lungs: several subpleural nodular opacities at LLL.
    • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
    • Mediastinum and hila: multiple small LNs in the visceral space and left anterior prevascular space
    • Vessels: extensive calcified plaques of the LAD, and LCX, and right coronary arteries.
    • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: dilated LA and concentric LVH. mild calcified aortic valves
    • Pleura: no effusion.
    • Chest wall and visible lower neck: marked enlarged thyroid gland with calcifications extending to superior mediastinum, and with mass effects on the trachea calcification.
    • Visible abdominal-pelvic contents: normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
    • Extensive atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
  • Impression:
    • nodular lesions in LLL of lung, recurrent lymphoma in lung or other pathology?
    • extensive 3V-CAD.
    • thyroid goiter with mediastinal extension.
• 2023-04-10 Nasopharyngoscopy
  • NP lymphoma
  • PND (postnasal drip), mucopus
• 2023-03-06 Nasopharyngoscopy
  • NP mass smaller
  • neck mass smaller after C/T
  • nasal mucopus
• 2023-02-19 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Low voltage QRS
• 2023-02-17 CXR
  • Widening of the upper mediastinum is noted, which may be due to torturous innominate vessel or tumor. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2023-02-17 MRI - nasopharynx
  • Indication: Right nasopharynx diffuse large B cell lymphoma, non-gernimal cell type
  • Findings
    • Diffuse mucosal thickening at nasopharynx.
    • Numeorus enlarged lymph nodes at both sides of the neck, including bilateral retrophayrngeal lymph nodes, and bilateral levels II, III, IV and V, and in visible superior mediastinum. The largest one, about 50 mm, confluent with necrotic change at left level V.
    • Severe enlargement of bilateral thyroid glands, with diffuse heterogeneous intensity, protruding into mediastinum, encasing trachea and compressin on great vessels.
    • A soft tissue intensity lesion, about 30 mm x 15 mm x 16 mm, with vivid enhacnement in right nasal cavity (mainly middle meatus).
  • IMP
    • C/W lymphoma involving nasopharynx, lymph nodes of both sides of neck, superior mediastinum and suspiciouly right nasal cavity.
• 2023-02-16 CT
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Some enhanced lymph nodes are found at bilateral neck, epiglottic, pharyngeal space, axillary, bilateral paratracheal region.
      • Enlarged thyroid tissue at both lobes with calcification is found.
      • No evidence of bilateral pleural effusion.
      • Patent airway is found.
      • Calcified coronary arteries is found.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Lymphadenopathy at bialteral neck, pharyngeal space, bilateral axillary and mediastinal region.
      • Enlarged bilateral thyoid glands.
      • Calcified coronary arteries is found.
• 2023-02-15 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
• 2023-02-14 ENT Hearing Test, PTA:
  • Reliability FAIR
  • Average RE 70 dB HL; LE 69 dB HL
  • RE moderately severe SNHL
  • LE moderately severe to severe SNHL
• 2023-02-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 22) / 91 = 75.82%
    • M-mode (Teichholz) = 75
  • Preserved LV and RV systolic function with normal wall motion
  • Dilated LA, grade 1 LV diastolic dysfunction
  • Mild MR, PR, trivial TR
• 2023-02-01 Whole body PET scan
  • The [F-18] Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 218 MBq of FDG on a GE Discovery ST PET-CT system. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
  • There was increased FDG uptake in bilateral N-P regions and right nasal cavity (SUVmax early: 28.95, delay: 41.80), bilateral cercial and SCF lymph nodes (SUVmax early: 30.05, delay: 32.62), bilateral axillary lymph nodes (SUVmax early: 7.85, delay: 10.53), left mediastinal and pulmonary hilar lymph nodes (SUVmax early: 7.87, delay: 15.17), right mediastinal and pulmonary hilar lymph nodes (SUVmax early: 4.76, delay: 8.86), and lymph nodes in the abdomen, pelvis, bilateral inguinal and upper thigh regions (SUVmax early: 12.35, delay: 9.02). In addition, increased FDG uptake was also noted in the left adrenal gland (SUVmax early: 4.24, delay: 7.76), bilateral kidneys and colon.
  • IMPRESSION:
    • Glucose-hypermetabolism in bilateral N-P regions and right nasal cavity (Deauville score 5), compatible with B-cell lymphoma.
      
    • Glucose-hypermetabolism in bilateral cercial and SCF lymph nodes, bilateral axillary lymph nodes, bilateral mediastinal and pulmonary hilar lymph nodes, and lymph nodes in the abdomen, pelvis, bilateral inguinal and upper thigh regions (Deauville score 5), highly suspected B-cell lymphoma with involvement of lymph node regions.
      
    • Increased FDG uptake in the left adrenal gland, probably a functing or non-functing benign tumor of the left adrenal gland, suggesting further investigation.
    • Increased FDG uptake in bilateral kidneys and colon, probably physiological uptake of FDG.
    • Diffuse large B-cell lymphoma with involvement of bilateral N-P regions, right nasal cavity and lymph node regions on both sides of the diaphragm, by this F-18 FDG PET scan.
• 2023-01-31 SONO - abdomen
  • A cystic lesion 1.88 x 0.74 cm in S5 of the liver, near the gallbladder, is noted. Follow up is indicated.
• 2023-01-30 Patho - nasopharyngeal/oropharyngeal biopsy
  • Labeled as “right nasopharynx”, biopsy — diffuse large B cell lymphoma, non-gernimal cell type. High grade.
  • IHC stains: CK (-), CD3 and CD20: a predominant B cell sub-population.
    • Bcl-2 (+, 90%), Bcl-6 (+, 90%), CD10 (<5%), C-myc: (+, 30-40%), Ki-67: (95%), MUM-1: (+, 90%), cyclin-D1 (-), CD23 (-). P16 (-), EBV (-).
• 2023-01-30, 2022-06-10 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Abnormal ECG
• 2023-01-30 Nasopharyngoscopy
  • Findings:
    • R NP tumor with yellowish crust coating; epiglottis lingual side tumor with patent airway; smooth HPx.
  • Diagnosis/Conclusion:
    • Nasopharyngeal and oropharyngeal tumor, suspect malignancy.
• 2022-06-22 Electroencephalography
  • This EEG study recorded background alpha rhythm (9-10Hz) and beta activity with transient diffuse slow waves.
  • No epileptiform discharge.
  • Please correlate with clinical features.
• 2022-06-22 Brainstem Auditory Evoked Potential, BAEP
  • Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulation to each ear.
  • This is a normal BAEP study.
  • Please correlate with clinical features.
• 2018-08-10 Flow Volume Curve
  • Mild restriction
• 2018-08-10 Bone densitometry - hip
  • Hip BMD performed by DXA revealed:
    • Left hip, BMD is 0.539 gms/cm2, about 2.5 SD below the peak bone mass (67%) and 0.0 SD below the mean of age-matched people (100%).
  • IMP: Osteoporosis

[MedRec]

• 2024-04-03 SOAP Dermatology Wu RuoWei
  • S
    • 2024/03/20
      • Lesion over left flank
      • PH: DLBCL, refer from Hema
    • 2024/03/21
      • For biopsy
    • 2024/04/3
      • Wound OK
      • Itchy over trunk and extremities
  • O
    • 2024/03/20
      • Indurated mass over left flank -> r/o DLBCL
    • 2024/03/21
      • r/o DLBCL
    • 2024/04/3
      • Patho: Diffuse large B-cell lymphoma
  • A/P
    • 2024/03/20
      • Arrange Skin biopsy
    • 2024/03/21
      • biopsy
    • 2024/04/3
      • Remove stitches
      • Topical mycomb and oral orolisin for itchy
  • Prescription
    • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# TID
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
    • Topsym (fluocinonide 0.05%) BID TOPI
• 2024-03-29 SOAP Metabolism and Endocrinology Hu YaHui
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type [E11.9]
    • Mixed hyperlipidemia [E78.2]
    • Nontoxic multinodular goiter [E04.2]
    • Chronic kidney disease, stage 2 (mild) [N18.2]
  • Prescription x3
    • Relinide (repaglinide 1mg) 0.5# PRNTIDAC
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Crestor (rosuvastatin 10mg) 0.5# QD
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
    • MgO 250mg 1# BID
    • Norvasc (amlodipine 5mg) 1# PRNQD
    • Uformin (metformin 500mg) 1# BIDCC
• 2024-03-20 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • Arrange Nasopharyngeal MRI and whole body CT, Q3M
    • Already communicated with son and patient, Suggest skin biopsy
      • If lymphoma (-), all keep observation
      • If lymphoma (+), options:
        • A. Keep observation, until sympotom develop
        • B. Back to R-COP or low intensity (oral or not) C/T
        • C. R/T to the necessary area, e.g., nasal area
    • Port-A flush Q3M, next on 2024-06-05
    • PET and/or CT Q3M, next in 2024-06
  • Presciption
    • Arcoxia (etoricoxib 60mg) 1# QD
    • clobetasol ointment 0.5mg/gm BID TOPI
• 2024-02-15 SOAP Gastroenterology Chen ZhiXiang
  • Prescription x3
    • Buscopan (hyoscine-N-butylbromide 10mg) 1# TIDAC
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
    • Alpraline (alprazolam 0.5mg) 1# PRNHS
    • Ulstop (famotidine 20mg) 1# BID
• 2023-10-17 SOAP Heamto-Oncology Xia HeXiong
  • A/P
    • Positive finding of chest region based on 2023-10-06 PET.
    • Alredy discuss with patient and family, may consider Follow up and re-check by CT scan.
• 2023-05-25 SOAP Hemato-Oncology Xia HeXiong
  • P
    • Already mention the lesion over LLL of lung. Will discuss with family for options
      • Biopsy, or
      • PET-CT, or
      • Observation.
• 2023-05-04 SOAP Gastroenterology
  • Diagnosis
    • Gastro-esophageal reflux disease with esophagitis K21.0
    • Constipation, unspecified K59.00
    • Generalized anxiety disorder F41.1
    • Type 2 diabetes mellitus without complications E11.9
  • Prescription (refillable)
    • Spasmotin (hyoscyamine sulfate 0.125mg) 1# TID
    • Strocain (oxethazaine, polymigel 5mg) 1# TIDAC
    • Alpraline (alprazolam 0.5mg) 1# PRNHS
    • MgO 250mg 2# TID
• 2023-04-28 SOAP Metabolism and Endocrinology
  • Diagnosis - same as 2023-03-03
  • Prescription (refillable)
    • dipyridamole 25mg 1 tab BID
    • Crestor (rosuvastatin 10mg) 0.5 tab QD
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1 tab BID
    • Norvasc (amlodipine 5mg) 1 tab PRNQD
    • Relinide (repaglinide 1mg) 1 tab TIDAC
    • Uformin (metformin 500mg) 1 tab BIDCC
    • Tresiba FlexTouch (insulin degludec) 6 unit QN (during steroid used)
• 2023-03-03 SOAP Metabolism and Endocrinology
  • Diagnosis
    • Type 2 diabetes mellitus without complications E11.9
    • Mixed hyperlipidemia E78.2
    • Nontoxic multinodular goiter E04.2
    • Chronic kidney disease, stage 2 (mild) N18.2
    • Anemia, unspecified D64.9
    • Atherosclerosis of other arteries I70.8
  • Prescription (refillable)
    • Crestor (rosuvastatin 10mg) 0.5# QD
    • Norvasc (amlodipine 5mg) 1# PRNQD
    • Relinide (repaglinide 1mg) 1# ASORDER (0.5# TIDAC, 1# TIDAC if ACD > 180)
    • Uformin (metformin 500mg) 1# BIDCC
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
• 2023-03-02 SOAP Hemato-Oncology
  • O: AE Leukopenia Gr 1 3000~4000/mm3
• 2023-03-02 SOAP Dermatology
  • S
    • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching.
    • fissuriform wound formaiton.
  • O
    • seborrhic dermatitis on scalp and face and trunk for yrs,
    • Generalized eczeam (+)
    • Polytar liquid for shampooing QOD
    • PHx:
      • sea food allergy (+-)
      • allergic rhinitis (+)
    • Travel histry: denied
    • fissuriform wound formaiton. -> hand eczema.
  • Plan:
    • education about drug side effec and explain
    • strongly suggested OPD f/u
  • Diagnosis
    • Seborrhoeic dermatitis, unspecified - L21.9
    • Infective dermatitis - L30.3
  • Prescription
    • Zalain External Gel (sertaconazole 2%) Q3D EXT
    • Topsym (fluocinonide 0.05%) BID TOPI
    • Asthan (ketotifen 1mg) 1# QN PO
    • Biomycin (neomycin, tyrothricin) BID TOPI
• 2023-02-13 ~ 2023-02-25 POMR Hemato-Oncology
  • Discharge diagnosis
    • Diffuse large B-cell lymphoma with involvement of bilateral nasopharynx regions, right nasal cavity and lymph node, non-gernimal cell type. High grade. IHC stains: CK (-), CD3 and CD20: a predominant B cell sub-population. Bcl-2 (+, 90%), Bcl-6 (+, 90%), CD10 (＜5%), C-myc: (+, 30-40%), Ki-67: (95%), MUM-1: (+, 90%), cyclin-D1 (-), CD23 (-). P16 (-), EBV (-)
    • Type 2 diabetes mellitus without complications
    • Mixed hyperlipidemia
    • Gastro-esophageal reflux disease with esophagitis
    • Osteoarthritis of knee, unspecified
    • Essential (primary) hypertension
    • Insomnia, unspecified
    • Sensorineural hearing loss, bilateral
    • Constipation, unspecified
    • Oral mucositis (ulcerative), unspecified
  • Prescription
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Crestor (rosuvastatin 10mg) 0.5# QD
    • dipyridamole 25mg 1# BID
    • MgO 250mg 2# TID
    • Spasmotin (hyoscyamine sulfate 0.125mg) 1# TID
    • Uformin (metformin 500mg) 1# TIDCC
    • Relinide (repaglinide 1mg) 0.5# TIDAC
    • Norvasc (amlodipine 5mg) 1# QD
    • Januvia (sitagliptin 100mg) 1# QD
    • diphenidol 25mg 1# TID
    • Arcoxia (etoricoxib 60mg) 1# QD
• 2023-02-07 SOAP Hemato-Oncology
  • S
    • 2022/08/29 Free-T4 = 0.74 ng/dL; TSH = 0.165 uIU/mL
    • 2023/01/30 HGB = 10.2 g/dL; HbA1c = 7.3 %;
    • 2023/01/30 fiber: large R NP tumor with downward extension, Bx done, L tonsil: uneven, bil huge epiglottic mass (smooth surface)
    • 2023/01/30 SCC/CRP (-)
      • SCC (NM) = 1.37 ng/mL; SCC = 1.4 ng/mL, CRP = 0.69 mg/dL
    • 2023/02/03 EBV DNA PCR <120 copies/mL
    • 2023/02/06 NP: diffuse large B-cell lymphoma + bil NM
    • Referred from Dr. Gao at BanQiao LMC due to bilateral neck mass.
    • Poor appetite and BW loss 1-2 kg in recent 2 months
  • O
    • History: lipid, DM, HT at Meta, GERD, OA knee
    • Living alone with her husband, four sons take turns to care for her.
  • P
    • Arrange admission for HN MRI, Chest/Abd/Pelvis CT and bone marrow study (aspiration, biopsy, chromosome study), cardiac echography, C/T with R-COP or R-CHOP.

[chemotherapy]

• 2024-04-11 - rituximab 375mg/m2 530mg NS 500mL 8hr + cyclophosphamide 750mg/m2 900mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# QD 8# QL D1-5 (R-COP Q3W)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] (before Mabthera) + [dexamethasone 4mg + palonosetron 250ug + NS 250mL] (before Endoxan)
• 2023-06-29 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 900mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] (before Mabthera) + [dexamethasone 4mg + palonosetron 250ug + NS 250mL] (before Endoxan)
• 2023-06-01 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 900mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] (before Mabthera) + [dexamethasone 4mg + palonosetron 250ug + NS 250mL] (before Endoxan)
• 2023-05-09 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 900mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-04-11 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-03-15 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-02-20 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[note: R-COP, R-mini-CHOP, R-CHOP21, EPOCH-R, daEPOCH]

R-CVP 2023-05-19 https://www.cancer.gov/about-cancer/treatment/drugs/r-cvp

• Drugs in the R-CVP combination:
  • R = Rituximab
  • C = Cyclophosphamide
  • V = Vincristine Sulfate
  • P = Prednisone
• R-CVP is used to treat: Non-Hodgkin lymphoma (NHL) that is indolent (slow-growing).
  • ChatGPT - Indolent NHL
    • “Indolent NHL” refers to a type of non-Hodgkin lymphoma that grows and spreads slowly. Non-Hodgkin lymphoma (NHL) is a group of blood cancers that includes all types of lymphomas, except Hodgkin’s lymphomas.
    • Examples of indolent NHL include follicular lymphoma, marginal zone lymphoma, and small lymphocytic lymphoma. Indolent lymphomas are typically associated with a relatively good prognosis, but they are usually not curable in advanced clinical stages.
    • It’s important to note that the term “indolent” doesn’t mean the disease is not serious. It’s still a type of cancer and requires treatment, but generally, it progresses more slowly than other types of lymphoma.

Initial treatment of advanced stage diffuse large B cell lymphoma 2023-05-19 https://www.uptodate.com/contents/initial-treatment-of-advanced-stage-diffuse-large-b-cell-lymphoma

• R-mini-CHOP - SPECIAL SCENARIOS - Older adults

  • Older patients with DLBCL generally have a worse prognosis compared to younger patients due, in part, to more comorbid conditions and lower treatment tolerance.
  • For patients >80 years with adequate heart, kidney, and liver function and for patients 60 to 80 years with modest impairments, we generally treat with R-mini-CHOP to reduce adverse effects (AE) associated with more intensive regimens.

• Pretreatment evaluation

  • For older patients, a comprehensive geriatric assessment can aid assessment of comorbid conditions and functional status and facilitate formulation of an appropriate, individualized treatment plan. Special considerations for the use of chemotherapy in older patients are discussed separately

• R-mini-CHOP Treatment

  • rituximab 375 mg/m2 D1
  • cyclophosphamide 400 mg/m2 D1
  • doxorubicin 25 mg/m2 D1
  • vincristine 1 mg D1
  • prednisone 40 mg/m2 D1-5

• A pre-treatment phase of a systemic steroid, with or without rituximab, may improve the patient’s performance status (PS) and facilitate treatment with R-mini-CHOP.

• Frail patients who require symptom palliation but cannot tolerate R-mini-CHOP may benefit from a systemic steroid (with or without rituximab) or single chemotherapeutic agents.

Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP21) for non-Hodgkin lymphoma 2023-05-19 https://www.uptodate.com/contents/image?topicKey=HEME%2F4729&imageKey=ONC%2F63586

• Cycle length: 21 days.

• Regimen

  • Rituximab
    • 375 mg/m2 IV
    • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated.[2] For subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count ≥5000/microL. Day 1
  • Cyclophosphamide
    • 750 mg/m2 IV
    • Dilute in 250 mL NS or D5W and administer over 30 minutes.
    • Day 1
  • Doxorubicin
    • 50 mg/m2 IV
    • Dilute in 50 mL NS or D5W and administer over three to five minutes.
    • Day 1
  • Vincristine
    • 1.4 mg/m2 IV (max dose 2 mg)
    • Dilute in 50 mL NS or D5W and administer over 15 to 20 minutes.
    • Day 1
  • Prednisone
    • 100 mg orally
    • Administer 30 minutes prior to chemotherapy on day 1, then every 24 hours on days 2 to 5. Days 1 to 5

Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma 2023-05-19 https://www.uptodate.com/contents/image?topicKey=HEME%2F4729&imageKey=ONC%2F88411

• Cycle length: 21 days.

• Regimen

  • Rituximab
    • 375 mg/m2 IV
    • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. In the absence of an initial infusion reaction, for subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count >=5000/microL.
    • Day 0 or 1
  • Etoposide
    • 50 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Doxorubicin
    • 10 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Vincristine
    • 0.4 mg/m2 per day IV (dose not capped)
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Cyclophosphamide
    • 750 mg/m2 IV
    • Dilute with 250 mL NS or D5W and administer over 30 minutes.
    • Day 5
  • Prednisone
    • 60 mg/m2 orally twice daily
    • Administer first dose 30 minutes prior to chemotherapy on day 1.
    • Days 1 to 5
  • Granulocyte colony stimulating factor (G-CSF)
    • Start day 6

Chemotherapy regimens for non-Hodgkin lymphoma: Dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (daEPOCH) 2023-05-19 https://www.uptodate.com/contents/image?topicKey=ONC%2F85686&imageKey=ONC%2F105216

• Cycle length: 21 days.
• Regimen
  • Etoposide
    • 50 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Doxorubicin
    • 10 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Vincristine
    • 0.4 mg/m2 per day IV (dose not capped)
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Cyclophosphamide
    • 750 mg/m2 IV
    • Dilute with 250 mL NS or D5W and administer over 30 minutes.
    • Day 5
  • Prednisone
    • 60 mg/m2 orally twice daily
    • Administer first dose 30 minutes prior to chemotherapy on day 1.
    • Days 1 to 5
  • Granulocyte colony-stimulating factor
    • Start day 6

==========

2024-04-11

[reintroduction of R-COP for recurrent DLBCL, monitoring PLT trends]

R-COP was reintroduced today for the patient with pathologically confirmed recurrent DLBCL.

Historical records indicate leukopenia developed only after several treatment cycles, while hemoglobin levels remained stable between 9 and 11 g/dL, and platelet counts were within the normal range, although showing a gradual declining trend, currently below 200K/uL.

During this hospitalization, vital signs and serum glucose levels have been stable, with no medication discrepancies identified.

2023-05-10

• The patient’s current active medication list correctly reflects the refillable prescriptions provided by our gastroenterologist and endocrinologist. These medications include Spasmotin (hyoscyamine), Strocain (oxethazaine), Alpraline (alprazolam), MgO from the gastroenterologist, and Crestor (rosuvastatin), Galvus Met (vildagliptin, metformin), Norvasc (amlodipine), Relinide (repaglinide), Uformin (metformin), Tresiba FlexTouch (insulin degludec), and dipyridamole from the endocrinologist. As such, there are no identified medication reconciliation issues at this time.

• Hyoscyamine, a tropane alkaloid and the levo-isomer of atropine, is often employed to manage acute episodes of gastric secretion, visceral spasm, hypermotility in spastic colitis, pylorospasm, and associated abdominal cramps. Additionally, it can serve as adjunctive therapy in the treatment of peptic ulcers. However, considering the patient’s constipation (in the clinical problem list), and the fact that metoclopramide is concomitantly prescribed to mitigate potential nausea and vomiting effects caused by the R-COP regimen, it might be advisable to temporarily withhold hyoscyamine during the chemoimmunotherapy sessions.

• The HbA1c level, which reflects the average blood glucose level over the past two to three months, has reached a record high of 8.1%. This suggests that the patient’s current diabetes management plan may not be effectively controlling her blood sugar levels.

  • 2023-04-22 HbA1c 8.1 %
    
  • 2023-02-13 HbA1c 6.9 %

• Despite the patient’s current use of antidiabetic agents Galvus Met (vildagliptin, metformin), Relinide (repaglinide), Uformin (metformin), and Tresiba FlexTouch (insulin degludec), recent blood glucose readings have exceeded 200mg/dL (187mg/dL at 17:03 2023-05-09, 204mg/dL 20:25 2023-05-09 and 202mg/dL at 06:13 2023-05-10). This suggests that the patient’s glycemic control is currently suboptimal. An adjustment to the patient’s insulin regimen may be needed. It is recommended that the dose of insulin degludec be increased to 7 or 8 units, with close monitoring of the patient’s blood glucose levels. This adjustment should be particularly considered during periods when the patient is receiving steroids (as part of the R-COP regimen).

2023-03-16

• Due to the patient’s senior age, R-COP was selected over R-CHOP as the regimen. The patient is currently admitted for the second cycle of this chemoimmunotherapy.

• According to the available data from the past 6 months, there have been no instances of leukopenia or thrombocytopenia observed. However, there has been a slight presence of anemia during this time period, which is unlikely to be caused by the R-COP regimen since it was present even before the start of treatment.

• Please ensure that the patient is adequately hydrated and monitor her BUN readings, which have been trending upward, while serum creatinine remains normal.

  • 2023-03-14 BUN 38 mg/dL
    
  • 2023-03-02 BUN 40 mg/dL
    
  • 2023-02-17 BUN 28 mg/dL
    
  • 2023-02-07 BUN 20 mg/dL

• This patient has a history of diabetes, and despite taking Uformin (metformin 500mg) 1# BID, Galvus Met (vildagliptin 50mg + metformin 500mg) 1# BID, and Relinide (repaglinide 1mg) total 2# daily (the daily dose of metformin has already reached 2g and should not be increased further), her blood sugar levels range from 284 to 301mg/dL. R-COP chemotherapy regimen includes high doses of prednisolone, which can contribute to hyperglycemia. Similar to the management of type 2 diabetes, stepwise intensification of antihyperglycemic therapy and frequent re-evaluation should be considered in cases of steroid-induced hyperglycemia. ref: A Practical Guide for the Management of Steroid Induced Hyperglycaemia in the Hospital. J Clin Med. 2021;10(10):2154. Published 2021 May 16. doi:10.3390/jcm10102154

• The addition of a rapid-acting insulin (RI) may be beneficial for controlling hyperglycemia in this patient. However, careful monitoring of blood glucose levels and titration of insulin dose are necessary to prevent hypoglycemia. It is also important to continue evaluating and adjusting the patient’s antihyperglycemic therapy as needed.

2023-02-21

• The patient’s HGB reading has decreased by more than 10%, which should be monitored closely. It may be necessary to investigate for any potential underlying bleeding.
  • 2023-02-17 HGB 9.1 g/dL
    
  • 2023-02-13 HGB 9.1 g/dL
    
  • 2023-02-07 HGB 10.6 g/dL
• 2023-02-14 cardiac sonography reveals normal wall motion and preserved systolic function in both the left and right ventricles, with a LVEF of 75%. 2023-02-19 ECG showed a normal sinus rhythm, left axis deviation, and low voltage QRS. Started R-COP (R-CVP) on 2023-02-20. No dose adjustment is needed based on grossly normal 2023-02-17 lab data except for a slightly high BUN (28mg/dL), which warrants monitoring.
• Patients with high white cell count or bulky disease are at an increased risk of developing tumor lysis syndrome and reacting to Rituximab. As the patient’s WBC count was 4.52K/uL on 2023-02-17, it is less likely for her to develop tumor lysis syndrome.
• Patients should be advised that cyclophosphamide can irritate the bladder mucosa, and it is important to maintain a fluid intake of at least 3 liters a day for the next few days.
• Given that this patient is more than 70 years old but not immunosuppressed prior to chemotherapy, primary prophylaxis with G-CSF may not be absolutely necessary.
• (ref: https://nssg.oxford-haematology.org.uk/lymphoma/documents/lymphoma-chemo-protocols/L-82-r-cvp.pdf)

2023-02-14

• This patient is diagnosed with high grade DLBCL (2023-01-30 patho IHC (not FISH): MYC + 30-40%, BCL2 + 90%, BCL6 + 90%; triple hit)

• International Prognostic Index = 3 => Risk Group: High-intermediate, 5-yr OS 43% (ref: UpToDate)

  • (+) Age >60 : 81
  • (-) Serum lactate dehydrogenase concentration above normal : 148U/L 2023-02-07
  • (-) ECOG performance status >=2 : score = 1, 2023-02-13
  • (+) Ann Arbor stage III or IV : PET 2023-02-01 both sides of the diaphragm
  • (+) Number of extranodal disease sites >1

• Considering the patient is elderly, R-CHOP might be an alternative to R-DA-EPOCH. It might be necessary to perform a cardiac ultrasound prior to the treatment in order to establish a baseline. A lumbar puncture may be necessary if the CNS is involved.

(not posted)

Because chemotherapy-induced immunosuppression can potentially lead to HBV reactivation, which can result in discontinuation of cancer treatment, fulminant hepatitis, liver failure, and even death, proactive measures should be taken. The patient’s lab data from 2023-02-08 shows anti-HBc reactivity and an anti-HBc level of 5.18 S/CO. As a preventive measure, it is recommended that the patient be prescribed either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD.

[drug identification]

• We did not receive the drugs awaiting identification that day. The next day, we contacted the nurse by phone, who explained that the medication was too fragmented, so only the in-house medication was used instead.

700737864

240410

[lab data]

2024-03-05 CD45+Total leukocyte 370410 /uL
2024-03-05 %CD34+ 2.09 %
2024-03-05 CD34+ Count 7748 /uL

2024-03-05 CD45+Total leukocyte 63591 /uL
2024-03-05 %CD34+ 0.26 %
2024-03-05 CD34+ Count 164 /uL

2024-03-04 CD45+Total leukocyte 274765 /uL
2024-03-04 %CD34+ 4.10 %
2024-03-04 CD34+ Count 11270 /uL
2024-03-04 CD45+Total leukocyte 31784 /uL
2024-03-04 %CD34+ 0.70 %
2024-03-04 CD34+ Count 223 /uL

2024-03-01 CD45+Total leukocyte 800 /uL
2024-03-01 %CD34+ 0.25 %
2024-03-01 CD34+ Count 2 /uL

2024-02-22 CMV_IgG Reactive
2024-02-22 CMV_IgG Value 83.3 AU/mL

2024-02-22 CMV IgM Nonreactive
2024-02-22 CMV IgM Value 0.09 Index

2024-02-22 Anti HTLV I/II Nonreactive
2024-02-22 Anti HTLV I/II Value 0.09 S/CO

2024-02-22 HIV Ab-EIA Nonreactive
2024-02-22 Anti-HIV Value 0.06 S/CO

[exam findings]

• 2023-11-14 Ocular Fundus Photography
  • Left: PDR - proliferative diabetic retinopathy
  • Right: NDR - no diabetic retinopathy
• 2023-10-24 SONO - thyroid
  • Findings:
    • L’t : 0.3 * 0.1 * 0.3 cm
    • R’t : 0.5 * 0.3 * 0.6 cm ; 0.5 * 0.4 * 0.6 cm
  • Diagnosis: Thyroid Nodules
• 2023-07-18 Long Bones Series
  • An osteolytic lesion in right proximal femur is highly suspected. Please correlate with CT.
• 2023-07-18 Patho - bone marrow biopsy (Y1)
  • Bone marrow, iliac, biopsy — myeloma.
  • Specimen submitted in B5 fixative consists of 2 piece(s) of tan, rod shape bone marrow tissue measuring 1.2 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
  • Section shows piece(s) of bone marrow with 60% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes with many plasmacytoid cells. Megakaryocytes are adequate in number.
  • IHC stains: CD138 70% (of the nucleated cells); Kappa and lambda light chains: a predominant kappa stain (of the CD138 positive cells).
• 2023-06-20 SONO - nephrology
  • Bilateral parenchymal renal disease with small left kidney
  • Single renal cyst, right kidney
  • Nephrolithiasis, left kidney

[MedRec]

• 2023-08-11 SOAP Hemato-Oncology Gao WeiYao
  • Prescription
    • Thado (thalidomide 50mg) 2# HS
• 2023-07-28 SOAP Hemato-Oncology Gao WeiYao
  • O:
    • Lab 2023/07/13 B2-microglobulin (NM) = 3.12 mg/L
    • Lab 2023/07/13 Anti-HBc (NM) = Positive
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-07-24
      • multiple myeloma ISS lambda type stage I, use VTd regimen
  • A: Multiple myeloma, kappa, IgG, ISS stage I with anemia and kidney invlvement
• 2023-07-17 ~ 2023-07-19 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • monoclonal gammopathy
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Chronic kidney disease, unspecified
  • CC
    • for multiple myeloma survey
  • Present illness
    • This 58-year-old man has history of 1) DM, hypertension for 5-6 years and hyperlipidemia under medication treatment, 2) LUS s/p ESWL on 2017/8 and 2022/07; 3) TRUSP biopsy on 2020/12 and pathology showed stromal and glandular hyperplasia; 4)Left ureteral stone s/p left ureterorenoscopic lithotripsy with double-J stenting on 2022-11-18.
    • He has refered to ONC OPD due to presence of paraprotein on 2023/07/03. He complaint of severe low back pain and usually general bone pain bother him. Due to M-peak postive, so he was admitted for bone marrow exam plus cytogenetic and staging, skeletal survey on 2023/07/17.
  • Course of inpatient treatment
    • After admission, he received bone marrow for monoclonal gammopathy survey and pending report. Tramacet 1tab Q12H for lower back pain control. Under the stable condition, he can be discharged on 2023/7/19. OPD follow up is arranged.
  • Discharge prescription
    • Valtrex (valaciclovir 500mg) 2# Q12H
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ12H
• 2023-07-10 SOAP Hemato-Oncology Gao WeiYao
  • O:
    • Lab 2023/07/04 IgG (blood) = 2542 mg/dL;
    • Lab 2023/06/27 Free Light Chain kappa/lambda
      • FKLC = 60.9 mg/L;
      • FLLC = 17.1 mg/L
  • A: Multiple myeloma should be ruled in; IgG
• 2023-07-09 SOAP Hemato-Oncology Gao WeiYao
  • O: 2023/06/23 M-peak = Positive;
• 2022-11-18 ~ 2022-11-19 POMR Urology Xu JunKai
  • Discharge diagnosis
    • Left ureteral stone status post left ureterorenoscopic lithotripsy with double-J stenting on 2022-11-18
    • Acute kidney failure, suspect ureter stone obstruction related
    • Left hydronephrosis
    • Type 2 diabetes mellitus without complications
    • Hyperlipidemia, unspecified
    • Essential (primary) hypertension
  • CC
    • Left flank soreness off and on was found in this month.
    • Voiding difficulty was also noted
  • Present illness
    • This 58-year-old man has history of 1) DM, hypertension and hyperlipidemia under medication treatment; 2) LUS s/p ESWL on 2017-08 and 2022-07; 3) TRUSP biopsy on 2020-12 and pathology showed stromal and glandular hyperplasia.
    • According for this patient statement, left flank soreness off and on was found in this month. Voiding difficulty was also noted. He then visited our OPD for further help where KUB revealed left renal stones. Renal echo revealed left hydronephrosis.
    • Under the impression of left hydronephrosis suspect upper ureteral stone, we advised the patient to receive left URSL. After well explaining, the patient agreed. This time, he was admitted for further evaluation and management.
  • Course of inpatient treatment
    • After admission, the surgery of left ureterorenoscopic lithotripsy with double J stenting was performed on 2022-11-18. Postoperative course was uneventful. With fair urination and stable condition, he was discharged today and would be followed up at urologic clinic.
  • Discharge prescription
    • cephalexin 500mg 1# TID
    • Acetal (acetaminophen 500mg) 1# PRNQID
• 2017-12-23 SOAP Urology Xu JunKai
  • Diagnosis
    • Nocturia [R35.1]
    • Hypertrophy (benign) of prostate [N40.1]
    • Elevated prostate specific antigen (PSA) [R97.2]
  • Prescription x3
    • Harnalidge (tamsulosin 0.4mg) 1# QDAC
• 2017-01-06 SOAP Metabolism and Endocrinology Yu LiJiao
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Dyslipidemia ; other and unspecified hyperlipidemia [E78.5]
    • Essential (primary) hypertension [I10]
  • Prescription x3
    • Aprovel (irbesartan 300mg) 1# QD
    • Cardizem Retard (diltiazem 90mg) 1# QN
    • Uformin (metformin 500mg) 1# BID

[surgical operation]

• 2022-11-18
  • Operation
    • Ureterorenoscopic lithotripsy & double-J stenting, left
  • Finding:
    • One 0.7 x 0.6 cm brownish stone impacted at left middle ureter with polyposis and hydroureter
    • ureter orifice is very near bladder neck

[chemotherapy]

• 2024-04-02 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2024-03-27 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2024-02-22 - Endoxan (cyclophosphamide) 3000mg/m2 4750mg NS 500mL (before PBSC stem cell collection)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2024-02-06 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2024-01-30 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2024-01-23 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2024-01-16 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2024-01-10 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-12-19 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-12-12 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-12-05 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-11-28 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-11-21 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-11-14 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-11-07 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-10-31 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-10-24 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-10-18 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-10-11 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-10-04 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-09-26 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-09-19 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-09-12 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

• 2023-09-05 - bortezomib 1.3mg/m2 2.14mg SC 1min (VTd)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2024-02-19 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

• Cycle length: 28 days.

• Regimen

  • Bortezomib
    • 1.3 mg/m2 SC
    • Given as a single SC injection.
    • Days 1, 8, 15, and 22
  • Thalidomide
    • 100 mg for first 14 days then 200 mg per day thereafter by mouth
    • Take with water on an empty stomach at least one hour after the evening meal.
    • Daily, days 1 through 21
  • Dexamethasone (“low dose”)
    • 40 mg by mouth
    • Take with food (after meals or with food or milk) in the morning.
    • Days 1, 8, 15, and 22

Multiple Myeloma - VTD (IV-28)-Bortezomib (IV)-Dexamethasone-Thalidomide (28 day) - 2024-02-19 - https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Myeloma/MyelomaVTDBortezomibIVDexamethasoneThalidomideVer1.pdf

• 28 day cycle for up to 6 cycles

• Cycle 1

  • Bortezomib
    • 1.3mg/m2
    • 1, 8, 15, 22
    • Intravenous injection over 5 seconds
  • Dexamethasone
    • 20mg once a day in the morning
    • 1, 2, 8, 9, 15, 16, 22, 23
    • Oral
  • Thalidomide
    • 50mg once a day at night
    • 1-28
    • Oral

• Cycle 2, 3, 4, 5, 6

  • Bortezomib
    • 1.3mg/m2
    • 1, 8, 15, 22
    • Intravenous injection over 5 seconds
  • Dexamethasone
    • 20mg once a day in the morning
    • 1, 2, 8, 9, 15, 16, 22, 23
    • Oral
  • Thalidomide
    • 100mg once a day at night
    • 1-28
    • Oral

VTD - Bortezomib, Thalidomide & Dexamethasone - Multiple Myeloma - 2024-02-19 - https://www.clatterbridgecc.nhs.uk/application/files/3415/9679/5924/VTD__Bortezomib_Thalidomide__Dexamethasone_Multiple_Myeloma_Protocol_V1.0.pdf

• Dosage
  • Bortezomib
    • 1.3mg/m2
    • S/C
    • Day 1, 4, 8 and 11 of a 28 day cycle
  • Thalidomide
    • 50mg once daily at night. Titrate up to max daily dose of 200mg nocte
    • Oral
    • Days 1 to 28 (continuous)
  • Dexamethasone
    • 40mg
    • Oral
    • Days 1 to 4 and days 8 to 11

==========

2024-04-10

[pre-transplant meeting scheduled for patient and family]

The patient is scheduled for an autologous stem cell transplant. A pre-transplant meeting, led by the attending physician Dr Gao, on 2024-04-10 at 10:00 in the ward’s conference room, with the patient’s wife, son and daughter attending. The importance and risks of the transplant, along with precautions during the process, were thoroughly discussed.

Concerns were raised about the family minimum caregiving time required, considering the children’s education and the spouse’s employment.

At the meeting’s conclusion, the patient consented to the transplant.

Post-meeting, I emphasized the importance of infection prevention, with the family expressing understanding and willingness to cooperate.

With the transplant process approaching, thalidomide is discontinued, and the chemotherapy preparation team has been informed to ensure the safety of the medication used in the conditioning regimen.

2024-02-19

Since Sep 2023, IgG levels have returned to the normal range. The patient admitted this time for peripheral blood stem cell (PBSC) collection. Lab findings from 2024-02-06 were largely within normal limits. Medication not found to be missing.

• 2024-02-07 IgG (blood) 527 mg/dL
• 2024-01-23 IgG (blood) 572 mg/dL
• 2024-01-09 IgG (blood) 564 mg/dL
• 2023-12-26 IgG (blood) 462 mg/dL
• 2023-12-12 IgG (blood) 429 mg/dL
• 2023-11-28 IgG (blood) 427 mg/dL
• 2023-11-14 IgG (blood) 383 mg/dL
• 2023-10-31 IgG (blood) 329 mg/dL
• 2023-10-17 IgG (blood) 338 mg/dL
• 2023-10-04 IgG (blood) 387 mg/dL
• 2023-09-19 IgG (blood) 636 mg/dL
• 2023-08-18 IgG (blood) 2352 mg/dL
• 2023-07-04 IgG (blood) 2542 mg/dL

700340788

240409

==========

2024-04-09

[Aminosteril N-Hepa 8% Solution for Infusion]

“Aminosteril N-Hepa 8%, 500mL/bottle” is recommended to be administered at a rate of 1.3 to 1.5 mL/kg body weight per hour, equating to approximately 30 to 35 drops per minute for someone weighing 70 kg.

On 2024-04-09, the patient weighed 86.3 kg, suggesting a rate of 112 to 130 mL per hour or 37 to 43 drops per minute. However, it is advisable not to exceed 100 mL per hour or 30 drops per minute.

700575407

240409

[diagnosis] - 20221220 admission note

• Follicular lymphoma, grade 1 with left axillary, mediastinum, mesentery and retroperitoeum invasion, stage III, FLIPI:4, IPI:2
• Irritable bowel syndrome with diarrhea
• Type 2 diabetes mellitus without complications
• Pure hypercholesterolemia
• Chronic viral hepatitis B without delta-agent

[exam findings]

• 2024-02-21 SONO - thyroid
  • Findings: R’t : 0.30.20.3 cm ; 1.10.81.5 cm
  • Diagnosis: multiple thyroid nodules, autoimmune thyroid disease
• 2024-01-29 SONO - breast
  • Bilateral breast tumors, r/o fibroadenomas. Suggest follow up.
  • BI-RADS2. benign finding
• 2024-01-29 CT - abdomen
  • History and indication: lymphoma
  • With and without contrast CT of abdomen - pelvis revealed:
    • Mild splenomegaly. Tiny liver cysts. S/P Port-A infusion catheter insertion.
    • Atherosclerosis of aorta.
  • IMP:
    • Mild splenomegaly. Tiny liver cysts.
• 2023-12-07 Ocular Fundus Photography
  • fundus : mild NPDR with hard exudate ou ou
• 2023-10-13 CT - abdomen
  • History and indication: Follicular lymphoma
  • Findings:
    • Prior CT identified a cystic lesion (2.4cm) at left axillary region. is not noted again in the current CT.
  • Impression:
    • There is no focal lesion in both lung and mediastinum.
• 2023-07-07 CT - abdomen
  • History and indication: Follicular lymphoma
  • Impression:
    • There is no focal lesion in both lung and mediastinum.
    • Prior CT identified a cystic lesion (2.4 cm) at left axillary region is not noted again.
    • Prior CT identified some LNs (up to 2.3cm) at bil. axillary regions, inguinal regions, mediastinum, mesentery and para-aortic space are not noted again.
• 2023-07-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (76.4 - 25.8) / 76.4 = 66.23%
    • M-mode (Teichholz) = 66.2
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Mild MR, TR and PR
    • No regional wall motion abnormalities
• 2023-06-20 Mammography
  • Impression: No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
  • BI-RADS: Category 1: negative. - annual screening.
• 2023-06-08 Sono-guide aspiration of right thyroid
  • Benign follicular nodule
    
  • Two wet smears show colloid, blood, lymphocytes, pigmented macrophages and benign follicular cell clusters with focal reactive atypia.
• 2023-05-10 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2023-05-05 Thyroid Ultrasound
  • Echo: Heterogeneous echo
  • Ultrasound Result - Nodules:
    • Right side: 0.30.20.4 cm ; 1.10.91.5 cm
  • Diagnosis: Multinodular goiter, Autoimmune thyroid disease
• 2023-04-18, -04-14 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
  • There are several nodular opacities on both lung and Patchy consolidation at right lower lung. Please correlate with clinical condition and CT.
• 2023-04-13 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A (minimal)
• 2023-04-12 CT - abdomen
  • History and indication: Follicular lymphoma
  • Findings:
    • There are several patchy consolidations of the RML, RLL and LLL of the lung.
      • In addition, few nodular infiltrations in RUL and LUL of the lung are suspected.
      • Bronchopneumonia is highly suspected. please correlate with clinical condition.
    • Mild bilateral pleura effusion are noted.
    • Prior CT identified a cystic lesion (7.8cm) at left axillary region. is noted again, marked decreasing in size to 2.4 cm.
    • Prior CT identified some LNs (up to 2.3cm) at bil. axillary regions, inguinal regions, mediastinum, mesentery and para-aortic space are noted again, decreasing in size.
    • Prior CT identified prominence in size of the spleen (long axis: 11.8 cm) is noted again, mild decreasing in size to 10.5 cm.
  • Impression:
    • Bronchopneumonia on both lungs are suspected.
• 2023-04-08 CXR
  • Consolidation in right lower lung.
  • Thoracic spondylosis.
• 2023-03-06 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2023-01-17 Sacrum & Coccyx
  • Spondylolisthesis of L4-5 or L5-S1 (< Grade I) is noted.
  • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
• 2023-01-03, 2022-11-30 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2022-11-29 Whole body PET scan
  • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above (stage III).
• 2022-11-28 Patho - bone marrow biopsy
  • PATHOLOGIC DIAGNOSIS
    • Bone marrow, buttock, biopsy — Free from lymphoma involvement
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of two strips of bone marrow tissue measuring up to 1.8 x 0.3 x 0.3 cm in size, fixed in B-5 solution. Grossly, it was red-tan in color and bony hard in consistence. All embedded for sections after short decalcification.
  • MICROSCOPIC EXAMINATION -Relatively normocellularity for her age, 40% -No increase of blast -A few lymphocyte aggregates, a mixture of T and B cells, interstitial or paratrabecular distribution, CD10(-) and Bcl-6(-), compatible with benign aggregates and free from follicular lymphoma involvement -Immunohistochemistry: CD3(+), CD20(+), CD34(+ for blast), CD10(-) and Bcl-6(-)
• 2022-11-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (85 - 27) / 85 = 68.24%
    • LVEF (%) = 68
    • M-mode (Teichholz) = 68
  • Normal LV systolic function with normal wall motion.
  • Normal LV diastolic function.
  • Normal RV systolic function.
  • Mild MR; mild TR.
• 2022-11-26 CT - abdomen
  • A cystic lesion (7.8cm) at left axillary region. Some LNs (up to 2.3cm) at bil. axillary regions, inguinal regions, mediastinum, mesentery and retroperitoeum. Splenomegaly.
• 2022-11-17 Thyroid Ultrasound
  • R’t : 0.30.20.3 cm ; 1.10.91.5 cm
  • Multinodular Goiter, Autoimmune thyroid disease
• 2022-11-09 Patho - lymph node region resection
  • DIAGNOSIS:
    • A: Lymph node, left mediastinum, group 5, dissection — Follicular lymphoma, grade 1
    • B: Lymph node, left mediastinum, group 11, dissection — Follicular lymphoma, grade 1
    • C: Lymph node, left axillary, dissection — Follicular lymphoma, grade 1
  • GROSS DESCRIPTION:
    • A: Specimen submitted in formalin consists of several lymph nodes measuring up to 1.3 x 1.1 x 0.5 cm. All for section in one cassette A.
    • B: Specimen submitted in formalin consists of a lymph node measuring 1.3 x 0.6 x 0.5 cm. All for section in one cassette B.
    • C: Specimen submitted in formalin consists of several lymph nodes measuring up to 4.0 x 2.2 x 1.5 cm. Representative sections are taken in 4 cassettes C1-4.
  • MICROSCOPIC DESCRIPTION:
    • Sections of specimens A, B, and C show enlarged lymph nodes with closely packed, atypical follicles.
    • The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(+), CD10(+), CD43(-), Cyclin D1(-), CD15(-), and CD30(-).
    • The centroblasts are < 5/HPF. The results are consistent with grade 1 follicular lymph
• 2022-10-17 Patho - lymphnode biopsy
  • DIAGNOSIS:
    • Lymph node, left axillary, core needle biopsy — reactive lymphoid hyperplasia
  • Description:
    • The specimen submitted consists of 2 tissue fragments measuring up to 0.8x 0.1x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic.
    • Microscopically, it shows hyperplasia of small-type lymphocytes.
    • Immunohistochemical stain reveals CK(-), CD3 (immunoreative at T-cells), CD20 (immunoreative at B-cells),
• 2022-10-13 CT - chest
  • Indication:
    • Neoplasm of uncertain behavior of skin
    • Unspecified lump in breast
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Extensive lymphadenopathy at left axillary region and in lesser degree at right axillary area.
      • Small lymph nodes are found at both sides of the mediastinum and subcarina region.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Small lymph nodes are found in the mesentery.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Bilateral axillary lymphadenopathy and mediastinal, mesenterric lymphadenopathy
• 2022-10-03 Patho - lymphnode biopsy
  • Lymph node, left axillary, CNB — Negative for malignancy
• 2022-10-03 SONO - breast
  • Findings
    • Parenchymal pattem, Involuted
    • Focal sonographic lesion, enlarged left axillary LNs
  • Diagnosis
    • enlarged left axillary lymph nodes, suspected LAPs
  • Treatment
    • Sono-guided biopsy, Core-needle biopsy
  • Suggestion and Plan
    • arrange biopsy
    • BI-RADS 4B - intermediate suspicion of malignancy Biopsy Should Be Considered
• 2022-09-29 SONO - breast
  • CC and Indication
    • Palpable axillary lymph nodes
  • History
    • No specific risk factors
  • Findings
    • Parenchymal pattem
      • Involuted
    • Focal sonographic lesion
      • tiny FCDs
      • enlarged left axillary LNs
  • Diagnosis
    • Benign neoplasm of breast, infavor of benign fibrocystic disease(FCD)enlarged left, axillary lymph nodes, suspected LAPs
  • Treatment
    • Sono-guided biopsy,Core-needle biopsy
  • Suggestion and Plan
    • arrange biopsy
    • chest CT scan
    • BI-RADS 4B - intermediate suspicion of malignancy Biopsy Should Be Considered
• 2022-08-18 Thyroid Ultrasound
  • R’t : 0.20.10.3 cm ; 1.00.71.5 cm
  • Multinodular Goiter
• 2022-04-19 SONO - breast
  • Findings
    • Parenchymal pattem, Involuted
    • Focal sonographic lesion, tiny FCDs
  • Diagnosis
    • Benign neoplasm of breast, infavor of benign fibrocystic disease (FCD)
  • Treatment
    • No need to biopsy
  • Suggestion and Plan
    • Regular OPD follow-up, Follow up breast sonography in next OPD visit
    • BI-RADS 2 - Benign Finding

[surgical operation]

• 2022-10-03
  • Surgery
    • Lymph node biopsy
    • Intraoperative sonography (19002B)
  • Finding
    • IOUS: multiple enlarged axillary LNs, suspected LAPs, or occult breast cancer with axillary LAPs

[chemoimmunotherapy]

• 2024-04-09 - rituximab 375mg/m2 600mg NS 500mL 10hr (rituximab maintenance, Q3M x8 cycles for 2 years)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + acetaminophen 500mg PO + NS 250mL
• 2024-01-09 - rituximab 375mg/m2 600mg NS 500mL 10hr (rituximab maintenance, Q3M x8 cycles for 2 years)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + acetaminophen 500mg PO + NS 250mL
• 2023-10-02 - rituximab 375mg/m2 600mg NS 500mL 12hr + vincristine 1mg NS 50mL 10min (rituximab maintenance, Q3M x8 cycles for 2 years, vincristine will be DC next time)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + acetaminophen 500mg PO + NS 250mL
• 2023-07-05 - rituximab 375mg/m2 600mg NS 500mL 12hr + vincristine 1mg NS 50mL 10min (rituximab maintenance, Q3M x8 cycles for 2 years, vincristine will be DC next time)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + acetaminophen 500mg PO + NS 250mL
• 2023-03-27 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W) (WBC 180/uL 2023-04-08)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• 2023-03-06 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W) (WBC 760/uL 2023-03-16)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• 2023-02-13 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-COP, leukopenia, WBC 620/uL 2022-12-13)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• 2023-01-16 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• 2022-12-20 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• 2022-12-01 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3

Rituximab (intravenous) including biosimilars - 2024-04-09 - https://www.uptodate.com/contents/rituximab-intravenous-including-biosimilars-drug-information

• Follicular, CD20-positive, B-cell, previously untreated (Rituxan and rituximab biosimilars): IV: 375 mg/m2 on day 1 of each chemotherapy cycle for up to 8 doses (in combination with first-line chemotherapy).
  • Maintenance therapy (as a single agent, in patients with partial or complete response to rituximab plus chemotherapy): Note: Begin 8 weeks after completion of rituximab in combination with chemotherapy. IV: 375 mg/m2 once every 8 weeks for 12 doses.
• Relapsed/Refractory, low-grade or follicular CD20-positive, B-cell (Rituxan and rituximab biosimilars): IV: 375 mg/m2 once weekly for 4 or 8 doses (as a single agent). Re-treatment following disease progression: 375 mg/m2 once weekly for 4 doses.
  • Follicular lymphoma, relapsed (single-agent therapy; off-label dosing): IV: 375 mg/m2 once weekly for 4 doses followed by 375 mg/m2 once every 2 months for 4 additional doses.
  • Follicular lymphoma, relapsed/refractory, maintenance therapy (as a single agent, in patients with response to induction therapy; off-label dosing): IV: 375 mg/m2 every 3 months until relapse or for maximum duration of 2 years.
  • Follicular lymphoma, relapsed/refractory (off-label combination): IV: 375 mg/m2 on days 1, 8, 15, and 22 of cycle 1 (28-day cycle), followed by 375 mg/m2 on day 1 every 28 days of cycles 2 to 5 (in combination with lenalidomide).

==========

2024-04-09

The patient was found to have mild microcytic anemia and hypomagnesemia.

MgSO4 is currently being administered, and iron supplementation might be added to address the anemia.

• 2024-04-08 HGB 11.6 g/dL
• 2024-04-08 MCV 72.4 fL
• 2024-04-08 Mg (Magnesium) 1.5 mg/dL

2023-07-06

• This patient has only visited our hospital in the past three months, mainly attending the hemato-oncology department, followed by the metabolism and endocrinology department. The former is for the treatment of follicular lymphoma, while the latter is for the management of type 2 diabetes mellitus.

• The Uformin (metformin 500mg) 1# BID and Januvia (sitagliptin 100mg) 1# QD prescribed on 2023-05-12 by the metabolism and endocrinology department have been listed as patient-carried items in the active medication list. No medication reconciliation issues have been identified.

• The last CT is dated on 2023-04-12, now in the beginning of July, a new CT scan could be considered to be arranged.

2023-04-10

• The patient’s ANC was 12.7/uL on 2023-04-08. However, after receiving lenograstim 250ug daily since that day, her ANC increased to 1725/uL on 2023-04-10.
• The patient has been experiencing intermittent fever since 2023-04-08. She is currently being treated with cefepime 2g Q8H for neutropenic fever.
• The management of serum glucose has been better during this hospitalization as it has not exceeded 200mg/dL except for the first day, which is an improvement compared to before.
• There is no problem with the active prescription when it comes to medication reconciliation.

2023-03-07

• WBC > 5K/uL post last leukopenia (WBC 620/uL 2022-12-13).
• The patient’s pre-prandial blood sugar level has increased from 208 to 225 mg/dL during this hospitalization. If hyperglycemia persists or worsens, the addition of some insulin regimen may be beneficial.

2023-02-14

• A leukopenia event was observed (WBC 620/uL 2022-12-13). The R-CHOP was changed to the R-COP (hold doxorubicin, 2023-02-13 lab WBC 2.65K/uL, Neutrophil 55% => ANC 1450/uL) during this hospitalization.
• The level of blood sugar is rising (127 -> 170 -> 232mg/dL). For individuals with pre-existing diabetes, their diabetes medications might need to be adjusted while taking steroids (R-COP’s P). If preprandial blood sugar level >= 200mg/dL, it is suggested to add some insulin to mitigate the steroid-induced hyperglycemia. (ref: Steroid hyperglycemia: Prevalence, early detection and therapeutic recommendations: A narrative review. World J Diabetes. 2015;6(8):1073-1081. doi:10.4239/wjd.v6.i8.1073)

2023-01-17

• 2023-01-10 lab data showed HGB 10.5g/dL, MCV 69.4fL, MCH 20.8pg, MCHC 30.0g/dL. These readings were all below their normal ranges.

• Assessment based on the above lab items:

  • MCV (mean corpuscular volume) is the average volume (size) of the RBCs. Microcytosis (low MCV), a decreased MCV (usually <80 fL) reflects a defect in cellular hemoglobin synthesis. Iron deficiency and thalassemia are the most likely causes of a very low MCV (<80 fL).
  • MCH (mean corpuscular hemoglobin) is the average hemoglobin content in a RBC. A low MCH is typically reflected in an enlarged area of central pallor in RBCs on the peripheral blood smear (greater than one-third of the RBC diameter), which defines “hypochromia” on the blood smear. This may be seen in iron deficiency and thalassemia.
  • MCHC (mean corpuscular hemoglobin concentration) is the average hemoglobin concentration per RBC. Very low MCHC values are typical of iron deficiency anemia

• Recommendation:

  • Foliromin (ferrous sodium citrate 50mg/tab) 1~2# BID PO

2022-12-21

• Pre-prandial FS glucose levels recorded as 222, 346, 241 mg/dL, under current oral metformin and RI injection, still remain high, so it might be appropriate to gradually increase the dose of RI by 2 to 3 units or to add back Januvia (sitagliptin 100mg) QD.
• A grade 4 leukopenia event occurred 2 weeks after the first R-CHOP treatment (WBC 620/uL 2022-12-13). The event is no more observed after immediate administration of G-CSF for the next 3 consecutive days. WBC levels might be monitored closely after chemotherapy, especially for the first 1 to 2 weeks.
• The bowl movement in this patient reached four times during the first half of the day 2022-12-21. Loperamide can help with short-term diarrhoea or irritable bowel syndrome. Loperamide can also be used for recurring or longer lasting diarrhoea from bowel conditions such as Crohn’s disease, ulcerative colitis and short bowel syndrome.

700064816

240403

[exam findings]

• 2024-03-25 Tc-99m MDP bone scan
  • A hot area in the left aspect of the mandible, the nature is to be determined (advanced cancer, dental problem, post-traumatic change or other nature ?), suggesting PET scan for further evaluation.
  • Suspected benign lesions in the right frontal region of the skull, maxilla, some T- and L-spine, right sternoclavicular junction, bilateral shoulders, and S-I joints.
• 2024-03-22 MRI - nasopharynx
  • Oralcavity
    • Impression (Imaging stage): T:4b N:2c M:0 STAGE:IVB
• 2024-03-22 SONO - abdomen
  • Pneumobilia, bil
  • Propable liver calcification, right
  • Pancreas and GB not shown
  • Suboptimal examination of liver, especially the subcostal view due to Very poor echo window(disruption of the transmission of US waves by bowel gas and patient’s body habitus)
• 2024-03-21 CXR erect
  • Diffuse emphysematous change of both lungs with fibortic change.
  • Bullae over right apical lung.
  • Degenerative joint disease of T-spine with marginal osteophytes.
  • S/P port-A catheter insertion.
• 2024-03-20 CXR erect
  • Tortuosity of the aorta with atherosclerotic change.
  • Diffuse emphysematous change of both lungs with fibortic change.
  • Bullae over right apical lung.
  • Degenerative joint disease of T-spine with marginal osteophytes.
• 2024-03-12 Patho - gingival/oral mucosa biopsy
  • Mandibular gingiva, left, incisional biopsy — Squamous cell carcinoma, moderately differentiated
  • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation and tumor necrosis are present.
• 2024-02-21 Patho - gingival/oral mucosa biopsy
  • Labeled as “left soft palate”, biopsy — ulcer with atypical squamous cells. Nuclear feature suggestive of herpes virus inclusions.
  • Section shows squamous mucosa lined tissue with ulcer and atypical squamous cells. Nuclear feature suggestive of herpes virus inclusions.
• 2024-02-20 Sinoscopy
  • Description:
    • thick crust at bi NP, removed;
    • right S ostium patent;
    • right F recess and E sinus edema (F ostium not seen),
    • no tumor found at right M sinus (PE: no enlarged neck mass, oral cavity and oropharynx: a 0.3 cm ulcerative lesion at left soft palate, biopsy done)
  • Impression:
    • right Nasal NK/T lymphoma s/p treatment, no tumor recurrence
    • right CPS s/p op
    • soft palate lesion, biopsy done
• 2023-10-17 CXR
  • PA chest image shows:
    • ring-shadows and dilated bronchi at volume loss RUL, reticulonodular opacities with ring-shadows at left upper lung zone, and reticular opacities over Rt midlung zone, stationary as compared with previous chest image
    • elongated and tortuosity of thoracic aorta
    • mild enlarged cardiac silhoutte
    • Mild dextroscoliosis of the T-spine
  • Impression:
    • Post-primary tuberculosis change, stationary

[MedRec]

• 2024-03-19 SOAP Oral and Maxillofacial Surgery Xu BoZhi
  • O
    • 2024/03/12 PATHO - Gingival/oral mucosa biopsy
      • Mandibular gingiva, left, incisional biopsy — Squamous cell carcinoma, moderately differentiated
    • Squamous cell carcinoma of left mandibular gingiva, cT4a N0M0 Steage IVa since 2024/03/12
  • A/P
    • Explain the finding and discuss the treatment plan with patient
    • Arrange admission for tumor survey
    • OPD follow up
• 2024-03-12 SOAP Oral and Maxillofacial Surgery Xu BoZhi
  • S:
    • Ask for oral examination
  • O
    • Panoramic findings:
      • Missing: 12 17 18 22 28 37 38
      • Impaction: nil
      • Crown and Bridge: nil
      • Caries: nil
      • Residual root: 13 14 15 23 24 25 26 27 31 32 33 34 35 36 41 42 43 44 45 46 47 48
      • Periodontal condition: chronic periodontitis
    • A protruding mass with ulcerative surface over left mandible, about 7*5 cm in size. Bone destruction over left mandible was noted on panoramic film.
  • A/P
    • Take panoramic film for FM check
    • Explain the finding and discuss the treatment plan with patient
    • Incisional biopsy of left mandibular gingiva
    • Medication
    • OPD follow up
  • Prescription
    • amoxicillin 250mg 2# Q8H
    • Acetal (acetaminophen 500mg) 1# QID
• 2023-04-02 ~ 2023-04-11 POMR General and Gastrointestinal Surgery Chen YenZhi
  • Discharge diagnosis
    • Rupture gallbladder with cholecystitis and liver abscess status post percutaneous transhepatic gallbladder drainage on 2023/04/06
    • Unspecified jaundice
    • Nasal Natural Killer/T-Cell lymphoma, stage IIEB
  • CC
    • Epigastric pain, nausea and vomiting on 2023/03/12.
    • Jaundice and tea color urine was noted for about 3 days and poor appetite for one week, body weight loss 5kg within 2weeks.
    • Abnormal finding of abdomen echo of gallbaldder
  • Present illness
    • This 60 year-old male has underlying with:
      • 1. Hypertension,
      • 2. Hypertensive cardiovascular disease with cardiomegaly,
      • 3. Old TB s/p treatment, completed in Apr, 2010/04, with RUL cystic bronchiectasis,
      • 4. Chronic alcoholism (sorghum liquor 500ml/day, for 20+ years, quit for several weeks),
      • 5. Nasal NK/T lymphoma, stage IIEB, s/p operation on 2009/09/30, s/p radiotherapy x 5040cGy/28fr from 2009/10/22 to 2009/12/11, s/p chemotherapy CHOP 8 cycles from 2009/10/16 to 2010/05/20,
      • 6. Right maxillay sinus floor large necrotic bone exposure s/p sequestrectomy on 2010/08/27,
      • 7. Intermittent right epistaxis since 2013/05, s/p cauterization on 2013/07/17, still intermittent epistaxis thereafter, s/p right FESS (for CPS) + SP artery ligation on 2013/08/07.
    • He came to our emergency department on 2023/03/12 with chief complaint of epigastric pain, nausea and vomiting. Laboratory data showed anemia (Hb:12.3 g/dL), hyponatremia (122 mmol/L), hypokalemia (2.9 mmol/L), hyperbilirubinemia (TBI:1.52 mg/dL). He was then discharged with symptomatic medicaitons. Then he came back to GI OPD on 2023/03/29, when jaundice and tea color urine was noted for about 3 days and poor appetite for one week, body weight loss 5kg within 2weeks.
      • Check laboratory data showed anemia (Hb:10.5 g/dL), hyponatremia (124 mmol/L), elevated liver enzymes (AST:87 U/L, ALT:84 U/L), hyperbilirubinemia (TBI:13.48 mg/dL, DBI:7.91 mg/dL), elevated biliary enzymes (GGT:499 U/L, ALK-P:414 U/L).
      • Tumor markers survey was done (AFP:2.4:ng/ml, CEA:1.95:ng/mL, elevated CA199:2045 U/ml).
      • Abdominal echo was done on 2023/03/31 which reported dilated bilateral IHDs and CBD, with one 4.9 x3.6cm hyperechoic lesion in GB with wall thickening. GB cancer was suspicious.
    • On 2023/04/01, he referred to our GS OPD. He had no more abdominal pain now but had no stool passage for 2 weeks. Now, physical examination showed icteric sclera, abdomen soft and flat, no tenderness nor Murphy’s sign.
    • With the impression of suspect gallbladder malignancy, the patient was admitted on 2023/04/02 for cancer survey.
  • Course of inpatient treatment
    • After admitted, on 2023/04/03 following lab data showed decrease of bilirubin (TBI: 13.48 -> 6.89).
    • We arrange liver CT for jaundice survey which revealed acute cholecystitis with gallstone impaction, rupture of the GB is suspected on 2023/04/03.
    • Thus, we add empiric antibiotic with Flumarin for cholecystitis treatment and consulted rediologist for PTGBD was performed on 2023/04/06.
    • He complained dyspnea, we following chest x-ray showed no pleural effusion no pneumonia patch and anemia (Hb: 8.3), thus blood transfusion with LPRBC 2U on 2023/04/07.
    • The bile culture showed Staphylococcus aureus, therefore antibio shift to Moxifloxacin on 2023/04/10. Patient is generally well beings and relativley stable.
    • There were no nosocomial infection and other complications. The bowel function, urinary or pulmonary function were normal was tolerable
    • Under improved general condition and lab data, he was allowed to discharge today, keep PTGBD drainage and antibiotic with oral Moxifloxacin then OPD follow up was arranged.
  • Discharge prescription
    • Biofermin0R (antibiotics resistant lactic acid bacteriae 1gm) 1# TID
    • Avelox (moxifloxacin 400mg) 1# QDAC
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • BaoGan (silymarin 150mg) 1# TID
    • Genurso (ursodeoxycholic acid 100mg) 1# BID
    • Lactul (lactulose 666mg/mL) 15mL PRNTID if constipation
    • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# TID
    • Mycom (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI

[consultation]

• 2024-03-25 Gastroenterology
  • Q
    • This 61 year-old male has underlying with 1) Nasal NK/T lymphoma, stage IIEB, post of operation on 2009/09/30, post of radiotherapy x 5040cGy/28fr from 2009/10/22 to 2009/12/11, post of chemotherapy CHOP 8 cycles from 2009/10/16 to 2010/05/20. 2) Right maxillay sinus floor large necrotic bone exposure post of sequestrectomy on 2010/08/27. Then he was followed up at ENT OPD regularly.
    • He suffered from squamous cell carcinoma of left mandibular gingiva, cT4aN0M0 Stage IVA. We will arrange induction chemotherapy for him.
    • His laboratory showed Albumin 3.8 , Anti-HBc (+), HbsAg (-) ,Anti-HBe (-). We need your further evaluation and suggestion. Thanks !
  • A
    • The 61 years old man with lymphoma, s/p operation and CCRT. Due to oral cancer, he would received chemotherapy in the future. For positve anti-HBc, we are consulted
    • Lab
      • 2024-03-25 Anti-HBe Nonreactive
        
      • 2024-03-25 HBsAg Nonreactive
        
      • 2024-03-25 Anti-HBs 2.57 mIU/mL
        
      • 2024-03-25 Anti-HBc Reactive
        
      • 2024-03-25 AFP 1.6 ng/mL
        
      • 2024-03-20 Creatinine 0.95 mg/dL
        
    • 2024/3/12 abdominal echo
      • Pneumobilia, bil
      • Propable liver calcification, right
      • Pancreas and GB not shown
    • impression
      • occult HBV infection
      • squamous cell carcinoma of left mandibular gingiva, cT4aN0M0 Stage IVA, plan for chemotherapy
      • Nasal NK/T lymphoma , stage IIEB, s/p op and CCRT since MK 2009
      • RT x5040cGy/28fr since 2009-10-22 to 2009-12-11
    • suggestion
      • prophylactic Nucleic acid analogs for the patient is indicated due to plan of chemotherapy.
      • we would prescribe the medication for the patient
      • GI OPD follow-up
• 2023-04-06 Diagnostic Radiology
  • Q
    • for PTGBD
    • This 60 y/o male with past history of 1. Hypertension 2. Hypertensive cardiovascular disease with cardiomegaly 3. TB s/p treatment, completed in 2010-04, with RUL cystic bronchiectasis 4. Chronic alcoholism (sorghum liquor 500ml/day, for 20+ years, quit for several weeks).
    • This time, he c/o epigastric pain, nausea and vomiting fo days. He came to our ER for help. Abdominal echo was done on 3/31 which reported dilated bilateral IHDs and CBD, with one 4.9 x3.6cm hyperechoic lesion in GB with wall thickening.
    • Due to acute cholecystitis r/o perforation with abscess, further PTGBD was indicated. We need your help for PTGBD management for this case. Thanks for your time!!
  • A
    • According to the clinical condition and imaging findings, PTGBD is indicated.

[chemotherapy]

• 2024-03-26 - docetaxel 40mg/m2 70mg NS 150mL 1hr + carboplatin AUC 2 150mg NS 300mL 3hr + fluorouracil 1000mg/m2 1700mg leucovorin 100mg/m2 170mg NS 1000mL 22hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

==========

2024-04-03

[chemo-related anemia (likely docetaxel/carboplatin) - transfusion given, monitor Hgb for repeat]

The patient received docetaxel, carboplatin, leucovorin, and fluorouracil chemotherapy on 2024-03-26. One week later, on 2024-04-02, grade 3 anemia was identified.

Docetaxel and carboplatin are both known to cause anemia. The incidence of grade 3/4 anemia with docetaxel is reported to be 8% to 9%, while the incidence with carboplatin is reported to range from 21% to 90%.

Given the anemia, a transfusion of LPRBC was appropriately initiated on 2024-04-02. It is recommended to continue monitoring Hgb levels to determine if further transfusions are necessary.

!!! make this fluent:

This patient received docetaxel + carboplatin + leucovorin + fluorouracil on 2024-03-26 and after 1 week 2024-04-02 grade 3 anemia was observed.

• 2024-04-02 HGB 7.5 g/dL
  
• 2024-03-20 HGB 10.0 g/dL
  
• 2024-02-27 HGB 11.3 g/dL

Anemia is likely to be associated with docetaxel and carboplatin, for the instance of the former is 65% to 97% (grades 3/4: 8% to 9%) and instance of the latter 21% to 90%.

LPRBC transfusion is indicated for this condition and has been conducted since 2024-04-02. Please keep follow up the HGB reading to decide if more transfusion is needed.

700370264

240403

{Recurrent hepatocellular carcinoma with lung metastasis, rycT3N0M1, stage IVB}

[diagnosis] - 2022-11-19 admission note

• Encounter for antineoplastic chemotherapy
• Liver cell carcinoma
• Secondary malignant neoplasm of unspecified lung
• Malignant neoplasm of pancreas, unspecified
• Encounter for antineoplastic immunotherapy
• Mild intermittent asthma, uncomplicated

[past history] - 2022-11-19 admission note

• Chronic hepatitis
• Frequent acute pancreatitis episodes in 2006, 2007, 2008, 2014/03/05 and 2014/09/30,
• Pancreatic intraductal papillary mucinous carcinoma, invasive pStage (pT1N0M0) s/p PPPD in 2014
• HCC s/p S8 segmentectomy on 2016/06/30, pT2Nx(cMx), stage II.
• Post S8 segmentectomy with liver abscesss/p pig-tail drainage on 2016/07/12, discharged on 2016/07/20.
• Hepatocellular carcinoma, recurrent (S2-3 and S7) rpT3bNx(cMx) stage IIIb s/p S2-3 hepatectomy and S7 partial hepatectomy on 2016/10/03. Keep Target therapy (Nexavar) side effect management since 2016/10/23-10/26. Post operation, liver abscess again s/p pig-tail insertion on 2016/11/02.
• Recurrent hepatocellular carcinoma, s/p TACE on 2017/08/08 and 2020/09/29, s/p S7 partial hepatectomy, adhesivelysis with bowel repair, and diaphragm resection with repair by chest surgeon on 2020/11/16; recurrent HCC s/p TACE on 2021/09/14, 2021/12/30, 2022/03/23 and immunotherapy with Nivolumab on 2021/09/08, 2021/10/08, 2021/12/07, 2021/12/31, 2022/01/24, 2022/03/23.     

[exam findings]

• 2024-03-18 Tc-99m MDP bone scan
  • Several faint hot spots in the anterior aspect of the right rib cage, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral shoulders, S-I joints, hips, femurs, knees, and right tibia.
• 2024-03-14 ECG
  • Right bundle branch block
  • T wave abnormality, consider inferior ischemia
• 2024-03-13 CXR erect
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2024-01-19 CT - chest
  • Chest and Abdominal CT with and without enhancement revealed:
    • Right pleural thickening is found.
    • S/p port-A placement with its tip at Superior vena cava
    • One lobulated nodule at left lower lobe measuring 1.43cm in largest dimension. (Se202 Im121). In comparison with CT dated on 2023-06-17, the lesion is new.
    • One ground glass nodule at right upper lobe measuring 0.67cm in largest dimension. (Se202 Im98). Stable.
    • Several nodular lesions are found at bilateral upper lobes which are not seen at previous CT. Meta is considered.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Marginal enhanced hepatic tumors are found at residual right lobe liver measuring 2.65cm and 2.61cm and 1.01cm respectively. (Se301 Im65, IM81)
    • s/p subtotal gastrectomy.
  • Imp:
    • HCC s/p op. with local recurrence and bilateral lung meta.
    • Bone meta.
• 2023-12-19 Patho - stomach subtotal/total (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Stomach, partial gastrectomy — Compatible with metastatic hepatocellular carcinoma
    • Unlabelled margin, ditto — Free of tumor invasion, closest margin is 0.6 cm
    • Lymph node — Not received
  • MACROSCOPIC EXAMINATION
    • Specimen type: stomach
    • Specimen size: 5.4 x 4.2 x 2.4 cm
    • Number of tumor: solitary
    • Tumor size: 2.7 x 1.9 x 1.5 cm
    • Tumor configuration: polypoid mass
    • Representatively embdeed for section in cassette A1-A2: tumor + margins, A3: tumor and A4: other unlabelled margins
  • MICROSCOPIC EXAMINATION
    • Histologic type: poorly differentiated carcinoma, compatible with metastatic hepatocellular carcinoma (according to the pathologic report of S2023-22397)
    • Histologic grade: Grade 3, poor differentiation
    • Depth of tumor invasion: submucosa layer
    • Lymph node: not received
    • Margin: free of tumor invasion
    • Additional pathologic findings: non-atrophic chronic gastritis. Colony of Helicobacter Pylori is not seen
    • Lymphovascular space invasion: identified
• 2023-12-18 ECG
  • Right bundle branch block
  • Nonspecific T wave abnormality
• 2023-11-13 Patho - duodenum biopsy
  • Duodenojejunostomy, biopsy — Benign nodular lesion, suspicious for schwannoma
  • Microscopically, it shows mucosal tissues with a proliferation of spindle-shaped cells and mixed infiltrate of lymphohistiocytes and leukocytes.
  • Immunohistochemical stain reveals S100(+), CD68(+), hepatocytes(-) and CK7(-).
  • NOTE: Correlation with imaging stuyd, endoscopic feature, and clinical findings is recommended.
• 2023-11-13 Miniprobe Endoscopic Ultrasound
  • Gastric polypoid tumor, Isp, 3 cm, upper body, GC, favor a mucosal lesion (suboptimal study of EUS)
  • Duodenojejunal lesion, IIa, 1 cm, r/o adenoma, s/p biopsy
  • Reflux esophagitis, LA grade A-
  • Post status duodenectomy with duodenojejunostomy
• 2023-11-13 SONO - abdomen
  • s/p left hepatectomy and cholecystectomy
  • Cirrhosis of liver
  • Hepatic lesion, right lobe, C/W recurrent HCC
  • Splenomegaly, moderate
• 2023-11-11 CT - abdomen
  • Indication:
    • Recurrent hepatocellular carcinoma with lung metastasis, Liver cirhrosis and HCC s/p Transcatheter arterial chemoembolization and operation. r/o Gastric submucosal mass lesions
  • With and without contrast enhancement CT of abdomen shows:
    • Two nodular lesions (1.6cm, 1.5cm, and 1.3cm) with peripheral enhancement in right hepatic lobe.
    • Nodular lesions, up to 0.9cm, in both lung fields.
    • No enlarged lymph nodes in para-aortic and pelvic regions.
    • Small amount of ascites.
    • No bony destructive lesion on these images. Suspect a hemagioma in T11 vertebral body.
  • Impression
    • c/w recurrent liver and lung tumors
• 2023-11-10 Patho - stomach biopsy
  • Stomach, middle body, GC site, biopsy — hepatocellular carcinoma, metastatic
  • Microscopically, it shows hepatocellular carcinoma composed of solid growth pattern of tumor with polygonal tumor cells, high N/C ratio, irregular membrane, clear to eosinophilic cytoplasm and prominent nucleoli.
  • Immunohistochemical stain reveals hepatocyte(+), CK(+), AFP(+), arginase-1(weak+).
• 2023-11-09 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Right bundle branch block
  • Abnormal ECG
• 2023-11-09 EGD
  • Diagnosis:
    • Esophageal varices, F1Cb Lmiddle to inferior. RCS(-) White nipple sign(-)
    • Gastric varices, cardia and fundus
    • Superficial gastritis
    • Abnormal gastric axis
    • Gastric polyp, middle body, GC, s/p biopsy and hemostasis with clipping
  • Suggestion:
    • Admission and PPI therapy; correct abnormal hemogram
• 2023-09-27 MRI - brain
  • Probably an acoustic neuroma (maximal diameter 1.6cm) at right CP angle and extending into IAC.
  • Minimal leukoaraiosis.
  • No image evidence of brain or skull metastasis.
• 2023-08-30 CT - abdomen
  • Findings: Comparison: prior CT dated 2022/05/06.
    • There is no focal lesion in the liver that is c/w prior HCCs S/P TACE and Nivolumab with complete response.
      
    • There is no focal lesions in both lower lungs.
    • S/P surgical enucleation of S7 HCC.
    • S/P cholecystectomy, Whipple operation, and left lateral segmentectomy and partial resection of S4/7/8 of the liver.
      
    • Prior CT identified bony metastasis in T11 vertebral body is noted again, stationary.
  • Impression:
    • Multiple HCCs in right hepatic lobe S/P TACE and Nivolumab show complete response.
      
    • Multiple lung metastases S/P Nivolumab show complete response.
• 2023-08-25 SONO - chest
  • Echo diagnosis
    • Right side subpleural consolidation with trivial pleural effusion
    • Left side: negative with splenomegaly
• 2023-07-28 SONO - abdomen
  • Suspected cirrhosis with splenomegaly
  • S/p left lobectomy
  • S/p cholecystectomy
  • Pancreas not shown
  • Suboptimal examination of liver,especially the subcostal view due to poor echo window
• 2023-06-17 CT - chest
  • Indication: HCC with lung mets
  • Chest CT with and without IV contrast ehnancement shows:
    • S/p port-A placement with its tip at left brachiocephalic vein.
    • Tiny nodular lesion at right upper lobe with attachement with pleura measuring 0.81cm in largest dimension is found. (Se302 IM37). In comparison with CT dated on 2023-05-29, the lesion is stationary.
    • small lymph nodes are found at both sides of the mediastinum. One calcified nodule at right upper lobe measuring 0.42cm is found. Stable.
    • Minimal Bronchiectatic change over right lower lobe and left lower lobe is found. Some infiltration at right lower lobe is noted.
    • Splenomegaly is found.
    • s/p op. and TACE at liver. The residual liver is lobuated but no definite focal abnormal enhancement is found. However, correlation with dynamic contrast study is suggested.
    • Sclerotic and lytic changes of the bony structure is found at T11. Bony metastasis is considered.
  • Imp:
    • Liver cirhrosis and HCC s/p TACE and op. One nodule at right upper lobe but nature should be further determined. (HCC is possible but not first considered) Suggest follow up.
    • Bone meta at T11.
    • One calcified nodule at right upper lobe. Meta not likely. Suggest follow up.
• 2023-05-29 CT - abdomen
  • History and indication: Recurrent hepatocellular carcinoma with lung metastasis
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P liver operation and TACE. Liver cirrhosis with portal hypertension and splenomegaly. A nodule (9.4mm) at RUL.
    • Some fluid collection in right subphrenic region.
    • Old fracture of right rib. R/O an osteolytic lesion at T11.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P liver operation and TACE. Liver cirrhosis with portal hypertension and splenomegaly. A nodule (9.4mm) at RUL.
    • R/O an osteolytic lesion at T11.
• 2023-05-25 ECG
  • Normal sinus rhythm
  • Right bundle branch block
• 2023-05-08, -04-07, -03-20, -03-13, -03-01 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Peri-bronchial wall thickening of the right lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2023-03-13 SONO - chest
  • No pleural effusion but right pleural thickening.
• 2023-03-11 CT - abdomen
  • Clinical history: 58 y/o male patient with fever and chills, SOB.
  • With and without contrast enhancement CT of abdomen
    • Focal loculated fluid (4x1.8cm) in right subphirenic region.
    • Segmental wall edema of S-colon.
    • Uneven surface of liver parenchyma, suggesting liver cirrhosis.
    • Post-op at the liver and pancrease.
    • Presence of splenomegaly.
    • No enlarged lymph node in the paraaortic region.
    • Consolidation in right lower lung and pleural effusion.
    • Bilateral lung nodules, stationary.
  • Impression:
    • Focal loculated fluidin right subphirenic region. Stationary as compare with CT study on 2023-02-10.
    • Post-op at the liver.
    • Liver cirrhosis and splenomegaly.
    • Segmental wall edema of S-colon.
    • Consolidation in RLL. Bilateral lung metastasis, stationary.
• 2023-03-11 ECG
  • Sinus tachycardia
  • Right bundle branch block
• 2023-03-09 Bladder Sonography
  • PVR 7.94mL
• 2023-03-09 Uroflowmetry
  • Q max: fair
  • flow pattern: obstructive
• 2023-03-03 Abdomen - standing (diaphragm)
  • Fecal material store in the colon.
  • splenomegaly.
  • Left hemi-diaphragm elevation is noted, which may be due to eventration or splenomegaly.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2023-02-25 Uroflowmetry
  • Q max: low
  • flow pattern: obstructive
• 2023-02-25 Bladder sonography
  • PVR 21 mL
• 2023-02-10 CT - chest
  • Indication: Liver cell carcinoma
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Consolidation over right lower lobe is found.
      • Nodular lesion at right upper lobe and left upper lobe is found. In comparison with CT dated on 2022-11-23, the lesions are regressed slightly.
      • Some lymph nodes are found at paratracheal and subcarina region.
      • Mild bilateral pleural effusion is found.
    • Visible abdomen:
      • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
      • s/p partial pancreatectomy.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • The portal vein and IVC are patent.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Minimal ascites is found.
  • IMp:
    • Liver cirrhosis with splenomegaly
    • Bilateral lung meta. In regression.
    • mediastinal lymphadenopathy. Stable.
• 2023-02-08 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-01-03 Bronchodilator Test
  • FEV1/FVC= 87%, FVC 51%, FEV1 56%
• 2022-12-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (62 - 11) / 62 = 82.26%
    • M-mode (Teichholz) = 83
  • Normal LV filling pressure and impaired RV relaxation.
  • Normal LV and RV systolic function.
  • Trivial TR.
• 2022-11-23 CT - chest
  • HCC with lung mets dyspnea
  • multiple lung metastases, seem stationary, and newly extensive lung infecion with hyperplastic mediastinal LAP r/o metastatic LAP as compared with CT on 2022/09/14
• 2022-11-22 SONO - abdomen
  • Chronic liver parenchymal disease
  • Hepatic tumor, rule out hemangioma
  • Post left lobectomy of liver
  • Post choleystectomy
  • Fluid collection, right subphrenic region
  • Splenomeglay, mild
• 2022-11-19 KUB
  • S/P clips projecting at right lobe liver.
  • S/P metalic autosuture at left middle abdomen.
  • Fecal material store in the colon.
• 2022-09-14 CT - chest
  • multiple lung metastases, with significant in regression as compared with CT on 2022/06/15 s/p C/T.
• 2022-06-15 CT - abdomen, pelvis
  • Findings:
    • Prior CT identified mutiple HCCs (> 10 lesions) in right hepatic lobe S/P TACE and Nivolumab are noted again, decreasing in size that are c/w HCCs S/P TACE and Nivolumab with partial response.
      
    • Prior CT identified multiple lung metastases are noted again, decreasing in size that is c/w lung metastases S/P Nivolumab with partial response.
      
    • S/P surgical enucleation of S7 HCC.
      • S/P cholecystectomy, Whipple operation, and left lateral segmentectomy and partial resection of S4/7/8 of the liver.
        
    • There is a osteolytic lesion in T11 vertebral body that may be bony metastasis.
    • There is no focal abnormality in the biliary system, spleen & both kidney.
      
    • There is no ascites or lymphadenopathy.
      
    • There is no bowel wall thickening, and no bowel obstruction.
      
    • The abdominal aorta and IVC are grossly unremarkable.
      
    • There is no evidence of intrinsic or extrinsic bladder mass.
      
    • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • Multiple HCCs in right hepatic lobe S/P TACE and Nivolumab show partial response.
      
    • Multiple lung metastases S/P Nivolumab show partial response.
    • Bony metastasis in T11 vertebral body is suspected. Please correlate with bone scan.
• 2022-05-18 CXR
  • S/P Port-A infusion catheter insertion.
  • Multiple nodules at bil. lungs.
  • HCCs s/p TACE.
• 2022-05-06 CT - liver, spleen, biliary duct, pancreas
  • Three recurrent HCCs in right hepatic lobe show stable in size. However, Several newly-developed recurrent HCCs in the right lobe liver are noted.
  • Multiple lung metastases show mild increasing in size.
• 2022-03-11 CT - liver, spleen, biliary duct, pancreas
  • Three recurrent HCCs in right hepatic lobe show mild increasing in size.
  • Multiple lung metastases show stable disease.
• 2021-12-29 CT - liver, spleen, biliary duct, pancreas
  • Three recurrent HCCs in right hepatic lobe are noted.
  • Multiple lung metastases show progressive disease.
• 2021-09-01 CT - liver, spleen, biliary duct, pancreas
  • Two recurrent HCCs 1.4 x 1.1 cm and 1.4 x 1.2 cm in right hepatic lobe are highly suspected.
  • Multiple lung metastases are highly suspected.
• 2021-06-01 SONO - abdomen
  • S/P surgical enucleation of S7, left lateral segmentectomy and partial resection of S4/7/8 of the liver.
    
  • S/P cholecystectomy and Whipple operation.
• 2021-02-19 CT - liver, spleen, biliary duct, pancreas
  • S/P surgical enucleation of S7 HCC.
  • There is no evidence of tumor recurrence.
• 2020-11-17 Patho - liver partial resection
  • pathologic diagnosis
    • Liver, segment 7, partial hepatectomy — Hepatocellular carcinoma
      
    • Pathologic Staging (AJCC) — rypT4 (if cN0 and cM0), stage IIIB
      
    • R’t diaphragm, frozen section (F2020-00457) — Tumor invasion
      
  • microscopic examination
    • Histologic Type: Hepatocellular carcinoma
      
    • Histologic Grade: G3, poorly differentiated
    • Cytological grade: III
      
    • Tumor necrosis: Present
      
    • Inflammatory cell infiltration: Mild
      
    • Tumor capsule: incomplete with capsular invasion
      
    • Satellite nodule: present
      
    • Venous (Large Vessel) Invasion: Absent
      
    • Portal Vein Thrombosis: (-), Capsular vein invasion: (-)
      
    • Perineural Invasion: Absent
      
    • Bile duct Invasion: Absent
      
    • Pathologic Staging (pTNM): Stage IIIB (pT4)
      
    • Margins
      • Parenchymal Margin: Free, 0.8 cm from closest margin
        
      • Hepatic capsule: involved by invasive carcinoma
        
    • Additional Pathologic Findings: clear cell change and fibrosis
      
    • Hepatitis (specify type): unknown (by medical record)
      
    • Ishak modified HAI grading: Necroinflammatory Scores 2
      
    • Ishak staging: 3 (occasional bridging)
      
    • Fatty change: focal and mild
      
    • Immunohistochemistry (F2020-00457): Arginase(+, focal), hepa-1(+, scant) for tumor cells
• 2020-11-16 Frozen resction
  • Diaphragm, right, frozen section — Tumor invasion
    
  • Margins — Tumor present at muscle side, other margins are free
• 2020-10-27 MRI - liver, spleen
  • HCC s/p operation. A biloma (2.6cm) at left liver margin. Right HCC s/p TACE with stable size (2.3cm).
  • Liver cirrhosis with splenomegaly.
• 2020-09-18 CT - liver, spleen, biliary duct, pancreas
  • A newly-developed HCC 2.3 cm in S7 of the liver is suspected. please correlate with AFP, sonography, or MRI.
• 2020-06-26 SONO - abdomen for follow-up
  • S/P surgical resection S2. S3, S4, and S7, and cholecystectomy.
• 2020-04-02 SONO - abdomen for follow-up
  • S/P left hepatic lobe operation and cholecystectomy.
• 2020-01-10 CT - liver, spleen, biliary duct
  • S/P cholecystectomy, Whipple operation, left lateral segmentectomy and partial resection of S4/7/8 of the liver.
    
  • There is no evidence of tumor recurrence.
• 2019-10-29 SONO - abdomen for follow-up
  • S/P surgical resection S2. S3, S4, and S7, and cholecystectomy.
• 2019-07-31 CT - liver, spleen, biliary duct
  • Liver cirrhosis
  • HCC s/p op. and TACE without evidence of tumor recurrence.
• 2019-05-06 SONO - abdomen for follow-up
  • Hepatic fibrocalcified lesion
  • Parenchymal liver disease
  • Status post cholecystectomy, left lateral segmentectomy, and partial resection of S4/7/8
  • Mild splenomegaly
• 2019-02-12 CT - liver, spleen, biliary duct
  • S/P cholecystectomy, Whipple operation, left lateral segmentectomy and partial resection of S4/7/8 of the liver.
    
  • There is no evidence of tumor recurrence.
• 2018-11-01 SONO - abdomen
  • diagnosis
    • Suspected chronic liver parenchyma disease (Please correlate with liver function)
    • S/p left lobectomy
    • S/p cholecystectomy
    • Pancreas not shown
  • suggestion
    • OPD f/u
    • Follow liver function test and AFP
• 2018-07-10 CT - liver, spleen, biliary duct
  • s/p op. and TACE with radiopaque materials in the rest of the liver.
  • Lobulated appearance of the liver is found. No significant abnormal enhancement is found but lobulated nodule at dome up to 4.6cm is found. suspected regereration nodule. In comparison with CT dated on 2017-10-27, the lesion is stationary.
• 2018-04-09 SONO - abdomen
  • Liver cirrhosis with mild splenomegaly
  • Compatible with HCC s/p resection
• 2018-02-06 CT - liver, spleen, biliary duct
  • S/P operation and TACE with minimal viable tumors.
• 2018-01-04 CT - lung/pleura (chest and upper abdomen)
  • Loculated Rt subphrenic fluid collection and diaphgramatic pleural effsuion, post op change or infection fluid collections.
  • No lung lesion.
• 2018-01-03 Echo - chest
  • Echo diagnosis:
    • Pleural thickening, right CP angle
    • No pleural effusion
    • Consolidation, minimal, RLL
  • Comment:
    • Arrange abdominal echoi, AFP recheck and abdominal/lung CT may be indicated also
• 2017-12-15 SONO - hepatobiliary
  • S/P operation. Mild liver cirrhosis.
  • A hypoechoic lesion (1.92x2.51cm) at left hepatic lobe.
  • S/P cholecystectomy.
  • Mild splenomegaly.
  • A hypoechoic lesion (2.21x3.95cm) at left kidney.
• 2017-10-27 CT - liver, spleen, biliary duct
  • Post-op and S/P TACE for HCCs, with decreased liver size and some defects, could be due to some viable tumors, suggest further treatment.
• 2017-07-28 CT - liver, spleen, biliary duct
  • HCC and pancreas tumor, s/p operation
  • suspected recurrent HCCs
  • suspected peritoneal seeding
• 2017-05-02 SONO - abdomen
  • Chronic liver parenchymal disease
  • Post operation change
  • Focal liver lesion, S6, possible tumor or previous abscess in regression.
  • Post cholecystectectomy
• 2017-02-07 CT - liver, spleen, biliary duct
  • S/P operation. No evidence of tumor recurrence.

[MedRec]

• 2023-07-06 MultiTeam - Palliative Care
  • Palliative Care Multidisciplinary Recommendation
  • Referral Date: 2023-07-05
  • Response Content:
    • The patient has cancer with distant metastasis and is still undergoing treatment. The original medical team referred the case to the palliative care team due to the patient’s flu and slight breathlessness. However, when the palliative care nurse and Dr. Xia visited together, the patient seemed a bit startled. The nurse explained that this is a routine referral for cancer patients to enhance the understanding of palliative care, to advocate against emergency resuscitation, and to complete a pre-established palliative care wish form. The patient seemed more relaxed and indicated that he understands the concept of palliative care and is inclined to forego emergency resuscitation. The nurse explained that if the patient does not fill out the form, it will be completed by the family. The patient said he would discuss it with his wife. The patient himself agreed to palliative co-care and to befriend the care team first.
  • Conclusion and Recommendation: Co-management with palliative care
  • Respondent: Yu XiuHong
  • Response Date: 2023-07-05 19:03

[consultation]

• 2023-07-05 Family Medicine
  • Q
    • A 58 years old man is a patient of pancreatic intraductal papillary mucinous carcinoma and hepatocellular carcinoma with bilateral lung metastasis and bone T11 metastasis, he was admitted under the impression of influenza A in this time, we need your help in planning future medical care due to terminal cancer, thank you
  • A
    • A 58 years old male had history of pancreatic intraductal papillary mucinous carcinoma and hepatocellular carcinoma with bilateral lung metastasis and bone T11 metastasis.
      • He was admitted for influenza A.
      • con’:E4V5M6
      • ECOG:1
    • We will arrange hospice combine care and follow up his condition.
    • Patient said he will discussed with his wife and other family.
    • Indication: pancreatic cancer, HCC with lung and bone metastasis.
    • Plan: hospice combined care
• 2023-05-30 Radiation Oncology
  • Q
    • The consultation is for T11 bone lesion radiotherapy evaluation.
    • Brief history: This was a 58 yr case of HCC with lung mets post partial hepaectomy and TACE; first diagnosed in 2016, then recurrent several times after. The patient was now on palliative chemotherapy with FOLFOX and Nivolumab.
    • This time he was admitted for unspecific origin fever; we treated with Brosym, no fever was detected during admission and CRP today was 2.7.
    • However, in the follow up ABD CT on 20230529, we found a osteolytic lesion in T11, may paralleled with the patient’s complaint about back pain.
    • We would love to have your consultation for radiotherapy
  • A
    • The ABD CT on 2023/5/29 showed a osteolytic lesion in T11. However, he said he had no backpain for now. Only his Rt flank pain was mentioned. Tracing back the previous CTs, the spine T11 metastatic lesion was first shown on Abd. CT on 2021/09/01. After long period of palliative systemic treatment, the T11 lesion has been under control and the re-ossification can be observed on recent CT images. Therefore, immediate RT to the T11 might not be indicated for now. If new back pain develops, palliative RT might be considered by then. Thank you very much.
• 2022-11-25 Chest Medicine
  • Q
    • The 58 y/o man has HCC with lung metastasis. Due to pneumonia with green like sputum, so he received antibiotics as Tapimycin and Targocid for infection control. Today, his SOB in progress and CXR showed right lung space decrease. We need your help for assessment. Thanks!
  • A
    • We were consulted for PN progression.
    • PE
      • E4V5M6, clear cons, shallow/rapid respiratory pattern with accessory muscle use
      • SpO2 > 95% under NRM full, no wheezing
      • much greenish/sticky sputum formation
    • ABG(2022/11/22)
      • PH 7.4/PCO2 39.9/PO2 163/HCO3 24.3/SpO2 99, FiO2 100%
      • PF ratio 163
    • Chest CT (2022/11/23)
      • lobar consolidation with air-bronchograms over both lower lobes and extensive consolidation over RML.
      • stationary of metastatic nodules in both lungs as compared with previous CT on 9/14
    • Impression
      • Bilateral pneumonia, impending hypoxic respiratory failure
      • Recurrent HCC with lung metastasis
    • Suggestion
      • May adjusted antibiotic treatment according to clinical condition and Sp/C reports
      • May check atypical pneumonia pathogen and TB/C*3
      • keep O2 support, if hemodynamic unstable or conscious change due to hydercapnia or hypoxia, ETT intubation is indicated
      • Chest care, percussion, and suction frequently
      • Treat underlying disease as your expertise
• 2020-11-17 Thoracic Surgery
  • Q
    • for diaphragm repair
    • This 56-year-old man had past histories of
      • Chronic hepatitis
      • Frequent acute pancreatitis episodes in 2006, 2007, 2008, 2014/03/05 and 2014/09/30,
      • Pancreatic intraductal papillary mucinous carcinoma, invasive pStage(pT1N0M0)s/p PPPD in 2014
      • HCC s/p S8 segmentectomy on 2016/06/30, pT2Nx(cMx), stage II.
      • Post S8 segmentectomy with liver abscesss/p pig-tail drainage on 2016/07/12, discharged on 2016/07/20.
      • Hepatocellular carcinoma, recurrent (S2-3 and S7) rpT3bNx(cMx) stage IIIb s/p op on 2016/10/03 discharge on 2016/10/08.
      • Hepatocellular carcinoma, recurrent (S2-3 and S7) rpT3bNx(cMx) stage IIIb s/p op on 2016/10/03. with Target therapy (Nexavar) side effect management since 2016/10/23 ~ 2016/10/26.
      • Post Hepatocellular carcinoma, recurrent (S2-3 and S7)rpT3bNx(cMx) stage IIIb operation, liver abscess again s/p pig-tail insertion on 2016/11/02.
    • This time, abdomen CT on 2020/09/18 which revealed a newly-developed HCC 2.3 cm in S7 of the liver is suspected. AFP on 2020/09/18 showed 10.3ng/mL was noted. TACE was performed on 2020/09/29. Liver MRI was performed on 2020/10/27 which revealed a biloma (2.6cm) at left liver margin. Right HCC s/p TACE with stable size (2.3cm). This time, he was admitted for S7 resection today. We need your help for combine surgery for diaphragm repair. Thanks for your help!!
  • A
    • I have performed diaphragm repair for this patient. Thanks for your consultaiton!

[surgical operation]

• 2020-11-16
  • Surgery
    • Diaphragm repair
  • Finding
    • HCC invasion to right diaphragm.
  • Procedure
    • Under GA, the patient was put in supine position. We was consulted for suspected tumor invasion to diaphram. Elliptical incision was made for involving area of diaphragm with electrocautery. Pneumolysis was performed for underlying lung parechyma. The resected diraphgram was sent for frozen section. The margin showed negative to malignancy. The residual diaphragm was repaired with No.2 silk with vertical matress suture. Then, GS Dr. Wu took over for following procedure.
• 2020-11-16
  • Surgery
    • S7 paritla hepatectomy
    • adhesivelysis with bowel repair
    • diaphragm resection with repair by chest surgeon
    • IOE
  • Finding
    • IOE revealed 1.8 x 1.8cm hypereechoic tumor at S7
    • tumor direct invadion to right diaphragm
    • severe intraabdominal adhesion
    • chronic abscess at previous resection space
  • Procedure
    • ETGA
    • midline extended to right subcostal laparotmy
    • adhesivelysis with small bowel repair
    • IOE
    • S7 partial resection
    • diaphragm partial resection with repair by chest surgeon
    • tow J-vac inserted
    • wound closed

[embolization]

• 2022-05-17 Embolization (TAE) - abdomen for tumor
• 2022-03-23 Embolization (TAE) - abdomen for tumor
• 2021-12-30 Embolization (TAE) - abdomen for tumor
• 2021-09-14 Embolization (TAE) - abdomen for tumor
• 2020-09-29 Embolization (TAE) - abdomen for tumor
• 2017-08-08 Embolization (TAE) - abdomen for tumor

[chemoimmunotherapy]

• 2024-04-03 - ramucirumab 8mg/kg 500mg NS 250mL 90min + oxaliplatin 50mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2200mg/m2 3900mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-14 - ramucirumab 8mg/kg 500mg NS 250mL 90min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-07 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 200mg/m2 350mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 700mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1050mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-07-10 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 200mg/m2 350mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 700mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1050mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-06-12 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 200mg/m2 360mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 730mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1095mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-05-08 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 710mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 710mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1065mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-07 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 710mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 710mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1065mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-01 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 690mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1035mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-08 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 670mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1035mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-02 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 700mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-06 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 700mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-09-05 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 670mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-08-08 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 660mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 990mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-07-05 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + leucovorin 200mg/m2 330mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 660mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 990mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-06-07 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + leucovorin 200mg/m2 330mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 660mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-03-23 - nivolumab 3mg/kg 100mg 1hr
• 2022-01-24 - nivolumab 3mg/kg 100mg 1hr
• 2021-12-30 - nivolumab 3mg/kg 100mg 1hr
• 2021-12-07 - nivolumab 3mg/kg 100mg 1hr
• 2021-11-09 - nivolumab 3mg/kg 100mg 1hr
• 2021-10-05 - nivolumab 3mg/kg 100mg 1hr
• 2021-12-31 ~ 2022-08-19 - Stivarga (regorafenib 40mg/tab) 4# QD (hand foot syndrome due to stivarga side effect?)
• 2017-10-06 ~ 2018-01-16 - Nexavar (sorafenib 200mg/tab) 1# BIDAC

[note]

Chemotherapy for advanced or metastatic disease treatment regimen listed in in-hospital “Revised Edition of Chemotherapy Prescription Collection for Liver Cancer” version 2022-03-01

• FOLFOX4
  • Oxaliplatin 85 mg/m2 I.V D1
  • Leucovorin 200 mg/m2 I.V 2 hrs D1 & D2
  • 5-FU 400 mg/m2, I.V bolus D1 & D2
  • 5-FU 600 mg/m2, I.V 22 hrs D1 & D2
  • Every 2 weeks
  • References: Qin S et al, J Clin Oncol. 2013;31:3501-3508

Principles of Systemic Therapy - NCCN Clinical Practice Guidelines in Oncology - Hepatocellular Carcinoma - Version 1.2023 - 2023-03-10 - HCC-G 1 of 2, p23

• First-Line Systemic Therapy
  • Preferred Regimens
    • Atezolizumab + bevacizumab (Child-Pugh Class A only) (category 1)
    • Tremelimumab-actl + durvalumab (category 1)
  • Other Recommended Regimens
    • Sorafenib (Child-Pugh Class A [category 1] or B7)
    • Lenvatinib (Child-Pugh Class A only) (category 1)
    • Durvalumab (category 1)
    • Pembrolizumab (category 2B)
  • Useful in Certain Circumstances
    • Nivolumab (Child-Pugh Class B only)
    • Atezolizumab + bevacizumab (Child-Pugh Class B only)
    • For TMB-H tumors:
      • Nivolumab + ipilimumab (category 2B)
• Subsequent-Line Systemic Therapy if Disease Progression
  • Preferred Regimens
    • Regorafenib (Child-Pugh Class A only) (category 1)
    • Cabozantinib (Child-Pugh Class A only) (category 1)
    • Lenvatinib (Child-Pugh Class A only)
    • Sorafenib (Child-Pugh Class A or B7)
  • Other Recommended Regimens
    • Nivolumab + ipilimumab (Child-Pugh Class A only)
    • Pembrolizumab (Child-Pugh Class A only)
  • Useful in Certain Circumstances
    • Ramucirumab (AFP >=400 ng/mL and Child-Pugh Class A only) (category 1)
    • Nivolumab (Child-Pugh Class B only)
    • For MSI-H/dMMR tumors
      • Dostarlimab-gxly (category 2B)
    • For RET gene fusion-positive tumors:
      • Selpercatinib (category 2B)
    • For TMB-H tumors:
      • Nivolumab + ipilimumab (category 2B)

Nivolumab: Drug information 2023-03-02 https://www.uptodate.com/contents/nivolumab-drug-information

• Dosing: Adult
  • Hepatocellular carcinoma
    • Hepatocellular carcinoma: IV: 1 mg/kg once every 3 weeks (in combination with ipilimumab) for 4 combination doses, followed by 240 mg once every 2 weeks (Yau 2020) or 480 mg once every 4 weeks (nivolumab monotherapy) until disease progression or unacceptable toxicity.

Regorafenib: Drug information 2023-03-02 https://www.uptodate.com/contents/regorafenib-drug-information

• Dosing: Adult
  • Hepatocellular carcinoma
    • Hepatocellular carcinoma: Oral: 160 mg once daily for the first 21 days of a 28-day cycle; continue until disease progression or unacceptable toxicity (Bruix 2017).
• Dosing: Adjustment for Toxicity: Adult
  • If dose reduction is necessary, reduce in 40 mg increments; the lowest recommended dose is 80 mg/day.
    • Dermatologic:
      • Grade 2 hand-foot skin reaction (HFSR; palmar-plantar erythrodysesthesia syndrome [PPES]) of any duration: Reduce dose to 120 mg once daily for first occurrence. If grade 2 HFSR recurs at this dose, further reduce the dose to 80 mg once daily. Interrupt therapy for grade 2 HFSR that is recurrent or fails to improve within 7 days in spite of dosage reduction.
      • Grade 3 HFSR: Interrupt therapy for a minimum of 7 days. Upon recovery, reduce dose to 120 mg once daily. If grade 2 to 3 toxicity recurs at this dose, further reduce dose to 80 mg once daily upon recovery. Interrupt therapy for grade 2 to 3 HFSR that is recurrent or fails to improve within 7 days in spite of dosage reduction.
      • Recurrent or persistent HFSR at 80 mg once daily: Discontinue treatment.
      • Other dermatologic toxicity: Withhold treatment, reduce dose or permanently discontinue treatment depending on the severity and persistence of the dermatologic toxicity. Symptomatic relief may be managed with supportive measures.
    • Hypertension: Grade 2 (symptomatic): Interrupt therapy.
    • Infection: Grade 3 or 4 (or worsening infection of any grade): Interrupt therapy; resume regorafenib at the same dose following infection resolution.
    • Other toxicity: Any grade 3 or 4 adverse reaction (other than hepatotoxicity or infection): Interrupt therapy; upon recovery, reduce dose to 120 mg once daily (except infection). If any grade 3 or 4 adverse reaction occurs (other than hepatotoxicity or infection) while on this reduced dose, may further reduce dose to 80 mg once daily upon recovery. For any grade 4 adverse reaction, only resume therapy if the benefit outweighs the risk. Permanently discontinue therapy if unable to tolerate 80 mg once daily.
    • Gastrointestinal perforation/fistula: Discontinue permanently.
    • Hemorrhage (severe or life-threatening): Discontinue permanently.
    • Reversible posterior leukoencephalopathy syndrome (RPLS): Discontinue.
    • Dosage adjustment for surgery: Temporarily withhold regorafenib at least 2 weeks prior to elective surgery; do not administer regorafenib for at least 2 weeks following major surgery and until adequate wound healing.

==========

2024-04-03

[only 3 bisphosphonates in stock: 2 injectable, 1 oral]

While our database contains information on 7 bisphosphonates, only 3 are currently in stock. These available options include both injectable and oral forms.

• DrugCode - Trade Name - Generic Name - Available Now
• CACLA01 - Aclasta 5mg/100mL/vial - zoledronic acid - Y
• KFOSA04 - FosaMax Plus 70mg & 140mcg (=5600IU)/tab - alendronate sodium, cholecalciferol, colecalciferol - Y
• CPAMI01 - Pamisol 15mg/5mL/vial - pamidronate disodium - N
• KSINC01 - Sinclote 400mg/cap - disodium clodronate tetrahydrate - N
• CBONV01 - Bonviva 3mg/3mL/syringe - ibandronic acid - N
• CZOBO01 - Zobonic 4mg/vial - zoledronic acid monohydrate - N
• CZOLE01 - Zodonic 4mg/5mL/vial - zoledronic acid monohydrate - Y

2023-07-11

Our gastroenterologist prescribed a multiple refill prescription for Baraclude (entecavir) on 2023-06-26, which the patient is using for prophylaxis of his HBV reactivation. This medication is included in the patient’s active medication list as a patient-carried item and no reconciliation issue has been identified.

2023-06-13

• This patient relies only on our hospital for his medical need on liver cell carcinoma, no other healthcare providers found in the PharmaCloud database, no medication reconciliation issues identified.

• The dosage of FOLFOX4 administered to this patient during this current treatment cycle has been adjusted in accordance with our in-hospital guidelines outlined in the “Revised Edition of Chemotherapy Prescription Collection for Liver Cancer, version 2023-03-01.” No issues have been identified with this adjustment.

• The lab data show a fluctuation in the tumor marker AFP levels, which initially decreased (2022 Q2 to Q3), troughed around 2022 Q3/Q4, and then increased after 2022Q4. This pattern suggests that the “nivolumab + FOLFOX4” regimen, administered monthly since 2022-06, might have become less effective after approximately a year of treatment, indicating potential disease resistance.

  • 2023-06-12 AFP 23.6 ng/mL
    
  • 2023-03-28 AFP 13.9 ng/mL
    
  • 2022-10-06 AFP 4.1 ng/mL
    
  • 2022-09-14 AFP 4.4 ng/mL
    
  • 2022-06-15 AFP 77.4 ng/mL
    
  • 2022-06-07 AFP 94.0 ng/mL
    
  • 2022-05-06 AFP 170.4 ng/mL

• This patient has previously been treated with sorafenib (from 2017-10 to 2018-01), regorafenib (from 2021-12 to 2022-08), and nivolumab (since 2021-10). If the disease is confirmed to have developed resistance to these treatments, then potential next-line therapy options could include cabozantinib or lenvatinib.

• According to the current version (2023-05-23) NHI medication reimbursement rules, for advanced hepatocellular carcinoma, patients can only choose to use either sorafenib or lenvatinib, but they cannot switch between the two. Additionally, cabozantinib is only covered for patients with intermediate or high-risk advanced renal cell carcinoma who have not previously undergone treatment. Thus, in this patient’s case, it appears cabozantinib or lenvatinib may not be covered based on these regulations.

2023-05-09

• During this chemotherapy session, facial flushing was noted approximately halfway through the oxaliplatin infusion (at 133 cc of a total of 250 cc). It might be beneficial to consider extending the infusion time beyond the current 2 hours to minimize this reaction.
• According to PharmaCloud records, all recent medications were prescribed at our hospital and no medication reconciliation issues were identified.

2023-03-02

• The CT scan conducted on 2023-02-10 revealed that the bilateral lung mets were regressing, indicating that the current treatment regimen (nivo + FOLFOX4) was still effective.
• Pulmonary symptoms was properly managed with the patient’s self-carried medications.

2022-12-06

Currently, Tecopin (teicoplanin 200mg/vial) is out of stock and has been replaced with Targocid (teicoplanin 200mg/vial). If the teicoplanin treatment should continue, please prescribe Targocid.

2022-11-21

• As of 2022-11-19 and 2022-11-20, the urine volume was recorded as 3850mL and 3350mL, respectively. This problem “decreased urine output” registered since 2022-11-19 should have been mitigated.
• As long as the body temperature remains high (38.5 degrees Celsius at 08:43 on 2022-11-21), there is no issue with the ongoing use of antimicrobial flomoxef.
• Please monitor the patient for anymore GI bleeding signs to determine the need to adjust the PPI.

2022-09-06

• A multicenter phase II trial (RENOBATE) demonstrated that regorafenib plus nivolumab as first-line therapy for unresectable hepatocellular carcinoma shows promising efficacy outcomes without unexpected safety signals. (ref: Regorafenib plus nivolumab as first-line therapy for unresectable hepatocellular carcinoma (uHCC): Multicenter phase 2 trial (RENOBATE). Changhoon Yoo, etc. Journal of Clinical Oncology 2022 40:4_suppl, 415-415. https://ascopubs.org/doi/abs/10.1200/JCO.2022.40.4_suppl.415 )

• Since the end of 2021, Stivarga (regorafenib 40mg/tab) has been prescribed. It is administered at 160mg once daily (4# QD) for the first 21 days of a 28-day cycle. Hand-foot skin reaction has been observed.

  • For grade 2 hand-foot skin reaction of any duration, it is recommended to reduce dose to 120 mg once daily for first occurrence. If grade 2 hand-foot skin reaction recurs at 120mg once daily, further reduce the dose to 80 mg once daily. Interrupt therapy for grade 2 hand-foot skin reaction that is recurrent or fails to improve within 7 days in spite of dosage reduction.
  • For grade 3 hand-foot skin reaction, it is recommended to interrupt therapy for a minimum of 7 days. Upon recovery, reduce dose to 120 mg once daily. If grade 2 to 3 toxicity recurs at 120 mg once daily, further reduce dose to 80 mg once daily upon recovery. Interrupt therapy for grade 2 to 3 hand-foot skin reaction that is recurrent or fails to improve within 7 days in spite of dosage reduction.
  • For recurrent or persistent hand-foot skin reaction at 80 mg once daily, it is recommended to discontinue the treatment.

2022-07-06

• Nivolumab was administered from early October 2021 to late March 2022. On 2022-06-25 CT, several recurrent HCCs were found in the right lobe liver, and on 2022-03-11 CT, recurrent HCCs were found with mild increases in size.
• There has been a shift in the regimen to FOLFOX4 + nivolumab since 2022-06-07. The AFP level declined to 77 (2022-06-15) from its recent peak 170 (2022-05-06), while CT results (2022-06-15) showed partial responses in right hepatic lobe and lung mets.
• A rapid drop in blood pressure (92/63 at 9:19 2022-07-06) has been recorded. Tracking of hemodynamics might be necessary.

701139535

240402

[exam findings]

• 2024-02-16 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Possible Inferior infarct, age undetermined
  • Abnormal ECG
• 2024-02-15 KUB
  • Degeneration of the lumbar spine
  • Atherosclerosis with wall calcification
• 2024-02-15 CXR erect
  • Mass lesion in right lower lung zone
  • Borderline enlargement of cardiac sihoutte
  • s/p sternostomy
  • s/p port A insertion
• 2024-02-15 ECG
  • Sinus rhythm with 1st degree A-V block
  • Possible Left atrial enlargement
  • Inferior infarct, age undetermined
  • ST & T wave abnormality, consider lateral ischemia
  • Abnormal ECG
• 2023-11-17 CT - abdomen
  • History and indication: Adenocarcinoma of rectum with multiple lung metastasis, stage IVA
  • Findings:
    • S/P LAR with autosuture retention over the rectum.
    • Prior CT identified soft tissue nodule with calcification component at LUL and RUL of the lung are noted again, stationary.
    • Prior CT identified multiple cysts in the liver and kidney is noted again, stationary. It is c/w adult type polycystic liver and kidney disease.
    • Prior CT identified atherosclerosis of aorta, iliac, coronary and visceral arteries is noted again, stationary.
  • Impression:
    • Prior CT identified soft tissue nodule with calcification component at LUL and RUL of the lung are noted again, stationary.
    • Lung metastases show stable disease.
• 2023-11-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 56) / 112 = 50.00%
    • M-mode (Teichholz) = 61.3
  • Conclusion
    • Normal LV systolic function with normal wall motion.
    • Hypertrophic cardiomyopathy without outflow tract obstruction, dilated LA; LV diastolic dysfunction Gr 1.
    • Normal RV systolic function.
    • Aortic valve sclerosis with mild AR; posterior mitral valve calcification with no MS, mild MR; trivial TR; mild PR.
    • An atheroma (5.7mm of thickness) at aortic root.
• 2023-09-13 CT - brain
  • Brain atrophy.
  • Intracranial arterhiosclerosis.
• 2023-08-04 ECG
  • Normal sinus rhythm
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2023-08-03 CT - abdomen
  • History and indication: Adenocarcinoma of rectum with multiple lung metastasis, stage IV
  • Non-contrast CT of abdomen-pelvis revealed:
    • S/P colon operation.
    • A nodule (1.2cm) at LUL. Regression of right lung nodules.
    • Polycystic liver and kidneys.
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • Surgical wires over the sternum.
  • IMP:
    • S/P colon operation.
    • A nodule (1.2cm) at LUL. Regression of right lung nodules.
• 2023-08-02 07:07 ECG
  • Sinus rhythm with 1st degree A-V block
  • Possible Left atrial enlargement
  • Inferior infarct old
  • right side EKG showing no RV infarct
• 2023-08-02 06:25 ECG
  • Sinus rhythm with 1st degree A-V block
  • Nonspecific ST abnormality
  • old inferior MI
  • Left atrial enlargement
• 2023-08-01, -05-23 CXR
  • S/P port-A implantation.
  • S/P median sternotomy with metalic wires fixation. Please correlate with clinical history.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • S/P metalic autosuture at right lung.
• 2023-05-18 CXR
  • Tortous aorta with calcification is noted.
  • s/p sternotomy with metalic wire fixation of the sternum.
  • s/p op. over right lung.
• 2023-05-04 ECG
  • Possible Left atrial enlargement
  • Inferior infarct, age undetermined
  • Nonspecific T wave abnormality
• 2023-04-24, -04-21 CXR
  • s/p right chest tube in place, its tip directed superiorly projecting over 3rd intercostal space
  • multifocal consolidation in Rt lung s/p wedge-resection at RUL and RLL
• 2023-04-24 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, upper lobe, wedge resection — Adenocarcinoma x 2, metastatic, consistent with colorectal origin
    • Lymph node, right, group No.11, lymphadenectomy — Negative for malignancy (0/2)
  • MACROSCOPIC EXAMINATION:
    • Specimen: Lung, 2 pieces of wedge resection; specimen A1: size: 6.0 x 3.0 x 3.0 cm, 22 g; specimen A2: 5.5 x 4.5 x 3.0 cm, 19 g.
      • Lymph nodes, a bottle, group 11; maximal size: 1.3 x 0.7 cm
    • Tumor Site: Periphery
    • Tumor Size: specimen A1: Solitary: 1.7 x 1.5 x 1.5 cm; specimen A2: 1.8 x 1.6 x 1.5 cm
    • Gross tumor patterns: poorly defined
      
    • Tissue for sections:
      • A1: resection margin, specimen A1; A2: lung, non-tumor, specimen A1; A3-4: tumor, specimen A1; A5: resection margin, specimen A2; A6: lung, non-tumor, specimen A2; A7-8: tumor, specimen A2; B: lymph node, group 11.
  • Microscopic Description
    • Tumor Focality: Separate tumor nodules of same histopathologic type in same lobe
    • Histologic Type (select all that apply) : Metastatic adenocarcinoma with abundant extravasated mucin, mucinous adenocarcinoma is favored; The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-), The results are consistent with colorectal origin
      
    • Histologic Grade: G2: Moderately differentiated
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Not identified
    • Lymphovascular Invasion (select all that apply): Present, Lymphatic
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): specimen A1: 0.3 cm; specimen A2: 0.3 cm
      • Specify closest margin: wedge resection margin
    • Regional Lymph Nodes: group 11: 0/2
    • Extranodal Extension: Not identified
    • Additional Pathologic Findings (select all that apply): None identified
• 2023-04-21 ECG
  • Sinus rhythm with occasional Premature ventricular complexes or aberrant conduction
  • Possible Left atrial enlargement
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2023-04-21 CXR
  • two nodular opacities (up to 20mm, lobular borders) over RUL
  • a tiny granuloma at lateral RLL
  • s/p prior median sternotomy with wires fixation s/p CABG
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
  • mild enlarged cardiac silhoutte due to dilated cardiac chamber (LVD) and prominent cardiophrenic angle mediastinal fat pad
  • Coronary arterial calcification (left circumflex artery, left anterior descending artery) indicating CAD
  • s/p prior median sternotomy with wires fixation
• 2023-03-23 CT - chest
  • Indication: for R’t lung nodules and sternum f/u
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Nodular lesions with central calcification scattered at both lungs up to 1.6cm is found at right upper lobe. Lung meta is considered first but other possibiity cannot be excluded.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • s/p sternotomy with metalic wire fixation of the sternum.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Polycystic change at both lobes of liver are found.
      • There is no ascites accumulation at abdominal cavity.
      • There is no evidence of destructive bone lesion.
  • Imp: Nodular lesions with central calcification at both lungs. Lung meta is favored. Suggest check tumor marker such as CEA or others.
• 2023-02-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (136 - 40.3) / 136 = 70.37%
    • M-mode (Teichholz) = 70.4
    • 2D (M-simpson) = 56.1
  • Conclusion:
    • Thickened AV with trivial AR
    • Calcification of posterior MV leaflet, mild MR
    • Concentric LVH, mildly dilated LV
    • Preserved LV and RV systolic function
    • Hypokinesia of basal to mid inferior wall
    • Mild PR, mild TR, normal IVC size
    • Dilated LA
• 2022-12-29 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • s/p sternotomy with metalic wire fixation of the sternum.
  • Nodular lesion at right upper lobe and right central lung field is found.
  • Clear bilateral costophrenic angle is noticed.
• 2022-12-29 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2022-04-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (186 - 76) / 186 = 59.14%
    • 2D (M-simpson) = 59
  • Conclusion:
    • Dilated LA, LV
    • Adequate LV, RV systolic function with normal wall motion
    • Concentric LV hypertrophy, Impaired LV relaxation
    • Mild AR
    • Calcified aortic valve and mitral annulus, No significant AS, MS
• 2021-10-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (144 - 42) / 144 = 70.83%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Dilated LV with hypokinesia of inferior wall, posterior wall; preserved LV and RV systolic function.
    • Septal and RV hypertrophy with indeterminated LV filling pressure and impaired RV relaxation.
    • Aortic valve sclerosis with trivial AR; marked mitral annulus calcification with mild MR; mild PR.
    • Dilated aortic root and proximal ascending aorta (39mm) with prominent calcification.
    • Minimal pericardial effusion (< 50ml); some R’t pleural effusion.
• 2021-09-24 CT - chest
  • Indication: CAD 3VD for CABG preoperative evaluation
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Calcified coronary arteries is found.
      • Mild pericardial effusion is found.
      • Tiny nodualr lesion at right upper lobe up to 0.3cm, and 0.17cm, left upper lobe about 0.24cm is found.
      • Several calcified dots at both lungs is found.
      • Minimal atelectatic change over left lower lung is found.
    • Visible abdomen:
      • s/p LAR.
      • Diffuse cystic change at liver and both kidneys are found. Polycystic kidney is considered.
      • The spleen, pancreas, both adrenals are intact.
  • Imp:
    • Nodular lesions at right upper lobe and left upper lobe, please exclude the possiblity of lung meta.
    • Polycystic liver and kidneys.
    • Calcified coronary arteries is found.
• 2021-09-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (142 - 88) / 142 = 38.03%
    • M-mode (Teichholz) = 37
    • 2D (M-simpson) = 30
  • Conclusion:
    • Dilated LA and LV; moderate to severely abnormal LV systolic function with inferoposterior wall hypokinesia
    • Septal hypertrophy
    • Mild MR, mild AR and trivial TR
    • Moderate pericardiac effusion without cardiac tamponade sign
    • Preserved RV systolic function
• 2021-09-22 Cardiac Catheterization
  • Exam: CATH
    
  • Diagnosis: MI, CAD with TVD
  • Past Medical History
    • The patient has a history of ESRD under H/D and Hypertension.
  • Indication
    • The patient was referred with NSTEMI. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
  • Approach
    • Percutaneous access was performed through the right radial artery where a 6F sheath was inserted.
  • Catheters
    • Left coronary angiography was performed using 6Fr JL3.5 catheter and right coronary angiography was performed using 6Fr JR4 catheter.
  • Procedure
    • Percutaneous 18020A-Cath one side
    • Percutaneous 18022A-CAG
    • Percutaneous 33076A-PTCA 1 Vessel
    • The patient was taken to the cardiac catheterization laboratory. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 120cc. The patient was treated with Heparin (Dosage=7000) and NTG (Dosage=200).
  • Activated Clotting Time and BP
    • The measurement data of ACT was 257 S (ACT 1).
  • Finding Summary
    • LAD-D2 : 90-99 % stenosis, Type: C, TIMI: (1)
    • Syntax Score = 32.5
    • Suggest OP : Wait discussion stage PCI or CABG
    • Euro Score = 9.52%
    • In conclusion : CAD with TVD
    • Recommendation : PCI for DB2 for possible thombotic occlusion
    • Left Main :
      • Calcification
    • Left Anterior Descending :
      • Calcification, proximal part 70-80% stenosis, distal part 60-70% stenosis; DB1 90-99% stenosis, DB2 haziness with TIMI 1 flow (thrombus?)
    • Left Circumflex :
      • Calcification, middle part CTO with collaterals from bridging collaterals
    • Right Coronary :
      • Calcification, middle part 70-80% stenosis, distal part 80-90% stenosis with collaterals from LCA
  • Intervention Summary
    • LAD-D1
    • MLD/RVD=0/2.5 mm
      
    • Guiding catheter: Medtronic Luncher 6F EBU3.5.
    • Guide Wire: Asahi Fielder FC wire.
    • Balloon: OrbusNeich Sapphine. 1.0 X 10 mm. Pressure: 10-16 atmospheres. Note: ruptured at 16 atm.
    • A workhorse soft-tip wire could not cross the DB2 lesion, which suggested it as a chronic obstruction. A 1.0mm SC balloon was tried to dilate the proximal part of DB2 but failed.
    • In conclusion : CAD with TVD
    • Recommendation : CABG first, or PCI/medical therapy if the patient refused the surgery.
• 2018-08-06 SONO - hepatobiliary
  • Sonography of hepatobiliary system revealed:
    • Diffuse anechoic nodules in the liver and bilateral kidneys, r/o polycystic renal and liver disease.
      
    • Normal appearance of gall bladder without stone.
    • Patency of PV, HVs, IVC and aorta in hepatic portion.
  • Impression:
    • Diffuse anechoic nodules in the liver and both kidneys, r/o polycystic renal and liver disease.

[MedRec]

• 2024-01-25 SOAP Cardiac Surgery Xu ZhanYang
  • Prescription x3
    • Doxaben (doxazosin 4mg) 2# QD
    • Bokey (aspirin 100mg) 1# QD
    • Caduet (amlodipine 5mg, atorvastatin 20mg) 1# QD
    • Plavix (clopidogrel 75mg) 1# QD
    • Ulstop (famotidine 20mg) 0.5# QD
    • Syntrend (carvedilol 25mg) 0.5# BID
• 2023-05-16 SOAP Hemato-Oncology
  • S
    • Metaastatic adenocarcinoma over right upper lobe, status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21.
    • Multiple lung nodules status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21
    • End stage renal disease
    • 2023-05-16 adenocarcinoma of rectum with multiple lung mets
    • explain the clinical utcome to patient and her daugther. suggest C/T with FOLFIRI. apply Avastin
• 2021-09-22 ~ 2021-10-08 POMR Cardiac Surgery Xu ZhanYang
  • Discharge diagnosis
    • Non-ST elevation myocardial infarction, 3-vessel disease, post coronary artery bypass graft 110/10/29
    • End stage renal disease
    • Essential (primary) hypertension
    • Pure hypercholesterolemia
  • CC
    • sudden onset severe chest pain around 2:00AM since this morning.
  • Present illness
    • This 65-year-old male has the past history of 1. Polycystic kidney under HD QW135, Hypertension for 6 years ago, LMD further 2. Colon cancer s/p operation for 1 year at NTUH. Denied diabetes mellitus, hyperlipidemia.
    • According to the description of the patient and medical record, he ever experienced pain of neck for 2 weeks ago, he visit LMD and medication used for pain control. This time, he suffered from anterior pain, onset around 2:00AM since this morning. The character was compressive sensation. No cold sweating or radiation to bilateral shoulders, jaw. The severity of chest pain was scoring 9 by pain score. So the patient was sent to ER for help. At ED, vital signs included HR:81/min; BP:142/69mmHg. Complete EKG: sinus, Q wave in III/aVF, STD in I/aVL. Emergent anti-platelet agents loading and heparin were given.
    • Cardiologist was consulted for arranging primary PCI. The intervention was performed and dignosis CAD with TVD. And consider CABG first, or PCI/medical therapy if the patient refused the surgery. The patient was admitted to ICU for further care.
  • Course of inpatient treatment
    • He received cardiac cath which showed CAD with TVD. And consider CABG first, or PCI/medical therapy if the patient refused the surgery. The patient was admitted to ICU for further care on 2021/09/22.
    • After admission to the MICU, nephrologist was consulted for arranging hemodialysis.
    • Dual antiplatelet therapy, Beta blocker, Statin, and H2 blocker was given.
    • The 2D transthoracic echocardiography was performed, which report as conclusion:
      • Dilated LA and LV; moderate to severely abnormal LV systolic function with inferoposterior wall hypokinesia.
      • Septal hypertrophy.
      • Mild MR, mild AR and trivial TR.
      • Moderate pericardiac effusion without cardiac tamponade sign.
      • Preserved RV systolic function.
    • Cardiovascular Surgeon was consulted for surgical intervention evaluation. After surgical risk and procedure well explained, he and his family was agreed surgical intervention. He was transferred to Cardiac Surgical Ward on 9/24 under stable condition.
    • After transferring to general ward, neck pain was complaining WHICH WAS SUSPECTED ONGOING ANGINA. Angidil infusion was prescribed. Brilinta was stopped, shift to Clexane FOR PRE-OP.
    • Cardiac enzyme was closely monitored, until 9/24 night, enzyme reaches the peak. Inform family shall be considered earlier CABG. Thus, he received CABG X4 and transferred to the SICU for postoperative intensive care on 9/29.
    • Postoperation, ABX WITH Vancomycin and Brosym use. Under CVVH since 9/29-10/01 then change to H/D.
    • Try weaning ventilator AND HE WAS extubated on 9/30. Under hemodynamic stable and he was transferred to ward.
    • At ward, general appearance was fair and no severe wound pain with well wound condition. Left chest tube was in place with well function. We encouraged him to PERFORM TRIFLOW TRAINING AND AMBULATION on bed for exercise and started to try ambulation.
    • Chest tube was removed on 2021/10/05. Respiratory pattern smoothly after chest tube removal. Cardiac echo was done on 10/8 with normal LVEF 59%.
    • With uneventful postoperative condition, he was discharged on 2021-10-08 and would be followed up at CVS clinic.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Bokey (aspirin 100mg) 1# QD
    • Caduet (amlodipine 5mg, atorvastatin 20mg) 1# QD
    • calcium carbonate 500mg 1# TIDCC
    • carvedilol 6.25mg 1# BID hold if HR < 60
    • Coxine (isosorbide-5-mononitrate 20mg) 1# BID
    • Doxaben (doxazosin 4mg) 1# QD
    • Folacin (folic acid 5mg) 1# QD
    • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# QD
    • Plavix (clopidogrel 75mg) 1# QD
    • Ulstop (famotidine 20mg) 0.5# QD
    • Sindine (povidone iodine 10% aq soln) ASORDER EXT

[consultation]

• 2024-04-01, -01-30, 2023-12-29, -12-12, -11-16, -10-24, -09-21, -08-24, -08-01, -07-10, -05-23, -04-21 Nephrology
  • Q
    • The patient is a 68 y/o male with the history of Polycystic kidney under HD QW135 for 9+ years, Hypertension for 9 years ago, Colon cancer s/p operation for 4 year at NTUH. Hyperlipidemia, Non-ST elevation myocardial infarction, 3-vessel disease, post coronary artery bypass graft s/p CABG x 4 in 2021/10/29, Metastatic adenocarcinoma over right upper lobe, status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21 and Multiple lung nodules status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21. The RUL lung wedge resection pathology showed adenocarcinoma x 2, metastatic, consistent with colorectal origin. The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-).
    • This time, he was admitted to our ward for chemotherapy. We need your expertise to arrange hemodialysis. Thanks a lot!
  • A
    • We will arrange hemodialysis QW135 for the patient during the course of hospitalization.
    • Please prescribe EPO 5000 IU QW if Hb < 11.
• 2023-08-02 Cardiology
  • Q
    • for suspect AMI
    • The patient is a 68 y/o male with the history of Polycystic kidney under HD QW135 for 9+ years, Hypertension for 9 years ago, Colon cancer s/p operation for 4 year at NTUH. Hyperlipidemia, Non-ST elevation myocardial infarction, 3-vessel disease, post coronary artery bypass graft s/p CABG x 4 in 2021/10/29, Metaastatic adenocarcinoma over right upper lobe, status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21 and Multiple lung nodules status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21. The RUL lung wedge resection pathology showed adenocarcinoma x 2, metastatic, consistent with colorectal origin. The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-).
    • This time, he was admitted to our ward for chemotherapy with C2D15 FOLFIRI/#4 Avastin.
    • During chemotherapy, he complaints headache, and chest tightness, the SBP 198mmHg, follow-up cardiac enzymes: CK-MB 3.2ng/mL, CPK 47U/L, Troponin-I 34.2pg/mL, 12-lead EKG suspect AMI, and gave Angidil 20mg in N/S 80ml with pump run 3ml/hr. We need your expertise to arrange hemodialysis. Thanks a lot!
  • A
    • This 68 y/o male patient is a case of HTN, polycystic kidney diseaes anbd ESRD under regular hemodialysis. He also had past history of old non-ST elevation MI and 3-V CAD s/p CABG (LIMA insitu to LAD; SVG sequentially to D2-OMx-PDA) with additional vein interposed between AsAo and SVG conduit. on 2021-10-29. He was diagnosed rectal cancer with lung metastasis and was admitted for C/T. However, sudden onset of chest pain over right chest wall developed in this morning. The chest pain was not associated withg dyspnea or diaphoresis. The duration of chest pain lasted for 1~2 hours. The folow-up EKG showed ST depression at lateral leads, and mild elevation of hsTroponin-I was detected. Now we are consulted. The patient denied chest pain at present.
      • 20230802 EKG: old inferior wall MI, ST depression with T wave inversion at V5~6, lead I and aVL
      • 20230214 Echo: LVEF: 56.1%, LV:53/32, IVS/PW;23/16, LA:44, AO:35, thickened AV with trivial AR, calcification of posterior MV leaflet, mild MR, concentric LVH, mildly dilated LV, preserved LV and RV systolic function, hypokinesia of basal to mid inferior wall, mild PR, mild TR, normal IVC size, dilated LA
    • Lab:
      • CKMB 2023-08-02 3.2
        
      • CK 2023-08-02 47
        
      • hs-Troponin I 2023-08-02 31.2
        
    • Impression:
      • Atypical chest pain
    • Suggestion:
      • The clinical presentation for right chest pain is atypical for angina pectoris. However, ST depression at lateral leads during chest pain was recorded from the EKG study.
      • Please follow cardiac markers (CK, CKMB and hsTroponin-I) and EKG again to clarify the diagnosis of acute NSTEMI.
      • If evolutional elevation of hsTroponin-I is detected, type II MI will be prefered.
      • Please keep on DAPT use.
      • Please repeated echocardiograpphy study to evaluate the LV wall motion asynergy and LV systolic function.

[immunochemotherapy]

• 2024-04-01 - ………………………………….. irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 395mg NS 250mL 2hr + fluorouracil 2400mg/m2 2990mg NS 500mL 46hr (FOLFIRI 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2024-01-30 - ………………………………….. irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 395mg NS 250mL 2hr + fluorouracil 2400mg/m2 2990mg NS 500mL 46hr (FOLFIRI 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-12-29 - ………………………………….. irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2970mg NS 500mL 46hr (FOLFIRI 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-12-12 - ………………………………….. irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2970mg NS 500mL 46hr (FOLFIRI 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-11-16 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2970mg NS 500mL 46hr (FOLFIRI 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-10-24 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRI 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-09-21 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRI 70%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-08-24 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 170mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2300mg NS 500mL 46hr (FOLFIRI 70% x 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-08-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2300mg NS 500mL 46hr (FOLFIRI 70% x 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-07-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2300mg NS 500mL 46hr (FOLFIRI 70% x 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-06-23 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (FOLFIRI 30% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-05-25 - bevacizumab 5mg/kg 200mg NS 100mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-05-24 - ………………………………….. irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (FOLFIRI 30% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg SC + NS 250mL

==========

2024-04-02

[ESRD & HD QW135: current meds okay]

This patient has end-stage renal disease (ESRD) and receives hemodialysis three times per week (HD QW135). Records in HIS5 have been reviewed, no dosage adjustment is required for the current medication regimen.”

2024-01-31

[adjusting chemotherapy for hemodialysis patients: fluorouracil and irinotecan]

Fluorouracil itself is not significantly removed by dialysis, but its metabolite, FBAL, can be, making no dosage adjustment necessary for patients on intermittent hemodialysis. Administration should occur post-dialysis on treatment days.

Irinotecan, with partial dialyzability and its active metabolite SN38 not dialyzable, is advised against in hemodialysis due to potential toxicity, especially in end-stage kidney disease. If used, initializing a reduced dose of 50% to 66% of the standard, is recommended, considering individual patient response.

2023-10-25

No medication discrepancies were noted. As of 2023-09-21, the doses of irinotecan and fluorouracil in the FOLFIRI regimen have been increased to 70% of the standard dose, and it appears that the patient is still able to tolerate them.

2023-08-02

• The patient recently obtained a 28-day supply of hydralazine on 2023-07-31. In stead of hydralazine, the active medication list includes carvedilol and Caduet (amlodipine, atorvastatin), no reconciliation issues found with these medications.

[hemodialysis]

• Hemodialysis QW135 is arranged for the patient during the course of hospitalization on 2023-08-01 by our nephrologist and EPO 5000 IU QW is suggested if Hb < 11.

• It is advisable to administer Vemlidy (tenofovir alafenamide) and famotidine after the dialysis session has been completed.

[hypertension]

Despite the patient’s current medication regimen of beta-blocker carvedilol and calcium channel blocker amlodipine, the hypertension readings remain elevated. Therefore, it may be worth considering the addition of an angiotensin-receptor blocker, such as valsartan, to better manage the patient’s hypertension.

2023-06-26

• Given that the patient is regularly receiving recombinant epoetin beta 2000IU every two or three days at a local clinic, it is likely that these treatments align with the dialysis schedule for his ESRD. Therefore, if the duration of hospital stay is anticipated to exceed the usual interval between dialysis sessions, there might be a need to arrange for in-hospital dialysis. Additionally, the administration of recombinant epoetin beta would need to be organized in accordance with this plan.
• If Vemlidy (tenofovir alafenamide) is to be given on the same day as dialysis, it should be given after the dialysis is completed.

2023-05-25

• The patient is currently taking Vemlidy (tenofovir alafenamide 25mg) once daily for his HBV condition. For patients undergoing intermittent hemodialysis (thrice weekly), Vemlidy does not require dosage adjustment. If the dose is scheduled on a dialysis day, it should be administered after the dialysis.

• If the treatment is switched to Baraclude (entecavir), dosage adjustments are needed for patients on intermittent hemodialysis (thrice weekly). Although entecavir is not significantly dialyzed (13%), it is recommended to administer 10% of the usual indication-specific dose daily. Alternatively, the usual indication-specific dose can be administered every 7 days. Similar to Vemlidy, if the dose falls on a dialysis day, it should be administered after hemodialysis.

• There appears to be no issue with the current anti-HBV medication listed in the active prescription for the patient.

• For patients on intermittent hemodialysis (thrice weekly), the dosage adjustments for famotidine are as follows: If the usual dose is 10 mg twice daily, use 10 mg every other day; if the usual dose is 20 mg once daily, use 10 mg every other day; and if the usual dose is 20 mg twice daily, use 10 mg once daily or 20 mg every other day. No supplemental dose is necessary, and it should be administered after hemodialysis on dialysis days.

• The current prescription of Ulstop (famotidine) at 10mg QD appears to be appropriate and doesn’t pose any issues.

2023-05-24

• According to the PharmaCloud database, it appears that the patient regularly visits a local physician (LMD) to refill his prescription for epoetin beta for anemia associated with end-stage renal disease (ESRD). However, this medication is not currently on the patient’s active medication list in our records. Therefore, it would be prudent to verify the patient’s continued use of epoetin beta and consider adding it to the active medication list to ensure proper medication reconciliation.

• It is about to apply the FOLFIRI plus Avastin to the patient on hemodialysis.

  • In patients with renal impairment and a glomerular filtration rate (GFR) less than 10 mL/minute, it is recommended to start irinotecan therapy at 50% to 66% of the initial dose and increase the dose if well tolerated. However, caution should be exercised in patients with impaired renal function.
  • In patients on hemodialysis, irinotecan may be started at 50% to 66% of the initial dose and increased if tolerated, although this is not usually recommended by the manufacturer. Alternatively, the weekly dose could be reduced from 125 mg/m2 to 50 mg/m2 and administered either after hemodialysis or on nondialysis days. This approach allows for better control of potential accumulation of the drug in the body due to impaired renal function.

• Fluorouracil is typically administered at a standard dose to patients undergoing hemodialysis without the need for dose adjustment. However, it is generally given after the hemodialysis session on dialysis days to prevent potential drug removal during the procedure.

• This patient also has coronary artery disease 3-vessel disease status post coronary artery bypass graft on 2021-10-29. Fluorouracil has been associated with cardiotoxicity, as reported in postmarketing studies. Manifestations of cardiotoxicity may include angina, myocardial infarction/ischemia, arrhythmia, and heart failure. The risk factors for this toxicity include continuous infusion administration (as opposed to intravenous bolus) and pre-existing coronary artery disease. The American Heart Association recognizes fluorouracil as an agent that may cause reversible direct myocardial toxicity or exacerbate underlying myocardial dysfunction. Therefore, if a patient has previously experienced cardiotoxicity related to fluorouracil, the risks of resuming treatment with this drug have not been well established and must be carefully weighed against the potential benefits. Given these risks, it is recommended to monitor the patient’s cardiovascular status closely during the course of treatment with fluorouracil.

• As with bevacizumab, no dose adjustment is required for any degree of renal impairment. However, cardiovascular toxicity, GI toxicity (perforation or fistula), thromboembolic events should be observed.

701455726

240402

[exam findings]

• 2024-01-16 CT - abdomen
  • History and indication: Pancreatic ductal adenocarcinoma with doudoenal obstruction with several mesenterric tumor seeding cT4N2M1, stage IV
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P gastro-jejunal bypass and internal drainage. Pancreatic head cancer with duodenal invasion. Some LNs at retroperitoneum. Increased soft tissues in peritoneal cavity with ascites.
    • A nodule (1.9cm) at right thyroid gland.
    • Liver cysts (up to 1.2cm).
    • Tiny renal stones.
    • Hyperplasia of bil. adrenal glands.
  • IMP:
    • S/P gastro-jejunal bypass and internal drainage. Pancreatic head cancer with duodenal invasion. Some LNs at retroperitoneum. Peritoneal carcinomatosis with ascites.
• 2023-10-12 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P gastro-jejunal bypass. Much regression of pancreatic cancer. Some LNs at retroperitoneum.
    • Liver cysts (up to 0.9cm).
    • Tiny renal stones.
    • Hyperplasia of bil. adrenal glands.
  • IMP:
    • S/P gastro-jejunal bypass. Much regression of pancreatic cancer. Some LNs at retroperitoneum.
• 2023-08-23 Needle Aspiration Cytology - thyroid
  • Negative; Benign
• 2023-08-22 SONO - thyroid
  • Right 0.35 cm; 2.84 cm heterogeneous, 1.29 cm thyroid nodule
  • Suggest FNA to dominant nodule
• 2023-07-13 CT - abdomen
  • History and indication:
    • Pancreatic ductal adenocarcinoma with doudoenal obstruction with several mesenterric tumor seeding cT4N2M1, stage IV.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P gastro-jejunal bypass. Much regression of pancreatic cancer but still presence duodenum, SMV and portal vein invasion. Some LNs at retroperitoneum.
    • Liver cysts (up to 0.9cm).
    • Focal fat stranding along D-colon.
    • Right thyroid nodules (up to 2.0cm).
  • IMP:
    • S/P gastro-jejunal bypass. Much regression of pancreatic cancer but still presence duodenum, SMV and portal vein invasion. Some LNs at retroperitoneum.
• 2023-06-07 All-RAS + BRAF mutation
  • Tissue Block No: S2022-17588
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 12 GGT > GAT, p.G12D)
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-03-11 CT - abdomen
  • Clinical history: 52 y/o male patient with pancreatic canceer
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P gastroenteral anastomosis and stenting.
    • There is still pancreatic head malignancy (around 3.5cm) with adjacent vascular involvement.
    • There are small liver nodules, suspected liver cysts.
    • Thyroid nodule, 2.1cm in right lobe, suspected thyroid goiter.
  • Impression:
    • Pancreatic malignancy with adjacent vascular involvement.
    • S/P gastroenteral anastomosis and stenting.
    • Suspected liver cysts. Suggest follow up.
• 2022-12-05 Standing KUB
  • S/P metalic autosuture projecting at left middle abdomen.
  • S/P endoscopic gastrojejunostomy.
• 2022-11-01 Patho - peritoneum biopsy
  • Labeled as “mesentery”, excision — ductal carcinoma.
  • Specimen submitted in formalin consists of 1 piece(s) of tan, irregular tissue measuring 0.5 x 0.4 x 0.3 cm. All for section(s) in one cassette(s).
  • Section shows markedly fibrotic tissue with ductal carcinoma.
  • IHC stains: CA-19-9 (weak +), CK19 (+), compatible with pamcreatic origin.
• 2022-10-24 Panendoscopy
  • Diagnosis
    • Status post endoscopic gastroenterostomy with LAMS placement (note: LAMS, lumen-apposing metal stent)
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric ulcer, LAMS site
    • Edematous duodeanl mucosa, bilateral loop
  • Suggestion
    • consider tubular SEMS (note: SEMS, self-expandable metallic stent)
• 2022-10-24 ERCP, Endoscopic Retrograde Cholangiopancreatography
  • Indication: For LAMS revision
  • Symptoms: vomiting
  • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
  • Anesthesia: IV anesthesia
  • Diagnosis:
    • Gastric outlet obstruction, s/p endoscopic gastroenterostomy with successful LAMS placment but poor functionality,
    • s/p double pigtail stenting
  • Suggestion:
    • Suggest further metal stent placement for definite treatment.
    • Liquid diet.
• 2022-10-21 CT - abdomen
  • History:
    • 20221009 CT：pancreatic uncinate process cancer 3.6 cm with adjacent duodenum invasion (causing gastric outlet obstruction), SMA, SMV and portal vein invasion. Some LNs at retroperitoneum. cT4N2M0, cstage:III
    • 20221018 EUS guided gastroenteral anastomosis is achieved with hot AXIOS LAMS under guidance of EUS and fluoroscopy.
  • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
  • Findings:
    • S/P gastroenteral anastomosis with hot AXIOS LAMS self expanding metal stent. However, the stomach still shows marked distention with fluid collection.
      • please correlate with clinical condition.
    • Prior CT identified pancreatic uncinate process cancer with gastric outlet obstruction is noted again, stationary.
    • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
    • There is no ascites or lymphadenopathy.
    • There is no bowel wall thickening, and no bowel obstruction.
    • The abdominal aorta and IVC are grossly unremarkable.
    • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
  • IMP:
    • S/P gastroenteral anastomosis with hot AXIOS LAMS self expanding metal stent. However, the stomach still shows marked distention with fluid collection.
• 2022-10-20 Upper GI series
  • Findings
    • S/P gastric stenting.
    • The contrast medium passage from oral cavity through esophagus to stomach, stasis of contrast medium in the stomach with passage of some contrast medium into the duodenum.
  • Impression:
    • S/P gastric stenting, partial gastric obstruction.
• 2022-10-18 EUS, Endoscopic Ultrasonography
  • Indication: pancreatic cancer with gastric outlet obstruction
  • Symptoms: refractory vomiting
  • Pre-EUS diagnosis: Gastaric outlet obstruction
  • Diagnosis
    • Pancreatic cancer, uncinate process, with gastric outlet obstruciton s/p AXIOS LAMS (2 cm)
    • trivial ascites
  • Suggestion
    • standing abdomen tomorrow
• 2022-10-13 Needle Aspiration Cytology - pancreas
  • Pancreas: adenocarcinoma
• 2022-10-13 Patho - pancreas biopsy
  • Pancreas, head, EUS-FNB — ductal adenocarcinoma
  • Microscopically, it shows ductal adenocarcinoma composed of neoplastic ductal glands with invasive growth pattern and surrounding fibrous stroma. The tumor shows nuclear hyperchromasia, pleomorphism and increased N/C ratio.
• 2022-10-12 EUS, Endoscopic Ultrasonography
  • Indication: panc head tumor
  • Symptoms: severe abdominal pain
  • Pre-EUS diagnosis: Panc cancer
  • Diagnosis
    • Highly suspected pancreatic head cancer, s/p CH-EUS & EUS/FNB (A)
    • Duodenal narrowing, IDA to proximal 3nd portion, with partial obstruction, s/p biopsy (B)
    • Pancreatic head cystic lesion
    • Reflux esophagitis LA Classification grade D
    • Post NG insertion
    • Ascites
• 2022-10-11 Panendoscopy
  • Indication: Abdominal distention
  • Premedication: Xylocaine local spray
  • Anesthesia: No anesthesia
  • Diagnosis
    • Suboptimal study due to much food residual retention in stomach and duodenum, favor gastric outlet obstruction cause by uncinate process tumor
    • Reflux esophagitis LA Classification grade C
  • Suggestion
    • Arrange EUS-FNB for uncinate process tumor
    • Please keep NG tube decompression for this patient
• 2022-10-11 SONO - abdomen
  • Indication：Pancreatic lesion
  • Diagnosis (poor echo window)
    • Pancreatic tumor, uncinate process
    • suspected calcified spot, right lobe
    • Duodenal 3rd portion and gastric lumen was dilated
  • Suggestion
    • Arrange EUS-FNB for pancrease tumor
• 2022-10-09 CT - abdomen
  • History and indication: suspect GI tract cancer
  • Findings
    • A poor enhancing tumor (3.6cm) at ucinate process of pancreas with adjacent duodenum, SMA, SMV and portal vein invasion. Some LNs at retroperitoneum.
    • Liver cysts (up to 0.9cm).
    • Small nodules at RLL.
    • Distention of stomach and duodneum.
    • Focal fat stranding along D-colon.
    • Normal appearance of spleen, adrenals and kidneys.
    • Normal appearance of gallbladder.
    • Right thyroid nodules (up to 2.0cm).
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • S/P NG tube indwelling.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)

[MedRec]

• 2024-03-27 SOAP Hemato-Oncology Xia HeXiong
  • S: BMI 19.4, BW from 66 to 61.6 within 1 month
• 2023-09-21 SOAP Gastroenterology Wang JiaQi
  • S
    • Dx: Pancreatic ductal adenocarcinoma with doudoenal obstruction with several mesenterric tumor seeding cT4N2M1, stage IV, status post laparoscpe vagotomy with gastrojejunostomy on 2022/10/31 under chemotherapy with FOLFINOX from 2022/12/07
    • CH-B under tx
    • Essential (primary) hypertension
    • diarrhea for ms. stool 5-10/day even under imodium 2/day. esp post meal. gurgling (+).
    • Now stool 3/day
    • herpes zoster
    • on C/T; just discharge
    • bw stable
    • No op due to tumor near vessel
  • Prescription
    • Protase (pancrelipase 280mg) 1# TID
    • Dicetel (pinaverium bromide 100mg) 1# TID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • loperamide 2mg 1# BID
• 2022-11-28 ~ 2022-12-08 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Pancreatic head and neck carcinoma with lymph node metastasis, T4N2M0, stage III
    • Malignant neoplasm of head of pancreas
    • Essential (primary) hypertension
    • Hypokalemia
    • Diarrhea, unspecified
    • Chronic viral hepatitis B without delta-agent
    • Fever, unspecified
    • Hypomagnesemia
  • Course of inpatient treatment
    • After admitted, IVF supplementation for poor appetite. Hypokalemia (K:2.9 -> 3.2 -> 3.7mmol/L) with 0.298% KCl in NS 500ml IVF BID from 2022/11/28~2022/12/07. Hypomagnesemia (Mg:1.7 -> 2.1mg/dL) with MgSO4 1pc iv QD from 2022/11/30~2022/12/07. Diarrhea with Smecta 1pk po TIDAC and Ufunin 1# po PRNQ6H. Fever, R/O sepsis with Antibiotic with Tapimycin 4.5gm iv Q6H from 2022/11/30~2022/12/07 and Panadol 1# po PRNQ6H for BT > 38’C. Chemotherapy with FOLFIRINOX (Oxalip 65mg/m2, Campto 120mg/m2, LV 300mg/m2, 5FU 300mg/m2, 5FU 300mg/m2 and 2400mg/m2) (C1D1) from 2022/12/05~2022/12/07. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2022/12/08 and OPD followed up later.
  • Prescription
    • Mopride (mosapride citrate 5mg) 1# TID
    • Smecta (dioctahedral smectite 3mg) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • loperamide 2mg 1# PRNQ6H (for diarrhea > 2 times)
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Protase (pancrelipase 280mg) 1# TID
• 2022-11-22 SOAP Hemato-Oncolgoy
  • Tx Plan: Neoadjuvant C/T with FOLFIRINOX followed by surgical intervention

[consultation]

• 2023-08-22 Metabolism and Endocrinology
  • Q
    • This 52-year-old man patient is a case of Pancreatic ductal adenocarcinoma with doudoenal obstruction with several mesenterric tumor seeding, cT4N2M1, stage IV, status post laparoscpe vagotomy with gastrojejunostomy on 2022/10/31 and chemotherapy with FOLFINOX from 2022/12/07 and immunity therapy with Nivolumab from 2023/08/21.
    • Abdominal CT on 2023/07/13 showed S/P gastro-jejunal bypass, much regression of pancreatic cancer but still presence duodenum, SMV and portal vein invasion, some LNs at retroperitoneum and right thyroid nodules (up to 2.0cm). Now, for evaluate right thyroid nodules (up to 2.0cm) examine. Thank you.
  • A
    • According to CT, the mass seem outside the thyroid lobe, unable to rule out lymphadenopathy.
    • A thyroid echo has already been ordered, and it is also noted to examine the condition of the neck lymph nodes.
    • Further orders may be required:
      • sono, neck => for cervical lymphadenopathy survey
      • thyroid nodule FNA or lymph node FNA => for tissue proof
• 2022-10-13 General and Digestive Surgery
  • Q
    • Under the impression of abdominal distened suspect GI tract lesion, he was admitted to ordinary ward for further evaluation and management.
      
    • Due to Abdominal CT was reported Pancreatic carcinoma T4N2M0, STAGE:III. EUS FNB of pancreas was performed on 20221012, the pathology was pending. We need your surgical evaluation, thank you
  • A
    • A case of pancreatic head tumor with SMA invation
    • further operation with indication of double bypass or endo stent
    • if pt want to operation, we will take over for this case
• 2022-10-14 Hemato-Oncology
  • Q
    • This 51-year-old male has the histories of 1) Hypertension, 2) Gastric ulcer. He suffered form abdmnial distened after eating and body weight lose about 8kg since 2022/07. This time, he suffered from epigastric pain for 7 days. Poor appetite, nausea with vomiting were noted. He visited local medical clinic for help. But the symptoms did not improved. This time, he sufferred from vomiting 3 times with coffee ground vomitus since 20221007 midnight. He denied tarry stool passage, dizziness, chest tightness/pain, diarrhea/constipation, dysuria/frequency found.
    • The patient was sent to our ER for help. COVID19 rapid test showed Negative. At ER, BT:36.2C, BP:143/109 mmHg, PR:90/min, RR:18/min, SpO2:95% under room air. Con’s:E4V5M6. Physical exam showed pink conjunctiva, no JVE or bruit, symmetric chest wall expansion, breath sound:clear, Abdomen:soft, distension, epigastric tenderness, no muslce guarding or rebounding pain, normoctive bowel sound, no flank knocking pain, no lower leg pitting edema, no wound lesion, normal skin turgor and no skin rash found. Under the impression of abdominal distened suspect GI tract lesion, he was admitted to ordinary ward for further evaluation and management.
      
    • Due to Abdominal CT was reported Pancreatic carcinoma T4N2M0, STAGE:III. EUS FNB of pancreas was performed on 20221012, the pathology was pending, we need your evaluation and advice.
  • A
    • A case of pancreatic tumor with underlined HTN, GU is noted. I am consulted for the further evaluation and management.
    • My suggestions:
      • Well discuss with patient and family
      • May Consider Bypass and excisional tissue proof first.
      • May consider neoadjuvant chemotherapy first followed by OP (if feasible) or CCRT

[surgical operation]

• 2022-10-31
  • Surgery
    • laparoscpe vagotomy with GJbypass
    • excision of mesenteric tumor suspected seeding
  • Finding
    • pancreatic ca with doudoenal obstruction and several mesenterroc tumor seeding (PCI:1/39)

[chemotherapy]

• 2024-03-18 - nivolumab 3mg/kg 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + irinotecan 120mg/m2 220mg D5W 250mL 90min + leucovorin 300mg/m2 540mg NS 500mL 2hr + fluorouracil 300mg/m2 540mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Opdivo + FOLFIRINOX)
  • diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2024-01-16 - nivolumab 3mg/kg 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 280mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Opdivo + FOLFIRINOX)
  • diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-12-11 - nivolumab 3mg/kg 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 280mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Opdivo + FOLFIRINOX)
  • diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-11-13 - nivolumab 3mg/kg 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 280mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Opdivo + FOLFIRINOX)
  • diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-10-11 - nivolumab 3mg/kg 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 280mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Opdivo + FOLFIRINOX)
  • diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-09-18 - nivolumab 3mg/kg 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 280mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Opdivo + FOLFIRINOX)
  • diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-08-21 - nivolumab 3mg/kg 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 280mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Opdivo + FOLFIRINOX)
  • diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-08-07 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-07-10 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-06-05 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-05-22 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-05-04 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-04-12 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-03-24 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-03-09 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-02-20 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 540mg NS 500mL 2hr + fluorouracil 300mg/m2 540mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-02-06 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 275mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-01-03 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 275mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2022-12-19 - oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + irinotecan 150mg/m2 275mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2022-12-05 - oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 225mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-06-06 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571

• Cycle length: 14 days.

• Regimen

  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin).
    • Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 180 mg/m2 IV
    • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 400 mg/m2 IV bolus
    • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
    • Day 1
  • FU
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

Modified FOLFIRINOX chemotherapy for pancreatic cancer 2023-06-06 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F109546

• Cycle length: 14 days.

• Regimen

  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 150 mg/m2 IV
    • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

==========

2024-04-02

[rising CEA/CA199 & ascites on CT: possible progression despite FOLFIRINOX]

The FOLFIRINOX regimen, initiated in Dec 2022 and enhanced with nivolumab since late Aug 2023, hasn’t curbed the rise in CA199 and CEA levels, hinting at disease progression, underscored by a CT scan (2024-01-16) revealing peritoneal carcinomatosis.

• 2024-03-27 CA199 2908.54 U/mL

• 2024-03-18 CA199 2821.58 U/mL
  

• 2024-01-30 CA199 1770.89 U/mL
  

• 2024-01-15 CA199 1205.64 U/mL
  

• 2023-12-28 CA199 751.61 U/mL
  

• 2023-12-11 CA199 429.13 U/mL
  

• 2023-10-24 CA199 142.37 U/mL
  

• 2023-08-31 CA199 34.20 U/mL
  

• 2023-08-02 CA199 22.44 U/mL
  

• 2023-07-26 CA199 19.26 U/mL

• 2024-03-27 CEA 5.46 ng/mL

• 2024-03-18 CEA 5.86 ng/mL

• 2024-01-30 CEA 5.26 ng/mL

• 2024-01-15 CEA 4.36 ng/mL

• 2023-12-28 CEA 3.97 ng/mL

• 2023-12-11 CEA 3.62 ng/mL

• 2023-10-24 CEA 3.36 ng/mL

Significant weight loss (more than 10%) noted between 2024-03-11 (68 kg) and 2024-04-01 (61.5 kg), suggests potential cachexia, possibly necessitating enhanced nutritional support.

• 2024-04-01 WBC 2.07 x10^3/uL
  

• 2024-04-01 Neutrophil 68.6 %
  

• 2024-04-01 HGB 9.2 g/dL

• 2024-04-01 K (Potassium) 3.0 mmol/L
  

• 2024-04-01 Albumin (BCG) 3.0 g/dL
  

• 2024-04-01 Ca (Calcium) 2.06 mmol/L

Concurrently observed conditions such as neutropenia, anemia, hypokalemia, and hypoalbuminemia are being managed with potassium and albumin supplements, showing no inappropriate issues so far.

2023-09-19

This patient recently refilled a 28-day supply of Urosin (atenolol) and nifedipine on 2023-08-26, and a prescription for Dicetel (pinaverium bromide), Gaslan, and Protase was refilled on 2023-08-14. While the latter group of medications has been added to the active medication list, the antihypertensive agents (atenolol and nifedipine) have not been included. Given that the patient’s blood pressure was recorded as 139/92 at 08:13 on 2023-09-19, it may be advisable to reinstate these antihypertensive drugs if the blood pressure continues to rise.

2023-08-22

Currently, the patient’s medication records are not accessible on PharmaCloud. However, after reviewing the HIS5 records, no medication reconciliation issues were found.

2023-08-08

The active medication list includes a repeat prescription by our gastroenterologist for Protase (pancrelipase), Dicetel (pinaverium bromide), and Gaslan (dimethylpolysiloxane). However, Urosin (atenolol) and nifedipine, which were refilled on 2023-07-26, are not currently being used as the patient’s blood pressure has not shown an elevation during this hospitalization. There are no medication reconciliation issues identified.

2023-07-11

The local pharmacy refilled atenolol and nifedipine on 2023-07-01. They are included in the active medication list, and no medication reconciliation issues were found.

2023-06-06

• According to the PharmaCloud database, the refillable prescription for the patient’s primary hypertension, which was filled on 2023-04-29, has now expired. Additionally, the patient’s TPR panel does not display any instances of elevated blood pressure during this current hospitalization. Therefore, no issues have been found during the medication reconciliation process.

2023-05-23

• There was a refillable prescription for nifedipine and atenolol to treat the patient’s primary hypertension that was filled on 2023-04-29 for another 28-day course. These two drugs, nifedipine and atenolol, are not currently on the patient’s formulary, which violates medication reconciliation principles. However, the patient’s blood pressure readings from the TPR panel have remained relatively stable during the hospitalization. It is recommended that the patient’s blood pressure continue to be monitored and that reintroduction of these medications be considered based on future blood pressure readings and the patient’s overall clinical condition.

2023-05-05

• The patient appears to be tolerating the current treatment regimen well, with the exception of occasional episodes of leukopenia and diarrhea. However, these side effects have been manageable and reversible with the appropriate medications.

2023-04-13

The patient’s WBC count has shown a decreasing trend since the start of the FOLFIRINOX regimen and is unlikely to fully recover at the current dose and interval.

• 2023-04-12 WBC 2.50 x10^3/uL
• 2023-04-06 WBC 3.85 x10^3/uL
• 2023-03-21 WBC 3.68 x10^3/uL
• 2023-03-09 WBC 2.55 x10^3/uL
• 2023-03-02 WBC 3.21 x10^3/uL
• 2023-02-16 WBC 4.53 x10^3/uL
• 2023-02-06 WBC 3.51 x10^3/uL
• 2023-01-31 WBC 5.03 x10^3/uL
• 2022-12-29 WBC 4.07 x10^3/uL
• 2022-12-15 WBC 5.02 x10^3/uL
• 2022-12-05 WBC 5.26 x10^3/uL

2023-03-27

On 2023-03-21, the patient’s WBC count remained at 3.68K/uL, which was an increase compared to 2.55K/uL on 2023-03-09 while receiving the same dose-reduced FOLFIRINOX regimen at a Q2W interval.

The patient experienced 5 bowel movements on 2023-03-23 and 2023-03-25, and 3 on 2023-03-26. Loperamide 2mg TIDAC was prescribed and effectively mitigated the diarrhea.

A low serum K level (3.1mmol/L) was noted on 2023-03-21, and potassium supplements have been properly prescribed to address this issue.

As of 2023-03-27 at 08:37, the patient’s blood pressure was recorded as 103/63mmHg. If the patient continues to maintain a relatively low blood pressure for an extended period of time, the discontinuation of Urosin (atenolol) may be considered while continuing nifedipine, with regularly monitoring of blood pressure.

There are no issues with the active prescription.

2023-03-10

Protase (pancrelipase 280mg/cap) is properly prescribed as 1# PO BID. Pancrelipase itself has the potential to cause various gastrointestinal signs and symptoms, including but not limited to abdominal pain, abnormal stools, constipation, diarrhea, duodenitis, dyspepsia, flatulence, frequent bowel movements, gastritis, nausea, and vomiting. It is recommended to monitor these symptoms.

The patient is receiving a dose-modified FOLFIRINOX regimen, which includes a lower dose of oxaliplatin (85mg/m2 reduced to 75mg/m2) and irinotecan (180mg/m2 reduced to 150mg/m2). Despite the reduction in dosage, recent lab data shows a trend towards leukopenia, which should be closely monitored.

• 2023-03-09 WBC 2.55 x10^3/uL
• 2023-03-02 WBC 3.21 x10^3/uL
• 2023-02-16 WBC 4.53 x10^3/uL
• 2023-02-06 WBC 3.51 x10^3/uL
• 2023-01-31 WBC 5.03 x10^3/uL
• 2022-12-29 WBC 4.07 x10^3/uL
• 2022-12-15 WBC 5.02 x10^3/uL
• 2022-12-05 WBC 5.26 x10^3/uL

2023-02-22

The patient has been admitted to receive his 5th FOLFIRINOX treatment, and he has been tolerating the treatment well.

Adjuvant therapy with a modified FOLFIRINOX regimen led to significantly longer survival than gemcitabine among patients with resected pancreatic cancer, at the expense of a higher incidence of toxic effects. (ref: FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer. N Engl J Med. 2018;379(25):2395-2406. doi:10.1056/NEJMoa1809775). Please continue to closely monitor the patient for any signs of adverse reactions.

2022-12-01

For this patient with a pancreatic CA with duodenal obstruction, a lumen-apposing metal stent revision was performed on 2022-10-24 and he is currently being treated with piperacillin and tazobactam for suspected sepsis.

There was a low level of K, Na, Mg, and Ca in the serum on 2022-11-30, possibly due to diarrhea (bowel movements 7 times on 28 and 4 times on 30). If the readings continue to decline, electrolyte supplements might be beneficial.

The regimen FOLFIRINOX might be delayed or at least initialized with a lower dose of irinotecan if the patient continues to experience diarrhea.

701230770

240401

[exam findings]

• 2024-03-30 MRI - L-spine
  • With and without-contrast multiplanar lumbar spine
    • Multiple intramedullar lesions of spine, more severe at T7, L3-4-5 vertebral bodies, as well as sacroiliac bone. Enhancement after contrast administration.
    • Normal alignament of vertebral column.
    • Focal compression fracture of L5 veretebral body.
    • No intramedullary signal abnormality.
  • Impression
    • Multiple bone metastasis
    • Suggest clinical correlation

[MedRec]

• 2024-03-30 SOAP Medical Emergency Hong ZhengLun
  • S
    • Back pain was noted
    • Hx of gastric cancer s/p Target therapy
    • 2024/02/26 –> MRI without contrast
      • Findings
        • Protruding disks are noted at the level of L2-L3, L3-L4, L4-L5 and L5-S1 with mild thecal sac compression.
        • Compression with narrowing of the intervertebral neuroforamina of L2-L3, L3-L4, L4-L5 and L5-S1 is noted bilaterally.
        • There is no evidence of mass lesion noted in the spinal canal.
        • Suspicious bone metastasis over L2, L3 and L4.
      • Impression:
        • Bulging disks at the level of L2-L3, L3-L4, L4-L5 and L5-S1 with mild thecal sac compression.
        • Narrowing of the intervertebral neuroforamina of L2-L3, L3-L4, L4- L5 and L5-S1, bilaterally.
        • Suspicious bone metastasis over L2, L3 and L4.

==========

2024-04-01

[evaluating pain management alternatives in extensive cancer treatment]

The PharmaCloud records indicate the patient has been consistently refilling TS-1 (oral 20mg BID) for her gastric cancer, with last refills on 2024-01-17, 2024-02-21, and 2024-03-20. However, TS-1 is absent from the current medication list. Unless contradicted clinically, it’s generally recommended to persist with this regimen to maintain its effectiveness, barring any new treatment plans.

Given the patient’s history of extensive radiotherapy (25 times) and chemotherapy (8 cycles), as noted in the DutyNote on 2024-03-20, and the presence of significant metastatic vertebral pain, a consultation with Radiation Oncology might be beneficial for addressing bone metastases.

If the current regimen of oral Celebrex, Tramacet, and injectable Tramtor doesn’t sufficiently alleviate the patient’s pain, considering a fentanyl patch could be a viable alternative. The lab results from 2024-03-30 indicate no abnormalities in liver or kidney function, which supports exploring this option.

[bedside visit: addressing concerns about pain and bowel movements in hospital]

During my visit to the patient at approximately 14:30 on 2024-04-01, her son was present.

The patient reported experiencing pain in her spine when turning in bed or sitting up and mentioned ongoing deep thigh pain, although currently bearable without the need for increased pain medication.

She also expressed concern about not having had a bowel movement since hospital admission, fearing constipation. I assured her that the medical team would be informed to consider medication adjustments.

If clinically permissible, laxatives MgO and/or sennosides could be considered to facilitate at least one bowel movement.

700622927

240329

[exam findings]

• 2023-06-30 SONO - nephrology
  • Chronic renal parenchymal disease, moderate degree

[MedRec]

• 2022-05-01 ~ 2022-06-10 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • MDS, Refractory anemia with excess of blasts 1, Karyotype：46,XX,del(20)(q11.2), IPSS-R: 4.5, intermediate risk. HCT-CI score: 0, low risk, status post MUD-allogeneic peripheral blood stem cell transplantation on 2022/05/10
    • Chronic viral hepatitis B without delta-agent
    • Mucositis (ulcerative) of perineal
    • Other hemorrhoids
  • CC
    • for allogeneic peripheral blood stem cell transplantation
  • Present illness
    • This 56 year-old female was in her usual health status before. She was diagnosed of pneumonia and pancytopenia in Oct,2021.The initial presentations were night sweating, body weight loss 5kg in 3 months and also appetite poor. Bone marrow in China’s hospital revealed no maglignancy.
    • Owing to personal reason,she came to our ONC OPD on Nov 26, 2021. Laboratory test revealed pancytopenia(WBC:2.47 10^3/uL Hb:6.6 g/dL,PLT: 183 10^3/uL) with atypical lymphocyte 16% and blast 16%. Under the impression of pancytopenia,unknown. She was admitted for further management.
    • After admission,bone marrow aspiration and biopsy was performed on 2021/11/29 which proved Refractory anemia with excess blasts-1 (RAEB-1).Family meeting held on 2021/12/3 and fully explaination to patient and family.Under the diagnosis of MDS,refractory anemia with excess blasts-1.She received vidaza (azacitadine) 75 mg/m2 sc x7d /Q3W
      • C1 on 2021/12/03-12/09
      • C2 on 2021/12/24-12/30
      • C3 on 2022/01/14-01/20
      • C4 on 2022/02/08-02/14.　
    • Neulogist was consulted due to twitching on right face for several years, severer recently and add Rivotril 1tab BID. Brain MRA was performed on 2022/2/11 which showed 1. low SI on T1WI in the bone marrow of the skull bones. Nature? Please　 correlate with contrast-enhanced study.2. spots with abnormal SI in the  white matter of the supratentorial brain with the largest one, about 5mm, in the left posterior frontal lobe.
      • C5 on 2022/03/02-03/08.
      • C6 on 2022/03/28-04/03.
    • IIP meeting held on 2022/03/30 for explained the crisk and complication of alloPBSCT, patient and her son can fully understood. Heart echo was performed which showed: 1) Adequate LV systolic function with no regional wall motion abnormality at resting state. 2) Mild mitral and tricuspid regurgitation, trivial aortic regurgitation. 3) Thick IVS and LVPW.
    • This time, she was admitted for for allogeneic peripheral blood stem cell transplantation
  • Course of inpatient treatment
    • After admission, Chemotherapy with FluMel140-ATG followed by MUD-allogeneic peripheral blood stem cell transplantation was administered on 5/4-5/8.
    • Hickman insertion on 5/2. We held the IPP on 5/4 10:00 and fully explained the further management to patient and her son.
    • ATG 2.5mg/kg total given 125mg on 2022/5/8-9.
    • MUD-allogeneic peripheral blood stem cell transplantation on 5/10, total CD34: 285.6110^6, 5.610^6/kg, total 357ml, infusion time: 14:24->14:46.
    • CSA 1.5mg/kg since 2022/5/9 till +22days, titration to 125mg Q12h then shifted to oral form Ciclosporin 100mg TID from 6/2- and MTX 15mg/m2 total given 22mg on D1(5/11), total given 15mg on D3(5/13), D6(5/16), D11(D21) for prophylaxis graft-versus-host disease.
    • Prophylaxis antibioitics with Cravit 500mg QDAC since 5/3-11, 5/18-22 Tapimycin 4.5g Q6H 5/11-14, Brosym 4g Q12H on 5/14-17, Tienam 500mg Q6H on 5/23-29, Targocid 600mg since 5/11-17, 5/22-29, antifungas with Mycamine 50mg QD on 5/3-29, blood culture all yielded negative.
    • PPN with Oliclinomel (Add Ca and Mg) and IVF with Taita No5 plus KCl 1amp BID.
    • Imolex 2cap PRNQ4H, Codeine 1tab TID, PRN Morphine 3mg SC, PRN Buscopan 1amp IM for hyperactive bowel sound.
    • Pain control with Difflam forte spray and Xylocaine jelly with Sucralfate for severe mucositis.
    • On NG tube on 5/23-30, Mycostatin and Nicort gel oint for severe mucositis.GCSF 300mcg was given on 5/11-29.
    • However, spiking fever with chills was noted on 6/3, empiric antibiotics with Culin 500mg Q6H and Targocid 600mg was administered on 6/3-9, blood culture yielded negative.
    • Chest film on 6/5 disclosed right pleural effusion. Covid PCR were negative on 6/5.
    • Blood transfusion with LRP 2U (UV treated) and LPRBC 2U (UV treated) for correct thrombocytopenia and anemia.
    • Followed up laboratory test recvealed fair CBC level and hypokalemia. A perineal wound 5*3cm was noted on 6/9, PS was consulted then suggested transfered to CRS OPD.
    • With the relatively stable condition, she was discharged on 2022/06/10 and will OPD follow up later.
  • Discharge prescription
    • Alginos Susp (sod. alginate, NaHCO3, CaCO3) 10mL Q6H
    • Eurodin (estazolam 2mg) 1# HS
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Rivotril (clonazepam 0.5mg) 1# BID
    • Ulstop (famotidine 20mg) 1# BID
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
    • Radi-K (potassium gluconate 595mg) 2# QID
    • Genurso (ursodeoxycholic acid 100mg) 2# TID
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Sandimmun Neoral (ciclosporin 100mg) 1# TID

==========

2024-03-29

[adjusting Feburic dosage for mild hyperuricemia management considerations for renal impairment]

The patient was prescribed Feburic (febuxostat) at 80mg daily for mild hyperuricemia, recorded at 6.9 mg/dL on 2024-03-28. However, for patients with CrCl below 30 mL/minute, a lower dose of 40 mg once daily is generally recommended (package insert).

• 2024-03-28 eGFR 24.84 ml/min/1.73m^2
• 2024-03-25 eGFR 18.51 ml/min/1.73m^2
• 2024-03-04 eGFR 21.00 ml/min/1.73m^2
• 2023-12-11 eGFR 28.61 ml/min/1.73m^2

2024-03-28

[to schedule therapeutic drug monitoring for Depakine]

Depakine (valproic acid) was started today, 2024-03-28, targeting a therapeutic trough range of 50 to 100 ug/mL for epilepsy management. While some patients may see improved seizure control at levels above 100 ug/mL, with an upper limit often set around 125 ug/mL by some experts, concentrations between 100 to 150 ug/mL may lead to toxicity. Seizure control might also be achieved at levels below the standard reference range.

Trough concentrations, typically measured just before the next dose for safety and efficacy, are recommended within 3 to 4 days post-initiation or dose adjustment. A trough level check could ideally be scheduled for 2024-04-01.

2022-06-08

[cyclosporine-A TDM]

• The level of serum cyclosporine-A gradually increases (normal range 100~400 ng/mL), please monitor for potential adverse reactions such as post-transplant diabetes mellitus, drug-induced gingival overgrowth, drug-induced thrombotic microangiopathy, neurotoxicity. (Recent laboratory data do not indicate liver toxicity, nephrotoxicity, hyperkalemia, or hypertension.)
  • 2022-06-06 307.0
  • 2022-06-02 287.9
  • 2022-04-09 165.8

2022-05-04

[Minutes of the Interprofessional Practice Meeting and Family Meeting]

• This was the second meeting held on 2022-05-04 at 10:00 in the ward, the first meeting being held on 2022-03-30. The patient’s son participated in the meeting via a smart phone.
• Dr. Kao explained the treatment schedule to the patient family, as well as the prognosis and possible risks.
• The patient asked questions about her small amount of bleeding from the catheter needle wound and the soybean-based meals in the hospital. These questions got immediate feedback, as she understood that willpower is an indispensable element of treatment for the disease.

2022-03-30

[Interprofessional Practice Meeting and Family Meeting following up]

• This meeting was held on 2022-03-30 at 9:00 in the ward, the patient was present, as was her son.
• Dr. Kao explained the treatment plan of the disease to the patient family, as well as the prognosis and possible risks, and interprofessional practice team members were present for inquiries.
• For the transplant will need relatively rare used drugs, the pharmacy should prepare in advance to ensure that the drugs are readily available and Dr. Kao will provide an updated version of conditioning agent schedule.

700557454

240328

[lab data]

2024-03-06 Anti-HBc Nonreactive
2024-03-06 Anti-HBc Value 0.19 S/CO
2024-03-06 Anti-HCV Nonreactive
2024-03-06 Anti-HCV Value 0.13 S/CO
2024-03-06 Anti-HBs 0.86 mIU/mL
2024-03-06 HBsAg Nonreactive
2024-03-06 HBsAg Value 0.25 S/CO

[exam findings]

• 2024-03-27 Pure Tone Audiometry, PTA

  • Reliability FAIR
  • Average RE 15 dB HL; LE 16 dB HL.
  • Bil WNL.

• 2024-03-20 SONO - gynecology

  • R/O LT upper Cyst: (70x34mm)

• 2024-03-15 CT - abdomen

  • Findings:
    • There is a cystic lesion in left pelvic side wall with surrounding fatty stranding, 9.4 cm in size (the largest dimension).
      • Lymphocele with secondary infection is highly suspected. please correlate with clinical condition.
    • S/P hysterectomy
    • Prior CT identified a well-defined, noncalcified solid nodule (9.5mm) in peripheral of LLL of the lung is noted again, mild decreasing in size to 8 mm. Follow up is indicated.
  • Impression:
    • There is a cystic lesion in left pelvic side wall with surrounding fatty stranding, 9.4 cm in size (the largest dimension).
    • Lymphocele with secondary infection is highly suspected.

• 2024-03-15 SONO - gynecology

  • R/O LT upper Cyst (92x36mm)

• 2024-03-11 Venous Duplex, peripheral echography

  • Conclusion:
    • No evidence of DVT, bilateral lower legs
    • Bilateral lower leg MVO/SVC is low.

• 2024-03-08 Bronchodilator Test

  • r/o mild restrictive ventilatory defect
  • negative BDT

• 2024-02-20 CT - chest

  • Findings
    • Lungs: a well defined, noncalcified solid nodule, with mild lobulated margins (9.5mm srs/img302/170) in peripheral of LLL.
      • mild paraspinal fibrosis of RLL, related to irritation of adjacent osteophytes of spine.
    • Chest wall and visible lower neck: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • solitary lung nodule 9.5mm, LLL. stable.

• 2024-02-16 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 29) / 83 = 65.06%
    • M-mode (Teichholz) = 64

• 2024-02-02 PET scan

  • No FDG uptake was noted in the soft tissue nodule in the lower lobe of left lung. The nature is to be determined. Please follow up chest CT scan for further evaluation.
  • Mild glucose hypermetabolism in bilateral shoulders. Inflammatory process may show this picture.
  • Mild glucose hypermetabolism in the midline anterior pelvic wall. Post-operative inflammation may show this picture.
  • Increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.

• 2024-01-11 Patho - ovary (tumor)

  • Diagnosis:
    • Ovary, left, oophorectomy —- Clear cell carcinoma, AJCC 8th edition: pStage IA, pT1aN0(if cM0), FIGO Stage: IA
    • Ovary, right, oophorectomy —- Negative for malignancy
    • Fallopian tube, bilateral, salpingectomy —- Negative for malignancy
    • Uterus, corpus, abdominal total hysterectomy —- Negative for malignancy —- Leiomyoma
    • Uterus, endometrium, abdominal total hysterectomy —- Negative for malignancy —- Endometrial polyp
    • Uterus, cervix, abdominal total hysterectomy —- Negative for malignancy
    • Omentum, omentectomy —- Negative for malignancy
    • Lymph node, left iliac, dissection —- Negative for malignancy (0/4)
    • Lymph node, left obturator, dissection —- Negative for malignancy (0/5)
    • Lymph node, right iliac, dissection —- Negative for malignancy (0/4)
    • Lymph node, right obturator, dissection —- Negative for malignancy (0/7)
  • Gross description:
    • Procedure (select all that apply): Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)
      
    • Specimen size:
      • F2024-00012
        • left ovary: 19.5 x 12.0 x 6.3 cm, 585 g;
        • left tube: 4.7 cm in length and 0.3 cm in diameter;
      • S2024-00826
        • right ovary: 2.0 x 1.3 x 0.7 cm;
        • right tube: 5.8 cm in length and 0.2 cm in diameter;
        • uterus: 8.7 x 5.5 x 3.7 cm, 145 g; cervix: 3.5 x 2.6 x 2.2 cm; endometrial cavity: 4.0 x 2.7 x 0.7 cm with an endometrial polyp, measuring 1.8 x 1.5 x 0.7 cm; Two leiomyomas, measuring up to 2.7 x 2.0 x 1.8 cm
        • omentum: 23.3 x 10.2 x 1.3 cm
    • Specimen Integrity
      • Specimen Integrity of Right Ovary (if applicable): Capsule intact
      • Specimen Integrity of Left Ovary (if applicable): Capsule intact
      • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
      • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
    • Tumor Site: Left ovary
    • Ovarian Surface Involvement (required only if applicable): Absent
    • Fallopian Tube Surface Involvement (required only if applicable): Absent
    • Tumor Size: Greatest dimension (centimeters): 19.5 cm
    • Additional dimensions (centimeters): 12.0 x 6.3 cm
    • Sections are taken and labeled as:
      • F2024-00012: Representative sections are taken and labeled as: FsA1-2, for frozen examination. After formalin fixation, additonal sections are taken and labeled as: X1: fallopian tube; X2-6: tumor.
      • S2024-00826: Representative sections are taken and labeled as: A: lymph node, left iliac; B1-2: lymph node, left obturator; C: lymph node, right iliac; D1-2: lymph node, right obturator; E1: cervix; E2: endometrium; E3: endometrial polyp; E4: leiomyoma; E5: left adnexal soft tissue; E6-7: right ovary and fallopian tube; E8: posterior wall.
  • Microscopic Description:
    • Histologic Type: Clear cell carcinoma; The immunohistochemical stains reveal PAX8(+), Napsin A(+), AMACR(+), WT-1(-), PR(-), and p53(wild type).
      
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors): not applicable
      • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.
    • Implants (required for advanced stage serous/seromucinous borderline tumors only): not identified
    • Other Tissue/ Organ Involvement (select all that apply): Not identified
    • Largest Extrapelvic Peritoneal Focus (required only if applicable): Not identified
      
    • Peritoneal/Ascitic Fluid: N2024-00156: Negative for malignancy (normal/benign)
      
    • Regional Lymph Nodes:
      • Negative for metastasis: left iliac: 0/4; left obturator: 0/5; right iliac: 0/4; right obturator: 0/7
    • Additional Pathologic Findings: Endomatrial polyp and leiomyomas are seen.

• 2024-01-10 Colonoscopy

• 2024-01-10 EGD

• 2023-12-18 CT - chest

• 2023-12-06 SONO - gynecology

• 2023-12-01 CT - abdomen

[MedRec]

• 2024-03-15 ~ 2024-03-25 POMR Obstetrics and Gynecology Zeng LunNa
  • Discharge diagnosis
    • Malignant neoplasm of left ovary
    • Pelvic abscess (2024/03/15 Pus discharge culture:Staphylococcus lugdunensis)
    • Abdominal pain
  • CC
    • Lower mid abdominal pain for 2 days.
  • Present illness
    • This 53 y/o woman, G2P2A0, menopause for 3 years. She had
      • Hyperlipidemia with regular medication control
      • Chronic Ischemic Heart disease with regular medication control
      • left cystic adenocarcinoma status psot debulking on 2024/01/11.
    • She denied any food or drug allergy, denied anticoagulants or hormone use.
    • She complained that she had lower left abdomianl pain for two days. She denies urinary frequency nor weight loss. She denied nausea or vomiting, no tarry/bloody stoool, no constipation, no unine retention,nor body weight loss.
    • She went to emergency department due to LEFT MID QUADRANT abdominal pain NEAR THE UMIBILICUS AREA. At ER, vital sign showed blood pressure showed 124/58mmHg, heart rate 99/min, temperature 35.3 degree, respiration rate was 18/min, Saturation 99% and her conscious was clear.
    • Lab data showed WBC 16990/uL, CRP WAS 19.3 mg/dL, Potassium 3.3 mmol/L, Creatinine 0.50 mg/dL and ALT = 114 U/L.
    • CT was done which revealed a cystic lesion in left pelvic side wall with surrounding fatty stranding, 9.4 cm in size (the largest dimension), lymphocele with secondary infection is highly suspected.
    • Sono- and CT-guide aspiration of LLQ fluid was also done and some reddish fluid was obtained.
    • She was admitted under the impression of lymphocele with secondary infection. Further examination and PROPHYLACTIC ANTIBIOTICS will be provided when she admitted.
  • Course of inpatient treatment
    • The patint is admitted under the impression of lymphocele. CT revealed. Sono revealed LT upper Cyst 92x36mm on 3/15. Lab data showed WBC 19660 /uL and CRP 19.3 on 3/15.
    • After admission, pus culture and blood culture was done. Urine analysis showed normal. Antibiotic with Cefazoline, Gentamycine and Metronidazole was given. Recheck of lab data was done after three day of treatment. Elevated CRP 22.2 mg/dL was noted on 3/18. Therefore, infectiologist was consulted and Brosym and Seforce was recommened. Sono was rechecked which revealed decreased of size to 70x34mm on 3/20.
    • Lab data was rechecked on 2024/03/25 which revealed improved CRP 3.6 mg/dL and WBC 8160 /uL. Due to the improved symptoms, she was allowed to discharge. OPD follow-up was arranged.
  • Discharge prescription
    • Actein (acetylcysteine 200mg) 1# TID
    • ZCough (benzonatate 100mg) 1# TID
    • Cough Mixture (platycodon) 10mL TID
    • Keto (ketorolac 10mg) 1# PRNQ6H
    • Through (sennoside 12mg) 2# HS
    • Cinolone (ciprofloxacin 250mg) 2# BIDAC
• 2024-03-13 SOAP Hemato-Oncology Xia HeXiong
  • S: 2024-03-13 Anti-HBs (-), Anti-HBc (-), HBs Ag (-), Anti-HCV (-)
  • A/P:
    • Admission for C/T with TP x6, audiometry, CCr, bone scan (for bone or joint soreness) and consult dietitian, consult psychiatrist for insomnia, Rheuma for the possibility of auto-immune-related joint pain
• 2024-03-06 SOAP Hemato-Oncology Xia HeXiong
  • O: Multi-disciplinary Cancer Team Meeting Conclusion, Meeting Date: 2024-01-18
    • Treatment Plan: Recommend post-operative adjuvant chemotherapy for clear cell carcinoma and monitoring of pulmonary nodules.
  • A/P:
    • Arrange Abd/Pelivs plus Chest CT (due to lung nodule), Q3M, next on post-C/T x6 or 3 months
    • Admission for C/T with TP x6 and consult dietitian
• 2024-01-09 ~ 2024-01-18 POMR Obstetrics and Gynecology Zeng LunNa
  • Discharge diagnosis
    • Left ovarian tumor cancer psot debulking (Abdominal Total Hysterectomy + Bilateral Salpingo-Oophorectomy + BPLND + infracolic omentectomy) on 2024-01-11
    • Ovary, left, oophorectomy —- Clear cell carcinoma, AJCC 8th edition: pStage IA, pT1aN0(if cM0), FIGO Stage: IA
    • Intramural leiomyoma of uterus
    • Excessive and frequent menstruation with regular cycle
    • Postmenopausal bleeding
    • Leiomyoma of uterus, unspecified
  • CC
    • vaginal bleeding since 2023-10-10, with dizziness and orthopnea
  • Present illness
    • This 53 y/o woman, G2P2A0, menopause for 3 years, menstural cycle regular with duration/interval of 5/28 days, presents with heavy bleeding but no dysmenorrhea. She complained that she felt dizziness recently with orthopnea. She turned to our GYN OPD for help on 2023-11-30.
    • She had pHx of 1) myoma on 2017 without regular follow-up; 2) Hyperlipidemia with regular medication control; 3) Chronic Ischemic Heart disease with regular medication control. She denied any food or drug allergy, denied anticoagulants or hormone use.
    • Heavy bleeding during the menstruation was noted by patient. During he peroid, blood clots could be found sometimes, with fresh red color. She denies urinary frequency nor weight loss. There were mild pale conjunctiva. There were no dyspnea, general malaise, orthostatic hypotension. She denied abdominal pain, no nausea or vomiting, no tarry/bloody stoool, no constipation, no unintentional body weight loss.
    • The transvaginal sono on 2023/12/06 showed uterus measuring uterus, AVF with size 12.8 x 4.9cm, EM was 1.26cm, myoma measuring 3.8x2.8cm, 1.5x0.9cm, and a huge cysytic mass over left pelvic area (>20cm)
    • 2023/12/01 Abdomen CT: 1) Cystic adenocarcinoma of the left ovary is highly suspected, 2) Soft tissue nodule 0.9cm in LLL of the lung.
    • Under the impression of cystic adenocarcinoma of the left ovary, she was admitted on 2023/01/09 for debulking surgery and gastrointerstinal tumor survey. Pre-operation survey and post-operation care would be arranged as schedule.
  • Course of inpatient treatment
    • After admisssion, pre-operative survey such as lablatory studies, EKG and CXR were done and showed normal results.
    • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy) was well performed on 2024-01-11, the whole procedure was smooth and the patient stood it well.
    • During the hospitalization, we rechecked her Hb level on the day after operation, which revealed acceptabled result (12.6 to 11.4).
    • Post-operative empirical antibiotics Cefazolin and analgesic agents were administered and the wound management was performed.
    • After no fever, good oral intake, toelerable wound pain & improved general condition, the patient may be allowed to discharge on 2024-01-18 and OPD follow up was suggested. Further treatment systemic chemotherapy will be arranged after the OPD visit.
  • Discharge prescription
    • cephalexin 500mg 1# QID
    • Keto (ketorolac 10mg) 1# QID
    • Gasmin (dimethylpolysiloxane 40mg) 1# QID
    • MgO 1# QID

[surgical operation]

• 2024-01-11
  • Op Method:
    • Diagnosis: Left ovarian tumor r/o malignancy -> frozen section: adenocarcinoma
    • Operation: Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)   - Finding:
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, free from adhesion. grossly normal.
    • Adnexa:
      • LOV: 18x15x10cm, capsule intact,multi-lobulated and clear fluid inside (around 1000cc).
      • ROV: 3x2x2cm, grossly normal, free from adhesion
      • Fallopian tube: bilateral grossly normal
    • CDS: free from adhesion or tumor invasion.
    • Ascites: nil, wash with normal saline 20cc and sent ascites cytology.
    • Bilateralpelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • Omentum: grossly normal.
    • Liver: grossly normal & smooth.
    • Appendix: grossly normal
    • Estimated blood loss: 200ml
    • Blood transfusion: nil
    • Complication: nil
    • Antiadhesion: Arista        

==========

2024-03-28

700862958

240328

[lab data]

2023-09-26 HBsAg (NM) Negative
2023-09-26 HBsAg Value (NM) 0.510
2023-09-26 Anti-HBc (NM) Negative
2023-09-26 Anti-HBc Value (NM) 2.500
2023-09-26 Anti-HCV (NM) Negative
2023-09-26 Anti-HCV Value (NM) 0.044
2023-09-26 Anti-HBs (NM) Negative
2023-09-26 Anti-HBs value (NM) <2.000 mIU/mL

[exam findings]

• 2024-01-04 Sigmoidoscopy
  • Rectal cancer s/p CCRT with significant tumor regression at 10 cm from AV
• 2023-11-06 Bladder Sonography
  • PVR: 7.38ml
• 2023-11-06 Uroflowmetry
  • Q max: fair
  • flow pattern: obstructive
• 2023-11-02 Anoscopy
  • Prolapsed mixed hemorrhoids
• 2023-09-27 MRI - pelvis
  • Findings:
    • There is circumferential mild asymmetrical wall thickening at the rectosigmoid junction, measuring 5 cm in size, that is c/w adenocarcinoma (T3).
    • There are four enlarged nodes in the peri-rectal space and sigmoid mesocolon (N2a) (Srs:8 Img:7,8,10).
  • IMP:
    • Adenocarcinoma of the rectosigmoid junction is noted.
    • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T3 N2a M0, stage: IIIB
• 2023-09-22 CT - abdomen
  • Findings:
    • There is circumferential mild asymmetrical wall thickening at the rectum, measuring 5 cm in size, that is c/w adenocarcinoma (T3).
    • There is no enlarged node in the peri-rectal space (N0). Please correlate with MRI.
    • There is no focal lesion in both lungs.
    • There are few small lymph nodes in the paratracheal space that may be benign reactive nodes.
• 2023-09-14 Patho - colon biopsy
  • Rectal tumor, biopsy — Adenocarcinoma
  • The specimen submitted consisted of multiple small pieces of colonic tissue measuring up to 0.3 x 0.2 x 0.2 cm in size, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for section.
  • Microscopically, the section shows a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with desmoplasia.
  • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
• 2023-09-14 Colonoscopy
  • Findings
    • The scope had been inserted up to cecum. A tumor was noted at about 10 cm above anal verge. Biopsy was done
    • Internal hemorrhoid was noted
  • Diagnosis
    • Rectal cancer s/p biopsy
    • Internal hemorrhoid

[MedRec]

• 2023-12-04 SOAP Urology Cai YaoZhou
  • Prescription x3
    • Uropin (phenazopyridine 100mg) 1# TID
    • Urief (silodosin 8mg) 1# QD
• 2023-09-28 SOAP Radiation Oncology Huang JingMin
  • S:
    • For pre-op CCRT (TNT) due to rectal adenocarcinoma.
    • PI: The patient suffered from bowel habite change with mucus coating. His diagnosis is adenocarcinoma of the rectum, CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+), stage cT3N0M0 (IIA).
    • Family history: (-)
    • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
    • Personal Hx: DM (-); HTN (-)
    • Previous RT Hx: (-)
  • O:
    • ECOG: 0
    • PE: left ear hearing loss; neck and bil SCF: neg.
    • Colonoscopy (2023-9-14): A tumor was noted at about 10 cm above anal verge. Biopsy was done. Diagnosis: Rectal cancer s/p biopsy. Internal hemorrhoid.
    • Pathology (S2023-18420, 2023-9-18): Rectal tumor, biopsy — Adenocarcinoma. CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
    • CXR (2023-9-21): Essential negative findings
    • CT scan of abdomen (2023-9-22): 1. There is circumferential mild asymmetrical wall thickening at the rectum, measuring 5 cm in size, that is c/w adenocarcinoma (T3). 2. There is no enlarged node in the peri-rectal space (N0). Please correlate with MRI. 3. There is no focal lesion in both lungs. There are few small lymph nodes in the paratracheal space that may be benign reactive nodes. Stage T3N0M0 (IIA).
  • A:
    • Adenocarcinoma of the rectum, CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+), stage cT3N0M0 (IIA)
  • P:
    • TNT is indicated for this patient with the following indicators: rectal cancer, stage cT3N0M0
    • Goal: curative
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fracions of the rectal tumor bed.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient ad his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2023-10-9 (in accordance with chemotherapy).
• 2023-09-28 SOAP Hemato-Oncology Xia HeXiong
  • P
    • Tx Plan: CCRT with infusional 5-FU -> FOLFOX for 12-16 weeks (favor 8 doses) -> OP
    • Arrange Port-A insertion
    • May consider admission for infusional FL
• 2023-09-28 SOAP Colorectal Surgery Xiao GuangHong
  • A: cT3N0M0, stage IIA
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-09-26
      • Suggest Pre-op CCRT (TNT) then follow up CT/MRI
  • P: F/U sigmoidoscopy 3 months later for evaluation of reponse
• 2023-09-21 SOAP Colorectal Surgery Xiao GuangHong
  • O
    • 2023/09/14 Colonoscopy: A tumor was noted at about 10 cm above anal verge
    • 2023/09/14 PATHO - Colon biopsy: Rectal tumor, biopsy — Adenocarcinoma
• 2019-03-14 SOAP Neurosurgery
  • S: low back pain off and on for a long time, which has worsened recently
  • O:
    • E4V5M6
    • cranial nerves: intact
    • mp: full
  • P: check L spine => L4-5 Gr.1 listhesis
  • Diagnosis
    • Other spondylosis with myelopathy, site unspecified [M47.10]
    • Spondylolysis, site unspecified [M43.00]

[radiotherapy]

• 2023-10-17 ~ 2023-11-23 - 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.

[chemotherapy]

• 2024-03-27 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-03-06 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-15 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-01 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-01-17 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-01-03 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-19 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Yang MuJun)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-20 - [leucovorin 20mg/m2 30mg NS 250mL 10min + fluorouracil 400mg/m2 600mg NS 250mL 10min] D1-4 (CCRT. Xia HeXiong)
  • [dexamethasone 4mg + NS 250mL] D1-4
• 2023-10-17 - [leucovorin 20mg/m2 30mg NS 250mL 10min + fluorouracil 400mg/m2 600mg NS 250mL 10min] D1-4 (CCRT. Xia HeXiong)
  • [dexamethasone 4mg + NS 250mL] D1-4

==========

2024-03-28

[reconciliation]

Both laboratory results from 2024-03-27 and vital signs taken throughout this hospital stay appear normal. Additionally, a thorough review of medications in both HIS5 and PharmaCloud records found no discrepancies with the current medication regimen.

2024-03-07

[reconciliation]

Lab results from 2024-03-06, and vital signs measured during this hospitalization were unremarkable. A comprehensive review of both HIS5 and PharmaCloud databases indicated no discrepancies in medication management.

2024-02-02

[reconciliation]

Lab findings dated 2024-02-01 and vital sign measurements from the TPR panel during this hospitalization were generally within normal parameters. A detailed review of both the HIS5 and PharmaCloud databases revealed no inconsistencies in medication management.

2024-01-18

[rectal cancer treatment: ongoing efficacy]

Lab results from 2024-01-17 indicated broadly normal values in blood cell counts, electrolytes, and liver and kidney functions, presenting no contraindications for proceeding with the third FOLFOX session during the current hospitalization.

Additionally, a sigmoidoscopy performed on 2024-01-04 revealed significant tumor regression in the rectal cancer post-chemoradiotherapy, suggesting that the overall treatment remains effective to date.

2024-01-03

[reconciliation]

The patient recently received a 28-day supply of Gaslan, glimepiride, aspirin, and dipyridamole from JingMei Hospital on 2023-12-27 to manage his blood glucose and cardiovascular conditions. Apart from Gaslan, all other medications prescribed by JingMei Hospital and our urology department on 2023-12-25 have been included in the active medication list. It is recommended to verify if the patient’s gastrointestinal symptoms have improved, to determine if there is still a need for Gaslan.

Lab results on 2024-01-02 showed no contraindication for the patient to receive another session of chemotherapy in this hospital stay.

2023-12-20

Lab data from 2023-12-19 and TPR readings, appear generally normal. After reviewing the PharmaCloud and HIS5 records, no discrepancies were found in the active medication list.

700960001

240328

[exam findings]

• 2024-03-16 KUB
  • Hepatomegaly is suspected.
• 2024-03-01 Her2/neu DISH
  • RESULT OF HER2/NEU IN SITU HYBRIDIZATION
    • There is AMPLIFICATION of HER2 detected
  • METHOD AND DETAILS:VENTANA HER2 Dual ISH DNA Probe Cocktail
    • Number of observers: 1
    • Number of invasive tumor cells counted: 20
    • Average number of HER2 gene copy signal per cell: 4.15
    • Average number of CEP17 gene copy signal per cell: 1.20
    • HER2/CEP17 ratio: 3.46
    • Heterogeneous signals: Absent
    • Origin slide and block number: EnChuKong Hospital CellBlock ECK S24-236
    • Specimen: Formalin-fixed paraffin embedded high grade ovarian serous carcinoma tumor
    • Adequacy of sample for evaluation: Yes
    • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
  • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
    • Amplified:
      • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
      • HER2/CEP17 ratio < 2.0 with an average HER2 gene copy number >=6.0 signals/cell
    • Not amplified:
      • HER2/CEP17 ratio < 2.0 with an average HER2 gene copy number < 4.0
      • HER2/CEP17 ratio < 2.0 with an average HER2 gene copy number >=4.0 and < 6.0 signals/cell
      • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number < 4.0
• 2024-03-01 CT - abdomen
  • FINDINGS: Comparison prior CT dated 2023/09/26.
    • Prior CT identified metastases in right lobe of the liver are noted again, marked increasing in size and number that is c/w liver metastases S/P C/T with progressive disease.
      • In addition, metastases in S4 and S1 of the liver are also noted.
    • There are several newly developed metastatic nodes in the celiac trunk and para-aortic space.
    • There is a newly developed soft tissue lesion 1.2 cm in LLL of the lung (Srs:601 Img:43), directly attached the diaphragm, that may be pleura or lung metastasis. Follow up is indicated.
    • S/P left lateral segmentectomy of the liver and S/P hysterectomy.
    • There is mild ascites.
    • A renal cyst measuring 0.4 cm in right lower pole is noted.
  • IMP:
    • Liver metastases S/P C/T show progressive disease.
    • Metastatic nodes in the celiac trunk and para-aortic space.
    • There is a newly developed soft tissue lesion 1.2 cm in LLL of the lung, directly attached the diaphragm, that may be pleura or lung metastasis. Follow up is indicated.
• 2023-09-26 CT - abdomen
  • With and without contrast enhancement CT of abdomen shows:
    • s/p left hepatectomy. Multiple nodular lesions with marginal enhancement in right hepatic lobe, up to 1.2cm.
    • s/p Hystero-oophorectomy.
  • Impression
    • s/p left hepatectomy.
    • Metastasis in right hepatic lobe.
    • Abdominal wall lesion; DDx: tumor seeding, infection, fibromatosis.
• 2023-09-15 Tc-99m MDP whole body bone scan
  • Mildly increased activity in the upper C-spine and L5-sacrum junction. Degenerative change may show this picture.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined. Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2023-09-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (103 - 38) / 103 = 63.11%
    • M-mode (Teichholz) = 64
• 2023-08-22 Patho - liver partial resection
  • PATHOLOGIC DIAGNOSIS
    • Liver, S2-3, S2-3 hepatectomy — Metastatic clear cell carcinoma, consistent with ovarian primary
      
  • MACROSCOPIC EXAMINATION
    • Procedures: S2-3 hepatectomy
      
    • Specimen Size: 11.9 x 10.9 x 4.5 cm and 248 gm
      
    • Tumor Focality: Multiple (number > 10)
      
    • Tumor Site: S2-3
      
    • Tumor Size: The greatest one measuring 9.3 x 7.2 x 3.0 cm
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Not cirrhotic
      
    • Sections are taken and labeled as: A1-A4= tumors, A5= tumor + closest cut margin, A6= non-neoplastic liver
  • MICROSCOPIC EXAMINATION
    • Diagnosis: Metastatic clear cell carcinoma, consistent with oavrian primary
      
    • Histologic grade: High grade
      
    • Tumor growth pattern: Infiltrating
      
    • Tumor pseudocapsule: Absent
      
    • Tumor necrosis: Absent
      
    • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 0.7 cm
    • Vascular invasion: Present
      
    • Perineural invasion: Absent
      
    • Non-neoplastic liver parenchyma: Mild lymphocytic portal inflammation, and mild fatty change (20%)
    • IHC, tumor cells reveal: PAX8(+), WT1(no nuclear staining), PR(-), Napsin A(-) and HNF1B(+)
• 2023-07-12 All-RAS + BRAF mutation
  • Cellblock No. S2023-04415
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene.
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-07-10 PET scan
  • Increased FDG uptake in the left lobe of the liver, compatible with the pathological findings of metastatic ovarian serous carcinoma.
    
  • Increased FDG uptake in skeleton including sternum, both rib cages, scapulae, multiple spines, sacrum, bilateral pelvic bones and femurs, cancer with multiple bone metastases should be considered, suggesing bone scan for investigation.
    
  • Left ovary cancer s/p treatment with liver and suspected multiple bone metastases, ycTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-06-14 CT - abdomen
  • FINDINGS: Comparison: prior CT dated 2023/03/02.
    • Prior CT identified metastases in S2-3 of the liver are noted again, increasing in size that is c/w liver metastases S/P C/T with progressive disease.
    • S/P hysterectomy
    • A renal cyst measuring 0.4 cm in right lower pole is noted.
  • IMP:
    • Liver metastases in S2-3 S/P C/T show progressive disease.
• 2023-03-10 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Compatible with metastatic ovarian serous carcinoma
  • The sections show a picture compatible with metastastic serous carcinoma of ovary, composed of nests large pleomorphic neoplastic cells arranged in solid and subtle papillary pattern in fibrous stroma.
  • IHC shows: PAX8(+) and WT1(-).
• 2023-03-02 CT - abdomen
  • Findings
    • S/P hysterectomy. Right ovary cyst (3.0cm).
    • Poor enhancing tumors (up to 3.3cm) at left hepatic lobe.
    • A tiny nodule (3mm) at left lung.
  • IMP
    • S/P hysterectomy. Poor enhancing tumors (up to 3.3cm) at left hepatic lobe r/o metastases.
    • A tiny nodule (3mm) at left lung.
• 2022-12-01 CT - abdomen
  • S/P hysterectomy.
  • A tiny nodule (3mm) at left lung.
• 2022-09-06 CT - abdomen
  • S/P hysterectomy.
  • A tiny nodule (2mm) at LUL.
• 2022-06-08 CT - abdomen
  • S/P hysterectomy.
  • There is no evidence of tumor recurrence.
• 2022-03-12 CT - chest
  • Left upper lobe tiny subpleural nodule. Stable.
• 2022-03-02 CT - abdomen
  • There is a small soft tissue nodule 4 mm in LLL of the lung. Follow up chest CT 6 months later is indicated.
  • S/P hysterectomy. There is no evidence of tumor recurrence.
• 2021-11-30 CT - abdomen
  • S/P hysterectomy and oophorectomy.
  • Focal fatty density in right subhepatic region, suggest follow up.
• 2021-10-08 Gynecologic ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2021-07-21 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 15 dB HL; LE 16 dB HL.
  • Bil normal to mild SNHL.
• 2021-06-30 Patho - uterus (with or without SO) neoplastic
  • Diagnosis:
    • Ovary, left, oophorectomy with frozen section (F2021-248) — Serous carcinoma, high grade.
      • IHC stains: ER: (-), PR (-), WT-1 (+), PAX8 (+), Napsin-A (-), p53 (+).
        
    • Fallopian tube, left, salpingectomy (F2021-248) — Free
      
    • Omentume, omentectomy —- Free
      
    • Lymph node, bilateral pelvic and right para-aortic, dissection — Free
      
    • pTIc1 pN0 (if cM0); FIGO stage:IC1.
      • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.” … “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologyists are ordered by this hospital adminstration (including the chiefs of cancer committee, hemato-oncology and radiation oncology) to assign the “cM” category although pathologists are not in the position of doing so.
        
  • Gross description:
    • Procedure (select all that apply)- Debulking surgery (Left salpingo-oophorectomy + infracolic omentectomy + pelvic lymph node dissection)
      
    • Specimen Integrity
      • Specimen Integrity of Right Ovary- not received
        
      • Specimen Integrity of Left Ovary- intra-operative rupture
        
      • Specimen Integrity of Right Fallopian Tube – not received
        
      • Specimen Integrity of Left Fallopian Tube- free
    • Tumor Site: Left ovary
      
    • Ovarian Surface Involvement (required only if applicable): Present (Left)
      
    • Fallopian Tube Surface Involvement (required only if applicable): Absent
      
    • Tumor Size-Greatest dimension (centimeters): Ovary: 16 x 12 x 9 cm, solid part: 6.5 x 4 x 4 cm.
      • Sections are taken and labeled as:
        
      • Tissue for frozen sections: F2021-248FSA1-2: left ovarian tumor.
        
      • Tissue for formalin fixation: F2021-248A1-5: left ovarian tumor;
        
      • S2021-8661A: left iliac LN; B: left obturator LN; C: right iliac LN; D: right obturator LN; E: right para-aortic LN; F: omentum.
        
  • Microscopic Description:
    • Histologic Type: Serous carcinoma
      
    • Histologic Grade - high grade
      
    • Implants- Not identified
      
    • Other Tissue/ Organ Involvement (select all that apply): Not identified
      
    • Largest Extrapelvic Peritoneal Focus (required only if applicable): not apllicable
      
    • Peritoneal/Ascitic Fluid - Negative for malignancy (normal/benign)
      
    • Regional Lymph Nodes: negative for metastasis: 0/22 (0/ total No. of nodes) = left iliac LN (0/1); left obturator LN (0/2); right iliac LN (0/7); right obturator LN (0/3); right para-aortic LN (0/9)
      
    • Additional Pathologic Findings - None identified
      
    • Comment(s): IHC stains: ER: (-), PR (-), WT-1 (+), PAX8 (+), Napsin-A (-), p53 (+).
• 2021-06-19 CT - abdomen
  • Indication: Suspect pelvis mass: 160x116mm
  • Abdominal CT with and without enhancement revealed:
    • Cystic lesion at pelvis up to 15.6cm in largest dimension is found. Some solid part is found. Ovarian cancer is considered. The left ureter is obliterated with left hydronephrosis and hydroureter.
  • Imp: Left ovarian cancer without ascites formation.
  • Imaging Report Form for Ovarian Carcinoma
  • Impression (Imaging stage): T:____(T_value) N:____(N_value) M:____(M_value) STAGE:____(Stage_value)
• 2021-06-18 Gynecologic ultrasonography
  • Suspect pelvis mass: 160x116mm
• 2020-07-29 CT - abdomen
  • History and Indication: 2020/07/28 sona: Total hysterectomy ATH, ROV Mass:59 x 31 mm; IMP: R/O Rt ovarian mass(no blood flow)
  • FINDINGS:
    • S/P hysterectomy
    • There is a cystic lesion with septum formation and mural nodule measuring 4.7 x 2.9 cm in right adnexa.
    • There are three kissing mixed solid and cystic lesion in left adnexa.
    • S/P double J catheter insertion, right side urinary tract.
    • A renal cyst measuring 0.7 cm in right middle pole is noted.
  • IMP:
    • Cystic mass lesion in bilateral adnexal area are noted. please correlate with clinical condition and MRI to rule out endometrioma or cystic tumor.
• 2017-03-27 Surgical pathology Level V
  • A. Cervix, uterus, complicated total hysterectomy — Chronic cervicitis, Nabothian cysts
    • Endometrium, uterus, ditto — Proliferative phase
    • Myometrium, uterus, ditto — Adenomyosis
  • B. Ovarian cyst, left, salpingo-oophorocystectomy — Endometriosis
  • C. Ovarian cyst, right, salpingo-oophorocystectomy — Endometriosis
• 2017-03-14 Gynecologic ultrasonography
  • Adenomyosis
  • R/O Bilateral endometrioma

[MedRec]

• 2024-02-05 ~ 2024-03-07 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Serous carcinoma, high grade of left ovary, pTIc1pN0 (if cM0); FIGO stage: IC, s/p Debulking sugery on 2021/06/30, IHC stains: ER(-), PR(-) s/p chemotherapy with Taxol(175mg/m2)/Carboplatin(AUC:5) from 2021/07/23~2021/11/11 (6 cycles) with liver meta s/p chemotherapy with Taxol(175mg/m2)/Carboplatin(AUC:5) from 2023/03/14~2023/07/12 (6 cycles), with liver meta s/p ressection of liver S2,3 on 2023/08/21, s/p lipodox 09/18, 10/17, 11/23, 12/22, Brain cerebellum meta s/p RT from 2/15~
    • Benign neoplasm of unspecified ovary
    • Endometriosis of ovary
    • Dysmenorrhea, unspecified
    • Unspecified lump in breast
    • Female pelvic inflammatory disease, unspecified
    • Cachexia
    • Secondary malignant neoplasm of brain
    • Secondary malignant neoplasm of liver and intrahepatic bile duct
    • Encounter for antineoplastic chemotherapy
    • Encounter for antineoplastic radiation therapy
  • CC
    • for later line chemotherapy
  • Present illness
    • This 48 year-old woman patient found that there was a mass on her left pelvic in 2021-05. Thus, she came to our GYN OPD for help until 2021-06-18. GYN echo on 2021-06-18 showed suspect pelvis mass: 160x116mm. The CT scan revealed a cystic lesion at pelvis up to 15.6 cm in the largest dimension on 2021-06-19. It was suspected as a ovarian cancer without ascites formation. Upper GI endoscopy on 2021-06-28 showed reflux esophagitis LA Classification grade A, gastric erosion, pre-pyloric ring, AW, s/p biopsy and hiatal hernia. Stomach, pre-pyloric ring, AW, s/p biopsy showed chronic gastritis with intestinal metaplasia and no H.pylori present. Colonoscopy on 2021/06/28 showed no immediate complication.
    • She underwent bilateral DBJ catheter insertion, Debulking surgery (left salpigo-oophorectomy + infracolic omentectomy + pelvic lymphnode dissection) on 2021-06-30. The report of pathology showed serous carcinoma, high grade. IHC stains: ER: (-), PR (-), WT-1 (+), PAX8 (+), Napsin-A (-), p53 (+). pTIc1pN0(if cM0); FIGO stage:IC1. Port-A catheter implantation on 2021/07/06. The removal of bilateral DBJ catheter was done on 2021-07-07. s/p chemotherapy with Taxol(175mg/m2)/Carboplatin(AUC:5) from 2021/07/23~2021/11/11(for 6 cycles) with liver metastasis.
    • Abdomianl CT on 2023/06/14 showed liver metastases in S2-3 s/p chemotherapy show progressive disease. ICG test on 2023/07/08 showed (ICG:7.4%). Whole body PET on 2023/07/10 which revealed increased FDG uptake in the left lobe of the liver, compatible with the pathological findings of metastatic ovarian serous carcinoma.
    • Ressection of liver S2,3 was done on 2023/08/21 smoothly, pathology showed Liver, S2-3, S2-3 hepatectomy — Metastatic clear cell carcinoma, consistent with ovarian primary, IHC, tumor cells reveal: PAX8(+), WT1(no nuclear staining), PR(-), Napsin A(-) and HNF1B(+).
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene; BRAF: There was no variant detect in the BRAF gene. s/p chemotherapy with Taxol(175mg/m2)/Carboplatin(AUC:5) from 2023/03/14~2023/07/12(6 cycles), with liver metastasis s/p ressection of liver S2,3 on 2023/08/21, s/p lipodox 2023/09/18, 2023/10/17, 2023/11/23 (En Chu Kong Hospital), 2023/12/22 (En Chu Kong Hospital).
    • In 2023-12-20+, vomiting attack & in 2024-01-early, unsteady gait attacked. On 2024-01-04, visit ER of En Chu Kong Hospital where metastatic lesion over left cerebellum. Craniotomy & metastatectomy was done on 2024-01-08. The pathological report showed metastatic carcinoma, compatible with high grade serous carcinoma.
    • By patient’s statements, the cerebellar lesion was totally removed. R/T to Brain cerebellum metastasis will start in 2023-02.
    • The level of tumor markers on 2023/09/06 showed (CA125:81.5 U/mL, CA199:12.19 U/mL, CEA:1.23ng/mL). CA125:933.5 U/mL, CA199:44.52 U/mL, CEA:3.77ng/mL on 2024/02/15
    • This time, the disease progression with cerebellum metastasis, arrange admission for later line chemotherapy.
  • Course of inpatient treatment
    • After admission, due to failure of liposomal doxorubicin in liver and cerebellum, may consider shift regimen to topotecan by NHI and check Her-2 level for T-Dxd. Send to our pathology department on 2024/02/16. We discuss with diagnostic radiologist for liver biopsy, due to high risk and poor postion to tissue proof and not favor. R/T with CT-simulation on 2024/02/01. Plan to deliver 18Gy/ 6fx to the whole brain . Then boost the Lt cerebellar preOP tumor bed to 36 Gy/ 12fx. RT was start on 2024/02/15 to 2024/03/04.
    • Cachexia with megest 10ml qd (BW 67 -> 61.2kg in half-year).
    • Steroid with dexamethasone 4mg IV Q12H for brain radiotherapy.
    • Stomach acid reflux with H2 block with famotidine 1# BID.
    • Brain metastsis with keppra 500mg/tab 1# bid.
    • Steroid slowly tirtraion, but feel swelling of head thus compresolon 5mg/tab 2# qd shift to bid since 2024/02/28.
    • Arrange abdominal CT extent to chest with contrast on 2024/03/01 and revealed 1. Liver metastases S/P C/T show progressive disease. 2. Metastatic nodes in the celiac trunk and para-aortic space. 3. There is a newly developed soft tissue lesion 1.2 cm in LLL of the lung, directly attached the diaphragm, that may be pleura or lung metastasis. Follow up is indicated. 4. Detailed findings, please see description.
    • There was AMPLIFICATION of HER2 detected.
    • Steroid with compresolon and slowly titration.
    • AST and ALT elevated gradually with silymarin 150mg/cap 1# TID.
    • Hypoalbuminemia with albumin 50ml/bot QD for 3days by self-payment (2024/03/04 ~ 2024/03/06).
    • Hypocalcemia with Calcium gluconate 10ml IVD for 3days (2024/03/04 ~ 2024/03/06).
    • Chemotherapy with Enhertu(5.4mg/kg) 300mg by self-payment from 2024/03/05(C1).
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2024/03/07 and OPD followed up later.
  • Discharge prescription
    • BaoGan (silymarin 150mg) 1# TID
    • Keppra (levetiracetam 500mg) 1# BID
    • MgO 250mg 2# TID
    • Megest (megestrol 40mg/mL) 10mL QD (67kg to 61kg in half year)
    • Through (sennoside 12mg) 2# HS
    • Ulstop (famotidine 20mg) 1# BID
    • Emend (aprepitant 125mg) 1# QD
    • Compesolon (prednisolone 5mg) 1# TID
• 2024-01-30 SOAP Radiation Oncology Wang YuNong
  • Plan:
    • CT-simulation will be arranged on 2/1. Plan to deliver 18 Gy/ 6 fx to the whole brain.
    • Then boost the Lt cerebellar preOP tumor bed to 36 Gy/ 12 fx.
    • RT will start around 2/5 or 2/6.

[consultation]

• 2021-07-07 Hemato-Oncology
  • Q
    • For post-op chemotherapy
      
    • This 46 y/o female, she was arranged to admit for Debulking surgery on 20210630.
    • The pathology report: Ovary, left, oophorectomy with frozen section —- Serous carcinoma, high grade. IHC stains: ER: (-), PR (-), WT-1 (+), PAX8 (+), Napsin-A (-), p53 (+). pTIc1 pN0 (if cM0); FIGO stage: IC1.
    • We need your expertise for help her further management for post-op chemotherapy. Thanks for you help!
  • A
    • Patient examined and Chart reviewed. A case of ovarian serous carcinoma, high grade, pathological Stage IC1 is noted. I am consulted for further management.
    • My suggestions would be:
      • Adjuvant CCRT with weekly cisplatin is indicated.
      • Please arrange Port-A insertion (Done)
      • Please arrange family meeting, regarding the issue of adjuvant treatment and genetic test.
      • Thanks for your consultation. Please let me know if any problem.

[surgical operation]

• 2023-08-21
  • Surgery
    • Left hepatectomy S2,3
    • Percutaneous endoscpic approach
  • Finding
    • Liver S2,3 lobe with liver surface malignancy noted.
    • Umbilical r/o hernia
• 2022-09-22
  • Surgery: Internal hemorrhoids rubber band ligation        
  • Finding: Enlarged internal hemorrhoids with congestion at 3 o’clock  
• 2022-09-01
  • Surgery: Internal hemorrhoids rubber band ligation        
  • Finding: Enlarged internal hemorrhoids with congestion at 7 o’clock  
• 2021-07-06
  • Operation
    • Port-A (47080B)
    • Fluoroscopy (32026C) 
• 2021-06-30
  • Surgery
    • Bilateral DBJ catheter insertion
  • Finding
    • External compression at posterior wall of urinary bladder
    • Left lower ureteral angulation
    • Bilateral 6Fr. 24cm DBJ inserted
• 2021-06-30
  • Surgery
    • Diagnosis: Left ovarian tumor r/o malignancy s/p debulking surgery.
    • Operation: Debulking surgery (LSO + infracolic omentectomy + pelvic lymphnode dissection)   - Finding
    • Left ovarian tumor, r/o malignancy.
    • Ovarian cancer, stage , pT1aN0M0(type)
    • Frozen: adenocarcinoma
    • Supraumbilical midline vertical skin incision
    • Uterus:s/p ATH
    • Adnexa:
      • LOV: cystic lesion, 16x12cm, capsule intact, smooth surface. intra-op rupture(+)
      • ROV: not seen.
    • CDS: invisible due to tumor mass occupied
    • Ascites: minimal, washing cytology was done.
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
    • Omentum: infracolic omentectomy was done.
    • Liver: grossly normal & smooth
    • After the operation, optimal debulking surgery was achieved.
    • Residue tumor: <2cm.
    • Estimated blood loss: 500ml
    • Blood transfusion: nil
    • Complication: nil  
• 2020-07-22
  • Surgery: Right ureterorenoscopic exam & double-J stenting  + retrograde pyelography       
  • Finding
    • Right upper ureter kinking was noted and confirmed by retrograde pyelography       
    • 6Fr 24 cm DBJ was placed
• 2017-03-27
  • Cystoscopy + retrograded ureteral catheterization
• 2017-03-27
  • Uterus: Avfl, hypertrophic and disfigured due to adenomyosis
  • RAD: enlarged with chocolate like content with severe adhesion to uterus, rectum, and LAD. cannot totally remove chocolate cyst due to severe adhesion.
  • LAD: enlarged with chocolate like content with severe adhesion to uterus, sigmoid colon, and RAD.
  • CDS: obliteration due to severe endometriosis.
  • Estimated blood loss: 900ml
  • Blood transfusion: pRBC2u
  • Complication: nil

[radiotherapy]

[immunochemotherapy]

• 2024-03-05 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 300mg D5W 100mL 90min
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-22 - liposome doxorubicin (at EnChuKong Hospital)
• 2023-11-23 - liposome doxorubicin (at EnChuKong Hospital)
• 2023-10-17 - liposome doxorubicin 50mg/m2 80mg D5W 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-09-18 - liposome doxorubicin 40mg/m2 70mg D5W 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-07-12 - paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1
• 2023-06-02 - bevacizumab 15mg/kg 900mg NS 250mL 90min + paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr (Avastin init)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1
• 2023-05-08 - paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-07 - paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-13 - paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-11-10 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-10-21 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-09-27 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-09-06 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-08-12 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + cisplatin 75mg/m2 120mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-07-23 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 24hr + NS 250mL 1hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 750mL

==========

2024-03-28

[addressing thrombocytopenia recovery and magnesium deficits]

Thrombocytopenia has shown some improvement, but the patient developed hypomagnesemia towards the end of Mar 2024. If the current oral MgO supplementation doesn’t increase the serum magnesium levels, the addition of MgSO4 injections may be considered.

• 2024-03-28 PLT 117 *10^3/uL

• 2024-03-25 PLT 76 *10^3/uL

• 2024-03-21 PLT 95 *10^3/uL

• 2024-03-19 PLT 24 *10^3/uL

• 2024-03-18 PLT 35 *10^3/uL

• 2024-03-17 PLT 54 *10^3/uL

• 2024-03-16 PLT 74 *10^3/uL

• 2024-03-15 PLT 11 *10^3/uL

• 2024-03-28 Mg (Magnesium) 1.6 mg/dL

• 2024-03-25 Mg (Magnesium) 1.8 mg/dL

• 2024-03-21 Mg (Magnesium) 2.0 mg/dL

2024-03-18

[dose-related neutropenia risks with trastuzumab deruxtecan and strategies for dose adjustment post-neutropenia]

Enhertu (trastuzumab deruxtecan) is associated with a high incidence of neutropenia, ranging from 52% to 72%, with severe cases (grades 3/4) occurring in 12% to 51% of patients. This effect is dose-related, and the onset of decreased neutrophil count varies, with the median time to the first onset being 16 days (range: 4 to 187 days) for patients with locally advanced or metastatic gastric cancer and 22 days (range: 2 to 664 days) for those with metastatic breast cancer.

Given that the last dose of Enhertu was administered on 2024-03-05, it is plausible that it could be the primary cause of the neutropenia observed.

• 2024-03-18 WBC 3.56 x10^3/uL
• 2024-03-17 WBC 1.59 x10^3/uL * G-CSF
• 2024-03-16 WBC 0.71 x10^3/uL ** G-CSF
• 2024-03-15 WBC 0.76 x10^3/uL ** G-CSF
• 2024-03-12 WBC 3.64 x10^3/uL
• 2024-03-04 WBC 15.20 x10^3/uL Enhertu (2024-03-05)

Starting from 2024-03-15, the patient was treated with Granocyte (lenograstim 250ug) for 3 consecutive days, which has since resolved the neutropenia.

Given the severity of this episode, being classified as grade 4 neutropenia (ANC < 500/uL), it is advisable to temporarily halt the administration of Enhertu until the condition improves to grade 2 or lower. Subsequently, a dose reduction should be considered, lowering the dosage from 5.4 mg/kg to 4.4 mg/kg.

[comprehensive approach to abnormal lab results in patient care - reconciliation]

G-CSF and furosemide were administered, a left-shift in the WBC DC as observed on 2024-03-18. Concurrently, hypokalemia (2.3 mmol/L) and hyponatremia (131 mmol/L) were also detected. To address these electrolyte imbalances, oral potassium supplements and intravenous normal saline are currently being utilized.

Uliden (ursodeoxycholic acid) has been prescribed to manage an elevated Direct Bilirubin (DBI) level of 0.49 mg/dL.

For the treatment of elevated PCT (27.19 ng/mL) and CRP (18.9 mg/dL), indicative of a bacterial infection, Cefim (cefepime) has been chosen.

No discrepancies in medication have been identified in the patient’s treatment plan.

2023-07-12

According to the PharmaCloud database, this patient only receives medical services at our hospital. Cross-referencing this with HIS5 records, there were no active prescriptions issued by other departments. Consequently, no medication reconciliation issues were identified.

2023-05-09

Granocyte (lenograstim) is pre-prescribed for 2 to 3 consecutive days, a few days after each chemotherapy session, as a prophylactic measure against leukopenia. Since mid-Nov 2021, the patient’s WBC count has remained consistently above 3K/uL.

701480646

240328

[exam findings]

• 2024-03-26 SONO - abdomen
  • Liver metastasis
  • Gallbladder stone
  • CBD dilatation
  • Small amount ascites
  • Ileus
• 2024-03-25, -03-21 KUB
  • Ascites is highly suspected. Please correlate with sonography.
  • Fecal material store in the colon.
• 2024-02-29 Abdomen - Standing (Diaphragm)
  • Fecal material store in the colon.
  • Small bowel obstruction is suspected. Please correlate with CT.
  • Ascites is highly suspected. Please correlate with sonography.
• 2024-02-28 CXR
  • Ground glass opacities in bil. lungs.
  • Deviation of trachea.
  • Fracture of left clavicle.
• 2024-02-28 KUB
  • A calcification at left sacral region.
  • Stool retention in the bowel.
  • Fracture of left 12th rib.
• 2024-02-28 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Low voltage QRS of precordial
  • Possible Septal infarct, age undetermined
  • Abnormal ECG
• 2024-02-02 SONO - abdomen
  • Diagnosis
    • Suspected chronic liver parenchyma disease
    • Suspected GB stones
    • Mild CBD dilatation
    • Ileus, bilateral LLQ
    • Pancreas not shown
    • Suboptimal examination of liver,especially the subcostal view due to poor echo window(disruption of the transmission of US waves by bowel gas and patient’s body habitus)
  • Suggestion:
    • CT of abd was suggested for ileus workup
    • Please correlate with liver function test and follow AFP
    • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
    • Because of poor echo window,please follow sono abd 3-6 months later if clinical needs
• 2024-01-31 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Left axis deviation
  • Low voltage QRS of precordial leads
  • Possible septal infarct, age undetermined
  • Abnormal ECG
• 2024-01-15 CXR erect
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • The trachea shows right lateral deviation in thoracic inlet level that may be intrathoracic goiter. Please correlate with CT.
  • A nodular opacity projecting in the right upper lung is suspected. Please correlate with CT.
• 2023-12-20 CT - abdomen
  • Findings:
    • Prior CT identified lobulated wall thickening of the gastric body and antrum with irregular contour is noted again, mild increasing in size that is c/w adenocarcinoma of the stomach with stable disease or progressive disease.
      • In addition, Prior CT identified four enlarged nodes in peri-gastric area are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again. Some of them show stable in size. Some of them show mild increasing in size.
      • Liver metastases S/P C/T with stable disease is highly suspected.
    • There is ascites and soft tissue lesions in the omentum. Carcinomatosis is highly suspected. Please correlate with ascites cytology.
    • There is a lobulated poor enhancing mass in the cul-de-sac with directly invasion the rectum, measuring 4.3 cm in size (Srs:301 Img:69) that is c/w tumor seeding (Krukenberg tumor).
    • The gallbladder shows stones and wall thickening at the fundus that may be adenocarcinoma. The differential diagnosis includes chronic cholecystitis and tumor seeding.
    • Prior CT identified a well-defined poor enhancing mass with suggestive fat component in left kidney, 2.7 x 2.1 cm in size, is noted again, mild increasing in size to 3 x 2.3 cm.
      • Renal cell carcinoma is highly suspected.
      • The differential diagnosis includes angiomyolipoma.
      • Follow up is indicated.
    • There are multiple osteopenic defects in the T-and L-spine, sacrum and bilateral ilium. Bony metastases are highly suspected.
      • Please correlate with bone scan.
    • S/P esophagectomy with colonic gastrostomy?
      • please correlate with clinical history.
  • Impression:
    • Adenocarcinoma of the stomach S/P C/T with stable disease or progressive disease is highly suspected. please correlate with clinical condition.
• 2023-09-16 CT - abdomen
  • History and indication: Gastric cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P esophageal operation with reconstruction. Wall thickening of stomach.
    • Fat stranding at pelvic cavity.
    • Some LNs at upper abodmen.
    • Some poor enhancing nodules in liver.
    • Mild splenomegaly.
    • Atherosclerosis of aorta, iliac arteries.
    • Some GGO at bilateral lungs.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P operation. Gastric cancer with LNs and liver metastases.
    • Fat stranding at pelvic cavity.
• 2023-05-02 Tc-99m MDP bone scan
  • Mildly inhomogenously increased activity in some T- and L-spines and sacrum and diffusely increased activity in bilateral iliac bones. The nature is to be determined. Please correlate with other imaging modalities and follow up bone scan to rule out the possibility of bone metastases.
  • Some hot spots in the skull. Please also follow up bone scan for further evaluation.
• 2023-04-27 Patho - colon biopsy (Y1)
  • Colorectum, rectum, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+), CK7 (-).
• 2023-04-27 Patho - stomach biopsy (Y1)
  • Labeled as “anstomosis and saddle portion of subtotal gastrectomy”, biopsy (A) — Adenocarcinoma.
  • Section shows pieces of bland gastric type mucosa and neoiplastic intestinal type tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+), Her2/neu: Negative (score=0+).
• 2023-04-27 Sigmoidoscopy
  • Finding
    • A large tumor with friable mucosa in upper rectum and RS colon, resulting in luminal stenosis and difficulty in manipulation of scope. The scope could not pass through the RS junction. Biopsy was taken at the tumor
  • Diagnosis:
    • Highly supsected colorectal malignancy, upper rectum and RS colon, s/p biopsy
    • Incomplete colonosocpy
  • Suggestion:
    • Pursue pathology result
    • Correlate with CT scan
  • Complication:
    • No immediate complication
• 2023-04-27 EGD
  • Diagnosis:
    • Large gastrojejunal ulcer, r/o malignancy, s/p biopsy (A)
    • Ulcer on the colon mucosa (esophageal reconstruction) near the esophageal orifice, s/p biopsy (B)
    • Status of total esophagectomy and esophageal reconstruction with colon
    • Status post radical subtotal gastrectomy with BII anastomosis
  • Suggestion:
    • Suggest high-dose PPI therapy
    • Pursue pathology result
    • Correlate with CT scan
• 2023-04-26 CT - abdomen
  • Indication:
    • CC: abdominal pain for 2 weeks. RLQ abdominal pain for 1 week and progressed last night
    • PI: RLQ abdominal cramping pain, especially after meal, mild epigastric dull pain, mild nausea, diarrhea
    • PH: esophageal surgery 40 years ago
      
  • Findings:
    • There is lobulated wall thickening of the gastric body and antrum with irregular contour, measuring 7 cm in size, that may be adenocarcinoma (T4a). Please correlate with gastroscopy.
      • In addition, there are four enlarged nodes in peri-gastric area that are c/w metastatic nodes (N2).
      • There are multiple poor enhancing masses on both hepatic lobes that are c/w liver metastases (M1). The largest one measuring 2.2 cm in S4.
    • There is ascites and soft tissue lesions in the omentum. Carcinomatosis is highly suspected. Please correlate with ascites cytology.
    • There is a lobulated poor enhancing mass in the cul-de-sac with directly invasion the rectum, measuring 4.3 cm in size (Srs:301 Img:69) that is c/w tumor seeding (Krukenberg tumor).
    • The gallbladder shows stones and wall thickening at the fundus that may be adenocarcinoma. The differential diagnosis includes chronic cholecystitis and tumor seeding.
    • There is a well-defined poor enhancing mass with suggestive fat component in left kidney, measuring 2.7 x 2.1 cm in size.
      • Renal cell carcinoma is highly suspected.
      • The differential diagnosis includes angiomyolipoma.
      • Please correlate with contrast enhanced dynamic CT.
    • There are multiple osteopenic defects in the T-and L-spine, sacrum and bilateral ilium. Bony metastases are highly suspected.
      • Please correlate with bone scan.
    • S/P esophagectomy with colonic gastrostomy?
      • please correlate with clinical history.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2(N_value) M:M1(M_value) STAGE:IVB(Stage_value)

[MedRec]

• 2024-01-31 ~ 2024-02-07 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Gastric adenocarcinoma presented stage IVB with progression, carcinomatosis and suspected multiple bony and hepatic metastases.
    • Anemia, unspecified
    • Disseminated malignant neoplasm, unspecified
  • CC
    • Acute diffuse abdominal pain and fullness, constipation for 2 days
  • Present Illness
    • This 71-year-old female with a history of stage IVB gastric adenocarcinoma presented with progression noted on her most recent scans showing carcinomatosis and suspected multiple bony and hepatic metastases. The disease was initially managed with FOLFOX 6 from Jun 2023 to Nov 2023, leading to a temporary response. Due to tumor marker elevation and suspected disease progression, chemotherapy was switched to Taxotere plus Ramucirumab, a self-paid program.
    • Subsequent INTAXEL therapy resulted in acute dyspnea, vomiting, and respiratory distress requiring ER evaluation where she was found hypoxic with O2 saturation initially at 83% on room air, responding to 93% with oxygen supplementation.
    • Imaging suggested pneumonia; she was treated with antibiotics and admitted for further oncology care.
    • Prior to the current admission, the patient presented to the ER with acute onset diffuse abdominal pain, tenderness, and bloating, with a 2-day history of constipation. A recent CT revealed stable liver metastases, new ascites and suspected carcinomatosis. Physical examination on admission showed tachycardia, hypotension, fever, and diffuse abdominal tenderness warranting inpatient monitoring.
  • Course of inpatient treatment
    • Upon admission, a 71-year-old female with a notable history of stage IVB gastric adenocarcinoma, was experiencing acute diffuse abdominal pain, fullness, and constipation, compounded by a prior ER visit for dyspnea, vomiting, and respiratory distress, which was managed with oxygen and antibiotics after imaging suggested pneumonia.
    • The initiation of an alternative chemotherapy regimen with Taxotere plus Ramucirumab, following progression on FOLFOX 6, was unfortunately associated with adverse events necessitating emergent care.
    • Current management has focused on stabilizing the patient’s condition through symptomatic and supportive measures.
    • Since the commencement of Total Parenteral Nutrition (TPN), her nutritional intake has been safeguarded, and IV hydration with saline ensures adequate fluid status.
    • Analgesic management has effectively kept her pain controlled, as indicated by consistently reported pain scales of zero.
    • Chemotherapy was initiated as Taxotere plus Ramucirumab on 02/02 due to disease progression.
    • After the chemo, Hb showed 6.0 on 02/05, and 2unit of pRBC was given, and the condition is relatively stable right now.
    • Due to the relatively stable condition, the patient was able to be discharged and OPD follow up was scheduled
  • Discharge prescription
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • Through (sennoside 12mg) 1# HS
    • Bisadyl supp (bisacodyl 10mg) 2# PRNHS RECT
    • Dulcolax (bisacodyl 5mg) 1# QN
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
• 2024-01-26 SOAP Hemato-Oncology Gao WeiYao
  • P: Start taxol weekly and plan to apply ramucirumab.
• 2024-01-15 SOAP Hemato-Oncology Gao WeiYao
  • P: The last chemo folfox6 done in Nov 2023. Plan to switch to taxotere plus ramucirumab self-paid.
• 2023-04-27 ~ 2023-05-19 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Adenocarcinoma of the gastric body and antrum, carcinomatosis and multiple bony metastases and colon metastases, cT4aN2M1, stageIVB
    • Other Gram-negative sepsis, blood culture yielded Acinetobacter ursingii
    • Iron deficiency anemia, unspecified
    • Microcytic anemia
  • CC
    • RLQ abdominal cramping pain, especially after meal for 2 weeks
  • Present illness
    • This 70 year old women has history of esophageal surgery 40 years ago, esophageal perforation s/p right half colectomy for esophageal reconstruction.
    • She presented to our hospital with RLQ abdominal cramping pain, especially after meal for 2 weeks with body weight loss for 3-4 kg in one month. Therefore, she came to our ER for help. At ER, there were no fever, no chest pain nor dysuria.
    • CT of abdominal was performed on 2023/4/27 revealed:
      • Adenocarcinoma of the gastric body and antrum is highly suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for gastric cancer: T4aN2M1, stage: IVB.
      • Carcinomatosis is highly suspected.
      • Krukenberg tumor in the cul-de-sac with direct invasion the rectum.
      • Adenocarcinoma of the gallbladder fundus is highly suspected.
      • Renal cell carcinoma in left kidney is highly suspected.
      • Multiple bony metastases are suspected.
    • EKG showed
      • Large gastrojejunal ulcer, r/o malignancy, s/p biopsy (A).
      • Ulcer on the colon mucosa (esophageal reconstruction) near the esophageal orifice, s/p biopsy (B).
      • Status of total esophagectomy and esophageal reconstruction with colon.
      • Status post radical subtotal gastrectomy with BII anastomosis.
    • Colonscopy showed Highly supsected colorectal malignancy, upper rectum and RS colon, s/p biopsy.
    • Laboratory test revealed anemia (Hb: 7.7g/dl) and elevated tumor marker of CEA (28.09ng/mL), CA199 (260.84 U/mL) and CA125 (53.8 U/mL).
    • Blood transfusion with LPRBC.
    • Empiric antibiotics with Cefuroxime was administered.
    • Under the impression of Adenocarcinoma of the gastric body and antrum, carcinomatosis and multiple bony metastases are suspected, cT4aN2M1, stageIVB. She was admitted for further management
  • Course of inpatient treatment
    • After admission, high dose PPI with pantoloc 20mg in N/S 500ml run 20ml/hr on 4/27-29 and Blood transfusion with LPRBC 2U for correct anemia.
    • Foliromin 1tab BID for Iron deficiency anemia.
    • Arrange the bone scan on 2023/5/2 showed:
      • Mildly inhomogenously increased activity in some T- and L-spines and sacrum and diffusely increased activity in bilateral iliac bones. The nature is to be determined. Please correlate with other imaging modalities and follow up bone scan to rule out the possibility of bone metastases.
      • Some hot spots in the skull. Please also follow up bone scan for further evaluation.
    • GS was consulted for port-A insertion on 5/4.
    • Empiric antibiotics with Cefuroxime 1500mg Q8H on 4/27-5/5 and shifted to Tapimycin, owing to watery diarrhea we shifted to antibiotics with Cravit on 5/12-19.
    • B/C yield Acinetobacter ursingii, we repeated the blood culture on 5/16 and pending.
    • Chemotherapy with C1D1 FOLFOX6 was administered on 2023/5/10-5/12. Patient tolerated the chemotherapy.
    • With the relatively stable condition,she was discharged on 2023/5/19 and will arrange next admission on 5/25
  • Course of inpatient treatment
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Nexium (esomeprazole 40mg) 1# QDAC for 4/27 EGD
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Zandip (lercanidipine 10mg) 1# QD
    • Cravit (levofloxacin 500mg) 1.5# QDAC
    • Smecta (dioctahedral smectite 3g) 1# PRNTIDAC if diarrhea

[consultation]

• 2023-05-16 Psychosomatic Medicine
  • Q
    • Suicidal ideation in cancer inpatients >=2 points.
  • A
    • This 70 y/o lady has been admitted for gastric adenocarcinoma, with severe gastric pain, nausea, poor intake. The patient wants to eat, but she vomits after eating even a little bit. In recent few months, she also developed low and anxious mood, disruptive sleep, hopelessness and worthlessness feelings, guilty feelings, death thoughts. She is worried that her continued treatment will be a drag on my family, and she wants to have euthanasia. However she had fine support from her family and could perceive pleasure when her son and husband came to acompany her, and she accept the current therapautic planning. I have discussed the treatment plan with the patient and her husband.
    • IMP: adjustment disorder with depressed and anxious mood.
    • Suggestion: brintellix 10mg 0.5# HS, alprazolam 0.5mg 0.5# HSPRN if insomnia
    • Arrange PSY OPD follow up.

[chemotherapy]

• 2024-03-08 - paclitaxel 80mg/m2 90mg NS 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL + palonosetron 250ug
• 2024-02-23 - paclitaxel 80mg/m2 90mg NS 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-02-16 - paclitaxel 80mg/m2 90mg NS 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-02-02 - paclitaxel 80mg/m2 90mg NS 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-01-26 - paclitaxel 80mg/m2 90mg NS 250mL 3hr
  • dexamethasone 20mg PO + dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2023-11-28 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-14 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-04 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-13 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-30 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-15 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-07-26 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-07-11 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-06-21 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-06-06 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-05-23 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-05-10 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

Paclitaxel - 2024-02-29 - https://www.uptodate.com/contents/paclitaxel-conventional-drug-information

• Gastric cancer, metastatic or unresectable locally advanced (off-label use) IV:
  • 80 mg/m2 on days 1, 8, and 15 every 28 days (in combination with ramucirumab) until disease progression or unacceptable toxicity or
  • 80 mg/m2 on days 1, 8, and 15 every 28 days (as a single agent) until disease progression or unacceptable toxicity or
  • 200 mg/m2 (cycle 1; escalated to 225 mg/m2 in cycle 2 if acceptable ANC and platelets) over 3 hours on day 1 every 3 weeks (in combination with carboplatin); evaluate for response every 2 cycles.

==========

2024-03-28

[safe practices for adding KCl to SmofKabiven bags]

The “SmofKabiven PI 1448mL/bag” contains 2g of KCl, equivalent to 28mmol of potassium ions (K+) as per the package insert, with a maximum potassium limit of 225mmol per bag. This allows for an additional 197mmol (or 197 mEq) of potassium to be added.

Given that “KCl injection 15% 10mL/amp” contains 20mEq of potassium, theoretically, up to 9 ampules could be added. However, general practice recommends not exceeding 20 to 30 mEq of potassium per hour.

SmofKabiven should be infused over 14 to 24 hours, with the addition of KCl adjusted as appropriate.

[reevaluating laxative use after frequent bowel movements; diarrhea as a contributing factor to hypokalemia]

The patient experienced seven instances of bowel movements on 2024-03-27, indicating that the currently prescribed oral Dulcolax tablet and rectal Bisadyl suppository could be paused or discontinued if there is no more fecal material storage observed in the colon.

This frequent diarrhea could be contributing to the patient’s low potassium levels.

2024-03-06

[improved HGB following transfusion, ileus resolved, trial of oral intake considered]

HGB increased (2024-03-04 7.7g/dL -> 2024-03-06 10.2g/dL) after LPRBC transfusion. Hypokalemia is not currently detected (2024-03-06 3.6mmol/L).

On 2024-02-29, an X-ray suggested possible fecal stasis within the colon, raising suspicion of small bowel obstruction. However, a subsequent X-ray performed on 2024-03-04 did not reveal evidence of obstruction. The previously observed ileus has been effectively managed.

Due to the patient’s underweight status (BMI 14.8, weight: 33.8 kg, height: 151.2 cm), adequate nutritional support is crucial. She is currently receiving TPN. As the ileus has resolved to some degree, a trial of oral intake might be considered, provided there are no clinical contraindications.

2024-02-29

[FOLFOX followed by paclitaxel: rising tumor markers & hypokalemia]

The patient’s treatment was initiated with the FOLFOX regimen in May 2023. Both CEA and CA199 tumor markers reached their nadir (lowest point) in Sep 2023, but still remained out of the normal reference range. Subsequently, the markers began to rise, and the last dose of FOLFOX was administered in late Nov 2023.

• 2024-02-27 CEA (NM) 30.060 ng/ml

• 2024-02-20 CEA (NM) 26.790 ng/ml

• 2024-01-30 CEA (NM) 24.157 ng/ml

• 2024-01-19 CEA (NM) 23.317 ng/ml

• 2023-12-29 CEA (NM) 22.383 ng/ml

• 2023-12-22 CEA (NM) 17.894 ng/ml

• 2023-12-15 CEA (NM) 14.477 ng/ml

• 2023-12-08 CEA (NM) 15.861 ng/ml

• 2023-12-01 CEA (NM) 14.718 ng/ml

• 2023-11-17 CEA (NM) 12.991 ng/ml

• 2023-10-24 CEA (NM) 10.527 ng/ml

• 2023-10-06 CEA (NM) 8.849 ng/ml

• 2023-09-28 CEA (NM) 8.549 ng/ml

• 2023-09-15 CEA (NM) 7.623 ng/ml

• 2023-09-01 CEA (NM) 7.170 ng/ml

• 2023-07-07 CEA (NM) 9.071 ng/ml

• 2023-06-23 CEA (NM) 10.524 ng/ml

• 2023-06-12 CEA (NM) 11.251 ng/ml

• 2023-06-02 CEA (NM) 14.962 ng/ml

• 2023-05-30 CEA (NM) 15.930 ng/ml

• 2023-04-27 CEA 28.09 ng/mL

• 2024-02-27 CA-199 (NM) 735.100 U/ml

• 2024-02-20 CA-199 (NM) 669.050 U/ml

• 2024-01-30 CA-199 (NM) 754.580 U/ml

• 2024-01-19 CA-199 (NM) 598.990 U/ml

• 2023-12-29 CA-199 (NM) 382.890 U/ml

• 2023-12-22 CA-199 (NM) 202.647 U/ml

• 2023-12-15 CA-199 (NM) 178.155 U/ml

• 2023-12-08 CA-199 (NM) 203.365 U/ml

• 2023-12-01 CA-199 (NM) 171.744 U/ml

• 2023-11-17 CA-199 (NM) 156.577 U/ml

• 2023-10-24 CA-199 (NM) 126.428 U/ml

• 2023-10-06 CA-199 (NM) 96.780 U/ml

• 2023-09-28 CA-199 (NM) 84.503 U/ml

• 2023-09-15 CA-199 (NM) 93.263 U/ml

• 2023-09-01 CA-199 (NM) 89.666 U/ml

• 2023-07-07 CA-199 (NM) 122.765 U/ml

• 2023-06-23 CA-199 (NM) 147.885 U/ml

• 2023-06-12 CA-199 (NM) 197.215 U/ml

• 2023-06-02 CA-199 (NM) 250.810 U/ml

• 2023-05-30 CA-199 (NM) 363.860 U/ml

• 2023-04-27 CA-199 260.84 U/mL

Paclitaxel was initiated on 2024-01-26. Ramucirumab, originally planned as a co-administered drug, has not yet been commenced. The paclitaxel treatment has not shown a clear trend of decreasing tumor marker levels.

Hypokalemia was identified on 2024-02-28, with a value of 2.9 mmol/L. Const-K and Spiron (spironolactone) are currently being administered, and no medication discrepancies were found.

700019531

240327

[exam findings]

• 2024-02-04 CT - abdomen
  • Non-contrast CT of abdomen-pelvis revealed:
    • R/O bil. renal cysts (up to 3.4cm). Small size of right kidney. Tiny stones in left kidney. Some stones (up to 8mm) in urinary bladder.
    • Enlargement of prostate with calcifications.
    • Atherosclerosis of aorta.
  • IMP:
    • R/O bil. renal cysts (up to 3.4cm). Small size of right kidney. Tiny stones in left kidney. Some stones (up to 8mm) in urinary bladder.
    • Enlargement of prostate with calcifications.
• 2023-11-07 SONO - nephrology
  • Parenchymal renal disease
  • Nephrolithiasis, left
  • Simple cyst, bilateral
• 2023-08-14 Cardiac Catheterization
  • Finding Summary
    • Syntax Score = 30
    • In conclusion : CAD LM and TVD s/p PCI with DES for LM to LAD and LCX, successful.
    • Recommendation : CABG was suggested to the patient and family and they asked for PCI first., PCI for LM to LAD and LCX
    • Left Ventriculogram :
      • Normal LV size and LV wall motion, no MR, LVEF = 88.9% LVEF 88.9 ％
    • Left Main :
      • 50% stenosis oer distal LM
    • Left Anterior Descending :
      • 70% stenosis over ostial LAD and 70% stenosis ove mid LAD jsut ater D2 bifurcation
    • Left Circumflex :
      • 70% stenosis over mid lcx
    • Right Coronary :
      • 70% stenosis over proximal RCA
  • Intervention Summary
    • LM-LAD-P, Pre-DS = 70% ostial LAD%
      • MLD/RVD=/3.5 mm → 60%/3.5 mm.
        • Guiding catheter: Boston 6F CLS3.5.
        • Guiding catheter2: Boston OptiCross HD.
        • Guide Wire: Asahi SION BLUE ES.
        • Guide Wire2: Asahi SION.
        • Guide Wire3: Terumo Runthrough Floppy.
        • Balloon: Medtronic NC Euphora. 3.5 X 20 mm. Pressure: 12 atmospheres. 15 secs.
        • Balloon2: Medtronic NC Euphora. 4.5 X 8 mm. Pressure: 16 atmospheres. 15 secs. with POT
        • Balloon3: Medtronic Euphora. 2.0 X 12 mm. Pressure: 16 atmospheres. 15 secs. to cross stent strut
        • Balloon4: Terumo Accuforce. 3.5 X 12 mm. Pressure: 14 atmospheres. 15 secs. with Kissing balloon
        • Stent: Biotronik Orsiro Mission drug-eluting stent. 3.5 X 40 mm. Pressure: 16 atmospheres. 15 secs.
      • Stent-MLD/RVD=/3.5 mm Stent DS = 0% residual stenosis.
    • LCX-M, Pre-DS = 70%%
      • MLD/RVD=/2.75 mm → 50%/2.75 mm.
        • Guiding catheter: Boston 6F CLS3.5.
        • Guiding catheter2: Boston OptiCross HD.
        • Guide Wire: Asahi SION BLUE ES.
        • Guide Wire2: Asahi SION.
        • Guide Wire3: Terumo Runthrough Floppy.
        • Balloon: Boston NC Emerge. 2.75 X 15 mm. Pressure: 8 atmospheres. 22 secs.
        • Balloon2: Medtronic NC Euphora. 3.0 X 12 mm. Pressure: 20 atmospheres. 10 secs.
        • Stent: Abbot Xience Sierra drug-eluting stent. 2.75 X 23 mm. Pressure: 16 atmospheres. 15 secs.
      • Stent-MLD/RVD=/2.75 mm Stent DS = 0% residual stenosis.
    • In conclusion : CAD LM and TVD s/p PCI with DES for LM to LAD and LCX, successful.
    • Recommendation : CABG was suggested to the patient and family and they asked for PCI first., PCI for LM to LAD and LCX
• 2023-08-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93.4 - 22.3) / 93.4 = 76.12%
    • M-mode (Teichholz) = 76
  • Conclusion:
    • Normal chamber size
    • Thickening of IVS
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Mild MR, AR, TR and PR
    • No regional wall motion abnormalities

[MedRec]

• 2024-03-21 SOAP Hemato-Oncology Gai WeiYao
  • O
    • 2024/02/04 CT: ABD - whole abdomen, Pelvis (no contrast)
      • R/O bil. renal cysts (up to 3.4cm). Small size of right kidney. Tiny stones in left kidney. Some stones (up to 8mm) in urinary bladder.
      • Enlargement of prostate with calcifications.
• 2024-03-21 SOAP Orthopedics Chen YingHe
  • S
    • acute LBP developed,
    • received T12 vertebroplasty at Cardinal Tien Hospital => persistent pain
  • O
    • scan image: multiple level lesion, Multiple myeloma is likely!
• 2023-12-25 SOAP Hemato-Oncology Gai WeiYao
  • O
    • 2023/12/23 IgD = < 13.38 mg/L;
    • 2023/12/21 B2-microglobulin (NM) = 3.26 mg/L;
    • 2023/12/20 IgE = 223 IU/mL;
    • 2023/12/20 IgG = 643 mg/dL;
    • 2023/12/20 IgA = 54 mg/dL;
    • 2023/12/20 IgM = < 20 mg/dL;
• 2023-12-19 SOAP Hemato-Oncology Gai WeiYao
  • O
    • 2023/12/11 Free Light Chain κ/λ: FKLC = 12.1 mg/L; FLLC = 580.0 mg/L;
    • 2023/12/09 M-peak = Positive;
  • A/P
    • Referred from Neprhro for M-protein and proteinuria (20231219)
    • Pain over Lt upper arm (20231219)
• 2023-12-06 SOAP Cardiology Ke YuLin
  • Prescription x3
    • Bokey (aspirin 100mg) 1# QD
    • Crestor (rosuvastatin 10mg) 1# QD
    • Ulstop (famotidine 20mg) 1# QD
    • Plavix (clopidogrel 75mg) 1# QD
    • Uformin (metformin 500mg) 1# BIDCC
    • Exforge (amlodipine 5mg, valsartan 160mg) 0.5# QD
    • Forxiga (dapagliflozin 10mg) 0.5# QDAC
• 2023-08-13 ~ 2023-08-16 POMR Cardiology Ke YuLin
  • Discharge diagnosis
    • Angina pectoris
    • Coronary artery disease, left main with triple vessel disease, status post percutaneous transluminal coronary angioplasty with drug eluting stent stenting for left main coronary artery to left anterior descending artery and mid-left circumflex coronary artery on 2023/08/14
    • Hypertension
    • Newly type 2 diabetes mellitus (HbA1c: 6.6% on 2023/03/01 -> 7.1% on 2023/07/11)
    • Benign prostatic hyperplasia
    • Reflux esophagitis Los Angeles (LA) Classification grade A (last panendoscopy on 2023/07/11)
    • Fatty liver, moderate~severe with abnormal liver function test
    • Mixed hyperlipidemia
    • Hyperuricemia
    • Cataract
  • CC
    • exertional chest tightness and dyspnea during climbing for 6 months
• 2020-06-15 ~ 2020-06-17 POMR Urology Zhang ShangRen
  • Discharge diagnosis
    • Left renal and ureteral stone status post flexible ureteroscopic lithotripsy & double J stenting on 2020-06-16
    • Hydronephrosis, left
    • Right renal stone
    • Essential (primary) hypertension

[surgical operation]

==========

2024-03-27

[bedside visit: assessing patient comfort and medication needs]

I visited the patient at around 16:10 on 2024-03-27. The patient and his female relatives were in the room. I inquired about any medication issues and asked if the current pain management was satisfactory.

The patient mentioned feeling more pain when needing to turn his body but did not require an increase in pain medication.

No further medication concerns were raised by the family.

2024-03-22

[possible MM detected]

Lab results supported the possibility of multiple myeloma.

• Presence of a monoclonal protein => 2023-12-09 M-peak positive
• Suppression of uninvolved immunoglobulins (immunoparesis) => 2024-03-22 IgG 535 mg/dL, IgM <20 mg/dL, IgA 50 mg/dL
• Free light chain assay => 2023-12-11 FLLC 580 mg/L, FK/FL ratio 0.02

However, in the most recent lab results, there was no extreme anemia, hypercalcemia.

The underlying condition HTN and DM are currently well managed. Vital signs and serum glucose levels are stable.

Osteolytic bone disease is a major feature of MM that can result in bone pain and pathologic fractures. Bone pain is now treated with oral Tramacet and PRN Tramtor injection with no discrepancy.

It is suggested to risk-stratify myeloma patients at initial diagnosis wiht FISH on the bone marrow for t(11;14), t(4;14), t(6;14), t(14;16), t(14;20), del17p13, gain 1q, and trisomies of odd numbered chromosomes.

700203683

240327

[MedRec]

• 2023-12-22 ~ 2023-12-31 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Non-keratinizing squamous cell carcinoma of nasal cavity cT4N1M0 stage IVA
    • Chronic viral hepatitis B
  • CC
    • Left eye blurred vision and progressed in the recent three days, blind now
  • Present illness
    • The patient underwent the operation of biopsy of bilateral nasal cavity tumor, myringotomy with ventilation tube insertion, left on 2023/12/18. The pathology report showed non-keratinizing squamous cell carcinoma, poorly differentiated (EBER+ and p16-). Consult OPH for left OS blurred vision, and suggest Sinomin and Duratears oint for superficial punctuate keratitis.
    • This time, she suffered from left eye blurred vision and progressed in the recent three days. Her left eye was blind now. She visited OPH OPD for help. Massive NPC involving optic tract was suspected and she was then referred to hematology oncology and radiation oncology OPD for further treatment. Under the impression of massive NPC involving optic tract, she was admitted for port-a insertion and first induction chemotherapy.
  • Course of inpatient treatment
    • After admission, we consulted CVS for port-a insertion, the surgery was done on 12/25.
    • We arranged first induction chemotherapy with PF4 on 12/26-12/29.
    • We gave norvasc 1# QD for high blood pressure, allegra for rhinorrhea, actein for sputum, promeran for nausea prevention. Baraclude 1# QDAC was also given due to Anti-HBc (+).
    • Radiotherapy localization was done on 12/27 and now waiting for radiotherapy. Her hemodynamic was stable, and no significant discomfort during chemotherapy.
    • She discharged on 12/31 and OPD follow up was arranged.
  • Discharge prescription
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Allegra (fexofenadine 60mg) 1# BID
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Norvasc (amlodipine 5mg) 1# QD
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2023-12-14 ~ 2023-12-19 POMR Ear Nose Throat Xu YingJie
  • Discharge diagnosis
    • Malignant neoplasm of nasal cavity status post biopsy of bilateral nasal cavity tumor on 2023/12/18
    • Left middle ear mucoid effusion status post myringotomy with ventilation tube insertion, left on 2023/12/18
    • Superficial keratitis, left eye
  • CC
    • Right nasal anosmia and left nasal obstruction for months
  • Present illness
    • This is a 48-year-old woman without underlying disease. She has right nasal anosmia and left nasal obstruction for months. Sometimes, nasal bleeding intermittent and water rhiniorrhea was noted.
    • She went to our ENT OPD for help. In physical examination showed nasal cavity mass, touch bleeding, involved hard palate, and neck mass about 5cm, over left level I region, firm and mild tenderness.
    • According to the patient statement left eye blurred vision intermittent and left ear stuffiness for 2 days. Admission for further examination was suggested, and the patient agreed after thorough consideration.
    • Therefore, under the impression of suspect nasopharyngeal cancer, the patient was admitted for cancer work-up.
  • Course of inpatient treatment
    • After admission, serial tests were arranged for tumor staging work up.
    • Nasopharynx MRI showed a huge soft tissue mass with vivid enhancement involving hard palate, bilateral nasal cavities and all sinus, pituitary fossa, left foramen ovale, left medial and lateral pterygoid muscles, left sphenoid wing and left nasopharynx; multiple enlarged and necrotic lymph nodes at left neck, with the largest one about 30 mm at left level II. D/D: NPC and lymphoma. Abdominal sonography showed negative.
    • Whole body bone scan showed increased activity in the maxilla and skull base. Malignancy with local bony involvement.
    • PTA arranged and showed average right 13 dB/HL; left 46 dB/HL, left mild to moderate mixed type HL.
    • Pre-operative evaluation was done. The patient underwent the operation of biopsy of bilateral nasal cavity tumor, myringotomy with ventilation tube insertion, left on 2023/12/18.
    • Consult OPH for left OS blurred vision, and suggest Sinomin and Duratears oint for superficial punctuate keratitis.
    • Under relative stable condition, the patient was dishcarged with OPD follow up.
  • Discharge prescription
    • Allegra (fexofenadine 60mg) 1# BID
    • Earflo Otic Soln (ofloxacin 3mg/mL) BID AS
    • cephalexin 500mg 1# QID
    • Acetal (acetaminophen 500mg) PRNQID if pain

[surgical operation]

• 2023-12-18
  • Op Method:
    • Biopsy of bilateral nasal cavity tumor
    • Myringotomy with ventilation tube insertion, left
  • Finding:
    • Bilateral nasal cavity granular tumor with easy touch bleeding
    • Middle ear mucoid effusion, left
    • Frozen section of left nasal cavity tumor: malignancy

[chemotherapy]

• 2024-03-25

• 2024-03-01

• 2024-02-22

• 2024-02-16

• 2024-02-06

• 2024-02-01

• 2024-01-25

• 2023-12-26

==========

701042575

240327

[exam findings]

• 2024-03-26 PET scan
  • Glucose hypermetabolism in the pancreatic head and in some regional lymph nodes, compatible with primary pancreatic malignancy with some regional lymph node metastases.
  • Glucose hypermetabolism in the right pulmonary hilar lymph nodes. The nature is to be determined (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the right upper anterior chest wall and around the port-A line. Inflammation may show this picture.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
• 2024-03-26 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (117 - 34) / 117 = 70.94%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Mild MR; trivial TR.
• 2024-03-22 Patho - pancreas biopsy
  • Pancreatic head, EUS/FNB — Ductal adenocarcinoma, moderately differentiated
  • The sections show a picture of ductal adenocarcinoma, moderately differentiated, composed of nests, cords, and single large pleomorphic neoplastic cells with focal glandular differentiation, in fibrous stroma. Tumor necrosis and mucin production are present.
• 2024-03-11 CT - abdomen
  • History and indication:
    • R/O pancreatic head lesion arrange CT
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A poor enhancing lesion (3.5cm) at pancreatic head with duodenum, SMV, portal vein, common hepatic artery invasion. Some LNs around pancratic head. Dilatation of p-duct.
    • Grade 4 fatty liver with cysts (up to 1.3cm).
    • S/P cholecystectomy.
    • Atherosclerosis of aorta.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)

[chemotherapy]

• 2024-03-27 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 175mg D5W 250mL 1.5hr + leucovorin 400mg/m2 480mg NS 250mL 2hr + fluorouracil 400mg/m2 480mg NS 100mL 10min + fluorouracil 2400mg/m2 2800mg NS 500mL 46hr (FOLFIRINOX, Oxa 70% for this first time)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.3mg SC + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-03-27

[bedside visit - patient education and care in chemotherapy initiation]

As the patient is undergoing chemotherapy for the first time today, I visited them around 16:15 on 2024-03-27 to inquire if anyone had explained the potential side effects of chemotherapy to her. The patient confirmed that both her doctor and nursing staff had provided an explanation.

The patient lives nearby, and her uncle on her mother’s side is a monk, which is why they chose to receive medical treatment at out hospital. I advised the patient to inform the medical staff as soon as possible if they suspect any adverse reactions to medications, to allow for prompt management.

701065666

240327

[exam findings]

• 2024-03-25 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — normocellularity.
  • Section shows piece(s) of bone marrow with 60 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number.
  • IHC stains: CD117: <1%; CD34: <1%; MPO: 60%, CD61: 35%; CD71: 5% (of the nucleated cells).

[MedRec]

• 2024-03-22 SOAP Medical Emergency Ni BoYang
  • S: Triage Level 3 > Pallor/anemia > Coagulopathy - mild to moderate bleeding. Bilateral lower extremity ecchymosis for one month
    • Ecchymosis over four limbs - refer from OPD for blood transfusion and arrange admission, r/o ITP
    • Past history: HTN
    • Allergy: denied
    • Exposure (TOCC): denied
  • A: Preliminary Impression: D69.6 Thrombocytopenia, unspecified
  • P: 2024/03/22 20:00 Shift Handover
    • r/o ITP, refer from OPD for blood transfusion and arrange admission.
    • Dexan, BT LRP, F/U CBC coming morning; OA onco
• 2024-03-22 SOAP Hemato-Oncology Gao WeiYao
  • S: Ecchymosis over bil thighs, Medication for hypertension
  • A: BW 65 BH 156; Isolated severe thrombocytopenia

701470742

240327

[exam findings]

[MedRec]

• 2023-03-17 ~ 2023-04-13 POMR General and Gastroenterological Surgery Wu ChaoQun
  • Discharge diagnosis
    • Poorly cohesive carcinoma of gastric body to antrum, pStage IV, pT4bN3aM1 status post distal subtotal gastrectomy with D2 dissection + en block T-colectomy with regional lymph node resection + cholecystectomy + multiple peritoneal tumor excision + Hyperthermic Intraperitoneal Chemotherapy with Oxaliplatin on 2023/03/30. ECOG:1
    • Gastro-esophageal reflux disease with esophagitis
    • Hypoalbuminemia
  • CC
    • Epigastric pain and reflux for more than 6 months.
  • Present illness
    • This is a 82 year old woman with the history of GERD. She had epigastric pain and reflux for since 2022/05. During the past 6 months, she had decreased body weight of 10kg. She also had bloating sensation. However, due to COVID she did not seek medication help. Until 2023/02, she went to TuCheng CGMH. Pathology showed a poorly differentiated gastric carcinoma with signet ring component. She then came to our ward for further treatment.
    • GS OPD on 2023/03/10, PE showed palpable mass at upper and middle abdomen. UGI scope distal Gastric cancer with multiple peritoneal seeding.
    • Abdominal CT revealed peritoneal seeding with huge gastric tumor. Due to massive velocity of tumor, she was referred to Oncology for neoadjuvant C/T and immunotherapy. However, her lab data revealed HGB 6.7 g/dL and Albumin 3.3 g/dL. Due to poor nutrition and severe anemia, she was admitted for further care before treatment of gastric cancer.
  • Course of inpatient treatment
    • After admission, we added TPN and blood transfusion for nutrition support and anemia treatment. The cardiac echo was arranged on 2023-03-20, it disclosed LVEF: 74%, 1.Normal LV systolic function with normal wall motion; 2.LV posterior wall thickening; dilated LA; LV diastolic dysfunction Gr 1; 3.Normal RV systolic function; 4.Moderate MR; aortic valve sclerosis with mild AR; mild to moderate TR; mild PR.
    • The chest CT was arranged on 2023-03-21, it revealed 1. a huge inhomgeneous hypodense gastric tumor in low body and antral parts with outlet obstruction, involving adjacent pancreas and small bowel loops, and with peritoneal seeding and perigastric LNs metastasis; 2. an ill-defined heterogeneous lesion Rt hepatic dome S7(26mm); 3. multiple low attenuated lesions in both lobes of the liver up to 1.5cm. mild enlarged Lt adrenal gland and several small left renal cysts; 4. no evidence of lung metastasis. advanced gastric cancer.
    • She underwent 1. distal subtotal gastrectomy with LND2 dissection; 2. en block T-colectomy with regional LN; 3. cholecystectomy; 3. multiple peritoneal tumor excision; 4. HIPEC with Oxaliplatinum (250mg/m2) 360mg at 41.5’C for 60 mins on 2023-03-30.
    • Post operation, extubation smoothly and she was transferred to SICU for intensive care on 2023/03/31, and she was transferred back to ordinary ward for further care on 2023/04/01 under stable condition.
    • After transferral, we kept antibiotics treatment of Metronidazole until 2023/04/06, and Finbax until 2023/04/08. We kept monitoring JP drain amount and removed the left one on 2023/04/06.
    • Clear-yellowish discharge was noted at the removal site but subsided afterwards. The patient complained about shortness of breath and inhalation therapy with Ipratran and Butanyl was prescribed.
    • The patient started trying PG1 diet on 4/4, and shifted to PG2 diet on 4/6, PG3 diet on 4/8. Intraperitoneal chemotherapy via JP tube with 5Fu was performed on 4/10, but FAILURE on 4/11.
    • SYSTEMIC CHEMOTHERAPY WITH MITIMYCIN-C WAS PERFORMED SMOOTHLY ON 2023/04/11.
    • The patient denied abdominal discomfort after chemotherapy. The remaining JP drain was removed on 4/12.
    • Port-A implantation was performed on 4/12, and the operation went uneventfully.
    • Under stable condition, she was discharged today and OPD follow up was aranged.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# BID
    • Mopride (mosapride citrate 5mg) 1# TID

[surgical operation]

[chemotherapy]

• 2024-03-26 - leucovorin 400mg/m2 550mg NS 500mL 10min + fluorouracil 1200mg/m2 1600mg NS 500mL 46hr

  • diphenhydramine 30mg + NS 250mL

• 2023-10-17 - leucovorin 300mg/m2 380mg NS 500mL 10min + fluorouracil 2400mg/m2 3000mg NS 250mL 48hr (infusor)

  • diphenhydramine 30mg + NS 250mL

• 2023-10-03 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr (Y-sited LV) + leucovorin 300mg/m2 390mg NS 500mL 2hr (Y-sited Oxa) + fluorouracil 2400mg/m2 3000mg NS 250mL 48hr (infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-09-19 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr (Y-sited LV) + leucovorin 300mg/m2 390mg NS 500mL 2hr (Y-sited Oxa) + fluorouracil 2400mg/m2 3000mg NS 250mL 48hr (infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-09-05 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr (Y-sited LV) + leucovorin 300mg/m2 390mg NS 500mL 2hr (Y-sited Oxa) + fluorouracil 2400mg/m2 3000mg NS 250mL 48hr (infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-08-22 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr (Y-sited LV) + leucovorin 300mg/m2 390mg NS 500mL 2hr (Y-sited Oxa) + fluorouracil 2400mg/m2 3000mg NS 250mL 48hr (infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-08-08 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr (Y-sited LV) + leucovorin 300mg/m2 390mg NS 500mL 2hr (Y-sited Oxa) + fluorouracil 2400mg/m2 3000mg NS 250mL 48hr (infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-07-25 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr (Y-sited LV) + leucovorin 300mg/m2 390mg NS 500mL 2hr (Y-sited Oxa) + fluorouracil 2400mg/m2 3000mg NS 250mL 48hr (infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-07-11 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr (Y-sited LV) + leucovorin 300mg/m2 390mg NS 500mL 2hr (Y-sited Oxa) + fluorouracil 2400mg/m2 3000mg NS 250mL 48hr (infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-06-27 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr (Y-sited LV) + leucovorin 300mg/m2 390mg NS 500mL 2hr (Y-sited Oxa) + fluorouracil 2400mg/m2 3000mg NS 250mL 48hr (infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-06-13 - leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr

  • diphenhydramine 30mg + NS 250mL

• 2023-05-25 - leucovorin 300mg/m2 400mg NS 500mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr

  • diphenhydramine 30mg + NS 250mL

• 2023-04-18 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr (Y-sited LV) + leucovorin 300mg/m2 400mg NS 500mL 2hr (Y-sited Oxa) + fluorouracil 2400mg/m2 3000mg NS 180mL 48hr (infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-04-10 - mitomycin-C 20mg/m2 30mg NS 800mL 3hr D2 + [fluorouracil 500mg NS 500mL + gentamicin 40mg + NaHCO3 4200mg] IP D1-5 1hr via JP tube drip then retention 23hr

• 2023-03-30 - oxaliplatin 250mg/m2 360mg IP 1hr

==========

701519651

240327

[lab data]

2024-03-27 Anti-HBc Reactive
2024-03-27 Anti-HBc Value 7.41 S/CO
2024-03-27 Anti-HBs 0.51 mIU/mL
2024-03-27 Anti-HCV Nonreactive
2024-03-27 Anti-HCV Value 0.12 S/CO
2024-03-27 HBsAg Reactive
2024-03-27 HBsAg Value 5361.11 S/CO

2024-03-27 CA125 237.3 U/mL
2024-03-27 CEA 133.71 ng/mL
2024-03-27 CA153 89.8 U/mL

[exam findings]

• 2024-03-27 SONO Guide biopsy - Breast lesion core needle
  • Impression: S/P sono-guided biopsy for left breast tumor.
• 2024-03-25 CXR erect
  • Nodular lesions in both lung fields, r/o lung metastasis
  • Normal heart size and configuration
  • Bilateral pleural effusion

[MedRec]

• 2024-03-25 SOAP Medical Emergency Jian Yong[Qiang/Cang]
  • S: Injury Severity Level: 2. Chest pain/discomfort > Suspected psychogenic chest pain/discomfort. MinSheng Hospital diagnosed left breast cancer with multiple metastases. The patient, a former volunteer of TzuChi, expressed a preference for treatment at TzuChi Hospital due to past association. Currently experiences chest discomfort and shortness of breath, but has not sought outpatient treatment.
    • PH: deny DM or HTN or CAD before
    • NKA
    • 2024/03/25 Chest PA (Erect) view
      • Nodular lesions in both lung fields, r/o lung metastasis
    • 2024/03/08 CT (at MinSheng Hospital)
      • A 12cm huge right breast cancer, involving skin and chest wall, with enlarged left axillary and internal mammary lymph nodes, right breast lesions, numerous pulmonary and pleural lesions, bilateral pleural effusion, and liver metastases, Tentative staging on this study: T4cN3bM1.
      • Mural calcifications at LAD, suggest F/U.
      • A thyroid nodule at left lobe, suggest F/U.
      • A left ovarian cyst, suggest F/U.
  • A: Preliminary Impression: C50.912 Malignant neoplasm of unspecified site of left female breast

==========

700561999

240326

[lab data]

2023-12-28 Anti-HCV Nonreactive
2023-12-28 Anti-HCV Value 0.33 S/CO

2023-12-27 Anti-HBc IgM Nonreactive
2023-12-27 Anti-HBc IgM Value 0.09 S/CO
2023-12-27 HBsAg Nonreactive
2023-12-27 HBsAg (Value) 0.57 S/CO
2023-12-27 Anti-HBc Nonreactive
2023-12-27 Anti-HBc-Value 0.21 S/CO

[exam findings]

• 2024-03-21 CT - abdomen
  • History and indication:
    • Recurrent Endometrioid cancer with pleural mets
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy.
    • Thickening of left pleural with pleural effusion.
    • Bil. renal cysts (up to 8.4mm) and stones (up to 5.4mm).
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • S/P hysterectomy.
    • Thickening of left pleural with pleural effusion.
    • Bil. renal cysts (up to 8.4mm) and stones (up to 5.4mm).
• 2024-02-03 Chest PA + Lat Rt
  • S/P port-A insertion via right subclavian vein.
  • Left pleural effusion.
  • Nodularity at left pleura, r/o pleural seeding.
• 2023-12-25, -12-19 CXR
  • Left pleural effusion.
• 2023-12-09 CXR
  • Left pleural effusion.
  • Left suparhilar soft tissue tumor, pleural or lung tumors.
• 2023-12-09 SONO - gynecology
  • Findings
    • CUL-DE-SAC: No fluid
      
    • Other: ATH + BSO
  • IMP: No obvious uterine or ovarian lesion
• 2023-12-02 CT - abdomen
  • Severe pleural thickening and pleural thickening at left hemithorax is found. r/o methothelioma or others.
• 2023-12-01 CXR
  • proression large volume of Lt pleural effusion s/p pigtail drain placement
• 2023-11-27 CXR
  • further regression large volume of Lt pleural effusion s/p pigtail drain placement
• 2023-11-24 Patho - pleural/pericardial biopsy
  • Pleura, left, biopsy — metastatic carcinoma, consistent with endometrioid carcinoma
  • Section shows skeletal muscle fibers and fibroadipose tissue with mild fibrosis, chronic inflammatory cell infiltration, and focal hyperchromatic tumor cells.
  • The immunohistochemical stains reveal CK(+), PAX8(+), GATA3(focal weak +), Calretinin(-), E-Cadherin(+), and TRPS1(+). The results are consistent with metastatic endometrioid carcinoma. The PAS and AFB special stains are negative.
• 2023-11-24 CXR
  • regression large volume of Lt pleural effusion s/p pigtail drain placement
  • marginal spurs of multiple vertebral bodies due to spondylosis.
  • widening of Lt paratracheal stripe due to ispace taking lesion or paratracheal lymph node enlargement?
• 2023-11-06 SONO - abdomen
  • Left renal stones, 0.36cm, 0.51cm and 0.85cm.
• 2023-11-06 SONO - breast
  • Suggestion and Plan
    • Post-op scar in left breast.
    • Right breast 9’region tumor, stationary.
    • Bilateral breast cysts and fibroadenomas. Suggest follow up.
  • BI-RADS 2. benign finding
• 2023-07-26 Patho - breast biopsy
  • Breast, right, 9’, core needle biopsy — fibrosis
• 2023-06-05 SONO - abdomen
  • Left renal stone.
• 2023-06-05 SONO - breast
  • Suggestion and Plan
    • Post-op at left breast.
    • Newly developed right breast tumor, 1.17cm, may consider biopsy.
  • BI-RADS: Category 4a: low suspicious abnormality-biopsy should be considered.
• 2023-06-05 Mammography
  • Indication: Left breast cancer s/p left BCT + SLND (2022-05-25)
  • Final assessment: BI-RADS category 2, Benign finding.
• 2023-05-09 Tc-99m MDP bone scan
  • In comparison with the previous study on 2022/05/26, the lesions in the lower L-spines and bilateral S-I joints are slightly more evident. Degenerative change in a little more severe status is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2023-04-28 Pap Smear
  • Atypical squamous cells (ASC-US)
• 2022-06-06 Bone densitometry - spine
  • L-spines BMD performed by DXA revealed:
    • AP L-spines, BMD of L1-4 0.844 gms/cm2, about 1.8 SD below the peak bone mass (81%) and 0.0 SD below the mean of age-matched people (100%).
  • Impression
    • Osteopenia
• 2022-05-26 Tc-99m MDP bone scan
  • Increased activity in the lower L-spines and bilateral S-I joints. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • A hot spot in the left anterior chest wall, probably due to previous SLN study.
  • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2022-05-11 Patho - breast biopsy (no need margin)
  • Breast tumor, left 3 o’clock / 3, core needle biopsy — Invasive lobular carcinoma
  • Microscopically, the sections show a picture of invasive lobular carcinoma characterized by a few monotonous tumor cells arranged in linear or cord pattern within two of six strips.
  • Immunohistochemistry shows CK5/6 and P63 (-) for myoepithelial cell and E-cadherin (-) for tumor. Because the tumor is to small, ER, PR, HER2 and Ki-67 are not recommended for this specimen. It is more suitable for subsequent surgery specimen. Clinician has been informed and consented.
• 2017-04-13 Surgical Pathology Level VI
  • DIAGNOSIS:
    • Uterus, endometrium, debulking operation
      • endometrioid adenocarcinoma, Grade 2
      • pTNM: pT1bNO(cMO), FIGO stage: IB, pStage IB
    • Uterus, myometrium, debulking operation
      • involoved by endometrioid adenocarcinoma (>1/2 thickness)
      • adenomyosis
    • Uterus, cervix, debulking operation
      • negative for malignancy
      • free of lower cervical margin
    • Fallopian tube, right, debulking operation
      • negative for malignancy
        
    • Fallopian tube, left, debulking operation
      • negative for malignancy
        
    • Ovary, right, debulking operation
      • negative for malignancy
        
    • Ovary, left, debulking operation
      • negative for malignancy
    • Lymph node, right iliac, dissection
      • negative for malignancy ( 0 / 5 )
    • Lymph node, right obturator, dissection
      • negative for malignancy ( 0 / 4 )
    • Lymph node, left iliac, dissection
      • negative for malignancy ( 0 / 5 )
    • Lymph node, left oburator, dissection
      • negative for malignancy ( 0 / 5 )
  • MacrodDescription:
    • The specimen submitted consists of multiple pieces of tissues measuring up to 3x 2.5x 1.2 cm in size, fixed in formalin. Grossly, they appear yellow-brownish and elastic.
    • The specimen submitted consists of several pieces of tissues measuring up to 3.2 x 2.5x 1.3 cm in size, fixed in formalin. Grossly, they appear yellow-brownish and elastic.
    • The specimen submitted consists of several pieces of tissues measuring up to 3.5 x 3.5x 1.4 cm in size, fixed in formalin. Grossly, they appear yellow-brownish and elastic.
    • The specimen submitted consists of several pieces of tissues measuring up to 3.3 x 2.3 x 1.2 cm in size, fixed in formalin. Grossly, they appear yellow-brownish and elastic.
    • The specimen submitted consists of a uterus attached with bilateral adnexae, in fixed state, Grossly, the uterus measures 11x 7x 5 cm in size and 230 gm in weight. The serosa is tan and focal fibrotic. On opening, the endometrium shows an ill-defined solid tumor measuring 3x 3 cm in size at the lower body and 3.5 cm away from tumor. The myometrium is involved by the tumor. The endocervical canal measures 2.5 cm in length and appears smooth anmd unremarkable. The exocervix is unremarkable.
    • The right fallopian tube measures 5.5 cm in length and up to 0.4 cm in diameter.
    • The right ovary measures 3x 2x 0.8 cm in size and appears tan and elastic.
    • The left fallopian tube measures 5.5 cm in length and up to 0.4 cm in diameter.
    • The left ovary measures 2.8x 1.7x 0.8 cm in size and appears tan and elastic.
    • Representative sections are taken and labeled as follows: A1-2: right iliac LN, B:right obturator LN, C1-2:right iliac LN, D:right obturator LN, E1-2:right adnexae,E3-4:left adnexae, E5:cx,E6-11: endometrial tumor, E12-13:myometrium
  • Microdescriptoin
    • Uterus Endometrial Cancer Checklist (2009 FIGO Stage System)
  • PATHOLOGIC DIAGNOSIS
    • Uterus, endometrium, debulking operation — endometrioid adenocarcinoma, Grade 2
    • Uterus, myometrium, debulking operation — involoved by endometrioid adenocarcinoma (>1/2 thickness) — adenomyosis
    • Uterus, cervix, debulking operation — negative for malignancy — free of lower cervical margin
    • Fallopian tube, right, debulking operation — negative for malignancy
      
    • Fallopian tube, left, debulking operation — negative for malignancy
      
    • Ovary, right, debulking operation — negative for malignancy
    • Ovary, left, debulking operation — negative for malignancy
    • Lymph node, right iliac, dissection — negative for malignancy ( 0 / 5 )
    • Lymph node, right obturator, dissection — negative for malignancy ( 0 / 4 )
    • Lymph node, left iliac, dissection — negative for malignancy ( 0 / 5 )
    • Lymph node, left oburator, dissection — negative for malignancy ( 0 / 5 )
    • Pathology stage: pTNM: pT1bNO(cMO), FIGO stage:IB, pStage IB
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: debulking operation
    • Specimens include: uterus, regional LNs, bilateral adnexae
    • Specimen size:
      • uterus: 11x 7x 5 cm
      • right ovary: 3x 2x 0.8 cm
      • left ovary: 12.8x 1.7x 0.8 cm
      • right tube: 5.5 cm;
      • left tube: 5.5 cm;
    • Tumor site: lower body
      
    • Tumor size: 3x 3 cm
    • The myometrium : Involved by tumor( 0.8 cm in depth)
    • The cervix : free of tumor
    • Adnexa: unremarkable
    • Lymph node: left iliac, left obturator and right iliac, right obturator, are received.
  • MICROSCOPIC EXAMINATION
    • Histology type: endometrioid adenocarcinoma
    • Histology grade: grade 2
      
    • Depth of invasion: 0.8 cm in depth
      
    • Lymphovascular invasion: Present
    • The cervical stroma involvement: absent
    • Resection margins of the cervix (or vagina): free 3.5 cm)
    • Additional pathologic findings:
      • Endometrial hyperplasia: absent
      • (squamous) metaplasia: present
      • adenomyosis: present
    • Bilateral adnexa: free of tumor
      
    • Lymph node metastasis
      • group as specified No. Positive / No. Total
      • left iliac ( 0 / 5 )
      • left obturator ( 0 / 5 )
      • right iliac ( 0 / 5 )
      • right obturator ( 0 / 4 )
      • over all 0 / 19
• 2017-04-11 CT - pelvis
  • Clinical history: 50 y/o female patient with endometrial cancer.
  • With and without contrast enhancement CT of abdomen - whole:
    • Suspicious soft tissue density in uterine fundus, r/o endometrial malignancy.
    • Cystic lesion, 2.5cm in left adnexa, could be due to left ovarian cyst.
    • Cystic lesions in the uterine cervix, could be due to Nabothin cysts.
    • Left renal cysts.
  • Imaging Report Form for Endometrial Carcinoma
  • Impression:
    • Uterine tumors, r/o malignancy. cstage T1b?N0Mx.
    • Nabothin cysts.
    • Left renal cysts.

[MedRec]

• 2023-12-27 ~ 2023-12-29 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Recurrent endometrioid adenocarcinoma s/p operation (LTH+BSO+BPLND) and radiotherapy with pleural metastasis, stage IV
    • Invasive lobular carcinoma of the left breast, pT1bN0(cM0). Prognostic stage: IA, s/p BCT+ALND, radiotherapy,
    • Constipation
    • Essential (primary) hypertension
  • CC
    • SOB without control and left lateral chest pain also noted for 2 weeks
  • Present illness
    • This 57-year-old female patient has past history of hypertensive over 5 years with regular medicine control, Endometrioid adenocarcinoma, Grade 2, of the uterus, stage pT1bN0(cM0), s/p operation (LTH + BSO + BPLND) and radiotherapy and Invasive lobular carcinoma of the left breast, , pT1bN0(cM0). Prognostic stage: IA, s/p BCT + ALND, radiotherapy, and status during endocrine therapy. Bone scan was done on 2023/05, but no evidence of bone metastasis.
    • Last time, she had cough with SOB and left chest wall pain, so she was admitted to Integrative (hospital) Medicine department for treatment. Pleural effusion drainage and pathology showed metastatic carcinoma, consistent with endometrioid carcinoma on 2023/11/24.
    • The chest CT was done on 2023/12/02, report showed severe pleural thickening and pleural thickening at left hemithorax is found.
    • This time, she also has SOB on exrcise and chest wall pain for 2 weeks, so she was brought to our ED for help on 2023/12/25.
    • The CXR showed left pleural effusion. Rib filme showed no fracture. The lab data showed elevated CRP 12.0g/dL and hypercalcemia 2.83 mmol/L. Initial antibiotic as Brosym for infection control and pain control with Tramadol iv form.
    • Under the impression of Endometrioid adenocarcinoma with pleural metastasis and SOB, so she was admitted for treatment on 2023/12/27.
  • Course of inpatient treatment
    • After admission, we check HBV and HCV for survey. Empiric antibiotic as Brosym 4g q12h for prevent pneumonia.
    • She received pre-medication as oral steroid and C1 chemo as Taxel + Cisplatin on 2023/12/28.
    • Under the stable condition, she can be discharged on 2023/12/29. OPD follow up is arranged.
  • Discharge prescription
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Through (sennoside 12mg) 2# HS
• 2023-12-09 SOAP Obstetrics and Gynecology Hong ZhengXiu
  • A: Conclusions of Cancer Multidisciplinary Team Meeting, Meeting date: 2023-12-07
    • Treatment plan: Notify the hemato-oncology department for systemic chemotherapy (lung metastasis).
• 2023-11-22 ~ 2023-12-05 POMR Chest Medicine Rao LunYu
  • Discharge diagnosis
    • Secondary malignant neoplasm of pleura
    • Left side massive pleural effusion due to endometrial CA with pleural metastasis
    • Malignant neoplasm of endometrium
    • Malignant neoplasm of unspecified site of left female breast
    • Left invasive lobular carcinoma, cT1N0M0, stage IIA status post left breast conserving therapy and axillary lymph node dissection on May 25, 2022.
  • CC
    • Severe dry cough and SOB for 2-3 weeks, left lateral chest pain was noted at OPD.
  • Present illness
    • This 57-year-old female patient has past history of hypertensive over 5 years with regular medicine control. She denied any TOCC histories in recent 3 months.
    • This time, she suffered from severe dry cough and SOB for 2-3 weeks, left lateral chest pain was noted today. Therefore she was brought to our ER for help. In ER, vital signs: Temp: 36.9’C, pulse: 98/min, respiration: 18/min and blood pressure: 118/78 mmHg, SpO2:96%. Laboratory data showed no leukocytosis with left shifted (WBC 8280/N.seg 76.1). CXR film showed massive left pleural effusion. After bed side chest echo tapping 1100ml of left chest in ER. Under the impression of massive pleural effusion, she was admitted to CM ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, antitussive, mucolytic agents and other palliative treatment were given for symptomatic relief. The chest echo arrange on 2023/11/23, which showed left side massive pleural effusion, and the pig-tail drinage was performed and serosangious fluid was drained out. Pleural biopsy, fluid culture and cytology was done. The pleural efffusion analysis dislcosed exaduate, added empiric antibiotic with Rocephine IV (2023/11/24~) for infection control. Further CXR will follow up on 2023/12/01.
    • The pleural effusion cytology disclosed atypia and plueral biopsy pathogy disclosed metastatic carcinoma, consistent with endometrioid carcinoma. Thus, GYN Dr as consulted on 2023/11/30 suggest arrange Abdominal CT to pelvis. However impove of laboratroy and Chest Film. We remove pigtail drainage on 2023/12/04 smoothly. Currently, stable vital sign and respiratory condition. She was discharge on 2023-12-05 then GYN and CM OPD for further management.
  • Discharge prescription
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Through (sennoside 12mg) 2# HS
    • codeine phosphate 15mg) 1# HS
• 2022-05-24 ~ 2022-05-26 POMR General and Gastrointestinal Surgery Li ChaoShu
  • Discharge diagnosis
    • Left breast cancer, invasive lobular carcinoma, cT1N0M0, clinical stage IA status post left breast conserving therapy and axillary lymph node dissection on 2022-05-25; ECOG 0
    • Malignant neoplasm of unspecified site of left female breast
    • Malignant neoplasm of endometrium
    • ECOG performance: 0
    • Endometrial cancer, pT1bN0M0, stage IB status post abdominal total hysterectomy and bilateral salpingo-oophorectomy
    • Insomnia
  • CC
    • She was diagnosed with abnormal under mammography by health examination.
  • Present illness
    • This 55-year-old female patient has past history of 1) hypertensive over 5 years with regular medicine control 2) insomnia 3) endometrial cancer s/p ATH + BSO on 2017/04/25 at Taipei TzuChi Hospital. She denied any TOCC histories in recent 3 months.
    • She was regular follow up by health examination. However, Mammography showed focal architectural distortion noted in outer portion of right breast (anterior third portion) and a benign calcification in left breast on 2022/04/27. So she visited to our OPD for help. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, no body weight loss. Breast sono showed benign neoplasm of breast, infavor of benign fibrocystic disease (FCD)left breast tumor, 3 o’clock location, r/o malignancy, location: left 3 o’clock / 3 cm, size: 0.5 x 1cm; suggest biopsy. Core needle biopsy revealed invasive lobular carcinoma, because the tumor is too small, ER, PR, HER2 and Ki-67 are not recommended for this specimen.
    • After fully explaination the treatment options with general surgery. This time, she was admitted to our ward for partial mastectomy + SLNB on 2022/05/25.
  • Course of inpatient treatment
    • After admittion, arragne abdominal sono was done that revealed no obvious lesion for metastasis. She underwent of left breast conserving therapy and axillary lymph node dissection on 2022-05-25. The post-operative course was relatively smooth without complication. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. The final pathology and Tc-99m MDP whole body bone scan report is pending. She was discharged on May 25, 2022 and OPD follow-up was arranged on 2022-06-02.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ8H
    • MgO 250mg 1# TID
• 2017-04-10 ~ 2017-04-17 POMR Obstetrics and Gynecology Hong ZhengXiu
  • Discharge diagnosis
    • C54.1 Endometrial endometrioid adenocarcinoma clinical stage Ib
    • N80.0 Adenomyosis
    • N80.3 Endometriosis of pelvic peritoneum
    • 2017/04/12 Cystoscopy and retrograded Ureteral catheterization
  • CC
    • vaginal spotting since November of 2016
  • Present illness
    • Miss Lu, a 50 y/o woman, G3P2AA1, presented to our OPD for vaginal spotting since November of 2016.
    • This patient was disturbed by prolonged mense duration and viginal spotting since last year, but lower abdominal pain, lower limbs edema, and fresh blood were denied. It was recognized as menopausal syndrome by herself, but the viginal spotting showed progressively when moving since March, 2017. GYN doctor of Cardinal Tien Hospital was visited and D&C revealed endometrial cancer. She visited Dr. Hung for second opinion on 2017/04/10. Repeated pap smear was done and she was admitted to our ward for laparoscopic staging operation with Thunderbeat arranged on 2017-04-12.
  • Course of inpatient treatment
    • After admission, pelvic CT revealed endometrial endometrioid adenocarcinoma clinical stage Ib on 2017-04-11. Patient underwent cystoscopy and bilateral ureteral catheter were inserted smoothly by GU doctor and laproscopic debulking operation (LTH + BSO + BPLND) and adhesionolysis by GYN doctor on 2017-04-12. Her postop course was uneventful. She remained afebrile and stable and was discharged on POD #5. She was discharged on 2017-04-17. Her followup appointment is scheduled on next week.

[consultation]

• 2023-11-30 Obstetrics and Gynecology
  • Q
    • This 57-year-old female patient has past history of hypertensive over 5 years with regular medicine control. She denied any TOCC histories in recent 3 months. This time, she suffered from severe dry cough and SOB for 2-3 weeks, left lateral chest pain was noted today. Therefore she was brought to our ER for help.
    • In ER, vital signs: Temp: 36.9’C, pulse: 98/min, respiration: 18/min and blood pressure: 118/78 mmHg, Spo2: 96%. Laboratory data showed no leukocytosis with left shifted ( WBC 8280 / N.seg 76.1). CXR film showed Massive left pleural effusion. After bed side chest echo tapping 1100ml of left chest in ER.
    • Under the impression of massive pleural effusion, she was admitted to CM ward for further evaluation and management.
      
    • After admission, antitussive, chest echo arrange on 2023/11/23, which showed left side massive pleural effusion, and the pig-tail drinage was performed and serosangious fluid was drained out.
    • Pleural biopsy, fluid culture and cytology was done. The pleural effusion cytology disclosed atypia and plueral biopsy pathogy disclosed metastatic carcinoma, consistent with endometrioid carcinoma, so we sincerly your special evaluation and help, TKS !!
  • A
    • This 57 y/o woman with medical history of
      • Endometrioid adenocarcinoma, Grade 2, of the uterus, stage pT1bN0(cM0), s/p operation (LTH + BSO + BPLND) and radiotherapy.
      • Invasive lobular carcinoma of the left breast, , pT1bN0(cM0). Prognostic stage: IA, s/p BCT + ALND, radiotherapy, and status during endocrine therapy.
      • Hypertension under medications control
    • She was admitted to our hospital under the impression of massive pleural effusion since 2023/11/22. Chest echo on 2023/11/23 showed left side massive pleural effusion, and the pig-tail drinage was performed and serosangious fluid was drained out. The pleural effusion cytology disclosed atypia and plueral biopsy pathogy disclosed metastatic carcinoma, consistent with endometrioid carcinoma. We were consulted for GYN evaluation.
    • Suggestion:
      • For metastatic evaluation, please arrange abdominal-pelvic CT scan (contrast) firstly
      • I will visit this patient on this coming Saturday (2023/12/02)

[surgical operation]

• 2022-05-25
  • Operation
    • BCT + ALND        
    • IOUS
  • Finding:
    • IOUS: left breast cancer, 3 o’clock/3cm location, was encountered.
    • Clinical tumor status:
      • Tumor size: <2cm (cT1)
      • Gross skin invasion: No
      • Gross pectoral fascia invasion: No
      • Tumor location: left side, lateral upper quadrum (3/3cm)
      • Clinical T stage: cT1 (<2cm)
    • Clinical nodal status:
      • Axillary dissection: SLND using isotope, but failed detection => converted ALND
      • Gross LNs: negative LAPs
      • Clinical N stage: cN0
    • OP status:
      • Procedures: BCT + ALND
      • Pre-OP tissue prove: CNB
      • Nerve preservation: long thoracic nerve and thoracodorsal nerve
      • Drainage: Blake x 1 (15Fr), in axillary space 　 - PostOP elastic bandage: Yes 　 - PostOP skin flap: No 　 - Closure of wound: two-layer, 3-0 Vicryl and 5-0 Nylon
    • Path of frozen section: free margins   - Procedure: 　 - Under ETGA, set the patient in supine position and prepared the OP field as usual. Made IOUS to defined margins. Made partial mastectomy and sent the specimen for frozen exam. The report disclosed malignancy. Commenced axillary LN dissection. Closed the wound as two layer sutures with 3-0 Vicryl and 5-0 Nylon. Finally, covered the wound with elastic bandage.
• 2017-04-12 13:00 doctor Hung ZhengXiu
  • Operation
    • debulking operation (LTH + BSO + BPLND) by LSC
    • Laparoscopic adhesionolysis
  • Finding
    • The uterus was enlarged as three months pregnancy in size.
    • The anterior and posterior cul-de-sac were denesly adhered due to previous twice Cesarean sections.
    • With the use of thunderbeat, at the beginning of the operation, the uterus was removed by dissecting bilateral uterine arteries down to the isthmus and paracervical stump.
    • And bilateral adnexae were also removed through vagina.
    • Bilateral pelvic lymph nodes were dissected with the aids of suction tip and monopolar coagulators.
    • No indurated pelvic lymph node were palpabled.
    • Bilateral obturator bleeders were checked and Surgicele were placed.
    • The vaginal cuff was repaired with continuous sutures with number one Vicryl.
    • At the end of vaginal suture repair, at central portion interrupted sutures were added.
    • Total blood loss was 150 cc.
• 2017/04/12 12:25 doctor Lin JiaDa
  • Operation
    • Cystoscopy + retrograded Ureteral catheterization
  • Finding
    • Bilateral ureteral catheter were inserted smoothly

[radiotherapy]

• 2022-06-29 ~ 2022-08-09 - 5000cGy/25 fractions of the left breast, and 6000cGy/30 fractions of the left breast tumor bed (scar) area.
• 2017-05-12 ~ 2017-06-30 - 4500cGy/25 fractions of the pelvic, and another 900cGy/3 fractions via IVRT to vaginal cuff mucosa surface.

[chemotherapy]

• 2024-03-13 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + cisplatin 75mg/m2 128mg NS 500mL 2hr + NS 500mL 1hr (after CDDP)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + NS 250mL
• 2024-02-16 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + cisplatin 75mg/m2 128mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-01-22 - paclitaxel 175mg/m2 297mg NS 250mL 3hr + cisplatin 75mg/m2 127mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-12-28 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + cisplatin 75mg/m2 128mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-03-26

[bedside visit: skin reaction post-CT contrast agent and dietary potassium sources]

I visited the patient at around 11:30 on 2024-03-26, and the patient was sitting up in bed, alert.

I inquired if there were any medication-related issues or thoughts she wished to discuss. The patient mentioned a possible adverse reaction to the contrast agent used during a CT scan on 2024-03-21, which caused widespread skin redness, but it has significantly subsided (showing her arm with scattered red spots remaining). I reassured the patient that antihistamine is already part of her medication, and if the condition is improving rather than worsening, there is no need for concern too much.

Additionally, I advised the patient to be cautious of infections due to low white blood cell counts, mentioning the use of G-CSF and potassium supplements due to hypokalemia.

The patient asked about obtaining potassium from her diet post-discharge, and I suggested that bananas could be a good source since her kidney function was normal, though she expressed a dislike for bananas. I mentioned that low-sodium salt, which substitutes sodium with potassium, might be a dietary alternative at home.

The patient had no further medication-related queries.

2024-03-20

[CA125 decline with paclitaxel/cisplatin & electrolyte management]

Since late Dec 2023, the patient has been treated with paclitaxel and cisplatin, leading to a noticeable decrease in CA125 levels, which may indicate the effectiveness of the treatment.

• 2024-03-04 CA-125 (NM) 892.740 U/ml
• 2024-02-08 CA-125 (NM) 2169.200 U/ml
• 2023-12-27 CA-125 3286.5 U/mL paclitaxel + cisplatin, since 2023-12-28
• 2023-10-21 CA-125 595.5 U/mL
• 2023-01-05 CA-125 5.1 U/mL

The patient has experienced mild hypokalemia, mild hypocalcemia, and moderate hypomagnesemia, and is currently receiving magnesium sulfate supplementation.

• 2024-03-19 K (Potassium) 3.3 mmol/L
• 2024-03-19 Ca (Calcium) 2.12 mmol/L
• 2024-03-19 Mg (Magnesium) 1.3 mg/dL

Lab results from 2024-03-19 showed WBC 2140, with seg 53.7%, ANC 1149, and both PCT and CRP within normal limits. Prophylactic use of Tapimycin (piperacillin, tazobactam) is ongoing.

A review of the PharmaCloud and HIS5 databases revealed no discrepancies in medication.

Cisplatin is known to lead to magnesium loss through the kidneys, so supplementing magnesium during cisplatin treatment could be advantageous.

700755070

240326

[exam findings]

• 2024-03-20 CT - abdomen
  • Findings:
    • There is ascites and omentum cake that is c/w carcinomatosis.
      • Ovarian malignancy with carcinomatosis is highly suspected.
      • The differential diagnosis includes lymphoma with lymphomatosis.
      • Please correlate with ascites cytology and diagnostic laparoscopy.
    • There is lobulated contour of the spleen that is compatible with primary lymphoma S/P C/T with complete response.
    • Fecal material store in the entire colon is noted that may be chronic constipation. please correlate with clinical condition.
    • There are several hepatic cysts in both lobes (up to 2 cm in S7).
    • There is mild bilateral Pleura effusion.
    • S/P nasogastric tube insertion
  • Impression:
    • Ovarian malignancy with carcinomatosis is highly suspected.
      • The differential diagnosis includes lymphoma with lymphomatosis.
      • Please correlate with ascites cytology and diagnostic laparoscopy.
• 2024-03-19 Abdomen - Standing (Diaphragm)
  • S/P nasogastric tube insertion
  • Spondylosis with scoliosis of the L-spine with convex to left side.
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon from L2 to S1.
  • Fecal material store in the colon.
  • Ascites is highly suspected.
• 2024-03-19 Ascites tapping
  • Indication: Asctes
  • Symptoms: Abdominal fullness
  • Course: 18 G needle was inserted under echo guided insertion.
  • Findings: 2600 ml yellowish color ascites were drained.
• 2024-03-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (47 - 11) / 47 = 76.60%
    • LVEF (%) = 76
    • M-mode (Teichholz) = 76
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • LV diastolic dysfunction Gr 1.
    • Normal RV systolic function.
    • posterior mitral annulus calcifcation with mild to moderate MR; moderate to severe TR; mild AR.
    • Possible mild pulmonary hypertension, estimated PASP: 40 mmHg.
• 2024-02-29 PET scan
  • Increased FDG uptake in a focal area in the spleen and in some soft tissue lesions in the omentum. Recurrent lymphoma can not be ruled out. Please correlate with other clinical findings for further evaluation.
  • Increased FDG uptake in some bilateral upper neck lymph nodes and in the left tonsil. The nature is to be determined (inflammation? lymphoma?). Please also correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
• 2024-02-27 Patho - colon biopsy
  • Colorectum, sigmoid colon, biopsy — Hyperplastic polyp with marked chronic inflammation
  • Section shows fragment(s) of polypoid colonic mucosal tissue with crowded benign hyperplastic mucinous glands and marked chronic inflammation.
• 2024-02-16 MRA - brain
  • IMP: Mild general brain atrophy. Cervical spondylosis.
• 2024-02-07 CT - abdomen
  • History: Splenic high grade B cell lymphoma diagnosed at our hospital 20180813. S∕P C6 chemotherpay with R-CHOP
  • Findings:
    • There is ascites in the pelvis and equivocal soft tissue lesions in the omentum that may be carcinomatosis.
      • The differential diagnosis includes lymphoma.
      • Please correlate with CA125, CEA, CA199, and GYN. sonography.
    • There is lobulated contour of the spleen that is compatible with primary lymphoma S/P C/T with complete response.
    • Fecal material store in the entire colon is noted that may be chronic constipation. please correlate with clinical condition.
    • There are several hepatic cysts in both lobes (up to 2 cm in S7).
  • Impression:
    • There is ascites in the pelvis and equivocal soft tissue lesions in the omentum that may be carcinomatosis.
    • The differential diagnosis includes lymphoma.
    • Please correlate with CA125, CEA, CA199, and GYN. sonography.
• 2024-02-06 EGD
  • Reflux esophagitis LA Classification grade A-
  • Superficial gastritis
  • Suspect angiodysplasia, body, LC
• 2024-02-06 SONO - abdomen
  • Hepatic cyst, multiple
  • Ascites, minimal
• 2023-04-10 CT - abdomen
  • Borderline splenic size is found. No evidence of abnormal focal lesion in the spleen.
  • Hepatic simple cysts.
• 2021-10-26 ENT Hearing Test
  • Tymp bil type B
  • ART bil absent
  • PTA:
    • Reliability POOR
    • Average RE 60 dB HL; LE 69 dB HL
    • RE moderate to profound HL
    • LE moderate to profound HL
• 2019-10-25 CT - abdomen
  • Findings:
    • There is lobulated contour of the spleen that is compatible with primary lymphoma S/P C/T with complete response .
    • There are several hepatic cysts in both lobes and the largest one is measured about 1.5 cm in size at S7.
  • Impression:
    • Primary splenic lymphoma S/P C/T show complete response .
• 2019-09-26 SONO - abdomen
  • Diagnosis
    • Liver tumor,left
    • Propable liver cyst, right
  • Suggestion
    • OPD f/u
    • Please correlate with other image
    • Follow liver function test and AFP

[MedRec]

• 2017-02-03 SOAP Hemato-Oncology Wan XiangLin
  • S
    • Splenic high grade B cell lymphoma.
    • S/P C6 chemotherpay with R-CHOP, for recheck. C/O abdominal fullness. For port-A flush. C/O abdominal fullness, for revaluation and port-A flush. cough with sputum
  • O
    • 2017-01-20 abdominal C.T.
      • Irregular hypodensity lesions in the spleen, stationary.
      • Liver cysts.
  • Diagnosis
    • Other lymphomas of spleen [C85.27]
    • Dyspepsia & other specified disorders of function of stomach [K30]
• 2015-12-07 ~ 2015-12-09 POMR Hemato-Oncology Wan XiangLin
  • Discharge diagnosis
    • Hight grade spenic B cell lymphoma, stage II
    • Chemotherapy with R-CHOP(I)
    • Constipation
  • CC
    • For chemotherapy.
  • Present illness
    • This 78-year-old woman patient suffered from lower abdominal distention with pain in 2015-10. Night sweat and body weight loss 3 kg(45 -> 42kg) for 2 months ago. No headache, cough, sputum, chest pain, dyspnea and tarry stool passage was noted. Splenic lymphoma s/p biopsy at Far Eastern Hospital on 2015-11-13. Pathology showed high grade splenic B cell lymphoma. Bone marrow study on 2015-11-13 and pathology showed negative for malignancy. Whole body PET scan on 2015-11-19 showed increase metablic activity at spleen and small intestine area.
    • She had Port-A catheter insertion on 2015-11-25. Now, she was admitted to our ward for chemotherapy with R-CHOP(I).

==========

2024-03-26

[bedside visit: evaluating alternative feeding methods]

I visited the patient at around 11:40 on 2024-03-26, with the patient’s husband present.

Her husband mentioned the patient was experiencing abdominal bloating, inability to eat, and vomiting upon consumption. They inquired about the possibility of injection medication or parenteral nutrition supplementation.

I explained that some patients might not tolerate a nasogastric tube well and that it doesn’t completely prevent vomiting. Furthermore, long-term use of Total Parenteral Nutrition (TPN) can reduce the small intestine’s absorptive capacity and should only be used as an emergency measure.

The family expressed expectation for improvement after the planned ascites tapping. No further medication issues were raised during the visit.

[addressing bowel movement issue]

According to HIS5 records, the patient has not had a bowel movement since 2024-03-22, which is 4 days up to today. If the currently used oral sennoside and bisacodyl suppository pill do not achieve the expected bowel movement effect, the use of lactulose may be considered for further action.

2024-03-18

[reconciliation]

BH 150mg, BW 45kg, BMI 20kg/m2, BSA 1.37m2.

No medication discrepancies identified after review of PharmaCloud and HIS5 records.

700971684

240326

[lab data]

2024-01-31 CMV IgM Nonreactive
2024-01-31 CMV IgM Value 0.10 Index
2024-01-31 Mycoplasma IgM Negative Index
2024-01-31 Mycoplasma IgM Value 0.5 Index
2024-01-31 BM chromosome analyz see attachment

• CYTOGENETICS LABORATORY REPORT
  • Chromosome Analysis
    • Tissue Examined: Bone marrow
    • Staining Method: G-Banding
    • Colony number: NA
    • Bands level: 350
    • Chromosome Counts: 45-(3), 46-(12), 47-(), Other-(), Total-(15)
    • Karyotype: 46,XY[12]
  • Interpretation：
    • Analysis of this bone marrow sample shows a male having 46,XY[12] karyotype. There was no significant clonal chromosomal abnormality detected. Additionally, out of 15 cells analyzed, three cells with abnormal karyotypes [45,X,-Y; 45,XY,-13 and 45,XY,-15, respectively] were observed. No clinical significance can be ascribed to these non-clonal findings at the present time.
  • Note：
    • ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

2024-01-25 FLT3-D835 mutation (BM) Undetectable
2024-01-24 CMV viral load assay Target not detecetedIU/mL
2024-01-23 Aspergillus Ag Negative
2024-01-23 Aspergillus Ag Value 0.1 Ratio
2024-01-23 FLT3/ITD mutation (BM) Presence of mutation
2024-01-23 NPM1 mutation (qualit BM) Undetectable

2024-01-12 Anti-HCV Nonreactive
2024-01-12 Anti-HCV Value 0.12 S/CO
2024-01-12 Anti-HBc Reactive
2024-01-12 Anti-HBc-Value 6.70 S/CO
2024-01-12 Anti-HBs 463.82 mIU/mL
2024-01-12 HBsAg Nonreactive
2024-01-12 HBsAg (Value) 0.46 S/CO

[exam findings]

• 2024-02-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (137 - 56) / 137 = 59.12%
    • M-mode (Teichholz) = 58.9
  • Conclusion:
    • Dilated LA, LV, Ao
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Moderate MR
    • Mild TR, AR
• 2024-01-16, -01-15 CXR
  • S/P PICC catheter insertion via left forearm.
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right middle lung and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Patchy consolidation of both lung is noted. Please correlate with clinical condition to rule out Bronchopneumonia.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2024-01-15 Peripherally Inserted Central Catheter
  • Indication of PICC: acute leukemia for further chemotherapy
  • We perform PICC at cath room. Under the peripheral echo guiding, We successful pucnture left basilic vein. Under the fluroscopy revealed the wire in true lumin. Micro-sheath was advanced. PICC catheter tip advanced in high right atrial under the fluroscopy smoothly.
  • SvO2 was also check, it revealed 69 %.
    • Estimated Fick Cardiac index 3.89 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
    • Estimated Fick cardiac output 6.7 L/min. (nomral cardiac output range 5~6 L/min)
• 2024-01-15 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Acute myeloid leukemia and see descripton
  • The specimen submitted consists of a strip of gray-brown and hard bony tissue, measuring 2.2 x 0.3 x 0.3 cm. All for section after decalcification.
  • The sections show hypercellular marrow (90%). The marrow space is near totally replaced by a population of medium to large-sized immature cells with round to oval nucleus and moderate amount cytoplasm. The CD71+ erythroid precursors are markedly decrease (3%).
  • IHC, the immature cells shows CD34+ (80%), CD117+ (90%) MPO+ (30%) and CD163+ (30%). The finding is compatible with acute myelomonocytic leukemia. Suggest bone marrow smear evaluation and clinic correlation.
• 2024-01-15 SONO - abdomen
  • Diagnosis:
    • Parenchymal liver disease, with Splenomegaly, r/o early liver cirrhosis
    • Liver cysts
    • Renal stones, RK
    • Chronic kidney disease
    • Renal cyst, LK
    • Bilateral pleural effusion
• 2024-01-11 CXR
  • Cardiomegaly
  • Increased infiltration over both lower lungs. May be active infection.
  • R/O right pleural effusion.
  • Degenerative joint disease of T-spine with marginal osteophytes.

[MedRec]

• 2024-01-11 Medical Emergency Yang YaZhi
  • S
    • Acute leukemia was diagnosed in Cardinal Tien Hospital, bone marrow biopsy result pending.
    • Pancytopenia noted, BT with LPRBC 2U on 1/10, PLT 1PH on 1/11
    • no fever, no cough, no sputum, no SOB, no chest pain, no abd pain, no back pain, no dysuria
    • Past history: HTN
    • Surgical history: nil
    • Allergy: NKA
    • Exposure (TOCC): denied
    • Discharge medication:
      • Amlodipine 1# QD
      • Telmisartan 1# QN
      • Esomeprazole 1# QDAC
      • Tramol 1# BID
  • A
    • Preliminary impression: C95.90 Leukemia, unspecified not having achieved remission

[consultation]

• 2024-03-19 Gastroenterology

  • Q
    • For jaundice survery
    • This in a 72 y/o male with past history of HTN. This time, he was admitted due to AML and 3+7 induction regimen (1/16 ~ 1/22), follow by low dose Ara-C (2/23 ~ 2/27), Hydroxyurea (2/27~3/13), and Venclextax (3/13~) was prescribed.
    • RUQ abdominal tenderness and jaundice was ever noted 2 months ago. Lab data on 1/12 revealed elevated AST, ALT, ALP, GGT, total bilirubin, direct bilirubin, anti-HBc (+), HBsAg (-). Therefroe, Baraclude 0.5mg/tab 1# QDAC (1/15~) was prescribed. HBV DNA on 2/2 showed negative. After treatment, Follow up lab data on 3/5 showed AST, ALT, total bilirubin, direct bilirubin were all in upper normal limit.
    • Unfortunately, jaundice pregress was noted on 3/18 with total bilirubin 2.2 and Direct bilirubin 1.1
    • Therefroe, we need your expert for further survery of jaundice. Thank you.
  • A
    • Lab
      • 2024-03-18 AST 10 U/L
        
      • 2024-03-18 LDH 108 U/L
        
      • 2024-03-18 Bilirubin direct 1.10 mg/dL
        
      • 2024-03-18 Bilirubin total 2.20 mg/dL
        
      • 2024-03-18 CRP 16.4 mg/dL
        
      • 2024-03-18 ALT 19 U/L
        
      • 2024-03-16 Blast 88.6 %
        
      • 2024-03-16 Atypical Lymphocyte 0.0 %
        
      • 2024-03-16 Reticulocyte count 0.110 %
        
      • 2024-03-16 CRP 23.8 mg/dL
        
      • 2024-03-15 ALT 16 U/L
        
      • 2024-03-15 AST 9 U/L
        
    • Diagnosis:
      • Parenchymal liver disease, with Splenomegaly, r/o early liver cirrhosis
      • Liver cysts
      • Renal stones, RK
      • Chronic kidney disease
      • Renal cyst, LK
      • Bilateral pleural effusion
    • Low dose araC: (https://www.ncbi.nlm.nih.gov/books/NBK548291/)
      • Serum aminotransferase elevations occur in 5% to 10% of patients on conventional doses of cytarabine and a greater proportion (9% to 75%) at higher doses.
      • However, the serum enzyme elevations are rarely associated with symptoms and are generally self-limited and resolve rapidly, rarely requiring dose modification.
      • Cases of clinically apparent liver injury attributed to cytarabine have been reported but are uncommon.
      • The time to onset was usually within the first few cycles of therapy, and the pattern of serum enzyme elevations ranged from cholestatic to hepatocellular.
      • Immunoallergic and autoimmune features were generally not present.
      • Antineoplastic regimens, including cytarabine, have been implicated in cases of sinusoidal obstruction syndrome and peliosis, but the role of cytarabine in these reactions was unclear.
      • Many examples of liver injury attributed to cytarabine in the literature were typical of jaundice of sepsis rather than acute hepatocellular or cholestatic injury, although high doses of cytarabine may cause hyperbilirubinemia independent of hepatic injury.
    • Venclextax: (https://www.ncbi.nlm.nih.gov/books/NBK548460/)
      • In clinical trials in 240 patients with CLL, serum aminotransferase elevations occurred in 20% of subjects treated with venetoclax, but the elevations were generally transient, mild and not associated with jaundice or symptoms.
      • In the preregistration trials, no cases of clinically apparent liver injury attributed to venetoclax were reported and few patients required drug discontinuation for liver test abnormalities.
      • Since approval, venetoclax has had limited clinical use, but has not been implicated in cases of clinically apparent liver injury.
      • Venetoclax decreases total white blood cell counts and can cause lymphopenia in addition to neutropenia.
      • As a consequence, venetoclax may be capable of inducing immune reactions including reactivation of hepatitis B.
      • However, instances of reactivation have not been reported, but neither has detailed information on the effects of venetoclax on hepatitis B virus levels in patients with preexisting hepatitis B or evidence of previous infection.
    • Hydroxyurea: (https://www.ncbi.nlm.nih.gov/books/NBK548724/)
      • rare instances of acute hepatitis that can be severe and lead to hepatic failure and death have been described in patients taking hydroxyurea and antiretroviral therapy for HIV/AIDS.
      • This presentation is clearly different from the hepatitis that accompanies drug fever from hydroxyurea, and resembles acute viral hepatitis with marked elevations in serum aminotransferase levels and jaundice and only mild-to-moderate elevations in alkaline phosphatase.
      • Immunoallergic and autoimmune features are not usually present. Some cases have been fatal; others have been marked by slow, but ultimately full recovery.
      • The cases of severe hepatitis attributed to hydroxyurea have been described largely in patients with HIV infection on antiretroviral regimens that include agents associated with hepatotoxicity, but the addition of hydroxyurea appeared to be responsible for the liver injury, these patients later tolerating resumption of antiretroviral therapy without recurrence.
    • Impression
      • Mild hyperbilirubinemia, mixed type
      • D/D: intrahepatic cholestasis, medication related, sepsis related
      • Resolved HBV infection, with prophylactic antiviral therapy of entecavir under chemotherapy
    • Suggestion
      • arrange abdominal echo
      • complete liver function test, including ALP, rGT, ALB
      • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
      • Consider CT scan if there is abnormal biliary enzymes or suspicious lesion in ultrasound

• 2024-02-22 Rehabilitation

• 2024-01-16 Chest Medicine

• 2024-01-16 Infectious Disease

• 2024-01-15 Cardiology

  • Q
    • This is a 72-year-old male with acute leukemia. We need your help for one-way PICC insertion. Thank you very much.
  • A
    • This 72 y/o male is a case of acute leukemia for further chemotherapy. We perform PICC at cath room.
    • Under the peripheral echo guiding, We successful pucnture left basilic vein. Under the fluroscopy revealed the wire in true lumin. Micro-sheath was advanced. PICC catheter tip advanced in high right atrial under the fluroscopy smoothly.
      • SvO2 was also check, it revealed 69 %.
      • Estimated Fick Cardiac index 3.89 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
      • Estimated Fick cardiac output 6.7 L/min. (nomral cardiac output range 5~6 L/min)

[chemotherapy]

• 2024-02-23 - cytarabine 20mg/m2 32mg SC D1-10 (low dose Ara-C)

• 2024-01-16 - daunorubicin 45mg/m2 60mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 140mg NS 500mL 24hr D1-7 (20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL

Chemotherapy induction regimens for acute myeloid leukemia - 2024-01-22 - https://www.uptodate.com/contents/image?imageKey=HEME%2F78251

• Cytarabine plus daunorubicin
  • Dosing
    • Cytarabine: 100 to 200 mg/m2 daily as a continuous infusion for 7 days;
    • Daunorubicin: 60 to 90 mg/m2 intravenous push on each of the first 3 days of treatment
  • “Standard 7+3” induction regimen resulting in approximately 60 to 80% remission rate and acceptable toxicity in patients under 60 years old
• Cytarabine (HiDAC) plus daunorubicin
  • Dosing
    • Cytarabine: 1 to 3 g/m2 twice daily for a total of 12 doses;
    • Daunorubicin: 45 mg/m2 intravenous push for 3 days following cytarabine
  • Yields a 90% remission rate; however, substantial toxicity precludes post-remission therapy in a high proportion of patients
• Cytarabine plus idarubicin
  • Dosing
    • Cytarabine: 100 to 200 mg/m2 daily as a continuous infusion for 7 days;
    • Idarubicin: 12 to 13 mg/m2 IV push on each of first 3 days of treatment
  • Has produced a greater remission rate (88 versus 70%) than cytarabine/daunorubicin in younger patients; appears superior to daunorubicin in patients with hyperleukocytosis; overall survival not clearly superior to “standard” regimen
• CPX-351: Liposomal daunorubicin plus cytarabine in a fixed 5:1 molar ratio
  • Dosing
    • Daunorubicin (44 mg/m2) and cytarabine (100 mg/m2) intravenously over 90 minutes on days 1, 3, and 5
  • CPX-351 achieved superior rates of remission and survival with comparable toxicity, when compared with 7+3 in older patients with AML

==========

2024-03-26

[optimizing hydroxyurea dosage for effective AML cytoreduction]

Hydroxyurea is utilized for cytoreduction in acute myeloid leukemia, with oral doses ranging from 50 to 100 mg/kg/day to reduce WBC counts below 100K/uL, or 50 to 60 mg/kg/day to bring WBC counts down to 10K to 20K/uL.

For this patient weighing 51.2kg with a WBC count of 67K/uL, a daily dose between 2560mg and 3072mg is advised. Currently, the patient’s dosage of 1000mg BID (2000mg daily) may be insufficient, potentially diminishing the cytoreduction effectiveness or prolonging the time needed to achieve desired outcomes.

2024-02-01 (not posted)

FLT3-ITD mutations are found in 1/3 of AML cases, while FLT3-TKD mutations are found in approximately 10%. Laboratory results on 2024-01-23 showed FLT3-ITD (+), FLT3-TKD (-) and NPM1 (-). Wild-type NPM1 with FLT3-ITD (no adverse genetic lesion) is stratified as intermediate risk in the European LeukemiaNet stratification scheme. Rydapt (midostaurin) 50 mg BID is initiated on day 8 of the standard 7 + 3 schedule for 2 weeks, it follows the schedule without discrepancies.

2024-01-22

[progress in AML following chemotherapy]

On 2024-01-15, the patient’s peripheral blood blast percentage was nearly 100%, and a bone marrow biopsy revealed AML, indicated by CD34+ (80%), CD117+ (90%), MPO+ (30%), and CD163+ (30%). No FLT3 mutation was found in the recent HIS5 records.

A reduced dose of the standard 7+3 regimen (cytarabine + daunorubicin) commenced on 2024-01-16. One week later, the peripheral blood blast percentage decreased to 72%, indicating an ongoing response.

• 2024-01-22 Blast 72.9 %
  
• 2024-01-21 Blast 83.0 %
  
• 2024-01-20 Blast 90.4 %
  
• 2024-01-19 Blast 97.0 %
  
• 2024-01-18 Blast 91.3 %
  
• 2024-01-17 Blast 91.6 %
  
• 2024-01-16 Blast 99.0 %
  
• 2024-01-15 Blast 98.0 %
  
• 2024-01-14 Blast 95.0 %
  
• 2024-01-13 Blast 95.0 %
  
• 2024-01-11 Blast 94.0 %

A follow-up bone marrow examination is recommended between day 14 to 22 for further response assessment.

701245682

240326

==========

2024-03-26

[Ampholipad (amphotericin B liposome) preparation and administration]

To nurse practioner / primary nurse:

Incompatibility: Avoid mixing with saline solutions or other medications. Inappropriate solvents or solutions containing antibacterial agents can cause Liposome Amphotericin B to precipitate.

Dissolution: For each 50mg vial, add 12mL of sterile water for injection, shaking vigorously for 30 seconds to disperse and dissolve into a 4 mg/mL solution.

Dilution: Withdraw the reconstituted solution with a sterile syringe, attach a 5-micron filter (one per vial), and infuse the correct amount of D5W through the filter, diluting to a concentration of 1-2mg/mL (for infants and small children, dilute to 0.2-0.5mg/mL). In this case, 250mg should use 250mL D5W.

Administration: Administer via intravenous infusion over more than 120 minutes with an infusion pump.

Precaution: For patients experiencing infusion-related reactions like chills, fever, hypotension, nausea, etc., premedicate 30 to 60 minutes prior with a nonsteroidal (e.g., ibuprofen) ± diphenhydramine or acetaminophen with diphenhydramine or hydrocortisone. Administer meperidine for rigors during infusion.

700146954

240325

[exam findings]

• 2024-03-22 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 22) / 91 = 75.82%
    • M-mode (Teichholz) = 76
  • Conclusion:
    • Septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Prominent posterior mitral annulus calcification with trivial MR; mild PR.
    • Mild aortic root calcification with protruding atheroma (9.3 mm of thickness); mildly dilated proximal ascending aorta ( 33 mm).
    • Thick epicardial fat.
• 2024-02-02 MRI - pelvis
  • Clinical history: 87 y/o female patient with 86y, P4 (NSD), Adenocarcinoma of the uterine endocervix, stage T3bN0M0 (IIIB).
  • With and without contrast enhancement MRI: Pelvis:
    • There are multiple soft tissue nodules in the peritoneal cavity and along liver surface, r/o carcinomatosis.
    • S/P IUD in the uterine cavity.
    • Cystic tumor in the uterine cervix with markder hydrometra.
    • Heteregeneous cystic lesions in left adnexa, r/o ovarian metastasis.
    • Non-enhancing nodules in right kidney, up to 3.2cm, r/o renal cysts.
    • Outpouching lesions in the sigmoid colon, suggesting colon diverticula.
  • Impression:
    • Cervical cystic tumor with hydrometra.
    • Diffuse peritoneal carcinomatosis.
    • Heteregeneous cystic lesions in left adnexa, r/o ovarian metastasis.
    • R/O right renal cysts.
    • Sigmoid colon diverticula.
• 2024-01-23 SONO - gynecology
  • R/O CX mass? 61mmx48mm
  • R/O Pelvis mass 119mmx86mm
  • R/O LT Ovarian cyst
• 2023-11-28 CT - abdomen
  • History and indication: Malignant neoplasm of endocervix
  • Non-contrast CT of abdomen-pelvis revealed:
    • Clinical history of endocervical cancer. Some soft tissues in peritoneal cavity. Some LNs at peritoneal cavity.
    • Right renal cyst (3.2cm).
    • Colonic diverticula.
    • Umbilical hernia with fat herniation.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • Clinical history of endocervical cancer. Some soft tissues in peritoneal cavity r/o tumor seeding. Some LNs at peritoneal cavity.
• 2023-10-04 SONO - abdomen
  • There are several renal cysts on right kidney and the largest one measuring 3 cm in size.
• 2023-10-04 Pap Smear
  • 4. Atypical squamous cells (ASC-US)
• 2023-10-03 SONO - gynecology
  • EM 5.7mm
• 2023-07-10 CT - abdomen
  • No evidence of free air is noted at the subphrenic region.
  • No evidence of intra-abdominal absscess in the study.
• 2023-07-04 MRI - pelvis
  • With and without contrast enhancement MRI: Pelvis
    • Presence of IUD in the uterine cavity.
    • Diffuse soft tissue tumors in the uterine cavity and endocervical region.
      
    • Soft tissue enhancement in left ovary, r/o metastasis.
    • R/O right renal cyst 3.1cm.
    • Outpouching lesions in the sigmoid colon, suggesting colon diverticula.
  • Imaging Report Form for Cervical Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:____(N_value) M:____(M_value) STAGE:____(Stage_value)
  • Impression:
    • R/O cervical malignancy, left ovarian involvement, cstage T3N0M0.
    • R/O right renal cysts.
    • Sigmoid colon diverticulosis
• 2023-06-21 Patho - endometrium curreage/biopsy
  • Uterus, endometrium, D＆C — adenocarcinoma.
  • IHC stains: p16 (+), vimentin (-), Napsin-A (focal +), p53 (diffuse +), WT-1 (-), pattern in favor of endocervical origin. Please correlate with clinical and image findings.
• 2023-06-21 Patho - endocervix curretage/biopsy
  • Uterus, endocervix, ECC — adenocarcinoma.
  • IHC stains: p16 (+), vimentin (-), Napsin-A (focal +), p53 (diffuse +), WT-1 (-), pattern in favor of endocervical origin. Please correlate with clinical and image findings.
• 2023-06-20 SONO - gynecology
  • R/O CX mass? 30mmx30mm
  • R/O Endometrial thickening, EM 21.4mm
• 2021-03-24 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 36) / 105 = 65.71%
    • M-mode (Teichholz) = 65
  • Conclusion:
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function
    • Mild AV sclerosis and posterior mitral annulus calcification with trivial MR; trivial TR; mild PR.
    • Mildly dilated proximal ascending aorta (34 mm) with mild calcification.

[MedRec]

• 2023-07-11 SOAP Radiation Oncology
  • S:
    • For radiotherapy due to cervical carcinoma.
    • PI: Vaginal bleeding since 2023-6, with occasional pain of low pevic area. Her diagnosis was adenocarcinoma of the uterine endocervix, stage T3bN0M0 (IIIB).
    • Family history: (daughter: rectal cancer)
    • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
    • Personal Hx: DM (-); HTN (+)
    • Allergy (-)
    • Previous RT Hx: (-)
  • O:
    • ECOG: 2
    • PE: neck and bil SCF: neg; bil low limbs: no edema.
    • Gyn sono (2023-06-20): 1.R/O CX mass?: (30mmx30mm). 2. R/O Endometrial thickening,EM:21.4mm
    • CXR (2023-06-20): Emphysematous change of bilateral lungs. No cardiomegaly. Intimal calcification of thoracic aorta. Thoracic spondylosis.
    • Operation (2023-06-21): Endoemtrial thickening and cervical mass s/p dilatation and curretage + endocervical curettage
    • Pathology (S2023-12411, 2023-06-26): Uterus, endocervix, ECC — adenocarcinoma. IHC stains: p16 (+), vimentin (-), Napsin-A (focal +), p53 (diffuse +), WT-1 (-), pattern in favor of endocervical origin. Please correlate with clinical and image findings.
    • Pathology (S2023-12412, 2023-06-26): Uterus, endometrium, D＆C — adenocarcinoma. IHC stains: p16 (+), vimentin (-), Napsin-A (focal +), p53 (diffuse +), WT-1 (-), pattern in favor of endocervical origin. Please correlate with clinical and image findings.
    • MRI of pelvis (2023-07-06): 1. R/O cervical malignancy, left ovarian involvement, cstage T3N0M0. 2. R/O right renal cysts. 3. Sigmoid colon diverticulosis
    • CXR (2023-07-10): Cardiomegaly is noted. Tortous aorta with calcification is noted. Patent airway is found. Osteopenia of the bony structure is noted. Clear bilateral costophrenic angle is noticed.
    • Lab
      • 2023/07/04 CEA = 2.24 ng/mL;
      • 2023/07/04 CA125 = 72.2 U/mL;
  • A: Adenocarcinoma of the uterine endocervix, stage T3bN0M0 (IIIB)
  • P: Radiotherapy is indicated for this patient with the following indicators: FIGO stage IIIB
    • Goal: curative
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT and ICRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvis, and about 7000cGy or higher to the points A (or tumor bed area).
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family (daughter and daughter-in-law). They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2023-07-12.
• 2017-01-26 SOAP Cardiology Xu ShunYi
  • Diagnosis
    • HCVD, unspecified, without CHF [I11.9]
    • Heart failure,unspecified [I50.9]
    • Unspecified hypothyrodism [E03.9]
    • Pure hypercholesterolemia [E78.0]
    • OA, localized,not specified whether primary or secondary, lower leg [M17.9]
    • Anemia of other chronic illness [D63.8]
    • Other insomnia [G47.00]
    • Peptic ulcer, site unspecified,chronic or unspecified with perforation without mention of obstructio [K27.5]
    • Chronic airway obstruction (COPD),NEC [J44.9]
  • Prescription x3
    • Celebrex (celecoxib 200mg) 1# PRNQD
    • Coxine (isosorbide-5-mononitrate 20mg) 1# BID
    • Euricon (benzbromarone 50mg) 1# QD
    • Xanthium (theophylline 200mg) 1# QD
    • Foliromin (sodium ferrous citrate 50mg) 1# QOD
    • Blopress (candesartan 8mg) 1# QD
    • Eltroxin (thyroxine 50ug) 1.5# QDAC
    • Vytorin (ezetimibe 10mg, simvastatin 20mg) 0.5# HS

[consultation]

[surgical operation]

[radiotherapy]

• 2023-07-17 ~ 2023-09-20 - 4500cGy/25 fractions of the pelvic area, and 1 fractions of ICRT (RA: 426.65cGy; LA: 423.35cGy, TSGH), and 6660cGy/37 fractions of the tumor bed area, the total RA = 7086.65 cGy, LA = 7083.35 cGy

[chemotherapy]

• 2024-03-15 - paclitaxel 175mg/m2 235mg NS 250mL 4hr + carboplatin AUC 5 230mg NS 250mL 2hr (20% off)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-09-19 - NS 500mL 1hr (preCDDP) + cisplatin 30mg/m2 50mg NS 500mL 2hr + NS 500mL 1hr (postCDDP) (CDDP QW)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-22 - NS 500mL 1hr (preCDDP) + cisplatin 30mg/m2 50mg NS 500mL 2hr + NS 500mL 1hr (postCDDP) (CDDP QW)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-15 - NS 500mL 1hr (preCDDP) + cisplatin 30mg/m2 50mg NS 500mL 2hr + NS 500mL 1hr (postCDDP) (CDDP QW)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-08 - NS 500mL 1hr (preCDDP) + cisplatin 30mg/m2 50mg NS 500mL 2hr + NS 500mL 1hr (postCDDP) (CDDP QW)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-07-25 - NS 500mL 1hr (preCDDP) + cisplatin 30mg/m2 50mg NS 500mL 2hr + NS 500mL 1hr (postCDDP) (CDDP QW)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-07-18 - NS 500mL 1hr (preCDDP) + cisplatin 30mg/m2 50mg NS 500mL 2hr + NS 500mL 1hr (postCDDP) (CDDP QW)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-03-25

[grade 4 neutropenia following chemo (cefepime ongoing) - potential use of G-CSF]

The patient developed grade 4 neutropenia 1 week after receiving paclitaxel and carboplatin on 2024-03-15. Cefim (cefepime) is currently being administered.

• 2024-03-24 WBC 0.55 x10^3/uL

• 2024-03-23 WBC 0.60 x10^3/uL

• 2024-03-22 WBC 2.45 x10^3/uL

• 2024-03-14 WBC 7.25 x10^3/uL

• 2024-03-24 Neutrophil 1.7 %

• 2024-03-23 Neutrophil 10.4 %

• 2024-03-22 Neutrophil 76.9 %

• 2024-03-14 Neutrophil 80.0 %

Due to neutropenia, G-CSF may be considered to help increase white blood cell count.

2024-03-15

[navigating post-CCRT options: considering carboplatin/paclitaxel and the role of HER2 status]

This patient underwent concurrent chemoradiotherapy (CCRT), receiving 4500cGy/25 fractions targeting the pelvic area, along with one fraction of intracavitary radiotherapy (ICRT) delivering 426.65cGy to the right anterior (RA) and 423.35cGy to the left anterior (LA) at TSGH, and 6660cGy/37 fractions directed at the tumor bed area. The total radiation exposure amounted to 7086.65cGy for the RA and 7083.35cGy for the LA. Concurrently, cisplatin was administered. There were no subsequent records of carboplatin/paclitaxel treatment following the CCRT, according to the HIS5 database.

If there was no continuation with carboplatin/paclitaxel treatment at that time, it may now be considered as an option. Additionally, if the HER2 status is positive, incorporating trastuzumab into the treatment plan could also be contemplated.

700308779

240325

[exam findings]

• 2024-03-04 CT - abdomen
  • History and indication: Malignant neoplasm of endometrium
  • Non-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. Some LNs (up to 0.9cm) at paraaortic region. R/O metastases at right pelvic bone and pelvic muscles.
    • Liver cysts (up to 1.2cm).
• 2023-11-20 Tc-99m MDP bone scan
  • Two hot areas/spots in the right pubic and ischial bones, respectively, highly suspected cancer with bone metastases.
  • Suspected benign lesions in the nasal bone, sternum, some C-, T- and L-spine, bilateral shoulders, elbows, knees, and feet.
• 2023-11-13 CT - abdomen
  • S/P hysterectomy. Some LNs (up to 0.9cm) at paraaortic region.
  • Liver cysts (up to 1.2cm).
• 2023-08-23 PET
  • Increased FDG uptake in four lymph nodes, at least, in the left para-aortic space, highly suspected cancer with regional lymph nodes metastases, suggesting biopsy for investigation.
    
  • Increased FDG uptake in the right pubic and ischial bones, highly suspected cancer with bone metastasis.
    
  • Increased FDG uptake in the stomach, probably inflammation process or other nature, suggesting gastroscopy for investigation.
    
  • EM cancer s/p treatment, ycTxN2M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-08-12 CT - abdomen
  • Impression:
    • S/P hysterectomy.
    • R/O liver cysts.
    • Left paraaortic lymph node (up to 1.3cm), progression. Metastasis?
• 2023-05-11 SONO - gynecology
  • No obvious uterine or ovarian lesion
• 2023-05-04 SONO - nephrology
  • Bilateral small kidneys with chronic parenchymal changes.
• 2023-02-10 CT - abdomen
  • Findings:
    • S/P hysterectomy
    • Two hepatic cyst 1 cm in S2 and 0.7 cm in S6 are noted.
  • IMP:
    • S/P hysterectomy. There is no evidence of tumor recurrence.
• 2023-01-20 SONO - abdomen
  • Impression
    • Two hepatic cyst 1.4 cm in S1 and 1 cm in S6 are noted.
    • Two gallbladder polyp (< 4 mm) are noted.
    • Several cysts on both kidney (< 1 cm).
• 2022-11-10 SONO - gynecology
  • No obvious uterine or ovarian lesion
• 2022-09-13 MRI - lower abdomen
  • Impression:
    • S/P hysterectomy, suggest follow up.
    • Minimal ascites.
    • R/O liver and renal cysts.
• 2022-06-20 SONO - abdomen
  • Diagnosis:
    • Parenchymal liver disease
    • Hepatic cysts, right lobe
    • GB polyps
    • Parenchymal renal disease
    • Renal cyst, RK
• 2022-05-03 Patho - soft tissue tumor, extensive resction
  • PATHOLOGIC DIAGNOSIS
    • Uterus, endometrium, total hysterectomy — serous adenocarcinoma, high grade
    • Uterus, myometrium, total hysterectomy — serous adenocarcinoma, invading > 1/2 thickness of the myometrium and 0.7 cm from serosal surface.
      
    • Uterus, cervix, total hysterectomy — free
    • Ovaries and fallopian tubes, bilateral, BSO — free
    • Lymph node, bilateral pelvic, dissection — free
      
    • pT1b pN0 (if cM0); AJCC 8th edition Pathology stage: IB
      
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: laparoscopic GYN cancer staging surgery (laparoscopic total hysterectomy + bil salpingo-oophoretomy + bliateral pelvic lymphnode dissection + partial omentectomy) and adhesiolysis
    • Specimens include: 01. uterus and bilateral adnexae; 02. omentim; 03. left iliac lymph nodes; 04. left obturator lymph modes; 05. right iliac lymph nodes; 06.right obturator lymph nodes.
    • Specimen size:
      • uterus: 130 gms; 10.5 x 8.5 x 4.6 cm, GROSSLY, tumor 4.2 x 3.5 cm. Myoma 2 x 2 cm.
      • right ovary: 2.6 x 1.5 x 1.5 cm;
        
      • left ovary: 2.6 x 1.5 x 1.5 cm;
        
      • right tube: 4.5 x 1 x 1 cm;
        
      • left tube: 4.5 x 1 x 1 cm;
        
      • omentum: 11 x 5 x 2 cm.
    • Tumor site: endometrial fundus and body.
    • Tumor size: 4.2 x 3.5 cm cm
      
    • The myometrium : invaded by tumor; invading > ½ thickness of the myometrium and 0.7 cm from serosal surface.
      
    • The cervix : free of tumor, 3.0 cm away.
    • Adnexa: unremarkable
    • Lymph node: 03. left iliac lymph nodes; 04. left obturator lymph modes; 05. right ilia lymph nodes; 06.right obturator lymph nodes.
    • Tissue for sections: A1: cervix; A2: myoma; A3: left adnexa; A4: right adnexa; A5-8: tumor; B: omentum; C: left iliac lymph nodes; D: left obturator lymph modes; E: right iliac lymph nodes; F: right obturator lymph nodes.
  • MICROSCOPIC EXAMINATION
    • Histology type: Serous carcinoma
      
    • Histology grade: high grade
    • Depth of invasion: invade > 1/2 thickness of the myometrial wall
      
    • Uterine Serosa Involvement - Not identified
    • Cervical Stromal Involvement - Not identified
    • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Bilateral/ Right/ Left ovary - Free
      • Bilateral/ Right/ Left fallopian tube - Free
      • Omentum - Free
    • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
      • Ectocervical/Vaginal Cuff Margin: Free, 3.0 cm away
      • Parametrial/Paracervical Margin: Free
    • Lymphovascular Invasion: Absent
    • Regional Lymph Nodes: Free 0/15 = C: left iliac lymph nodes (0/7); D: left obturator lymph modes (0/3); E: right iliac lymph nodes (0/3); F: right obturator lymph nodes (0/2).
    • Additional Pathologic Findings - None identified
    • Ancillary Studies - result of S2022-06155: p53(diffusely strong +), p16(diffusely strong +), ER(+), WT1(-) and Napsin A (focal+).
• 2022-05-02 MRI - pelvis
  • With and without contrast enhancement MRI: Pelvis
    • Soft tissue tumor in the uterine cavity, mainly in fundus region, r/o endometrial malignancy.
    • There are T2 hypointensity tumor, up to 2.3cm, r/o uterine myomas.
    • No enlarged lymph node in the paraaortic region.
    • Presence of ascites.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • Impression:
    • R/O endometrial malignancy, cstage T1bN0M0.
    • Uterine tumor, r/o myoma.
• 2022-04-12 Patho - leiomyoma of uterus, myomectomy
  • PATHOLOGIC DIAGNOSIS
    • Uterus, endometrium, hysteroscopic myomectomy + endometrial curettage — Serous carcinoma
    • Uterus, myometrium, hysteroscopic myomectomy + endometrial curettage — Adenomyoma
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consists of multiple pieces of white firm soft tissue, measuring up to 2.5 x 1.0 x 0.4 cm. Representastive parts are taken for section as: A1-A3.
  • MICROSCOPIC EXAMINATION
    • The sections of endometrium show serous carcinoma, composed of polygonal neoplastic cells with marked cytological atypia, in glandular and papillary patterns. Tumor necrosis is present.
      • IHC, the tumor cells reveal: p53(diffusely strong +), p16(diffusely strong +), ER(+), WT1(-) and Napsin A(focal+).
    • The sections of myometrium show adenomyoma, composed of an admixture of morphologically benign endometrioid-type glands and smooth muscle.
• 2022-03-24 SONO - gynecology
  • R/O Endometrial thickening: (EM:33.7mm)
  • R/O Uterine myoma
• 2021-10-25 Patho - soft tissue nontumor/mass/lipoma/debridement
  • Tumor, left index, excision — Neurofibroma
    
  • Microscopically, the sections show a picture of neurofibroma characterized by haphazard spindle cells with small wavy or comma-shape nuclei within myxoid stroma.
  • Immunohistochemistry of SMA(-) and S-100(+) for tumor.

[MedRec]

[surgical operation]

[radiotherapy]

• 2024-01-12 ~ 2024-01-25 - 2000cGy/10 fractions of the right pubic and ischial bones.

[chemotherapy]

• 2024-03-13 - liposome doxorubicin 40mg D5W 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-12-20 - paclitaxel 60mg/m2 80mg NS 250mL 3hr + carboplatin AUC 2 150mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-28 - paclitaxel 60mg/m2 80mg NS 250mL 3hr + carboplatin AUC 2 150mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-21 - paclitaxel 60mg/m2 80mg NS 250mL 3hr + carboplatin AUC 2 150mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-07 - paclitaxel 60mg/m2 80mg NS 250mL 3hr + carboplatin AUC 2 150mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-31 - paclitaxel 60mg/m2 80mg NS 250mL 3hr + carboplatin AUC 2 150mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-03 - paclitaxel 60mg/m2 80mg NS 250mL 3hr + carboplatin AUC 2 150mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-19 - paclitaxel 60mg/m2 80mg NS 250mL 3hr + carboplatin AUC 2 150mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-06-15 - paclitaxel 160mg/m2 230mg NS 250mL 3hr + carboplatin AUC 5 280mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

==========

2024-03-25

[elevated CA-125 following paclitaxel and carboplatin therapy, monitoring cardiac function during liposomal doxorubicin treatment]

The patient underwent a chemotherapy regimen with paclitaxel and carboplatin from 2023-09-19 to 2023-12-20. Since 2023-12, a rapid increase in the CA-125 marker was observed, culminating in a historical peak of 535 on 2024-03-18.

• 2024-03-18 CA-125 (NM) 535.870 U/ml
• 2024-03-04 CA-125 (NM) 323.970 U/ml
• 2024-02-05 CA-125 (NM) 291.660 U/ml
• 2024-01-15 CA-125 (NM) 169.230 U/ml
• 2024-01-08 CA-125 (NM) 170.240 U/ml
• 2023-12-26 CA-125 (NM) 127.290 U/ml
• 2023-12-18 CA-125 (NM) 116.420 U/ml
• 2023-11-30 CA-125 (NM) 69.804 U/ml
• 2023-11-23 CA-125 (NM) 64.828 U/ml
• 2023-11-09 CA-125 (NM) 76.860 U/ml
• 2023-11-06 CA-125 (NM) 84.356 U/ml
• 2023-10-30 CA-125 (NM) 73.718 U/ml
• 2023-10-16 CA-125 (NM) 38.361 U/ml
• 2023-10-05 CA-125 (NM) 39.175 U/ml
• 2023-09-28 CA-125 (NM) 49.474 U/ml
• 2023-08-10 CA-125 33.000 U/ml
• 2023-05-05 CA-125 11.500 U/ml
• 2023-02-09 CA-125 5.700 U/ml

A new regimen involving liposomal doxorubicin was initiated on 2024-03-13. It is noted that there are no recent records of LVEF, so it’s recommended to assess left ventricular cardiac function before starting, as well as during and after the liposomal doxorubicin treatment.

700557035

240325

[exam findings]

• 2023-11-01 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (75.5 - 20.0) / 75.5 = 73.51%
    • M-mode (Teichholz) = 73.5
  • Conclusion:
    • Normal chamber size
    • Thickening of IVS and LVPW
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Mild MR, TR and PR
    • No regional wall motion abnormalities
• 2023-10-05 Patho - breast simple/partial mastectomy
  • PATHOLOGIC DIAGNOSIS
    • Tumor, right breast, frozen + partial mastectomy —- Invasive carcinoma of no special type with focal ductal carcinoma in situ, intermediate grade
    • Resection margins, frozen — Tumor involved at upper margin, other margins are free
    • Margin, 9 o’colck, re-excision — Free of tumor invasion
      
    • Sentinel lymph node, R’t axillary, frozen — Micrometastasis (1/2)
    • Lymph node, R’t axillary level I and II, dissection — Free of tumor metastasis (0/15)
    • Skin of R’t breast — Free of tumor invasion
    • AJCC Pathologic Anatomic Stage — pT1cN1mi, if cM0, stage IB; Prognostic Stage — Stage IA
  • MACROSCOPIC EXAMINATION
    • Breast size: 7 x 6.2 x 3 cm
    • Skin size: 2.8 x 0.6 cm
    • Nipple: Not received
    • Tumor: 1.4 x 1.2 cm
    • Resection margins: Free, tumor involved at upper margin, 2.3 cm from base and at least 1.2 cm from peripheral margins
    • Lymph node: R’t axillary sentinel and non-sentinel (level I + II) lymph nodes
    • 9 o’clock recut breast margin: 3.9 x 2.3 x 1.5 cm with ink
    • All embedded for sections as A1-A4: 9 o’clock margin re-excision, B1-B3: R’t axillary level I and II LNs [Reference: F2023-00441 frozen section, FSA: R’t axillary sentinel lymph nodes, FSB: tumor + upper margin (ink), A1: 3 (blue ink) + 6 (green ink) + 9 (orange ink) + 12 o’clock + base (yellow) margins, A2 -A3: tumor, A4: tumor + skin]
  • MICROSCOPIC EXAMINATION
    • Histologic type: invasive carcinoma of no special type with focal ductal carcinoma in situ, intermediate grade
      
    • Size of invasive carcinoma: 1.4 x 1.2 cm
    • Histologic grade (Nottingham histologic score): Grade III (score 8) including [(A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 3 and (C) Mitotic count: score 2]
    • Margins (frozen + re-excision): free of tumor invasion, 2.3 cm from base and at least 1.2 cm from peripheral margins
    • Nodal status:
      • R’t axillary sentinel lymph node: micrometastasis (1/2)
      • R’t axillary level I and II lymph node: free of tumor metastasis (0/15)
    • Treatment Effect: N/A
    • Lymphovascular space invasion: identified
    • Perineural invasion: identified
    • Immunohistochemistry: please refer to S2023-17624
    • Stromal tumor-infiltrating lymphocytes (TILs): 10%
• 2023-10-04 Lymphoscintigraphy
  • Probably one sentinel lymph node at the right axillary region.
• 2023-09-19 Tc-99m MDP bone scan
  • Increased activity in the L4 spine. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Prominently increased activity in the right knee. The nature is to be determined (severe degenerative change? other nature?). Please correlate with other clinical findings and follow up bone scan for further evaluation.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and feet, compatible with benign joint lesions.
• 2023-09-15 CT - chest
  • Spiculated nodule at right outer breast measuring 1.15cm in largest dimension. (Se301 Im32). Breast cancer is considered.
  • Non-specific lymph nodes are found at right axillary region.
• 2023-09-04 Patho - breast biopsy (no need margin)
  • Breast, right, 9/2, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (+, 100%, STRONG intensity), PR (+, 70 %, STRONG intensity), Her2/neu: positive (score=3+), Ki-67 (20%), P63 (-), E-cadherin (+).
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2023-08-25 SONO - breast
  • Diagnosis: Highly suspicious of malignancy, with sonographic negative axillary LNs
  • Treatment: Core-needle biopsy
  • Suggestion: Regular OPD follow-up
  • BI-RADS: 4A - low suspicion for malignancy Biopsy Should Be Considered
• 2023-08-17 Mammography
  • Hyperdense spiculated tumor, 1.6cm in UOQ of right breast(anterior third portion), r/o malignancy, suggest biopsy.
    
  • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.

[MedRec]

• 2023-10-27 SOAP Cardiology Duan DeMin
  • Prescription x3
    • Exforge (amlodipine 5mg, valsartan 160mg)
    • Syntrend (carvedilol 25mg)
• 2023-10-19 SOAP Hemato-Oncology
  • S
    • For further managemenet of breast cancer
    • Hx of ovary cancer s/p OP 44 y/o
    • Anti-HBs (+), Anti-HBc (+), HBs (-), Anti-HCV (-)
  • A/P
    • right breas cancer, HER-2 type, pT1cN1miM0, stage IB
    • refer to oncologist for following R/T and C/T
    • Plan:
      • AC x 4 -> TH(P)
      • R/T
    • Hormonal therapy and H(P) upto 1 year
    • Admission for heart echo -> C/T AC x 4 then TH(P)
    • OP for Port-A on 2023-10-31
• 2023-10-03 ~ 2023-10-09 POMR General and Digestive Surgery
  • Discharge diagnosis
    • Right beast cancer, cT1cN0M0, stage IA. IHC stains: ER (+, 100%), PR (+, 70 %), Her2/neu: positive (score=3+), Ki-67(20%) status post partial mastectomy and axillary lymph node dissection on 2023/10/04. ECOG：0
    • Hypertension
  • CC
    • diagnosed with abnormal under mammography by health examination.
  • Presnet illness
    • This 57-year-old female patient has past history of
      • hypertension over 4-5 years without irregular medicine control about for 1 years
      • ovarian cancer, stage 0 post abdominal total hysterectomy for 11-12 years ago.
    • She denied any TOCC histories in recent 3 months.
    • She was diagnosed with abnormal under mammography by health examination. She came to our OPD for help on 2023/08/25. Breast sono showed highly suspicious of malignancy with sonographic negative axillary LNs, Right 9 o’clock / 2 cm, size:1.01 x 1.19 x 1.37 cm.
    • Guide biopsy was performed. Pathology revealed invasive carcinoma, ER (+, 100%), PR (+, 70 %), Her2/neu: positive (score=3+), Ki-67 (20%).
    • The tumor marker showed CA-153：34.844 U/ml, CEA：1.972 ng/ml.
    • Tc-99m MDP whole body bone scan and chest CT showed no obvious lesion for metastasis.
    • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
    • PE: symmetrical of bilateral breasts. A hard, non-tender, fixed mass and irregular margin at right breast around 2x2 cm without discharge. The nipple was no dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulitis change, no lymph nodes at right axilla.
    • Under the impression of right breast invasive carcinoma. After fully explaination the treatment of surgical method at OPD.
    • This time, she was admission for surgery of partial mastectomy + sentinel lymph node biopsy.
  • Course of inpatient treatment
    • After admission, right breast partial mastectomy and ALND was perfromed on 2023/10/04. The post-operative course was relatively smooth without complication. The wound is clean and dry and the wound pain was tolerable. The final pathology report is pending.
    • Under the stable condition, she was discharged with remove jp drain x2 today and re-follow at OPD.
  • Discharge diagnosis
    • Acetal (acetaminophen 500mg) 1# QID
    • Norvasc (amlodipine 5mg) 1# QD
    • Diovan (valsartan 160mg) 0.5# QD

[surgical operation]

• 2023-10-04
  • Surgery
    • partial mastectomy and ALND      
  • Finding
    • right 9/2 tumor, CNB: IDC
    • SLNB: micrometastasis, 1/2

[immunochemotherapy]

• 2024-03-23 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 130mg NS 250mL 1hr
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2024-02-27 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 130mg NS 250mL 1hr
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2024-02-03 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 130mg NS 250mL 1hr
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2024-01-12 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-22 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-24 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-01 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-02-27

[reconciliation]

Throughout this hospitalization, the patient has maintained stable vital signs. Lab tests obrained on 2024-02-26 revealed grossly normal readings. Based on these findings, no contraindications to the administration of trastuzumab plus docetaxel were identified. Additionally, a review of the HIS5 and PharmaCloud revealed no discrepancies.

701176274

240325

[exam findings]

• 2024-03-22 - MRA - brain
  • Old small infarcts at right frontal region and bil. basal ganglia.
  • Brain atrophy.
  • R/O bony metastases at skull base and C1.
• 2024-03-22 CT - brain
  • Osteoblastic change of bony structures r/o metastases.
  • Brain atrophy.
• 2024-03-22 ECG
  • Sinus tachycardia
  • T wave abnormality, consider anterior ischemia
  • Abnormal ECG
• 2024-03-22 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Clinical history of prostate cancer.
    • Poor enhancing lesions (up to 2.6cm) in both hepatic lobes.
    • Much stool retention in colon.
    • Right minimal pleural effusion. Partial consolidation of bil. basal lungs.
    • Some osteoblastic lesions in bony structures.
    • S/P cholecystectomy. R/O tiny stones in CBD.
    • Right renal cyst (1.5cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • Prostate cancer with liver and bony metastases.
    • Much stool retention in colon.
    • Partial consolidation of bil. basal lungs.
    • R/O tiny stones in CBD.
• 2023-08-12 CT - brain
  • Brain atrophy.

[consultation]

• 2023-08-15 Infectious Disease
  • A
    • This is a case of pneumonia with respiratory failure.
      • Cr: 0.82, WBC: 19350, CRP: 20.6
      • Current antibiotcs with brosym and cubicin.
    • Please consider zyvox or vancomycin before the use of cubicin to cover MRSA infection.
    • Please adjust antibiotic according to culture results and clinical conditions.
    • Arrange abdominal sono and CV-echo as infectious survey.
• 2023-05-17 Hemato-Oncology
  • Q
    • For prostate cancer further care.
    • This 82-year-old male has past history of Type 2 DM and prostate cancer s/p RT with bone meta for 10 years at NTUH OPD follow, under Xtandi (enzalutamide) treatment.
    • This time, he suffered from conscious drowsy with poor appetite and poor intake for 2 weeks. Thus, he was brought to our ER for help.
    • At ER, vital signs showed TPR: 36.9’C/126bpm/22, BP: 114/56 mmHg; Con’s: E3V5M6, SpO2: 94%.
    • Laboratory data revealed leukocytosis (WBC:15.99 x10^3/uL), hypergalycemia (Glucose: 299 mg/dL ), elevated hs-Troponin I (2399.3 pg/mL) and impaired renal function (creatinine: 1.68 mg/dL).
    • Chest X-ray showed bilateral lower lobe pneumonia. 12 lead EKG showed sinus tachycardia.
    • Under the impression of pneumonia, she was admitted to our ward for further evaluation and treatment.
      
    • After admitted, he received NG tube placement and empirical antibiotic with cefotaxime for pneumonia control.
    • We need your expertise to evaluate for prostate cancer further evaluation, sincerely thanks!
  • A
    • This 82 year old man is a case of DM, prostate cancer s/p RT, with bone meta for 10 years and follow up at NTUH OPD under ADT + enzalutamide treatment. He was admiited for suspect pneumonia. We are consulted for prostate cancer evaluation.
    • Keep enzalutamide if no contraindication. Please follow up PSA, testosterone. Thanks for your consultation.
• 2023-05-17 Metabolism and Endocrinology
  • Q
    • After admitted, NG tube placement with NG DM diet 1200Kcal/day was perscribed.
    • OHA with Metformin 500mg 2# BID, Actos 30mg 1# QD, Jardiance 10mg 1# PO for DM control.
    • Finger sugar arround 206-401.
    • We need your expertise to evauate, sincerely thanks!
  • A
    • This 82-year-old male, with past history of type 2 DM and prostate cancer s/p RT with bone meta for 10 years at NTUH OPD follow, was admitted due to bilateral lower lobe pneumonia. We were consulted for blood sugar control.
    • O:
      • BW: 53.15 kg
      • Diet: NG, DM diet 1200 kcal/day
      • Medication in OPD: Ryzodeg, Metformin, Glyxambi, Actos
      • Medication during hospitalization: Metformin, Actos, Jardiance
      • Na: 158, K: 4.2
      • ALT: 18
      • BUN/Cr: 33/0.90 (eGFR: 85.86)
      • F/S: 5/14 5/15 5/16
        • QDAC 288 273 214
        • QLAC 356 400 350
        • QNAC 373 436
        • HS 376 342
      • HbA1c: unavailable
      • Urine ACR: unavailable
      • OPH OPD: nil
    • A:
      • Type 2 DM, poor control
    • Suggestions:
      • Avoid all OADs at this moment
      • RI 7U TIDAC with correction scales
        • F/S < 80，RI hold
        • F/S 081~090，RI -2U
        • F/S 091~100，RI -1U
        • F/S 201~250，RI +1U
        • F/S 251~300，RI +2U
        • F/S 301~350，RI +3U
      • Tresiba 12U HS (F/S HS < 140, let the patient eat a simple snack before going to bed. Tresiba will not be reduced.)
        • F/S QDAC < 100 (for 1 day), Tresiba -2U
        • F/S QDAC > 140 (for consecutive 3 days), Tresiba +2U
      • Check HbA1c, lipid profile, urine ACR
      • Contact us if needed. I’d like to follow up this patient.
• 2023-05-07 Cardiology
  • Q
    • Hx of prostate ca with bone metastasis, DM, post cholecystectomy -A
    • The patient was examined and hx was reviewed.
    • PH of DM with OHA control; prostate ca with bone metastasis s/p R/T + hormone therapy in NTUH;
      • general weakness for 2-3 weeks and fall episode;
      • drowsy consciouness for 1 week; no definite chest pain or dyspnea;
      • denied hypnotic or anti-depressant agent use;
    • PE
      • arousable; SBP 110+ mmhg;
      • atypical diffuse ST elevation at precordial leads; no evolutional changes;
      • bed side 2D echo: apical akinesia with hyperkinetic basal-mid wall of LV; visually preserved global LV systolic function;
      • leukocytosis with left shift; metabolic acidosis+; elevated blood osmolarity;
    • Imp
      • Suspected stress cardiomyopathy.
      • Consciousness disturbance, cause?
      • DM poor control
      • Prostate ca with bone metastasis;
      • Fall episode
    • Suggestion
      • U/A, U/C for infection study.
      • Check Ca level.
      • May arrange brain CT for weakenss and consciousness disturbance to rule out CNS lesion.
      • Arrange formal 2D echo study after admission.
      • Please ask his family members to apply for ECGs from NTUH.

==========

2024-03-25

[switching medications for tube feeding: Urief replaces Harnalidge, Urotrol FC for Oxbu ER]

Harnalidge OCAS (tamsulosin 0.4mg): Due to its formulation, Harnalidge isn’t suitable for tube feeding. Therefore, it is recommended transitioning to Urief (silodosin 8mg) as a more appropriate alternative to manage the patient’s condition.

Oxbu ER (oxybutynin 5mg): Since this is an extended-release medication, it might not be ideal for tube feeding. Urotrol FC (propiverine) could be a better option for this situation. (Ref: Propiverine compared to oxybutynin in neurogenic detrusor overactivity–results of a randomized, double-blind, multicenter clinical study. Eur Urol. 2007 Jan;51(1):235-42. doi: 10.1016/j.eururo.2006.03.016.)

701502074

240325

[exam findings]

• 2024-03-21 CTA - brain (head, neck)

  • Necrotic soft tissue/tumor at right orohypopharyx walls, with free air, around right hyoid bone.
  • But, no active contrast extravasation was noted.
  • No pseudoaneurysm was found.
  • Mild narrowing of right cervical ICA, around carotid bifurcation.

• 2024-03-21 CXR

  • No active lung lesion.
  • Mild cardiomegaly.
  • Tortuous thoracic aorta with intimal calcification.
  • Thoracic spondylosis.
  • S/P port-A insertion via right subclavian vein.

• 2023-12-28 ECG

  • Atrial fibrillation with rapid ventricular response
  • Abnormal ECG

• 2023-11-16

  • Atrial fibrillation
  • Abnormal ECG

• 2023-11-01 MRI - larynx

  • Neck MRI without/with Gadolinium-based contrast enhancement shows:
    • well-enhancing mass with ulceration at right lateral wall and posterior wall of oropharynx, extending down to posterior wall of hypopharynx, oropharyngeal and hypopharyngeal cancer is compatible. It measures about 6.0cm in greatest dimension in coronal plane. T3 disease is favored.
    • enlarged lymph nodes at left retropharyngeal area and right level IIb. N2 disease is favored.
    • no abnormal bone marrow signal lesion.
  • Impression:
    • Oropharyngeal and hypopharyngeal cancer, favor T3N2.
  • Oropharnx p16(+)
    • Impression (Imaging stage): T: 3(T_value) N: 2(N_value) M: 0(M_value) STAGE: II(Stage_value)

• 2023-10-24 Patho - stomach biopsy

  • Stomach,antrum, biopsy — Helicobacter-associated non-atrophic chronic gastritis

• 2023-10-23 CT - neck

  • With and Without contrast Neck CT showed
    • heterogeneous enhancing and thickened mucosa from the right lateral wall and bilateral posterior wall of the oropharynx to the bilateral posterior wall of the hypopharynx
    • a necrotic lymph node, about 15mm, in the left retropharyngeal space
    • nodular lesions in the bilateral thyroid glands.
  • IMP:
    • extensive nucosal thickening from the right lateral wall and posterior wall of the oropharynx to the posterior wall of the hypopharynx
    • a necrotic lymph node in the left rtropharyngeal space.

• 2023-10-23 SONO - abdomen

  • Impression:
    • Calcified spot in right lobe liver.
    • Gallbladder polyp.
    • Bilateral renal cysts.

• 2023-10-23 EGD

  • Diagnosis:
    • Suspected hypopharngeal cancer, right side
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis
    • Gastric shallow ulcers, ulcer scars and erosions, low body and antrum, s/p CLO test and biopsy at prepyloric antrum, LC.
  • CLO test: Positive

• 2023-10-20 PET

  • A glucose hypermetabolic lesion involving the right oropharyngeal wall and posterior pharyngeal wall, compatible with primary malignancy in this region.
  • Glucose hypermetabolism in a left retropharyngeal lymph node and some right neck level II lymph nodes. Metastatic lymph nodes may show this picture.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.

• 2023-10-19 Patho - gingival/oral mucosa biopsy

  • Labeled as “right lateral pharyngeal wall”, punch biopsy — squamous cell carcinoma. IHC stains: CK5/6 (+), p40 (+), p16 (+, > 70%).
  • Section shows squamous cell carcinoma. IHC stains: CK5/6 (+), p40 (+), p16 (+, > 70%).

• 2023-10-19 Nasopharyngoscopy

  • Oropharynx: R tonsil and post. pharyngeal wall ulcerative tumor
  • Scope: smooth NPx, HPx
  • bil vocal cord uneven surface

[MedRec]

• 2024-01-01 ProgressNote
  • Problem #1: Squamous cell carcinoma of the right and posterior oropharyngeal wall, p16 (+, > 70%), AJCC, 8th, stage cT3N2M0 (prognostic stage II)
    • Assessment:
      • severe dysphagia
      • hold R/T since 12/27
      • CRP 8.1 mg/dL
      • WBC 600 uL
      • PLT 44000 uL
      • port-a insertion on 12/29
      • OB 2+, clear urine bacteria 1+
    • Plan:
      • pending for blood culture
      • Filgrastim (G-CSF) 300 mcg QD for three days 12/28-12/30
      • empirical antibiotic with Cefim 2000 mg Q12H 12/28-
      • Actein Effervescent 1# BID for sputum
      • MgO 1# TID, through 1# HS for constipation
      • fluid supplement with TPN since 12/29, check finger sugar Q6H
      • consult GI for PEG, hesitate
  • Problem #2: DM, CKD, BPH, A-fib, AMI 7 years ago s/p stent x5
    • Assessment:
      • unable to take oral medications for one week
      • The patient and his family have been informed of the risks of stopping oral medication, and they all expressed their understanding.
    • Plan:
      • Doxaben 1# QD, hold if BP < 110
      • Concor 1# QD, hold if BP < 110
      • Pentop 1# BID
      • Feburic 0.5# QD
      • Canaglu 1# QDAC
      • Crestor 1# QD
      • Bokey 1# QD
      • Ulstop 1# QD
      • Ezetrol 1# QD
• 2023-10-27 SOAP Oral and Maxillofacial Surgery Xia YiRang
  • S: He is referred by Dr. Huang becuause of throat cancer and in the process of radiation therapy.
  • O: under-bridge caries of #31 and #41 with local inflammation are noted. Poor long bridge is noted. gingivitis and gingival recession of residual teeth are noted. no crown and no wisdom teeth are noted.
  • A:
    • under-bridge caries of #31 and #41 with local inflammation
    • Hypertension, heart disease, anticoagulants (Keelung ChangGung). Laryngeal cancer.
  • P
    • His panoramic film showed periodontal bone loss and no bone lesion.
    • Explain the finding and treatment plan to the patient and his family memberes
    • Debridement and curetage at the right mandible to remove food debris and necrotic tissue
    • premedication before tooth extraction
    • oral hygiene instruction and closely follow up.
• 2023-10-26 SOAP Radiation Oncology Huang JingMin
  • S: For CCRT due to oropharyngeal carcinoma.
    • PI: The patient suffered from sore throat and swallowing difficulty since 2023-01. Under the impression of squamous cell carcinoma of the right and posterior oropharyngeal wall, p16 (+, >70%), AJCC, 8th, stage cT3N2M0 (stage III), he was referred for CCRT.
    • Family history: (gastric carcinoma)
    • Cancer site specific factors: Alcohol (+); Smoking (+); Betel nut (-).
    • Personal Hx: DM (+); HTN (+)
    • Previous RT Hx: (-)
  • O: ECOG: 1
    • PE: neck and bil SCF: neg.
    • CXR (2023-10-19): No cardiomegaly. No active lung lesion. Tortuosity of the aorta with atherosclerotic change. Degenerative joint disease of T-spine with marginal osteophytes.
    • PET (2023-10-20): 1. A glucose hypermetabolic lesion involving the right oropharyngeal wall and posterior pharyngeal wall, compatible with primary malignancy in this region. 2. Glucose hypermetabolism in a left retropharyngeal lymph node and some right neck level II lymph nodes. Metastatic lymph nodes may show this picture.
    • Abd sono (2023-10-23): 1. Calcified spot in right lobe liver. 2. Gallbladder polyp. 3. Bilateral renal cysts.
    • CT scan of neck (2023-10-23): 1. extensive nucosal thickening from the right lateral wall and posterior wall of the oropharynx to the posterior wall of the hypopharynx. 2. a necrotic lymph node in the left rtropharyngeal space.
    • Pathology (S2023-20804, 2023-10-24): Labeled as “right lateral pharyngeal wall”, punch biopsy — squamous cell carcinoma. IHC stains: CK5/6 (+), p40 (+), p16 (+, > 70%).
  • A: Squamous cell carcinoma of the right and posterior oropharyngeal wall, p16 (+, > 70%), AJCC, 8th, stage cT3N2M0 (stage III)
  • P: CCRT is indicated for this patient with the following indicators: stage T3N2M0
    • Goal: curative
    • Treatment target and volume: oropharyngeal wall tumor to bilateral neck.
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 5000cGy/25 fractions of the oropharyngeal to bilateral neck, and 7000cGy/35 fractions of the oropharyngeal tumor bed and involved nodal lesions. The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-11-02.
    • Refer to Dental OPD for pre RT dental evaluation and management.
• 2023-10-26 SOAP Ear Nose Throat Su WangYu
  • S: 2023/10/26 R para-ph ca (SCC, p16+) + L retro-ph LN(+) = cT3N2M0 (stage II), PET = bil neck+
  • O:
    • 2023/10/24 PATHO - stomach biopsy
      • Stomach, antrum, biopsy — Helicobacter-associated non-atrophic chronic gastritis
    • 2023/10/23 CT: Neck
      • extensive nucosal thickening from the right lateral wall and posterior wall of the oropharynx to the posterior wall of the hypopharynx
      • a necrotic lymph node in the left rtropharyngeal space.
    • 2023/10/19 PATHO - Gingival/oral mucosa biopsy
      • Labeled as “right lateral pharyngeal wall”, punch biopsy — squamous cell carcinoma.
      • IHC stains: CK5/6 (+), p40 (+), p16 (+, >70%).
  • Prescription
    • Acetal (acetaminophen 500mg) 1# Q6H
    • Lindacin (clindamycin 150mg) 2# Q6H
    • Mefno (mephenoxalone 200mg) 1# BID
    • Parmason Gargle Solution (chlorhexidine) TID GAR

[consultation]

• 2024-03-21 Ear Nose Throat
  • Q
    • hematemesis and dizziness since 3 days ago
    • general malaise and poor appetite
    • the patient vomited a lot of blood this morning
    • denied cough and fever
    • denied abdominal pain and diarrhea
    • Past history: Squamous cell carcinoma of the right and posterior oropharyngeal wall, p16 (+, > 70%), AJCC, 8th, stage cT3N2M0 (prognostic stage II) s/p CCRT.
    • DM, CAD s/p stent, HTN, CKD.
    • Allergy: denied
    • s/p TAZOCIN 2024/03/18~ Keelung CGMH
    • IMP: Mass lesion in right oropharynx down to right hypopharynx (72 mm) with necrosis, ulceration and a suspicious tiny foreign body (3.5 mm) C/W cancer, no enlarged nodes in bil. neckNo active bleedingCalcified coronary arteries as CADs. Wall thickening along greater curvature of stomach (13.6 mm). Incidental finding of engorged left superior ophthalmic vein (7 mm), follow up suggested.
    • Hemoglobin 9.1 g/dL
  • A
    • S
      • Intermittent hematemesis since 4-5 days ago. 1 episode of syncope? previously
      • choking(-). dyspnea(-), odynophagia(-), dysphagia(+/-)
    • O
      • PHx:
        • CKD3, DM, HT, CAD 3-vessel-disease s/p stenting under Bokey (D/C for 5 days)
      • Right para-pharyngeal SCC, p16, cT3N2M0 (stage II), s/p CCRT, RT completed at 20240208 and hold chemotherapy chemo due to low WBC (20231219) (20231226)
      • Local finding:
        • Fair oral cavity without visible bloody content of mass lesion
        • Portable scope:
          • Bil narrow nasal cavity. Fair NPx.
          • Mass lesion extending mainly in superior to inferior direction at right parapharyngeal wall at level of oropharynx, with minimal fresh blood but no prominent active bleeder
          • Fair hypopharynx and adequate airway during examination
    • A
      • Suspect oropharyngeal tumor bleeding
    • P
      • Discontinue anti-platlet as current strategy
      • Keep current hemoclot, blood transfusion and supportive care, could try bosmin inhalation.
      • Consider CTA for occult, persistent tumor bleeding
      • Keep monitoring airway and consider intubation if sudden massive bleeding and compromise airway were noted.
      • Return to ENT Dr.Su’s OPD after discharge

[radiotherapy]

• 2023-11-24 ~ 2024-01-18 - 5000cGy/25 fractions (6MV photon) of the oropharyngeal to bilateral neck, and 7000cGy/35 fractiond of the oropharyngeal tumor bed and involved nodal lesions.

[chemotherapy]

• 2024-01-16 - carboplatin AUC 2 150mg D5W 250mL 1hr + NS 500mL 1hr (after carboplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + NS 250mL
• 2024-01-09 - carboplatin AUC 2 150mg D5W 250mL 1hr + NS 500mL 1hr (after carboplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + NS 250mL
• 2023-12-12 - carboplatin AUC 2 150mg D5W 250mL 1hr + NS 500mL 1hr (after carboplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + NS 250mL
• 2023-12-05 - carboplatin AUC 2 150mg D5W 250mL 1hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-28 - carboplatin AUC 2 150mg D5W 250mL 1hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-21 - carboplatin AUC 2 150mg D5W 250mL 1hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2024-03-25

[assessing leukopenia risks beyond chemotherapy effects]

The most recent CCRT, which utilized carboplatin, concluded in late Jan / early Feb 2024.

Despite this, the patient is currently experiencing rapidly developing leukopenia, an occurrence unlikely to be induced by the CCRT due to the nearly 2-month gap since its completion.

• 2024-03-25 WBC 2.87 x10^3/uL
• 2024-03-23 WBC 3.75 x10^3/uL
• 2024-03-21 WBC 5.18 x10^3/uL

The administration of piperacillin on 2024-03-18 at KeeLung CGMH (according to PharmaCloud database) is suspected to be a possible cause, as myelosuppression, particularly neutropenia, is a known side effect of this drug.

Should the WBC count continue to decrease, the use of G-CSF may be considered to counteract this effect.

2024-01-02

Culture results from both sputum and urine samples collected on 2023-12-29, reported on 2024-01-01, revealed mixed normal flora and less than 1000 CFU/mL, respectively. This, along with the declining CRP level, might suggest a positive response to ongoing cefepime 2000mg Q12H therapy.

• 2024-01-02 CRP 3.3 mg/dL
• 2023-12-28 CRP 8.1 mg/dL

Additionally, G-CSF administered since 2023-12-28 has effectively mitigated the leukopenia.

• 2024-01-02 WBC 2.12 x10^3/uL *
• 2023-12-28 WBC 0.60 x10^3/uL ***
• 2023-12-25 WBC 0.98 x10^3/uL ***
• 2023-12-18 WBC 2.67 x10^3/uL *
• 2023-12-11 WBC 4.12 x10^3/uL
• 2023-12-04 WBC 5.67 x10^3/uL
• 2023-11-28 WBC 5.23 x10^3/uL
• 2023-11-16 WBC 6.13 x10^3/uL
• 2023-10-19 WBC 6.45 x10^3/uL

No medication discrepancies were identified during reconciliation.

700052492

240322

[exam findings]

• 2024-03-16 Nasopharyngoscopy
  • edema bil AE fold and much salive around esophageal orifice
• 2024-03-06 SONO - abdomen
  • Parenchymal liver disease
• 2024-02-20 CTA brain (head, neck)
  • Indication: hypopharyngeal cancer, cT2N0M0, stage II (diagnosed on 2020/08/04), with neck recurrence s/p CCRT and C/T. right neck mass lesion with reddish and icthing about 6x3cm for 10-12 days. R/O disease progression
    • for R/O carotid vessel related bleeding
  • Findings:
    • LAPs at right neck, level III-IV, up to 5.6 cm, central necrotic change was noted, with intervally enlarged size.
    • Involvement of right common carotid artery with irregular wall by the tumor. Inpending carotid blow-out syndrome. No active contrast extravasation.
• 2024-01-22 Fine Needle Aspiration Cytology - lymph node
  • Indication: Squamous cell carcinoma of the postcricoid area, p16 (-), stage cT2N0M0, s/p CCRT, with right neck level III~IV neck node metastasis, status post right modified radical neck dissection and CCRT, with lung metastases, status post VATS RUL and RML wedge + LN sampling, with tumor recurrence at right lower neck and progression.
  • Result: 2 alcohol fixed slides and 1 cc red, cloudy — Malignancy
  • MICROSCOPIC DESCRIPTION: Smears show necrotic debris, neutrophils, histiocytes, and atypical hyperchromatic cells with focal keratinization. Metastatic squmaous cell carcinoma is favored. Please correlate with the clinical presentation and further examination is suggested.
• 2024-01-19 SONO - head and neck soft tissue
  • Clinical Impression/Intent: right level 4 neck mass
  • Sonographic Impression: right level 4 neck mass, size: 3.55*1.96, heterogenous, suspect metastatic LN
• 2024-01-18 CT - neck
  • Indication:
    • hypopharyngeal cancer, cT2N0M0, stage II (diagnosed on 2020/08/04), with neck recurrence s/p CCRT and C/T.
    • right neck mass lesion with reddish and icthing about 6x3cm for 10-12 days. R/O disease progression
  • Head and Neck CT with and without IV contrast administration shows: comparison 2023/12/22 CT
    • LAPs at right neck, level III-IV, up to 5.6 cm, central necrotic change was noted, with intervally enlarged size.
    • No evident nodule or mass in the post-cricoid region.
    • No nodule was seen in the bil. visible apical lungs.
    • Correlation with previous imaging study for comparison is suggested.
• 2024-01-18 Nasopharyngoscopy
  • Findings
    • smooth nasopharynx, oropharynx and hypopharynx; right vocal cord paralysis.
  • Conclusion
    • History of hypopharyngeal cancer s/p CCRT
• 2023-12-22 CT - chest
  • Indication: Squamous cell carcinoma of the postcricoid area, p16 (-), stage cT2N0M0, s/p CCRT, with right neck level III~IV neck node metastasis, status post right modified radical neck dissection and CCRT
  • Chest CT with and without IV contrast ehnancement shows:
    • Necrotic lymphadenopathy at right lower neck measuring 3.8cm in largest dimension. (SE304 IM3).
    • s/p right upper lobe op.
    • No evidence of bilateral pleural effusion.
    • S/p port-A placement with its tip at Superior vena cava
  • Imp:
    • Right lower neck lymphadenopathy. The lesion is new as compared with previous CT on 2023-02-21.
    • NO evidence of lung meta in the study.
• 2023-11-15 CXR erect
  • Atherosclerotic change of aortic arch
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2023-10-13 Nerve Conduction Velocity, NCV
  • Findings
    • prolonged DLs, lower CMAP amplitudes and normal NCVs of bil. ulnar and right peroneal n.
    • prolonged sensory DLs, lower SNAP amplitudes on bil. median, ulnar and sural n. with marked slowing of NCVs
    • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal.
    • the H-reflex study of bil. tibial n. were prolonged
  • Conclusion:
    • sensory predominant polyneuropathies
• 2023-10-03 Neurosonography
  • wall thickening on bil. common carotid arteries
  • damped peak systolic velocities on right ICA and ECA, may suggest post-stenotic or increased resistance distally, smaller diameter (0.24cm) and lower flow (26cc/min) on right VA
• 2023-09-30 CT - brain
  • No brain nodule or mass.
• 2023-09-12 SONO - abdomen
  • Chronic liver parenchymal disease
• 2023-08-23 MRI - brachial plexus
  • Findings
    • normal bone alignment of the spine; post-OP change at the middle adn lower C-spine.
    • heterogeneous enhancing soft tissue at the right lower neck, involving right carotid space, paravertebral space at the lower C-spine with extention to the right brachial pelxus. As compared with previous MRI on 20230512, the sizes were mildly decreased
    • an enlarged lymph node in the right middle carotid space
  • IMP:
    • tumors in the right lower neck, mild decrease in size
    • an enlarged lymph node in the right carotid space
• 2023-07-11 Nasopharyngoscopy
  • much saliva over right pyriform sinus. invisible vocal cord
• 2023-05-12 MRI - brachial plexus
  • Indication: right upper limb weakness
  • Without- and with-contrast MRI of brachial plexuses, focusing on right side, with axial, sagittal and coronal T1WI and T2WI using 3 mm - 5 mm thickness reveal:
    • Severe progressive enlargement of the enhancing soft tissue mass at right lower neck, involving carotid space, paravertebral space (C4-T1 levels), and extending along brachial plexus, as compared with MRI on 20221214. Progressive recurrence is considered.
    • S/P disc prosthesis at C3-4-5-6-7.
    • No enlarged lymph node.
    • Scoliosis of C-spine.
  • IMP: C/W Tumor recurrence at right lower neck, involving carotid and paravertebral space and brachial plexus. Severe progression as compared with MRI on 20221214.
• 2023-03-29 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in bilateral rib cages, lower C-spine, lower L-spine, bilateral shoulders, right femoral shaft, D/3, and left knee.
• 2023-03-14 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, middle lobe, wedge resection —- Metastatic squamous cell carcinoma
    • Lymph node, right, group No.7, lymphadenectomy —- Negative for malignancy (0/16)
    • Pleura, right, excision —- Metastatic squamous cell carcinoma
  • MACROSCOPIC EXAMINATION:
    • Specimen: Lung, size: 6.0 x 3.2 x 2.4 cm, 14 g
      • Lymph nodes, a bottle, group 7, maximal size: 1.3 x 0.7 cm
    • Tumor Site: Periphery
    • Tumor Size: Solitary: 3.0 x 2.7 x 1.8 cm
    • Gross tumor patterns: poorly defined, Pleural retraction
    • A piece of pleural nodule, measuring 1.0 x 1.0 x 0.5 cm, is received
    • Tissue for sections: A1: resection margin; A2: lung; A3-5: tumor; B: lymph node, group 7; C: pleural nodule.
  • Microscopic Description
    • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes
    • Histologic Type (select all that apply): Consistent with metastatic squamous cell carcinoma, keratinizing
      
    • Histologic Grade: G2: Moderately differentiated
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Present (PL1)
    • Lymphovascular Invasion (select all that apply): Present, Lymphatic, Arterial, Venous
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.3 cm
      • Specify closest margin: resection margin
    • Treatment Effect: No known presurgical therapy
    • Regional Lymph Nodes: group 7: 0/16
    • Extranodal Extension: Not identified
    • Additional Pathologic Findings: The pleural nodule reveals metastatic squamous cell carcinoma.
• 2023-03-14 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, upper lobe, wedge resection — Metastatic squamous cell carcinoma,
  • MACROSCOPIC EXAMINATION:
    • Specimen: Lung, size: 6.0 x 5.8 x 3.0 cm, 38 g
    • Tumor Site: Periphery
    • Tumor Size: Solitary: 2.2 x 2.0 x 1.5 cm
    • Gross tumor patterns: poorly defined
      
    • Several pleural fibrotic nodules, measuring up to 0.5 x 0.4 x 0.2 cm, are seen.
    • Tissue for sections: A1: resection margin; A2: lung; A3: bronchus; A4-6: tumor; A7: pleural fibrosis.
  • Microscopic Description
    • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes
    • Histologic Type (select all that apply): Consistent with metastatic squamous cell carcinoma, keratinizing
      
    • Histologic Grade: G2: Moderately differentiated
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Not identified
    • Lymphovascular Invasion (select all that apply): Not identified
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.3 cm
      • Specify closest margin: resection margin
    • Treatment Effect: No known presurgical therapy
    • Additional Pathologic Findings: Several pleural fibrotic nodules are seen.
• 2022-07-19 MRI - larynx
  • The current study was compared to the prior one obtained on 2021/08/23.
  • Progressive effacement of right pyriform sinus with mucosal thickening. Suggest clinical correlation and tissue proof.
  • Diffuse softt issue swelling at AE folds and retropharyngeal wall.
  • Paranasal sinusitis.
• 2022-05-17 Tc-99m MDP bone scan
  • In comparison with the previous study on 2020/7/31, the lesions in the lower C-spine and L4-5 spines are a little more evident. The nature is to be determined (degenerative change in a little more severe status? other nature?). Please correlate with other imaging modalities for further evaluation.
  • Some new faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders and left knee. Benign joint lesions such as arthritis are more likely.
• 2022-02-22 Patho - lymph node region resection
  • PATHOLOGIC DIAGNOSIS
    • Lymph nodes, level III-IV, right, neck LN dissection — Metastatic squamous cell carcinoma (1/7)
    • Lymph nodes, level II, right, neck LN dissection — Negative for malignancy (0/4)
    • Soft tissue, level IV, biopsy for frozen section — Metastatic squamous cell carcinoma
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure(s): Right neck LN dissection
    • Specimen Type: Right neck lymph node dissection, including level II and level III-IV
      • Representative parts ae taken for section as: S2022-02835A= level II lymph nodes, B1-B2= level III-IV lymph nodes.
    • Specimen received for frozen section: two pieces of pink gray soft tissue, labeled level IV, measuring up to 0.9 x 0.5 x 0.3 cm. All for section as: F2022-00064.
  • MICROSCOPIC EXAMINATION
    • Number of lymph nodes involved: 1 (level III-IV)
    • Number of lymph nodes examined: 4 (level II), 7 (level III-IV)
    • Size of largest metastatic deposit: 2.2 cm
    • Extranodal extension: Present
    • The sections of frozen section specimen also show metastatic squamous cell carcinoma (not identified in frozen section slide), composed a few neoplastic cells in fibrous stroma. No lymphoid tissue can be found.
    • IHC, the neoplastic cells reveal: CK(+) and P40(+).
• 2021-03-09 MRI - larynx
  • Intervally increased soft tissue in the supraglottic, post-cricoid region, combined with edema likely
  • Severe narrowed supaglottic airway.
• 2020-07-31 Patho - larynx biopsy
  • Labeled as “postcricoid tumor”, biopsy — squamous cell carcinoma.
    
  • IHC stains: p16 (-), p40 (+).

[MedRec]

• 2024-01-10 SOAP Neurology Liu ZhiYang
  • Prescription x3
    • Pentop (pentoxifylline 400mg) 0.5# BID
    • Toppamax (topiramate 25mg) 1# BID
• 2023-12-13 SOAP Neurology Liu ZhiYang
  • Prescription x3
    • Cymbalta (duloxetine 30mg) 1# BID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
    • Pentop (pentoxifylline 400mg) 0.5# BID
• 2023-12-13 SOAP Gastroenterology
  • Diagnosis
    • Chronic viral hepatitis B without delta-agent [B18.1]
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-09-28 SOAP Neurology Liu ZhiYang
  • S:
    • left arm and bil. leg numb, also right shoulder pain under medication
    • Phx: Squamous cell carcinoma of the postcricoid area
  • A:
    • C-spine MRI: Cervical spondylosis s/p oepration with diffuse spinal canal stenosis. compressive myelopathy and neuroforaminal narrowings at C3-4-5-6-7.
• 2023-09-12 SOAP Gastroenterology
  • Diagnosis
    • Chronic viral hepatitis B without delta-agent [B18.1]
  • Prescription x3
    • Baraclude (entecavir 0.5mg) 1# QOD
• 2020-07-29 ~ 2020-07-31 POMR Ear Nose Throat
  • Discharge diagnosis
    • C13.0 Post-cricoid tumor, suspect malignant status post laryngomicrosurgery and esophagoscopy on 2020-07-31
    • Gastro-esophageal reflux disease with esophagitis, LA Classification grade A
    • Essential (primary) hypertension
    • Carrier of viral hepatitis B
  • CC
    • Sorethroat and cough for 1 year
  • Present illness
    • This 48-year-old man is a hepatitis B carrier who has history of GERD and hypertension without medication control. He has smoking for 30 years with alcohol drinking. He suffered from sorethroat and cough for 1 year. Regurgitation was also complained. He treated at local clinic but in vain. He then visited our ENT OPD for help. At OPD, fiberscope found post-cricoid tumor. Under the suspect of malignancy, we suggest him admission for tumor survey and LMS biopsy.
  • Course of inpatient treatment
    • After admission, tumor survey were arranged. MRI was done on 7/29 which revealed submucosal tumor at posterior hypopharyneal wall. D/D: inflammatory/infectious mass, malignancy. UGI/PES was done on 7/30 which revealed erosive esophagitis LA Classification grade A. The patient underwent larygomicrosurgery and esophagoscopy on 2020/7/31. Post-operation, there was no active oral bleeding but throat pain with cough were noted. Clindamycin and paran were added for symptoms relief. Bone scan was done on 7/31 which revealed no strong evidence of bone metastasis. Under relatviely stable condition, the patient was discharged with medication and OPD follow-up. 
  • Discharge prescription
    • Lindacin (clindamycin 150mg) 2# QID
    • Lactam (acetaminophen 500mg) 1# QID
    • Nexium (esomeprazole 40mg) 1# QDAC
• 2023-03-12 ~ 2023-03-15 POMR Thoracic Surgery Xie MinXiao
  • Discharge diagnosis
    • Right upper and right middle lobe lung nodules, suspect metastatic status post three-dimensional video-assisted thoracoscopic surgery right upper and right middle lobe wedge resection and lymph node sampling on 2023-03-13
    • Hypopharyngeal cancer (squamous cell carcinoma) cT2N0M0 stage II status post concurrent chemoradiotherapy
    • Viral hepatitis B without hepatic coma
    • Gastro-esophageal reflux disease
    • Essential (primary) hypertension
  • CC
    • lung nodules was told by chest CT and PET while ENT OPD follow up        
  • Present illness
    • This is a 50 y/o male patient with history of hypopharyngeal cancer with neck recurrence s/p CCRT, HTN, HBV carrier, psoriasis vulgaris. Abnormal finding of lung was noted on CT and PET while ENT OPD follow up. He was then referred to our CS OPD due to lung nodules over RUL, RML. He denied poor appetite, dyspnea, dysphagia, chest discomfort, abdominal discomfort, nor dysuria. Dry cough was noted for many years.
    • He suffered from right shoulder pain and soreness in the recent one month. He took painkillers but in vain. Body weight loss 2 kg in the rescent three months was also mentioned.
    • Whole body PET scan done on 2023/01/17 showed two glucose hypermetabolic lesions in the upper lobe of right lung and a glucose hypermetabolic lesion in the middle lobe of right lung, lung metastases should be watched out.
    • Chest CT revealed many ill-defined nodular lesions of variable sizes in RUL and RML mesuaring up to 24mm, due to metastases.
    • After discussing with the patient and his family on the benefits of surgical treatment as well as subsequent risks and possible complications, the patient was admitted for 3D VATS RML, RUL metastectomy on 2023/03/13 under the impression of lung nodules over RUL, RML, suspect lung metastasis.
  • Course of inpatient treatment
    • After admission, pre-op assessment was done. Operation of three-dimensional video-assisted thoracoscopic surgery right upper and right middle lobe wedge resection and lymph node sampling was performed smoothly on 2023-03-13. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Right chest tube with LPS 18 cm H2O was done. Chest tube was removed on 2023-03-15. He was discharged under stable hemodynamics and OPD follow up will be arranged.
  • Discharge prescription
    • Actein (acetylcysteine 200mg) 1# TID
    • Ripam (clonazepam 0.5mg) 1# BID
    • Celebrex (celecoxib 200mg) 1# BID
    • Sindine (povidone iodine Aq soln) QD EXT

[consultation]

• 2024-02-15 Ear Nose Throat
  • Q
    • for large right neck tumor with rupture and bleeding
    • This is a 51 y/o male patient with history of hypopharyngeal cancer, cT2N0M0, stage II (diagnosed on 2020/08/04), with neck recurrence s/p CCRT and C/T. He was admitted for C3D1 target therapy with Cetuximab 500mg/m2 (Q2W) on 2024/01/17. Last time chemotherapy with taxotere (self-paid) was given on 1/26 24.
    • A large right neck tumor with rupture and bleeding was noted. We need expertise to evaluate his condition thanks!
  • A
    • S
      • A case of hypopharyngeal cancer, cT2N0M0 initially s/p CCRT, with right neck recurrence and lung metastasis, s/p R neck dissection and VATS (RUL and RML wedge)
      • Under chemotherapy curently
      • We are consulted for R neck tumor rupture and bleeding for 5 days
      • under hemoclot and empirical abx with augmentin
    • O
      • Local finding: 3*3 cm necrotic mass lesion over R neck, no active bleeding during visiting
      • Scope: smooth NPx, saliva accumulation over pyriform sinus
    • A
      • Hypopharyngeal cancer, with right neck tumor mass rupture and bleeding
    • P
      • After discussion with VS Hsu
        • topical wound care with neomycin
        • bosmin gauze compression if active bleeding noticed
        • consider arrange CTA for ruling out carotid vessel related bleeding
        • if vital sign stable and no more active bleeding episode, chemotherapy can be arranged as schedule
• 2024-01-18 Ear Nose Throat
  • Q
    • for new hard mass tumor at right neck
      
    • This is a 51 y/o male patient with history of hypopharyngeal cancer, cT2N0M0, stage II (diagnosed on 2020/08/04), with neck recurrence s/p CCRT and C/T. He was admitted for C3D1 target therapy with Cetuximab 500mg/m2 (Q2W) on 2024/01/17.
    • He complained of right neck mass lesion with reddish and icthing about 6x3cm for 10-12 days. R/O disease progression. We need expertise to evaluate his condition thanks!
  • A
    • Local finding: an about 5-6cm firm mass over right level IV region, with mild tenderness.
    • Scope: smooth nasopharynx, oropharynx and hypopharynx; right vocal cord paralysis.
    • Impression: Right lower neck mass, r/o malignancy.
    • Plan: We will arrange visit at Dr. Xu YingJie’s OPD on tomorrow afternoon at PM4:30.
    • Further instruction will follow.
• 2023-05-08 Neurology
  • Q
    • The 50 y/o man has recurrent hypopharynx with right upper and right middle lobe lung nodules, suspect metastatic status post three-dimensional video-assisted thoracoscopic surgery right upper and right middle lobe wedge resection and lymph node sampling on 2023-03-13. Due to he has right upper limb numbness with painful sensation, MP 3 to weak 4, we need your help for management. Thanks!
  • A
    • CC: Rt upper limb weakness and numbness for more then 2 months
    • O
      • CN: intact
      • MP: RU:4 RL:5 LU:5 LL:5
      • Pinprick: allodynia over right upper limb.
    • Imp: r/o brachial plexopathy due to mets.
    • Suggestion:
      • arrange NCV (Motor sensory nerve conduction of upper and lower limbs, H reflex, F wave, QST)
      • You may try lyrica #1 BID for neuralgia
• 2023-05-08 Neurosurgery
  • Q
    • The 50 y/o man has recurrent hypopharynx with right upper and right middle lobe lung nodules, suspect metastatic status post three-dimensional video-assisted thoracoscopic surgery right upper and right middle lobe wedge resection and lymph node sampling on 2023-03-13. Due to he has right upper limb numbness with painful sensation, MP 3 to weak 4, we need your help for management. Thanks!
  • A
    • A case of recurrent hypopharyngeal cacner with distal metastasis;
    • NS is consulted for right UE numbness/ weakness for months.
    • O
      • Current status: MP: RT UE 2-3; sensation: Rt UE hypothesia
      • DTR: 0-+; Sphincter: continence
    • A: metastastic tumor, involving right neck?
    • P: Please arrange right brachial plexus MRI with and without Gd;

[surgical operation]

• 2023-03-13
  • Surgery
    • VATS RUL and RML wedge + LN sampling.
  • Finding
    • One tumor was noted over the apex of RUL, another nodular lesion was noted over RML, size about 2.0cm in diameter.
    • One 24 Fr. straight chest tube was inserted via right 8th ICS.

[radiotherapy]

[chemotherapy]

• 2024-02-22 - docetaxel 75mg/m2 113mg NS 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2024-01-26 - docetaxel 75mg/m2 115mg NS 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-12-25 - cetuximab 500mg/m2 700mg 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-11-16 - cetuximab 500mg/m2 700mg 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-10-23 - cetuximab 500mg/m2 700mg 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-10-06 - cetuximab 500mg/m2 700mg 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-09-04 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-07-31 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-07-03 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-06-05 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-05-08 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-04-03 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2022-04-26 - (cisplatin, QW)

• 2022-04-19

• 2022-04-12

• 2022-04-08

• 2022-03-29

• 2022-03-22

• 2020-10-20 - (cisplatin, QW)

• 2020-10-13

• 2020-10-06

• 2020-09-29

• 2020-09-22

• 2020-09-15

Docetaxel - 2024-03-22 - https://www.uptodate.com/contents/docetaxel-drug-information

• Adult Dosing
  • Head and neck cancer: IV: 75 mg/m2 every 3 weeks (in combination with cisplatin and fluorouracil) for 3 or 4 cycles, followed by radiation therapy.
  • Nasopharyngeal carcinoma, locally advanced: IV: 60 mg/m2 every 3 weeks (in combination with cisplatin and fluorouracil) for 3 induction cycles, followed by concurrent chemoradiotherapy or 75 mg/m2 every 3 weeks (in combination with cisplatin) for 2 cycles, followed by chemoradiotherapy.

==========

2024-03-22

[treating stubborn bleeding neck wounds: topical tranexamic acid as an option]

Topical application of tranexamic acid to the bleeding surface has the potential to inhibit local fibrinolysis at the site of bleeding, reducing bleeding with minimal systemic effects. The effects of topical tranexamic acid have been evaluated primarily during orthopedic surgery but also with head and neck surgery, cardiac surgery, and breast surgery.

For poorly healing neck skin ruptures with bleeding, topical tranexamic acid may be a helpful option.

2024-01-26

[neurological follow-up in this cisplatin-treated patient]

This is a patient who has a long history of underlying neurological conditions. Cervical polyradiculopathy was found on 2010-06-30. On 2010-07-23, the patient was diagnosed with herniated intervertebral discs (HIVD) at the C3, C4, C5, C6, and C7 levels, along with canal stenosis. He subsequently underwent Anterior Cervical Discectomy and Fusion (ACDF) and right Trans-Ulnar Synovectomy (TUS) / Carpal Tunnel Syndrome (CTS) neurolysis on 2010-07-07. On 2016-02-06, the patient presented with a mass on the left dorsal ear and was undergoing follow-up after cervical surgery. He also exhibited muscular atrophy in his limbs. On 2016-03-04, the patient reported soreness, especially in cold weather conditions. Later, on 2023-03-07, the patient experienced pain in the back of the neck and radiating numbness and weakness in the right upper extremity, persisting for three months. The pain was not relieved by painkillers.

The patient had used cisplatin in Sep and Oct in 2020, Mar and Apr in 2022, 2nd and 3rd quarters in 2023. Cisplatin is known associated with peripheral neuropathy.

While the patient’s neurological issues cannot be solely attributed to cisplatin, its potential role in causing neuropathy cannot be excluded. The patient has been more frequently visiting neurology since Sep 2023, with the most recent appointment on 2024-01-10. Monitoring the effectiveness of symptom control proposed by our neurologist is suggested.

Additionally, docetaxel, started during this hospitalization, is also associated with neurological adverse reactions. These include central nervous system toxicity (20% to 58%; dysesthesia and paresthesia both ≤6%), neuromuscular and skeletal issues like asthenia (53% to 66%; severe weakness 13% to 18%), myalgia (3% to 23%; severe myalgia 2%), and neuromuscular reactions (16%), as well as peripheral motor neuropathy (4%; mainly distal extremity weakness) and arthralgia (3% to 9%).

Given that chemotherapy-induced peripheral neuropathy remains a challenging medical issue to fully overcome, continued follow-up in neurology outpatient clinics is recommended.

2023-07-31

The patient just refilled Ultracet (tramadol, acetaminophen) and Lyrica (pregabalin) for his aalignant neoplasm of hypopharynx at a local pharmacy on 2023-07-27. In current active medication list, there were Tramacet, Lyrica and Durogesic (fentanyl) prescribed, no reconciliation issues identified.

700165097

240322

[exam findings]

• 2023-12-04 Patho - breast simple/partial mastectomy
  • Diagnosis:
    • Breast, left, simple mastectomy — invasive lobular carcinoma, grade 1
    • Nipple base — Negative for malignancy
    • Lymph node, left axilla sentinel, excision — Negative for malignancy (0/3)
    • AJCC 8th edition pathology stage: pT2(m)N0(if cM0); anatomic stage IIA; AJCC prognostic stage IA
  • Gross Description
    • Procedure: Simple mastectomy (without nipple and skin)
    • Lymph node sampling (if lymph nodes are present in the specimen): Sentinel lymph node(s)
    • Specimen laterality: Left
    • Sections are taken and labeled as: F2023-548FSA1-2:SLN; F2023-548FSB:nipple base; A1-22:tumor
  • Microscopic Description
    • For Invasive Carcinoma
      • Histologic type: Invasive lobular carcinoma
      • Size of invasive carcinoma (mm): up to 2.5 cm, multiple foci
      • Histologic grade (Nottingham histologic score): Grade I (score 5)
      • Extent of tumor (required only if the structures are present and involved)
      • Skin involvement: not included
      • Chest wall invasion deeper than pectoralis muscle: Absent
    • For Ductal Carcinoma In Situ: not applicable
      • Tumor size (mm):not applicable
      • Nuclear grade: not applicable
      • Architectural pattern: not applicable
      • Tumor necrosis: not applicable
    • Margins:Negative, Closest margin ( 10 mm from deep margin)
    • Nodal status: Negative
      • No. examined: 3
      • No. macrometastases (> 2 mm): 0
      • No. micrometastases (> 0.2 ~ 2 mm and/or > 200 cells): 0
      • No. isolated tumor cells (<= 0.2 mm and <= 200 cells): 0
    • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
      • In the Breast: No applicable
      • In the Lymph nodes: No applicable
    • Immunohistochemical Study
      • CK (for SLN): Negative
        
    • Reference: S2023-22581
• 2023-11-27 Tc-99m MDP bone scan
  • Faint hot spots in both rib cages, and increased activity in some upper T-spine, and inferior angle of hte right scapula, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in some T- and L-spine, bilateral shoulders, elbows, S-I joints, and hips.
• 2023-11-22 CT - chest
  • Findings
    • suspect increased enhancing nodules in Lt breast as compared with Rt side.
    • two Rt renal cysts measuring up to 1cm (longest axial diameter)
  • Impression:
    • Lt breast tumor(s). no lungs abnormaltiy.
• 2023-11-13 Patho - breast biopsy (no need margin)
  • Breast, left, 11 o’clock, core biopsy — Invasive lobular carcinoma, no special type, NST. IHC stains (using block S2023-22581A): ER (+, 95%, strong intensity), PR (+, 90%, strong intensity), Her2/neu: negative (score=0), Ki-67(8 %), E-cadherin (-).
  • Breast, left, 12 o’clock, core biopsy — Invasive lobular carcinoma, no special type, NST. IHC stains (using block S2023-22581B): ER (+, 95%, strong intensity), PR (+, 90%, strong intensity), Her2/neu: negative (score=0), Ki-67(15 %), E-cadherin (-).
• 2023-10-27, -08-01 SONO - breast
  • Diagnosis: Bil. fibroadenomas as described
  • BI-RADS: 2. benign finding
• 2022-07-23 Gynecologic ultrasonography
  • IMP: Uterine myoma
• 2022-07-23 SONO - nephrology
  • R/O Left parapelvic renal cyst, r/o Dilated renal calyx.

[MedRec]

• 2024-01-26 SOAP Hemato-Oncology Gao WeiYao
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Bafen (baclofen 5mg) 1# HS
    • Granocyte (lenograstim 250ug) QD SC on 1/26, 1/27, 1/29

[consultation]

• 2023-12-25 Plastic and Reconstructive Surgery
  • Q
    • for left breast swelling & pain for days
    • This 49-year-old woman, a patient of left breast Invasive lobular carcinoma, no special type, NST. IHC stains (using block S2023-22581A): ER (+, 95%, strong intensity), PR (+, 90%, strong intensity), Her2/neu: negative (score=0), Ki-67(8%), E-cadherin (-). She was admitted for chemotherapy. We need expertise to evaluate her condition thanks!
  • A
    • I checked patient’s left breast, and I think she does not tolerate the tissue expander as well as I expected. However, there is no obvious sign of infection or severe inflammation. so I explained current situation to the patient. And I will check on her often. Please arrange out-patient appointment for me and her on 12/28. Thanks.
• 2023-11-30 Plastic and Reconstructive Surgery
  • Q
    • This is a 49 years old woman patient. Due to left breast cancer, she was admitted for surgery of left simple mastectomy + SLNB on 2023/12/01. We need your help for expander. Thank you so much!!
  • A
    • First stage breast reconstruction was planned, and tissue expander will be used. Thanks.

[MedRec]

• 2024-03-21 - docetaxel 75mg/m2 120mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1000mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-02-16 - docetaxel 75mg/m2 120mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1000mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-18 - docetaxel 75mg/m2 120mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1000mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-26 - docetaxel 75mg/m2 120mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1000mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-03-22

A review of 2024-03-21 lab results, including CBC, basic metabolic panel (BMP), showed grossly normal values. Similarly, recent TPR readings are stable. No discrepancies were identified between the active medication list after reviewing PharmaCloud and HIS5 records.

2024-02-16

[repeated leukopenia episodes after chemo, g-csf prophylaxis may be prudent]

Following the first chemotherapy session on 2023-12-26, and the second session on 2024-01-18, the patient experienced episodes of leukopenia with nadir WBC counts of 1.43 K/uL on 2024-01-02 and 2.06 K/uL on 2024-01-26. Given these observations, prophylactic G-CSF administration may be prudent.

700274667

240322

[exam findings]

• 2024-03-22 EGD
  • Indication: UGI bleeding
  • Findings
    • Minimal mucosa break < 5mm was noted at EC junction.
    • Erythematous change of gastric mucosa was found
    • One large ulcerative mass lesion with elevated surroundings was noted from middle body, LC to antrum, LC, with 50% cirrcumferrential. There was ozzing blood at the edge of the mass lesion,s/p Argon plasma coagulation for hemostasis.
  • Diagnosis:
    • Gastric adenocarcinoma, from middle body, LC to antrum, LC, Borrmann type III, with edge ozzing blood, s/p Argon plasma coagulation for hemostasis
    • Reflux esophagitis LA Classification grade A (minimal)
• 2024-03-21 PET
  • Glucose hypermetabolism involving the LC of the body and antrum of the stomach and in some regional lymph nodes, compatible with primary gastric malignancy with some regional lymph node metastases. Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in bilateral pulmonary hilar and some mediastinal lymph nodes. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Glucose hypermetabolism in some focal areas in the maxilla and mandible. Dental problem may show this picture.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
• 2024-03-20 CT - abdomen
  • Findings:
    • There is lobulated wall thickening of the gastric low body and antrum with irregular contour, 9 cm in size, that is c/w adenocarcinoma of the stomach (T4a).
    • There are seven enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament that may be regional metastatic nodes (N3a).
    • There is ascites and equivocal soft tissue lesions in the omentum.
      • Carcinomatosis (M1) is suspected.
      • Please correlate with ascites cytology.
        
    • There are bilateral Pleura effusion and passive atelectasis in bilateral posterior basal lung.
    • A renal cyst 3 cm in left lower pole is noted.
  • Impression:
    • Adenocarcinoma of the stomach is noted.
    • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for gastric cancer: T4a N3a M0 or 1; stage: III or IVB.
• 2024-03-18 CXR
  • Supine chest image shows:
    • extensive hazy increased opacity over Rt mid to lower lung zone
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
      
    • mild enlarged cardiac silhoutte due to supine position
• 2024-03-13 Patho - stomach biopsy
  • Stomach, antrum, LC and middle body, biopsy — Adenocarcinoma, poorly diggerentiated
  • The secvtions show a picture of adenocarcinoma, poorly differentiated, composed of cuboidal neoplastic cells, arranged in tubular, papillary, and solid patterns with desmoplastic stromal reaction. Ulcer and tumor necrosis are present.
• 2024-03-12 EGD
  • Diagnosis:
    • Gastric ulcerative lesion, from middle body, LC to antrum, LC, r/o malignancy, if gastric malignancy was confirmed, then Borrmann type III
    • Reflux esophagitis LA Classification grade A (minimal)
  • CLO test: Negative
• 2024-03-12 Colonoscopy
  • Diagnosis:
    • mixed hemorrhoids.
    • mild melanosis coli

701492978

240322

[exam findings]

• 2024-02-16 Patho - breast mastectomy with regional lymph nodes
  • Diagnosis
    • Breast, right, partial mastectomy —- Invasive carcinoma of no special type, s/p chemotherapy
    • Resection margin: free
      
    • Lymph node, right axilla, sentinel, lymphadenecomy —- Negative for malignancy (0/2)
    • AJCC 8 th edition, Pathology stage: Anatomic stage: ypStage IA, ypT1aN0(sn)(if cM0)
  • Gross Description
    • Breast: Size: 5.6 x 5.6 x 5.2 cm
    • Skin: Size: 3.7 x 0.6 cm.
    • Nipple: Not Included
      
    • Tumor: Size: Grossly, no tumor is seen. Microscopically, several tumor clusters, measuring up to 0.3 x 0.2 cm, are seen.
    • Resection Margin: Free, 0.3 cm from the 3 o’clock margin
      
    • Lymph node: sentinel
      
    • Sections are taken and labeled as: Representative sections are taken and labeled as: FsA1-2: sentinel lymph node, bisected; FsB1:12 o’clock resection margin; FsB2: 3 o’clock resection margin; FsB3: 6 o’clock resection margin; FsB4: 9 o’clock resection margin; FsB5: deep resection margin, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: skin; X2-10: breast (X2-5, X6-7, X9-10: the same level).
  • Microscopic Description
    • For Invasive Carcinoma
      • Histologic type: Invasive carcinoma of no special type, s/p chemotherapy
        
      • Size of invasive carcinoma (mm): Grossly, no tumor is seen. Microscopically, several tumor clusters, measuring up to 3 x 2 mm, are seen. The immunohistochemical stains reveal CK5/6(-) and p63(-).
      • Histologic grade (Nottingham histologic score): grade III (score 8)
        • Tubule formation: score 3
        • Nuclear pleomorphism: score 3
        • Mitotic count: score 2
      • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: Absent
        • Chest wall invasion deeper than pectoralis muscle: Not applicable
    • For Ductal Carcinoma In Situ: not found
      
    • Margins: Negative, Closest margin (3 mm from 3 o’clock margin)
    • Nodal status: Negative, sentinel
      • No. examined: 2
      • No. macrometastases (> 2 mm): 0
      • No. micrometastases (> 0.2 ~ 2 mm and/or > 200 cells): 0
      • No. isolated tumor cells (<= 0.2 mm and <= 200 cells): 0
    • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
      • In the Breast: Probable or definite response to presurgical therapy in the invasive carcinoma
      • In the Lymph nodes: No lymph node metastases. Fibrous scarring, possibly related to prior lymph node metastases with pathologic complete response
    • Lymphovascular invasion: present
    • Perineural invasion: absent.
    • Immunohistochemical Study
      • ER (Ab): Negative (Internal control: positive)
      • PR (Ab): Negative (Internal control: positive)
      • Her-2/neu (Ab): Positive (3+)
      • Ki-67: 40%
• 2024-01-31 PET
  • Increased FDG uptake in the right breast, compatible with cancer s/p surgical reaction.
  • Increased FDG uptake in the left breast, probably benign in nature, suggesting breast sonogram for follow-up.
    
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
  • Right breast cancer s/p treatment, no evidence of residual/recurrent or metastatic tumor is noted by this F-18 FDG PET scan.
• 2023-12-15 SONO - breast
  • Diagnosis
    • Bil. fibroadenomas as described
    • Right breast cancer (#2)
  • Treatment
    • explain the finding
  • Suggestion and Plan
    • further treatment
  • BI-RADS: 6. known biopsy-proven malignancy
• 2023-12-01 CT - chest
  • Indication: Malignant neoplasm of unspecified site of right female breast
  • Chest CT with and without IV contrast ehnancement shows:
    • Residual soft tissue lesion at right outer breast with minimal enhancement is found. In comparison with CT dated on 2023-08-16, the lesion regressed. However, one nodular lesion at left breast just below nipple is found. Suggest correlate with breast echo. (Se401 Im29).
  • Imp:
    • Right breast cancer s/p C/T with regression of main mass and shringkage of right axillary lymphadenopathy.
    • Left breast nodule. Suggest correlate with breast echo.
• 2023-09-08 Doppler color flow mapping
  • LVEF = (LVEDV - LVESV) / LVEDV = (92.0 - 27.5) / 92.0 = 70.11%
    • M-mode (Teichholz) = 75.4-70.1
    • 2D (M-Simpson) = 73
  • Conclusion:
    • Normal AV/MV with no AR/<R
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, no TR, normal IVC size
• 2023-08-17 Tc-99m MDP bone scan
  • Increased activity in the lower T-spine and L5 spine. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips, knees and feet, compatible with benign joint lesions.
• 2023-08-16 CT - chest
  • Indication: breast cancer
  • Findings:
    • Chest wall and visible lower neck:
      • multiple discrete enlarged LNs at Rt deep axilla.
      • ill-defined enhancing tumor at Rt breast upper outer quadrant.
    • Visible abdominal contents:
      • several small gall bladder stones.
      • several hepatic cysts measuring up to 21mm. suspect minimal retrouterine space ascites.
    • Visualized bones:
      • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • Rt breast cancer T1or T3?N1Mx.
• 2023-08-07 Patho - breast biopsy (no need margin)
  • Breast, right, core needle biopsy — Invasive carcinoma of no special type
  • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid to ductal architecture and stromal fibrosis with lymphocytic infiltrate. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
  • Immunohistochemical study demonstrates:
    • ER: negative
    • PR: negative
    • Her2/neu: positive (3+)
    • Ki-67 inedex: 40%
    • E-cadherin: positive
    • p63: negative
• 2023-08-07 Patho - lymphnode biopsy
  • Lymph node, right axillary, CT guide buiosy — Inasive carcinoma, metastatic
  • Microscopically, it shows presence of nests of invasive carcinoma with syromal fibrosis and lymphocytic infiltrate.
• 2023-08-04 SONO - breast
  • CC and Indication
    • Breast lumps
  • History
    • No specific risk factors
  • Findings
    • Parenchymal pattem: Loosely (inhomogeneously) sonodense
    • Focal sonographic lesion: Yes
      • Location: Right 9.5 o’clock / 5 cm
        
      • Size: 2.35 x 2.20 x 2.52 cm
      • Margins : Sharp, jagged
      • Shape: Irregular
        
      • Orientation: Not parallel
        
      • Axillary lymph node: Yes
      • Vascularity: Present immediately adjacent to lesion
        
      • Echogenicity: hypoechoic
        
      • Internal echo pattern: nonhomogeneous
  • Diagnosis
    • Highly suspicious of malignancy,with sonographic positive axillary LAP
  • Treatment
    • Core-needle biopsy
  • Suggestion
    • Regular OPD follow-up
  • BI-RADS:
    • 4C-moderate concern, but not classic for malignancy Biopsy Should Be Considered

[MedRec]

• 2023-09-07 ~ 2023-09-13 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Right breast cancer, ER(-), PR(-), HER-2 type, cT1N1M0, stage IB s/p Adjuvant chemotherapy with TCHP from 2023/09/12~
    • Hypokalemia
    • Insomnia, unspecified
  • CC
    • For prepare adjuvant chemotherapy with TCHP (C1).
  • Present illness
    • This 47-year-old woman patient suffered from right breast lump was noted without nipple discharge in 2023/07.
    • Breast sono on 2023/08/04 showed right 9.5/5 irregular shape tumor, 2.35x2.20x2.52cm, LAP(+). Right axillary lymph node SONO guide biosy on 2023/08/07 showed inasive carcinoma, metastatic.
    • Right breast core needle SONO guide biopsy on 2023/08/07 showed invasive carcinoma of no special type, Immunohistochemical study demonstrates: (1) ER: negative (2) PR: negative (3) Her2/neu: positive(3+) (4) Ki-67 inedex: 40% (5) E-cadherin: positive (6) p63: negative.
    • Chest CT on 2023/08/16 showed right breast cancer, T1 or T3?N1Mx.
    • Whole body bone scan on 2023/08/17 showed no bone metastasis. Port-A catheter implantation on 2023/08/23.
    • Explain her condition and chemotherapy with TCHP * 6 or AC * 4 -> TPH to patient and her family on 2023/08/29 with TCHP * 6 -> favored by patient.
    • Now, she was admitted to ward for adjuvant chemotherapy with TCHP (Taxotere 60mg/m2, Carboplatin AUC:4, Herceptin (self pay) 600mg SC, Pertuzumab (self pay) 840mg -> hereafter 420mg) (C1).
  • Course of inpatient treatment
    • After admitted, 2D echo on 2023/09/08 showed M-mode (Teichholz) = 75.4-70.1; 1. Normal AV/MV with no AR/<R; 2. Normal LV chamber size and wall thickness; 3. Preserved LV and RV systolic function; 4. No PR, no TR, normal IVC size.
    • Applying Major Illness on 2023/09/12.
    • Dorsion 1# po BID and Cimetidine 1# po BID on D1~D3 from 2023/09/11~2023/09/13.
    • Adjuvant chemotherapy with TCHP (Taxotere 60mg/m2, Carboplatin AUC:4, Herceptin (self pay) 600mg SC, Pertuzuman (self pay) 840mg -> hereafter 420mg) (C1) on 2023/09/12.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • Hypokalemia (K:3.0mmol/L) with 0.298% KCl in NS 500ml IVF BID from 2023/09/08~2023/09/11.
    • Insomnia with Xanax 1# po PRNHS.
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, she was discharged on 2023/09/13 and OPD followed up later.        
  • Discharge prescription
    • Limeson (dexamethasone 4mg) 1# BID
    • Alpraline (alprazolam 0.5mg) 1# PRNHS
    • Stogamet (cimetidine 300mg) 1# BID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2023-08-29 SOAP Hemato-Oncology Xia HeXiong
  • A: right breast cancer, HER-2 type, cT1N1M0
  • P: Already suggeset
    • TCHP * 6 -> favored by patient
    • AC * 4 -> TPH

[consultation]

• 2024-02-15 Rehabilitation

[immunochemotherapy]

• 2024-02-29 - trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr
  • diphenhydramine 30mg + NS 250mL
• 2024-01-24 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr (TCHP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-30 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr (TCHP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-01 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr (TCHP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-02 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr (TCHP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr (TCHP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 840mg NS 100mL 1hr (TCHP, pertuzumab loading)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-24

Apart from a mild case of hypokalemia (3.3mmol/L), the lab results from 2024-01-23 were largely normal. The decision to use oral potassium supplements can be based on clinical assessment and necessity.

The planned 6 cycles of TCHP therapy will be completed during this hospitalization. Subsequent treatment plans and follow-up schedules might be discussed with the patient to achieve a consensus through shared decision making. (The CT scan on 2023-12-01 revealed regression of the lesion in the right breast and the emergence of a new nodular lesion in the left breast.)

2023-11-02

Lab results from 2023-11-01 showed normal values for CBC, WBC-DC, electrolytes, and liver and kidney function tests.

No moderate or severe treatment related adverse events have been documented. As a result, the 3rd cycle of the docetaxel, carboplatin, trastuzumab and pertuzumab chemotherapy regimen was administered on 2023-11-02 without any complications to date.

2023-10-12

Review of PharmaCloud and HIS5 records revealed no medication reconciliation issues.

700769565

240321

[exam findings]

• 2024-02-24 MRI - brain
  • Imp: No evidence of brain nodule or metastasis. Mild brain atrophy.
• 2024-02-16 CT - abdomen
  • 20230808 CC: body weight loss recently.
  • 20230811 CT: Multiple liver metastases are highly suspected.
  • 20230815 CEA: 18ng/mL (<5), CA153: 394U/mL (<35), AFP: 568ng/mL (<9).
  • 20230815 CT-guided biopsy: Adenocarcinoma, moderately differentiated; Either primary cholangiocarcinoma or metastatic adenocarcinoma from upper GI and biliary tract should be considered. Metastatic breast invasive carcinoma is less likely.
  • History: Left breast cancer s/p MRM on 2012/03/28.
  • Findings: Comparison: prior CT dated 2023/11/17.
    • Prior CT identified multiple poor enhancing masses on both hepatic lobes are noted again, increasing in size and number.
      • It is c/w progressive disease.
      • Small size of S4 and S8 portal vein is noted again that is c/w tumor compression.
    • Prior CT identified multiple lung metastases are noted again at the current CT. Part of metastases show mild increasing in size and part of metastases show mild decreasing in size.
      • Lung metastases S/P C/T with stable disease is highly suspected.
    • Prior CT identified few metastatic nodes in the hepatoduodenal ligament are noted again, stable in size.
    • Prior CT identified carcinomatosis and massive ascites is noted again, increasing in size and number that is c/w progressive disease.
    • There is prominence in size of the spleen (long axis: 12.2 cm) that may be portal hypertension.
    • Normal gallbladder is not visualized in the gallbladder fossa.
      • There is mild dilatation of left lobe IHDs that may be tumor compression.
    • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
  • Impression:
    • Multiple liver metastases show progressive disease.
    • Multiple lung metastases show stable disease.
    • Metastatic nodes in the hepatoduodenal ligament show stable disease.
    • Carcinomatosis show progressive disease.
• 2024-01-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (59 - 14) / 59 = 76.27%
    • M-mode (Teichholz) = 76
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Mild MR, TR
• 2024-01-15, 2023-11-17, -08-29 CXR (erect)
  • S/P port-A implantation.
  • S/P Mastectomy, left.
  • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • Atherosclerotic change of aortic arch
• 2024-01-15 ECG
  • Sinus tachycardia
  • Left axis deviation
  • Abnormal ECG
• 2023-12-26 KUB
  • Ascites is noted after correlate with prior CT.
• 2023-12-06 Thyroid Ultrasound
  • a thyroid nodule 0.64 x 0.48 x 0.61 cm
• 2023-11-17 CT - abdomen
  • Findings: Comparison prior CT dated 2023/08/11.
    • Prior CT identified multiple poor enhancing masses on both hepatic lobes are noted again, decreasing in size.
      • The differential diagnosis includes cholangiocarcinoma and hepato-cholangiocarcinoma.
      • Prior CT identified poor visualization of S4 and S8 portal vein is noted again, stationary. The etiology may be tumor compression.
    • Prior CT identified multiple lung metastases are noted again, mild increasing in size.
    • Prior CT identified few metastatic nodes in the hepatoduodenal ligament are noted again, mild decreasing in size.
    • There is massive ascites and soft tissue lesions in the omentum that is c/w carcinomatosis. Please correlate with ascites cytology.
    • There is prominence in size of the spleen (long axis: 12.2 cm) that may be portal hypertension.
    • Normal gallbladder is not visualized in the gallbladder fossa.
      • There is mild dilatation of left lobe IHDs that may be tumor compression.
    • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
  • Impression:
    • Prior CT identified multiple poor enhancing masses on both hepatic lobes are noted again, decreasing in size.
    • Prior CT identified multiple lung metastases are noted again, mild increasing in size.
    • Prior CT identified few metastatic nodes in the hepatoduodenal ligament are noted again, mild decreasing in size.
    • Carcinomatosis is noted. Please correlate with ascites cytology.
• 2023-08-31 SONO - abdomen
  • Hepatic tumor, huge, right lobe, with suspicious RPV invasion
  • Ascites, small
  • Pleural effusion, right
• 2023-08-28 CXR (erect)
  • S/P port-A implantation.
  • S/P Mastectomy, left.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • Atherosclerotic change of aortic arch
• 2023-08-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (97.3 - 18.9) / 97.3 = 80.58%
    • M-mode (Teichholz) = 80.6
  • Conclusion:
    • Dilated LA
    • Adequate LV,RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild AR
• 2023-08-17 MRA - brain
  • No evidence of brain nodule or metastasis.
• 2023-08-16 PET scan
  • No previous PET scan for comparison.
  • Several focal or nodular lesions of increased FDG uptake in both lobes of the liver and in the right subphrenic lymph nodes, highly suspected the primary or secondary malignancy.
    
  • Increased FDG uptake in the left upper and left lower lungs and in the right upper and right lower lungs, highly suspected the secondary malignancy.
    
  • Left breast cancer s/p treatment, no lesion of increased FDG uptake in bilateral breasts and axillae; highly suspected the primary or secondary malignancy in the liver with right subphrenic lymph nodes involvement, and secondary malignancy in bilateral lungs, by this F-18 FDG PET scan.
• 2023-08-15 Patho - liver biopsy needle/wedge
  • Liver, CT guide biopsy — Adenocarcinoma, moderately differentiated
  • The specimen submitted consists of two strips of yellow gray soft tissue, labeled liver, measuring up to 1.5 x 0.1 x 0.1 cm. All for section.
  • The sections show a picture of adenocarcinoma, moderately differentiated, composed of low columnar neoplastic cells, arranged in gladular pattern embedded within fibrous stroma. Tumor necrosis is present.
  • IHC, the tumor cells show: CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-). Either primary cholangiocarcinoma or metastatic adenocarcinoma from upper GI and biliary tract should be considered. Metastatic breast invasive carcinoma is less likely.
• 2023-08-11 CT - abdomen
  • Findings:
    • There are multiple poor enhancing masses on both hepatic lobes, the largest one in S4/5/8 measuring 13 cm in size (the largest dimension).
      • There is small size of S4, S8, and S5-6 portal vein that is c/w tumor encasement. Ascites and prominence in size of the spleen (long axis: 12.2 cm) is noted that is c/w portal hypertension.
      • In addition, there are two soft tissue nodules 9 mm and 4 mm at right lower perihepatic space omentum that may be direct tumor seeding.
      • Cholangiocarcinoma (T4) is highly suspected.
      • The differential diagnosis includes multiple liver metastases.
    • There are few enlarged nodes in the hepatoduodenal ligament and adenocarcinoma that are c/w regional metastatic nodes (N1).
    • There are several soft tissue nodules on both lungs that are c/w lung metastases (M1).
    • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
    • Normal gallbladder is not visualized in the gallbladder fossa.
  • Imaging Report Form for Cholangiocarcinoma
    • Impression (Imaging stage) : T:T4(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)
• 2021-06-24 Thyroid Ultrasound
  • a thyroid nodule 0.5 x 0.3 x 0.6 cm
• 2021-01-07 Thyroid Ultrasound
  • a thyroid nodule 0.6 x 0.4 x 0.6 cm

[MedRec]

• 2023-08-14 ~ 2023-09-07 POMR Hemato-Oncology He JingLiang
  • Discharge note
    • Liver adenocarcinoma with moderately differentiated stage IV. Tumor cells: CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-), s/p port-a catheter insertion on 2023/08/23.
    • Left breast cancer, infiltrating ductal carcinoma, pT2N0(0/22)M0, stage I, ER(+, 70%), PR(+, 70%), HER-2 FISH (-) in 2012, s/p left modified radical mastectomy, s/p completion of adjuvant chemotherapy with FEC (Fluorouracil, Epirubicin, Cyclophosphamide) x6 and Tamoxifen, then refill Arimidex, 2023/8/11 CT: multiple liver and lung metastases are highly suspected.
    • Hypercalcaemia
    • Chronic viral hepatitis B without delta-agent
    • Type 2 diabetes mellitus
    • Hyperlipidemia
    • Thyrotoxicosis, unspecified without thyrotoxic crisis or storm
    • Hyponatremia
    • Hypomagnesemia
    • Hypokalemia
  • CC
    • She suffered from fatique, poor appetited and body weight loss 6 kg in half year.
  • Present illness
    • This 66-year-old post menopausal woman has 1) Type 2 diabetes mellitus 2) Hyperlipidemia 3) Hyperthyroidism 4) Hepatitis B carrier. She denied any TOCC histories in recent 3 months.
    • She was diagnosed with left breast cancer pT2N0M0 status post left modified radical mastectomy on 2012/03/28 with completion of adjuvant C/T with FEC x6 and Tamoxifen. IHC revealed ER(+,70%), PR(+,70%), HER-2 FISH (-). She loss follow up for 6 years.
    • However, she suffered from fatique, poor appetited and body weight loss 6 kg in half year. As such, she went to Dr. Li’s OPD for further survey.
    • Abdominal CT revealed multiple liver and lung metastases and two soft tissue nodules 9 mm and 4 mm at right lower perihepatic space omentum on 2023/08/14.
    • After well explain including image and the possible treatment were well explained to the patient. This time, she was admitted to our ward for liver biopsy and PET.
  • Course of inpatient treatment
    • After admission, liver CT-guide biopsy was done that revealed adenocarcinoma, moderately differentiated. The tumor cells show CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-). The tumor marker showed CEA: 18.890 ng/ml, CA-153: 394.860 U/ml, AFP: 568.200 ng/ml and CA-125: 187.565 U/ml.
    • Gastroscopy and colonstomy were done that reaveld reflux esophagitis, lower esophagus, LA classification, grade A and Colon polyp at cecum, s/p polypectomy + cliping Colon polyp, sigmoid colon, s/p biopsy. The biopsy revealed Hyperplastic polyp.
    • Brain MRA revealed no evidence of brain nodule or metastasis, Breast sono and Mammography revealed no dominent mass lesion in the breast. As such, consult Oncology for palliative chemotherapy. She underwent of Port-A at right subclavian vein on 8/23 23.
    • She was transfered to Oncology ward for further treatment on 2023/08/24. The lab of electrolyte showed hypercalcaemia (Ca: 2.71mmol/L), so gave hydration with normal saline, Lasix treatmet. She received chemotherapy with C1 Gemzar (800mg/m2)/ Cisplatin (40mg/m2) weekly x 12 on 2023/08/25.
    • Promeran 1tab TIDAC, Imperan 1amp PRNQ6H for vomiting. Vemlidy 1tab QD for Anti-HBC: positive.
    • After treatment, the lab of electrolyte of hypercalcaemia improved (Ca: 2.71 -> 2.72 -> 2.45 -> 2.51mmol/L). Then, she complaints abdomen bolating, and pitting edema 1+ at bilateral lower limbs, the lab of electrolyte showed hyponatremia (Na: 125mmol/L), albumin level 2.8 g/dL, gave Albumin 1bot BID by self-paid x 2 days, Lasix 0.5tab QD, GASLAN 1tab TID,
    • Mint oil and chrysanthemum oil are used for abdominal massage. Dietary education includes adding 2g of salt per day or using salt tablets dissolved in water. A consultation with a dietitian has been arranged to assist with dietary education.
    • Followed-up D-dimer: 8012.80 -> >10000 ng/mL(FEU), so gave Lixiana 1tab QD.
    • KUB: not ileus noted. The symptom of abdomen bolating, pitting edema, and hyponatremia (Na: 125 -> 131 mmol/L), Albumin: 2.8 -> 3.1 g/dL.
    • Followed-up abdomen echo (2023/08/31) relvealed Hepatic tumor, huge, right lobe, with suspicious RPV invasion. Ascites, small. Pleural effusion, right.
    • She received C2 Gemzar (800mg/m2)/ Cisplatin (40mg/m2) weekly x 12 on 2023/09/1, and TS-1 1 tab BID by self-paid since 2023/09/04.
    • After chemotherapy, she deniede having a fever, vomiting, diarrhea, or any complaints. And the lab of CBC/DC showed anemia (Hb: 8.4 g/dL), the lab of electrolyte showed hypomagnesemia (Mg: 1.7mg/dL), hypokalemia (K: 3.3mmol/L), so gave blood transfusion with LPRBC, MgSO4 IVD plus MgO 1tab TID, and Const-K 1tab QD treatmen.
    • She can be discharged on 2023/09/07, the OPD follow-up will be arranged.
  • Discharge prescription
    • Const-K (potassium chloride 750mg/10mEq/tab) 1# QD
    • Lixiana (edoxaban 30mg) 1# QD
    • TS-1 (tegafur, gimeracil, oteracil; 25mg) 1# QD
    • BaoGan (silymarin 150mg) 1# BID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • MgO 250mg 1# TID
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Vemlidy (tenofovir alafenamide 25mg) 1# QDAC
    • Uretropic (furosemide 40mg) 1# QD
    • Uformin (metformin 500mg) 1# TIDCC
    • methimazole 5mg 1# QOD
    • Tulip (atorvastatin 20mg) 0.5# QD

[consultation]

• 2024-02-22 Metabolism and Endocrinology
  • Q
    • for Hyperthyroidism for evaluation
    • This 68-year-old woman, who hasing the history of: 1) Type 2 diabetes mellitus under medication control (Uformin 500mg/tab 1tab TIDCC), 2) Hyperlipidemia under medication control (Tulip 0.5tab QD), 3) Hyperthyroidism under medication control since 2012/2~ (Methimazole 5MG/TAB 0.5tab QOD), 4). Letf breast cancer pT2N0M0 status post left modified radical mastectomy on 2012/03/28 with completion of adjuvant C/T with FECx6 and Tamoxifen. IHC revealed ER(+,70%), PR(+,70%), HER-2 FISH (-), 5) Right breast tumor post tumor excision on 2019/11/27.
    • A patient of intrahepatic cholangiocarcinoma with moderately differentiated stage IV. Tumor cells: CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-) was diagnosed on 2023-08-17, s/p chemotherapy with Gemzar (800mg/m2) /Cisplatin (40mg/m2) + TS-1 (self-paid) 1# po bid x 12 days. Abdomen CT (2024/02/16) revealed 1. Multiple liver metastases show progressive disease, and massive ascites is noted. 2. Multiple lung metastases show stable disease. 3. Metastatic nodes in the hepatoduodenal ligament show stable disease. 4. Carcinomatosis show progressive disease.
    • The patient request to consult Metabolism Department Dr. Yu for Hyperthyroidism for evaluation, so we need your help, thanks a lot!!
  • A
    • This 67 year old female with DM, dyslipidemia, hyperthyroidism, and left breast cancer was admitted for intrahepatic cholangiocarcinoma. We were consulted for hyperthyrodisim evaluation.
    • S:
      • QOD
    • O:
      • BH 161 cm BW 57 kg
      • HR 80 bpm
      • BT 36.4’C
      • EKG ( 2/15 ) Sinus tachycardia with occasional Premature ventricular complexes
      • WBC/Seg/Band/ANC ( 2/21 ) 1620/60.9/0/972
        • 2024-02-21 WBC 1.62 x10^3/uL
          
        • 2024-02-19 WBC 4.13 x10^3/uL
          
        • 2024-02-15 WBC 5.56 x10^3/uL
          
        • 2024-01-31 WBC 2.66 x10^3/uL
          
        • 2024-01-22 WBC 3.88 x10^3/uL
          
        • 2024-01-19 WBC 8.28 x10^3/uL
          
        • 2024-01-18 WBC 1.65 x10^3/uL
          
      • ALT/AST/Bilirubin Total/direct ( 2/21 ) 34/59/1.39/0.77
      • TSH/fT4 ( 2/19 ) 2.423/0.92
        • 2024-02-19 TSH 2.423 uIU/mL
          
        • 2024-01-18 TSH 2.228 uIU/mL
          
        • 2023-11-20 TSH 3.057 uIU/mL
          
        • 2023-10-24 TSH 2.432 uIU/mL
          
        • 2024-02-19 Free-T4 0.92 ng/dL
          
        • 2024-01-18 Free-T4 1.22 ng/dL
          
        • 2023-11-20 Free-T4 0.99 ng/dL
          
        • 2023-10-24 Free-T4 1.02 ng/dL
          
        • 2024-02-21 TSH receptor Ab 18 %
          
        • 2023-12-27 TSH receptor Ab 12 %
          
      • LDL/HDL/TG (2/19) 56/29/78
      • Medication at OPD: methimazole 1# QOD
    • A:
      • Hyperthyroidism, under methimazole
      • Type 2 DM, under metformin
      • Liver adenocarcinoma with moderately differentiated, highly suspected of lung metastasis, stage IV. Tumor cells: CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-), s/p Gemzar/ Cisplatin
      • Left breast cancer, infiltrating ductal carcinoma, pT2N0(0/22)M0, stage I, ER(+, 70%), PR(+, 70%), HER-2 FISH (-) in 2012, s/p left modified radical mastectomy, s/p completion of adjuvant chemotherapy with FEC (Fluorouracil, Epirubicin, Cyclophosphamide) x6 and Tamoxifen, then refill Arimidex.last chemotherapy on 2024/2/15
      • Type 2 diabetes mellitus
      • dyslipidemia
    • P:
      • Avoid antithyroid drug (Lica) at this moment for ANC < 1000.
      • Regular follow up liver function, bilirubin, and check WBC/DC.
      • Recheck TSH/FT4 1 week later.
      • We will arrange thyroid echo at OPD later, and please arrange OPD follow up.
• 2024-02-19 Radiation Oncology
  • Q: for pig-tail insertion, due to ascites.
  • A: According to the clinical condition and imaging findings, drainage is indicated.
• 2023-08-22 Obstetrics and Gynecology
  • Q: same as for Hemato-Oncology
  • A
    • 66 y/o, P0, married woman (menopaused at 50 y/o) was admitted to our GS ward for suspected liver adenocarcinoma with lung metases.
    • Fatigue, poor appetited and body weight loss 6 kg in half year was mentioned
    • PHx:
      • left breast cancer pT2N0M0 status post left modified radical mastectomy on 2012/3/28 with completion of adjuvant C/T with FEC x6 and Tamoxifen.
      • type 2 diabetes mellitus
      • Hyperlipidemia
      • Hyperthyroidism
      • Hepatitis B carrier
    • Abdominal CT: multiple liver and lung metastases and two soft tissue nodules 9 mm and 4 mm at right lower perihepatic space omentum on 2023/08/14.
    • After admission, certain surveys were done:
      • Tumor marker :CEA 18.890 ; AFP: 568.200, CA-153: 394.860 and CA-125: 187.565.
      • liver biopsy: adenocarcinoma, moderately differentiated, the tumor cells show CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-).
        
      • Gastroscopy and colonstomy: no metastasis evidence.
    • We were consulted for elevated Ca-125: 187.565 U/ml.
    • PV:
      • scanty discharge
      • cervix: grossly normal
    • TVUS:
      • Uterus: AVFL, EM 0.6mm, grossly normal
      • Bilateral adnexa: free, no ovarian mass was noted
      • CDS: massive ascites
    • IMP/Suggestion:
      • No obvious gynecologic lesions
      • elevated serum CA 125 concentration might be related to ascites, liver diseases/cancer etc.
• 2023-08-22 Hemato-Oncology
  • Q
    • for suspicious chalagiocarcinoma
    • This 66-year-old post menopausal woman has 1) Type 2 diabetes mellitus 2) Hyperlipidemia 3) Hyperthyroidism 4) Hepatitis B carrier. She denied any TOCC histories in recent 3 months. She was diagnosed with left breast cancer pT2N0M0 status post left modified radical mastectomy on 2012/03/28 with completion of adjuvant C/T with FEC x6 and Tamoxifen. IHC revealed ER(+,70%), PR(+,70%), HER-2 FISH (-).
    • She loss follow up for 6 years. However, she suffered from fatique, poor appetited and body weight loss 6 kg in half year. As such, she went to Dr. Li’s OPD for further survey.
    • Abdominal CT revealed multiple liver and lung metastases and two soft tissue nodules 9 mm and 4 mm at right lower perihepatic space omentum on 2023/08/14. After well explain including image and the possible treatment were well explained to the patient. She was admitted to our ward for further suevey on 8/14. After ward, liver biopsy was done that revealed adenocarcinoma, moderately differentiated, the tumor cells show CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-).
    • Gastroscopy and colonstomy were done that reaveld aeflux esophagitis, lower esophagus, LA classification, grade A and Colon polyp at cecum, s/p polypectomy + cliping Colon polyp, sigmoid colon, s/p biopsy.
    • The tumor marker revealed CEA 18.890, AFP: 568.200, CA-153: 394.860 and CA-125: 187.565. As such, we need your help for palliative chemotherapy .
  • A
    • Under the impression of cholangiocarcinoma with liver and lung metastasis, we are consulted for palliative chemotherapy.
    • Suggestion:
      • Please check Anti HBc, arrange port A insertion.
      • We had well explaint to patient about palliative chemotherapy (Gem+Cis). We will take over this case if you agree (May transfer to 11A on Dr He’s service) Thanks for your consultation.
• 2023-08-14 Radiation Oncology
  • Q: This 66 years old woman was giagnosed with left breast cancer then underwent of MRM on 2012/3/28 and completion of adjuvant C/T with FEC x6 and Tamoxifen. However, Abdomial CT showed Multiple liver and lung metastases are highly suspected. As such, we need your help for liver biopsy, thanks.
  • A: According to the clinical condition and imaging findings, biopsy is indicated.

[chemotherapy]

• 2024-03-20 - oxaliplatin 85mg/m2 100mg D5W 100mg 2hr + leucovorin 400mg/m2 610mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-02-23 - oxaliplatin 85mg/m2 100mg D5W 100mg 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (PLT 48K: 3840 -> 3500mg) (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-02-15 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2024-01-19 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2024-01-12 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-12-27 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-12-19 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-11-22 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-11-15 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-10-24 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-10-19 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-09-27 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-09-21 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-09-01 - gemcitabine 800mg/m2 1000mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2023-08-25 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL

TS-1

• 2023-08-14 ~ 2024-02-15 - TS-1 (tegafur 25mg, gimeracil 7.25mg, oteracil potassium 24.5mg)

==========

2024-03-21

[recent decline in renal function - encourage hydration upon discharge]

The patient’s recent kidney function appears to have declined. As the patient is about to be discharged, please advise her to maintain adequate hydration after discharge.

• 2024-03-20 eGFR 78.30
• 2024-03-06 eGFR 96.63
• 2024-02-23 eGFR 147.71
• 2024-02-21 eGFR 185.15

2024-02-23

[leukopenia & thrombocytopenia following chemotherapy: monitoring PLT for Transfusion]

Gemcitabine, cisplatin, and TS-1 combination chemotherapy was initiated in 2023-08. The disease remained stable until a CT scan performed on 2024-02-16 revealed multiple liver metastases and carcinomatosis, indicating disease progression. Consequently, the treatment regimen was switched to FOLFOX, which was first administered during this hospitalization.

Leukopenia and thrombocytopenia developed following the last dose of gemcitabine, cisplatin, and TS-1 on 2024-02-15.

• 2024-02-23 WBC 3.45 x10^3/uL
  

• 2024-02-21 WBC 1.62 x10^3/uL
  

• 2024-02-19 WBC 4.13 x10^3/uL
  

• 2024-02-15 WBC 5.56 x10^3/uL

• 2024-02-23 PLT 48 *10^3/uL
  

• 2024-02-21 PLT 78 *10^3/uL
  

• 2024-02-19 PLT 102 *10^3/uL
  

• 2024-02-15 PLT 184 *10^3/uL

The WBC count has since recovered to 3.45 K/uL; however, the PLT count remains low at 48 K/uL. If the bleeding risk is assessed as high, leukocyte-reduced packed red blood cell (LRP) transfusion may be necessary.

2024-01-19

[leukopenia]

Granocyte (lenograstim) was administered on 2024-01-11. Subsequently, the WBC nadir, occurred on 2024-01-18. However, by 2024-01-19, this nadir had resolved, indicating a recovery in WBC count.

• 2024-01-19 WBC 8.28 x10^3/uL
• 2024-01-18 WBC 1.65 x10^3/uL **
• 2024-01-15 WBC 2.35 x10^3/uL *
• 2024-01-11 WBC 2.45 x10^3/uL * Granocyte
• 2024-01-03 WBC 2.08 x10^3/uL *
• 2023-12-29 WBC 4.34 x10^3/uL

2024-01-12

[gemcitabine + cisplatin: success might falter as markers surge]

The gemcitabine + cisplatin treatment started on 2023-08-25 and continues, but lab results from 2024-01-09 show record highs for both CEA and CA199 markers. This could potentially indicate developing resistance in the disease.

• 2024-01-09 CEA (NM) 26.176 ng/ml

• 2023-12-12 CEA (NM) 18.186 ng/ml

• 2023-12-05 CEA (NM) 21.272 ng/ml

• 2023-11-14 CEA (NM) 16.023 ng/ml

• 2023-11-07 CEA (NM) 19.729 ng/ml

• 2023-10-24 CEA (NM) 12.994 ng/ml

• 2023-10-09 CEA (NM) 12.462 ng/ml

• 2023-09-26 CEA (NM) 7.880 ng/ml

• 2023-09-19 CEA (NM) 6.288 ng/ml

• 2023-08-15 CEA (NM) 18.890 ng/ml

• 2024-01-09 CA-199 (NM) 59.203 U/ml

• 2023-12-12 CA-199 (NM) 45.760 U/ml

• 2023-12-05 CA-199 (NM) 51.454 U/ml

• 2023-11-14 CA-199 (NM) 45.873 U/ml

• 2023-11-07 CA-199 (NM) 40.871 U/ml

• 2023-10-24 CA-199 (NM) 42.186 U/ml

• 2023-10-09 CA-199 (NM) 45.064 U/ml

• 2023-09-26 CA-199 (NM) 31.407 U/ml

• 2023-09-19 CA-199 (NM) 33.127 U/ml

• 2023-08-15 CA-199 (NM) 26.597 U/ml

2023-09-25

This patient’s PharmaCloud is currently inaccessible. After reviewing the HIS5 records, no medication reconciliation issues were identified.

701474911

240321

[MedRec]

• 2023-05-26 ~ 2023-06-16 POMR Chest Medicine Huang JunYao
  • Discharge diagnosis
    • Right upper lobe Lung cancer, adenocarcinoma, with bone metastasis, T4N3M1b, stage IVA, ECOG 1
    • Chronic obstructive pulmonary disease, unspecified
  • CC
    • For lung cancer treatment
  • Present illness
    • This 67 y/o male, a smoker with 1 ppd for 40+ years quitted for 1 month, with (1) moderate COPD, (2) bilateral renal with ureteral stones s/p lithotripsy and double J stenting on 2023/03/14 and 03/28, he was regular follow up at GU OPD, (3) lung adenocarcinoma, with bone metastasis, T4N3M1b, stage IVA, ECOG 1. This time admission for lung cancer teratment.
    • Taken history with RUL tumor was done, including biopsy (2023/04/11) + brain MRI (2023/04/11) + PET (2023/04/12) + bone scan (2023/04/13). Reports confirmed 5.8cm RUL lung adenocarcinoma, with inf. pulmonary artery, right hilar LNs and bil. mediastinal LNs involvement, T6 spinal metastasis but no brain metastasis. Staging was as follows: RUL lung adenocarcinoma, with bone metastasis, pT4N3M1b, stage IVB. Gene tests including EGFR, ROS-1, PD-L1 were sent and radiotherapist was consulted for R/T.
    • Bone RT for 3000cGy/10 fx is suggested for pain control. CT simulation was done on 4/18 and R/T initiated on 2023/04/19. Gene tests reported on 2023/04/24 ROS-1 (-) and PD-L1 70%, EGFR wild type. First time C1-1 Cyramza 500mg was given on 2023-05-04.
    • This time, he was admission for lung cancer treatment. He was complain about he has cold, cough with sputum for days, no fever noted, mild fatigue and poor appetite were also noted.
    • Under the impression of Lung adenocarcinoma, with bone metastasis, T4N3M1b, stage IVA,
    • Hhe was admitted to our CM ward for chemotherapy with C1 Pemetred, immunotherapy with Atezolizumab, Bevacizumab, CDDP if self insurence payment due to NHIA rejected Pembrolizumab admission to our cm ward for future treatment and management.
  • Course of inpatient treatment
    • After admission, this time he was admission for lung cancer treatment. Under the normal ANC count, C1 Avastin 500mg (free) was smothly given on 2023/05/29, chmotherapy with C1 Alimta 800mg plus CDDP 50mg were also smoothly given on 2023/05/30, immunotherapy with C1 Atezo 1200mg given on 2023/05/31, we’ll keep close monitor about the side effect with chemotherapy and immunotherapy. Beside, We consulted Thoracic surgeon for prot A insertion for future chemotherapy, and will be OP on 2023/06/01.
    • However fever episode on 2023/05/30, hold Port-A implantantion. Antibioitc with Sintrix was given for intermittent fever since 2023/06/05. However spike fever episode again,we change antibiotic to Brosym + Zyvox, and DC port-A operation in this times. Adequate IVF was given for poor intake. As present, stable vital sign and condition. He will discharge on 2023-06-16 thne CM OPD for further management.
  • Discharge prescription
    • aminophylline 100mg 1# BID
    • Folacin (folic acid 5mg) 1# QD
    • naproxen 250mg 1# TID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Ulstop (famotidine 20mg) 1# BID
    • Xyzal (levocetirizine 5mg) 1# HS
    • Actein Effervescent (acetylcysteine 600mg) 1# BID

[immunochemotherapy]

• 2024-03-21 - atezolizumab 1200mg NS 250mL 60min
• 2024-03-20 - pemetrexed 500mg/m2 800mg NS 100mL 10min
  • dexamethasone 4mg + hydroxocobalamin 1mg IM + NS 50mL
• 2024-03-19 - bevacizumab 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2024-02-21 - atezolizumab 1200mg NS 250mL 60min
• 2024-02-20 - pemetrexed 500mg/m2 800mg NS 100mL 10min
  • dexamethasone 4mg + hydroxocobalamin 1mg IM + NS 50mL
• 2024-02-19 - bevacizumab 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2024-01-10 - atezolizumab 1200mg NS 250mL 60min
• 2024-01-09 - pemetrexed 500mg/m2 800mg NS 100mL 10min
  • dexamethasone 4mg + hydroxocobalamin 1mg IM + NS 50mL
• 2024-01-08 - bevacizumab 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-12-13 - atezolizumab 1200mg NS 250mL 60min
• 2023-12-12 - pemetrexed 500mg/m2 800mg NS 100mL 10min
  • dexamethasone 4mg + hydroxocobalamin 1mg IM + NS 50mL
• 2023-12-11 - bevacizumab 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-11-15 - atezolizumab 1200mg NS 250mL 60min
• 2023-11-14 - pemetrexed 500mg/m2 800mg NS 100mL 10min
  • dexamethasone 4mg + hydroxocobalamin 1mg IM + NS 50mL
• 2023-11-13 - bevacizumab 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-10-23 - [KCl 15% 5mL NS 500mL 2hr + KCl 15% 5mL D5W 500mL] 2hr (before CDDP) + cisplatin 75mg/m2 50mg NS 350mL 3hr + [KCl 15% 5mL NS 500mL 2hr + KCl 15% 5mL D5W 500mL] 2hr (after CDDP)
  • granisetron 3mg NS 100mL 30min + mannitol 20% 150mL + lorazepam 0.5mg PO
• 2023-10-18 - atezolizumab 1200mg NS 250mL 60min
• 2023-10-17 - pemetrexed 500mg/m2 800mg NS 100mL 10min
  • dexamethasone 4mg + hydroxocobalamin 1mg IM + NS 50mL
• 2023-10-16 - bevacizumab 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-09-20 - atezolizumab 1200mg NS 250mL 60min
• 2023-09-19 - [KCl 15% 5mL NS 500mL 2hr + KCl 15% 5mL D5W 500mL] 2hr (before CDDP) + cisplatin 75mg/m2 50mg NS 350mL 3hr + [KCl 15% 5mL NS 500mL 2hr + KCl 15% 5mL D5W 500mL] 2hr (after CDDP)
  • granisetron 3mg NS 100mL 30min + mannitol 20% 150mL + lorazepam 0.5mg PO
• 2023-09-18 - bevacizumab 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-08-23 - atezolizumab 1200mg NS 250mL 60min
• 2023-08-22 - [KCl 15% 5mL NS 500mL 2hr + KCl 15% 5mL D5W 500mL] 2hr (before CDDP) + cisplatin 75mg/m2 50mg NS 350mL 3hr + [KCl 15% 5mL NS 500mL 2hr + KCl 15% 5mL D5W 500mL] 2hr (after CDDP)
  • granisetron 3mg NS 100mL 30min + mannitol 20% 150mL + lorazepam 0.5mg PO
• 2023-08-21 - bevacizumab 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-07-19 - atezolizumab 1200mg NS 250mL 60min
• 2023-07-17 - bevacizumab 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-05-30 - [KCl 15% 5mL NS 500mL 2hr + KCl 15% 5mL D5W 500mL] 2hr (before CDDP) + cisplatin 75mg/m2 50mg NS 350mL 3hr + [KCl 15% 5mL NS 500mL 2hr + KCl 15% 5mL D5W 500mL] 2hr (after CDDP)
  • granisetron 3mg NS 100mL 30min + mannitol 20% 150mL + lorazepam 0.5mg PO
• 2023-05-30 - pemetrexed 500mg/m2 800mg NS 100mL 10min
  • dexamethasone 4mg + hydroxocobalamin 1mg IM + NS 50mL
• 2023-05-29 - bevacizumab 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-05-04 - ramucirumab 500mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 50mL

700077322

240320

[exam findings]

[MedRec]

• 2024-03-01 ~ 2024-03-07 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Malignant neoplasm of bladder, unspecified
    • Secondary malignant neoplasm of unspecified lung, multiple lung metastases
    • Thalassemia, unspecified
    • Enlarged prostate with lower urinary tract symptoms
    • Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions
    • Hypertensive heart disease without heart failure
    • Type 2 diabetes mellitus without complications
  • CC
    • For first Taxotere regimens
  • Present illness
    • This is a 48 year-old man, has the past history of
      • Bladder mucinous adenocarcinoma over dome s/p adjuvant CMV, with metastasis to pelvic lymph node, s/p salvage therapy with M-VAC followed by radiotherapy, with metastasis to lung, s/p 5-FU and leucovorin, in progression, s/p CAL056, refrectory for lung tumor progression, s/p PFL from 2023/03/08~2023/09/07 (8 cycles)
      • hypertension
      • diabetes mellitus
      • resolved hyperthyroidism after the treatment of Lica from 2017/08 to 2018/05.
    • The patient had the initial presentation of hematuria noted in 2015/04. The abdomen/pelvis MRI on 2015-05-06 showed a mass with 4.3 * 2.6 cm in size over the dome of urinary bladder. On 2015/05/22, the laparoscopic partial cystectomy with en block resection of the urachus and bilateral pelvic lymph node dissection was performed. The pathological report revealed adenocarcinoma of urachus. The initial pathological stage was pT3aN0M0, Stage III. The subject was treated with the adjuvant chemotherapy with 6 courses of CMV (Cisplatin, Methotrexate, Vinblastine) from 2015/07/21 to 2015/12/15. The best response was CR, and the chemotherapy was discontinued because the adjuvant treatment was completed.
    • On 2017/06/28, CT scan demonstrated the enlarging right pelvic LN up to 1.7*3 cm, the pathological report showed metastatic adenocarcinoma. The subject was treated with M-VAC (Methotrexate, Vinblastine, Adriamycin, Cisplatin) from 2017/11/01 to 2018/02/06, and received radiotherapy with 4500cGy/25 fractions to the metastatic pelvic and paraaortic lymph nodes from 2018/03/08 to 2018/04/12. The best response was CR, and the chemotherapy was discontinued because the treatment was completed.
    • On 2020/05/04, the follow-up CT disclosed that there were metastases to bilateral lung fields and mediastinal-left axillary LNs. The sono-guided biopsy on 2020/05/15 showed adenocarcinoma. The subject received the regimen of high dose of 5-FU and leucovorin from 2020/07/21 to 2021/12/29. The best response was SD and the chemotherapy was discontinued due to PD. The current stage is cT0N0M1, Stage IV. Because the subject failed to the standard treatment, the subject and family agreed to sign the informed consent form, after adequate discussion with the treatment of CAL056. The ECOG performance status was “0”. Then the subject started to take the screening process. The subject started to receive the investigational product since 2022/02/08. Abdominal CT on 2022/04/01 showed prior CT identified mutliple metastases on both lung are noted again, mild increasing in size. PTA on 2022/04/07 showed R’t normal to mild SNHL, L’t normal to moderate SNHL.
    • For CT on 2023/10/11 showed bladder cancer lung and bone meta as well as the lymphadenopathy in the mediastinum, in progression. Therefore, the patient had received cryotherapy on 11/20.
    • However, follow up Tc-99m MDP bone scan on 2024/01/05 revealed multiple bone metastases. Chest CT on 2024/01/23 showed bladder cancer with lungs and distant LNs metastases, in progression and stationary of RT chest wal metastasis as compared with CT on 2023/10/11.
    • This time, he was admission for first time Taxotere regimens.
  • Course of inpatient treatment
    • After admission, he had reveived first dose of Paclitaxel on 2024/03/06. Mild numbness over right hand was noted. There was no fever, no hypotension, no skin rash, no diarrhea after Paclitaxel infusion. Under the relative stable clinical condition, the patient was discharged on 2024/03/07 with outpatient department follow-up.
  • Discharge prescription
    • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# TID
    • Allegra (fexofenadine 60mg) 1# BID
    • Deflam-K (diclofenac 25mg) 1# PRNTID if pain

[chemotherapy]

• 2024-03-05 - paclitaxel 80mg/m2 120mg NS 250mL 3hr

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL

• 2023-09-06 - cisplatin 30mg/m2 60mg NS 500mL 2hr (Y-sited LV) + leucovorin 300mg/m2 550mg NS 250mL 2hr (Y-sited CDDP) + fluorouracil 2000mg/m2 3600mg NS 160mL 24hr (infusor) (PFL)

  • dexamethasone 4mg + metoclopramide 10mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + NS 1000mL (Y-sited CDDP & LV)

• 2023-07-26 - (PFL)

• 2023-07-12 - (PFL)

• 2023-06-14 - (PFL)

• 2023-05-31 - (PFL)

• 2023-04-26 - (PFL)

• 2023-04-12 - (PFL)

• 2023-03-08 - (PFL)

• 2023-02-03 - gemcitabine 800mg/m2 1500mg NS 100mL 30min + cisplatin 25mg/m2 45mg NS 500mL 3hr + NS 1500mL (Y-sited) (Gemzar/CDDP)

  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-01-05 - (Gemzar/CDDP)

• 2022-12-29 - (Gemzar/CDDP)

• 2022-12-08 - (Gemzar/CDDP)

• 2022-12-01 - (Gemzar/CDDP)

• 2022-11-10 - (Gemzar/CDDP)

• 2022-11-03 - (Gemzar/CDDP)

• 2022-10-13 - (Gemzar/CDDP)

• 2022-10-06 - (Gemzar/CDDP)

• 2022-09-15 - (Gemzar/CDDP)

• 2022-09-08 - (Gemzar/CDDP)

• 2022-08-18 - (Gemzar/CDDP)

• 2022-08-11 - (Gemzar/CDDP)

• 2022-07-28 - (Gemzar/CDDP)

• 2022-07-21 - (Gemzar/CDDP)

• 2022-06-29 - (Gemzar/CDDP)

• 2022-06-23 - (Gemzar/CDDP)

• 2022-05-11 - (Gemzar/CDDP)

• 2022-05-04 - (Gemzar/CDDP)

• 2022-04-21 - (Gemzar/CDDP)

• 2022-04-14 - (Gemzar/CDDP)

• 2022-04-08 - (Gemzar/CDDP)

• 2021-12-29 - leucovorin 400mg/m2 720mg NS 500mL 2hr + fluorouracil 2600mg/m2 4600mg NS 140mL 22hr (infusor)

• 2021-12-15

• 2021-12-01

• 2021-11-24

• 2021-11-17

• 2021-11-03

• 2021-10-27

• 2021-10-19

• 2021-10-05

• 2021-09-28

• 2021-08-24

• 2021-08-10

• 2021-07-27

• 2021-07-13

• 2021-06-29

• 2021-06-15

• 2021-06-01

• 2021-05-11

• 2021-04-27

• 2021-04-20

• 2021-03-30

• 2021-03-23

• 2021-03-16

• 2021-03-02

• 2021-02-23

• 2021-02-02

• 2021-01-26

• 2021-01-19

• 2021-01-05

• 2020-12-29

• 2020-12-22

• 2020-12-01

• 2020-11-24

• 2020-11-17

• 2020-11-03

• 2020-10-27

• 2020-10-20

• 2020-09-29

• 2020-09-08

• 2020-09-01

• 2020-08-25

• 2020-08-11

• 2020-08-04

• 2020-07-21

==========

700254699

240320

[exam findings]

• 2024-03-18 Patho - bone marrow biopsy
  • Bone marrow, iliac crest, biopsy — No lymphoma involvement
  • The sections show normocellular marrow (30%). M/E ratio = 5:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. No focal lymphoid aggregation.
  • IHC, scattered small CD3+ T-cell and CD20+ B lymphocytes in interstitium can be identified. There is no evidence of lymphoma involvement in the sections examined. Suggest further bone marrow smear evaluation and clinic correlation.
• 2024-03-13 CT - abdomen
  • Findings:
    • There is segmental circumferential mild asymmetrical wall thickening at the terminal ileum, measuring 9 cm in size.
      • In addition, there are several enlarged nodes in right side mesentery.
      • Lymphoma of the terminal ileum is highly suspected.
      • Please correlate with colonoscopy.
    • There is mild ascites in the cul-de-sac.
    • There are several renal cysts on both kidney (up to 2.6 cm).
      • In addition, there is focal parenchyma defect at left kidney lower pole that is c/w old inflammatory process.
  • Impression:
    • Lymphoma of the terminal ileum is highly suspected. Please correlate with colonoscopy.
• 2024-03-08 PET scan
  • Glucose hypermetabolism in the right tongue base. Primary malignancy in the right tongue base may show this picture.
  • Glucose hypermetabolism in multiple right neck level II to IV lymph nodes, compatible with metastatic lymph nodes.
  • Glucose hypermetabolism in a focal area in the right anterior lower pelvic cavity, near the proximal portion of the ascending colon. Another primary malignancy in this region may show this picture. Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in multiple bilateral paraaortic and right pelvic lymph nodes, suggesting metastatic lymph nodes.
• 2024-03-07 SONO - abdomen
  • Left renal cyst (1.82x2.27cm).
• 2024-03-04 ECG
  • Sinus rhythm with 1st degree A-V block
• 2024-03-04 Patho - gingival/oral mucosa biopsy
  • Tongue base, right, biopsy — Diffuse large B-cell lymphoma, GCB type
  • Section shows squamous mucosa with infiltration of large pleomorphic tumor cells and marked crushed artifact.
  • The immunohistochemical stains reveal CK(-), CD20(+), CD3(-), CD5(-), CD10(+), CD30(-), MUM1(+), BCL2(-), BCL6(-), Cyclin D1(-), and cMYC(-). The Ki-67 is > 90%.
• 2024-03-04 MRI - nasopharynx
  • p16(+) Oropharnxy
    • Impression (Imaging stage): T: 3 if P16+(T_value) N: 1(N_value) M: 0(M_value) STAGE: II(Stage_value)
• 2024-03-04 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Gastric shallow ulcers, antrum, s/p biopsy
    • Gastric polyps, fundus
  • CLO test:
    • Negative
• 2024-03-04 Nasopharyngoscopy
  • Findings
    • smooth NPx, HPx
    • 4*3 cm protruding mass over R tonge base
  • Dx/Conclusion
    • R tonge base tumor and R neck mass
• 2023-09-04 Patho - colorectal polyp
  • Colorectum, cecum (120 cm from anal verge) Polypectomy (cold snaring) Specimen: A — Tubular adenoma with low grade dysplasia
  • Colorectum, sigmoid colon (30 cm from anal verge) Biopsy removal Specimen: B — Hyperplastic polyp
• 2021-02-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (75.1 - 12.2) / 75.1 = 83.75%
    • LVEF (%) = 65.4
    • M-mode (Teichholz) = 83.8
    • 2D (M-Simpson) = 63.0
  • Conclusion:
    • Normal AV with trivial AR
    • Normal MV with mild MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • No PR, Mild TR, normal IVC size

700954521

240320

[exam findings]

• 2024-03-06 Patho - peritoneum biopsy
  • Retroperitoneal, biopsy — metastatic invasive carcinoma, compatible with breast origin
  • Immunohistochemical study demonstrates - ER: negative, PR: negative , Her2/neu: negative (1+), GATA3: positive, CK20: negative.
• 2024-03-05 CT - abdomen
  • Imp
    • Left breast cancer. Bil. pleural effusion.
    • Peritoneal and retroperitoneal carcinomatosis with ascites.
    • Bony metastases at T7, T10, L2-3.
    • Some enlarged LNs at retroperitoneum along aorta/ IVC and iliac vessels.
• 2024-03-03 KUB
  • S/P bilateral double J catheters insertion.
  • Spine metastases.
• 2024-02-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (77.3 - 23.9) / 77.3 = 69.08%
    • M-mode (Teichholz) = 69.1
  • Conclusion:
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Left pleural effusion
    • Poor echo window
• 2024-02-13 KUB
  • Sclerotic densities in lumbar spine, r/o bone metastasis.
• 2024-02-10 CT - abdomen
  • Retroperitoneal mass, in progression
  • s/p double J catheter insertions
  • Para-aortic lymph node and bone metastasis
• 2024-01-15 CT - abdomen
  • IMP:
    • Some enlarged LNs at retroperitoneum along aorta/ IVC and iliac vessels r/o metastases. Bil. hydronephrosis.
    • Swelling of left abdominal wall.
    • Bony metastases at T10, L2-3.
• 2024-01-12 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis
  • CLO test: Negative
• 2024-01-12 SONO - abdomen
  • Diagnosis:
    • Fatty liver, severe
    • Liver cyst, S3 and S8
    • Hydronephrosis, bilateral
    • fat infiltration of pancreas.
  • Suggestion:
    • Urology OPD for further evaluation.
• 2024-01-06 SONO - nephrology
  • Interpretation:
    • Bilateral hydronephrosis with hydroureter, mild to moderate degree.
    • NO evidence of urinary retention
• 2023-12-21 PET
  • As compared with the previous study on 2023-06-28, most of the glucose hypermetabolic lesions in the left breast, left axillary lymph nodes, left paraspinal area about T9 spine level and in multiple bones as mentioened above are either new or more prominent, suggesting disease in progression.
  • The glucose hypermetabolism in the right axillary lymph nodes is a little more evident. The nature is to be determined (inflammation in a little more severe status? other nature?). Please correlate with other clinical findings for further evaluation.
• 2023-12-19 SONO - breast
  • Diagnosis
    • Left fibroadenomas as described
    • R/O left breast tumor (#3)
    • s/p left breast operation
    • Bil. axillary LAP
  • BI-RADS:
    • 4a. suspicious abnormality, biopsy should be considered (low suspicion for malignancy: 2-10%)
• 2023-06-28 PET
  • Compared with the previous study on 2022-08-12, several old glucose hypermetabolic lesions disappear or come to much less evident including in the left neck region, left upper back region, left surpra- and infraclavicular regions, suprasternal region, left parasternal region, around the proximal portion of left upper arm, upper mediastinum, abdominal bilateral paraaortic regions, and in bilateral some ribs.
  • However, there are still focal lesions of increased FDG uptake in the left breast, several left axillary lymph nodes, and in skeleton including T7, T10, L2 and L3 spines, and right femoral head.
    
  • Increased FDG uptake in the right axillary lymph nodes, probably reactive or metastatic nodes.
    
  • Left breast cancer s/p treatment with partial response to current therapy, ycTxN2M1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2022-12-13 CT - chest
  • Impression: recurrent Lt breast with left axillary and supraclavicular fossa LNs metastases, and bony metastasis, in regression compared with CT on 2022/08/16
• 2022-08-25 Patho - lymphnode biopsy
  • Labeled as “left neck lymph nodes (zone 2)”, biopsy — metastatic carinoma (3/3) with extranodal extension.
  • Section shows metastatic carinoma (3/3) occupying entire lymph nodes with extranodal extension.
  • IHC stain: GATA-3 (+), compatible with breast origin.
• 2022-08-16 CT - chest
  • Impression: recurrent Lt breast with extensive left axillary and supraclavicular fossa LNs metastases, and bony metastasis.
• 2022-08-15 MRI - brain
  • IMP: No evidence of intracranial lesion.
• 2022-08-12 PET
  • Glucose hypermetabolism in the left breast, compatible with recurrent breast malignancy.
  • Glucose hypermetabolism in left upper and lower neck regions, in the left upper back region, in the left surpra- and infraclavicular regions, in the suprasternal region, in the left parasternal region, around the proximal portion of left upper arm, in the left axillary region, in the upper mediastinum and in the abdominal bilateral paraaortic regions, compatible with multiple metastatic lesions such as metastatic lymph nodes.
  • Glucose hypermetabolism in multipe bones as mentioned above, suggesting multiple bone metastases.
• 2022-08-10 Patho - lymphnode biopsy
  • Lymph node, left axillary, core needle biopsy — Positive for invasive carcinoma
  • Microscopically, section shows presence of invasive carcinoma with stromal fibrosis.
• 2022-08-10 Patho - breast biopsy (no need margin) (Y1)
  • Breast, left, core needle biopsy — Invasive carcinoma
    
  • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
  • Immunohistochemical study demonstrates:
    • ER (+, strong, 99%)
    • PR (-)
    • Her2/neu: negative (0/1+)
    • p53 (diffuse strong +, aberrant-type)
    • GATA3 (+)
    • Ki-67 inedex: 30%
    • E-cadherin (+)

[MedRec]

• 2024-03-05 ~ 2024-03-07 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Malignant neoplasm of unspecified site of left female breast
    • Hydronephrosis with ureteral stricture, not elsewhere classified
    • Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
    • Secondary malignant neoplasm of bone
  • CC
    • Abdominal fullness since 2024/01/30
  • Present illness
    • The is a 56-year-old female ,with past history of
      • Acute kidney failure, with no recovery, start regular hemodialysis QW246 since 2024-02-14, s/p perm catheter insertion.
      • Bilateral hydronephrosis status post bilateral tumor stent double-J replacement on 2024/01/15 and 01/30
      • Left breast cancer, stage I, s/p lumpectomy on 2014-05 and follow by Femara (and ?) for 3 month and lost follow up, recurrent left breast cancer with bone and lymph node metastasis.
    • According to patient’s statement and medical record, she was diagnosed of Left breast cancer, stage I, was diagnosed at 2014 in MacKay Hospital. Lumpectomy without ALND was performed immediately on 2014-05 and follow by Femara (and ?) for 3 month and she discontinue medication on her own and lost follow up in OPD.
    • As time goes on, enlarged lymph node was noted over left axilla and left neck. Therefore, she went to our GS OPD for help. Core needle biopsy of left breat and left axillary lymph noth both revealed Invasive carcinoma with ER (+, strong, 99%), PR (-), Her2/neu: negatitive (0/1+), p53 (diffuse strong +, aberrant-type), GATA3 (+), Ki-67 inedex: 30%.
    • Whole body PET on 2022-08-12 showed recurrent of left breast cancer with multiple LN and bone metastasis. Therefore, she start treatment with Femara, Denosumab, Ribociclib since 2022/09/23.
    • Abdominal CT on 2024/01/15 showed ome enlarged LNs at retroperitoneum along aorta/ IVC and iliac vessels r/o metastases. The follow up abdominal CT on 2024/02/10 revealed retroperitoneal mass in progression.
    • This time, she was in her usual health status until 1 months ago, when she started to feel adbominal fullness, accompanied with short of breath which was exacerbated in recent days. Due to the symptom, she went to our ER for help. In ER, her vital sign showed BP:125/85 mmHg, HR:128 bpm, BT: 34.8’C, RR:20/min, conscious E4V5M6.
    • Physical examination showed soft and oviod abdominal, but no tenderness. Laboratory data revealed anemia (Hb:9.8 g/dL), but no leukocytosis (WBC:5.28 *10^3/uL). Elevated CRP: 4.5mg/dL, BUN: 27mg/dL, Cre 5.15 mg/dL, eGFR = 9.2%. CXR showed Left pleural effusion.
    • Under the impression of progression of retroperitoneal mass, the patient was admitted for CT guided biopsy.
  • Course of inpatient treatment
    • After admission, symptomatic relief drug was administered. We had consult nephro. and H/D was performed on 2024/03/05 and 03/07.
    • Abdominal contrast CT on 2024/03/05 reveaeld (1) left breast cancer. Bil. pleural effusion. (2) Peritoneal and retroperitoneal carcinomatosis with ascites. (3) Bony metastases at T7, T10, L2-3. (4) Some enlarged LNs at retroperitoneum along aorta/ IVC and iliac vessels.
    • The CT guided retroperitoneal mass biopsy was performed smoothly on 2024/03/06. There was no active bleeding after biopsy. Under the relative stable clinical condition, the patient was discharged on 2024/03/07 with outpatient department follow-up.

701049767

240320

[exam findings]

• 2024-02-20 Patho - cholesteatoma
  • Labeled as “middle ear cavity and mastoid air cells, right”, Tympanoplasty-with mastoidectomy — Granulation tissue.
• 2024-02-19 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • R’t : >90 dB HL, moderately severe to profound mixed type HL
  • L’t : 34 dB HL, normal to severe SNHL.
• 2024-01-11 CT - temporal bone HRCT
  • CT scan of the temporal bone without IV contrast enhancement was performed in axial planes, and the result showed as following:
  • Impression:
    • Note inflammatory debris in the right EAC, middle ear cavity and under-pneumatization of the mastoid with fluid collection.
    • Perforation of right tympanic membrane.
  • Favor right chronic otitis media & externa and mastoiditis.
• 2023-09-15 NCV
  • Findings
    • The NCV study showed
      • Decreased CMAP amplitude in bilateral tibial nerves.
      • Slowing motor conduction velocity in right tibial nerve.
    • The F wave study showed prolonged latency in left peroneal and bilateral tibial nerves.
    • The H reflex study showed both prolonged.
  • Conclusion
    • The above findings suggest bilateral lumbosacral radiculopathy. Advise clincal correlation.

[MedRec]

• 2024-03-15 SOAP Hemato-Oncology Gao WeiYao
  • A: R/I ITP -> unlikely
    • Clinically, leukemia or MPD should be considered.
• 2024-03-08, -03-01 SOAP Hemato-Oncology Gao WeiYao
  • A: R/I ITP
  • Prescription
    • Compesolon (prednisolone 5mg) 5# BID 7D
    • Stogamet (cimetidine 300mg) 1# TID 7D
• 2024-02-26 SOAP Hemato-Oncology Gao WeiYao
  • S: He was informed to have severe thrombocytopenia during his operation for otitis last week
  • A: Severe thrombocytopenia nature?

701447674

240320

[MedRec]

• 2022-08-18 ~ 2022-08-24 POMR Colorectal Surgery Lv ZongRu
  • Discharge diagnosis
    • Sigmoid colon cancer obstruction post placement of Self-expandable metal stent (SEMS) cT4aN1bM0 stage IIIb
  • CC
    • Abdominal fullness and no stool passage for 4 days
  • Present illness
    • This 85 years old male patient was quite well until he suffered from abdominal fullness and no stool passage for 4 days.
    • According to patient statement, had abdominal fullness sensation since monday morning, last defecation was on saturday. Due to unbearable fullness sensation, he went to LMD and was given stool softnener. He then went home and felt better. Thus he ate on tuesday noon (half bowl rice and some dragonfruits) but vomitted all the food 30mins post ingestion. Due to scared of throwing up again, he ate very little and all he ate is semiliquid diet. Due to extreme dyscomfort, he then opt for enema on wednesday but only 3 solid round stool was found.
    • As his dyscomfort began to cause insomnia and affect daily life, he came to our emergent department. Physical examination showed abdominal round, tenderness (+, diffuse, pain score 4-5, with fullness), tympanic all around 4 quadrant, no muscle guarding, no rebounding pain.
    • Image of abdominal CT revealed wall thickening of sigmoid colon with adjacent fat stranding, regional LAP and obstruction, cT4aN1bM0 stage IIIb; dilatation of appendix (8.3mm) and renal cysts (up to 1.2cm).
    • NG tube insert with depression for severe nausea and abdominal fullness. Consult our CRS for further evaluation and then he was admitted to our CRS ward for further treatment of colon cancer obstruction, and passible surgery treatment.
  • Course of inpatient treatment
    • After admission with ward routine and blood examination were done. NPO and IV fluids support, antibiotic treatment.
    • Consult GI for colonic stent insert of the colon cancer osbtruction.
    • Colonic stent was performed under colonoscopy procedure on 2022/08/19.
    • Flatus and stool passage after colonic stent, and then follow KUB revealed distension of the colon and small bowel loops was improved.
    • No abdomianl discomfort and stool passage after full liquid diet. Well bowel movement and stools passage with low residue soft diet was suggested and educated.
    • Now, the patient no fever and no complication. Discharged in general condition stable on 2022/08/24 and will follow up in our out-patient department next week.    
  • Discharge prescription
    • Stogamet (cimetidine 300mg) 1# BID
    • Through (sennoside 12mg) 1# HS
    • MgO 250mg 1# TID
    • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# Q12H

[surgical operation]

[chemotherapy]

• 2024-03-20 - irinotecan 180mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3450mg NS 500mL 46hr (FOLFIRI 20% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL (no atropine?)

701491453

240320

[exam findings]

• 2023-12-15 MRI - brain
  • Indication: CT susp. Brain meta. dizziness for half month. Rt arm weakness?
  • Pre- and post-contrast multiplanar cerebral MRI and cerebral TOF MRA reveal:
    • A total of 5 intra-axial enhancing lesions associating with extensive white matter edema in left frontal lobe, left thalamus, right parietal lobe and bilateral cerebellar hemispheres, with the largest one about 25 mm in left cerebellum. C/W multiple brain metastases.
  • IMP:
    • Multiple brain metastases.
• 2023-12-15 ECG
  • Normal sinus rhythm
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2023-12-13 CT - brain
  • Indication: dizziness, right side chorioathetosis since 2023-11-28
  • Head CT without contrast enhancement shows:
    • intraaxial space-occupying lesion associated with vasogenic edema at right parietal lobe, left cerebellum, and left thalamus. Brain tumors are favored. Suggest contrast-enhanced MRI study.
    • underlying brain atrophy with prominent sulci, fissures and dilated ventricles.
  • Impression:
    • Probably multiple brain tumors at right parietal lobe, left cerebellum, and left thalamus. Suggest contrast-enhanced MRI study.
• 2023-09-11 ECG
  • Normal sinus rhythm
  • Minimal voltage criteria for LVH, may be normal variant
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2023-08-05 KUB
  • S/P double J catheter insertion in place, both sides.
  • S/P drainge tube in the pelvic cavity.
  • Lumbar spondylosis and scoliosis.
  • Focal small bowel ileus.
• 2023-08-01 Patho - uterus (with or without SO) neoplastic
  • Diagnosis:
    • Uterus, endometrium, total hysterectomy — endometrioid adenocarcinoma.
    • Uterus, myometrium, total hysterectomy — endometrioid adencarcinoma, involving > 1/2 thickness of the myometrium
    • Uterus, cervix, total hysterectomy — endometrioid adenocarcinoma with para-metrial involvement
    • Ovaries and fallopian tubes, bilateral, BSO — endometrioidadenocarcinoma, bilateral ovaries and tubes involvement
    • Lymph node, bilateral pelvic and para-aortic, dissection — metastatic adenocarcinoma, for details, see microscopic description.
      
    • pT3b pN1a (if cM0) AJCC 8th edition Pathology stage: IIIC1, at least.
    • IHC stains: p53 (wild type), Napsin-A (-), PMS2 (focal +), MSH6 (+), MSH2 (+), MLH1 (focal+).
    • AJCC 9th edition pT3b pN1a (if cM0); FIGO pathology stage; IIIC1ii, at least.
  • Gross description:
    • Procedure (select all that apply) - Staging surgery (ATH + BSO + BPLND + infracolic omentectomy)
      • Total abdominal hysterectomy: 365 gms 13 x 9 x 6 cm; serosal surface tumor involvemt
      • Bilateral salpingo-oophorectomy: right ovary 5 x 5 x 5 cm, right tube: 6 x 0.4 x 0.4 cm; left ovary 6 x 5 x 5 cm. Left tube: 6 x 0.4 x 0.4 cm. Both ovaries and tubes: tumor present with surface involvement.
      • Omentectomy - 30 x 15 x 2 cm. free
      • Peritoneal washing - free
      • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
    • Tumor Site (select all that apply) - Endometrium, entire endometrial cavity, > 1/2 thickness of the myometrium to the external surface of the uterus.
    • Tumor Size:
      • Greatest dimension: 10 cm
      • Additional dimensions (centimeters): 9 x 9 cm
    • Sections are taken and labeled as: A1-2: left iliac lymph nodes; B: left obturator lymph nodes; C1-2: right iliac lymph nodes; D: right obturator lymph nodes; E: left para-aortic lymph nodes; F: right par-aortic lymph nodes; G1-2: right tube and ovary; G3-5: left tube and ovary; G6: cervix, varginal, distal margin and bilateral parametrium; G7-11: tumor; H: omentum.
  • Microscopic Description:
    • Histologic Type:Endometrioid carcinoma
    • Histologic Grade: (required only if applicable) - FIGO grade 2 (low-grade)
    • Myometrial Invasion: present (whole thickness)
    • Uterine Serosa Involvement- Present
    • Cervical Stromal Involvement- Present
    • Other Tissue/ Organ Involvement (select all that apply):
      • Bilateral ovaries: involved, with rupture
      • Bilateral fallopian tubes: ivolved.
      • Vagina - involved, with positive distal margin.
      • Bilateral parametrium- involvement
      • Omentum - free
    • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
      • Ectocervical/Vaginal Cuff Margin: Not Free
      • Parametrial/Paracervical Margin: Not Free
    • Lymphovascular Invasion: Present; < 5 vessels
      • Regional Lymph Nodes:
        • Right Pelvic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): metastatic adenocarcinoma (1/24) 2.6 mm in size with extranodal extension.
      • Left Pelvic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): free (0/21)
        • Para-aortic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): free (0/12)
    • Greatest dimension of largest nodal metastatic deposit (required only if macrometastasis or micrometastasis present): 2.6 mm
    • Additional Pathologic Findings - None identified
    • Ancillary Studies- IHC stains: p53 (wild type), Napsin-A (-), PMS2 (focal +), MSH6 (+), MSH2 (+), MLH1 (focal+).
• 2023-07-24 CT - chest
  • Indication: uterus tumor
  • Findings
    • lungs: minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine. normal appearance of RUL, RML, and left lung.
    • Chest wall and visible lower neck: enlarged Rt thyroid lobe with heterogeeous enhancement and calcification.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
      
  • Impression:
    • no lung metastasis and no mediastinal LAP. thyroid goiter.
• 2023-07-24 Colonoscopy
  • Mixed hemorrhoid was noted.
  • No definite mucosal lesion was seen.
  • But a protruding mass lesion with smooth mucosal surface was found at upper rectum that external compression by ovarian tumor is considered.
• 2023-07-24 EGD
  • Reflux esophagitis LA Classification grade A
  • GAstric erosion, antrum, GC
  • Duodenal ulcer scar, bulb.
• 2023-07-21 Patho - cervix biopsy
  • Tissue, labeled as “cervix”, biopsy — Adenocarcinoma
    • NOTE: The possibility of tumor origin of endometrium cannot be completely excluded. Correlation with image and clinical findings is recommended.
  • Microscopically, it shows adenocarcinoma composed of irregular neoplastic glands with infiltrative growth pattern. The tumor cells display hyperchromatic nuclei, pleomorphism,and high N/C ratio.
  • Immunohistochemical stain reveals vimentine (+), p16 (focal patchy+, <30%), CEA (-), Ki67 index: 60%, ER: positive (moderate, 80%).
• 2023-07-21 MRI - pelvis
  • Clinical history: 54 y/o female patient with IMP: Endometrial thickening, EM:57.4mm, endometrial (+fluid)
  • With and without contrast enhancement MRI: Pelvis
    • Diffuse soft tissue tumors in the uterine body, endocerix and cervical region with parametrial involvement and hydrometra, r/o endometrial malignancy. DDx: cervical malignancy.
    • Tubular cystic lesion in left adnexa, suggesting hematosalpinx.
    • Cystic lesion with mural soft tissue in left adnexa, r/o left ovarian malignancy.
    • Dilatation of left pelvicaliceal system and ureter.
    • Enlarged lymph nodes in right iliac region.
    • No ascites.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:____(N_value) M:M0(M_value) STAGE:____(Stage_value)
      
  • Impression:
    • Diffuse soft tissue tumor in the uterine cavity and cervical region with parametrial involvement and hydrometra, pelvic lymph nodes, r/o endometrial malignancy, cstage T3bN1aM0.
    • Left hematometra with left ovarian cystic tumor, r/o malignancy (metastasis?).
• 2023-07-21 ECG
  • Normal sinus rhythm
  • Left ventricular hypertrophy with repolarization abnormality (Sokolow-Lyon)
  • Abnormal ECG
• 2023-07-20 SONO - gynecology
  • Endometrial thickening, EM:57.4mm, endometrial (+fluid)
  • R/O LT Ovarian cyst

[MedRec]

• 2023-07-21 ~ 2023-07-25 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of endometrium
    • Endometrial hyperplasia
    • Postmenopausal bleeding
    • Anemia due to abnormal vaginal bleeding
  • CC
    • Vaginal bleeding for 1 week
  • Present illness
    • This is a 54 year-old female, G1P1, without systemic disease, admitted because of large amount of vaginal bleeding for 1 week.
    • Tracing back to her history, her menstrual cycle was irregular with unknown last mestrual period and intermittend vaginal spoting for years. There was also a palpable mass below the umbilicus noted for years. She also lost weight about 3kg in 2 weeks. This time, she had large amount vaginal bleeding one week ago and needed to change pad 5-6 times a night, with blood clots found sometimes, accompanied with dizziness. Therefore, she came to our GYN OPD for help. At OPD, her lab data revealed anemia (Hb 6.2g/dL). Sonography was done and revealed endometrium 5.74mm and left ovarian cyst 8.1*4.8cm.
    • Under the impression of endometrial cancer, she was admitted for further survey and management.
  • Course of inpatient treatment
    • Under the impression of endometrial hyperplasia with polyp suspected endometrial cancer. She was admission for further survey and management on 2023/07/22.
    • Due to anemia (Hb = 6.0) and blood transfusion with LP-RBC 4U/2U were given on 2023/07/22 and 2023/07/24.
    • The pelvic MRI was done and revealed diffuse soft tissue tumor in the uterine cavity and cervical region with parametrial involvement and hydrometra, pelvic lymph nodes, r/o endometrial malignancy, cstage T3bN1aM0. We was consult GU for cystoscopic because of suspected cervical cancer on 2023/07/22. The cervix biopsy was performed on 2023/07/23 and showed Adenocarcinoma.
    • The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey. We arranged discharge for her for further OPD follow up on 2023/07/27.  
  • Discharge prescription
    • Anxiedin (lorazepam 0.5mg) 1# HS

[consultation]

• 2023-12-15 Radiation Oncology
  • Q
    • This is a 54-year-old female with endometrioid adenocarcinoma of the uterine endometrium, stage pT3bN1a (cM0), AJCC 8th edition Pathology stage: IIIC1, s/p staging surgery (ATH + BSO + BPLND + infracolic omentectomy), with surgical margin involved, s/p CCRT.
    • She suffered from dizziness, right side chorioathetosis since Nov 28. Brain MRI showed multiple brain metastases.
    • We need your help for further evaluation. Thank you.
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For radiotherapy due to brain metastases.
      • PI: The patient was a case of endometrioid adenocarcinoma of the uterine endometrium, stage pT3b pN1a (cM0), AJCC 8th edition Pathology stage: IIIC1, s/p staging surgery (ATH + BSO + BPLND + infracolic omentectomy) and CCRT. She suffered from dizziness and right upper limb motor dysfunction. MRI of brain (2023-12-15) showed multiple brain metastases.
      • Chemotherapy: 2023-(08-22, 09-12, 10-25, 11-01, 11-08, 11-15)
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-)
      • Personal Hx: DM (-); HTN (-)
    • O: ECOG: 3 .
      • PE: right upper limb motor dysfunction.
      • 2023/07/21 CA125 = 560.9 U/mL;
      • 2023/07/21 CA199 = 35.84 U/mL;
      • 2023/07/21 CEA = 1.13 ng/mL;
      • MRI of pelvis (2023-07-21): 1. Diffuse soft tissue tumor in the uterine cavity and cervical region with parametrial involvement and hydrometra, pelvic lymph nodes, r/o endometrial malignancy, cstage T3bN1aM0. 2. Left hematometra with left ovarian cystic tumor, r/o malignancy (metastasis?).
      • CT scan of lung (2023-07-24): no lung metastasis and no mediastinal LAP. Thyroid goiter.
      • Operation (2023-07-31): Staging surgery (ATH + BSO + BPLND + infracolic omentectomy)
      • Ascites (N2023-02949, 2023-08-02): negative
      • Pathology (S2023-15174, 2023-08-07): 1. Uterus, endometrium, total hysterectomy — endometrioid adenocarcinoma. 2. Uterus, myometrium, total hysterectomy — endometrioid adencarcinoma, involving ＞ 1/2 thickness of the myometrium. 3. Uterus, cervix, total hysterectomy — endometrioid adenocarcinoma with para-metrial involvement. 4. Ovaries and fallopian tubes, bilateral, BSO — endometrioidadenocarcinoma, bilateral ovaries and tubes involvement. 5. Lymph node, bilateral pelvic and para-aortic, dissection —- metastatic adenocarcinoma, for details, see microscopic description. 6. pT3b pN1a (if cM0) AJCC 8th edition Pathology stage: IIIC1, at least. Ectocervical/Vaginal Cuff Margin: Not Free. Parametrial/ Paracervical Margin: Not Free. Lymphovascular Invasion: Present.
      • RT (2023-10-11 ~ 2023-11-23): 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.
      • MRI of brain (2023-12-15): A total of 5 intra-axial enhancing lesions associating with extensive white matter edema in left frontal lobe, left thalamus, right parietal lobe and bilateral cerebellar hemispheres, with the largest one about 25 mm in left cerebellum. C/W multiple brain metastases. Imp: Multiple brain metastases.
    • A: Endometrioid adenocarcinoma of the uterine endometrium, stage pT3bN1a (cM0), AJCC 8th edition Pathology stage: IIIC1, s/p staging surgery (ATH + BSO + BPLND + infracolic omentectomy), with surgical margin involved, s/p 2 cycle of chemotherapy and CCRT, with brain metastases.
    • P: Radiotherapy is indicated for this patient with the following indicators: brain metastases
      • Goal: pallaition
      • Treatment target and volume: brain
      • Technique: VMAT/2D
      • Preliminary planning dose: 1000cGy/4 fractions of the whole brain, and 3000cGy/12 fractions of the metastatic brain tumors.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 1430, 2023-12-19.
• 2023-07-21 Urology
  • Q
    • This 54 years old female, G1P1. She had final cessation of menstruatioon at the age of 50+ years and has never received hormone replacement therapy.
    • She had suffered from vaginal bleeding for 1 weeks. However, she also felt the symptoms became worse and visited our OPD for seeking management, where GYN echo was done, which revealed
      • Endometrial thickening, EM:57.4mm, endometrial (+fluid)
      • R/O LT Ovarian cyst.
      • Tumor marker showed CA125 560.9, CA199 35.84.
    • 2022/07/21 Abdomen MRI showed :
      • Diffuse soft tissue tumor in the uterine cavity and cervical region with parametrial involvement and hydrometra, pelvic lymph nodes, r/o endometrial malignancy, cstage T3bN1aM0.
      • Left hematometra with left ovarian cystic tumor, r/o malignancy (metastasis?).
    • We need your help for Cystoscopy. Thank you very much for your help and expertise.
  • A
    • MRI showed suspicous pelvic tumor with lymph node
    • Cystoscopy was arranged on 2023/07/22 0900 Thanks for your consultation
  • A 2023-07-23 08:35:10
    • 2023/07/22 Cystoscopy:
      • posterior wall indentation (suspect uterine mass compression)
      • Urinary bladder mucosa are healthy
      • urethra and bladder neck both normal
      • no sign of bladder involvement

[radiotherapy]

• 2023-12-20 ~ 2024-01-05 - 1000cGy/4 fractions of the whole brain, and 3000cGy/12 fractions of the metastatic brain tumors.

[chemotherapy]

• 2024-03-20 - paclitaxel 175mg/m2 270mg NS 250mL 4hr + carboplatin AUC 5 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-01-23 - paclitaxel 175mg/m2 260mg NS 250mL 4hr + carboplatin AUC 5 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-01-23 - paclitaxel 175mg/m2 238mg NS 250mL 4hr + carboplatin AUC 5 675mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-12-20 - paclitaxel 175mg/m2 240mg NS 250mL 4hr + carboplatin AUC 5 825mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-11-15 - cisplatin 35mg/m2 50mg NS 500mL 90min + NS 500mL 1hr (post cisplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 1000mL
• 2023-11-08 - cisplatin 35mg/m2 50mg NS 500mL 90min + NS 500mL 1hr (post cisplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 1000mL
• 2023-11-01 - cisplatin 35mg/m2 50mg NS 500mL 90min + NS 500mL 1hr (post cisplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 1000mL
• 2023-10-25 - cisplatin 35mg/m2 50mg NS 500mL 90min + NS 500mL 1hr (post cisplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 1000mL
• 2023-09-12 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 1000mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-08-22 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 960mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-03-20

[no contraindications for subsequent chemotherapy session]

Brain metastases have been addressed with CCRT in 2023Q4. The patient’s recent vital signs are stable, and lab results on 2024-03-19 were unremarkable. There seems to be no contraindication to proceeding with an additional chemotherapy session scheduled on 2024-03-20.

701497593

240320

[exam findings]

• 2024-03-14 CT - abdomen
  • History and indication: for left hydronephrosis
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of S-colon with calcification, adjacent fat stranding and regional LAP. Enlargement of prostate. Mild left hydronephrosis and hydroureter.
    • Some LNs at mediastinum.
    • Tiny liver cysts.
    • Atherosclerosis of aorta, iliac arteries.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2024-03-12 ECG
  • Atrial flutter with variable A-V block
  • Low voltage QRS
• 2024-03-12 Patho - colon biopsy
  • Intestine, large, sigmoid colon, 20 cm AAV, biopsy — adenocarcinoma
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2024-03-11 CT - abdomen
  • Non-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of S-colon with calcification, adjacent fat stranding and regional LAP.
    • Enlargement of prostate.
    • Mild left hydronephrosis and hydroureter.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • R/O S-colon cancer with calcification, adjacent fat stranding and regional LAP.
    • Enlargement of prostate.
    • Mild left hydronephrosis and hydroureter.
• 2023-09-22 uroflowmetry
  • Q max : low
  • flow pattern : obstructive
• 2023-09-12 Bladder Sonography
  • PVR: 410.02mL

701516416

240320

[exam findings]

• 2024-03-15 CT - abdomen
  • Findings: Comparison: prior CT dated 2024/02/27.
    • Prior CT identified heterogeneous poor enhancing masses on right hepatic lobe, 11.8 cm in size (the largest dimension), with right lobe inferior segment portal vein encasement is noted again, stationary.
    • Prior CT identified bony metastases in T10 and L2 vertebral body are noted again, mild increasing in size.
    • There are multiple enlarged in para-aortic space and para-cava space that are c/w metastatic nodes.
    • Presence of gallbladder stones.
    • Bilateral renal cysts, up to 0.6cm.
  • Impression:
    • Prior CT identified heterogeneous poor enhancing masses on right hepatic lobe, 11.8 cm in size (the largest dimension), with right lobe inferior segment portal vein encasement is noted again, stationary.
    • Prior CT identified bony metastases in T10 and L2 vertebral body are noted again, mild increasing in size.
    • There are multiple enlarged in para-aortic space and para-cava space that are c/w metastatic nodes.
• 2024-03-15 ECG
  • Sinus tachycardia with occasional Premature ventricular complexes
  • Voltage criteria for left ventricular hypertrophy
  • Abnormal ECG
• 2024-03-06 Tc-99m MDP bone scan with SPECT
  • A faint hot area in the sternum, the nature is to be determined (post-traumatic change, bone mets, or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, sacrum, bilateral sternoclavicular junctions, shoulders, left elbow, S-I joints, hips, and knees.
• 2024-03-05 PET
  • A large inhomogesous glucose hypermetabolic lesion in the right lobe of the liver. Primary liver malignancy may show this picture. However, liver metastasis can not be ruled out.
  • A glucose hypermetabolic lesion in the upper rectum. Primary malignancy of the rectum should be watched out. Please correlate with other clinical findings for further evaluation.
  • A glucose hypermetabolic lesion in the T10 spine. Bone metastasis may show this picture.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes. Inflammatory process may show this picture.
  • Mild glucose hypermetabolism in the prostate. The nature is to be determined (inflammation? hyperplasia? malignancy of low FDG uptake?). Please also correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
• 2024-03-04 Patho - colon biopsy
  • Upper rectum, 15 cm AAV, biopsy — Tubulovillous adenoma, high-grade dysplasia
  • The sections show tubulovillous adenoma, composed of rectal mucosal tissue with atypical glands lined by pseudostratified, high-grade dysplastic columnar cells, in tubular, cribriform, and villous arrangements. Suggest closely follow up.
• 2024-03-04 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A(minimal)
    • Superficial gastritis, antrum, s/p CLO test.
    • Gastric erosions, antrum.
  • CLO test: Negative
• 2024-03-04 Colonoscopy
  • Diagnosis:
    • Suspected appendicitis, s/p biopsy (A)
    • Colon polyp, Paris classification 0-IIa, transverse colon, s/p biopsy removal.(B)
    • Large colon polyp, 25 mm, Paris classification 0-Is, JNET types 2A-2B, upper rectum(about 15cm AAV), s/p biopsy.(C)
    • Colon polyp, Paris classification 0-Is, rectum, s/p cold snare polypectomy.(D)
    • Mixed hemorrhoid
  • Suggestion:
    • F/U pathology report
    • Correlate with the clinical symptoms and imaging study for the endoscopic suspicion of appenditis
    • Consider to ESD or surgical intervention for the large colon polyp
• 2024-03-01 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated, and see description
  • The sections show adenocarcinoma, poorly differentiated, composed of nests of large polyonal neoplastic cells with abundant eosinophilic cytoplasm, arranged in solid pattern and fibrous stromal reaction. Extensive tumor necrosis is present.
  • IHC, tumor cells reveal: CK7(focal +), CK20(+), Hepa-1(-), Glypican-3(-) and Arginase-1(-). The finding is compatible with cholangiocarcinoma but metastatic adenocarcinoma cannot be completely excluded. Suggest further clinic correlation.
• 2024-02-29 MRI - liver, spleen
  • Indication: suspect HCC
  • Abdominal MRI with and without IV contrast enhancement shows:
    • Heterogeneous, low signal intensity lesion with septation and scattered daughter nodules are found at right lobe liver with displacement of the INFERIOR VENA CAVA rather than invsion or thormboses is found measuring 10.5cm in largest dimension. Surface retraction at right liver surface is also found. HCC is less likely. Metastatic tumor, cholangiocarcinoma is more favored.
    • One enhanced lesion at vertebral body measuring 1.4cm (Se12 Im33), another cold area at lumbar spine is found. (SE83 Im12), bone meta is favored.
    • Minimal infiltration at right perirenal space and subhepatic space with minimal ascites formation.
    • Minimal pleural effuison is found.
  • Imp:
    • Huge hepatic necrotic, septated lesion measuring 10.5cm at right lobe liver with scattered small daugther lesions, IVC displacement and liver surface retraction. Liver meta or cholangiocarcinoma is favored.
    • Bone tumor. r/o bone meta.
    • After reviewing CT on 2024-02-27, there is abnormal enhanced prostatic lesion with indentation of the urinarry bladder. Please exclude the possiblity of prostate cancer.
    • The possibility of liver abscess is less likely due to liver surface retraction. Suggest correlate with lab data.
  • Imaging Report Form for Cholangiocarcinoma
    • Impression (Imaging stage) : T:2(T_value) N:2(N_value) M:1(M_value) STAGE:____(Stage_value)
• 2024-02-29 SONO - abdomen
  • Diagnosis:
    • Liver tumor, suspect HCC
    • GB stones and sludge
  • Suggestion:
    • Check HBV, HCV, AFP, CA-199, CEA
    • Consider liver biopsy
• 2024-02-27 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Presence of gallbladder stones.
    • Multifocal heteregeneous lesions in right lobe liver, up to 11x8.2cm, r/o abscess. DDx: Liver malignancy.
    • Bilateral renal cysts, up to 0.6cm.
  • Impression:
    • Heteregeneous liver tumors, r/o abscess. DDx: liver malignancy. Suggest clinical correlation and study.
    • Bilateral renal cysts.

[chemotherapy]

• 2024-03-20 - gemcitabine 1000mg/m2 800mg NS 250mL 1hr (Gemzar + TS-1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-03-06 - gemcitabine 1000mg/m2 800mg NS 250mL 1hr (Gemzar + TS-1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-03-13 ~ 2024-03-26 TS-1 (tegafur, gimeracil, oteracil; 25mg) 1# BID (TS-1 two weeks on and one week off)

700039421

240319

[consultation]

• 2024-03-08 Gastroenterology
• 2024-03-08 Thoracic Surgery
• 2024-03-09 Nephrology
• 2024-02-21 Oral and Maxillofacial Surgery
  • Q
    • This 68 y/o man has history of DM, old CVA, CKD under regular medication and OPD follow up.
    • He was a newly diagnosed left buccal cancer, admitted for cancer work up.
    • Since surgery or CCRT were indicated, we request your consultation for dental evaluation.
  • A
    • This is a 68 y/o male who suffered from left buccal cancer.
    • O: Poor prognosis of tooth 17 16 13 12 23 24 26 27 35 34 33 32
    • P:
      • Physical examination and explain the fiding and treatment plan to patient
      • Suggest tooth 17 16 13 12 23 24 26 27 35 34 33 32 extraction due to poor prognois

[chemotherapy]

• 2024-03-11 - docetaxel 40mg/m2 70mg NS 150mL 1hr + carboplatin AUC 2 60mg NS 300mL 3hr + fluorouracil 1000mg/m2 1700mg leucovorin 100mg/m2 170mg NS 1000mL 22hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

==========

2024-03-19

[leukopenia & anemia risks with TPF: management strategies]

The patient’s treatment regimen transitioned to a TPF scheme on 2024-03-11. Carboplatin was substituted for cisplatin due to concerns about impaired renal function. However, leukopenia and anemia was observed after one week of treatment.

Laboratory Findings

• 2024-03-18 WBC 2.69 x10^3/uL
  

• 2024-03-08 WBC 11.41 x10^3/uL

• 2024-03-18 HGB 7.8 g/dL
  

• 2024-03-08 HGB 10.7 g/dL

Literature Review

• Docetaxel is well-documented to cause leukopenia (incidence 84-99%, with 49% developing grade 3/4 and 32-44% experiencing grade 4). The median nadir typically occurs within 7 days, with neutropenia following a similar pattern (incidence 84-99%, grade 3/4: 65%, grade 4: 75-86%). Additionally, anemia is reported in 65-97% of patients receiving docetaxel, with 8-9% developing grade 3/4.
• Carboplatin is also associated with leukopenia (15-85%) and neutropenia (16-67%). Anemia is another potential side effect, occurring in 21-90% of patients.

Treatment Considerations

• Given the risk of severe infection with leukopenia, G-CSF prophylaxis may be warranted.
• For anemia management, LPRBC transfusion is a possible course of action.

701466626

240319

[exam findings]

• 2024-02-29 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (53.3 - 15.7) / 53.3 = 70.54%
    • M-mode (Teichholz) = 70.5
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Mild MR, AR, TR and PR
    • No regional wall motion abnormalities
    • Left massive pleural effusion

• 2023-12-26 Body fluid cytology

  • 50 cc brown turbid pleural effusion — malignancy

• 2023-12-21 CT - chest

  • Indication: left female breast invasive carcinoma, status post total mastectomy, sentinel lymphnode disection and reconstruction on 2023/09/07. ECOG:1, ypT4cN1M0, stage IIIC
  • Chest CT with and without IV contrast ehnancement shows:
    • Soft tissue mass at left chest is found. Left breast cancer is considered.
    • Lymphadenopathy at mediastinum is found.
    • Bilateral axillary lymphadenopathy is found.
    • Moderate bilateral pleural effusion is found.
    • Interstitial change at right lower lobe is found. Lymphangitis carcinommatosis is considered.
    • Abnormal fluid accumulation at anterior abdominal wall is found.
  • Imp:
    • s/p left breast op with recurrent/residual tumor at both lungs and right lymphangitis carcinomatosis and lymphadenopathy at mediastinum and axillary region. In progression.
    • Post op. change at anterior abdominal wall fluid collection.

• 2023-12-19 Body fluid cytology

  • 3 cc red cloudy pleural effusion — malignancy

• 2023-11-13 Patho - soft tissue debridment

  • Skin, left chest, s/p chemotherapy and mastectomy, now debridement — residual invasive carcinoma (3 mm x 2 mm).
  • Sections show skin with residual invasive carcinoma (3 mm x 2 mm). Involving un-oriented unspecified side margin.
  • Immunohistochemical Study: (S2023-22602A2): ER: negative, PR: negative, Her2/neu: negative (score = 1+), GATA-3: (+), Ki-67: (95%). Many suture granulomas are present.

• 2023-09-07 Patho - breast mastectomy with regional lymph nodes

  • Diagnosis
    • Breast, left, s/p neoadjuvant chemotherapy, simple mastectomy — invasive carcinoma, NST, no special type.
    • Margin: free
    • Lymph node, left, axillary, s/p neoadjuvant chemotherapy, dissection — metastatic carcinoma
    • ypT4c ypN1 (if cM0); anatomic stage: IIIB at least, pathology prgnostic stage group: IIIC, at least
  • Gross Description
    • Procedure - Total mastectomy : 17 x 15 x 5 cm (including nipple and skin: 16 x 15 cm invaded by tumor)
    • Lymph node sampling (if lymph nodes are present in the specimen) - Axillary dissection
    • Specimen laterality - Left
    • Sections are taken and labeled as: Tissue for formalin fixation: A1: deep margin; A2-6: tumor; A7: skin; A8: nipple.
  • Microscopic Description
    • For Invasive Carcinoma
      • Histologic type: Invasive carcinoma, NST. micropapillary carcinoma component is also present.
      • Size of invasive carcinoma (mm): 85 x 75 x 25 mm.
      • Histologic grade (Nottingham histologic score): grade II (score 6,7).
      • Extent of tumor (required only if the structures are present and involved)
        • involvement: Present (with ulceration)
        • Chest wall invasion deeper than pectoralis muscle: Present
    • For Ductal Carcinoma In Situ:
      • Tumor size (mm): 5 x 2 mm
      • Nuclear grade: 2
      • Architectural pattern: comedo
      • Tumor necrosis: present
    • Margins:
      • Negative, Closest margin (1 mm from deep margin)
    • Nodal status: Positive (s/p neoadjuvant chemotherapy)
      • No. examined: 1
      • No. macrometastases (>2 mm): 1
      • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
      • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
    • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
      • In the Breast - No definite response to presurgical therapy in the invasive carcinoma
      • In the Lymph nodes - No definite response to presurgical therapy in metastatic carcinoma
    • Immunohistochemical Study - (S2023-17991A1):
      • ER: negative, PR: negative, Her2/neu: negative (score = 1+), E-cadherin : (+), Ki-67 : (80%).

• 2023-08-18 CT - chest

• 2023-04-21 CT - chest

• 2023-02-02 2D transthoracic echocardiography

• 2023-01-31 CT - brain

  • No evidence of intracranial metastatic lesion.
  • Mild cerebral atrophy.

• 2023-01-10 2D transthoracic echocardiography

• 2023-01-09 Tc-99m MDP bone scan

  • Increased activity in the mandible, the nature is to be determined (dental problem or other nature ?), suggesting further evaluation and follow-up with bone scan in 3months.
  • Suspected benign lesions in both rib cages, maxilla, mandible, some C-, T- and L-spine, bilateral sternoclavicular junctions, shoulders, right elbow, S-I joints, hips, and knees.

• 2023-01-06 Patho - breast biopsy (Y1)

  • Breast, left, sono guide biopsy — Invasive carcinoma of no special type. Tumor grade: grade 2
  • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid or ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
  • Immunohistochemical study demonstrates - ER: negative, PR: negative, Her2/neu: negative (1+), E-cadherin: positive, Ki-67 inedex: 80%.

• 2023-01-05 CT - chest

  • left breast cancer with left axillary lymphadenopathy. T3N3bMx

[MedRec]

• 2023-01-05 ~ 2023-01-10 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Malignant neoplasm of central portion of left female breast
    • Huge tumor over upper part of breast, suspect left breast cancer with left axillary lymph node metastasis, cT3-4N1M0
    • Essential (primary) hypertension
    • Hypothyroidism, unspecified
  • CC
    • Left breast has significant mass for 3~4 months.
  • Present illness
    • This 82-year-old woman patient suffered left breast mass noted in 2022/09, swelling and body weight loss 4kg within 2 months. Due to left breast painful sensation for 1 week, so she did the mammography and suspect breast cancer over left side. She came to our ONC ward for help on 2023/01/04. Chest CT on 2023/01/05 showed left breast cancer with left axillary lymphadenopathy. Now, under the impression of suspect left breast cancer, so she was admitted for examination and further treatment.
  • Course of inpatient treatment
    • After admitted, consult diagnostic radiologist for Left breast tumor SONO Guide biopsy on 2023/01/06. Wait SONO Guide biopsy pathology. Whole body bone scan on 203/01/09. 2D echo on 2023/01/10. Ultracet 0.5# po HS+PRNQ6H and Tramadol 50mg iv PRNQ6H for pain control. Hypertension with Divoan 80mg 1# po QD and Norvasc 1# po QD. Hypothyroidism with Thyroxine 50mcg 1# po QDAC. With the stable condition, she was discharged on 2023/01/10 and OPD followed up later.    
  • Discharge prescription
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# HS
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# PRNQ6H if VAS > 3

[consultation]

• 2023-09-07 Plastic and Reconstructive Surgery
  • Q
    • This is a 83 years old woman patient. Due to left breast cancer , she was admitted for surgery of left simple mastectomy+SLNB on 2023/09/07. We need your help for combine suurgery. Thank you so much!!
  • A
    • Combine surgery was done with TRAM flap reconstruction of left breast. Thanks.
• 2023-01-31 Metabolism and Endocrinology
  • Q
    • For Hypothyroidism history, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • This 82-year-old female, with past history of 1) hypertension over 10 years with regular medicine control 2) Hypothyroidism with medicine control for 20+ years. cervical cancer s/p ATH for 20+ years in ZhongShan Hospital, was admitted due to first C/T for breast CA. We were consulted for hypothyroidism survey.
    • O:
      • BW: 53.5 kg
      • HR: 55-67
      • Possible related medication: thyroxine 50mcg 1# QDAC
      • AST/ALT: 16/6
      • BUN/Cr: 25/1.02
      • Na: 139, K: 3.5
      • TSH/FT4: unavailable
      • T3: unavailable
      • ATPO, ATG, TSH receptor Ab: unavailable
      • ACTH/Cortisol (8am): unavailable
      • Thyroid echo: nil
      • ECG: sinus rhythm with 1st degree AV block
      • CT- small thyroid gland
    • A: History of hypothyroidism
    • Suggestions:
      • Keep thyroxine 50mcg 1# QDAC
      • The patient is scheduled to return to ZhongShan Hospital for thyroid follow-up. If the patient is receiving immunotherapy, thyroid function could be monitored regularly during hospitalization.
      • Any problem, please call me
• 2023-01-30 Cardiology
  • Q
    • This 82-year-old female patient has past history of 1) hypertension over 10 years with regular medicine control 2) Hypothyroidism with medicine control for 20+ years. cervical cancer s/p ATH for 20+ years in ZhongShan Hospital. She denied any TOCC histories in recent 3 months. She noted a palpable mass at left breast and assiciated with mastalgia about 4-5 months ago. The tumor grew larger quickly recently. As such, she visited to ZhongShan Hospital for help and biopsy was performed, pathology showed invasive ductal carcinoma. She referred to our OPD on 2023/01/04. Chest CT showed left breast cancer with left axillary lymphadenopathy. Guide biopsy was performed. Pathology revealed invasive carcinoma of no special type, ER: negative, PR: negative, Her2/neu: negative (1+), E-cadherin :positive, Ki-67 inedex: 80%. CA-153：96.339 U/ml, CEA：0.920 ng/ml. Whole body bone scan was done that revealed no obvious lesion for metastasis. Left breast around 14*14 cm without discharge.
    • This time, she was admitted for first chemotherapy.
    • Arrhythmia was found via EKG, before chemotherapy, we need your consultation for evaluation for heart function. Thanks a lot!!!
  • A
    • The 12-lead ECG showed frequent APC and first AV block, basically, there is no lethal problem in these 2 ECGs.
    • However, you can arrange the 24-holter holter to find whether other arrythmia is present or not as well as the frequency of premature beats
    • The cardiac echo disclosed the preserved LV and RV performance without significant organic heart disease
    • you can proceed your treatment and continue monitoring the heart rate and cardiac rhythm, we will follow-up if Holter report is available or not

[radiotherapy]

• 2023-12-05 ~ 2024-01-23 - 5000cGy/25 fractions of the left chest wall to SCF, and 6600cGy/33 fractions of the left chest wall skin nodular lesions.

[immunochemotherapy]

• 2024-02-21 - bevacizumab 15mg/kg 800mg NS 100mL 2hr + paclitaxel 80mg/m2 116mg NS 250mL 90min + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2024-01-24 - bevacizumab 15mg/kg 800mg NS 100mL 2hr + paclitaxel 80mg/m2 116mg NS 250mL 90min + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-12-26 - bevacizumab 15mg/kg 800mg NS 100mL 2hr + paclitaxel 80mg/m2 116mg NS 250mL 90min + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-07-11 - bevacizumab 15mg/kg 800mg NS 100mL 2hr + paclitaxel 80mg/m2 120mg NS 250mL 90min + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-06-27 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-06-13 - bevacizumab 15mg/kg 800mg NS 100mL 2hr + paclitaxel 80mg/m2 120mg NS 250mL 90min + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-05-23 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-05-16 - bevacizumab 15mg/kg 800mg NS 100mL 2hr + paclitaxel 80mg/m2 120mg NS 250mL 90min + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-05-02 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-04-25 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-04-11 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-03-28 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-03-10 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-03-02 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-02-14 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-02-07 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-02-01 - …………………………………. paclitaxel 80mg/m2 118mg NS 250mL 90min + carboplatin AUC 5 400mg NS 250mL 2hr (paclitaxel D1,8,15)
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL

==========

2024-03-19

[rising CA153 since 2023H2 & malignant pleural effusion: consider pleural tapping]

CA153 levels have been steadily rising since the latter half of 2023. Bevacizumab, paclitaxel, and carboplatin therapy was restarted in late 2023.

• 2024-03-05 CA-153 (NM) 187.920 U/ml
  
• 2024-02-27 CA-153 (NM) 130.170 U/ml
  
• 2024-02-06 CA-153 (NM) 143.865 U/ml
  
• 2024-01-26 CA-153 (NM) 126.906 U/ml
  
• 2024-01-17 CA-153 (NM) 119.021 U/ml
  
• 2024-01-09 CA-153 (NM) 92.682 U/ml
  
• 2023-12-22 CA-153 (NM) 74.132 U/ml
  
• 2023-08-01 CA-153 (NM) 37.998 U/ml
  
• 2023-07-14 CA-153 (NM) 33.839 U/ml
  
• 2023-05-30 CA-153 (NM) 29.200 U/ml

The patient has experienced episodes of significant pleural effusion. Cytological analysis of the pleural fluid revealed malignant cells. Pleural tapping may be necessary to remove the fluid.

701492006

240319

[exam findings]

• 2024-01-30 CT - abdomen
  • S/P hysterectomy.
  • Metastatic lymph nodes with regression as compare with CT study on 2023-08-30.
  • Right renal cyst.
• 2023-11-01 Patho - uterus (with or without SO) neoplastic
  • Diagnosis:
    • Endometrium, GYN cancer staging surgery — endometrioid carcinoma, grade 3 and grade 2
    • Myometrium, GYN cancer staging surgery — tumor involving serosa and > 1/2 myometrial thickness
    • Cervix, GYN cancer staging surgery — tumor invading stromal connective tissue and margin free
    • Ovary, right, GYN cancer staging surgery — metastatic endometrioid carcinoma
    • Ovary, left, GYN cancer staging surgery — metastatic endometrioid carcinoma
    • Fallopian tube, right, GYN cancer staging surgery — negative for malignancy
    • Fallopian tube, left, GYN cancer staging surgery — metastatic endometrioid carcinoma
    • Omentum, GYN cancer staging surgery — metastatic endometrioid carcinoma
    • Lymph node, right iliac, dissection — metastatic endometrioid carcinoma
      
    • Lymph node, right obturator, dissection — metastatic endometrioid carcinoma
      
    • Lymph node, left iliac, dissection — metastatic endometrioid carcinoma
      
    • Lymph node, left obturator, dissection — metastatic endometrioid carcinoma
      
    • AJCC 8th edition pathology stage: pT3aN1aM1; AJCC prognostic stage IVB; 2023 FIGO stage IVB; 2023 FIGO stage IVBm MMRd
  • Gross description:
    • Procedure (select all that apply)
      • GYN cancer staging surgery (total abdominal hysterectomy + bil salpingo-oophoretomy + bilateral pelvic lymphonode dissection + omentectomy)
        • Uterus: 12x 8x 5 cm and 284-g
        • Right ovary: 8x 5x 4 cm
        • Left ovary: 18x 18x 1 2 cm
        • Right fallopian tube: 8 cm in length and 0.6 cm in diameter
        • Left fallopian tube: 8 cm in length and 0.7 cm in diameter
        • Omentum: 15x 10x 2 cm
    • Tumor Site (select all that apply)
      • Endometrium and ovaries
    • Tumor Size:
      • Endometrium: Greatest dimension: 7 cm
      • Additional dimensions (centimeters): 5 x 3 cm
      • Ovary, left: Greatest dimension: 17x 16x 10 cm
    • Sections are taken and labeled as:A1:right tube, A2-3:right ovary, A4:cervix, A5-14:tumor and corpus, A15:omentum, A16:left tube, A17-20:left ovary, A21-22:right iliac LN, A23-24:right obturator LN, A25:left iliac LN, A26:left obturator LN
  • Microscopic Description:
    • Histologic Type:
      • Endometrioid carcinoma
    • Histologic Grade: (required only if applicable*)
      • FIGO grade 3 (high-grade) and FIGO grade 2 (low-grade)
      • (NOTE: FIGO Grading System applies to endometrioid carcinomas only. Serous, clear cell, transitional, small cell and large cell neuroendocrine carcinomas, undifferentiated/ dedifferentiated carcinomas, and carcinosarcomas are generally considered to be high grade and it is not recommended to assign a histologic grade to these tumor types.)
    • Myometrial Invasion
      • Present ( > 1/2 whole thickness)
    • Uterine Serosa Involvement
      • Present
    • Cervical Stromal Involvement
      • Present
    • Other Tissue / Organ Involvement (select all that apply):
      • Bilateral ovaries
      • Left fallopian tube
      • Omentum
    • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
      • Ectocervical/Vaginal Cuff Margin: Free (7 mm of closest margin distance)
      • Parametrial/Paracervical Margin: Free
    • Lymphovascular Invasion: Present
    • Regional Lymph Nodes:
      • Right Pelvic Node: 2 / 23
      • Left Pelvic Node: 2 / 8
      • Para-aortic Node: not applicable
      • Greatest dimension of largest nodal metastatic deposit (required only if macrometastasis or micrometastasis present): 3 cm
      • Isolated tumor cells (0.2 mm or less and not more than 200 cells) (required only in the absence of macrometastasis or micrometastasis in other lymph nodes): Absent
        
      • (Note: Number of lymph nodes with macrometastasis, lymph nodes with micrometastasis, and lymph nodes with isolated tumor cells may be reported separately but this is not mandatory. )
    • Additional Pathologic Findings
      • Atypical hyperplasia/endometrial intraepithelial neoplasia (EIN)
    • Ancillary Studies:
      • IHC stain — WT-1 (-), CK20 (-), CK7 (+), ER (+, moderate, 70%), p16 (-, patchy), p53: wild-type, napsain A (-), MLH1: negative (loss expression), PMS2: negative (loss expression), MSH2: positive, MSH6: positive
• 2023-08-30 MRI - pelvis
  • With and without contrast enhancement MRI: Pelvis
    • Huge cystic tumor, 13.1x19.2cm in the pelvic cavity, r/o left ovarian malignancy.
    • Soft tissue tumors in the uterine cavity(fundus and body), involvement of almost layer of myometrium, r/o endometrial malignancy.
    • Non-enhancing nodule in right kidney, 1.3cm, r/o right renal cyst.
    • Unremarkable change of the liver, spleen, pancreas and left kidney.
    • There are multiple enlarged lymph nodes in the paraaortic and pelvic cavity, could be due to metastatic lymph nodes.
    • Presence of ascites.
    • Left pleural effusion.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T3a(T_value) N:N2a(N_value) M:M1(M_value) STAGE:IVB__(Stage_value)
  • Impression:
    • R/O endometrial malignancy with multiple metastatic lymph nodes in pelvic cavity and paraaortic regions. cstage T3aN2aM1(if malignant pleural effusion)
    • Huge cystic tumor in pelvic cavity, r/o left ovarian malignancy, metastasis or primary?
    • Left pleural effusion, metastasis? Suggest cytology.

[MedRec]

• 2023-10-30 ~ 2023-11-08 POMR Obstetrics and Gynecology Chen GuoHu
  • Discharge diagnosis
    • endometrial cancer (endometrioid carcinoma, grade 3 and grade 2), pT3aN1aM1; AJCC prognostic stage IVB; 2023 FIGO stage IVB; 2023 FIGO stage IVBm MMRd, post staging surgery on 2023/10/31
    • large left ovarian tumor 18x18cm, metastatic cancer from endometrium
    • adenomyosis
    • Female pelvic peritoneal adhesions (postinfective)
    • Iron deficiency anemia secondary to blood loss (chronic)
    • Acute posthemorrhagic anemia
  • CC
    • Lower abdominal pain for 4 months
  • Present illness
    • This is a 43 y/o woman, G0, SEX(+), LMP: 2023/05/10, with no significant past medical history except undergoing a gastric surgery. This time, she was admitted due to lower abdominal pain for 4 months.
    • According to the patient, she was found with endometrium thickening since 2021 while doing GYN sonography for in vitro fertilization. The IVF center then referred her to TMUH in 2021/09. At TMUH, Pelvic MRI showed small size uterine tumor about 1*1cm. Hysteroscopy biopsy was done and the pathology revealed endometrial carcinoma, grade 2 (patho No: TH2109223). however, previous endometrial cancer was noted in 2021 without aggresive treatment. After 3 times of hysteroscopy D&C, the doctor suggested her to undergo total hysterectomy due to disease progression but the patient refused because she still wanted a baby and never went back to visit the doctor until now.
    • On early July 2023, the patient complianed of intolerable continuous lower abdominal dull pain, Also accompanied with bilateral leg numbness and muscle cramping, fever in 2023/07, poor appetite, body weight loss (decrease 10kg in half year), intermittent diarrhea and constipation. She came to Dr. Chen’s OPD for help in 2023/07. The blood test showed CA125 416.6 U/mL, CEA 32.57 U/mL. Trans-abdominal ultrasound on 2023/07/26 showed Uterus: AVF, 10.05.0cm; Endometrium: 19.3mm; Cul-de-sac: with fluid 10-100 cc; a large pelvic mass 14.59.5cm, mixed solid & cystic component.
    • Pelvic MRI on 2023/08/30 showed Huge cystic tumor in pelvic cavity: 19.2*13.1cm, suspected left ovarian malignancy; Soft tissue tumor in uterine cavity (fundus & body), involved almost all layer of myometrium, suspected endometrial malignancy; Multiple enlarge lymph nodes in paraaortic area & pelvic cavity; Ascites were noted; Left pleural effusion, r/o malignant pleural effusion. The AJCC clinical staging was cT3aN2aM0-1 (if malignant pleural effusion), FIGO stage: III OR IVB.
    • The patient denied recent headache, dizziness, chest pain/tightness, dyspnea, palpitation, dysuria, urinary frequency, urinary urgency, leg swelling.
    • Under the impression of endometrial carcinoma progression with a large pelvic mass, suspected metastatic left ovarian cancer or primary ovarian cancer, the patient was admitted for staging surgery (TAH + BSO + BPLND + Omentectomy +/- PALND) and enterolysis on 2023/10/31 and further treatment.
  • Course of inpatient treatment
    • The patient was admitted on 2023/10/30. Due to pre-operative anemia (Hb = 8.9) and intra operation blood loss, a total of blood transfusion with LP-RBC 5U before and during operation were given.
    • She underwent staging surgery (total abdominal hysterectomy + bil salpingo-oophoretomy + bilateral pelvic lymphonode dissection + omentectomy) and enterolysis on 2023/10/31.
    • We gave her Cefazolin and Gentamycin IV form for 3 day and then shifted her antibiotics to Cephalexin oral form. Post-operation wound was dry and clean without dehiscence, discharge, or oozing. Her lab data on 2023/11/01 also showed mild anemia and elevated WBC. Nevertheless, her condition was stable without fever and special complaints since 3 days after the staging surgery. After flatus, her eating, self voiding and defecation were all ok. The JP drain was removed on 2023/11/07 smoothly. Since all her general conditions were all improved and relatively stable, we arranged discharge on 2023/11/08 for her for further OPD follow up of her recovery status and surgical wound conditions.  
  • Discharge prescription
    • cephalexin 500mg 1# QID
    • MgO 250mg 2# QID
    • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

[radiotherapy]

2023-12-06 ~ 2024-01-22 - 4500cGy/25 fractions of the pelvic to paraaortic area, and another 1200cGy/3 fraction of the vaginal cuff mucosa surface by IVRT.

[chemotherapy]

• 2024-03-19 - paclitaxel 175mg/m2 350mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-01-16 - cisplatin 30mg/m2 60mg NS 500mL 2hr + NS 500mL 30min (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-09 - cisplatin 30mg/m2 60mg NS 500mL 2hr + NS 500mL 30min (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-04 - cisplatin 30mg/m2 60mg NS 500mL 2hr + NS 500mL 30min (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-20 - cisplatin 30mg/m2 60mg NS 500mL 2hr + NS 500mL 30min (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-14 - cisplatin 30mg/m2 60mg NS 500mL 2hr + NS 500mL 30min (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-05 - cisplatin 30mg/m2 60mg NS 500mL 2hr + NS 500mL 30min (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-03-19

[successful tumor marker normalization]

Cisplatin plus RT (early Dec 2023 to late Jan 2024) followed by carboplatin/paclitaxel (since this hospital stay Mar 2024) were applied to this patient. Encouragingly, both CEA and CA125 tumor markers have normalized. Vital signs during this hospitalization and laboratory results from March 18, 2024, showed no significant abnormalities. Additionally, no medication discrepancies were identified.

• 2024-03-01 CEA (NM) 3.479 ng/ml

• 2024-02-23 CEA (NM) 5.255 ng/ml

• 2024-01-19 CEA (NM) 31.623 ng/ml

• 2024-01-15 CEA (NM) 47.102 ng/ml

• 2024-01-05 CEA (NM) 70.602 ng/ml

• 2023-12-26 CEA (NM) 102.115 ng/ml

• 2023-12-18 CEA (NM) 98.865 ng/ml

• 2023-12-11 CEA (NM) 84.885 ng/ml

• 2024-03-01 CA-125 (NM) 14.534 U/ml

• 2024-02-23 CA-125 (NM) 19.631 U/ml

• 2024-01-19 CA-125 (NM) 25.216 U/ml

• 2024-01-15 CA-125 (NM) 37.914 U/ml

• 2024-01-05 CA-125 (NM) 54.741 U/ml

• 2023-12-26 CA-125 (NM) 80.554 U/ml

• 2023-12-18 CA-125 (NM) 73.020 U/ml

• 2023-12-11 CA-125 (NM) 76.992 U/ml

Throughout this hospitalization, vital signs and lab tests on 2024-03-18, have shown no significant abnormalities. There are also no medication discrepancies identified.

701502293

240319

[exam findings]

• 2024-01-08 Patho - small intestine biopsy

  • Jejunum, saddle portion, biopsy — ulcer

• 2024-01-08 EGD

  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Duodenal obstruction 2nd portion, s/p gastrojejunostomy bypass
    • Jejunal ulcers, shallow, s/p biopsy
  • Suggestion:
    • PPI Rx if necessary.

• 2023-12-14 Percutaneous gall bladder drainage

• 2023-12-14 Patho - pancreas biopsy

  • Tumor, pancreatic uncinate process, EUS biopsy — Ductal adenocarcinoma
  • Microscopically, the sections show a picture of ductal adenocarcinoma characterized by tumor cells with enlarged, hyperchromatic nuclei, infiltrated in fibrous stroma arranged in nest or tubular patterns.
  • Immunohistochemistry of CK7(+), CK19-9(+), CK20(-) and DPC4(-, focal) for tumor cell.

• 2023-12-09 CT - abdomen

  • Soft tissue mass at 3rd portion of doudenum measuring 5.5cm in largest dimension is found. The lesion obliterate CBD and IHDs with dilatation of the biliary trees. Suggest contrast enhanced study.
  • Some lymph nodes are found at mesenterric region.

[MedRec]

• 2023-12-09 ~ 2023-12-27 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Severe sepsis with septic shock
    • Adenocarcinoma of pancreatic ductal with retroperitoneal and superior mesenteric artery involvement stage IV
    • Obstructive jaundice related to tumor status post percutaneous trannshepatic gallbladder drainage on December 14, 2023
    • Hypocalcemia
    • Hypertension
    • Constipation
    • Type 2 diabetes mellitus
    • Port-a insertion on 2023/12/14
  • CC
    • abdominal pain for two weeks, fever and dysuria were noted today
  • Present illness
    • This 49 y/o female patient has past history of 1) Hypertension 2) Diabetes mellitus 3) mesenteric tumors s/p operation and radiotherapy x7 (last date 2023/12/08) at Cardinal Tien Hospital.
    • The patient stated that she began seeing a doctor at Cardinal Tien Hospital six months ago due to abdominal pain. After six months of tests, she was diagnosed with a tumor. She underwent surgery and radiation therapy. She felt that she did not have a good connection with the doctors at Cardinal Tien Hospital and did not want to return. The patient’s family member stated that Cardinal Tien Hospital had informed them that the patient had only one month to live. The patient hopes that coming to TzuChi Hospital may give her a better chance. She hopes to continue her treatment here in the future.
    • According to the description of the patient record. This time, she was presented to our ER with abdominal pain for two weeks, fever and dysuria were noted today. At ER, GCS:E4V5M6, HR:140/min, RR: 20/min, BP:74/39mmHg, SpO2:95%. A chest film disclosed the lung fields are clear. Laboratory studies disclosed WBC:2920u/L, hypokalemia(K:3.3mmol/L), hyponatremia(Na:127mmol/L), PCT:48.94ng/mL and hyperbilirubinemia(TBI:5.12mg/dl, DBI:3.14mg/dl). On vasopressor with levophed titration for septic shock.
    • Abdomen CT showed soft tissue mass at 3rd portion of doudenum measuring 5.5cm in largest dimension is found. The lesion obliterate CBD and IHDs with dilatation of the biliary trees. Some lymph nodes are found at mesenterric region. Therefore, GS was consulted and suggested transfer to ICU.
    • Under the impression of 1) Septic shock 2) Retroperitoneal tumor with SMA involvement, unknown stage, she was admitted to ICU for further treatment on 2023-12-09.
  • Course of inpatient treatment
    • She sent to MICU at first due to shock and she received fluid hydration and vasopressin agent titration. Empiric antiboltic with Brosym (since 12/9) was prescribed for infection control. Pain control for abdominal discomfort.
    • After stable of hemodyanemic, she was transferred to ward.
    • EUS-biopsy was done and showed one 50 x 46 mm heterogeneous hypoechoic lesion with calcification component arising from the uncinate process of pancreas, indicating a pancreatic uncinate process tumor and pathology showed pancreatic ductal adenocarcinoma on 2023/12/18.
    • Due to jaundice and tumor obstruction, PTGBD was placed on 2023/12/13. Port-A was implanted on 2023/12/13.
    • Radiology was consulted for radiotherapy and the treatment planning was done on 2023/12/18.
    • Currently, Cravit 750mg QD was given for infection control, imperan 10mg TID for nausea and vomiting since admission.
    • Panzolec 40mg for ulcer prevention. RI 25U in PPN, forxiga 1tab QD, Pioglit 1tab QD for surgar control.
    • Concor 1tab QD, Exforge 1tab QD for BP control. Acetal 1tab QID, tramator 100mg IVD PRNQ12H, Fentanyl patch Q3D for pain control.
    • Semiliquid diet 1200kcal and PPN for nutrition support.
    • Due to Hb dropped from 10.3 to 7.0, blood transfusion with LPRBC 3U was done on 12/15-16.
    • Hypokalemia correct during hospitalization. PTGBD revision revealed due to dislocation of the catheter on 12/21.
    • At ONC ward, she received Mycostatin (Nystatin) 3ml qd qid for oral candidas.
    • Chemo as Gemzar/Abraxance on 2023/12/25.
    • We taper Fentanyl 50mcg to 12 mcg with Morphine 3mg sc prnq4h. Thus, her painful condition got well after chemotherapy.
    • Standing abdomen film was done for abdominal distention and vomit, the image showed stool impaction.
    • Under the stable condition, she can be discharged on 2023/12/27. OPD follow up is arranged.
  • Discharge prescription
    • Lactul Syrup (lactulose 666mg/mL) 10mL TID
    • Durogesic (fentanyl 12ug/h, 2.1mg/patch) 1# Q3D EXT for 2023-12-30
    • Bisadyl supp (bisacodyl 10mg) 2# QD RECT
    • Through (sennoside 12mg) 2# HS
    • Morphine 15mg 1# PRNQ6H

[consultation]

• 2024-03-18 Cardiology
  • Q
    • For Hypotension with sinus tachycardia
    • This 49 y/o female patient has past history of mesenteric tumors s/p operation and radiotherapy and under C/T now. This time, she was admited due to sorethroat, abd pain, N/V after CT. Hypotension with BP: 83/47 and EKG revealed sinus tachycardia in ER.
    • Therefore, we need your expert for further survery of hypotension with sinus tachycardia. Thank you.
  • A
    • Emergency Department
      • Chief Complaint:
        • Nausea and vomiting > acute persistent vomiting
        • Chemotherapy-induced stomatitis (mouth sores)
        • Sore throat
        • Abdominal pain and vomiting
      • Vital signs: BP:83/47; HR:143; BT:36.6’C; RR:18;
      • Con’s:E4V5M6
      • SpO2:100%
    • Discharge diagnosis 20231228-20240114
      • Malignant neoplasm of retroperitoneum
      • sepsis with septic shock due to hypotension and acute kindey injury R/O dehydration related
      • Adenocarcinoma of pancreatic HEAD with retroperitoneal and superior mesenteric artery involvement stage IV
      • Severe sepsis without septic shock blood culture x 2 set: No growth for 5 days aerobically & anaerobically
    • LAB
      • hsTnI 195.7 -> 203.9 -> 220.9
      • K 5.7 Cre 2.0 ALT 14 CRP 22.4 lactate 2.3, metamyelocyte 8% Hb 11
      • ECG 20240318 sinus tachycardia, nonspecific ST change as ECG of 20231228
      • CXR 20240318 no cardiomegaly, clear lung field
    • Impression
      • Hypotension, cause? sepsis? (high CRP) hypovolemia? (vomiting, poor intake?)
      • Acute on chronic kidney disease
    • Suggestion
      • adequate fluid and sepsis control
      • may arrange echocardiogram if persistent hypotension
• 2024-01-04 Gastroenterology
  • Q
    • for Luminal narrowing of duodenum, 3rd portion and stent evaluation
    • This 46-year-old woman, a patient of Adenocarcinoma of pancreatic ductal with retroperitoneal and superior mesenteric artery involvement stage IV and Obstructive jaundice related to tumor status post percutaneous trannshepatic gallbladder drainage on 2023-12-14. She was admitted due to sepsis for anti treatment.
    • Owing to nausea with vomiting progression noted and small bowel series showed Luminal narrowing of duodenum, 3rd portion. We need expertise to evaluate her condition thanks!
  • A
    • Patient was not on the bed while I visited at 2024/01/04 1730-1745
    • Tracing back her medical history, patient recieved gastrojejunal anastomosis at Cardinal Tien Hospital
    • Lab
      • 2024-01-04 Na (Sodium) 134 mmol/L
        
      • 2024-01-04 K(Potassium) 2.5 mmol/L
        
      • 2024-01-04 Mg (Magnesium) 1.9 mg/dL
        
      • 2024-01-01 Procalcitonin (PCT) 0.06 ng/mL
        
      • 2024-01-01 AST 25 U/L
        
      • 2024-01-01 ALT 20 U/L
        
      • 2024-01-01 BUN 14 mg/dL
        
      • 2024-01-01 Creatinine 0.68 mg/dL
        
      • 2024-01-01 Bilirubin total 1.20 mg/dL
        
      • 2024-01-01 Bilirubin direct 0.44 mg/dL
        
      • 2024-01-01 CRP 5.4 mg/dL
        
      • 2024-01-01 WBC 3.06 x10^3/uL
        
      • 2024-01-01 HGB 10.0 g/dL
        
      • 2024-01-01 PLT 314 *10^3/uL
        
      • 2024-01-01 Neutrophil 69.6 %
        
    • Small intestine series: Luminal narrowing of duodenum, 3rd portion.
    • A:
      • vomitus, maybe related to medication, chemotherapy, r/o mechanical obstruction at gastrojejunal anastomosis
    • P:
      • Upper GI endoscopy is indicated if the patient and family could take the risk (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, etc)
      • Arrange Abdomen echo
      • Contact us, if any problems
• 2023-12-13 Radiation Oncology
  • Q
    • This is a 46y/o female with past history of HTN and T2DM. She was diagnosed with a retroperitoneal tumor with SMA involvement, unknown stage, s/p exploratory and retroperitoneal laparotomy + gastrojejunostomy bypass on 2023/11/07 in Cardinal Tien Hspital. The patient was discharged from Cardinal Tien Hospital after receiving the surgery and radiotherapy, yet no information about radiotherapy was mentioned in her previous medical chart.
    • This time, she was admitted to our hospital due to septic shock, after levophed control in ICU (2023/12/09-12/12), her hemodynamic status became stable and was transferred to ward.
    • We need your expertise for radiotherapy to treat this patient. Thanks a lot!
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For radiotherapy due to unresectable pancreatic carcinoma.
      • PI: Initially, the patient was diagnosed with a retroperitoneal tumor with SMA involvement, s/p exploratory and retroperitoneal laparotomy + gastrojejunostomy bypass on 2023/11/07 in Cardinal Tien Hospital. Referred for radiotherapy.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM (+); HTN (+)
        • Previous RT Hx: s/p incomplete radiotherapy at Cardinal Tien Hospital
    • O: ECOG: 3
      • PE: neck and bil SCF: neg.; abdomen: a surgical scar, abdominal pain with radiate to back.
      • CT scan of abdomen (2023-10-31, Cardinal Tien Hospital): Mesenteric root mass, malignancy can not be ruled out.
      • Pathology (2023-11-06, Cardinal Tien Hospital): soft tissue, mesenteric tumor, Exp Lap and tumor (core needle) biopsy of mesenteric tumor and gastrojejunostomy bypass – metastatic carcinoma.
      • Operation (2023-11-07, Cardinal Tien Hospital): Exploratory and retroperitoneal laparotomy + gastrojejunostomy.
      • Tumor marker (2023-12-09): CA125(107.5), CEA(8.23), CA199(>19450).
      • CXR (2023-12-09): neg.
      • CT scan of abdomen (2023-12-09): Soft tissue mass at 3rd portion of doudenum measuring 5.5cm in largest dimension is found. The lesion obliterate CBD and IHDs with dilatation of the biliary trees. Suggest contrast enhanced study. Some lymph nodes are found at mesenterric region.
      • EUS (2023-12-13): Pancreatic uncinate process tumor, s/p CH-EUS & EUS/FNB
    • A: Pancreatic carcinoma, s/p Exploratory and retroperitoneal laparotomy + gastrojejunostomy, and s/p incomplete radiotherapy.
    • P: Radiotherapy is indicated for this patient with the following indicators: unresectable pancreatic tumor
      • Goal: palliation
      • Treatment target and volume: pancreatic tumor and peripheral involved area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: need to check the previous radiation dose at Cardinal Tien Hospital before radiotherapy.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2023-12-18.
      • Apply the details of radiotherapy from Cardinal Tien Hospital.

[chemotherapy]

• 2024-03-12 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + Nab-paclitaxel 125mg/m2 200mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2024-02-20 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + Nab-paclitaxel 125mg/m2 200mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2024-02-07 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + Nab-paclitaxel 125mg/m2 200mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2024-01-23 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + Nab-paclitaxel 125mg/m2 200mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2024-01-09 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + Nab-paclitaxel 125mg/m2 200mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-12-25 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + Nab-paclitaxel 125mg/m2 200mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2024-03-19

[Hyperkalemia with Troponin I Increase & Rising Bilirubin]

While Kalimate (calcium polystyrene sulfonate) is being used to manage the hyperkalemia, the rising hs-Troponin I level has prompted consultation with our cardiologist.

• 2024-03-18 K(Potassium) 5.7 mmol/L

• 2024-03-18 hs-Troponin I 220.9 pg/mL
  

• 2024-03-18 hs-Troponin I 203.9 pg/mL
  

• 2024-03-18 hs-Troponin I 195.7 pg/mL

Is a PTCD (percutaneous transhepatic bile duct drainage) revision necessary due to the rising bilirubin level?

• 2024-03-18 Bilirubin total 1.59 mg/dL
  
• 2024-03-11 Bilirubin total 1.01 mg/dL

All medications on the active medication list can be administered via feeding tube, and no medication discrepancies were identified.

700370877

240318

[exam findings]

• 2023-12-30 - CT - chest
  • History and indication:
    • Small cell lung cancer with brain, bone and lung metastasis
  • With and without-contrast CT of chest revealed:
    • A tumor (2.7cm) at LLL with bil. lung metastases.
    • Multiple bony metastases.
    • A hypodense nodule (1.0cm) at spleen.
    • Some LNs at mediastinum and retroperitoneum.
    • A tumor (1.6cm) at right kidney.
    • Mild left hydronephrosis.
    • Some calcifications in prostate.
    • Tiny gallbladder stone.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Lung cancer (LLL) with LNs, lung and bony metastases. A hypodense nodule (1.0cm) at spleen. A tumor (1.6cm) at right kidney. Mild left hydronephrosis.
• 2023-12-26 Tc-99m MDP bone scan with SPECT
  • In comparison with the previous study on 2023/08/16, some bone lesions in the right 8th rib, some right costovertebral junctions, left iliac bone and left femur are either more prominent or new, suggesting multiple bone metastases in progression.
  • Two new hot spots in the anterior aspect of left rib cage. The nature is to be determined (new bone metastases? other nature?). Please correlate with other clinical findings for further evaluation.
  • Probably benign lesions in bilateral shoulders and knees.
• 2023-12-01 CT - brain
  • Bony erosion of left mandible. S/P craniotomy. Encephalomalacia at rgiht parietal region. A bony defect at left parietal skull.
• 2023-11-29 MRI - L-spine
  • Focal T2W hyperintensity lesion in conus medullaris (T11-12 level), suspect spinal cord lesion. Myelitis or tumor? Suggest further evaluation.
  • Degenerative spinal and disc disease.
  • Mild L2-3 retrolisthesis. Grade 1 degenerative spondylolisthesis at L4-5 level.
  • Moderate L2-3, L3-4, severe L4-5 central canal stenosis.
  • Mild spinal cord compression at lower cervical level without myelopathy change.
• 2023-11-29 L-spine AP + Lat. (including sacrum)
  • Grade 1 degenerative spondylolisthesis at L4-5 level. L5-S1 disc space narrowing. Degenerative change of the spine with marginal spur formation.
• 2023-08-17 PET scan
  • Glucose hypermetabolism in a focal area in the lower lobe of left lung. Primary lung malignancy may show this picture. However, please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in a focal area in the right posterior upper abdomen just between liver and right kidney and in a focal in the soft tissue of left lower back region. Metastatic lesions may show this picture.
  • Glucose hypermetabolism in some left paraaortic and left common iliac lymph nodes. Metastatic lymph nodes may show this picture.
  • Glucose hypermetabolism in multipe bones as mentioned above, suggesting lmultiple bone metastases.
  • Mild glucose hypermetabolism in a right axillary lymph node and in a focal area in the dome of the liver. The nature is to be determined (early metastatic lesions? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Decreased FDG uptake in the right parietal area of the brain, compatible with post-operative change.
• 2023-08-16 Tc-99m MDP bone scan
  • A faint hot spot in the posterior aspect of the right 8th rib, and mildly increased activity in the left parietal region of the skull, left aspect of the mandible, left humeral head, and left iliac bone, compatible with the previous PET scan findings of metastatic bone disease.
  • Probably benign lesions in some T- and L-spine, bilateral shoulders, and knees.
• 2023-08-15 MRI - brain
  • The MRA study shows mild arteriosclerosis of the neck and intracranial vessels with irregular outline but without focal severe stenosis or complete occlusion. Segmental stenoses at left M1-2.
  • Imp: Post resection for right parietal tumor. Left parietal skull tumor still was noted. Small bifrontal and right cerebellar enhancing nodules, c/w metastases.
• 2023-08-10 Patho - brain/menings (tumor) (Y1)
  • Labeled as “brain”, craniotomy — metastatic carcinoma.
  • Sections of F2023-358FS and S2023-15852 show large round blue cell tumor with marked nucrosis, many mitoses > 10 mitoses/high per field, nuclear molding.
  • IHC stains: CK5/6: (-), p40 (-): dis-favor squamous cell carcinoma, TTF-1 (+), Napsin-A (-), CD56 (+), suggestive of neuroendicrine carcinoma. An addendum report of additional IHC stains will be followed.
  • addtional IHC stains: synaptophysin (+), chromogranin (+), Ki-67: (60-70%).
• 2023-08-10 Frozen Section
  • Preliminary diagnosis: brain: malignant.
    • The possibility of metastatic carcinoma cannot be excluded.
• 2023-08-07 CT - chest
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N0(N_value) M:M1c(M_value) STAGE:____(Stage_value)
      
  • Findings
    • an irregular soft-tissue tumor at paraspinal superior segment of LLL (about 32mm in longest axial dimension), contacting the adjacent descending thoracic aorta and associated small pleural effusion. tiny nodules at both lungs too
    • a large Rt T6-T8 paraspinal tumor with destruction of adjacent vertebrae and rib is found due to metastasis.
    • Mediastinum and hila: no enlarged LN mild calcified plaques of the LAD coronary artery.
    • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: dilated LV.
    • Rt renal cyst measuring 2.2cm (longest axial diameter)
    • marginal spurs of multiple vertebrae due to spondylosis. degenerative spinal canal and lateral recesses stenosis at L5-S1 or L4-5.
  • Impression: LLL cancer T4N0M1c
• 2023-08-05 MRI - brain
  • Clinical information: general weakness for 2 weeks, unsteady gait 3-4 days.
  • MR of the brain and MRA of the intracranial vessels and neck carotid systems were performed on a 1.5 T superconducting magnet on supine position utilizing head coil with 6 mm slice thickness and 24 cm field of view with intravenous injection of Gadolinium.
  • Findings:
    • One large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema, showing irregular rim-enhancement. Another tiny enhancing nodule over left frontal lobe. One bony destructive lesion (2.6cm) over left parietal bone. Favor metastatic lesions.
    • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
    • Short segmental moderate stenosis of left MCA.
• 2019-04-02 SONO - abdomen
  • Parenchymal liver disease, C/W alcoholic liver disease
  • Fatty liver, mild
  • suspicious, Renal stone, left

[MedRec]

• 2023-08-07 ~ 2023-08-24 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Small cell lung cancer with brain, bone and lung metastasis, extensive stage, cT4N0M1c stage IVB, s/p right parietal-occipital craniotomy to remove brain tumor on 2023-08-09. C1 chemotherapy with EP on 8/21-8/23
    • Secondary malignant neoplasm of brain, status post right parietal-occipital craniotomy to remove brain tumor on 2023-08-09
    • Essential (primary) hypertension
    • Hypomagnesemia
  • CC
    • General weakness for 2 weeks and unsteady gait 3-4 days.
  • Present illness
    • This 58-year-old male, deniend any medical history. Ths time, he was suffered from general weakness for 2 weeks and unsteady gait for 3-4 days.
    • On 2023-08-02, he visited to our ER, during which he was diagnosed of hypomagnesemia and received treatment with magnesium oxide (MgO) and B complex vitamins.
    • The patient also mentioned that he had chest discomfort. He admitted to regular alcohol consumption, consuming 300-400cc of spirits (shochu) daily. He was sent to our ER by his family.
    • Vita signs(T/P/R): 37.2/113/16, BP: 206/99mmHg, SPO2: 96%. Con’s:E4V5M6. He denied having fever, headaches, nausea, vomiting, or diarrhea. He also denied experiencing symptoms related to upper respiratory tract infections and urinary burning sensation.
    • The Brain MRI (contrast and non contrast) revealed 1. One large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema, showing irregular rim-enhancement. Another tiny enhancing nodule over left frontal lobe. One bony destructive lesion (2.6cm) over left parietal bone. Favor metastatic lesions 2. MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels 3. Short segmental moderate stenosis of left MCA.
    • The chest CT for preoperation survey, showed LLL cancer T4N0M1c (E1).
    • NS was consulted, suggested admitted SICU for prepare operation survey and intensive care.
  • Course of inpatient treatment
    • After admission, intravenous Dexamethason and Mannitol and anticonvulsant agent Keppra were prescribed for brain swelling & seizure prevention.
    • Image study with brain MRI (2023-08-05) revealed one large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema, showing irregular rim-enhancement. Another tiny enhancing nodule over left frontal lobe. One bony destructive lesion (2.6cm) over left parietal bone. Favor metastatic lesions.
    • Chest CT (with abdominal CT) for tumor survey on 2023/08/07, which showed 1) irregular soft-tissue tumor at paraspinal superior segment of left lower lung (about 32mm in longest axial dimension), contacting the adjacent descending thoracic aorta and associated small pleural effusion; 2) tiny nodules at both lungs too; 3) a large Rt T6-T8 paraspinal tumor with destruction of adjacent vertebrae and rib is found due to metastasis.
    • He underwent operation of right parietal-occipital craniotomy to remove brain tumor on 8/9 23. Labeled as “brain”, craniotomy (8/14 23) proved metastatic carcinoma. IHC stains: CK5/6: (-), p40 (-): dis-favor squamous cell carcinoma, TTF-1 (+), Napsin-A (-), CD56 (+), suggestive of neuroendicrine carcinoma.
    • Repeat brain MRI (8/15 23) showed Post resection for right parietal tumor. Left parietal skull tumor still was noted. Small bifrontal and right cerebellar enhancing nodules, c/w metastases. Bone scan (8/17 23) showed multiple bone mets.
    • Whole PET scan (8/18 23) showed in a focal area in the lower lobe of left lung. Primary lung malignancy may show this picture. However, please correlate with other clinical findings for further evaluation. Glucose hypermetabolism in a focal area in the right posterior upper abdomen just between liver and right kidney and in a focal in the soft tissue of left lower back region. Metastatic lesions may show this picture. Glucose hypermetabolism in some left paraaortic and left common iliac lymph nodes. Metastatic lymph nodes may show this picture.Glucose hypermetabolism in multipe bones as mentioned above, suggesting multiple bone metastases.
    • HBsAg, anti-Hbc and anti-HCV showed negative. The tumor marker showed CA-199:352 U/ml, CEA:1194ng/ml, CA-125:52U/ml, SCC:1.6ng/ml. Port-A was inserted on 8/17 23. We had removed the head surgical stiches on 8/18 23 after the wound healing well with gauze cover. He was transferred to our ward for further evaluation and chemotherapy.
    • Chemotherapy with Etoposide (100mg/m2, D1-D3) plus Cisplatin (75mg/m2, D1) were given on 8/21-8/23 23, smoothly without obvious side effect. He was discharged on 8/24 23 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID 8D
    • Norvasc (amlodipine 5mg) 1# QD 8D
    • Through (sennoside 12mg) 2# HS 8D
    • Keppra (levetiracetam 500mg) 1# BID 8D
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 3D

[consultation]

• 2023-12-27 Radiation Oncology
  • Q
    • for radiotherapy evaluation due to bone metas
    • This 58-year-old male, a patient of Small cell lung cancer with brain, bone and lung metastasis, extensive stage, cT4N0M1c stage IVB was diagnosed on 8/9 23 and s/p right parietal-occipital craniotomy to remove brain tumor. S/P C1 Chemotherapy with Etoposide (100mg/m2, D1-D3) plus Cisplatin.
    • This time, he was admitted for C5 chemotherapy with EP on 12/22 23. He complaints right ribs pain, followed-up bone scan (2023/12/26) revealed 1. In comparison with the previous study on 2023/08/16, some bone lesions in the right 8th rib, some right costovertebral junctions, left iliac bone and left femur are either more prominent or new, suggesting multiple bone metastases in progression. 2. Two new hot spots in the anterior aspect of left rib cage. The nature is to be determined (new bone metastases? other nature?). So we need your help for radiotherapy evaluation due to bone metas. Thanks a lot!!
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For radiotherapy due to lung carcinoma with bone metastases and pain.
      • PI: The patient was a case of small cell lung cancer with brain, bone and lung metastasis, extensive stage, cT4N0M1c stage IVB was diagnosed on 8/9 23 and s/p right parietal-occipital craniotomy to remove brain tumor. S/P C1 Chemotherapy with Etoposide (100mg/m2, D1-D3) plus Cisplatin. This time, he was admitted for C5 chemotherapy with EP on 12/22 23. He complaints right ribs pain. For radiotherapy.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (+); Smoking (+); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
      • Previous RT Hx: (-)
    • O: ECOG: 1
      • PE: neck and bil SCF: neg.; back pain.
      • MRI of brain (2023-08-05): 1. One large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema, showing irregular rim-enhancement. Another tiny enhancing nodule over left frontal lobe. One bony destructive lesion (2.6cm) over left parietal bone. Favor metastatic lesions. 2. MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels. 3. Short segmental moderate stenosis of left MCA.
      • CT scan of lung (2023-08-07): LLL cancer T4N0M1c
      • Operation (2023-08-09): right P-O craniotomy to remove brain tumor, navigation assisted, microscope assisted
      • Pathology (S2023-15852, 2023-08-14): ADDENDUM: addtional IHC stains: synaptophysin (+), chromogranin (+), Ki-67: (60-70%). Labeled as “brain”, craniotomy — metastatic carcinoma. IHC stains: CK5/6: (-), p40 (-): dis-favor squamous cell carcinoma, TTF-1 (+), Napsin-A (-), CD56 (+), suggestive of neuroendicrine carcinoma. An addendum report of additional IHC stains will be followed.
      • MRI of brain (2023-08-15): Post resection for right parietal tumor. Left parietal skull tumor still was noted. Small bifrontal and right cerebellar enhancing nodules, c/w metastases.
      • Bone scan (2023-12-27): 1. In comparison with the previous study on 2023/08/16, some bone lesions in the right 8th rib, some right costovertebral junctions, left iliac bone and left femur are either more prominent or new, suggesting multiple bone metastases in progression. 2. Two new hot spots in the anterior aspect of left rib cage. The nature is to be determined (new bone metastases? other nature?).
    • A: Neuroendicrine carcinoma of the lung, LLL, stage cT4N0M1c, with brain, bone, and lung metastases, s/p right P-O craniotomy to remove brain tumor and chemotherapy.
    • P: Radiotherapy is indicated for this patient with the following indicators: bone metastases with pain.
      • Goal: palliation
      • Treatment target and volume: right costovertebral junctional area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 3000cGy/10 fractions of the right costovertebral junctional area
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-12-28.
• 2023-11-29 Neurosurgery
  • Q
    • Acute weakness/inability to move; General weakness
    • CC: bil. leg weakness for a long time , but worsen since yesterday
    • PHx:
      • Small cell lung cancer with brain, bone and lung metastasis, extensive stage, cT4N0M1c stage IVB, s/p right parietal-occipital craniotomy to remove brain tumor on 8/9. C1 chemotherapy with EP on 8/21-8/23
      • Secondary malignant neoplasm of brain, status post right parietal-occipital craniotomy to remove brain tumor on 2023-08-09
      • Essential (primary) hypertension
      • Hypomagnesemia
    • Allergy: NKA
  • A
    • 58 y/o male.
    • L-spine MRI:
      • Focal T2W hyperintensity lesion in conus medullaris (T11-12 level), suspected spinal cord lesion. Myelitis or tumor?
      • Degenerative spinal and disc disease.
      • Mild L2-3 retrolisthesis. Grade 1 degenerative spondylolisthesis at L4-5 level.
      • Moderate L2-3-4 and severe L4-5 canal stenosis.
      • Mild spinal cord compression at lower cervical level without myelopathy change.
    • Plan:
      • No neurosurgery is required now. OPD F/U.
• 2023-08-14 Hemato-Oncology
  • Q
    • This 58 years old male patient who deniend any medical history before. According to the patient’s, he had suffered from general weakness for 2 weeks and unsteady gait for 3-4 days. He visited our ER for help. Initial consciousness remained E4V5M6. He denied having fever, headaches, nausea, vomiting, or diarrhea.
    • Brain MRI with/without contrast revealed 1) one large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema, showing irregular rim-enhancement. Another tiny enhancing nodule over left frontal lobe. One bony destructive lesion (2.6cm) over left parietal bone. Favor metastatic lesions.
    • Chest CT (with abdominal CT) showed 1) irregular soft-tissue tumor at paraspinal superior segment of LLL (about 32mm in longest axial dimension), contacting the adjacent descending thoracic aorta and associated small pleural effusion; 2) tiny nodules at both lungs too; 3) a large Rt T6-T8 paraspinal tumor with destruction of adjacent vertebrae and rib is found due to metastasis. LLL cancer T4N0M1c,(E1).
    • Regular alcohol consumption, consuming 300-400cc of spirits (shochu) daily was told. He then underwent right parietal-occipital craniotomy to remove brain tumor on 8/9. Pathology report showed metastatic carcinoma. IHC stains: CK5/6: (-), p40 (-): dis-favor squamous cell carcinoma, TTF-1 (+), Napsin-A (-), CD56 (+), suggestive of neuroendicrine carcinoma.
    • Thus, we need your professional evaluation and recommendation for further management. Thank you very much for your time!
  • A
    • This 58 year old man is a case of newly diagnosis small cell lung cancer with brain, bone and lung metastasis, extensive stage, cT4N0M1c stage IVB, s/p right parietal-occipital craniotomy to remove brain tumor on 8/9. We are consulted for further evaluation.
    • Suggestion:
      • Please arrange PET scan, bone scan, check Anti HBc, AntiHBs, HBsAg, Anti HCV, LDH.
      • We will discuss with patient about further chemotherapy (EP). Please arrange port A insertion. We wil take over this case.
• 2023-08-09 Anesthesia
  • Q
    • Consult for anesthesia assessment
    • This 58-year-old male, deniend any medical history. Ths time, he was suffered from general weakness for 2 weeks and unsteady gait for 3-4 days. Brain MRI (contrast and non contrast) revealed One large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema. We will be arrange operation for brain tumor excision on level B on today.
    • We need your help for anesthesia assessment. Thank you a lot !!!
  • A
    • Dear doctors and nurse practitioners. I have visited the patient and reviewed the history.
    • Patient general condition:
      • GCS: E4V5M6
    • Pre-anesthesia diagnosis:
      • brain tumor
    • Scheduled Operation:
      • brain tumor excision
    • Past history:
      • Denied
    • Lab data:
      • GOT 60
    • CXR:
      • Increased infiltration
    • ECG:
      • NSR, QT prolong
    • Assessment: ASA 2E
    • Plan and recommendation:
      • We will arrange ETGA for anesthesia, and closely monitor during anesthesia.
      • Patient and family have been informed and understood about the risk and plan of aneshtesia for operation, including cardiovascular risks (hypotension, stroke, acute myocardial infarction, shock), pulmonary risks (hypoxia, pulmonary embolism,delay extubation), ICU care and other possible complications.
• 2023-08-07 Neurosurgery
  • Q
    • Acute weakness/unable to move - general weakness for many days. The patient went to the doctor on 2023/08/02 and was told that the magnesium ions were too low. He admitted because his symptoms did not improve.
    • general weakness for 2 weeks , unsteady gait 3-4 days.
    • Not improved compared to 3 days ago (came to the ED with hypomagnesemia -> MBD with MgO and B complex)
    • chest discomfort+
    • alchohol drinking+, Sorghum liquor 300-400cc everyday.
    • Denied Fever, headache, Nausea, vomiting, diarrhea
    • Denied URI symptoms, Denied urinary burning sensation
    • PmHx Gout
    • NKDA
  • A
    • The patient, a 58-year-old male, presented with a state of overall weakness and fatigue that progressed to an acute inability to walk due to profound weakness. On August 2nd, he sought medical attention and was informed that his magnesium ion levels were abnormally low. However, his symptoms did not show improvement, prompting his current visit.
    • He reported experiencing general weakness for the past two weeks, along with an unsteady gait persisting for 3-4 days. His condition had not improved since his last visit to the Emergency Department, during which he was diagnosed with hypomagnesemia and received treatment with magnesium oxide (MgO) and B complex vitamins. The patient also mentioned feeling chest discomfort. He admitted to regular alcohol consumption, consuming 300-400cc of spirits (shochu) daily.
    • He denied having fever, headaches, nausea, vomiting, or diarrhea. He also denied experiencing symptoms related to upper respiratory tract infections and urinary burning sensation.
    • The patient’s past medical history includes gout. A brain MRI revealed the following findings:
      • A large cystic mass lesion measuring 4.5cm located in the right parietal lobe, accompanied by noticeable peritumoral edema and irregular rim-enhancement. A smaller enhancing nodule was detected in the left frontal lobe. Furthermore, a bony destructive lesion measuring 2.6cm was observed in the left parietal bone. These findings are indicative of potential metastatic lesions.
      • MR angiography of the brain revealed atherosclerotic changes in both intracranial and carotid vessels.
      • A short segmental moderate stenosis of the left middle cerebral artery (MCA) was identified.
    • Considering the clinical and imaging findings, the patient has been advised of the risks and potential outcomes. Surgical intervention has been recommended. Thank you for the consultation.

[chemotherapy]

• 2024-03-15 - etoposide 100mg/m2 150mg NS 500mL 2hr D1-3 + carboplatin AUC 3 180mg NS 250mL 2hr D1
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-22 - etoposide 100mg/m2 165mg NS 500mL 2hr D1-3 + carboplatin AUC 3 200mg NS 250mL 2hr D1
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-27 - etoposide 100mg/m2 168mg NS 500mL 2hr D1-3 + carboplatin AUC 5 340mg NS 250mL 2hr D1
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-16 - etoposide 100mg/m2 168mg NS 500mL 2hr D1-3 + NS 1000mL 4hr (before CDDP) + cisplatin 75mg/m2 125mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) (VP-16 + CDDP, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-18 - etoposide 100mg/m2 168mg NS 500mL 2hr D1-3 + NS 1000mL 4hr (before CDDP) + cisplatin 75mg/m2 125mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) (VP-16 + CDDP, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-19 - etoposide 100mg/m2 166mg NS 500mL 2hr D1-3 + NS 1000mL 4hr (before CDDP) + cisplatin 75mg/m2 120mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) (VP-16 + CDDP, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-21 - etoposide 100mg/m2 170mg NS 500mL 2hr D1-3 + NS 1000mL 4hr (before CDDP) + cisplatin 75mg/m2 120mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) (VP-16 + CDDP, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-04-22

[monitoring BP for Norvasc dosage adjustments]

Liver function has been deteriorating since mid-April 2024. Norvasc (amlodipine) undergoes extensive hepatic metabolism, with about 90% being converted to inactive metabolites; only 10% of the parent drug and 60% of the metabolites are excreted in the urine. If there are any signs of declining blood pressure in the patient, it is advisable to reduce or temporarily discontinue the dosage of Norvasc.

• 2024-04-21 Bilirubin total 6.71 mg/dL

• 2024-04-17 Bilirubin total 4.81 mg/dL

• 2024-04-03 Bilirubin total 0.31 mg/dL

• 2024-04-21 Bilirubin direct 4.58 mg/dL

• 2024-04-03 Bilirubin direct 0.09 mg/dL

• 2024-04-21 ALT 105 U/L

• 2024-04-17 ALT 103 U/L

• 2024-04-03 ALT 12 U/L

• 2024-03-27 ALT 14 U/L

• 2024-03-15 ALT 14 U/L

• 2024-02-29 ALT 13 U/L

• 2024-02-22 ALT 5 U/L

• 2024-04-21 AST 66 U/L

• 2024-04-17 AST 69 U/L

• 2024-04-03 AST 19 U/L

• 2024-03-27 AST 19 U/L

• 2024-03-15 AST 19 U/L

• 2024-02-29 AST 21 U/L

• 2024-02-22 AST 15 U/L

2024-03-18

[combining atezolizumab with carboplatin and etoposide for ES-SCLC]

In the context of small cell lung cancer with brain metastases, atezolizumab, when combined with carboplatin and etoposide, has been approved for the first-line treatment of adult patients with extensive-stage small cell lung cancer (ES-SCLC) who have not received prior chemotherapy for extensive stage disease and have an ECOG performance status of 0 or 1. This approval was based on the IMpower133 trial, which demonstrated significant improvements in both overall survival and progression-free survival for patients receiving atezolizumab with chemotherapy compared to those receiving placebo with chemotherapy. (Ref: https://www.fda.gov/drugs/drug-approvals-and-databases/fda-approves-atezolizumab-extensive-stage-small-cell-lung-cancer)

Given this patient’s brain metastases, the direct applicability of atezolizumab in combination with carboplatin and etoposide under the NHI coverage may be uncertain due to the specific eligibility criteria. However, considering the efficacy of atezolizumab in ES-SCLC, and if the patient’s economic situation allows, it might be worth considering the inclusion of atezolizumab in the treatment regimen.

2024-02-23

[reconciliation]

The patient’s vital signs remain stable. However, lab results on 2024-02-22 indicate renal insufficiency. Consequently, the dosage of Keppra (levetiracetam) listed in the active medication list should be adjusted to reflect renal function. The current dose of 500mg BID falls within the recommended range for patients with a CrCl of 50 to 80. No medication discrepancies were identified.

2023-12-25

[kidney concerns prompt cisplatin swap: carboplatin steps in]

Despite receiving normal saline hydration 1L before and 1L after each cisplatin dose (reduced to 75mg/m2, standard 100mg/m2), the patient experienced elevations in both serum creatinine and BUN values following initiation of etoposide and cisplatin therapy on 2023-08-21.

• 2023-12-25 Creatinine 1.70 mg/dL

• 2023-12-22 Creatinine 2.07 mg/dL

• 2023-12-01 Creatinine 1.63 mg/dL

• 2023-11-29 Creatinine 1.91 mg/dL

• 2023-11-15 Creatinine 1.88 mg/dL

• 2023-10-31 Creatinine 1.91 mg/dL

• 2023-10-17 Creatinine 0.88 mg/dL

• 2023-09-27 Creatinine 1.27 mg/dL

• 2023-09-18 Creatinine 0.71 mg/dL

• 2023-08-31 Creatinine 0.78 mg/dL

• 2023-08-21 Creatinine 0.70 mg/dL

• 2023-08-14 Creatinine 0.67 mg/dL

• 2023-08-11 Creatinine 0.62 mg/dL

• 2023-08-09 Creatinine 0.84 mg/dL

• 2023-08-08 Creatinine 0.64 mg/dL

• 2023-08-02 Creatinine 0.80 mg/dL

• 2023-12-25 BUN 30 mg/dL

• 2023-12-22 BUN 27 mg/dL

• 2023-12-01 BUN 37 mg/dL

• 2023-11-29 BUN 41 mg/dL

• 2023-11-15 BUN 42 mg/dL

• 2023-10-31 BUN 46 mg/dL

• 2023-10-17 BUN 13 mg/dL

• 2023-09-27 BUN 30 mg/dL

• 2023-09-18 BUN 14 mg/dL

• 2023-08-31 BUN 18 mg/dL

• 2023-08-21 BUN 21 mg/dL

• 2023-08-14 BUN 17 mg/dL

• 2023-08-11 BUN 11 mg/dL

• 2023-08-09 BUN 12 mg/dL

• 2023-08-08 BUN 12 mg/dL

• 2023-08-02 BUN 15 mg/dL

To minimize the risk of further kidney damage, considering a switch from cisplatin to carboplatin (AUC 5) in the treatment plan could be beneficial, as carboplatin is known to have less impact on kidney function.

Ref: - Comparison of Carboplatin With Cisplatin in Small Cell Lung Cancer in US Veterans. JAMA Netw Open. 2022 Oct 3;5(10):e2237699. doi: 10.1001/jamanetworkopen.2022.37699. Erratum in: JAMA Netw Open. 2023 Jan 3;6(1):e2246257. PMID: 36264573; PMCID: PMC9585434. - Etoposide phosphate with carboplatin in the treatment of elderly patients with small-cell lung cancer: a phase II study. Ann Oncol. 2001 Jul;12(7):957-62. doi: 10.1023/a:1011171722175. PMID: 11521802.

700931488

240318

[exam findings]

[MedRec]

• 2022-03-24 SOAP Hemato-Oncology
  • Discharge diagnosis
    • Diffuse large B-cell lymphoma, GCB type, at least Lugano stage III, PS:1
    • Chronic viral hepatitis B without delta-agent
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
  • CC
    • for chemotherapy
  • Present illness
    • This 70-year-old man has histories of diabetes mellitus and hypertension for years under regular medication control. The patient has history of left neck level Vb tumor status post excision on 2018-12-28 by our VS. Su. This time, the patient noted a right neck palpable mass for one week. He came to our ENT OPD for help. Physical examination revealed right neck level V a 3 cm movable firm mass without tenderness. Fiberscope revealed right pyfiorm sinus medial wall mass and left aryepiglottic folds mass.
    • We arrange neck CT on 2022-03-14 which showed R/O a right palatine tonsil cancer with right retropharygeal and bilateral neck LAPs as mentioned above. A Small enhancing nodule in right medial pyriform sinus and possibly in left AE fold also were noted.
    • The patient underwent the operation of: 1. Excision of oropharyngeal tonsillar tumor, right; 2. Laryngomicrosurgery excision of right pyrifor apex tumor + left tongue  base tumor; 3. Regional neck dissection, right level Va+Vb. The whole procedure performed smoothly, and the patient tolerated the procedure well.
    • The surgical frozen section revealed Diffuse large B-cell lymphoma, GCB type.
    • PET was performed on 2022/03/25 which showed There was increased FDG uptake in multiple bilateral neck lymph nodes (SUVmax early: 26.30, delay: 30.67), bilateral supraclavicular lymph nodes (SUVmax early: 16.23, delay: 26.82), bilateral axillary lymph nodes (SUVmax early: 20.90, delay: 30.12) and multiple abdominal lymph nodes (SUVmax early: 13.12, delay: 19.11). Besides, there was increased FDG uptake in the region about right tonsil (SUVmax early: 10.70, delay: 7.34) and in a focal area in the region about lower portion of the esophagus (SUVmax early: 8.08, delay: 10.41).
    • With the diagnosis of Diffuse large B-cell lymphoma, GCB type with multiple bilateral neck lymph nodes, bilateral supraclavicular lymph nodes, bilateral axillary lymph nodes, right tonsil and in lower portion of the esophagus and paraaortic LNs involvement, Lugano stage IIIE at least, PS:1. He was admitted for further management
  • Course of inpatient treatment
    • After admission, bone marrow aspiration and biopsy for lymphoma staging on 2022/03/28. Port-A insertion on 2022/03/29. With the relatively stable condition, he was discharged on 2022/03/30 and next admission was arranged.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H

[surgical operation]

• 2024-02-06
  • Surgery
    • Excision of left tongue base tumor
    • Laryngomicrosurgery and tumor mapping
  • Finding
    • L tongue base tumor, suspect malignancy (recurrent DLBCL > changes of SCC)
• 2023-03-27
  • Surgery
    • TURBT  
  • Finding
    • Multiple hypervascular carpet like tumors in the bladder, mainly at the left side and right side of dome
    • all papillary tumors are 0.1-0.2 cm much smaller than resecton loop
  • Risk evaluation:
    • Tumor size: <=3cm (V), >3cm()
    • Multifocality: Multifocal(V), solitary()
    • Recurrence within 1 year: Yes(V), No()
• 2022-10-07
  • Surgery
    • TURBT + cystoscopic random biopsy
  • Finding
    • Two small papillary tumor with hypervascularity was noted in right posterior wall of bladder.    
    • A erythematous mucosa at left dome -> TURBT third specimen
  • Risk evaluation:
    • Tumor size: <=3cm (V), >3cm()
    • Multifocality: Multifocal(V), solitary()
    • Recurrence within 1 year: Yes(), No(V)
• 2022-06-27
  • Surgery
    • TURBT        
    • right ureterorenoscopic exam & double-J stenting        
  • Finding
    • A small tumor with was noted at right lateral wall of bladder(not papillary, pointed shape)
    • small edema with hypervascular of bladder posterior –> suspect Foley catheter irritated
  • Risk evaluation:
    • Tumor size: <=3cm (+), >3cm()
    • Multifocality: Multifocal(), solitary(+)*
    • Recurrence within 1 year: Yes(), No(+)
• 2022-03-15
  • Surgery
    • Excision of oropharyngeal tonsillar tumor, right
    • Laryngomicrosurgery excision of right pyrifor apex tumor+ left tongue base tumor
    • Regional neck dissection, right level Va+Vb
  • Finding
    • 2022/03/14 CT: Neck: R/O a R palatine tonsil CA (2.2cm) with R retropharygeal and bil. neck LAPs as mentioned above. A Small enhancing nodule in right medial pyriform sinus and possibly in left AE fold also were noted.
    • Tumor tonsillectomy, right (sent for frozen section)
    • LMS excision of right pyfiorm apex tumor+ left tongue base tumor
    • Vab junction tumor adherent to CN 11 and the latter was well preserved
• 2018-12-28
  • Diagnosis
    • neck mass, left level Vb
  • PCS code
    • 64116B
    • Benign neck massexcision (simple)
  • Finding
    • level Vb mass, deep

[immunochemotherapy]

• 2024-03-15 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + oxaliplatin 100mg/m2 185mg D5W 500mL 2hr D2 + gemcitabine 1000mg/m2 1800mg NS 100mL 30min D2 (R-GemOx)

  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2

• 2024-02-29 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + oxaliplatin 100mg/m2 185mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1800mg NS 100mL 30min D2 (R-GemOx)

  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2

• 2023-08-09 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr

• 2023-08-02 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr

• 2023-07-26 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr

• 2023-07-19 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr

• 2023-07-12 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr

• 2023-07-05 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr

• 2023-06-28 - mitomycin-C 30mg ST BI 1hr

• 2022-11-30 - mitomycin-C 30mg ST BI 1hr

• 2022-11-23 - mitomycin-C 30mg ST BI 1hr

• 2022-11-16 - mitomycin-C 30mg ST BI 1hr

• 2022-11-09 - mitomycin-C 30mg ST BI 1hr

• 2022-11-02 - mitomycin-C 30mg ST BI 1hr

• 2022-10-26 - mitomycin-C 30mg ST BI 1hr

• 2022-10-07 - mitomycin-C 30mg ST BI 1hr

• 2022-08-29 - rituximab 375mg/m2 684mg NS 500mL 6hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 60mg D5W 500mL 2hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 25mg PO QID D2-6 (R-CHOP)

  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2

• 2022-08-05 - (R-CHOP)

• 2022-07-07 - (R-CHOP)

• 2022-05-30 - (R-CHOP)

• 2022-05-03 - (R-CHOP)

• 2023-04-12 - (R-CHOP)

Intravesical Bacillus Calmette-Guerin - 2024-03-18 - https://www.uptodate.com/contents/intravesical-bacillus-calmette-guerin-drug-information

• Bladder cancer
  • TICE BCG: Induction: Intravesicular:
    • One dose (~50 mg or 1 vial) instilled into the bladder (retain for 2 hours) once weekly for 6 weeks beginning 7 to 14 days after biopsy (may repeat cycle 1 time if tumor remission not achieved), followed by maintenance therapy of ~50 mg (one vial) approximately once a month for at least 6 to 12 months.
  • Guideline recommendations:
    • According to the American Urological Association/Society of Urologic Oncology guideline on the diagnosis and treatment of nonmuscle invasive bladder cancer, and the Society for Immunotherapy of Cancer clinical practice guideline on immunotherapy for the treatment of urothelial cancer, BCG (intravesical) induction and 1 year of maintenance therapy should be considered for intermediate-risk disease; in high-risk disease, induction and 3 years of maintenance therapy should be administered.

Mitomycin (intravenous and intravesical) (systemic) - 2024-03-18 - https://www.uptodate.com/contents/mitomycin-intravenous-and-intravesical-systemic-drug-information

• Bladder cancer (off-label use):
  • Muscle invasive: IV (mitomycin injection solution):
    • 12 mg/m2 on day 1 (in combination with fluorouracil and radiation).
  • Nonmuscle invasive (off-label route): Intravesicular instillation of mitomycin injection solution:
    • Low risk of recurrence (uncomplicated): Intravesical ar instillation: 40 mg as a single dose postoperatively; retain in bladder for 1 to 2 hours.
    • Increased risk of recurrence: Intravesical ar instillation: 20 mg weekly for 6 weeks, followed by 20 mg monthly for 3 years; retain in bladder for 1 to 2 hours or 40 mg weekly for 6 weeks (with urine alkalinization and decreased urine volume to increase drug concentration); retain in bladder for 2 hours.

701049924

240315

[exam findings]

• 2024-02-16 Patho - bone marrow biopsy
  • Bone marrow, biopsy — No evidence of lymphoma involvement
  • The sections show normocellular marrow (35%). M/E ratio = 4:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. No lymphoid aggregates. There is no evidence of lymphoma involvement in CD3 and CD20 immunostains. Suggest further bone marrow smear evaluation and clinic correlation.
• 2024-02-08 PET scan
  • The FDG PET findings are compatible with lymphoma involving a single lymphatic site as mentioned above (stage I).
  • Increased FDG accumulation in the colon, both kidneys and right ureter. Physiological FDG accumulation is more likely.
• 2024-02-01 Nasopharyngoscopy
  • Findings
    • bi nasal cavity and middle meatus clear; smooth nasopharynx, tongue base and hypopharynx mucosa; normal vocal function, no tumor found at pharynx
  • Conclusion
    • right neck mass, suspicious malignancy with secondary infection (according to FNAC result)
    • no pharyngeal lesion found
• 2024-01-31 Patho - lymphnode biopsy
  • Lymph node, right neck, core needle biopsy — diffuse large B-cell lymphoma, GCB subtype
    
  • Sections show lymphoid tissue with infiltraition of large pleomorphic tumor cells and tumor necrosis.
  • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(+), CD5(-), CD30(-), BCL2(+), BCL6(+), cMYC(-), MUM1(-), and Cyclin D1(-). The results are consistent with diffuse large B-cell lymphoma, GCB subtype.
• 2024-01-25 CT - neck
  • Several enlarged necrotic nodes (max: 4.0cm) over right level II & III of neck. Suggest tissue proof to rule out malignant nodes. Relative effacement of right Rosenmuller fossa. Suggest clinical correlation.

[MedRec]

• 2024-02-15 ~ 2024-02-19 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Diffuse large B-cell lymphoma over neck, GCB subtype, stage I
    • Hepatitis B virus
    • hyperuricemia
  • CC
    • for chemotherapy at first
  • Present illness
    • This is a 81-year-old man with past history of
      • Hypertension
      • S/P cholecystectomy for gall stone
    • He had sorethroat with progressive right neck swelling for two days and a 3*3 cm soft mass over right neck level II region. Neck CT revealed several enlarged necrotic nodes over right neck level II & III. Sono-guide core-needle biopsy was done on 2024/01/31, pathology showed diffuse large B-cell lymphoma, GCB subtype. PET showed lymphoma involving a single lymphatic site as mentioned above (stage I).
    • Port-a insertion, wound healing well. Under the impression of neck diffuse large B-cell lymphoma, GCB subtype, stage 1, so he was admitted for first chemotherapy on 2024/02/15.
  • Course of inpatient treatment
    • After admission, IVF hydration and Feburic for hyperuricemia at first.
    • Baraclude 0.5mg 1# qdac for HBV. Bone marrow wsa done on 2/16.
    • Chemotherapy with R-COP on 2024/02/16-02/17. Check laboratory on 2024/02/17-02/18 without tumor lysis syndrom.
    • Under the stable condition, he can be discharged on 2024/02/19. OPD follow up is arranged.
  • Discharge diagnosis
    • Through (sennoside 12mg) 2# HS
    • Feburic (febuxostat 80mg) 1# QD
    • Ulstop (famotidine 20mg) 1# BID
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Compesolon (prednisolone 5mg) 6# BID 3D eat until 2024/02/21
• 2024-01-26 ~ 2024-02-02 POMR Ear Nose Throat Huang TongCun
  • Discharge diagnosis
    • Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
    • Peritonsillar abscess with right deep neck infection
    • Right neck mass
    • Enlarged prostate with lower urinary tract symptoms
  • CC
    • Fever and sorethroat for 2 days        
  • Present illness
    • This is a 81-year-old man with past history of Hypertension.
    • According to this patient`s statements, he had been suffered from sorethroat with progressive right neck swelling for two days. No trismus, hot-potato voice, mouth drooling, otalgia, dysphagia, dyspnea, recent body weight loss were noted.
    • Phsyical examination revealed no ulcer over oral cavity but swelling over right peritonsillar area, and a 3*3 cm soft mass over right neck level II region. Endoscope examination showed smooth nasopharynx, without swelling or pus coating over epiglottis or bulging over pharyngeal wall. Labaratory data revealed leukocytosis but no elevation of CRP.
    • Neck CT revealed several enlarged necrotic nodes over right neck level II & III. Under the impression of right neck lymphadenitis, we advised the patient to receive IV antibiotics treatment at ward. After careful consideration, the patient was admitted for IV antibiotics treatment and further management.
  • Course of inpatient treatment
    • After admission, empirical antibiotic of Augmentin was prescribed. Sono-guide aspiration was done, but no obvious pus was found. The clinical symptoms of sore throat improved gradually after the medication and daily throat local treatment.
    • Cytology revealed malignancy is highly suspected. Hence, sono-guide core-needle biopsy was done on 2024/01/31. After the procedure, the patient did not have prominent discomfort and the symptom of neck swelling had been improving after antibiotic. Therefore, the patient would be smoothly discharged on 2024/02/02.
  • Discharge diagnosis
    • Acetal (acetaminophen 500mg) 1# QID
    • Cough Mixture (platycodon) 10mL QID
    • Parmason Gargle Soln (chlorhexidine) QID GAR
    • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# BID

[immunochemotherapy]

• 2024-03-14 - rituximab 375mg/m2 735mg NS 500mL 4hr D1 + cyclophosphamide 750mg/m2 1475mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 60mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg BID (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-02-16 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1400mg NS 250mL 30min D2 ……………………………………………. + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 30mg BID (R-COP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2

==========

2024-03-15

[underdosed prednisolone in RCOP/RCHOP]

In the R-CHOP regimen, prednisolone may serve several functions including a cytotoxic effect (Ref: Clin Cancer Res (2002) 8 (6): 1681–1694.), anti-inflammatory properties, enhancing the efficacy of chemotherapy, and mitigating side effects. A clinical study mentioned in “Clinical Cancer Research” (2002) highlighted the cytotoxic potential of prednisolone.

For this patient, with a height of 172cm and weight of 81kg, resulting in an estimated BSA of approximately 1.97m² (rounded to 2m²), the standard dosage for R-CHOP or R-COP would be 60mg/m² per day. This translates to 120mg daily for this patient. However, during the two cycles of treatment, the patient actually received 60mg daily, which is about 30mg/m², effectively half the standard dosage. This reduced dosage could potentially impact the overall effectiveness of the treatment.

If age is a concern, then all components of the treatment regimen should be proportionally reduced in dosage, not just prednisolone.

[liposomal doxorubicin & cardiomyopathy: baseline echo needed for monitoring]

Doxorubicin (liposomal) can cause heart muscle damage, including a sudden decline in left ventricle function (acute left ventricular failure). The risk of this heart muscle damage (cardiomyopathy) increases to 11% when the total cumulative dose of doxorubicin reaches between 450 and 550 mg/m2.

Cardiomyopathy is defined as a decrease in the resting left ventricular ejection fraction (LVEF) by more than 20% from baseline (if the baseline LVEF was within the normal range) or a decrease of more than 10% from baseline (if the baseline LVEF was already below the normal range).

A review of HIS5 did not reveal any prior 2D transthoracic echocardiography exams. Therefore, it is highly recommended to perform this test to assess baseline LVEF. Changes in LVEF following treatment will be crucial in detecting potential doxorubicin-induced cardiomyopathy.

701345085

240315

{Mucinous adenocarcinoma of the sigmoid colon with uterus invasion, stage pT4bN2bM0, stage IIIC, s/p LAR in 2017, with local regional recurrence s/p concurrent chemoradiotherapy}

[exam findings]

• 2024-03-15 CT - brain
  • General brain swelling. R/O brain edema.
• 2024-02-21 CT - abdomen
  • Prior CT identified multiple metastatic nodes in para-aortic space and para-cava space are noted again, increasing in size. Disease progression is highly suspected.
• 2023-11-21 Tc-99m MDP bone scan
  • The scintigraphic findings suggest multiple bone metastases.
• 2023-09-21 MRI - pelvis
  • Local tumor recurrence at the uterine cervix area and left adnexa S/P C/T show stable disease.
  • Multiple metastatic lymph nodes S/P C/T show stable disease.
  • Please correlate with dynamic CT.
• 2023-08-30 CT - chest
  • recurrent colon cancer with asjacent structures involvement, with regional and distant metastatic lymph nodes.
• 2023-08-29 MRI - larynx
  • One enlarged node (2.0cm) within left supraclavicular fossa. Favor one malignant node.
  • Normal mucosal linings of naso-, oro- and hypopharyngeal spaces.
  • Normal appearance of both mastoid air-cells.
  • Clear appearacne of all paranasal sinuses.
• 2023-06-08 CT - abdomen
  • Colon cancer s/p operation with local recurrence and adjacent structures invasion (stable).
  • Some LNs (up to 1.4cm) at pelvic cavity and paraaortic region (stable).
  • Grade 5 fatty liver.
• 2023-03-15, 2022-12-19 CT - abdomen
  • Local recurrent adenocacinoma in the rectosigmoid, below and beyond prior autosuture, is highly suspected.
    • Please correlate with colonoscopy.
  • Local recurrent adenocarcinoma in the uterine fossa, cervix area and left adnexa involvement show stable in size.
  • Multiple metastatic lymph nodes show stable in size.
• 2022-09-15 CT - abdomen, pelvis
  • Colon cancer s/p operation with local recurrence and adjacent structures invasion (stable).
  • Some LNs (up to 1.4cm) at pelvic cavity and paraaortic region (stable).
  • Grade 5 fatty liver.
• 2022-04-28 CT - abdomen, pelvis
  • Colon cancer s/p operation.
  • Increased soft tissues in pelvic cavity suspected tumor recurrence.
  • Some LNs (up to 1.4cm) at paraaortic region c/w metastases.
  • Grade 5 fatty liver.
• 2022-01-19 CT - abdomen, pelvis
  • History and Indication:
    • 2017/07 at CGMH keelung: Mucinous adenocarcinoma of the sigmoid colon with direct invasion the uterus, pT4bN2b (8/61).
    • 2021/09 at CGMH keelung: Adenomyosis s/p subtotal hysterectomy + right oophrectomy, and appendectomy.
    • 2021/11 at CGMH keelung: Pelvic tumor with colonic obstruction s/p T-loop colostomy 2021/11/02
  • Findings:
    • S/P LAR with autosuture retention over the sigmoid colon.
      • Wall thickening in the rectosigmoid colon, below and beyond autosuture, is noted that may be local recurrent adenocarcinoma of the colon. Please correlate with colonoscopy.
    • prior MRI identified ill-defined soft tissue mass in the uterine cervix area and left adnexa is noted again, stable in size.
    • Prior MRI identified multiple enlarged nodes in the perirectal space, left interal iliac chain, left common iliac chain, para-aortic space and para-cava space ar noted again, stable in size.
    • S/P colostomy at right transverse colon.
    • The uterus shows enlarged in size and mild heterogeneous density. please correlate with clinical condition.
  • IMP:
    • Local recurrent colon cancer in the rectosigmoid, below and beyond prior autosuture, is highly suspected. Please correlate with colonoscopy.
    • Local recurrent rectosigmoid cancer with uterine cervix area and left adnexa involvement show stable in size.
    • Multiple metastatic lymph nodes show stable in size.
• 2021-12-09 SONO - abdomen
  • Diagnosis
    • Mass lesion, lower abdomen, c/w tumor recurrence
    • Hydronephrosis, bilateral, suspected mass effect due to tumor
    • Incomplete study of liver
  • Suggestion
    • Please corelated with other images.
• 2021-11-19 Cardiopulmonary Exercise Testing, CPX
  • summary:
    • low exercise capacity (VO2 57%, WR 71%)
    • normal stroke volume response during exercise
    • slow HR response, 68%
    • normal ventilatory function (FVC 93%, FEV1 102%)
    • low respiratory muscle strength (MIP 108%, MEP 54%)
  • suggestions:
    • treat underlying condition
    • survey and treat slow HR response, such as thyroid function or drugs
    • arrange pulmonary rehab with exercise training
• 2021-11-05 MRI - pelvis
  • History and Indication:
    • 2017/07 at CGMH keelung: Mucinous adenocarcinoma of the sigmoid colon with direct invasion the uterus, pT4bN2b (8/61).
    • 2021/09 at CGMH keelung: Adenomyosis s/p subtotal hysterectomy + right oophrectomy, and appendectomy.
    • 2021/11 at CGMH keelung: Pelvic tumor with colonic obstruction s/p T-loop colostomy 2021/11/02
  • Findings:
    • There is an ill-defined soft tissue mass in the uterine cervix area and left adnexa measuring 6.6 x 5.5 cm in size, showing mild hyperintensity on both T2WI and DWI, and mild enhancement, causing mild left hydroureteronephrosis and delayed contrast excretion of left kidney that may be local tumor recurrence with distal ureter invasion induce obstructive uropathy. Please correlate with retrograde pyelography.
    • S/P LAR with autosuture retention over the sigmoid colon.
      • Wall thickening in the sigmoid colon, just beyond autosuture, is noted that may be left adnexa mass with sigmoid colon invasion? Please correlate with colonoscopy.
      • The differential diagnosis include local tumor recurrence of the sigmoid colon with outward extension, left adnexa and uterine invasion?
        
    • There are multiple enlarged nodes in the perirectal space, left interal iliac chain, left common iliac chain, para-aortic space and para-cava space that are c/w metastatic nodes.
    • S/P colostomy at right transverse colon.
    • The uterus shows enlarged in size and heterogeneous hypointensity on T2WI at right lateral aspect of the body and fundus that may be adenomyosis.
      • However, the left lateral aspect of the uerine body and fundus shows heterogeneous mild hyperintensity on T2WI and DWI, and contrast enhancement that may be tumor invasion?
  • IMP:
    • Local tumor recurrence at the uterine cervix area and left adnexa with direct sigmoid colon invasion and left distal ureter invasion induce obstructive uropathy.
    • Multiple metastatic lymph nodes.
    • Tumor invasion in left lateral aspect of the uterine body and fundus are highly suspected.
• 2021-11-02 Colonoscopy
  • Diagnosis
    • Rectal tumor, with lumen stenosis nearing obstruction, 10cm above anal verge, s/p biopsy
    • Mixed hemorrhoid
  • Suggestion
    • F/U pathology report
  • Complication：
    • No immediate complication
• 2021-09-22 PET (CGMH Keelung)
  • Findings
    • Main tumor status: rectum (SUV 2.18, score 2)
    • Regional LN status: not found
    • Distant site status: uterine mass (SUV 3.83, score 2)
  • Impression:
    • Compatible with recurrent colon cancer in post-operative status, tentative stage rT0N0M0 (AJCC 2017).
    • Rectum lesion, probably bowel physiological uptakes.
    • Uterine lesion, uterine myoma may show this picture.
  • Suggesstion:
    • Please correlate with other image and clinical findings.
    • Comment: Score 0 = normal; Score 1 = benign lesion; Score 2 = equivocal lesion; Score 3 = possible malignancy; Score 4 = high probability of malignancy
• 2021-09-22 Pathology (CGMH Keelung)
  • biopsy date 2021/09/10
  • DX:
    • Uterus, endometrium, uncomplicated subtotal hysterectomy —- Proliferative phase
    • Uterus, myometrium, uncomplicated subtotal hysterectomy —- Adenomyosis
    • Fallopian tube, bilateral, prophylactic salpingectomy —- No pathological diagnosis made.
• 2021-09-22 Pathology (CGMH Keelung)
  • biopsy date 2021/09/10
  • DX:
    • Appendix, appendectomy —- Mucinous adenocarcinoma, in favor of metastatic mucinous adenocarcinoma of colorectal origin (Reference: S2017G-09314 and S2017G-10251)
  • GROSS D:
    • The specimen submitted is an appendix measuring 8.0 cm in length and 1.5 cm in maximal diameter, fixed in formalin. The external surface is smooth. The cut surface reveals a narrowed lumen filled with mucoid material. The wall is markedly thickened with a mucoid appearance. The mesoappendix is not inflamed. Sections of the tip portion and representative cross sections are taken.
  • MICRO D:
    • Sections of appendix show nearly totally infiltrated by a mucinous adenocarcinoma. Based on the history, metastatic mucinous and signet-ring cell adenocarcinoma is favored.

[consultation]

[surgical operation]

• 2021-11-02
  • Surgery
    • T loop colostomy        
  • Finding
    • Pelvic tumor with colonic obstruction, suspected rectal cancer
    • Dilation of colon and severe adhesion around midline laparotomy
    • RUQ stoma with stent
    • Previous surgery:
      • Sigmoid mucinous adenocarcinoma, pT4bN3a s/p LAR on 2017
      • Adenomytosis s/p total hysterectomy with right salpingo-oophorectomy, appendectomy on 2021/09, appendix pathology: metastatic Sigmoid mucinous adenocarcinoma
• 2021-09-XX
  • Operation: subtotal hysterectomy + R’t oophrectomy, appendectomy.

[radiotherapy]

• 2021-11-22 ~ 2021-12-30 - 4500cGy/25 fractions (15 MV photon) of the pelvic to paraaortic area

[immunochemotherapy]

• 2024-03-14 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2022-10-19 ~ 2024-02-28 - Xeloda (capecitabine 500mg) 2# BID PO
• 2022-05-25 ~ 2022-09-19 - FOLFIRI + bevacizumab (7 times)
• 2022-02-08 ~ 2022-04-28 - FOLFIRI (5 times)
• 2021-11-22 ~ 2021-12-20 - FL (400mg/m2, CCRT) (2 times)
• 2017-XX-XX ~ ????-??-?? - adjuvant chemothoerapy 12 times.

                                    ### ==========

2024-03-15

[rising tumor markers and imaging evidence of disease progression, transitioning to FOLFOX after Xeloda]

Reviewing the records from the past 12 months, both CEA and CA199 markers have shown a notable increase since the 2nd half of 2023. An abdominal CT on 2024-02-21 and a Tc-99m MDP bone scan on 2023-11-21 also indicated disease progression. During this period of disease expansion, the primary treatment utilized was Xeloda (capecitabine).

• 2024-02-27 CEA 888.53 ng/mL
  

• 2024-02-01 CEA 904.19 ng/mL
  

• 2024-01-04 CEA 708.40 ng/mL
  

• 2023-12-06 CEA 347.79 ng/mL
  

• 2023-11-03 CEA 105.08 ng/mL
  

• 2023-09-28 CEA 20.97 ng/mL
  

• 2023-09-06 CEA 17.02 ng/mL
  

• 2023-08-09 CEA 10.16 ng/mL
  

• 2023-07-05 CEA 3.04 ng/mL
  

• 2023-06-07 CEA 1.66 ng/mL
  

• 2023-05-10 CEA 1.42 ng/mL
  

• 2023-04-12 CEA 1.08 ng/mL
  

• 2023-03-15 CEA 1.05 ng/mL

• 2024-02-27 CA199 968.66 U/mL

• 2024-02-01 CA199 760.08 U/mL

• 2024-01-04 CA199 618.76 U/mL

• 2023-12-06 CA199 340.52 U/mL

• 2023-11-03 CA199 144.03 U/mL

• 2023-09-28 CA199 35.74 U/mL

• 2023-09-06 CA199 32.93 U/mL

• 2023-08-09 CA199 27.84 U/mL

• 2023-07-05 CA199 25.02 U/mL

• 2023-06-07 CA199 26.37 U/mL

• 2023-05-10 CA199 24.48 U/mL

• 2023-04-12 CA199 25.50 U/mL

• 2023-03-15 CA199 27.99 U/mL

Since being admitted, the patient has been administered FOLFOX on 2024-03-14. Lab data from the same day showed normal liver and kidney function, posing no contraindications to the medication and not necessitating any dosage adjustments.

701470566

240315

[exam findings]

• 2023-11-14 Patho - lung transbronchial biopsy
  • Lung, RUL, CT-guide biopsy — acute suppurative inflammation
  • Sections show alveolar lung tissue with abundant fibrinopurulent exudate and mild interstitial fibrosis. No granuloma or malignancy is found. The PAS and AFB special stains are negative.
  • The immunohistochemical stain of CK reveals no invasive tumor. Please correlate with the clinical presentation.
• 2023-11-09 CT - chest
  • Indication: Right upper lung mass
  • Chest CT with and without IV contrast ehnancement shows:
    • Mass like lesion at right upper lobe measuring 2.53cm in largest dimension is found. Regional Consolidation is also noted.
    • Small lymph nodes are found at both sides of the paratracheal region.
    • Calcified coronary arteries is found.
    • There is moderate bilateral pleural effusion.
    • Enlarged left adrenal gland is found.
  • Imp: Right upper lobe mass lesion measuring 2.53cm. r/o lung cancer.
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T1(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-11-08 Patho - bone marrow biopsy
  • Bone marrow, post iliac crest, biopsy — Marrow hypoplasia. Correlated with clinic features, the histological finding is compatible with aplastic anemia
  • The sections show hypocellular marrow (<5%). All three lineages are markedly decreased. Scattered CD138+ mature plasma cells in interstitium, account for 25% of marrow cells. No increased CD34+ and/or CD117+ blasts. Suggest further bone marrow smear evaluation and clinic correlation.
• 2023-11-05 CT - brain
  • Non-contrast brain CT revealed:
    • Subacute SDH along falx, tentorium and bil. cerebral convexity with repeat bleeding and mass effect causing midline shift to right.
  • IMP:
    • Subacute SDH along falx, tentorium and bil. cerebral convexity with repeat bleeding and mass effect.

[MedRec]

• 2023-12-05 SOAP Hemato-Oncology Gao WeiYao
  • O: 2023/11/08 PATHO - bone marrow biopsy
    • Bone marrow, post iliac crest, biopsy — Marrow hypoplasia
    • Correlated with clinic features, the histological finding is compatible with aplastic anemia
  • A
    • Severe aplastic anemia
    • Gastrointestinal hemorrhage
    • Other pancytopenia
    • Hypokalemia
    • Hypomagnesemia
  • Prescription
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
    • Sandimmun Neoral (ciclosporin 100mg) 1# BID
• 2023-11-22 ~ 2023-12-02 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Severe aplastic anemia
    • Gastrointestinal hemorrhage
    • Other pancytopenia
    • Hypokalemia
    • Hypomagnesemia
  • CC
    • hemtochezia (red colored) since this morning amd vomited today but no bloody material
  • Present illness
    • This 70-year-old female has a medical history of anemia.
    • She experienced a traumatic SDH along the falx, tentorium, and bilateral cerebral convexity with a mass effect causing midline shift to the right, following which she underwent burr hole drainage on 2023-11-05. She was discharged on 2023/11/16. TOCC(-).
    • She presented with hematuria and bloody stools for several days, prompting her family to bring her to our ED. Upon arrival, her vital signs were recorded as follows: Temperature (T) 36’C, Pulse (P) 94 beats per minute, Respiratory Rate (R) 18 breaths per minute, Blood Pressure (BP) 123/59 mmHg, and SPO2 (oxygen saturation) at 97%. Her Glasgow Coma Scale (GCS) score was clear.
    • Laboratory tests revealed a low platelet count (PLT: 10,000), decreased WBC 1000/uL, anemia (Hb: 3.7g/dL) and PL 1000/uL. Following a blood transfusion, her platelet count increased to 44,000, and her hemoglobin levels rose from 6.9 to 7.4g/dL.
    • After treatment with GCSF, her WBC count increased from 1.41 to 1.64. Lactic acid was measured at 2.4, stool occult blood was 4+, and BUN was 27. She reported an approximate body weight loss of 2kg this month. Chest x-ray revealed patch density at the right upper lobe (RUL). A computed tomography guided biopsy was performed on a mass lesion in the right upper lobe on 2023-11-15, yielding negative findings. Urine analysis showed no abnormalities. She denied any recent travel or specific contact/cluster history.
    • Under the impression of pancytopenia and severe aplastic anemia, so she wsa admitted.
  • Course of inpatient treatment
    • After admission, we administered empirical antibiotics such as cefotaxime to prevent infection.
    • The patient was kept NPO (nothing by mouth) due to GI bleeding and hematuria, and received IV fluid supply.
    • We administered another blood transfusion to address her pancytopenia and low thrombocyte count.
    • There was mild swelling in her eyes following the blood transfusion, but she declined an injection of antihistamine.
    • We consulted with oncology for pancytopenia, so she transfer to 11A care on 2023/11/23.
    • On critical care for severe aplastic anemia and we told family condition. Apply Major Illness and blood transfusion during hospitalization.
    • Under the stable condition, she can be discharged on 2023/12/02. OPD follow up is arranged.
  • Discharge prescription
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
    • Sandimmun Neoral (ciclosporin 100mg) 1# BID
• 2023-11-05 ~ 2023-11-16 POMR Neurosurgery Xu XianDa
  • Discharge diagnosis
    • Traumatic subdural hemorrhage along falx, tentorium and bilateral cerebral convexity with mass effect causing midline shift to right status post burr hole drainage on 2023-11-05.
    • Pancytopenia
    • Right upper lobe mass lesion post computed tomography guided biopsy on 2023-11-15.
    • Fever
    • Idiopathic aplastic anemia
    • Thrombocytopenia
    • Neutropenia
  • CC
    • Suffered from right side weakness suspect due to fall down.
  • Present illness
    • This is a 70-year-old female with a medical history of anemia. Her current presentation includes right-sided weakness, which is suspected to be a result of a fall, along with signs of potential oral bleeding. She was brought to our Emergency Room (ER) by her family.
    • Upon arrival at the ER, her vital signs were recorded as follows: Temperature (T) 40’C, Pulse (P) 107 beats per minute, Respiratory Rate (R) 18 breaths per minute, Blood Pressure (BP) 176/84 mmHg, and SPO2 (oxygen saturation) at 98%. Her Glasgow Coma Scale (GCS) score was E4V2M5, indicating immobility in her right hand and a recent decline in her level of consciousness.
    • According to her family, she had experienced a recent deterioration in her level of consciousness and reduced function in her right hand. A brain CT scan revealed the presence of a chronic subdural hematoma on the left side with midline displacement.
    • Her serum laboratory data indicated low platelet count (PLT: 19 x10^3/uL), decreased white blood cell count (WBC: 0.70 x10^3/uL), and low hemoglobin levels (HGB: 7.6 g/dL). Neurosurgery (NS) was consulted and recommended immediate admission to the Surgical Intensive Care Unit (SICU) for intensive care.
  • Course of inpatient treatment
    • A woman who required infection control measures, including the use of Tapimycin, received treatment for pancytopenia through G-CSF administration and blood transfusions with FFP, Cryo, and LPR. On 2023-11-05, she underwent Burr hole drainage to remove a chronic subdural hematoma. Successful ventilator weaning and extubation took place on 2023-11-06. Hematology consultation was sought to evaluate her pancytopenia. Her latest assessment revealed a Glasgow Coma Scale (GCS) score of E4V5M6, and she remained stable from a hemodynamic perspective. Consequently, she was transferred to a ward for ongoing care on 2023-11-08, maintaining clear consciousness throughout her stay.
    • The surgical wound on her left scalp was observed to be clean and dry. To prevent seizures, she was prescribed the anticonvulsant medication Keppra. Rheumatology consultation was also sought, and they suggested potential causes for the pancytopenia, including infection, drug reactions, bone marrow diseases (often cancer), and SLE. Pending the bone marrow pathology report, a bone marrow aspiration and biopsy were performed, revealing marrow hypoplasia.
    • In addition to this, she received 2 units of packed red blood cells (PRBC) and 2 units of platelet (PH) transfusions to address anemia and thrombocytopenia. A chest CT scan was conducted to investigate a suspected lung cancer in the right upper lung mass, and a lung biopsy was performed after consultation with a chest specialist. Rehabilitation programs were initiated to address leg weakness. Once her neurological and overall condition stabilized, she was discharged home, with outpatient follow-up appointments scheduled. Suture removal would be performed during one of these outpatient visits.
  • Discharge prescription
    • Allegra (fexofenadine 60mg) 1# BID
    • Norvasc (amlodipine 5mg) 1# QD
    • Through (sennoside 12mg) 2# HS
    • Acetal (acetaminophen 500mg) 1# QID
    • Keppra (levetiracetam 500mg) 1# BID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Sindine (povidone iodine aq soln) ASORDER EXT
    • Ceficin (cefixime 100mg) 2# Q12H
• 2023-02-08 SOAP Hemato-Oncology Wan XiangLin
  • S: She was referred on account of anemia told at LMD
  • Assessment:
    • Pancytopenia, suggest bone marrow study
    • refuse transfusion.
  • Plan:
    • Check BCS
    • Check CBC&DC, PT, aPTT, bleeding time and stool OB
    • Check CXR

[consultation]

• 2023-11-22 Hemato-Oncology

  • Q
    • For Leukopenia. (GCS-F 150mcg stat is administered in the emergency department) Is continuing to administer it? How often is it administered? Is it covered by NHI?
    • This is a 70-year-old female with a medical history of anemia. She suffered from traumatic subdural hemorrhage along falx, tentorium and bilateral cerebral convexity with mass effect causing midline shift to right status post burr hole drainage on 2023-11-05. She just discharge on 2023/11/16.
    • She had hematuria and bloody stool for several days. She was brought to our Emergency Room (ER) by her family. Upon arrival at the ER, her vital signs were recorded as follows: Temperature (T) 36’C, Pulse (P) 94 beats per minute, Respiratory Rate (R) 18 breaths per minute, Blood Pressure (BP) 123/59 mmHg, and SPO2 (oxygen saturation) at 97%. Her Glasgow Coma Scale (GCS) score was clear.
    • Her serum laboratory data indicated low platelet count (PLT:10000), decreased white blood cell count (WBC:1000), and low hemoglobin levels (HGB:3.7g/dL). After blood transfushion her platelet become (44000); (Hb:6.9 -> 7.4). After GCSF WBC(1.41 -> 16.4); Lactic:2.4, stool OB4+; BUN:27.
    • She compliant her body weight loss around 2kg this month. Her chest x ray showed Patch density at RUL. She was done right upper lobe mass lesion post computed tomography guided biopsy on 2023-11-15. Negative finding was found by urine analysis. She denied travel or specific contact/cluster history currently.
    • Under the impression of Anemia cause know,she was admitted to our ward for further evaluation and management.
    • So we need your help and accessment. Thank you.
  • A
    • Dear doctor: This 70 year old woman is a case of 1. Traumatic subdural hemorrhage along falx, tentorium and bilateral cerebral convexity with mass effect causing midline shift to right status post burr hole drainage on 2023-11-05. 2. aplastic anemia. She was admiited due to hematuria and bloody stool. We are consulted for aplastic anemia (AA).
    • AA is an immune-mediated hematopoietic disorder characterized by hypocellular bone marrow and possible life-threatening cytopenias. Please complete survey causes of acquired aplastic anemia: PNH, HSV (herpes simplex virus) IgM 1+2.
    • For the patient frail with severe AA, may try lower-intensity treatments: cyclosporin 5 mg/kg/day. (BW:42.5kg)
    • Initial cyclosporin 100mg BID and then check cyclosporin level at least weekly for the first month and then every 2 weeks for the next 2 months and later every month if there was no significant elevation of serum creatinine. [Dose adjusted to keep trough blood level of 150 to 250 ng/ml].
    • In addition, check Complete blood counts, liver and renal function tests at least weekly for the first month and then every 2 weeks for the next 2 months and later every month if there was no significant elevation of serum creatinine.
    • Furthermore, during using cyclosporin, please watch for blood pressure, and eletrolye because CsA may cause renal insufficiency, hypertension, and magnesium wasting. Also, neurologic symptoms should be evaluated promptly because CsA can rarely be associated with development of serious neurotoxicity, including posterior reversible encephalopathy syndrome (PRES) and progressive multifocal leukoencephalopathy (PML).
    • Moreover, CsA also can cause hemolysis, tremor, vitiligo, gingival hyperplasia, and hypertrichosis. Hence, we need to discuss with patient about the benefit and risk of using CsA before using it.
    • On the other way, best supportive care is very important for aplatic anemia including blood transfusion when Hgb < 7-8 or Plt < 20k (prevent spontaneous bleeding).
    • GCSF is indicated for patient with severe aplastic anemia with infection.
    • Thanks for your consultation.

• 2023-11-13 Rehabilitation

  • A
    • Physical examination
      • 2023/11/13 12:38 T/P/R: 36.4’C / 77bpm / 17bpm BP:126/60mmHg
      • Body weight: 42.5
        
    • Ranchos Los Amigo level: VI
      • Consciousness: clear
      • Cognition: grossly intact
      • Speech: intact
      • Swallowing: NG(-)
        • 3-cc clear water test: choking(-), wet voice(-), drooling(-)
        • 30-cc clear water test: choking(-), wet voice(-), drooling(-)
        • 90-cc clear water test: choking(-), wet voice(-), drooling(-)
      • Sphincter: urinary and stool continence
      • Brunnstrom’s stage: RUE P/D: VI/VI, RLE: V
        
      • Muscle power:
        • RUE/RLE: 5/4
        • LUE/LLE: 5/5
      • Functional ability: walk slowly under contact guard with mildly unsteady gait
      • BADL: grossly ID under contact guard
    • Assessment
      • Traumatic subdural hemorrhage along falx, tentorium and bilateral cerebral convexity with mass effect causing midline shift to right status post burr hole drainage on 2023/11/05 with right monoparesis
      • Pancytopenia
    • Plan
      • Rehabilitation programs: arrange PT rehabilitation programs.
      • Goal: Ambulation with device smoothly.

• 2023-11-09 Rheumatology and Immunology

  • Q
    • This 70-year-old female patient had suffered from bilateral SDH s/p burr hole on 2023/11/05.
    • However, we found her serum laboratory data indicated low platelet count (PLT: 19 *10^3/uL), decreased white blood cell count (WBC: 0.70 x10^3/uL), and low hemoglobin levels (HGB: 7.6 g/dL). G-CSF and blood transfusion with FFP, Cryo, LPR for pancytopenia.
    • According the patient’s statement, she complained general weakness, unstable gait after received Pneumococcal Vaccine in 2022.
    • She visited LMD for help, where pancytopenia was told then referred to TuCheng ChangGung Hospital for help. Thrombocytopenia was diagnosed and blood transfusion in 2022. She loss follow-up on hematology clinic.
    • The latest bloodwork results on 11/8 showed WBC: 0.60 x10^3/uL, Hb: 8.5g/dl, Platelet: 128 *10^3/uL. We had consulted hematology who bone marrow aspiration and biopsy was done. We will check autoimmune profile (ANA, C3, C4, anti ds DNA, RF, anti Ro/La, Anti sm/RNP), nutrition profile (vitamin B12, folic acid), LDH, HIV (EIA), EB-VCA IgM, serum EP, serum IFE, serum light chain, IgG, IgA, IgM, B2 microglobulin, albumin, Total protein by Hema suggested.
    • We need your professional evaluation and recommendation for further management. Thank you very much for your time!
  • A
    • For pancytopenia, infection, drug, bone marrow disease (often cancer), and SLE is often the cause.
    • Please complete hematological survey first, inform me if any of the autoimmune test showed abnormal results.

• 2023-11-08 Hemato-Oncology

  • A
    • Dear doctor: This 70 year old woman is a case of chronic subdural hematoma on the left side with midline displacement. We are consulted for pancytopenia.
    • Pancytopenia may be caused by bone marrow aplasia, marrow infiltration/replacement, ineffective hematopoiesis, and/or excessive blood cell destruction or sequestration.
    • Please check autoimmune profile (ANA, C3, C4, anti ds DNA, RF, anti Ro/La, Anti sm/RNP), nutrition profile (vitamin B12, folic acid), LDH, HIV (EIA), EB-VCA IgM, serum EP, serum IFE, serum light chain, IgG, IgA, IgM, B2 microglobulin, albumin, Total protein.
    • Survey medication history which may cause bone marrow suppression.
    • Arrange abdominal echo to survey splenomegaly.
    • Bone marrow aspiration and biopsy are also indicated for pancytopenia.

• 2023-11-08 Anesthesia

  • Q
    • Consult for anesthesia assessment
    • This 70-year-old female. Had medical history of anemia (The patient is anemic and it is not known if she has any hematology-oncology disease. The family member informed that the patient went to TuCheng Hospital for medical treatment and was advised to have a lumpar puncture, but the patient refused. It is not known about the extent of the current treatment. PharmaCloud showed the patient have been regularily injected iron supplement in the outpatient clinic. The current consciousness is E3V2M5-6, and normal conversations are not possible. The patient and her family members do not know the condition of the disease.)
    • This time, she suffered from fall down noticing potential oral bleeding, immobility in his right hand, and a recent deterioration in his level of consciousness. Brain CT scan revealed a chronic subdural hematoma on the left side with midline displacement. We will be arrange operation for removal chronic SDH on B level on today.
  • A
    • We were informed about the emergency case of removal chronic SDH.
    • We’ll prepare GA for the coming procedures.
    • Assessment: ASA IV/E (High risk of neurologic deficits, hemorrhage, shock, or even death)
    • Thanks for your consultation

• 2023-11-05 Neurosurgery

• 2023-11-05 Neurology

[medication]

ciclosporin 100mg 1# TID PO 2024-02-16 ~ IPD Thymoglobuline 150mg QD IVD 2024-02-24 ~ 2024-02-27 4D

Treatment of aplastic anemia in adults - 2024-03-21 - https://www.uptodate.com/contents/treatment-of-aplastic-anemia-in-adults

• Medically fit
  • For patients ≥40 years (some other experts advise ≥50 years), we suggest triple IST (ie, horse antithymocyte globulin [hATG], cyclosporine [CsA], and eltrombopag) rather than immunosuppressive therapy (IST) with hATG plus CsA alone (without eltrombopag) or other regimens, based on superior outcomes with an acceptable safety profile.
  • Allogeneic HCT is associated with excessive morbidity and transplant-related mortality (TRM) in this setting; long-term survival is approximately 50 percent (inferior to that of younger patients) and has not changed significantly for several decades [8,9].

==========

2024-03-15

[TDM: proactive reduction of ciclosporin to prevent toxicity]

Since being admitted on 2024-02-16, the patient has been on “Sandimmun Neoral (ciclosporin 100mg) 1# TID”. The trough concentration on 2024-03-05 was 290 ng/mL, and it increased to 368 ng/mL by 2024-03-13. Continuing this trend without reducing the dosage could potentially result in levels exceeding the recommended upper limit of 400 ng/mL next week. Therefore, it’s suggested to decrease the current daily dosage of 300 mg to either 250 mg or 275 mg.

2024-03-06

[ciclosporin TDM: acceptable result despite non-ideal blood draw timing (no dosage change)]

The patient is taking Sandimmun Neoral (ciclosporin 100mg) 1# TID.

The TDM for ciclosporin on 2024-03-05 in HIS5 showed that the blood draw time was recorded as 04:21 and the drug administration time was recorded as 09:35, a difference of several hours. Ideally, the trough concentration should be drawn within half an hour before the next administration. The current value is 290 ng/mL, and it should still be within a reasonable range after about 5 hours. Therefore, there is no special dosage adjustment recommended.

Cyclosporine (ciclosporin) trough level target for aplastic anemia:

• Severe: 200-400 ng/mL (Ref: N Engl J Med. 2011;365(5):430-438. doi:10.1056/NEJMoa1103975)
• Non-severe: 75-200 ng/mL (Ref: Blood. 1999;93(7):2191-2195)

[blood transfusion safety: recognizing and preventing complications]

Hypocalcemia is observed:

• 2024-03-06 Ca (Calcium) 2.02 mmol/L
  
• 2024-03-05 Ca (Calcium) 2.09 mmol/L
  
• 2024-03-04 Ca (Calcium) 2.08 mmol/L
  
• 2024-03-01 Ca (Calcium) 2.04 mmol/L

Multiple transfusion complications can arise during or after a blood transfusion:

• Citrate toxicity: The anticoagulant used in blood storage (citrate) can bind calcium in the recipient’s blood, leading to hypocalcemia (low calcium levels) and muscle cramps.
• Iron overload: Repeated transfusions can lead to iron overload in the body, which can damage organs like the liver and heart. (iron storage test is advised)
• Human leukocyte antigen (HLA) alloimmunization: The recipient may develop antibodies against donor white blood cells, making future transfusions more difficult.

701495156

240315

[exam findings]

• 2024-01-11 CT - chest
  • Indication: Left lung small cell carcinoma with left pulmonary hilar and bilateral mediastinal lymph nodes metastases, T4N3M0, stage IIIC, s/p C/T with EP from 2023/10/02, s/p radiotherapy with mediastinal tumor and LAPs: (66~70 Gy/ 35 fx, from 2023/10/02~).
  • Chest CT without IV contrast ehnancement shows:
    • Plate like opaicty over left upper lobe measuring 2.46cm in largest dimension is found. In comparison with CT dated on 2023-08-30, the lesion regressed.
    • Mild centrilobular Emphysematous change over both lungs is found.
    • Small lymph nodes are found at AP window is found. In regression.
    • Old rib fracture over left posterior ribs is found.
    • S/p port-A placement with its tip at Superior vena cava
    • Calcified coronary arteries is found.
    • Tiny hepatic cysts at both lobes of liver is found.
  • Imp:
    • left upper lobe lung cancer with mediastinal lymphadenopathy, the lymphadenopathy regressed markedly and the primary tumor regressed also.
• 2024-01-10, 2023-11-08, -10-09 CXR
  • Atherosclerotic change of aortic arch
• 2024-09-22 CXR erect
  • Atherosclerotic change of aortic arch
  • Left hilum mass is noted after correlate with prior CT.
  • Linear infiltration over left upper lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2023-09-21 Tc-99m MDP bone scan
  • Mildly increased activity in some L-spines and sacrum. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Multiple hot spots in the left rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2023-09-20 PET scan
  • Focal or nodular lesions of increased FDG uptake in the left upper lung, left pulmonary hilar region, and bilateral mediastinal space, highly suspected left lung cancer with regional lymph nodes metastases.
    
  • Increased FDG uptake in the right upper and right lower lungs, the nature is to be determined (inflammation/infection process or other nature ), suggesting further investigation.
  • Several FDG-avid lesions in the left rib cage, probably post-traumatic change or/and bone mets.
    
  • Two FDG-avid lesions in the in the right aspect of hypopharynx, the nature is to be determined (inflammation/infection process or other nature ?), suggesting further investigation.
  • FDG-avid lesions iin skin layer of the left upper back and right post. upper thigh regions, in the left upper arm, in soft tissue around the right hip joint, and in the right inguinal lymph nodes, the nature is to be determined also. Please correlate with other clinical findings for further evaluation.
  • Left upper lung cancer, cT4N3M0-1 (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-09-14 Patho - bronchus biopsy
  • Lung, left second carina, bronchoscopic biopsy — small cell carcinoma
  • Sections show large nests of small hyperchromatic tumor cells with scanty cytoplasm and marked crushing artifact, infiltrating in the bronchial wall.
  • The immunohistochemical stains reveal CK(+), TTF-1(+), CD56(+), and Synaptophysin(+). The Ki-67 is >90%.
• 2023-09-14 Bronchoscopy
  • Clinical diagnosis: Lung tumor, for tissue prove
  • Bronchoscopic diagnosis:
    • Left 2nd carina tumor invasion, extended to LULbronchus and LLL bronchus, s/p biopsy
    • Lower trachea left side submucosal tumor invasion
    • LM bronchus distal superior submucosal tumor invasion
  • Bronchoscopic finding:
    • The nasal mucosa was hypertrophic.
    • The nasal lumen was moderately narrowed.
    • The was copious mucoid nasal discharge retained in the nasal cavity.
    • Mucosa of nasopharynx was hypertrophic .
    • Nasopharynx was moderately narrowed.
    • Mucosa of pharynx cobble-stone in shape .
    • Movement of the both. vocal cord(s) was normal .
    • Bilateral arytenoid proceww was normal .
    • Trachea whole segment. : patent but horse-saddle shape of whole trachea; the mucosa was hypertrophic.
    • Lower third tracheal left side submucosal tumor invaion was noted under EBUS finding but intact mucosa wall by EBUS and fluoroscent scopy.
      • Main carina: sharp and movable on deep breathing.
    • Bilateral endobronchial trees:
      • Left 2nd carina tumor invasion, extended to LULbronchus and LLL bronchus
      • LM bronchus distal superior mucosal and submucosal tumor invasion by EBUS finding and fluorosccent scopy.
  • Special Procedures: Left 2nd carina tumor invasion, extended to LULbronchus and LLL bronchus, s/p biopsy
  • Complication: Nil
  • Notes: Please Watch for the possibilties of hemoptysis, fever
• 2023-08-30 CT - abdomen
  • CC: easy falling for 2 months. BW loss (more then 10 kg), poor appetite, easy choking and memory impairment.
  • History: alcoholism (one bottle sorghum liqour a day for 5 to 6 years, no drinking these 3 months)
  • Indication: r/o liver cirrhosis or other malignancy
  • Findings:
    • There is a poor enhancing mild heterogeneous soft tissue mass in left hilum, measuring 7.8 cm in size (the largest dimension), causing mild narrowing of left upper lobe bronchus.
      • Small cell lung cancer is highly suspected.
      • The differential diagnosis includes lymphoma.
      • please correlate with PET scan and biopsy.
    • There are several enlarged nodes in paratracheal space and subcarinal space. Metastatic nodes are highly suspected.
    • There is small patchy consolidation with air-bronchogram in LUL of the lung that is c/w Bronchopneumonia.
      • In addition, there is mild left Pleura effusion.
    • There are several hepatic cysts in both lobes and the largest one 3.6 cm in size at S4/5.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidneys.
    • There is no evidence of ascites or lymphadenopathy.
    • There is no bowel wall thickening, and no bowel obstruction.
    • The abdominal aorta and IVC are grossly unremarkable.
    • There is no evidence of intrinsic or extrinsic bladder mass.
    • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • Small cell lung cancer at left hilum is highly suspected.
    • The differential diagnosis includes lymphoma.
    • please correlate with PET scan and biopsy.
• 2023-08-25 MRA - brain
  • Indication: limping gait and bradykinesia r/o PD or other brain lesion
  • Without- and with-contrast multiplanar cerebral MRI and cerebral TOF MRA reveal:
    • General enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
    • A T2- and FLAIR-hyperintensity lesion, about 12 mm x 9 mm without obvious enhancement, nor diffusion change in white matter of right lower cerebellum.
    • A small T2- and FLAIR-hyperintensity lesion in white matter of left inferior frontal gyrus.
    • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
    • No midline shift, nor mass effect.
    • No remarkable finding of skull base and bony structures.
    • No remarkable finding of bilateral orbital contents and optic nerves.
    • No remarkable finding of nasopharynx visible in these images.
    • Diffuse mild luminal irregularity without obvious stenosis of major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
  • IMP:
    • General brain atrophy.
    • White matter lesions in right cerebellum and left frontal lobe.
    • Demyelination due to old insults is first considered. Tumor is unlikely.
• 2023-08-24 ECG
  • Nonspecific ST and T wave abnormality
  • Prolonged QT

[MedRec]

• 2024-01-31 SOAP Neurology Zhang WanLing
  • Prescription x3
    • Eurodin (estazolam 2mg) 1# HS
    • Norvasc (amlodipine 5mg) 1# PRNQD if SBP > 140mmHg
    • Vit B1 thiamin 100mg 1# QD
• 2024-01-10 ~ 2024-01-15 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Left lung small cell carcinoma with left pulmonary hilar and bilateral mediastinal lymph nodes metastases, T4N3M0, stage IIIC, s/p chemotherapy with EP from 2023/10/02, s/p radiotherapy with mediastinal tumor and LAPs (66~70 Gy/ 35 fx, from 2023/10/02~).
    • Alcohol use, unspecified with intoxication, unspecified
    • Essential (primary) hypertension
    • Insomnia, unspecified
    • Constipation, unspecified
    • Parkinson’s disease
    • Chronic viral hepatitis B without delta-agent
    • Encounter for antineoplastic chemotherapy
  • CC
    • For chemotherapy with EP (C4)
  • Present illness
    • This 59-year-old man patient suffered from body weight loss 11kg (60 -> 49kg) for 2 months. Progression cough with sputum for 2 months. Poor appetite, easy choking and memory impairment. He was brought to our NM OPD for help. There was no numbness, slurred speech, headache, fever or recent head trauma. Neurological examintation showed liming gait, muscle power RUE/LUE: 5/4+, RLE/LLE: 5/5 and FNF: no dysmetria. No night sweats and fever was noted.
    • Brain MRA on 2023/08/25 showed general brain atrophy, white matter lesions in right cerebellum and left frontal lobe, demyelination due to old insults is first considered and tumor is unlikely.
    • Abdominal CT on 2023/08/30 showed small cell lung cancer at left hilum is highly suspected and the differential diagnosis includes lymphoma.
    • Headache and chest pain in 2023/09. Bronchoscopic for biopsy on 2023/09/14 showed left 2nd carina tumor invasion, extended to LUL bronchus and LLL bronchus, s/p biopsy. Lung, left second carina, bronchoscopic biopsy showed small cell carcinoma, immunohistochemical stains reveal CK(+), TTF-1(+), CD56(+), and Synaptophysin(+). The Ki-67 is > 90%. Port-A catheter insertion on 2023/09/22. Whole body PET scan on 2023/09/20 showed left upper lung, left pulmonary hilar region, and bilateral mediastinal space, highly suspected left lung cancer with regional lymph nodes metastases, left upper lung cancer, cT4N3M0-1. Wholw body bone scan on 2023/09/21 showed no bone metastasis. Diagonsisi was left lung small cell carcinoma with left pulmonary hilar and bilateral mediastinal lymph nodes metastases, T4N3M0, stage IIIC. After discussion plan to received concurrent chemoradiotherapy and explain side effect with patient and his family on 2023/09/25. Consult RTO on 2023/09/25 for evaluate concurrent chemoradiotherapy, - CT-simulation on 2023/09/25. Plan to deliver 50 Gy/ 25 fx to the Rt mediastinal LAPs. The Lt side lung tumor and LAPs: 66~70 Gy/ 35 fx. RT start from 2023/10/02 to 2023/11/20. S/p chemotherapy with EP (etoposide 80mg/m2, cisplatin 20mg/m2, C1D1) on 2023/10/04, EP (etoposide 80mg/m2, cisplatin 20mg/m2, C1D2) on 2023/10/11, EP (etoposide 80mg/m2, cisplatin 25mg/m2, C1D3) on 2023/10/17, EP (Etoposide 80mg/m2 + Cisplatin 25mg/m2 for 3days) on 2023/11/09 (C2D1-3), on 2023/12/11(C3D1-3).
  • Course of inpatient treatment
    • After admission, follow up Chest CT on 2024/01/11 showed left upper lobe lung cancer with mediastinal lymphadenopathy, the lymphadenopathy regressed markedly and the primary tumor regressed also.
    • He received concurrent chemoradiotherapy with EP (Etoposide 80mg/m2 + Cisplatin 25mg/m2 for 3 days)(C4), after CT image on 2024/01/11~2024/01/13.
    • Mopride 1# po TID for abdominal distention. Codeine 1# po HS for cough. Primperan 1# PO TIDAC was given for nausea and vomiting. Codeine 1# po HS for cough.
    • Alcohol use, unspecified with intoxication with Folic Acid 1# po QD and Vit B1 1# po QD.
    • Hypertension subside and discontinues Norvasc 1# po QD and Diovan F.C 160mg 1# po QD.
    • Insomnia with Eurodin 1# po HS. Constipation with Sennoside 2# po HS.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for Anti-HBc reactive.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/12/15 and OPD followed up later.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • codeine phosphate 15mg 1# HS
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Through (sennoside 12mg) 2# HS
• 2023-11-15 SOAP Neurology Zhang WanLing
  • Prescription x3
    • Diovan (valsartan 160mg) 1# QD
    • Eurodin (estazolam 2mg) 1# HS
    • Folacin (folic acid 5mg) 1# QD
    • Norvasc (amlodipine 5mg) 1# QD
    • Vit B1 thiamin 100mg 1# QD
• 2023-08-23 ~ 2023-09-01 POMR Neurology Zhang WanLing
  • Discharge diagnosis
    • Wernicke’s encephalopathy, with cerebellar ataxia and cognitive decline
    • Cerebellar ataxia, alcohol intoxication related
    • Alcohol use, unspecified with intoxication, unspecified
    • Hyponatremia
    • Hypokalemia
    • Soft tissue mass in left hilum, measuring 7.8 cm in size, suspect small cell lung cancer
    • Essential (primary) hypertension
    • Insomnia
  • CC
    • Easy falling for 2 months with complained about BW loss (more then 10 kg), poor appetite, easy choking and memory impairment
  • Present illness
    • This 59 y/o patient with alcoholism (one bottle sorghum liqour a day for 5 to 6 years, no drinking these 3 months) presented with easy falling for 2 months.
    • He also complained about BW loss (more then 10 kg), poor appetite, easy choking and memory impairment. He was brought to our OPD for help.
    • There was no numbness, slurred speech, headache, fever or recent head trauma. Neurological examintation showed liming gait, muscle power: RUE/LUE: 5/4+ RLE/LLE: 5/5 and FNF: no dysmetria.
    • Under the impression of Parkinson’s disease or maligancy, he was admitted for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, we kept closely monitoring his hemodynamic status and vital signs. Adequate hydration with 0.298 KCL in 0.9% N/S was administered for hyponatremia and hypokalemia.
    • We arranged blood rest for cerebellar ataxia and memory decline, including DM, infection, nutritional status, thyroid function, cortisol, and tumor markers. Brain MRA with contrast was arranged and showed white matter lesions in right cerebellum and left frontal lobe, which were suspected demyelination due to old insults.
    • Laboratory data showed pancytopenia, abnormal liver function, low folic acid, and lower albumin. CSF study was performed (open pressure: 13 cm H2O, close pressure: 14 cm H2O; clear, color). CSF analysis revealed normal WBC count and total protein level. Therefore, we sent CSF culture and waiting for its final result. We also sent CSF and serum for PNS (paraneoplastic neurological syndrome) self-paid for body weight loss and jaundice r/o maligamcy. Folic acid and Thiamin supplement were given. His unsteady gait was related to Wernicke encephalopathy.
    • We consulted rehabilitation department for rehabilitation program arranged.
    • The chest and abdominal CT were arranged for suspected lung or liver maligancy. A mass lesion at left hilum was noted, indicating possible small cell lung cancer or lymphoma. We explained lung tumor and hepatic cysts in chest and abdominal CT to the patient and his elder sister.
    • The patient wants to be discharged after completing exam for ataxia, and then received further exam in the chest medicine OPD. Under stable condition, he was discharged on 2023/09/01. We suggested OPD follow up at neurology and oncology.
  • Discharge diagnosis
    • Diovan (valsartan 160mg) 1# QD
    • Actein Effervescent (acetaylcysteine 600mg) 1# BID
    • Eurodin (estazolam 2mg) 1# HS
    • Folacin (folic acid 5mg) 1# QD
    • Vit B1 (thiamine 100mg) 1# QD
    • Through (sennoside 12mg) 2# HS (if no stool passage)

[consultation]

• 2023-09-26 Radiation Oncology
  • Q
    • This 59-year-old man patient is a case of Left lung small cell carcinoma with left pulmonary hilar and bilateral mediastinal lymph nodes metastases, T4N3M0, stage IIIC. He was admitted for prepare therapy. Now, for evaluate concurrent radiotherapy to lung tumor. Thank you.
  • A
    • CCRT is indicated. CT-simulation will be arranged today. Plan to deliver 50 Gy/ 25 fx to the Rt mediastinal LAPs. The Lt side lung tumor and LAPs: 66~70 Gy/ 33~35 fx. RT will start around 10/2. Thank you very much.
• 2023-09-18 Nephrology
  • Q
    • This 59-year-old man patient is a case of Mediastinal mass, R/O lung cancer or lymphoma. He was admitted for lung tumor biopsy. This time, Alcohol use, unspecified with intoxication with hyponatremia (Na:113mmol/L) and hypomagnesemia (mg:1.7mg/dL) with weakness. Hyponatremia with 3% NS IVF supplementation and hypomagnesemia with MgSO4 1pc iv QD therapy, but, hyponatremia without improving. Now, for evaluate hyponatremia examine and therapy. Thank you.
  • A
    • We visited the patient at the bedside and evaluated his condition. His consciousness was clear, speech was coherent showed no signs of distress. Bilateral lower limb were slightly edematous 2+.
    • Blood test showed refractory hyponatremia
      • 2023-09-18 Na (Sodium) 113 mmol/L
      • 2023-09-17 Na (Sodium) 114 mmol/L
      • 2023-09-16 Na (Sodium) 116 mmol/L
      • 2023-09-15 Na (Sodium) 113 mmol/L
      • 2023-09-14 Na (Sodium) 106 mmol/L
      • 2023-09-14 Na (Sodium) 105 mmol/L
      • 2023-09-13 Na (Sodium) 101 mmol/L
      • 2023-08-31 Na (Sodium) 122 mmol/L
      • 2023-08-27 Na (Sodium) 126 mmol/L
      • 2023-08-24 Na (Sodium) 111 mmol/L
    • Our impressions are as follows:
      • Hyper/euvolemic hypotonic hyponatremia (but no evidence of cirrhosis, heart failure, CKD or nephrotic syndrome)
      • r/o pseudohyponatremia due to serum high protein or lipid content (e.g hyperlipidemia, plasma cell dyscrasia)
      • r/o SIADH, perhaps secondary to lung tumor (especially SCLC)
    • Our advices are as follows:
      • Record daily I/O and BW
      • Check urine Na, Cre, Osm
      • Check serum Osm, glucose, T Protein, TG, LDL, HDL (fasting)
      • Restrict FREE WATER intake to < 1000mL/day, soup or beverages are reasonable fluid alternatives
      • Infuse IV 3% saline 15-30mL/h until serum Na > 120mEq/L
      • May consider IV Furosemide 20mg QD-BID in conjunction with IV 3% saline if 3% saline alone is ineffective
      • Monitor serum Na levels at least Q12H to QD, change in Na levels should not exceed 6-8mEq/L within any 24-hour period
    • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance.

[radiotherapy]

• 2023-10-02 ~ 2023-11-20 - completed RT to the mediastinal tumor and LAPs: 70 Gy/ 35 fx.

[chemotherapy]

• 2024-03-14 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
  • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D1-3
• 2024-02-15 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
  • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D1-3
• 2024-01-11 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
  • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D1-3
• 2023-12-11 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
  • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D1-3
• 2023-11-10 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
  • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D1-3
• 2023-10-18 - etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (VP-16 + CDDP)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-10-11 - etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 24hr + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (VP-16 + CDDP)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-10-04 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 24hr + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

Chemotherapy regimens for small cell lung cancer: Cisplatin (80 mg/m2) plus etoposide - 2024-03-15 - https://www.uptodate.com/contents/image?imageKey=ONC%2F66855

• Cycle length:
  • Every 21 days for four cycles.
• Regimen
  • Cisplatin
    • 80 mg/m2 IV
    • Dilute in 250 mL normal saline (NS) and administer over 60 minutes. Do not administer with aluminum needles or sets.
    • Day 1
  • Etoposide
    • 100 mg/m2 IV daily
    • Dilute in 500 mL NS or 5% dextrose in water (D5W) to final concentration <0.4 mg/mL. Infuse over 30 to 60 minutes; if infused more rapidly, severe hypotension may occur.
    • Days 1, 2, and 3

Chemotherapy regimens for chemotherapy-naïve extensive-stage small cell lung cancer: Carboplatin plus etoposide - 2024-03-15 - https://www.uptodate.com/contents/image?imageKey=ONC%2F75586

• Cycle length:
  • 21 days, for a maximum of six cycles.
• Regimen
  • Carboplatin
    • AUC = 5 mg/mL × min IV
    • Dilute in 250 mL NS and administer over 30 minutes.
    • Day 1
  • Etoposide
    • 100 mg/m2 IV
    • Dilute in 500 mL NS or D5W to final concentration <0.4 mg/mL. Infuse over 30 to 60 minutes; if infused more rapidly, severe hypotension may occur.
    • Days 1, 2, and 3

==========

[assessing treatment efficacy with chest CT follow-up, dose adjustment strategies for cisplatin and etoposide in renal decline]

The patient’s renal function appears to be on a gradual decline, with the eGFR dropping to the 50s, potentially due to the administration of cisplatin. Continuous monitoring of renal function changes is advised.

Chest CT scans from 2024-01-11 indicate that the current cisplatin-etoposide treatment regimen remains effective.

• 2024-03-14 Creatinine 1.31 mg/dL

• 2024-02-26 Creatinine 1.45 mg/dL

• 2024-02-15 Creatinine 1.03 mg/dL

• 2024-01-22 Creatinine 1.15 mg/dL

• 2024-01-10 Creatinine 0.87 mg/dL

• 2023-12-20 Creatinine 0.80 mg/dL

• 2024-03-14 eGFR 59.32 ml/min/1.73m^2

• 2024-02-26 eGFR 52.94 ml/min/1.73m^2

• 2024-02-15 eGFR 78.56 ml/min/1.73m^2

• 2024-01-22 eGFR 69.18 ml/min/1.73m^2

• 2024-01-10 eGFR 95.46 ml/min/1.73m^2

• 2023-12-20 eGFR 105.16 ml/min/1.73m^2

For cisplatin, when the CrCl is between 50 and less than 60, it is recommended to administer 75% of the usual dose specific to the indication. For etoposide, when CrCl is between 15 to 50, 75% of the dose should be administered.

If there is a continued decline in renal function, consideration may be given to substituting cisplatin with carboplatin (administered at AUC 5 on day 1).

2024-02-16

No instances of hyponatremia have been observed since Oct 2023. During the current hospitalization, vital signs have remained stable and lab findings on 2024-02-15 were unremarkable. No medication discrepancies were identified.

2023-09-18

Hyponatremia is noted. The serum sodium levels in this patient over the past three months have been documented as follows:

2023-09-18 Na (Sodium) 113 mmol/L 2023-09-17 Na (Sodium) 114 mmol/L 2023-09-16 Na (Sodium) 116 mmol/L 2023-09-15 Na (Sodium) 113 mmol/L 2023-09-14 Na (Sodium) 106 mmol/L 2023-09-14 Na (Sodium) 105 mmol/L 2023-09-13 Na (Sodium) 101 mmol/L 2023-08-31 Na (Sodium) 122 mmol/L 2023-08-27 Na (Sodium) 126 mmol/L 2023-08-24 Na (Sodium) 111 mmol/L

Hyponatremia, with some cases being severe (sodium <120 mmol/L), has been associated with tramadol use. Although it is less likely that the current case of hyponatremia is due to Tramacet 0.5# Q6H, which was initiated on 2023-09-13, well after the onset of hyponatremia, it would be prudent to hold tramadol-containing medications and monitor the patient’s sodium levels for several days.

701517295

240315

[exam findings]

• 2024-03-11 CT - chest
  • Indication: hoarseness (+), r/o right supraclavicular tumor, DDx; lymphoma, LAPs
  • Findings:
    • Lungs:
      • multiple soft-tissue attenuated nodules of variable sizes in both lungs measuring up to 27mm at RML
      • mosaic attenuation changes in both lower lobes due to obstructive airway disease,
    • Chest wall, visible neck, mediastinum and hila:
      • extensive lymphadenopathy in the right supraclavicular fossa, visible neck, in the upper visceral space and Rt anterior prevascular space, which enaces and displaces the adjacent great vessels.
      • nodular lesion in Rt upper anterior chest wall and enlarged LN at Rt axilla.
    • Vessels:
      • moderate coronary arterial calcification
    • Thoracic aorta:
      • normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries:
      • dilated trunk (3.2cm) and right (2.8cm) and left pulmonary arteries.
    • Heart:
      • normal size of cardiac chambers.
    • Pleura:
      • trace Rt-sided effusion
    • Visible abdominal-pelvic contents:
      • two tiny gall bladder stones.
      • unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • no enlarged lymph node. no focal wall thickening of visible GO tract..
    • Visualized bones:
      • unremarkable.
  • Impression:
    • metastatic LAP in neck (involving phrenic nerve), mediadtinum and axilla and lung metastasis or malignant lymphoma. no visible tumor in abdomen.
• 2024-03-11 Flow Volume Chart
  • Severe restrictive ventilatory impairment, please correlated with clinical condition
• 2024-03-06 Patho - lymphnode biopsy (Y1)
  • Tissue, right supraclavicular, core needle biopsy — moderately differentiated squamous cell carcinoma
  • The specimen submitted consists of 3 tissue fragments measuring up to 1x 0.1x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic.
  • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests of tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity. The stroma is fibrotic.
  • Immunohistochemical stains reveal CK(+) and p40(+) at tumor; p16(-)
• 2024-03-06 SONO guide biopsy - lymph nodes
  • right level 4 lymph node, r/o biopsy
  • r/o thyroic CA with lymph node metastasis
• 2024-03-05 CXR
  • Elevated right hemidiaphragm.
  • Atherosclerosis of the aorta.
  • Ground glass opacity in bilateral lower lungs.
• 2024-03-05 SONO - abdomen
  • Symptoms: right neck mass
  • Diagnosis: Multiple bulky tumors in right supraclavicular fossa, DDx: LAPs

==========

2024-03-15

[alternative medicine]

Sinbisol (bisoprolol hemifumarate 5mg) 1# => Concor (bisoprolol fumarate 5mg) 1# Atorin (atorvastatin calcium 10mg) 1# => Atotin (atorvastatin calcium 20mg) 0.5#

[SCC: lung nodules & enlarged nodes, negative tumor markers & normal labs]

This patient has been diagnosed with squamous cell carcinoma through tissue biopsy, and a chest CT revealed lung nodules, changes in airflow, and enlarged lymph nodes. The patient’s regular use of Bokey (aspirin) has been temporarily halted for the scheduled examinations.

There is no evidence of HBV or HCV infection. The tumor markers AFP, CEA, CA125, and CA153 are all within normal ranges. Lab data from 2024-03-15 showed no significant findings.

No detection of medication problems.

700136476

240314

[exam findings]

• 2024-02-26 ROS1 fluorescent in situ hybridization (FISH)
  • Cellblock No.S2024-00059
  • RESULTS：
    • Number of invasive tumor cells counted: 50
    • Number of observers: 1
    • Number of cells (%) classified as negative: 49 (98%)
    • Number of cells (%) classified as positive: 1 (2%)
  • INTERPRETATION:
    • Rearrangement of ROS1 gene is NOT detected. Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
• 2024-02-26 SONO - chest
  • Echo diagnosis: right lower lung consolidation and trivial amount of pleural effusion, no thoracentesis was done due to high risk.
• 2024-02-18 ECG
  • Atrial fibrillation with rapid ventricular response
  • Rightward axis
• 2024-02-14 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Right pleural effusion with adjacent lung collapse.
    • Cystic lesions (up to 2.0cm) in uterine cervix.
    • A hypodense nodule (1.0cm) in spleen.
    • Atrophy of kidneys with cysts (up to 2.7cm) and tiny stones.
    • Gallbladder and CBD stones (up to 1.5cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P NG tube indwelling. S/P foley catheter indwelling.
• 2024-02-01 PET scan
  • A glucose hypermetabolic lesion in the upper lobe of left lung with invasion to adjacent T3 spine and left 3rd costovertebral junction, compatible with primary lung malignancy with invasion to adjacent bones.
  • A glucose hypermetabolic lesion in the upper lobe of right lung. Either another primary lung malignancy or lung metastasis may show this picture.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar regions, in the posterior aspect of bilateral lower lungs and in the vagina. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • No prominent abnormal focal FDG uptake was noted in the spleen.
• 2024-01-31 Tc-99m MDP bone scan
  • Faint hot spots in the sternum and both rib cages, the nature is to be determined (post-traumatic change, bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, several right costovertebral junctions, lower L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, S-I joints, left knee, and left ankle.
• 2024-01-30 CT - brain
  • Indication: Adenocarcinoma of Right upper lobe and left upper lobe, pending the staging
  • Imp:
    • Brain atrophy.
    • Old infarcts in left medial temporal occipital lobes and right corona radiata.
    • Chronic bil. mastoiditis.
    • Chronic sphenoid sinusitis.
• 2024-01-27 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Low density lesion at splenic hilum is found. Splenic meta is considered.
    • Lobulated cysts at vigina is found. r/o regional infection.
    • Osteopenia of the bony structure is noted.
    • Buldging mass at left upper lobe with neuroforamen invasion at left lateral upper thoracic spine is found up to 3.6cm in largest dimension (Se7 Im14), bone meta with nerve root invasion is considered.
    • Consolidation of right lower lobe and left lower lobe is found.
    • There is stone at dependent portion of GB. GB stone(s) are noted.
    • Atrophy of both kidneys are found.
    • Calcified coronary arteries is found.
  • Imp:
    • Left upper lobe tumor mass with neuroforamen invasion. Lung cancer with bone meta?
    • Splenic hilar lesion. r/o meta.
    • Consolidation of right lower lobe is found. Pneumonia is conisdered.
    • Lobulated cysts at vigina is found. r/o regional infection.
• 2024-01-27 CXR erect
  • Cardiomegaly is noted.
  • s/p double lumen catheter placement with its tip at Superior vena cava
  • Mass like lesion at left upper lobe is found.
  • Faint aveolar opacity over right lower lobe and left lower lobe is found.
• 2024-01-27 ECG
  • Atrial fibrillation with rapid ventricular response
  • Nonspecific ST abnormality
  • Abnormal ECG
• 2024-01-16 CXR erect
  • S/P double lumen insertion, right side.
  • Bilateral upper lung tumors.
  • Right pleural effusion.
  • Mild cardiomegaly.
  • Tortuous thoracic aorta with intimal calcification.
  • Thoracic spondylosis.
• 2024-01-16 ECG
  • Atrial fibrillation
• 2024-01-11 PD-L1 (22C3)
  • Cellblock No. S2024-00596
  • RESULTS：
    • Tumor Proportion Score (TPS) assessment: TPS >= 1% and < 50%
    • Tumor Proportion Score (TPS): 4%
• 2024-01-11 ROS1 IHC
  • Cellblock No. S2024-00596
  • RESULTS：2+
• 2024-01-11 EGFR mutation
  • Cellblock No. S2024-596
  • Result: A point mutation was detected at exon 21 (L858R) of EGFR gene in this specimen.
• 2024-01-09 CXR supine
  • S/P nasogastric tube insertion
  • S/P PERM catheter insertion
  • Prior CT identified mass projecting at left and right upper lung zone is noted again.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Pleura effusion of right and left costal-phrenic angle
  • Spondylosis of the T-spine
• 2024-01-09 Patho - lung transbronchial biopsy
  • Lung, RUL, CT-guide biopsy — adenocarcinoma, moderately differentiated
  • Sections show papillary and acinar glandular cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal TTF-1 (+) and Napsin A (+). The results are supportive for the diagnosis.
• 2024-01-06 CT - chest
  • Indication: Mass lesions (2.8cm, 5.7cm) at bil. upper lungs was noted on Oct 2023 suspect lung cancer
  • Chest CT without IV contrast ehnancement shows:
    • Lobulated mass with smooth margin at left upper lobe measuring 7.13cm in largest dimension is found. Another lobualted soft tissue mass at right upper lobe measuring 3.01cm in largest dimension. (Se307 Im114).
    • Consolidation of right lower lobe and part of left lower lobe is found.
    • Mild Pleural effusion over bilateral pleural space is found.
    • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening.
    • Atrophy of both kidneys are found.
    • s/p Foley catheter placement.
  • Imp:
    • Right upper lobe and left upper lobe lobulated mass, r/o lung cancer.
• 2023-11-09 CT - brain
  • CC: drowsy for 2 days
  • Imp: Brain atrophy. Old infarcts in left medial temporal occipital lobes and right corona radiata.
• 2023-10-19 SONO - nephrology
  • Chronic parenchymal renal disease.
  • Bilateral renal cysts, cortical and parapelvic ones.
  • Left renal stone.
• 2023-10-10 CT - chest
  • Mass lesions (2.8cm, 5.7cm) at bil. upper lungs. Bil. pleural effusion with adjacent lung collapse.
  • Gallbladder stones (up to 1.7cm).
• 2023-09-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (91.5 - 36.2) / 91.5 = 60.44%
    • M-mode (Teichholz) = 60.4-63.4
  • Conclusion:
    • Normal AV with mild AR
    • Thickened MV with moderate MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • Mild PR, mild to moderate TR, dilated IVC size
    • Dilated LA, moderate pulmonary hypertension
• 2023-09-16 ECG
  • Atrial fibrillation with rapid ventricular response
• 2023-09-15 KUB supine
  • Gallstones.
  • Degenerative joint disease of lumbar spine with marginal osteophytes.
• 2023-09-15 SONO - chest
  • Echo diagnosis: left side trivial amount of pleural effusion, no thoracentesis was done due to high risk.
• 2023-06-03 CT - abdomen
  • Non-contrast CT of abdomen-pelvis revealed:
    • Tumors (3.1cm, 6.8cm) at bil. upper lungs. Bil. pleural effusions. Some LNs at mediastinum.
    • Some hypodense lesions (up to 2.2cm) in liver.
    • Normal appearance of spleen, pancreas, adrenals.
    • R/O left renal cyst (2.1cm). Bil. renal stones (2-3mm).
    • Gallbladder stones (up to 1.7cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P NG tube indwelling.
    • Degeneration and spondylosis of L-S spine.
• 2023-06-02 KUB
  • S/P NG tube indwelling.
  • Presence of radiopaque gallbladder stones.
  • Presence of ileus.
  • Radiopaque spot(s) at pelvic region r/o phlebolith(s).
  • Degeneration and spondylosis of L-S spine.

[MedRec]

• 2023-02-15 ~ 2023-02-25 POMR Integrative Medicine Li Zhong
  • Discharge diagnosis
    • RUL tumor with lung to lung metasatsis, highly suspect malignancy, family refused tissue prove
    • LUL tumor, in progression slowly within 30 years, suspected bronchogenic cyst, Loculated effusion at interlobar fissure
    • Acute on chronic kidney disease with hyperkalemia and metabolic acidosis s/p emergent hemodialysis (2/15, 2/16)
    • Urinary tract infection (Urine Culture Escherichia coli, Klebsiella pneumoniae)
    • Imbalance of electrolyte as hyperkalemia, hyper-P and hyper-Mg
    • Paroxysmal atrial fibrillation with SVR
    • Chronic kidney disease, unspecified (stage 4)
    • Type 2 diabetes mellitus without complications
    • Acidosis
    • Adrenocortical insufficiency
    • Insomnia, unspecified
    • Essential (primary) hypertension
  • CC
    • palpitation, dizziness, and N/V for one day
  • Present illness
    • This 79 y/o female has history of DM for 20+ yrs, HTN, CKD, pAf, old CVA with left side weakness, LUL mass for 30 yrs, Anxiety, Insomnia under regular follow up at TSGH.
    • This time, according to the patient’s daughter and our medical records, the patient was found with poor appetite and little feeding for couple of days firstly and then decreased urine amount, nausea, vomiting, dizziness, palpitation was noted in these 1-2 days while no fever, chills, URI symptoms, dyspnea, chest pain, cold sweating, abdominal pain, dysuria, urgency, frequency, or watery diarrhea was found.
    • Due to the problem, she was sent to our ER for help this night, where vital signs showed BP 137/60, HR 31bpm; BT 36’C, RR 18, and SpO2 100%; EKG showed undetermined rhythm, low voltage QRS, and nonspecific ST and T wave abnormality; PE showed clear consciousness, smooth breath with clear bilateral breathing sound, regular heart beat, no pitting edema, but mild epigastric tenderness; Lab data showed Hb 10.4, Plt 140,000, Glu 176, Na 136, K 7.9, BUN 81, Cre 5.06 (Cre:3.6 on 20230209 at TSGH), Ca 2.16, P 6.3, hsTnI 16.5, d-dimer 531.68, PT 80.3, APTT 85.3, Vein Gas with PH 7.25 and HCO3 17.3;
    • CXR showed increased density over left upper lung in progression, increase bilateral lung markings, mild cardiomegaly, tortuous thoracic aorta with intimal calcification, and thoracic spondylosis. So, under impression of 1.) Bradycardia 2.) AKI on CKD with hyperkalemia, metabolic acidosis, and uremia, she was admitted to MICU for further survey and management.
  • Course of inpatient treatment
    • Admitted to MICU, O2 therapy and blood transfusion with FFP 4u for correct PT/APTT prolong. Correct imbalance of electrolyte as hyperkalemia with metabolic acidosis.
    • Emergnt contect nephrologiest and hemodialysis (2/15-2/16). Empiric antiboltic with Rocephin (since 2/15) was perscribed for infection control.
    • Echocardiography was arranged for heart function survey, the conculsion of LVEF 70%.
    • Insulin plus Toujeo were added for sugar control and kept OPD medication therapy.
    • However, the chest films disclosed LUL and RUL mass was found. Chest CT was arranged and the which revealed of RIGHT UPPER LOBE mass with several ground glass nodules scattered at both lungs.
    • Right upper lobe lung cancer with synchronous small stage 0-1 lung cancer is suspected, Loculated effusion at interlobar fissure of left upper lobe. Considor evaluation lung cancer survey.
    • This time, hyperkalemia and metabolic acidosis became to subside, the nephrologiest suggest hold hemodialysis. Under the stable of hemodyanemic and she was transferred to ward for evaluation lung cancer survey with further treatment.
    • After she was trasnferred to general ward, her consciousness clear and respiratory pattern smooth. We remove double-lumen under stable condition on 2/24. We complete Flumarin use for UTI treatment during 2/18-2/25. At present, her clinical condition stable, she was then discharged on 2023/02/24 and referred to OPD F/U.
  • Discharge prescription
    • Relinide (repaglinide 1mg) 1# TIDAC
    • Promeran (metoclopramide 3.84mg) 1# BIDAC
    • Lactul (lactulose 666mg/mL) 30mL QD
    • calcium carbonate 500mg 1# BID
    • Uretropic (furosemide 40mg) 0.5# QOD
    • Trajenta (linagliptin 5mg) 1# QD
    • Through (sennoside 12mg) 2# HS
    • Cortisone (cortisone acetate 25mg) 2# QD

[consultation]

==========

2024-03-14

[navigating erlotinib side effects with nincort oral gel, MASCC/ISOO guidelines on oral mucositis]

An EGFR mutation test conducted on 2024-01-11 identified a point mutation at exon 21 (L858R) of the EGFR gene in specimen S2024-596. Tarceva (erlotinib 150mg) was administered QDAC, from 2024-01-30 to 2024-02-07 for a duration of 9 days, and again from 2024-02-23 to 2024-02-29 for 7 days. Ramucirumab was not used concurrently with erlotinib.

Erlotinib is known to be associated with stomatitis in 17% of cases, with less than 1% experiencing grade 3 severity. The use of Nincort Oral Gel (triamcinolone acetonide, available in stock now) might provide relief for this side effect.

Additionally, the oral supplementation of glutamine (WellCare store on B1 level may sell it) could also be considered. The updated 2020 guidelines from the MASCC/ISOO for the prevention and treatment of oral mucositis recommend the use of oral glutamine for preventing oral mucositis in individuals with head and neck cancer undergoing chemoradiotherapy, although no recommendation is made for other patient groups. (Ref: MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020 Oct 1;126(19):4423-4431. doi: 10.1002/cncr.33100. Epub 2020 Jul 28. Erratum in: Cancer. 2021 Oct 1;127(19):3700.)

700553809

240314

[lab data]

2023-09-30 Anti-HBc Nonreactive
2023-09-30 Anti-HBc Value 0.08 S/CO
2023-09-30 Anti-HBs 0.17 mIU/mL
2023-09-30 HBsAg Nonreactive
2023-09-30 HBsAg Value 0.39 S/CO
2023-09-30 Anti-HCV Nonreactive
2023-09-30 Anti-HCV Value 0.08 S/CO

2023-07-03 CA125 158.1 U/mL
2023-02-15 CA125 107.4 U/mL

[exam findings]

• 2023-12-29 Fundus color photo
  • Result: abnomal
  • Clinical diagnosis: retinal break
  • Report: c/d 0.6 ou, pigmented break at 6o’c and dot hemorrhage at 3o’c os
• 2023-12-29 Microsonography
  • Clinical diagnosis: staphyloma ou
  • Report: RNFL 66/0.67/diffuse thin 70/0.79/falsely detected PPA, staphyloma ou
• 2023-12-28 Fundus color photo
  • L Eye: nonproliferative diabetic retinopathy, NPDR - moderate
  • R Eye: nonproliferative diabetic retinopathy, NPDR - moderate
• 2023-09-15 Patho - uterus (with or without SO) neoplastic
  • PATHOLOGIC DIAGNOSIS
    • Endometrium, uterus, staging surgery — Endometrioid carcinoma
    • Myometrium, uterus, ditto — Tumor invasion, more than half thickness
    • Cervix, uterus, ditto — Endocervical stromal invasion
    • Ovary, left, ditto — Free of tumor invasion, cystic follicle
    • Fallopian tube, left, ditto — Free of tumor invasion
    • Ovary, right, ditto — Free of tumor invasion
    • Fallopian tube, right, ditto — Free of tumor invasion
    • Lymph node, right iliac, dissection — Free of tumor metastasis (0/7)
    • Lymph node, right oburator, ditto — Free of tumor metastasis (0/3)
    • Lymph node, left iliac, ditto — Tumor metastasis (2/10)
    • Lymph node, left oburator, ditto — Free of tumor metastasis (0/2)
    • AJCC Pathologic stage — pT2N1a, if cM0, stage IIIC1 / FIGO stage IIIC1
    • 2023 FIGO staging — Stage IIIC1ii
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: staging surgery (TAH, BSO and BPLND)
    • Specimens include: uterus with bilateral adnexa and pelvic LNs
    • Specimen size:
      • uterus: 8.6 x 6.2 x 4.5 cm in size, 147 gm in weight
      • right ovary: 2.3 x 1.2 x 0.9 cm
      • left ovary: 2.3 x 1.6 x 1.5 cm
      • right fallopian tube: 4 cm in length; 0.5 cm in diameter
      • left fallopian tube: 4 cm in length; 0.5 cm in diameter
    • Tumor site: endometrium
    • Tumor size: 3.3 x 2.8 cm
    • The myometrium: tumor invasion greater than 1/2 thickness
    • The cervix : mucus cysts
    • Bilateral adnexa: Not invaded by tumor
    • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs and right obturator LNs
    • Representative sections as A: right iliac LNs; B: right obturator LNs; C1-C2: left iliac LNs; D: left obturator LNs, E1: R’t ovary, E2: R’t F-tube, E3: L’t ovary, E4: L’t F-tube, E5-E7: uterus from fundus to cervix, E8-E12: tumor + serosa (ink), E13-E15: low segment of uterus to cervix
  • MICROSCOPIC EXAMINATION
    • Histology type: endometrioid carcinoma
    • Histology grade: grade 1
    • Depth of invasion: greater than half thickness of myometrium
    • Lymphovascular invasion: identified
    • The cervical stroma involvement: involved
    • Resection margins of the cervix: Free, 3 cm away from tumor
    • Additional pathologic findings: squamous metaplasia
    • Lymph nodes: metastatic carcinoma (2/10) in left iliac LNs without extracapsular extension (0/2)
    • Immunohistochemistry: P16(+, patchy), PMS2(+), MSH2(+), MSH6(+) and MLH1(+) for tumor
    • Ascites cytology: positive
• 2023-09-15 Body fluid cytology - ascites
  • 37 cc orange cloudy ascites — Malignancy
  • The smears show lymphocytes, reactive mesothelial cells and hyperchromatic atypical epithelial clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
• 2023-07-27 MRI - pelvis
  • Clinical history: 52 y/o female patient with Uterus, endometrium, D&C — endometrioid adenocarcinoma, grade 1. IHC stains: p53 (wild type); Napsin-A (-), ER (+, 50%, strong intensity), PR (+, 50%, strong intensity), vimentin (focal +), p16 (+), CK5/6 (focal +).
  • With and without contrast enhancement MRI: Pelvis
    • Soft tissue tumor in the uterine wall(fundus and body), involvement of more than half of myometrium, r/o endometrial malignancy.
    • More prominent soft tissue in the ovary.
    • There are lymph nodes, up to 0.7cm, in right obturator region. suggest follow up.
    • Cysts in the uterine cervix, suggesting Nabothin cysts.
    • Presence of ascites in the pelvic cavity.
    • Presence of perineural cyst in S1 region.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T1b(T_value) N:N0(N_value) M:M0(M_value) STAGE:_ IB___(Stage_value)
      
  • Impression:
    • Endometrial malignancy, cstage T1bN0M0.
    • Small lymph nodes in right obturator region, suggest follow up.
    • Prominent soft tissue in right ovary, nature?
    • Nabothin cysts.
• 2023-07-17 Patho - endometrium curretage/biopsy
  • Uterus, endometrium, D&C — endometrioid adenocarcinoma, grade 1.
  • IHC stains: p53 (wild type); Napsin-A (-), ER (+, 50%, strong intensity), PR (+, 50%, strong intensity), vimentin (focal +), p16 (+), CK5/6 (focal +).
• 2023-07-12 Gynecologic ultrasonography
  • R/O Adenomyosis
  • R/O Endometrial thickening, EM 23.5mm
• 2023-02-15 Gynecologic ultrasonography
  • Adenomyosis

[MedRec]

• 2023-12-28 SOAP Metabolism and Endocrinology Yu LiJiao
  • Prescription x3
    • Blopress (candesartan 8mg) 1# HS
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
    • Norvasc (amlodipine 5mg) 1# QD
    • Zulitor (pitavastatin 4mg) 1# Q3D
    • Uformin (metformin 500mg) 0.5# BID
    • Lipanthyl Supra (fenofibrate 160mg) 1# QOD
• 2023-10-05 SOAP Metabolism and Endocrinology Yu LiJiao
  • Prescription x3
    • Blopress (candesartan 8mg) 1# HS
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
    • Norvasc (amlodipine 5mg) 1# QD
    • Zulitor (pitavastatin 4mg) 1# Q3D
    • Uformin (metformin 500mg) 0.5# BID
• 2023-09-28 SOAP Radiation Oncology Huang JingMin
  • A: Endometrioid carcinoma of the uterine endometrium, grade 1, AJCC Pathologic stage pT2N1a, cM0, stage IIIC1 / FIGO stage IIIC1. 2023 FIGO stage IIIC1ii, s/p staging surgery (ATH + BSO + BPLND)
  • P: Radiotherapy is indicated for this patient with the following indicators: FIGO stage IIIC1. 2023 FIGO stage IIIC1ii
    • Goal: curative
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT and IVRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions via IVRT to vaginal cuff mucosa surface.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient. She understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-10-11.
• 2023-08-10 SOAP Metabolism and Endocrinology Yu LiJiao
  • Prescription x2
    • Blopress (candesartan 8mg) 1# HS
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
    • Norvasc (amlodipine 5mg) 1# QD
    • Zulitor (pitavastatin 4mg) 0.5# QN
    • Uformin (metformin 500mg) 0.5# BID
• 2023-05-11 SOAP Metabolism and Endocrinology Yu LiJiao
  • Prescription x3
    • Blopress (candesartan 8mg) 1# HS
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
    • Norvasc (amlodipine 5mg) 1# QD
    • Zulitor (pitavastatin 4mg) 0.5# QN

[surgical operation]

• 2023-09-14
  • Surgery
    • Diagnosis: Endometrial cancer
    • Operation: Staging surgery (ATH + BSO + BPLND)   - Finding
    • Uterus: normal size, without invasion to myometrium, cervix was grossly normal.
    • Adnexa:
      • LOV: 2x1x1cm, capsule intact, smooth surface.
      • ROV: 2x1x1cm, capsule intact, smooth surface.
      • Fallopian tube: bilateral grossly normal
    • CDS: free of adhesion, mild clear ascites
    • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • Bladder and rectum: Normal
    • Omentum: Normal
    • Anti-adhesive agent: Arista
    • Estimated blood loss: 150ml
    • Blood transfusion: nil.
    • Complication: nil.
• 2023-07-17
  • Surgery
    • Diagnosis: R/O endometrial hyperplasia
    • Surgery: Dilatation and curettage
  • Finding
    • Uterus: Anteversion, 10 cm.
    • Some hyperplastic tissues with blood clots were curetted out.
    • Estimated blood loss: 10 mL, Blood transfusion: nil, complication: nil.   

[radiotherapy]

• 2023-10-18 ~ 2023-11-30 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT. (20231212 SOAP)

[chemotherapy]

• 2024-02-20 - paclitaxel 175mg/m2 360mg NS 300mL 3hr + cisplatin 75mg/m2 150mg NS 500mL 2hr (Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-01-29 - paclitaxel 175mg/m2 355mg NS 300mL 3hr + cisplatin 75mg/m2 150mg NS 500mL 2hr (Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-01-05 - paclitaxel 175mg/m2 360mg NS 250mL 3hr + cisplatin 75mg/m2 150mg NS 500mL 2hr (Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-11-15 - cisplatin 40mg/m2 80mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (Gao WeiYao)
  • dexamethasone 4mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) + NS 250mL
• 2023-11-08 - cisplatin 40mg/m2 80mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (Gao WeiYao)
  • dexamethasone 4mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) + NS 250mL
• 2023-11-01 - cisplatin 40mg/m2 80mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (Gao WeiYao)
  • dexamethasone 4mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) + NS 250mL
• 2023-10-23 - cisplatin 40mg/m2 80mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (Xia HeXiong)
  • dexamethasone 4mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) + NS 250mL

==========

2024-03-14

[assessing DIC risk in the context of elevated NT-proBNP and D-dimer levels]

The sputum Gram stain performed on 2024-03-13, did not provide a clear indication of the infection source. Results from the blood culture and urine culture, both ordered on 2024-03-12, are still pending.

Despite the unremarkable CXR taken on 2024-03-12 in the supine position for the patient’s SOB, she has been started on Tapimycin (piperacillin/tazobactam) as an empirical treatment.

Thrombocytopenia with hypofibrinogenemia while elevated NT-proBNP and D-dimer were evident with recent lab results.

• 2024-03-14 PLT 26 *10^3/uL
  
• 2024-03-13 NT-proBNP 3432.9 pg/mL
  
• 2024-03-13 D-dimer >10000 ng/mL(FEU)
  
• 2024-03-13 Fibrinogen (quantita) 140.2 mg/dL

The combination of thrombocytopenia, low fibrinogen, elevated D-dimer, and elevated NT-proBNP could suggest a complex clinical picture possibly involving ‘cardiac stress’ (as indicated by NT-proBNP) and a ‘hypercoagulable state’ or ‘coagulopathy’ (as indicated by the coagulation abnormalities). The presence of both thrombocytopenia and coagulation abnormalities might raise suspicion for DIC. This can consume platelets and clotting factors, leading to bleeding. The elevated NT-proBNP suggests that there could be a ‘cardiac component’ to the patient’s condition, such as acute coronary syndrome, especially if there are clinical symptoms like shortness of breath.

Here are 3 titles focusing on the declining kidney function:

[monitor closely as kidney function declines]

The patient’s kidney function is decreasing, but Tapimycin (piperacillin/tazobactam) dose adjustment isn’t needed at this time.

• 2024-03-12 Creatinine 1.48 mg/dL
  

• 2024-02-27 Creatinine 1.00 mg/dL
  

• 2024-02-19 Creatinine 0.98 mg/dL

• 2024-03-12 eGFR 39.21 ml/min/1.73m^2
  

• 2024-02-27 eGFR 61.64 ml/min/1.73m^2
  

• 2024-02-19 eGFR 63.10 ml/min/1.73m^2

2024-02-20

[low Mg detected, MgSO4 IVD started & high glucose]

Lab on 2024-02-19 showed Mg 1.4 mg/dL, indicating hypomagnesemia, MgSO4 IVD is in use since 2024-02-20 with no discrepancy.

Blood glucose 331 mg/dL on 2024-02-20 05:07, regular insulin could be considered to mitigate the hyperglycemia.

2024-01-29

[hypomagnesemia detected]

The eGFR has improved to 62, and cisplatin continues to be included in the treatment regimen.

• 2024-01-28 eGFR 62.36 ml/min/1.73m^2
  
• 2024-01-12 eGFR 39.52 ml/min/1.73m^2
  
• 2024-01-04 eGFR 56.41 ml/min/1.73m^2

On 2024-01-28, serum magnesium was measured at 1.5 mg/dL, prompting the administration of magnesium sulfate injection. Apart from hypomagnesemia, other laboratory findings and vital signs are grossly within normal limits, with no issues detected.

2024-01-05

[declining eGFR: consider carboplatin over cisplatin]

This is the patient’s initial administration of paclitaxel alongside cisplatin. There is a potential for additive myelosuppressive effects, so it’s important to closely monitor the patient’s CBC and WBC DC for at least three weeks following the treatment.

On 2024-01-04, the patient’s eGFR of 56.41 confirmed a decrease in renal function. Given this decline trend and no contraindications, it is recommended to use carboplatin as a substitute for cisplatin.

• 2024-01-04 eGFR 56.41 ml/min/1.73m^2
• 2023-12-19 eGFR 76.43 ml/min/1.73m^2
  
• 2023-11-28 eGFR 70.52 ml/min/1.73m^2
  
• 2023-11-21 eGFR 77.51 ml/min/1.73m^2
  
• 2023-11-14 eGFR 75.38 ml/min/1.73m^2
  
• 2023-11-07 eGFR 79.75 ml/min/1.73m^2
  
• 2023-10-31 eGFR 68.73 ml/min/1.73m^2
  
• 2023-10-12 eGFR 79.75 ml/min/1.73m^2
  
• 2023-09-27 eGFR 96.20 ml/min/1.73m^2
  
• 2023-09-13 eGFR 103.17 ml/min/1.73m^2

701123478

240314

[exam findings]

• 2024-01-18 Colonoscopy
  • Findings
    • The scope reach the cecum under good colon preparation.
    • One mass was noted in the Size 7 cm. (3~10 cm from anal verge), 75 % circumferential
  • Diagnosis:
    • Advanced rectal cancer
      
  • Suggestion:
    • Pre-op TNT then op
  • Complication:
    • No immediate complication
• 2024-01-10 MRI - pelvis
  • Findings:
    • There is segmental circumferential asymmetrical wall thickening at the rectum, 6 cm in size (the largest dimension).
      • Adenocarcinoma of the rectum (T3) is highly suspected.
    • There are fifteen enlarged nodes in the peri-rectal space, pre-sacral space, and sigmoid mesocolon that are c/w regional metastatic nodes (N2b).
    • There are several renal cysts on both kidney (up to 0.9 cm).
    • Otherwise, no significant abnormal finding is noted.
  • IMP:
    • Adenocarcinoma of the rectum is noted.
    • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T3 N2b M0; stage: IIIC.
• 2024-01-05 CT - abdomen
  • Findings:
    • There is segmental circumferential mild asymmetrical wall thickening at the upper rectum, 6 cm in size.
      • Adenocarcinoma of the upper rectum (T3) is highly suspected.
      • Please correlate with MRI.
    • There are five enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w regional metastatic nodes (N2a).
    • There is no focal lesion in both lung and mediastinum.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)
• 2024-01-05 Patho - colorectal polyp
  • Rectal mass, 5 cm above anal verge, biopsy — Adenocarcinoma
  • Microscopically, the section shows a picture of adenocarcinoma characterized by glandular tumor cell infiltrate with desmoplasia and ulcer.
  • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
• 2024-01-04 Colonoscopy
  • Findings
    • The scope reach the cecum under good colon preparation.
    • One large ulcerative mass was noted in the rectum (5cm from anal verge), 75% circumferential
  • Management: Biopsy
  • Diagnosis:
    • Rectal cancer s/p biopsy
    • Incomplete colonoscopy due to stool impaction
  • Suggestion:
    • OPD F/U
  • Complication:
    • No immediate complication
• 2023-06-21 EGD
  • Diagnosis:
    • No active bleeder or blood clot during exam.
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, antrum
  • CLO test: not done
  • Suggestion:
    • No active bleeder or blood clot during exam.

[MedRec]

• 2024-01-11 SOAP Hemato-Oncology Yang MuJun
  • S: arrange admission for TNT, CCRT with 5FL and then FOLFOX 8 doses, refer to GS for port A insertion and radio-oncologist for RT
• 2024-01-11 SOAP Radiation Oncology Huang JingMin
  • A:
    • Adenocarcinoma of the rectum, stage cT3N2aM0(IIIB).
  • P:
    • TNT then operation is indicated for this patient with the following indicators: stage cT3N2aM0(IIIB).
      • Goal: curative
      • Treatment target and volume: the pelvic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the recta tumor bed.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2024-01-18.
• 2024-01-11 SOAP Colorectal Surgery Xiao GuangHong
  • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2024-01-09
    • Complete colonoscopy.
    • TNT then OP.

[consultation]

• 2024-02-23 Oral and Maxillofacial Surgery
  • Q
    • The patient has a toothache on the left side and would like you to see if he need a root canal
    • The 41 y/o male had suffered from change in stool pattern, tiny stool mixed with few fresh blood least for one year. Anal fresh bleeding off and on and noted again, the condition is worse than before within this year. He had came to our CRS OPD for help.
    • Colonoscope was done on 2024/01/04 showed one large ulcerative mass was noted in the rectum, 5 cm from anal verge s/p biopsy, incomplete colonoscopy due to stool impaction. Biopsy done and pathologic reported adenocarcinoma characterized by glandular tumor cell infiltrate with desmoplasia and ulcer. Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
    • Abdominal CT on 2023/01/05 reported 1. There is segmental circumferential mild asymmetrical wall thickening at the upper rectum, 6 cm in size, Adenocarcinoma of the upper rectum (T3) is highly suspected、2. There are five enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w regional metastatic nodes (N2a)、3. There is no focal lesion in both lung and mediastinum.
    • Pelvis MRI on 2024/01/10 showed 1. Adenocarcinoma of the rectum is noted.c According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T3 N2b M0; stage: IIIC. Team discussion suggest TNT then OP. Refer to GS for Port-A insertion and radio-oncologist for radiotherapy.
    • Port-A insertion on 2024/01/12. Denied TOCC history in recent three months.
    • The rectum cancer treatment regimen as below: => CCRT with 5Fu；RT to pelvic of 4500cGy/25fx, rectal tumor bed of 5040cGy/28fx from 2024/01/23~；chemotherapy with 5Fu(LV 20mg/m2, 5FU 400mg/m2) from 2024/01/24~2024/01/27(C1).
    • Then he was admitted to our Oncology ward for Total neoadjuvant therapy, CCRT with 5Fu(C2).
  • A
    • Will arrange time for inspection.

[chemotherapy]

• 2024-02-26 - [leucovorin 20mg/m2 33mg 10min + fluorouracil 400mg/m2 660mg NS 100mL 10min] D1-2 (CCRT QW)
• 2024-02-22 - [leucovorin 20mg/m2 33mg 10min + fluorouracil 400mg/m2 660mg NS 100mL 10min] D1-2 (CCRT QW)
• 2024-01-24 - [leucovorin 20mg/m2 33mg 10min + fluorouracil 400mg/m2 660mg NS 100mL 10min] D1-4 (CCRT QW)

==========

2024-03-14

[Granocyte intervention for chemotherapy-induced leukopenia]

Lab WBC level change:

• 2024-03-13 WBC 2.00 x10^3/uL *
• 2024-03-04 WBC 3.24 x10^3/uL
• 2024-02-21 WBC 7.01 x10^3/uL 5-FU 2/22 D1-2,5-6
• 2024-02-19 WBC 18.63 x10^3/uL
• 2024-02-14 WBC 1.37 x10^3/uL **
• 2024-02-07 WBC 3.47 x10^3/uL
• 2024-01-18 WBC 7.85 x10^3/uL 5-FU 1/24 D1-4
• 2024-01-11 WBC 5.74 x10^3/uL
• 2024-01-04 WBC 6.01 x10^3/uL

The patient has been undergoing concurrent chemoradiotherapy (CCRT) since early to mid-January 2024, receiving radiotherapy from 2024-01-23 to 2024-03-08. The treatment included 4500 cGy in 25 fractions targeting the pelvic area and 5040 cGy in 28 fractions focused on the rectal tumor bed area. Additionally, a 4-day regimen of 5-FU commenced on 2024-01-24 and was repeated on 2024-02-22.

Chronologically, the nadir in the WBC count occurred approximately in the end of the third week following the initiation of chemotherapy, suggesting the possibility of leukopenia induced by the chemotherapeutic agents. A 3-day prescription of Granocyte (lenograstim) has been issued to manage this condition.

700891456

240312

==========

2024-03-12

[tube feeding for Takepron (lansoprazole)]

For tube feeding, using a simple suspension method is recommended for Takepron (lansoprazole). Here’s how to do it:

• Gather your supplies: You’ll need a small container, warm water, a syringe or feeding pump, and the Takepron medication.
• Prepare the mixture: Place the Takepron in the container and add warm water. Make sure the medication is completely covered.
• Mix it well: Stir or shake the mixture thoroughly until the medication dissolves or breaks down into tiny particles that can easily pass through the feeding tube.
• Administer through the tube: Use a syringe or feeding pump to carefully introduce the medication mixture through the NG tube.

Here are some additional tips:

• Warm water helps: Using warm water can make it easier to dissolve the medication.
• Mix thoroughly: Make sure the mixture is well-mixed to avoid any undissolved particles clogging the feeding tube.
• Capsules need opening: If the medication comes in capsules, you’ll need to open them and empty the contents before adding them to the water.

701164956

240312

[exam findings] (not completed)

• 2019-05-23 Surgical Pathology Level IV
  • Bone marrow, iliac, (S2019-7638 follicular lymphoma), biopsy — Negative for malignancy
  • Section shows one piece of bone marrow with 30 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
• 2019-05-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (76.4 - 14.6) / 76.4 = 80.89%
    • M-mode (Teichholz) = 80.9
  • Conclusion
    • Dilated LA
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild PR, TR
• 2019-05-22 CT - chest
  • Indication: Lymphoma, staging
  • Chest CT with and without IV contrast ehnancement shows:
    • S/p central line catheter placement with its tip at SUPERIOR VENA CAVA.
    • A small nodular lesin at right lower lobe up to 0.4cm in largest dimension. Suggest follow up 12-24 months later.
    • Emphysematous change over both lungs.
    • Confluent and necrotic lymph nodes are found in the mesentry with obliteration of the bile duct is found. Lymphoma is compatible.
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • Impression:
    • Compatible with lymphoma with only abdominal cavity involement. The chest is spared.
    • Tiny right lower lobe nodule.
• 2019-05-15 Surgical Pathology Level IV
  • PATHOLOGIC DIAGNOSIS
    • Soft tissue, intra-abdominal, biopsy — follicular lymphoma, grade 3A
      
  • MACROSCOPIC DESCRIPTION
    • Operation procedure: biopsy
    • Topology: intra-abdominal
    • Specimen size and number: 2 pieces, up to 2x 0.1x 0.1 cm in size
  • MICROSCOPIC EXAMINATION
    • Histology type:
      • B-cell neoplasms
        • Follicular lymphoma, Grade 3A
    • Immunohistochemical stain profiles: Bcl-2(+), Bcl-6(+), CD10(+), CD20(+), c-myc(+), MUM1(-), cyclin-D1 (-), CD56(-), NSE(-), chromogranin a(-), synapthophysin(-), CK(-), CD3(-).
• 2019-05-14 CT - pancreas, liver
  • Findings:
    • There are huge kissing lobulated soft tissue masses in the celiac trunk, mesentery, para-aortic space and para-cava space causing visceral vessel encasement that may be malignant lymphoma.
    • There is a soft tissue mass measuring about 1.8 cm in the distal CBD causing dilatation of the proximal bile duct and gallbladder that also may be due to lymphoma.
  • Impression:
    • Malignant lymphoma is highly suspected.
    • Sono-or CT-guided biopsy is indicated.

[MedRec]

• 2024-03-11 ~ 2024-03-12 POMR Hemato-Oncology
  • Discharge diagnosis
    • Follicular lymphoma, unspecified, unspecified site
  • CC
    • For recurrent anemia survery
  • Present illness
    • This is a 63-year-old femaile with past history of
      • Folliculat lymphoma, grade 3A, satge IV, double hits (+), with > 12cm at mesentery, and pancreas involvement, and suspcted bone marrow involvment s/p
        • 1# chemotherapy with Mabthera + vincristine + Etoposide + Doxorubicin from 2019/05/23-2019/05/26.
        • 2# Mabthera + Vincristine + Adramycin + Endoxan from 2019/06/19-2019/06/24.
        • 3# chemotherapy with E-SHOP from 2019/07/09-2019/07/13.
        • 4# on 2019/07/31-2019/08/03.
        • 5# on 2019/08/22-2019/08/26.
        • 6# on 2019/09/23-2019/09/27.
        • 1# R-ESHOP on 2019/12/09.
        • 2# R-ESHOP on 2020/01/06.
        • BCNU + Ara-C + Etoposide + Melphalan from 2020/04/01 to 2020/04/06.
        • Autologous PBSCT on 2020/04/08, partial response.
      • Recurrent anemia
    • Initial, she presented with abdominal pain with intermittent watery diarrhea, weight loss up to 7Kg in recent 6 months. She visited a GI physician Taipei Chang Gung Memorial Hospital who suspected that she had pancreatic head tumor by sono abdomen. Hence the patient was brought to our GI OPD for evaluation and management. An examination of the patient’s abdomen in our GI OPD showed soft and flat, no abdomen tenderness, no rebound tenderness, no pale conjuctiva, mild icteric sclera. A series of examinations including blood routine, blood biochemistry and image were performed. Under the tentative diagnosis of pancreatic head tumor with obstructive jaundice. The abdominal CT was arranged on 2019/5/14 to survey the pancreatic head tumor noted by previous sono abdomen showed: a huge kissing lobulated soft tissue masses in the celiac trunk, mesentery, para-aortic space and para-cava space causing visceral vessel encasement that may be malignant lymphoma.
    • Sono-or CT-guided biopsy is indicated. Biopsy was performed on 2019/5/15 smoothly. Pathology report showed follicular lymphoma, grade 3A.
    • However, dizziness and short of breath was noted in recent month. She ever visit our ER on 2024/02/06 and anemia with Hb: 4.7g/dL was noted and 6U pRBC was transfusion. This time, same symptom was noted and she visit our ER on 2024/03/09.
    • In ER, her vital sign showed BP:125/64 mmHg, HR:113 bpm, BT:36.6’C, RR:18/min, conscious E4V5M6. Physical examination showed pale conjunctiva(+). Laboratory data revealed normocytic anemia (Hb 6.3g/dL, MCV 91.6fL), thrombocytopnea (PLT 91000uL). Elevated CRP 8.1 mg/dL, and LDH 532U/L and hypomagnesemia (Mg 1.3mg/dL) , hypopotassemia (K 2.8mg/dL) was noted after admission. CXR showed RLL consolidation. However, she denied fever(-), night sweat(-), abdominal pain(-). Body weight loss from 44 to 40mg in recent 6 months.
    • Under the impression of recurrent anemia, the patient was admitted for bone marrow biopsy.
  • Course of inpatient treatment
    • After admission, bone marrow biopsy was performed smoothly on 2024/03/12. Follow-up lab datas on 2024/03/12 showed stable Hb level. No infection sign and no active bleeding was noted over puncture wound. The patient’s general status was good and no obvious discomfort. Under the relative stable clinical condition, the patient was discharged on 2024/03/12 with outpatient department follow-up.
  • Discharge prescription
    • none
• 2019-05-13 ~ 2019-05-28 POMR Hemato-Oncology Liu JunHuang
  • Discharge diagnosis
    • C82.90 Folliculat lymphoma suspected bone marrow involvment, stage IV (with CBD and pancreatic head involvement).
  • CC
    • Abdominal pain with intermittent watery diarrhea, weight loss up to 7Kg in recent 6 months
  • Present illness
    • This is a 58-year-old female patient denied any systemic disease before. She presented with abdominal pain with intermittent watery diarrhea, weight loss up to 7Kg in recent 6 months. Today She visited a GI physician Taipei Chang Gung Memorial Hospital who suspected that she had pancreatic head tumor by sono abdomen. Hence the patient was brought to our GI OPD for evaluation and management. An examination of the patient’s abdomen in our GI OPD showed soft and flat, no abdomen tenderness, no rebound tenderness, no pale conjuctiva, mild icteric sclera. A series of examinations including blood routine, blood biochemistry and image were performed. Under the tentative diagnosis of pancreatic head tumor with obstructive jaundice, the patient was admitted for further evaluation and treatment.

[chemotherapy]

• 2020-04-01 - carmustine 375mg D5W 250mL 3hr D1 + etoposide 100mg/m2 125mg D5W 500mL 1hr BID D2-5 + cytarabine 125mg D5W 100mL 1hr BID D2-5 + melphalan 50mg NS 500mL 1hr D6
  • [dexamethasone 5mg + granisetron 2mg + NS 250mL] D1-6
• 2020-01-07 - fytosid 60mg/m2 75mg D5W 250mL 1hr D1-2 + cisplatin 20mg/m2 25mg NS 100mL 3hr D1-2 (with mannitol) + cytarabine 1875mg D5W 250mL 3hr D3

701358867

240312

[lab data]

2024-03-08 HBV DNA PCR 25900000 IU/mL

2024-03-08 HBeAg Nonreactive
2024-03-08 HBeAg(Value) 0.382 S/CO

2024-03-05 EBV DNA PCR 52 IU/mL

2024-03-01 HIV Ab-EIA Nonreactive
2024-03-01 Anti-HIV Value 0.06 S/CO

2024-03-01 Anti-HCV Nonreactive
2024-03-01 Anti-HCV Value 0.11 S/CO

2024-03-01 HBsAg Reactive
2024-03-01 HBsAg Value 5099.41 S/CO

[exam findings]

• 2024-03-07 CT - abdomen
  • Enlarged LNs at retroperitoneum and upper abdomen with vascular encasement c/w lymphoma.
• 2024-02-29 PET scan
  • The FDG PET findings suggest that lymphoma involving multiple lymph nodes on both sides of the diaphragm and spleen should be considered first.
  • Increased FDG uptake in the left aspect of the nasopharynx. Lymphoma is more likely. However, please correlate with the pathologic findings for further evaluation.
• 2024-02-27 MRI - nasopharynx
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:1(T_value) N:3(N_value) M:0(M_value) STAGE:IVA (Stage_value)
• 2024-02-27 SONO - abdomen
  • The liver shows heterogeneous echo-pattern that may be infiltrative type HCCs and multiple metastases?
    • In addition, there are multiple hypoechoic masses (up to 6.34 cm) in the upper abdomen that may be metastatic nodes.
      
    • Please correlate with contrast enhanced dynamic CT.
      
  • The spleen shows prominence in size (long axis: 11.6 cm) and heterogeneous echogenicity.
• 2024-02-26 Patho - nasopharyngeal/oropharyngeal biopsy (Y1)
  • PATHOLOGIC DIAGNOSIS
    • Tumor, left lateral pharyngeal and nasopharyngeal wall, punch biopsy — Diffuse large B-cell lymphoma
      
  • MACROSCOPIC DESCRIPTION
    • Operation procedure: punch biopsy
    • Topology: left lateral pharyngeal and nasopharyngeal wall
    • Specimen size and number: two small pieces, up to 0.7 x 0.6 x 0.3 cm in size
  • MICROSCOPIC EXAMINATION
    • Histology type: diffuse large B-cell lymphoma shows large atypical lymphoid cells with nucleoli, mitoses and focal necrosis
    • Immunohistochemistry: CK(-), CD3(-), CD20(+), CD56(-), P63(+), P16(-), EBER ISH(-) for tumor. And Bcl-2, CD30, CD10, Bcl-6 and C-MYC are pending
    • Addendum Immunohistochemistry of CD30(+, patch), Bcl-2(+), Bcl-6(+), C-MYC(10%, +) and CD10(+), compatible with germinal center B cell (GCB) subtype
• 2024-02-26 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2024-02-26 Nasopharyngoscopy
  • Findings:
    • smooth HPx
    • dark red mass over R tongue base
    • necrotic bulging over L posterior wall of nasopharynx
  • Diagnosis/conclusion
    • L neck mass with L NPx tumor

[MedRec]

• 2024-03-07 SOAP Gastroenterology Xiao ZongXian
  • S: Prepare chemotherapy next week. For HBV prophylaxis
  • A: 2024/03/01 HBsAg = Reactive; HBsAg (Value) = 5099.41 S/CO;
  • Prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD

[immunochemotherapy]

• 2024-03-12 - rituximab 375mg/m2 570mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1140mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg PO BID D2-6 (R-COP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + NS 250mL D1-2

==========

2024-03-12

[newly diagnosed double/triple-hit DLBCL (GCB): R-COP initiated]

This patient was recently diagnosed with double/triple-hit DLBCL (germinal center B-cell subtype) with the following markers:

• Bcl-2 (+)
• Bcl-6 (+)
• C-MYC (10%, +)

She is currently admitted for the first cycle of the R-COP regimen.

Calglon (calcium gluconate) injection is being administered to treat hypocalcemia (2.03 mmol/L on 2024-03-11). Vemlidy (tenofovir alafenamide) is being used to manage reactive HBsAg detected on 2024-03-01. No medication discrepancies were identified.

701376621

240312

[exam findings]

• 2024-02-27 CT - abdomen
  • Clinical history: 77 y/o female patient with A-colon cancer s/p SILS right hemicolectomy, pT4aN2bM1c, stage IVC Loss follow up
  • Impression:
    • S/P right hemicolectomy.
    • Multiple metastatic lymph nodes in the pelvic cavity, paraaortic and axillary regions.
    • Irregular soft tissue in the pelvic cavity, adjacent to the uterus, r/o recurrence with abuttting the uterus.
      
    • GB stones.
• 2022-05-05 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Tumor, ascending colon, laparoscopic right hemicolectomy — Mucinous adenocarcinoma
    • Resection margins, bilateral, ditto — Free from tumor
    • Lymph node, mesocolic, dissection — Tumor metastasis (13/17) with extracapsular extension (6/13)
    • Appendix, excision — Free from tumor
    • Omentum, omentectomy — Mucinous adenocarcinoma
    • AJCC pathologic stage — pT4aN2bM1c, stage IVC
  • MACROSCOPIC EXAMINATION
    • Operation procedure: laparoscopic right hemicolectomy
    • Specimen site: Ascending colon, terminal ileum, appendix and omentum
    • Specimen size: (a) A-colon: 13.5 cm in length, up to 2.2 cm in diameter, (b) Terminal ileum: 9 cm in length, 3.7 cm in diameter and (c) Appendix: 4.5 cm in length, 0.8 cm in diameter
    • Tumor size: 4.6 x 3.7 cm
    • Tumor location: 7.6 and 8.6 cm away from bilateral resection margins
    • Tumor appearance: annular mass
    • Depth of invasion grossly: visceral peritoneum
    • Omentum: 41 x 15 x 0.5 cm with three nodules, up to 1.7 x 0.9 cm
    • Representative sections as follows: A1: ileum margin, A2: colonic margin, A3: appendix, A4: tumor + serosa(ink), A5-A6: tumor + radial margin(ink), A7-A9: tumor, A10-A14: lymph nodes, A15-A16: enlarged calcified lymph node (4.2 x 3.2 x 2.3 cm, after decalcification ) and B1-B2: omentum
  • MICROSCOPIC EXAMINATION
    • Histology: mucinous adenocarcinoma
    • Histology Grade: G2, moderately differentiated
      
    • Depth of invasion: visceral peritoneum
    • Angiolymphatic invasion: Present
    • Perineural invasion: Present
    • Discontinuous extramural tumor extension: present
    • Circumferential (radial) margin of rectosigmoid: involved
    • Lymph node metastasis, mesocolic: tumor metastasis (13/17)
    • Lymph node metastasis, IMA / SMA: N/A
    • Extranodal involvement: present (6/13)
    • Pathological TNM Stage: pT4aN2bM1c, stage IVC
    • Type of polyp in which invasive carcinoma arose: N/A
    • Additional pathologic findings: focal necrosis and calcification
    • TNM descriptors: N/A
      
    • Tumor regression grading S/P CCRT: N/A
    • Immunohistochemistry: CDX-2(+), PMS2(+), MLH1(+), MSH2(+) and MSH6(+) for tumor
• 2022-05-03 Flow Volume Chart
  • mild restrictive impairment
• 2022-05-03 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (92 - 17) / 92 = 81.52%
    • M-mode (Teichholz) = 81
  • Conclusion:
    • Septal hypertrophy with Gr I LV diastolic dysfunction.
    • Normal LV and RV systolic function.
    • Trivial MR; mild TR.
• 2022-05-02 CT - abdomen
  • Indication: Malignant neoplasm of colon, unspecified
  • Abdominal CT with and without enhancement revealed:
    • Soft tissue mass at ascending colon is found up to 7.85cm in largest dimension is found. Colon cancer is considered. Some lymph nodes are found around the main mass. (n＝4).
    • Swelling of the appendix is found.
    • Some ascites at subhepatic space and abdominal cavity is found.
    • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening.
    • Calcified nodule at RLQ of the mesentery is found. r/o calcified lymph nodes
    • There is no evidence of paraarotic LAPs.
    • Increased intestinal gas is found.
    • Enhanced uterine mass is found up to 3.4cm in largest dimension. r/o myoma.
    • There is no evidence of destructive bone lesion.
  • Imp:
    • Compatible with ascending colon with ascites formation. Suggest correlate with other findings.
    • swelling of the appendix probably secondary to the ascending colon mass.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)

[MedRec]

• 2022-05-02 ~ 2022-05-09 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Advanced ascending colon cancer with partial obstruction cT3Na cM0 stage IIIb status post 3D single incisional laparoscopic surgery right hemicolectomy on 2022/05/04.
    • Hypertension
    • Type II diabetes without complications
    • Hyperlipidemia
  • CC
    • Poor appetite for months with body weight loss was noted.
    • Vomiting after meal in the recent week.
  • Present illness
    • This 75 years old female patient was a case of hypertension, diabetes and hyperlipidemia with medications control for years. She had loose stool passage was noted since earlier this year, and was diagnosed of the colon cancer on 2022/04 by colonoscopy was done at clinic that show colon cancer about 70 cm from AV, partial obstructed. Biopsy was done and pathology proved adenocarcinoma. She without undergo surgery.
    • This time, she suffered from oor appetite for months with body weight loss was noted. Vomiting after meal in the recent week. Thus she visited our emergency department for further evaluation of abdominal fullness and vomiting. Abdominal CT revealed GB stones, ascending colon cancer cT3N2a cM0 stage IIIb on 2022/05/02. KUB showed increased air in nondistended loops of small bowel over LUQ and LLQ. Consult our CRS for evaluation and ascending colon cancer with partial obstruction was diagnosed. After discussing with the patient and her family, she was admitted to our CRS further management.
  • Course of inpatient treatment
    • After admission with ward routine and blood examination were done. Operation of 3D SILS right hemicolectomy under general anesthesia was performed on 2022/05/04. NPO and IV fluids support. The wound healing well and no erythema change. Chewing cookies, toast, rice with gum was started at post-op 1. No nausea and no vomiting, flatus passage. On low residual DM soft diet was suggested. Well bowel movement and stools passage with diet well tolerant. No fever and no complication. Discharged in general condition stable on 2022/05/09 and will follow up in our out-patient department next week.  
  • Discharge prescription
    • Ulstop (famotidine 20mg) 1# PRNQ12H
    • Meitifen (diclofenac 75mg) 1# PRNQ12H

[surgical operation]

• 2022-05-04
  • Op Method:
    • 3D SILS right hemicolectomy         
  • Finding:
    • Advanced A-colon cancer with partial obstruction with mesentary LN enlarged and calcificationPeritoneal seeding noted (+).
    • Three Omental seeding was also noted (+)

[chemotherapy]

• 2022-06-27 - bevacizumab 5mg/kg 250mg NS 100mL 90min + irinotecan 160mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFORI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL

701490020

240312

[lab data]

• 2024-01-09 AFP (NM) 4.645 ng/ml
  
• 2024-01-05 HBsAg (NM) Positive
  
• 2024-01-05 HBsAg Value (NM) 44.1
  
• 2024-01-05 Anti-HBc (NM) Positive
  
• 2024-01-05 Anti-HBc Value (NM) 0.007
  
• 2024-01-05 Anti-HCV (NM) Negative
  
• 2024-01-05 Anti-HCV Value (NM) 0.037
  
• 2024-01-05 Anti-HBs (NM) Negative
  
• 2024-01-05 Anti-HBs value (NM) <2.0 mIU/mL

[exam findings]

• 2024-01-04 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Metastatic adenocarcinoma, consistent with colorectal primary
  • The sections show a picture of adenocarcinoma, moderately differentiated, composed of nests of columnar-shaped neoplastic cells, arranged in glandular and cribriform patterns, embedded in fibrous stroma. Focal tumor necrosis present.
  • IHC shows: CK7(-), CK20(+), and CDX2(+). The finding is consistent with metastatic colorectal carcinoma.
• 2024-01-02 Patho - colon biopsy
  • Colon, RS, 15 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2023-12-28 CT - abdomen
  • History and indication: diarrhea
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thicekning of R-S colon junction with adjacent fat stranding, bladder invasion and regional LAP. Some air in urinary bladder. An encapsulated air and debris collection at pelvic cavity.
    • Poor enhancing tumors (3.2cm, 5.3cm) at right hepatic lobe.
    • Some LNs at mediastinum.
    • Atherosclerosis of aorta.
    • Emphysema at bilateral upper lungs.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
• 2023-08-10 SONO - abdomen
  • Indication: CHB follow up
  • Symptoms:
    • Liver: Smooth liver surface. One 2.75*2.20cm hyperechoic lesion with hypoechoic ring was noted at S7.
  • Diagnosis:
    • Liver tumor, S7, unknown etology
  • Suggestion:
    • arrange CT for liver tumor survey and check tumor marker

[MedRec]

• 2023-12-28 ~ 2024-01-08 POMR Colorectal Surgery Lv ZongRu
  • Discharge diagnosis
    • Rectosigmoid junction colon cancer with rupture, bladder invasion and liver metastases, cT4bN2bM1a, stage: IVA status post Loop transverse colostomy on 2024/01/02
    • Hypokalemia, potassium level: 2.1 mmol/L
    • Anemia: hemoglobin level: 8.5 g/dL
    • Emphysema at bilateral upper lungs
  • CC
    • diarrhea in recent days, weight loss of 4 kg. in the last 6 months.
  • Present illness
    • This 57 years old male patient denied any history of systemic disease.
    • He suffered from difficult defecation 6 months ago, and he ever went to Saint Paul’s Hospital where is told to have constipation. Due to intermittent abdominal pain, decreased appetite for ten days. He visited GI OPD for help on 2023/07/10. KUB showed no mechanical ileus but plenty of stool found. Abdominal sona was done on 2023/08/10 and revealed liver tumor, S7, arrange CT for liver tumor survey and check tumor marker were suggested. But loss to follow-up.
    • This time, he complained of diarrhea in recent days, weight loss of 4 kg. in the last 6 months. He call at our ER for further evluation and management on 2023/12/28. At ER, elevated CRP level and low potassium level were found. KUB showed stool retention in the bowel. Abdominal CT revealed In favor of R-S colon cancer with rupture, bladder invasion, LNs and liver metastases. Antibiotic treatment and CRS was consulted.
    • Under the impression of suspect advancer RS colon cancer with liver metastasis and bladder invasion, he is admitted for further management and care.

[surgical operation]

• 2024-01-02 - Op Method: T loop colostomy         
  • Finding: Dilation of colon   

[chemotherapy]

• 2024-03-11 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/ms 4200mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-02-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/ms 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-22 - ………………………………….. irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 455mg NS 250mL 2hr + fluorouracil 2800mg/ms 3200mg NS 500mL 46hr (FOLFIRI 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-03-12

[FOLFIRI effective: CEA & CA199 decline]

Following the initiation of FOLFIRI on 2024-01-22, lab data have shown a decline in both CEA and CA199 tumor markers.

2024-03-05 CEA (NM) 10.030 ng/ml 2024-02-06 CEA (NM) 21.741 ng/ml 2023-12-30 CEA 22.66 ng/mL

2024-03-05 CA-199 (NM) 102.515 U/ml 2024-02-06 CA-199 (NM) 180.080 U/ml 2024-01-09 CA-199 (NM) 267.800 U/ml

Baraclude (entecavir) has been administered for positive HBsAg/Anti-HBc, with no discrepancies in medication identified.

701517913

240312

[exam findings]

• 2024-03-09 CT - abdomen
  • Without contrast Abdomen CT showed
    • Bilateral hydronephrosis and bilateral hydroureter were noted.
    • dilated colone walls in the rectum, sgimoid colon, A-colon and hepatic fracture with dirty adjacent fat planes.
    • mild bilateral pleural effusion, more on the right side.
  • IMP:
    • r/o diffuse colitis
• 2024-03-09 KUB
  • No abnormal opaque density along the urinary collecting system.
  • post-OP change in the right pelvic cavity

[MedRec]

• 2024-03-09 Medical Emergency Laio ShiLiang
  • S
    • vomiting 10+ times/day for 1 month
    • diarrhea(+), poor appetite, weight loss
    • RLQ tenderness(+)
    • hospitalization in CMUH XinZhu Branch twice, but no improvement,
    • Ever had bilateral hydronephrosis /p D-J stent, due to uterine myoima. The D-J was removed and the uterine myoma will be treated conservatively. (Due to perimenopause, by GYN Dr.)
    • fever(-)
    • URI symptoms(-)
    • PHx: rectal CA stage III s/p OP,C/T
    • Allergy: NKA
  • O
    • Vital signs: BP 141/65; HR 72; BT 36.8’C; RR 16;
    • Con’s E4V5M6
    • SpO2 100%
  • A/P
    • Preliminary impression
      • K52.89 Other specified noninfective gastroenteritis and colitis
    • Ileus, vomiting, dairrhea at NTUH XinChu Branch and CMUH XinChu Branch, Hx rectal Ca s/p op, C/T, Abd CT: Rt>Lt PE, bowel wall edema, bil hydronephrosis
    • GU recommends consultation after hospitalization, OA Oncology

701323099

240311

[exam findings]

[MedRec]

• 2024-03-08 ~ 2024-03-10 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Bil ovarian CA, pT3cN0 cM0, FIGO I IIIC; AJCC stage III s/p debulking surgery on 8/9 21, Multiple liver metastases, multiple LNs metastases, and one metastasis in the omentum are noted. Recurrence in the pelvic cavity, metastatic lymph nodes in the pelvic cavity and paraaortic regions, liver metastasis.
    • No BRCA 1/2 mutation
    • Secondary hypertension
    • Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
    • Anemia due to antineoplastic chemotherapy
    • Thrombocytopenia
  • CC
    • for chemotherapy
  • Present illness
    • This 69-year-old female, a pt of bil ovarian CA, pT3cN0 cM0, FIGO IIIC; AJCC stage III s/p debulking surgery on 8/9 21 by Pro Huang SiCheng s/p post-Op adjuvant C/T wt Taxol / carboplatin / Avastin IV A3W x 6 finishing in March 2022 & 1-yr course of Avastin IV Q3W x 18 finishing in Nov 2022.
    • Surgical pathology with ovary, bilateral, debulking surgery (8/9 21) proved Serous carcinoma, high-grade.
      • Fallopian tube, bilateral, debulking surgery: Serous carcinoma, seeding Uterus, corpus, debulking surgery — Serous carcinoma, seeding,
      • Uterus, cervix, total hysterectomy — Negative for malignancy,
      • Uterus, endometrium, debulking surgery — Negative for malignancy,
      • Omentume, debulking surgery — Serous carcinoma, seeding,
      • Appendix, debulking surgery — Serous carcinoma, seeding,
      • Tumor from bladder, debulking surgery — Serous carcinoma, seeding,
      • Tumor from mesentery, debulking surgery — Serous carcinoma, seeding,
      • Lymph node, left iliac, dissection — Negative for malignancy (0/5)
      • Lymph node, left obturator, dissection — Negative for malignancy (0/2),
      • Lymph node, right iliac, dissection — Negative for malignancy (0/2),
      • Lymph node, right obturator, dissection — Negative for malignancy (0/2),
      • Lymph node, left para aortic, dissection — Negative for malignancy (0/4),
      • Lymph node, right para aortic, dissection — Negative for malignancy (0/4)
      • Douglasr, debulking surgery—- Serous carcinoma, seeding.
      • PATHOLOGIC STAGE: pT3cN0(if cM0); FIGO IIIC; AJCC stage IIIC.
    • Image study with Abd CT (8/2 21 at BoAi Hospital) showed 9.5 cm huge tumor at pelvis.
    • Colonscopy (8/5 21) revealed colonic subepithelial lesion, cecum. Mixed hemorrhoid, Telangiectasia, nature?
    • EGD (8/5 21) showed Reflux esophagitis LA Classification grade A, Atrophic gastritis, whole stomach, s/p CLO test, Gastic erosions, body and fundus Gastric polyp, cardia, s/p biopsy. Suspect gastric xanthoma, low body, LC.
      • Stomach, cardia, biopsy (8/5 21) proved inflammatory polyp with Helicobacter infection
    • She was referred to our hemato-oncologic clinic on 9/18 21 for post-Op adjuvant C/T by Pro Huang SiCheng for bil ovarian CA, pT3cN0 cM0, FIGO I IIIC; AJCC stage III s/p debulking surgery in Aug 2021.
    • We explain to pt & her daughter & son about the indication & risk / benefit of post-Op adjuvant C/T wt Taxol / carboplatin / Avastin (self-paid) IV A3W x 6 & Avastin for 1 yrs & will do BRCA mutation test then apply Olaparib if BRCA mutation (+).
    • PD tube inserion on 2021/08/09, s/p port-A implantation on 2021/08/18 were performed.
    • #1 chemotherapy with Taxol/Carboplatin + IP C/T with Taxol/Cisplatin IV Q3W x 6 on 10/1 21, #2 on 10/25 21, #3 post-Op adjuvant C/T wt Taxol / carboplatin / (#1) Avastin (self-paid) IV Q3W x 6 on 11/15 21, #4 post-Op adjuvant C/T wt Taxol / carboplatin / (#2) Avastin ( self-paid ) IV Q3W x 6 on 12/6 21, #5 post-Op adjuvant C/T wt Taxol / carboplatin / (#3) Avastin (free) IV Q3W x 6 on 12/27 21, #6 post-Op adjuvant C/T wt Taxol / carboplatin / (#4) Avastin ( self-paid ) IV Q3W x 6 on 1/17 22, (#5) Avastin (self-paid) on 2/7 22, #6 targeted therapy with Avastin (free) on 3/2 22, #7 on 3/28 22, #8 on 4/19 22, #9 targeted therapy with Avastin (free) IV Q3W on 5/11 22, #10 on 6/6 22, #11 on 6/28 22. #12 targeted therapy with Avastin (free) 7/21 22, #13 on 8/12 22, #14 on 9/1 22.#15 targeted therapy with Avastin (free) 9/26 22, # 16 targeted therapy with Avastin (self-paid) on 10/19 22, #17 on 11/9 22, #18 Avastin (free) IV Q3W on 11/30 22.  
    • On 05/26/2023, follow ABD CT showed RECURRENT OVARIAN CA WITH DISTANT METASTASES 1. Local recurrent ovarian cancer 5 cm in the uterine fossa is highly suspected. 2. Multiple liver metastases, multiple LNs metastases, and one metastasis in the omentum are noted.
    • C1 self paid of Avastin + Lipodox on 2023/06/27, C2 on 2023/07/31, C3 of Avastin (free, buy 2 get 1 free) + Lipodox on 2023/09/06.
    • Follow up abd CT on 2023/09/04, image showed ovary cancer s/p operation with peritoneal seeding, LNs and liver metastases. Tumor maker progress as CA 199 (236), CA 125 (171) on 2023/9.
    • New regieme chemotherapy of C1D1 Avastin (self-paid) + Gemzar + Cisplatin (Q3W D1,D8) on 2023/10/02, C1D8 Gemzar/Cisplatin on 2023/10/11, C2D1 on 2023/11/10, C2D8 not given C/T due to pencytopenia, C3D1 Avastin (free) + Gemzar + Cisplatin on 2023/12/12, C3D8 not given C/T due to pencytopenia. C4D1 Avastin (self-paid) + Gemzar + Cisplatin (Q3W D1,D8) on 2024/01/02, C5D1 Avastin (self-paid) + Gemzar + Carboplatin 150mg due to poor renal function (Q3W D1,D8) on 2024/01/06, C6D1 Avastin (free) + Gemzar + Carboplatin (Q3W D1,D8) on 2024/02/16.
    • The tumor markers as CA-199 showed 172 U/ml (2023/12/22) -> 165 U/ml (2024/01/05) -> 232 U/ml (2024/01/22) -> 206 U/ml on 2024/02/23 and CA-125 shwoed 40 U/ml (2023/12/22) -> 38 U/ml (2024/01/05) -> 45 U/ml (2024/01/22) -> 47 U/ml (2024/02/23).
    • Follow-up abdominal CT (2024/01/23) showed S/P hysterectomy and oophorectomy. Recurrence in the pelvic cavity, metastatic lymph nodes in the pelvic cavity and paraaortic regions, liver metastasis. Regression as compare with CT study on 2023-09-04.
    • Today, she was admitted for C7D1 chemotherapy with Avastin (self-paid)/Gemzar/Carboplatin on 2024/03/08.

[surgical operation]

[immunochemotherapy]

• 2024-03-09 - bevacizumab 400mg NS 250mL + gemcitabine 600mg/m2 900mg NS 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-02-16 - bevacizumab 400mg NS 100mL + gemcitabine 600mg/m2 900mg NS 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-02 - bevacizumab 400mg NS 100mL + gemcitabine 600mg/m2 900mg NS 250mL 1hr + NS 500mL 1hr (before CDDP) + cisplatin 30mg/m2 45mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-12 - bevacizumab 400mg NS 100mL + gemcitabine 600mg/m2 900mg NS 250mL 1hr + NS 500mL 1hr (before CDDP) + cisplatin 30mg/m2 45mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-10 - bevacizumab 400mg NS 100mL + gemcitabine 600mg/m2 900mg NS 250mL 1hr + NS 500mL 1hr (before CDDP) + cisplatin 30mg/m2 45mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-09 - ………………………. gemcitabine 600mg/m2 900mg NS 250mL 1hr + NS 500mL 2hr (before CDDP) + cisplatin 30mg/m2 45mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-03 - bevacizumab 400mg NS 100mL + gemcitabine 600mg/m2 900mg NS 250mL 1hr + NS 500mL 2hr (before CDDP) + cisplatin 30mg/m2 45mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-06 - bevacizumab 400mg NS 100mL 1.5hr + liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-07-31 - bevacizumab 400mg NS 100mL 1.5hr + liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-06-27 - bevacizumab 400mg NS 100mL 1.5hr + liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-11-30 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-11-09 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-10-19 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-09-26 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-09-01 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-08-12 - bevacizumab 7.5mg/m2 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-07-21 - bevacizumab 7.5mg/m2 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-06-28 - bevacizumab 7.5mg/m2 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-06-06 - bevacizumab 7.5mg/m2 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-05-12 - bevacizumab 7.5mg/m2 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-04-20 - bevacizumab 7.5mg/m2 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-03-28 - bevacizumab 7.5mg/m2 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-03-02 - bevacizumab 7.5mg/m2 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + NS 250mL
• 2022-02-08 - bevacizumab 7.5mg/m2 400mg NS 250mL 1.5hr
  • none
• 2022-01-17 - bevacizumab 7.5mg/m2 400mg NS 250mL + paclitaxel 135mg/m2 200mg NS 250mL 3hr + carboplatin AUC 3 300mg NS 250mL 2hr + [paclitaxel 40mg/m2 59mg + cisplatin 40mg/m2 59mg + gentamicin 40mg + sodium bicarbonate 70mg/mL 40mL 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2021-12-28 - bevacizumab 7.5mg/m2 400mg NS 250mL + paclitaxel 135mg/m2 200mg NS 250mL 3hr + carboplatin AUC 3 300mg NS 250mL 2hr + [paclitaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + sodium bicarbonate 70mg/mL 40mL 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2021-12-07 - bevacizumab 7.5mg/m2 400mg NS 250mL + paclitaxel 135mg/m2 200mg NS 250mL 3hr + carboplatin AUC 3 300mg NS 250mL 2hr + [paclitaxel 40mg/m2 58mg + cisplatin 40mg/m2 58mg + gentamicin 40mg + sodium bicarbonate 70mg/mL 40mL 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2021-11-16 - bevacizumab 7.5mg/m2 400mg NS 250mL + paclitaxel 135mg/m2 200mg NS 250mL 3hr + carboplatin AUC 3 300mg NS 250mL 2hr + [paclitaxel 40mg/m2 58mg + cisplatin 40mg/m2 58mg + gentamicin 40mg + sodium bicarbonate 70mg/mL 40mL 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2021-10-26 - ………………………………. paclitaxel 135mg/m2 200mg NS 250mL 3hr + carboplatin AUC 3 300mg NS 250mL 2hr + [paclitaxel 40mg/m2 58mg + cisplatin 40mg/m2 58mg + gentamicin 40mg + sodium bicarbonate 70mg/mL 40mL 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2021-10-04 - ………………………………. paclitaxel 135mg/m2 200mg NS 250mL 3hr + carboplatin AUC 3 300mg NS 250mL 2hr + [paclitaxel 40mg/m2 58mg + cisplatin 40mg/m2 58mg + gentamicin 40mg + sodium bicarbonate 70mg/mL 40mL 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL

==========

2024-03-11

[platelet count monitoring & transfusion thresholds for bleeding prevention]

Lab data showed that the patient’s platelet count has been consistently below the reference range since 2023Q4. The patient was initially treated with bevacizumab, gemcitabine, and cisplatin in 2023Q4. Cisplatin was replaced with carboplatin in 2024-02.

• 2024-03-08 PLT 48 x10^3/uL ***
• 2024-02-16 PLT 113 x10^3/uL *
• 2024-01-30 PLT 40 x10^3/uL ***
• 2024-01-23 PLT 57 x10^3/uL **
• 2024-01-16 PLT 73 x10^3/uL **
• 2024-01-02 PLT 118 x10^3/uL *
• 2023-12-19 PLT 90 x10^3/uL **
• 2023-12-12 PLT 126 x10^3/uL *
• 2023-11-24 PLT 61 x10^3/uL **
• 2023-11-17 PLT 61 x10^3/uL **
• 2023-11-10 PLT 109 x10^3/uL *
• 2023-11-03 PLT 45 x10^3/uL ***
• 2023-10-27 PLT 54 x10^3/uL **
• 2023-10-26 PLT 34 x10^3/uL ***
• 2023-10-23 PLT 81 x10^3/uL **
• 2023-10-21 PLT 76 x10^3/uL **
• 2023-10-20 PLT 9 x10^3/uL ****
• 2023-10-17 PLT 45 x10^3/uL ***
• 2023-10-16 PLT 57 x10^3/uL **
• 2023-10-15 PLT 23 x10^3/uL ***
• 2023-10-14 PLT 15 x10^3/uL ***
• 2023-10-09 PLT 74 x10^3/uL **
• 2023-10-03 PLT 88 x10^3/uL **
• 2023-10-01 PLT 78 x10^3/uL **
• 2023-09-15 PLT 187 x10^3/uL
• 2023-09-04 PLT 235 x10^3/uL
• 2023-08-28 PLT 156 x10^3/uL
• 2023-08-24 PLT 125 x10^3/uL *
• 2023-08-20 PLT 135 x10^3/uL *
• 2023-08-08 PLT 164 x10^3/uL
• 2023-07-31 PLT 212 x10^3/uL
• 2023-07-17 PLT 156 x10^3/uL
• 2023-07-04 PLT 190 x10^3/uL
• 2023-06-23 PLT 165 x10^3/uL
• 2023-03-07 PLT 165 x10^3/uL

Prophylactic platelet transfusion is recommended to prevent spontaneous bleeding in most afebrile patients with platelet counts <10K/uL due to bone marrow suppression. This is consistent with a 2023 guideline from the International Society on Thrombosis and Haemostasis.

For patients with fever, infection, or inflammation, a platelet count ≤15K to 20K/uL is generally recommended due to the increased risk of bleeding.

700204503

240308

[exam findings]

• 2024-02-17 Gynecologic ultrasonography
  • Findings
    • CUL-DE-SAC: No fluid
      
    • Other: ATH+BSO
  • IMP:
    • R/O RT Pelvis mass (54x23mm, 36x22mm),
    • R/O LT cyst : (15mm x14mm)
• 2024-02-15 MRI - pelvis
  • With and without contrast enhancement MRI: Pelvis:
    • S/P hysterectomy and oophorectomy.
    • There are cystic lesions in the pelvic cavity (4.1cm and 3.2cm in right, 1.7cm and 1cm in left), r/o lymphocele.
    • Minimal ascites.
  • Impression:
    • Clinical ovarian malignancy, s/p hysterectomy and oophorectomy.
    • R/O lymphocele in the pelvic cavity.
• 2023-12-20 Gynecologic ultrasonography
  • Findings
    • CUL-DE-SAC: No fluid
    • Other: ATH + BSO
  • IMP:
    • R/O Pelvis mass (67 x 33mm, 37 x 25mm)
    • R/O LT cyst (17mm x 14mm)
• 2023-12-06 Gynecologic ultrasonography
  • ATH + BSO
  • IMP: R/O Pelvis mass (97 x 40mm, 63 x 31mm)
• 2023-11-22 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • R’t : 15 dB HL, normal to mild SNHL
  • L’t : 6 dB HL, WNL.
• 2023-11-07 Patho - uterus (with or without SO) neoplastic
  • PATHOLOGIC DIAGNOSIS
    • Ovary, left, salpingo-oophorectomy —- high grade serous adenocarcinoma.
    • Ovary, right, salpingo-oophorectomy —- high grade serous adenocarcinoma. P53 (aberrant type), Napsin-A (-), PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+), ER (+, 40%, intermediate intensity), PR (+, 50%, stron gintensity).
    • Fallopian tube, left, salpingo-oophorectomy —- free
    • Fallopian tube, right, salpingo-oophorectomy —- tumor seeding.
    • Uterus, corpus, total hysterectomy — benign proliferative phase; myomas; adenomyosis.
    • Uterus, cervix, total hysterectomy — free
    • Omentume, omentectomy —- free
    • Lymph node, bilateral pelvic, dissection — free.
    • AJCC cancer staging 8 th edition: pT1c1 pN0 (if cM0); pStage: IC1, at least.
      
  • MACROSCOPIC EXAMINATION
    • Procedure (select all that apply) - Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)  
    • Specimen size:
      • right ovary: 158 gms; 10 x 6 x 6 cm;
      • left ovary: 540 gms; 18 x 11 x 7 cm; operative findings: “intraoperative rupture due to severe adhesion”
      • right tube: 6 x 0.4 x 0.4 cm. Tumor seeding: 2.1 x 0.6 cm;
      • left tube: 6 x 0.4 x 0.4 cm, free;
      • uterus: 125 gms; 12 x 6 x 6 cm; 2 myomas: up to 3 x 3 x 3 cm. Adenomyosis present. Endometrium free.
      • Omentum: 28 x 5 x 1.5 cm: free.
    • Specimen Integrity
      • Specimen Integrity of Right Ovary: Capsule intact
      • Specimen Integrity of Left Ovary: ruptured
      • Specimen Integrity of Right Fallopian Tube: tumor seeding
      • Specimen Integrity of Left Fallopian Tube- free
    • Tumor Site: Bilateral ovaries
      • Right fallopian tube seeding
    • Ovarian Surface Involvement - Present ( Left)
    • Fallopian Tube Surface Involvement- Present ( Right)
    • Tumor Size: left ovarian tumor (the larger one)
    • Greatest dimension (centimeters): 18 cm
    • Additional dimensions (centimeters): 11 x 7 cm
    • Sections are taken and labeled as: A1: cervix; A2: uterine corpus; A3: myomas; A4: left tube; A5-8: left ovary; A9: right tube; A10-12: right ovary; A13: omentum; A14-15: left common iliac lymph nodes; A16: left obturator lymph nodes; A17: right common iliac lymph nodes; A18-19: right obturator lymph nodes.
  • MICROSCOPIC EXAMINATION:
    • Histologic type: serous adenocarcinoma
    • Histologic grade: high grade
    • Contralateral ovary involvement: present
    • Tumor side ovarian surface involvement: present
    • Contralateral ovary surface involvement: absent
    • Right tube involvement: present
    • Left tube involvement: absent
    • In situ adenocarcinoma in right ＆/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: present
    • Left adnexa soft tissue involvement: present
    • Pelvic soft tissue involvement: absent
    • Uterine serosa involvement: absent
    • Omentum involvement: absent
    • Uterine Cervix involvement: absent
    • Endometrium involvement: absent
    • Myometrium involvement: absent
    • Appendix involvement: not received
    • Largest Extrapelvic Peritoneal Focus (required only if applicable)- not applicable.
    • Peritoneal/Ascitic Fluid- Negative for malignancy (normal/benign)
    • Regional Lymph Nodes: free: A14-15: left common iliac lymph nodes (0/16); A16: left obturator lymph nodes (0/2); A17: right common iliac lymph nodes (0/4); A18-19: right obturator lymph nodes (0/12).
      • Negative for metastasis: (0/ total No. of nodes: 0/34)
    • Other organs or specimens involvement: absent.
• 2023-10-30 Gynecologic ultrasonography
  • R/O Huge Pelvis mass (202 mm x 79 mm) , RI : 0.47

[MedRec]

• 2023-11-05 ~ 2023-11-12 POMR Obstetrics and Gynecology Zen LunNa
  • Discharge diagnosis
    • Malignant neoplasm of left ovary, Debulking surgery on 2023-11-06
    • Malignant neoplasm of right ovary
    • Female pelvic peritoneal adhesions (postinfective)
  • CC
    • Abdominal fullness for 2 months (since September 2023).
  • Present illness
    • This 47-year-old, G0P0, sex(+), married woman without systemic disease. Her last menstrual period was on 10/27/2023, duration lasted for 4 days. Hypermenorrhea with blood clots occasionally was mentioned.
    • She was in her usual health status until she experienced abdominal fullness with palpable abdominal mass since September 2023. She had been visited Hualien Tzu Chi Hospital GI OPD where irritable bowel syndrome was told and medications were given but in vain. Upper endoscopy and coloscopy were arranged that showed no specific abnormality.
    • Abdominal CT scan was done and revaled Ovarian Carcinoma T1bN0M0 and uterine myoma (2.7 cm). Blood test showed tumor markers: CA 125 level was 4076 and CA 199 level was 56.3. She came to our GYN OPD for further management on 10/30/2023. Physical examination showed a palpable mass noted below the umbilicus.
    • Transvaginal sonography showed a huge pelvic mass(202x79mm) and no ascites. After well explaination and discussion with patient and family, debulking surgery for ovarian cancer was decided and she was scheduled on 11/06/2023. She was admitted to our ward on 11/05/2023 for scheduled operation and further management. Urologist was consulted for ureter catheter insertion.
  • Course of inpatient treatment
    • The patient was admitted on 11/5/2023 due to ovarian cancer. She underwent Debulking surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para aortic lymph note sampling + infracolic omentectomy) on 11/06/2023.
    • The pathology report:
      • Ovary, left, salpingo-oophorectomy —- high grade serous adenocarcinoma.
      • Ovary, right, salpingo-oophorectomy —- high grade serous adenocarcinoma.
    • Bilateral ovarian cancer AJCC cancer staging 8 th edition: pT1c1 pN0 (if cM0); pStage: IC1, at least.
    • Her post operative condition was stable and so she discharged on 11/12/2023 and she will have her OPD follow up next week.
  • Discharge prescription
    • Keto (ketorolac 10mg) 1# QID
    • Gasmin (dimethylpolysiloxane 40mg) 1# QID
    • MgO 250mg 2# QID
    • Through (sennoside 12mg) 2# HS
    • tetracycline HCl TID EXT
    • cephalexin 500mg 1# QID
    • Anxiedin (lorazepam 0.5mg) 1# HS

[consultation]

• 2023-11-06 Urology
  • Q
    • For on bilateral ureteral catheterization.
    • This 47-year-old female with ovarian cancer was admitted for Debulking staging surgery at 2023/11/06 08:00AM.
    • We need your evaluation of her condition for on bilateral ureteral catheterization.
    • Thanks for your help!
  • A
    • A 47-year-old female with ovarian cancer
    • Debulking staging surgery on 2023/11/06
    • arrange bilateral ureteral catheterization

[surgical operation]

• 2023-11-06
  • Surgery
    • Diagnosis:
      • Bilateral huge ovarian mass, r/o ovarian cancer
    • Surgery:
      • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy + para aortic lymph note sampling)
        • ATH = abdominal total hysterectomy
        • BSO = bilateral salpingo-oophorectomy
        • BPLND = bilateral pelvic lymph node dissection
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, severe dense adhesion to the ovaries, bowel and cul de sac due to the tumor mass.
    • Adnexa:
      • LOV: huge ovarian mass, about 18 X 10 X 10 cm-sized; multiple septums with solid content, fluid content and mucoid content; with severe dense adhesion to the uterus and bowel; intraoperative rupture due to severe adhesion
      • ROV: 10 X 8 X 6 cm-sized solid ovarian mass; with severe dense adhesion to the uterus and bowel
      • Fallopian tube: bilateral grossly normal
    • CDS: adhesion (+)
    • Ascites: bloody, about 50 ml
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
    • Omentum: grossly normal without palpable tumor mass; infracolic omentectomy was done.
    • Liver: grossly normal & smooth
    • Appendix: grossly normal
    • After the operation, optimal debulking surgery was achieved without visible residual tumor.
    • Estimated blood loss: 1300 mL
    • Blood transfusion: pRBC 2U
    • Complication: nil       

[chemotherapy]

• 2024-03-08 - paclitaxel 175mg/m2 290mg NS 500mL 3hr + carboplatin AUC 5 700mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
• 2024-02-16 - paclitaxel 175mg/m2 290mg NS 500mL 3hr + carboplatin AUC 5 700mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-01-26 - paclitaxel 175mg/m2 290mg NS 500mL 3hr + carboplatin AUC 5 700mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
• 2024-01-05 - paclitaxel 175mg/m2 290mg NS 500mL 3hr + carboplatin AUC 5 700mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
• 2023-12-15 - paclitaxel 175mg/m2 290mg NS 500mL 3hr + carboplatin AUC 5 700mg NS 250mL 2hr (He JingLiang)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-22 - paclitaxel 175mg/m2 290mg NS 500mL 3hr + carboplatin AUC 5 700mg NS 250mL 2hr (He JingLiang)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tube, and peritoneal cancer - 2024-03-08 - https://www.uptodate.com/contents/first-line-chemotherapy-for-advanced-stage-iii-or-iv-epithelial-ovarian-fallopian-tube-and-peritoneal-cancer

• TREATMENT SELECTION AND METHOD OF ADMINISTRATION
  • Women with suboptimally cytoreduced disease - For patients with suboptimally cytoreduced EOC, we suggest IV treatment rather than IV/IP therapy.
    • Choice of agents
      • For women requiring first-line chemotherapy for EOC, the standard IV regimen utilizes platinum and taxane agents. For select patients at higher risk of recurrence (eg, those with pleural effusions or ascites who lack a BRCA mutation), we suggest the addition of bevacizumab, which is administered with chemotherapy and continued as maintenance therapy.
      • Although cisplatin and/or docetaxel are sometimes used in this setting, we prefer carboplatin plus paclitaxel. Our rationale is based on the following:
        • We prefer carboplatin rather than cisplatin because multiple trials have consistently demonstrated that carboplatin produces equivalent response rates and survival outcomes to cisplatin, but is associated with less toxicity.
        • Although both paclitaxel and docetaxel (the most commonly used taxanes for EOC) can be administered along with carboplatin in this setting, we prefer paclitaxel because it is less myelosuppressive than docetaxel. However, a consideration between these two taxanes can be individualized based on their differing toxicities. For paclitaxel, these include a higher risk of neuropathy, myalgias, and weakness compared with docetaxel; for docetaxel, these include a higher risk of neutropenia, hypersensitivity reactions, and nausea and vomiting.
        • We prefer to treat for a maximum of six cycles rather than more because there are no data that treatment beyond six cycles improves outcomes, although further treatment increases the risk of treatment-related toxicities. The administration of further treatment for patients who respond (or do not progress) after six cycles of first-line therapy (ie, maintenance therapy) is covered below.
• MAINTENANCE THERAPY
  • BRCA-associated and other homologous recombination-deficient cancers
  • BRCA-wildtype cancers that are homologous recombination proficient
    • PARP inhibitors
      • Niraparib
      • Rucaparib
      • Olaparib
    • Angiogenesis inhibition
      • Bevacizumab
    • Others
      • Pazopanib
        • Pazopanib is an orally administered tyrosine kinase inhibitor against the VEGF, platelet-derived growth factor (PDGF), and c-kit receptors.
      • Nintedanib
        • Nintedanib is an orally administered tyrosine kinase inhibitor against the VEGF, fibroblast growth factor (FGF), and PDGF receptors.

==========

2024-03-08

[electrolyte correction (K & Mg) & paclitaxel monitoring]

Hypokalemia and hypomagnesemia are now managed with Const-K tablets and MgSO4 injection, other lab results on 2024-03-07 are unremarkable.

• 2024-03-07 K (Potassium) 3.3 mmol/L
  
• 2024-03-07 Mg (Magnesium) 1.6 mg/dL

While paclitaxel offers a reduced risk of myelosuppression compared to docetaxel, it is associated with a higher incidence of neuropathy, myalgias, and weakness. Conversely, docetaxel carries a greater risk of neutropenia, hypersensitivity reactions, and nausea and vomiting compared to paclitaxel.

As paclitaxel is currently being administered, be vigilant for the following

• Nervous system symptoms:
  • Asthenia (weakness): Incidence of 17%
  • Peripheral neuropathy (numbness, tingling, or pain in hands and feet): Incidence of 42% to 70%, with a lower risk (≤7%) of severe grades 3 or 4.
• Neuromuscular symptoms:
  • Arthralgia (joint pain): Incidence of up to 60%
  • Myalgia (muscle pain): Incidence of up to 60%

2024-01-05

[tumors have decreased in size]

On 2023-10-30, a gynecologic ultrasound revealed a large pelvic mass measuring 202 mm x 79 mm. A debulking surgery performed on 2023-11-06 confirmed the tumor to be high-grade serous adenocarcinoma. Following this, a regimen of paclitaxel and carboplatin was initiated on 2023-11-22, with the third cycle administered during this hospitalization on 2024-01-05. Subsequent gynecologic ultrasounds on 2023-12-06 and 2023-12-20 showed a reduction in the size of the pelvic mass to 97 x 40 mm and 63 x 31 mm, and then to 67 x 33 mm and 37 x 25 mm, respectively, indicating a decrease in size.

The patient, with an ECOG Performance Status of 0, had lab results that were generally normal as of 2024-01-01. Currently, access to the patient’s PharmaCloud records is unavailable. However, a review of HIS5 records revealed no discrepancies in medication.

701478306

240308

[exam findings]

• 2023-09-21 PET
  • In comparison with the previous study on 2023/04/14, the previous FDG avid lesions involving multiple lymph node regions on both sides of the diaphragm are less evident, suggesting partial response to the treatment.
  • The FDG uptake in some focal areas in the right lung is also less evident.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
• 2023-09-19 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy
  • Sections show 20-30 % cellularity. The M/E ratio is about 3/1. Megakaryocytes are found about 0-6/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells.
  • The immunohistochemical stains reveals CD3 (scattered cells +), CD20(-), Cyclin D1(-), BCL2(scattered cells +), and BCL6(-).
• 2023-08-08 CT - chest
  • Findings - comparison was made with CT on 2023/02/03 (other hospital)
    • massive moderate Rt pleural effusion.
    • lungs: relaxation atelectasis of RLL and RML. extensive centrilobular emphysema in both lungs, upper lobes predominance,
    • visible neck, mediastinum and hila: small residual lymphadenopathy in both axillary regions and visceral space of the mediastium,
      
    • visible abdominal-pelvic contents:
    • multiple residual enlarged lymph nodes in the paraaortic region and mesenetery root. prominent soft-tissue in perirectal and prescral spaces is found.
  • Impression:
    • significant of neoplastic LAP in both sides of diaphgram especially above the diaphgram, but still presence of massive Rt pleural effusion compared with CT on 2023/02/03
• 2023-07-04, -06-06, 05-24 CXR
  • Atherosclerotic change of aortic arch
  • Pleura effusion of right costal-phrenic angle
  • Widening of the right upper mediastinum is noted that is c/w lymphoma after correlate with CT.
• 2023-06-16 SONO - chest
  • left side minimal amount of pleural effusion
  • right side moderate amount of pleural effusion, 1000cc serosangious fluid was aspirated for analysis.
• 2023-06-12 CXR
  • Increased infiltration in right lung zone
  • Bilateral pleural effusion, more on right side
• 2023-06-12 SONO - chest
  • Pleural tapping - right side 1150 mL yellowish, cloudy
  • Echo diagnosis: Bilateral pleural effusion (Left minimal to small and Right massive), post right therapeutic thoracentesis.
• 2023-05-24 SONO - chest
  • Pleural tapping - 1100mL yellow fluid was drained.
  • Echo diagnosis:
    • pleural effusion, massive, right
    • atelectasis, LLL, RLL
• 2023-04-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (69 - 17) / 69 = 75.36%
    • M-mode (Teichholz) = 75.9
  • Conclusion:
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Minimal amount pericardial effusion, No tamponade, No pericardial constriction at present
    • Trivial MR
    • Moderate TR
    • Moderate Pulmonary HTN
    • Left pleural effusion
• 2023-04-21 SONO - chest
  • Echo diagnosis
    • left side minimal amount of pleural effusion
    • right side massive amount of pleural effusion, 1200cc serosangious fluid was aspirated for analysis
• 2023-04-17, -04-13 CXR
  • Patchy consolidation over RLL.
  • Suspected superior mediastinal lesion.
  • Increased infiltration over both lower lungs. May be active infection.
  • Bilateral pleural effusion.
• 2023-04-13 Patho - bone marrow biopsy
  • Bone marrow, biopsy — involved by B-cell lymphoma
  • Microscopically, the bone marrow shows presence of aggregations of B-cell lymphoma. The bone marrow component shows 40% of cellularity, 3:1 of myeloid to erythroid ratio and 3 megakaryocytes of per HPF. No blast is seen.
  • Immunohistochemical stain CD20 and Bcl-2: positive at lymphoma, CD117(-), CD34(-), CD71(+ at erythroid cells), CD61( + at megakaryocytes), TdT(-).
• 2023-04-14 PET scan
  • The FDG PET findings are compatible with lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm.
  • Mildly increased FDG uptake in some focal areas in the right lung. The nature is to be determined (inflammation? lymphoma?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
• 2023-01-13 SONO - chest
  • Echo diagnosis:
    • pleural effusion
    • Chest echography was performed first. The suitable intercostal space was selected and located.
    • Catheter was inserted with negative pressure smoothly.
    • Right side pleural effusion was drawn smoothly.
    • Watch out BP after tapping.
  • Suggestion:
    • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
• 2023-04-12 CXR
  • R/O mass lesion over superior mediastinum.
  • Patchy consolidation or atelectasis of RLL. Suggest check CT scan.
  • Moderate amount of right pleural effusion.
  • Small amount of left pleural effusion.
• 2023-04-10 Nasopharyngoscopy
  • 2023/4/10 Admission
    • consult Hema (arrange staging workup and thne bed transfer + treatment)
    • multiple bil cervical LAPs since 2yr ago
    • dyspnea+, cough with much sputum, cough with blood+
    • BWL-, fever-, cold sweating-, NVR supraclavicular Bx in 2023/02 by Dr. Lin JiengFu at Mackey (refer to Hema, but he escaped? or nurse sign permit)
    • R lung effusion s/p regular tapping (around 700-1000mL)
    • fiber = much mucopus with PND, no vocal palsy

[chemoimmunotherapy]

• 2024-03-05 - busulfan 3.2mg/kg 180mg NS 300mL 3hr D1-3 + etoposide 400mg/m2 658mg NS 33mL 6hr D3-4 + cyclophosphamide 50mg/kg 2900mg NS 500mL 4hr D5-6 (BuCyE)
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + palonosetron 250ug D1-2 + granisetron 2mg D3-6 + NS 250mL D1-6
• 2023-12-05 - methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 64mg NS 250mL 1hr D1-4 + cisplatin 25mg/m2 40mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 3200mg NS 500mL 2hr D5 (ESHAP)
  • dexamethasone 4mg D1-5 + diphenhydramine 30mg D2-5 + palonosetron 250ug D1-5 + NS 250mL D1-5
• 2023-10-23 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1150mg NS 250mL 30min D2 + doxorubicin 50mg/m2 75mg NS 100mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 90mg PO D2-6 (R-CHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + aprepitant 125mg PO D2-4
• 2023-09-21 - rituximab 375mg/m2 590mg NS 500mL 8hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3000mg NS 500mL 3hr Q12H D3 + dexamethasone 40mg PO QD D2-5 (R-DHAP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D2-4
• 2023-08-09 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1150mg NS 250mL 30min D1 + doxorubicin 50mg/m2 75mg NS 100mL 30min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + prednisolone 60mg/m2 90mg PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-11 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cisplatin 75mg/m2 120mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3000mg NS 500mL 3hr Q12H D3 + dexamethasone 40mg PO QD D2-5 (R-DHAP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D2-3
• 2023-06-19 - rituximab 375mg/m2 580mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1150mg NS 250mL 30min D1 + doxorubicin 50mg/m2 75mg NS 100mL 30min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + prednisolone 60mg/m2 90mg PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-2
• 2023-05-24 - rituximab 375mg/m2 590mg NS 500mL 8hr D1 + cisplatin 75mg/m2 120mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3000mg NS 500mL 3hr Q12H D3 + dexamethasone 40mg PO QD D2-5 (R-DHAP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D2-4
• 2023-04-20 - rituximab 375mg/m2 580mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1170mg NS 250mL 30min D1 + doxorubicin 50mg/m2 75mg NS 50mL 30min D5 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + prednisolone 60mg/m2 90mg PO D1-5 (R-CHOP where doxorubicin was administered last, is pending the results of a 2D transthoracic echocardiography)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3

R-DHAP (Rituximab, dexamethasone, high dose cytarabine, cisplatin) - DLBCL Salvage regimens - 2023-06-13 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients

• Administration
  • R-DHAP includes
    • rituximab (375 mg/m2 on day -1),
    • dexamethasone (40 mg/d on days 1 to 4),
    • cisplatin (100 mg/m2 on day 1 by continuous infusion), and
    • cytarabine (2 g/m2 in a three-hour infusion on day 2)
    • every three weeks.
  • For patients with pre-existent kidney insufficiency, some experts replace cisplatin with carboplatin or oxaliplatin to lessen nephrotoxicity, but there are limited outcomes data with these regimens.
• Adverse effects
  • Hematologic toxicity is universal, with one-third of patients requiring transfusions, and grade >=3 nonhematologic adverse effects include infection (in up to one-quarter of patients) and occasional nephrotoxicity.

R-DHAP - Cisplatin, Cytarabine and Dexamethasone +/- Rituximab - ref https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2018/11/RDHAP.pdf

• Indication
  • Salvage chemotherapy for relapsed/refractory Hodgkin’s or Non-Hodgkin’s Lymphoma
  • First line therapy in combination with alternating R-CHOP in patients with Mantle Cell Lymphoma with stage III/IV disease up to 65 years of age.
• ICD-10 codes
  • Code with prefix C81-86
• Regimen details
  • Day 1-4 = Dexamethasone 40mg IV or PO
  • Day 1* = Rituximab 375mg/m2 IV infusion
  • Day 1 = Cisplatin 100mg/m2 IV infusion
  • Day 2 = Cytarabine 2g/m2 BD (12 hours apart) IV infusion
  • • Rituximab for B cell Non Hodgkin’s lymphoma patients only.
  • Consider starting GCSF (according to local policy, dose based on weight) either to shorten the duration of neutropenia (days 3-9) or to facilitate peripheral bloods stem cell collection (days 6-12).
• Cycle frequency
  • Repeated every 21-28 days - as soon as blood counts recovered i.e. neutrophils >1.0x10^9/L and platelets (unsupported) > 100x10^9/L (unless cytopenias related to disease).
• Number of cycles
  • Relapse setting: 2 cycles - then reassess disease for suitability for consolidation with stem cell transplant.
  • Non-transplant eligible: up to 6 cycles (total).
  • Mantle cell lymphoma: 3 cycles alternating with R-CHOP followed by consolidation with autograft.
• Administration
  • Day 1
    • Rituximab is administered in 500mL sodium chloride 0.9%. The first infusion should be initiated at 50mg/hour and if tolerated the rate can be increased at 50mg/hour every 30 minutes to a maximum of 400mg/hour. Subsequent infusions should be initiated at 100 mg/hour and if tolerated increased at 100mg/hour increments every 30 minutes to a maximum of 400 mg/hour.
    • Cisplatin is administered in 1000mL sodium chloride 0.9% over 2 hours following the pre and post hydration as per protocol below:
      • Sodium Chloride 0.9% 1000mL 1 hour
      • Mannitol 20% 200mL 30 minutes or Mannitol 10% 400mL 30 minutes
      • Cisplatin in Sodium Chloride 0.9% 1000mL 2 hours
      • Sodium Chloride 0.9% + 2g MgSO4 + 20mmol KCL. 1000mL 2 hours
      • TOTAL 3200mL or 3400mL 5 hours 30 minutes
      • Ensure urine output > 100mL/hour prior to giving cisplatin. Give a single dose of furosemide 20mg IV if necessary.
    • Additional pre hydration may be given as per local policy or required for individual patients.
    • Patients with low magnesium levels (< 0.7 mmol/L) should have an additional 2g magnesium sulphate added to the pre-hydration bag.
    • An accurate fluid balance record must be kept.
    • All patients must be advised to drink at least 2 litres of fluid over the following 24 hours.
  • Day 2
    • Cytarabine is administered in 1000mL sodium chloride 0.9% over 3 hours. Start time of each infusion must be 12 hours apart. A total of 2 doses are given.
    • Pre-medication
      • Rituximab premedication:
        • Paracetamol 500mg-1g PO 30-60 minutes prior to rituximab infusion
        • Chlorphenamine 10mg IV bolus 15-30 minutes prior to rituximab infusion
        • Dexamethasone 8mg IV bolus or hydrocortisone 100mg IV bolus 15 minutes prior to rituximab infusion (may be omitted if day 1 dexamethasone has been taken at least 30 minutes prior to the start of the rituximab infusion)
    • Emetogenicity
      • This regimen has high emetic potential
    • Additional supportive medication
      • Allopurinol 300mg OD (100mg OD if CrCl < 20mL/min) for the first 2 weeks.
      • Antiemetics as per local policy
      • Antiviral prophylaxis as per local policy.
      • Prophylactic antibiotics may be required e.g. ciprofloxacin (or as per local policy) when neutrophil count < 0.5 x10^9/L.
      • Consider antifungal and PCP prophylaxis as per local policy.
      • Mouthwashes as per local policy.
      • H2 antagonist or proton-pump inhibitor if required.
      • Prednisolone 0.5% eye drops 1 drop QDS to both eyes (to avoid chemical conjunctivitis from high dose cytarabine) to start on day 2 for 5-7 days.
      • If magnesium/potassium levels < normal reference range, replace as per local policy.
    • Extravasation
      • Rituximab and cytarabine are neutral (Group 1)
      • Cisplatin is an exfoliant (Group 4)
• Dose modifications (omitted, please refer to the original document)
  • Haematological toxicity
  • Renal impairment
  • Hepatic impairment
  • Other toxicities
• Adverse effects (omitted, please refer to the original document)
• Significant drug interactions (omitted, please refer to the original document)

R-CHOP/R-DHAP (Rituximab + Cyclophos­phamide + Doxorubicin + Vincristine + Prednisone + Dexamethasone + Cytarabine + Cisplatin) is a Chemotherapy Regimen for Lymphoma, Mantle Cell - 2023-06-13 https://www.chemoexperts.com/rchop-rdhap-mcl.html

• R-CHOP

  • R - Rituximab (Rituxan)
  • C - Cyclophosphamide (Cytoxan)
  • H - Hydroxydaunorubicin (Doxorubicin, Adriamycin)
  • O - Oncovin (Vincristine)
  • P - Prednisone

• R-DHAP

  • R - Rituximab (Rituxan)
  • D - Dexamethasone (Decadron)
  • HA - High-dose Ara-C (Cytarabine)
  • P - CisPlatin (Platinol)

• Goals of therapy:

  • R-CHOP/R-DHAP is given to shrink tumors and decrease symptoms of mantle cell lymphoma. It is commonly given with the goal of cure, but may require a bone marrow transplant.

• Schedule

  • Cycles
    • R-CHOP cycles:
      • Rituximab intravenous (I.V.) infusion on Day 1
      • Cyclophosphamide I.V. infusion over 30 to 60 minutes on Day 1
      • Doxorubicin I.V. push or I.V infusion over 10 to 30 minutes on Day 1
      • Vincristine I.V. infusion over 10 to 30 minutes on Day 1
      • Prednisone 100 mg (two 50 mg tablets) by mouth once daily on Days 1, 2, 3, 4, and 5
    • R-DHAP cycles:
      • Rituximab I.V. infusion on Day 1
      • Dexamethasone 40 mg (ten 4 mg tablets) by mouth once daily on Days 1, 2, 3, and 4
      • Cytarabine I.V. infusion over 3 hours every 12 hours on Day 2
      • Cisplatin I.V. infusion over 24 hours on Day 1
  • Estimated total infusion time for this treatment:
    • R-CHOP cycles: Up to 6 hours for Cycle 1; as short as 3 for the first day of next cycles if well tolerated
    • R-DHAP cycles: 24 hours for Day 1 of each cycle; 3 hours for each dose of cytarabine on Day 2
    • Infusion times are based on clinical studies but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time.
    • The R-CHOP portion of treatment is usually given in an outpatient infusion center, allowing the person to go home afterwards. The R-DHAP portion of treatment typically requires a 2 to 3 day stay in a hospital.
    • R-CHOP is alternated with R-DHAP every 21 days. When one treatment of each is given, this is known as one Cycle (one treatment of R-CHOP + one treatment of R-DHAP = 1 cycle). Each cycle may be repeated up to 3 times, depending upon the stage of the disease. Duration of therapy may last up to 5 months, depending upon response, tolerability, and number of cycles prescribed.

• Side Effects (omitted, please refer to the original document)

• Monitoring (omitted, please refer to the original document)

Regimen Reference Order - LYMP - R-CHOP alternating with R-DHAP - 2023-10-24 - https://www.cancercare.mb.ca/export/sites/default/For-Health-Professionals/.galleries/files/treatment-guidelines-rro-files/regimen-reference-orders/lymphoproliferative-disorders/LYMP-R-CHOP-alternating-with-R-DHAP.pdf

• Planned Course: Every 21 days for 6 cycles
  • R-CHOP given on cycles 1, 3 and 5;
  • R-DHAP given on cycles 2, 4 and 6.
• Indication for Use: Non-Hodgkin Lymphoma (Mantle Cell)

R-ESHAP (rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) - 2024-03-08 - https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-patients-who-are-medically-fit

• Administration
  • rituximab 375 mg/m2 on day 1,
  • etoposide 40 mg/m2/day as a one-hour infusion on days 1 to 4,
  • methylprednisolone 250 to 500 mg/day as a 15-minute infusion on days 1 to 5,
  • cisplatin 25 mg/m2/day as a continuous infusion from day 1 to 4, and
  • cytarabine 2 g/m2 as a two-hour infusion on day 5, every three or four weeks

Mesna: Drug information - 2024-03-08 - https://www.uptodate.com/contents/mesna-drug-information

• Prevention of cyclophosphamide-induced hemorrhagic cystitis in patients with rheumatic or autoimmune disorders
  • Prevention of cyclophosphamide-induced hemorrhagic cystitis in patients with rheumatic or autoimmune disorders (off-label use; based on limited data):
    • IV: Each mesna dose is equal to 20% of the daily cyclophosphamide dose given for 3 doses, 15 to 30 minutes prior to cyclophosphamide (hour 0), and 4 and 8 hours after cyclophosphamide
      • if administering mesna orally, each oral mesna dose is equal to 40% of the daily cyclophosphamide dose, with the first dose administered 2 hours prior to cyclophosphamide, and 4 and 8 hours after cyclophosphamide
    • or each mesna dose is equal to 20% of the daily cyclophosphamide dose given for 3 doses at 3, 6, and 8 hours following cyclophosphamide each day for 4 days.

==========

2024-03-08

[ensuring precise timing in mesna and cyclophosphamide dosing]

Cyclophosphamide, at a dosage of 2900 mg, is planned for administration on 2024-08-09 and 2024-08-10.

To mitigate the risk of cyclophosphamide-induced hemorrhagic cystitis, it is advised to administer at least 580 mg of mesna (20% of the daily cyclophosphamide dose) for three doses. Mesna should be given 15 to 30 minutes before cyclophosphamide (hour 0), and then 4 and 8 hours post-cyclophosphamide administration.

As of now, a mesna regimen of 690 mg, initiated on 2024-03-09 for two days with three repeat prescriptions, has been noted in the active medication list. It is imperative to ensure that the primary nursing staff administers the medication precisely as recommended, adhering to the specified timing.

2023-10-24

[reconciliation]

Per the PharmaCloud records, the patient hasn’t attended any medical consultations at different hospitals recently, only having appointments with a hematologist/oncologist at the present hospital. Also, there appear to be no inconsistencies in the medication records.

[R-CHOP/R-DHAP - dose adjustment for renal impairment]

The treatment initiated in 2023-04, alternating between R-CHOP and R-DHAP, appears to be yielding positive results. A PET scan from 2023-09-21, shows a reduction in the intensity of previously identified FDG avid lesions across various lymph node regions on both sides of the diaphragm. Additionally, there’s a noticeable decrease in FDG uptake in specific areas of the right lung, indicating a partial response to the therapy.

However, lab data over the past 6 months reveals a concerning trend: the patient’s eGFR has been on a notable decline, with recent measurements approximately half of what they were initially.

• 2023-10-23 eGFR 65.07 ml/min/1.73m^2
  
• 2023-10-09 eGFR 65.70 ml/min/1.73m^2
  
• 2023-09-28 eGFR 68.29 ml/min/1.73m^2
  
• 2023-09-18 eGFR 72.57 ml/min/1.73m^2
  
• 2023-08-29 eGFR 75.71 ml/min/1.73m^2
  
• 2023-08-02 eGFR 63.86 ml/min/1.73m^2
  
• 2023-07-11 eGFR 82.81 ml/min/1.73m^2
  
• 2023-07-04 eGFR 97.42 ml/min/1.73m^2
  
• 2023-06-15 eGFR 92.44 ml/min/1.73m^2
  
• 2023-06-12 eGFR 92.44 ml/min/1.73m^2
  
• 2023-06-08 eGFR 65.70 ml/min/1.73m^2
  
• 2023-06-01 eGFR 70.37 ml/min/1.73m^2
  
• 2023-05-23 eGFR 84.79 ml/min/1.73m^2
  
• 2023-05-10 eGFR 92.44 ml/min/1.73m^2
  
• 2023-05-02 eGFR 107.45 ml/min/1.73m^2
  
• 2023-04-24 eGFR 142.12 ml/min/1.73m^2
  
• 2023-04-21 eGFR 105.90 ml/min/1.73m^2
  
• 2023-04-20 eGFR 112.36 ml/min/1.73m^2
  
• 2023-04-12 eGFR 82.81 ml/min/1.73m^2

If the patient’s renal function continues to decline, it might be necessary to consider dose adjustments for certain elements within the R-CHOP/R-DHAP regimen. The following are the recommended modifications:

• cisplatin
  • CrCl >= 60 mL/minute: IV: No dosage adjustment necessary.
  • CrCl 50 to < 60 mL/minute: IV: Administer 75% of the usual indication-specific recommended dose.
  • CrCl 40 to < 50 mL/minute: IV: Administer 50% of the usual indication-specific recommended dose.
  • CrCl < 40 mL/minute: Use is not recommended.
• cytarabine
  • CrCl 46 to 60 mL/minute: Administer 60% of dose.
  • CrCl 31 to 45 mL/minute: Administer 50% of dose.
  • CrCl <30 mL/minute: Consider use of alternative drug.
• cyclophosphamide
  • CrCl >= 30 mL/minute: No dosage adjustment necessary.
  • CrCl 10 to 29 mL/minute: Administer 75% or 100% of normal dose.
  • CrCl < 10 mL/minute: Administer 50%, 75%, or 100% of normal dose.

2023-07-11

Lab data:

• 2023-07-11 WBC 9.14 x10^3/uL
  
• 2023-07-04 WBC 2.16 x10^3/uL *
• 2023-06-19 WBC 16.08 x10^3/uL

Regimen administered:

• 2023-07-11 R-DHAP
• 2023-06-19 R-CHOP
• 2023-05-24 R-DHAP
• 2023-04-20 R-CHOP

The patient, who has been diagnosed with mantle cell lymphoma, is currently receiving an alternating regimen of R-CHOP and R-DHAP. The most recent cycle of R-CHOP began on 2023-06-19, and the latest cycle of R-DHAP just started today on 2023-07-11.

The lowest point of the patient’s white blood cell count (nadir) occurred on 2023-07-04, when it was recorded at 2.16K/uL. On both 2023-07-04 and 2023-07-06, the patient was administered a dose of Granocyte (lenograstim 250ug). The white blood cell count has significantly recovered by 2023-07-11, reaching 9.14K/uL, which should not hinder the delivery of the R-DHAP regimen.

2023-06-13

Lab data revealed an episode of leukopenia on 2023-06-08 with a WBC of 1.3K/uL. This was managed with a consecutive 3 day course of Granocyte (lenograstim 250ug). The leukopenia is believed to be related to the R-DHAP treatment administered on 2023-05-24, approximately 2 weeks prior to the identified episode. In addition, the first administration of R-CHOP on 2023-04-20 also resulted in a decrease in the WBC count, which reached its lowest level on 2023-05-02. Currently, the patient is not experiencing leukopenia. Instead, he is experiencing leukocytosis.

• 2023-06-12 WBC 57.96 x10^3/uL
  
• 2023-06-08 WBC 1.30 x10^3/uL
  
• 2023-06-01 WBC 6.12 x10^3/uL
  
• 2023-05-23 WBC 14.43 x10^3/uL
  
• 2023-05-10 WBC 6.97 x10^3/uL
  
• 2023-05-02 WBC 4.99 x10^3/uL
  
• 2023-04-24 WBC 12.13 x10^3/uL
  
• 2023-04-21 WBC 13.62 x10^3/uL
  
• 2023-04-20 WBC 10.14 x10^3/uL
  
• 2023-04-12 WBC 16.90 x10^3/uL

2023-04-21

• The patient started R-COP treatment on 2023-04-20 and shortness of breath (SOB) and dyspnea were observed at 69.8 mL of Mabthera. Subsequently, a slower infusion rate was applied and the patient’s condition improved.
• Feburic (febuxostat) has been prescribed for prophylaxis of hyperuricemia, and no issues have been identified with the current prescription.

700028521

240307

[exam findings]

• 2024-03-06 KUB
  • Presence of scoliosis of the lumbar spine.

[MedRec]

• 2024-03-06 SOAP Medical Emergency Chen YuLong
  • S
    • Triage:2 Bloody stools/black stools > Large amounts of bloody stools/black stools. Family members said that the patient has been having bloody stools.
    • PALPITATIONS, EPIGASTRIC DISCOMFORT AND PASSAGE OF TARRY STOOL FOR 2 DAYS. TOCC- NO KNOWN ALLERGY.
    • MED FROM Taipei City Hospital: EUCLIDAN SIMALON Omeprazole
    • 2024-03-03 at RenAi Hosp Impression:
      • Liver cirrhosis with splenomegaly.
      • Progression of intrahepatic HCC tumor size S5/8 3.4cm [4-13] S2 1.9 cm [4-13] S5/6 1.1 cm [4-15]
      • Increased number of small hypodense hypoenhancing kiver nodules, suspecting HCC
      • Right peritoneal/lateralconal fascia metastasis, progression, with invasion to ascending colon.
      • Progression of pulmonary metastatic nodules.
      • New bone metastasis at Left 6th lateral rib [2-41] and left sacral wing [2-94]
    • 2024-02-25 at RenAi Hosp HGB 12.2, PLT 36K.
  • O
    • Vital Signs: BP 129/65; HR 126; BT 38’C; RR 18; Con’s E4V4M6; SpO2 97%
    • CONS:CLEAR;
    • HEENT: SOFT; NO JVE; Coarse BS, no WHEEZING; fine crackles(-)
    • HEART: REGULAR HB;
    • ABDOMEN:SOFT; ovoid, Epigastric TENDERNESS;
    • EXTREMITIES: FREE ROM. Pitting edema
  • A
    • Preliminary Impression: C22.0 Liver cell carcinoma
    • Bloody stool, fever, WBC 13K, Hb 8.5 => BT 2U, PLT 57K, AST 86, TBI 1.16, alb 2.5, CRP 4.2, Loforan, Levophed pump, OA ONC
    • LC, HC with multiple mets
    • in D5W 250ml/hr run 10ml/hr

==========

2024-03-07

[reconciliation]

On 2024-03-04, the patient replenished a 28-day stock of omeprazole, mosapride, Vitamin B12, and nicametate, prescribed by Taipei City Hospital. Currently, according to the PharmaCloud database. Vitamin B12 and mosapride are not being administered to the patient.

[post-transfusion HGB monitoring: additional LPRBC transfusion might be necessary for ongoing symptoms]

HGB level on 2024-03-07, was 7.9 g/dL following a blood transfusion on 2024-03-06. If the patient remains symptomatic, consideration for further LPRBC transfusion may be necessary.

700070871

240307

{Diffuse large B-cell lymphoma, stage IV, with bilateral lung and adrenal gland metastasis. triple hit, IPI:4}

[diagnosis] - 2022-08-04 Discharge diagnosis

• Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
• Diffuse large B-cell lymphoma, stage IV, with bilateral lung and adrenal gland metastasis. triple hit, IPI:4.
• Acute respiratory failure post intubation on 111-06-16
• Pneumonia due to Pseudomonas and Oxacillin-resistant Staphylococcus aureus (ORSA)
• Anemia, unspecified
• Gastrointestinal hemorrhage, unspecified
• Diarrhea, postive of stool GDH
• Chronic viral hepatitis B without delta-agent
• Constipation, unspecified
• Other forms of stomatitis
• Port-A catheter insertion 2022/6/30
• Fistulotomy and debridement on 2022/8/3

[exam findings]

• 2023-01-27 CT - chest
  • Indication
    • Dyspnea, unspecified
    • Secondary malignant neoplasm of unspecified lung
  • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window,5 mm soft-tissue window slice thickness)
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • MInimal dense opacity over right lower lobe, left lower lobe and left peripheral lung is found.
      • No evidence of bilateral pleural effusion.
      • Calcified coronary arteries is found.
      • Dense calcified lymph nodes at mediastinal and both hilar region is found.
    • Visible abdomen:
      • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
      • The GB is well distended without soft tissue lesion
      • Suggest clinical correlation
  • Imp:
    • MInimal dense opacity over right lower lobe, left lower lobe and left peripheral lung is found.
    • Calcified lymph nodes at mediastinum and bilateral pulmonary hilum.
• 2023-01-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (97 - 33) / 97 = 65.98%
    • M-mode (Teichholz) = 65
  • Adequate LV systolic function with normal resting wall motion
  • Mild MR and mild TR
  • LV diastolic dysfunction, Gr 1
  • Preserved RV systolic function
• 2023-01-11, 2022-12-05 CXR
  • multiple nodules in both lungs, in regression
• 2023-01-11 ECG
  • Normal sinus rhythm
  • Nonspecific T wave abnormality
• 2023-01-11 Spirometry
  • normal standard spirometry
  • negative BDT (back diffusion technique)
  • normal DLCO (diffusing capacity of the lungs for carbon monoxide)
• 2022-10-25 CT - neck
  • Indication:
    • triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
  • Head and Neck CT with and without IV contrast administration shows: (Comparison: 2022/07/03 CT)
    • Head and Neck
      • A large mass lesion, can be confluent LAPs, in right middle low lateral neck.
      • Regressed size from 95x80x60 mm to 77x57x37 mm (RL-AP-CC). [CC: Cranial-caudal; RL: Right-left; AP: Anterior-Posterior]
      • After IV contrast administration shows well or heterogenous enhancement of the mass or LAPs with central necrosis.
    • Thorax:
      • Presence of multiple lung nodules/masses.
      • One enlarged LN in right paratracheal space, seems with central necrotic change. With unknown size change, not scanned on last CT study, 2022/07/03 CT.
      • Several LAPs in AP window and pretracheal space.
    • Abdomen and pelvis:
      • One enlarged LN in anterior part of celiac root. With unknown size change, not scanned on last CT study, 2022/07/03 CT.
      • No evident other abnormal enlarged lymph node in paraaortic space or iliac chain.
  • IMP: Decreased right neck LAPs when compared with 20220703 CT as mentioned above.
• 2022-08-03 Patho - fissure/fistula
  • Anus, fistulotomy — Anal fistula with abscess
  • Section shows piece(s) of cutaneous-colonic junctional tissue with one fistula surrounded by abscess composed of debri and diffuse acute as well as chronic inflammation.
• 2022-07-31 CXR
  • a mass shadow in over the Rt neck, in regression
  • multiple nodules in both lungs, in regression
• 2022-07-26 PET
  • Mildly increased FDG uptake in a large focal area in the right neck, compatible with lymphoma of low FDG uptake.
  • Mildly increased FDG uptake in multiple lymph nodes on both sides of the diaphragm as mentioned above and Increased FDG uptake in multiple focal areas in bilateral lung fields. Lymphoma can not be ruled out. Please correlate with other clinical findings for further evaluation.
  • Mildly increased FDG uptake in the bone marrow of bilateral thighs. The nature is to be determined (bone marrow hyperplasia? lymphoma of low FDG uptake?). Please also correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in the intestine and both kidneys. Physiological FDG accumulaiton may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2022-07-21 Patho - intestine
  • Large intestine, ICV, biopsy —- ulcer with non-specific colitis
  • Small intestine, terminal ileum, biopsy —- ulcer with chronic inflammation
• 2022-07-21 SONO
  • Right neck heteroechoic tumor with some necrosis
• 2022-07-03 CT
  • No evidence of intracranial hemorrhage.
  • A large mass (8.1cm) at right neck.
  • Some patchy densities at bil. upper lungs.
• 2022-06-24 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (95.9 - 33.9) / 95.9 = 64.65%
    • M-mode (Teichholz) = 64.7
  • Adequate LV systolic function with no regional wall motion abnormality at resting state
  • Mild to moderate tricuspid regurgitaition and mild mitral regurgitation
  • Dilated LA and IVC; mildly thick IVS and LVPW (IVC = inferior vena cava; IVS = interventricular septum; LVPW = left ventricular posterior wall)
  • Mild pulmonary hypertension
• 2022-06-23 Patho - bone marrow biopsy
  • Bone marrow, biopsy — No evidence of lymphoma involvement and see description.
  • The sections show normocellular marrow (35%). M/E ratio = 4:1. The myeloid cells show maturation. The megakaryocytes are increased in number with a few small megakaryocytes. No focal lymphoid aggregation. Scattered CD34+ and/or CD117+ immature cells, account for 3% of marrow cells can be found. There is no evidence of lymphoma involvement in CD3 and CD20 immunostains. Suggest further bone marrow smear evaluation and clinic correlation.
• 2022-06-21 Patho - lymph node region resection
  • Tissue, neck, right, incisional biopsy — Diffuse large B cell lymphoma, GCB
    
  • Immunohistochemical stain profiles: CD20(+), CD3 (focal+ at background T-cells), Bcl-2(+), Bcl-6(+), MUM-1(-), CK(-), CD56(-), CD10(+), Cyclin D1(-), C-MYC(+).
• 2022-06-17 Patho - lymphnode biopsy
  • Labeled as “Right neck lymph node”, SONO guided biopsy — B cell lymphoma, high grade.
  • IHC stains: CK (-), CD56 (-), CD3 and CD20: a predominant B cell sub-population, Bcl-2 (+), bcl-6(+), MUM-1(-), Ki-67: 95%, CD10 (-), cyclin-D1 (equivocal), CD23 (-), CD30 (-), C-myc (+, focally >30%), a pattern, in favor of diffuse large B cell lymphoma, double-expressor.
• 2022-06-16 CXR
  • Diffuse nodular lesions at both lungs is found.
• 2022-06-16 CT - neck
  • Neck lymphadenopathy with lung meta and extensive lymphadenopathy, suggest biopsy.
• 2022-06-16 CT - lung
  • Huge right neck lymphadenopathy with bilateral lung meta, adrenal meta and mediastinal, bilatral axillary and paraaortic lymphadenopathy, please check neck, oral pharyngeal region for primary tumor.
• 2022-06-16 CXR
  • Patch density at bil. lungs.

[MedRec]

• 2023-02-12 Progress Note
  • Problem 1# triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, HCT-CI score: 0, IPI score: 4, High risk group, PS: 1
    • Assessment: autoPBSCT on 2023/02/24 (D0)
    • Plan
      • Blood transfusion with LPRBC (ZhaoGuang) and LRP (ZhaoGuang) for anemia and thrombocytopenia (In this context, “ZhaoGuang” refers to a leukocyte reduction process in which blood products such as LPRBC and LRP are exposed to ultraviolet light to inactivate leukocytes. This is done to reduce the risk of transfusion-related reactions and complications.)
      • Nincort and Mycostatin 5ml QID for mucositis
      • PPN with Oliclinomel was administered for poor appetite from 3/2
      • AutoPBSCT on 2023/02/24(D0),infusion time 10:11AM-10:17AM;10:19AM-10:26AM, (12/6 CD34: 5.49x10^6/kg and 12/5 CD34: 4.05x10^6/kg, total 9.54x10^6/kg)  
      • Baktar 2tab QD for PJP prevention
      • Prophylaxis antibiotivcs with Cravit 1.5tab from 2/16-23,antifungas with Fluconazole 300mg QD IVD from 2/16-23,then shifted to Tienam,Targocid from 2/24-3/2 then shifted to Zyvox from 3/2(D6) and Mycamine from 2/24(D12),pending blood culture
      • Conditioning regimen for autologous PBSCT with BuCyE was administered on 2023/2/17-22
      • Adequate hydration
      • Oral surgerist was consulted for oral examination
      • CVS was consulted for Hickman insertion on 2/16
      • closely monitor clinical condition  

[consultation]

• 2024-03-04 Infectious Disease

• 2023-09-06 Cardiology

• 2023-08-26 Infectious Disease

• 2023-06-06 Rehabilitation

• 2023-05-31 Chest Medicine

• 2023-05-24 Urology

• 2023-05-19 Dermatology

• 2023-05-15 Infectious Disease

• 2023-05-13 Anesthesia

• 2023-02-13 Vascular Surgery

  • Q
    • This 53 year old male is a case of triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
    • Will prepare autoPBSCT this time, we need your expertise for hickman insertion on 2023/02/16, thanks.
  • A
    • For BMT preparation, insertion of perm-cath will be scheduled on 20230216. Thanks for your consultation.

• 2023-02-13 Oral and Maxillofacial Surgery

  • Q
    • This 53 year old male is a case of triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
    • Will receive autoPBSCT on 20230224, we need your expertise for oral examination, thanks
  • A
    • after examining the intraoral condition and taking radiographic study, no pathology was noticed neither hopeless tooth was noticed
    • Plaque deposition over upper dentition was noticed.
    • Plan:
      • Teach him how to reinforce oral hygiene

• 2022-11-21 Vascular Surgery

  • Q
    • A case of triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
    • will receive PBSC harvest on 20221206 ~ 20221209, we need your expertise for double lumen insertion on 20221205, thanks
  • A
    • I have had the pleasure of involving with the patient’s care. In brief, He is a 53 year old male seen in consultation for opinion regarding treatment options for double lumen cath insertion for PRBC harvest access.
    • The pt’s hx/Dx was noted for Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
    • Lab/CXR reviewed.
    • SUGGESTION & PLAN:
      • D/L insertion will be arranged on R’t side on 2022/12/05 under LA 8AM
      • please prepare a 16cm D/L (double lumen catheter) to bring to OR.

• 2022-08-01 Colorectal Surgery

  • Q
    • The 53 y/o neck diffuse large B cell lymphoma case s/p R-DA-EPOCH at MICU. Due to a carbuncle over left buttock without discharge for 2-3 days. PS was consulted and who assessment of abscess just located nearby anus and it is likely anal fistula with anal abscess, so we need your help. Thanks!
  • A
    • We’ll go to see the patient tomorrow morning

• 2022-08-01 Reconstructive and Plastic Surgery

  • Q
    • The 53 y/o neck diffuse large B cell lymphoma case s/p R-DA-EPOCH at MICU. Due to a carbuncle over left buttock without discharge for 2-3 days, so we need your help for management. Thanks!
  • A
    • abscess just located nearby anus
    • it is likely anal fistula with anal abscess
    • plan and suggestion:
      • please consult CRS for this problem
      • sitz bath with warm water after stool passage

• 2022-06-24 Gastroenterology

  • Q
    • For HBV evaluation
    • This is a 53 years old man, a case denided Diabetes, Hypertension or heart disease history. This time, he suffered from shortness of breath was noted since today. right neck swelling for 6 months. so he went to ER for help. At ER, conscious clear, vital sign showed BP:163/91mmHg; HR:139; BT:36.3; RR:20; SPO2:88%, follow up Lab data showed leukocytosis (wbc:16930 CRP:11.55). chest films revealed diffuse nodular lesions at both lungs is found. chest CT revealed huge right neck lymphadenopathy with bilateral lung mets, adrenal mets and mediastinal, bilatral axillary and paraaortic lymphadenopathy, please check neck, oral pharyngeal region for primary tumor.Because of dyspnea, desaturation progression, emergent intubation with ventilator support and then transfer to ICU for further care.
    • After admission. B cell lymphoma was diagnosis. HbsAg(-), Anti-Hbc reactive. We sinecerely need your help. Thanks a lot.
  • A
    • O
      • Abdominal echo: nil
      • ALT:15 , BUN:20, Cr:0.45
      • HBsAg(-), Anti-HBsAb:(-), Anti-HBc:(+), Anti-HCV(-)
    • Impression
      • Resolved HBV infection
      • Diffuse large B cell lymphoma, triple hit, IPI:4, stage IV
    • Suggestion
      • We will prescribe Baraclude 0.5mg QD (GFR>50 QD, GFR 30-49 QOD, GFR 15-29 Q3D, GFR<15 or HD QW)
      • Arrange abdominal sonography after transfer to general ward
      • Regular/close monitor liver function
      • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication

• 2022-06-23 Hemato-Oncology

  • Q
    • For B cell lymphoma evaluation
  • A
    • Impression:
      • Diffuse large B cell lymphoma, triple hit, IPI:4, stage IV
      • Acute respiratory failure s/p intubation on 20220617
      • Bilateral lung pneumonia, sputum culture yeild Pseudomonas aeruginosa on 20220617
    • Suggestion:
      • Bone marrow aspiration and biopsy for further staging. Arrange PET after remove endo.
      • We had well explaint to his brother and will arrange R-COP for cyto-reduction. Please watch for tumorlysis syndrome
      • Check HbsAg, AntiHCV, Anti Hbc
      • We may take over this case after remove endo with stable condition.
      • Thanks for your consultation. If there is any problem, please feel free to let us know

• 2022-06-20 Anesthesiology

  • Q
    • For pre-op evaluation
  • A
    • Condition: Stable V/S Cons. clear, previous walking ok but now weakness and tired, no dyspnea, chest tightness or leg edema, fighting with ventilator
    • EKG: ST
    • CXR: a huge mass shadow in over the Rt neckmultiple nodules and several large massses of variable sizes in both lungs due to metastases. Cardiomegaly, Tortous aorta with calcification, Osteopenia, Senile fibrotic change
    • Neck CT: Neck lymphadenopathy with lung meta and extensive lymphadenopathy, suggest biopsy
    • Lung CT: Huge right neck lymphadenopathy with bilateral lung meta, adrenal meta and mediastinal, bilatral axillary and paraaortic lymphadenopathy, please check neck, oral pharyngeal region for primary tumor.
    • Airway: adequate open
    • ASA3
      • NOTE: AMERICAN SOCIETY OF ANESTHESIOLOGY PATIENT CLASSIFICATION STATUS
        • ASA I
          • Normal healthy Pt
        • ASA II
          • Pt with mild systemic disease; no functional limitation–eg, smoker with well-controlled HTN
        • ASA III
          • Pt with severe systemic disease; definite functional impairment–eg, DM and angina with relatively stable disease, but requiring therapy
        • ASA IV
          • Pt with severe systemic disease that is a constant threat to life–eg, DM + angina + CHF; Pts have dyspnea on mild exertion and chest pain
        • ASA V
          • Unstable moribund Pt who is not expected to survive 24 hours with or without the operation
        • ASA VI
          • Brain-dead Pt whose organs are removed for donation to another
        • E
          • Emergency operation of any type, which is added to any of the 6 above categories, as in ASA II E
    • Plan:
      • High risk of aspiration, sepsis, shock
      • Anes. plan and risk was told to him at bedside and brother at door of SICU
      • Resucitation will be procedured if emergence condition.
      • We will arrange ETGA
      • Correct underly dx as your expertise.
      • Follow onetouch q6h when nil per os if DM or high risk of hypoglycemia

• 2022-06-20 ENT

  • Q
    • For A huge indurated mass (over 10cm in largest dimension) with partial skin erosion (2*2cm) over right lateral-posterior neck without tendeness.
  • A
    • CT: right neck lymphadenopathy with bilateral lung meta, adrenal meta and mediastinal, bilatral axillary and paraaortic lymphadenopathy
    • PE:
      • Oral: N-P
    • Scope: unable to evaluate due to saliva pooling
    • Imp: R neck lympahdenopathy with metastasis, origin?
    • Plan:
      • Arrange excisional biopsy for tissue proof on 20220621 On call.

• 2022-06-16 Oral and Maxillofacial Surgery

  • Q
    • shortness of breath was noted since today
    • right neck swelling for 3 month
    • Hx of NIL
  • A
    • This is a 53-year-old male who felt a little hard to breath and went to our ER for help
    • PMH: denied
    • S: I felt a little hard to breath
    • O: BP:163/91; P:139; T:36.3; R:20;
      • Con’s: E4V5M6
      • SpO2:88%
      • Extraoral finding:
        • mass (width 4 fingers, length 9 fingers) over his right neck was noted (it was so small 3 months ago)
    • A: tumor of right neck
    • P:
      • Physical exam and explain the findings to the patient.
      • Consult Hemato-Oncology for further survey

• 2022-06-16 ENT

  • Q
    • shortness of breath was noted since today
    • right neck swelling for 3 month
    • Hx of NIL
  • A
    • O
      • Local finding:
        • No stridor but shortness of breath
        • Fair oral cavity and oropharynx
        • A huge indurated mass (over 10cm in largest dimension) with partial skin erosion (2*2cm) over right lateral-posterior neck without tendeness.
      • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx and hypopharynx; patent airway through subglottic level; no vocal palsy.
      • Neck and Chest CT Report: A huge solid mass measuring up to 12cm in greatest dimention over right posterior-lateral neck with partial liquid component, along with bilateral multiple pulmonary/mediastinal nodular/mass lesion.
    • Impression:
      • Suspect malignancy, pulmonary origin with multiple metastasis should be primarily considered.
    • Plan:
      • Closely monitor airway condition.
    • Suggest consult Chest Physician or Hemato-oncologist for further evaluation and management.

[surgical operation]

• 2024-03-06
  • Surgery
    • Debridement and Synovectomy
  • Finding
    • Left knee septic arthritis with much dirty pus in knee joint with infected synovium noticed
• 2022-12-05
  • Surgery
    • D/L insertion (RIJV approach, 16cm)  
• 2022-08-03
  • Surgery
    • Fistulotomy and debridement
  • Finding
    • Inflammation and swelling over left perianal region with much pus was drained. Debridement and irrigation using H2O2 was done.
• 2022-06-21
  • Surgery
    • Incisional biopsy of right neck mass
  • Finding
    • Right neck indurated mass, measuring up to 12cm in greatest dimention

[immunochemotherapy]

• 2023-02-17 - busulfan 3.2mg/kg 200mg NS 400mL 3hr D1-3 + etoposide 400mg/m2 657mg NS 30mL 6hr D3-4 + cyclophosphamide 50mg/kg 3135mg NS 500mL 4hr D5-6 (BuCyE)
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + palonosetron 250ug D1-3 + granisetron 2mg D4-6 + aprepitant 125mg PO D5-6 + NS 250mL D1-6
• 2022-12-19 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
• 2022-11-21 - rituximab 375mg/m2 600mg 8hr D1 + methylprednisolone 500mg 1hr D2-6 + etoposide 40mg/m2 63mg 1hr D1-5 + cisplatin 25mg/m2 39mg 18hr D1-5 + cytarabine 2000mg/m2 3160mg 2hr D6 (R-ESHAP)
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + palonosetron 250ug D1-6
• 2022-10-25 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
• 2022-09-16 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
• 2022-08-18 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
• 2022-07-11 - rituximab 375mg/m2 600mg 6hr D1 + prednisolone 60mg/m2 5mg/tab 19tab BID D1-5 + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 15mg 24hr D1-4 + vincristine 0.4mg/m2 0.5mg 24hr D1-4 + cyclophosphamide 750mg/m2 1200mg D5 (R-DA-EPOCH)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D1 + famotidine 20mg D1
• 2022-06-23 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1260mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 tmg/tab 10tab BID D1-6 (R-COP)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D1

R-ESHAP - 2024-03-04 - https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/cancer-drugs/drugs/r-eshap

• R - rituximab (ri-tuk-si-mab)
• E - etoposide (ee-top-o-side)
• S - solu-medrone (sol-you-med-rone), you commonly hear it called methylprednisolone
• HA -high dose cytarabine (sye-ta-ra-bin), also known as Ara C
• P - cisplatin (sis-pla-tin)

R-CVP - 2024-03-04 - http://nssg.oxford-haematology.org.uk/lymphoma/documents/lymphoma-chemo-protocols/L-82-r-cvp.pdf

• INDICATION: Non-Hodgkin lymphoma.
• Omit rituximab if CD20-negative.

G-CSF

• Granocyte (lenograstim 250mg SC) 2022-11-04, -05, -07 (20221104 OPD)
• Granocyte (lenograstim 250mg SC) 2022-11-01, -02, -03 (20221023 IPD)
• Granocyte (lenograstim 250mg SC) 2022-09-26, -27, -28 (20220926 OPD)
• Granocyte (lenograstim 250mg SC) 2022-09-20, -21, -22 (20220913 OPD)
• Granocyte (lenograstim 250mg SC) 2022-08-30, -31, -09-01 (20220830 OPD)
• Granocyte (lenograstim 250mg SC) 2022-08-24, -25 (20220818 IPD)

==========

2024-03-07

[Zinforo for MRSA+ synovial fluid: debridement & synovectomy done (stable vitals)]

The results of the synovial fluid aerobic culture, sampled on 2024-03-02 and reported on 2024-03-06, indicated a 2+ presence of S. aureus (MRSA), with susceptibility to vancomycin (SIR S) and a Minimum Inhibitory Concentration (MIC) of 1 µg/mL.

The patient is currently receiving Zinforo (ceftaroline) 600 mg IVD Q12H, which is effective against MRSA. (Ref: Ceftaroline: A New Cephalosporin with Activity against Methicillin-Resistant Staphylococcus aureus (MRSA). Clin Med Rev Ther. 2011 Feb 10;3:a2466. doi: 10.4137/CMRT.S1637.)

Debridement and synovectomy surgery was carried out on 2024-03-06. Currently, the patient’s vital signs are stable.

2024-03-04

[septic arthritis: elevated synovial fluid WBC, pending cultures, uncertain antibiotic duration]

WBC count in synovial fluid on 2024-03-02 was 14.5K/uL (reference < 200).

Septic arthritis is suspected for this patient. Blood cultures, urine cultures, and both aerobic and anaerobic cultures were obtained on 2024-03-02 and are currently pending results. Empirical antibiotic therapy with Tapimycin (piperacillin/tazobactam) has been initiated on the same day.

Management of confirmed septic arthritis typically involves both joint drainage and antibiotic therapy. Joint drainage is crucial due to the presence of a closed abscess within the joint. (Ref: 2024-03-04 https://www.uptodate.com/contents/septic-arthritis-in-adults)

While there isn’t conclusive evidence from randomized trials, initial antibiotic therapy should broadly cover the most likely causative pathogens. Additionally, the optimal duration of antibiotic treatment for septic arthritis remains unclear.

Zinforo (ceftaroline fosamil 600mg) Q12H IVD might be tried for the patient’s septic arthritis.

2023-03-07

[assessment - Improvement in WBC Count Trend Observed]

• Today (2023-03-07) marks the 11th day since autoPBSCT. Based on recent lab data, there is a noticeable upward trend in WBC count over these two days, indicating a return to the normal range.
  • 2023-03-07 D11 WBC 4.87 x10^3/uL
    
  • 2023-03-06 D10 WBC 2.51 x10^3/uL
    
  • 2023-03-05 D 9 WBC 0.91 x10^3/uL
    
  • 2023-03-04 D 8 WBC 0.28 x10^3/uL
    
  • 2023-03-03 D 7 WBC 0.04 x10^3/uL
    
  • 2023-03-02 D 6 WBC 0.01 x10^3/uL
    
  • 2023-03-01 D 5 WBC 0.01 x10^3/uL
    
  • 2023-02-27 D 3 WBC 0.01 x10^3/uL
    
  • 2023-02-26 D 2 WBC 0.02 x10^3/uL
    
  • 2023-02-24 D 0 WBC 0.11 x10^3/uL
    
  • 2023-02-22 D-2 WBC 1.16 x10^3/uL
    
  • 2023-02-20 D-4 WBC 1.22 x10^3/uL
    
  • 2023-02-16 D-8 WBC 1.08 x10^3/uL

2023-02-15

[preparation and administration of mesna]

• Mesna can be dissolved in 0.9% normal saline (NS) or 5% dextrose in water (D5W).

• As the patient weighs 60kg, the scheduled (since 2023-02-21) dose of mesna is 12mg/kg, which means that 720mg of mesna should be dissolved in the aforementioned solvent no less than 50mL (final concentration no more than 20 mg/mL).

• To ensure optimal administration, it is recommended that the injection lasts for no less than 30 minutes.

701019197

240307

[MedRec]

• 2024-03-04 ~ 2024-03-05 POMR General and Gastroenterological Surgery Zhang YaoRen
  • Discharge diagnosis
    • Recurrent right breast cancer with chest wall and multiple bone metastasis rpT4aN0M1, stage IV. ECOG performance:1
    • Type 2 diabetes mellitus
  • CC
    • For Faslodex injection     
  • Present illness
    • A 76-year-old post menopausal woman has 1) Type 2 diabetes mellitus 2) Hyperlipedemia 3) Appendectony. She denied any TOCC histories in recent 3 months.
    • According ot her statement, she was diagnosed with right breast cancer, then underwent simple mastectomy and sentinel lymph node biopsy, pT1bN0M0 stageI on 2016/08/19 and received Aromatase inhibitor since 2016/08/29 for five years. She regular follow up at Dr. Chang’s OPD. However, she palpable a mass around right surgery scar last February. Also, she suffered from low back pain for a long time. Breast sono revealed right chest wall nodules that biopsy showed invasive carcinoma on 2023/02/24. IHC: ER: positive (strong, >95%), PR: negative, Her2/neu:negative (score= 1+), Ki-67 inedex: 10-15%. L-spine showed diffuse bony metastases involving T1-12, L1-5 and S1-2 vertebral bodies, bilateral sacral alae and iliac bones and biopsy revealed metastatic carcinoma.
    • She reveived CDK4/6 inhibitor with Ibrance since 2023/03/13. Under surgery of chest wall tumor excision on 2023/11/21. Pathology report showed Invasive carcinoma, ER(3+, >90%), PR(-, 0%) and HER2 (-, Dako score 1+). After well explain including pathology and the possible treatment modality were well explained to the patient.
    • Under the impression of recurrent right breast cancer wiht multiple metastasis, rpT4aN0M1, stage IV. After fully explaination the treatment options. This time, she was admitted to our ward for Faslodex.
  • Course of inpatient treatment
    • After admission, Faslodex were given. No discomfort after Faslodex. Under the stable condition, she was discharged today, and arrange next admission four weeks later.
  • Discharge prescription
    • Ibrance (palbociclib 75mg) 1# BIDCC
• 2023-11-20 ~ 2023-11-22 POMR General and Gastroenterological Surgery Zhang YaoRen
  • Discharge diagnosis
    • Recurrent right breast cancer wiht multiple metastasis (involving T1-12, L1-5 and S1-2 vertebral bodies, bilateral sacral alae and iliac bones), rcT4aN0M1, stage IV status post chest wall tumor excision on 2023/11/21. ECOG performance:1
    • Type 2 diabetes mellitus
  • CC
    • She palpable a mass around right surgery scar this February.
  • Present illness
    • A 76-year-old post menopausal woman has 1) Type 2 diabetes mellitus 2) Hyperlipedemia 3) Appendectony. She denied any TOCC histories in recent 3 months.
    • According ot her statement, she was diagnosed with right breast cancer, then underwent simple mastectomy and sentinel lymph node biopsy, pT1bN0M0 stageI on 2016/08/19 and received Aromatase inhibitor since 2016/08/29 for five years. She regular follow up at Dr. Chang’s OPD. However, she palpable a mass around right surgery scar this February. Also, she suffered from low back pain for a long time.
    • Breast sono revealed right chest wall nodules that biopsy showed invasive carcinoma on 2023/02/24. IHC: ER: positive (strong, >95%), PR: negative, Her2/neu:negative (score= 1+), Ki-67 inedex: 10-15%.
    • L-spine showed diffuse bony metastases involving T1-12, L1-5 and S1-2 vertebral bodies, bilateral sacral alae and iliac bones and biopsy revealed metastatic carcinoma. After well explain including pathology and the possible treatment modality were well explained to the patient.
    • She reveived CDK4/6 inhibitor with Ibrancesince 2023/03/13.
    • Under the impression of recurrent right breast cancer wiht multiple metastasis, rcT4aN0M1, stage IV. After fully explaination the treatment options. This time, she was admitted to our ward for tumor excision.
  • Course of inpatient treatment
    • After admittion, she underwent of right chest wall tumor excision on 2023/11/21.
    • The post-operative course was relatively smooth without complication. The wound is clean and dry and the wound pain was tolerable. The final pathology report is pending. Under the stable condition, she was discharged today and re-follow at OPD on 2023/11/27.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • MgO 250mg 1# QID
    • Xanthium (theophylline 200mg) 1# BID
    • ZCough (benzonatate 100mg) 1# TID
• 2023-02-08 ~ 2023-02-14 POMR Neurosurgery Huang GuoFeng
  • Discharge diagnosis
    • L1 spinal tumor suspect metastasis status post computed tomography guide biopsy on 2023/02/13.
    • Diffuse bony metastases involving T1-12, L1-5 and S1-2 vertebral bodies, bilateral sacral alae and iliac bones.  
    • Type 2 diabetes mellitus without complications
  • CC
    • Pain and soreness in both buttocks for a period of two months.
  • Present illness
    • The patient is a 75-year-old female who has been experiencing low back pain for 8 years and received physical medicine and rehabilitation, which relieved her symptoms to a certain extent. However, she has recently been experiencing bilateral buttock pain and soreness for two months, which is exacerbated by activities such as arising, forward bending, prolonged sitting/standing, and is relieved by bed rest. The examination revealed neurogenic claudication.
    • She visited a neurosurgery clinic and follow-up L-spine films showed L-spine spondylolysis. A bone densimetry study of the spine showed that the patient has osteoporosis. The patient was admitted for further imaging studies.
  • Course of inpatient treatment
    • After admission, the patient accepted her pain control with Ultracet 1 tablet every 6 hours. MRI of the lumbar spine was planned and showed diffuse bony metastases involving thoracic vertebrae 1-12, lumbar vertebrae 1-5, sacral vertebrae 1-2, bilateral sacrum, and ilium.
    • We consulted with a radiologist for a CT-guided biopsy and he suggested being on call to schedule a biopsy for 2023/02/13. Arrange lumbar spine r/o tumor metastasis biopsy 1. The postoperative process went smoothly. Analgesics are used to control wound pain. She was discharged home for outpatient follow-up pending further pathology reports.
  • Discharge prescription
    • Celebrex (celecoxib 200mg) 1# BID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
    • Sindine (povidone iodine aq soln) ASORDER EXT
• 2017-02-15 SOAP General and Gastroenterological Surgery Zhang YaoRen
  • S
    • palpable lump, right breast for days
    • family (-)
    • g4
    • no HRT
    • menarche 14 y-0
    • breast feeding (+)
    • Rt breast ca proved by CNB on 2016-08-09
    • Rt breast ca s/p simple mastectomy+SLNB on 2016-08-19
    • E/T only
    • AI since 2016-08-29 and E/T 5yrs
    • condition stable
    • follow-up
  • O
    • r/o ca or fibrocystic disease, 1cm over 2-3 oclock, 1 and 2 cm from the nipple
    • arrange sono
    • 20160809 A. Breast, right, 2 o’clock, core needle biopsy — Infiltrating ductal carcinoma.
    • 2016/08/15 CA-153：9.159 U/ml、CEA：5.123 ng/ml
    • 2016-08-19
      • Rt breast ca s/p simple mastectomy + SLNB
      • invasive ca-
      • size 0.6 cm Gr 2
      • DCIS-
      • size 4.5 cm
      • SLN 0/6 nonSLN 0/1
      • pT1bN0M0 stage 1
      • ER (+, 95%), PR (+ 2%), Her2/neu: Positive (score=3+), Ki-67: 25%, p53: (80%, weak intensity).
    • 2016/11/17 CA-153：8.053 U/ml、CEA：0.751 ng/ml
    • 2017/02/03 CEA：0.973 ng/ml、CA-153：9.665 U/ml
  • Diagnosis
    • Malignant female breast neoplasm, NOS [C50.911]
  • Prescription x3
    • Femara (letrozole 2.5mg) 1# QD

[surgical operation]

• 2023-11-21
  • Op Method: Rt chest wall tumor excision         
  • Finding:
    • a 2x2x1 cm slight firm mass at rt chest wall         - s/p rt mastectomy r/o chest wall recurrence    

[chemotherapy]

• 2024-03-04 - Faslodex (fulvestrant) 500mg IM

• 2024-01-08 - Faslodex (fulvestrant) 500mg IM

• 2023-12-11 - Faslodex (fulvestrant) 500mg IM

• 2023-03-13 ~ 2024-03-07 ongoing - Ibrance (palbociclib 100mg) 1# QD

• 2017-02-15 ~ 2023-12-15 - Femara (letrozole 2.5mg) 1# QD

Prolia (denosumab) 60mg SC Q6M on 2023-11-27, 2023-05-22

Zobonic (zoledronic acid) 4mg IVD on 2024-01-22, 2023-11-13, -10-16, -09-25, -08-28, -07-31, -05-08, -03-01

Fulvestrant - 2024-03-07 - https://www.uptodate.com/contents/fulvestrant-drug-information

• Breast cancer, advanced, monotherapy
  • Breast cancer, advanced, monotherapy (postmenopausal patients; HR-positive): IM:
    • Initial: 500 mg on days 1, 15, and 29;
    • Maintenance: 500 mg once monthly
  • Breast cancer, advanced, monotherapy (postmenopausal patients; HR-positive, HER2-negative): IM:
    • Initial: 500 mg on days 1, 15, and 29;
    • Maintenance: 500 mg once monthly
• Breast cancer, advanced or metastatic, combination therapy
  • Breast cancer, advanced or metastatic, combination therapy (postmenopausal patients; HR-positive, HER2-negative): IM:
    • Note: A luteinizing hormone-releasing hormone (LHRH) agonist should be administered to pre-/perimenopausal patients receiving fulvestrant in combination with ribociclib.
      • Initial: 500 mg on days 1, 15, and 29;
      • Maintenance: 500 mg once every 28 days.
      • Administer in combination with ribociclib; continue until disease progression or unacceptable toxicity.
  • Breast cancer, advanced or metastatic, combination therapy (second-line endocrine-based combination therapy; pre- or postmenopausal patients, HR-positive, HER2-negative): IM:
    • Note: An LHRH agonist should be administered to pre-/perimenopausal patients receiving fulvestrant in combination with abemaciclib or palbociclib.
    • Initial: 500 mg on days 1, 15, and 29;
    • Maintenance: 500 mg once every 28 days.
    • Administer in combination with palbociclib or abemaciclib; continue until disease progression or unacceptable toxicity.
  • Breast cancer, advanced or metastatic, HR-positive, HER2-negative (off-label combinations):
    • PIK3CA-mutated: Males and postmenopausal patients: IM:
      • Initial: 500 mg on days 1, 15, and 29;
      • Maintenance: 500 mg once every 28 days (in combination with alpelisib); continue until disease progression or unacceptable toxicity.
    • PIK3CA, AKT1, and/or PTEN-altered: IM:
      • Note: For pre- and peri-menopausal patients, also administer an LHRH agonist (according to current clinical practice standards). For male patients, consider administering an LHRH agonist (according to current clinical practice standards).
      • Initial: 500 mg on days 1, 15, and 29;
      • maintenance: 500 mg once every 28 days (in combination with capivasertib); continue until disease progression or unacceptable toxicity.

Palbociclib - 2024-03-07 - https://www.uptodate.com/contents/palbociclib-drug-information

• Breast cancer, advanced, initial endocrine-based therapy
  • Breast cancer, advanced, initial endocrine-based therapy: HER-2 negative:
    • Oral: Tablets or capsules: 125 mg once daily for 21 days, followed by 7 days off, repeat every 28 days (in combination with continuous aromatase inhibitor therapy); continue until disease progression or unacceptable toxicity.
    • Pre/perimenopausal patients should also receive a luteinizing hormone-releasing hormone (LHRH) agonist.
    • For males receiving palbociclib in combination with an aromatase inhibitor, also consider treatment with an LHRH agonist.
• Breast cancer, advanced, with disease progression following endocrine therapy
  • Breast cancer, advanced, with disease progression following endocrine therapy: HER-2 negative:
    • Oral: Tablets or capsules: 125 mg once daily for 21 days, followed by 7 days off, repeat every 28 days (in combination with fulvestrant [and an LHRH agonist or a gonadotropin-releasing hormone agonist if pre/perimenopausal]); continue until disease progression or unacceptable toxicity.

==========

2024-03-07

[mitigating hematologic toxicity in hormonal and targeted therapy: neutropenia risk with palbociclib]

The aromatase inhibitor Femara (letrozole) was administered from 2017-02 to 2023-12. The CDK4/6 inhibitor Ibrance (palbociclib) was introduced in 2023-03, and monthly treatments with the estrogen receptor antagonist Faslodex (fulvestrant) commenced as a replacement for letrozole since 2023-12.

Since 2023, there have been only 6 recorded instances of WBC levels, with the patient frequently experiencing leukopenia:

• 2024-03-04 WBC 1.56 x10^3/uL **
• 2024-01-29 WBC 1.21 x10^3/uL **
• 2023-11-20 WBC 2.07 x10^3/uL *
• 2023-05-08 WBC 2.59 x10^3/uL *
• 2023-04-10 WBC 1.16 x10^3/uL **
• 2023-02-22 WBC 6.97 x10^3/uL

WBC levels were notably low (< 2K/uL) starting from 2023-12 recently, potentially influenced by fulvestrant. Literature indicates fulvestrant’s adverse reactions include leukopenia (≤5%; grade 3: 1%; grade 4: 1%) and neutropenia (2%; grade 3: 1%; grade 4: <1%), rates that are relatively low compared to chemotherapeutic drugs, making fulvestrant a less likely cause.

Palbociclib, however, has a significantly higher incidence of neutropenia (80% to 83%; grade 3: 55% to 56%; grade 4: 10% to 11%) and has been in use since 2023-03, aligning with the period of observed low WBC levels, suggesting a greater impact from this medication.

Neutropenia, including grades 3 and 4, was commonly observed in clinical studies among patients taking palbociclib, with the median duration of ≥ grade 3 neutropenia lasting 7 days. Febrile neutropenia and neutropenic sepsis have also been reported. Neutropenia is rapidly reversible upon discontinuation of palbociclib.

• The mechanism of neutropenia is dose-related; palbociclib inhibits CDK6, crucial for the proliferation of hematopoietic precursors, causing cytostatic effects on neutrophil cell cycles.
• The median onset for any grade of neutropenia is 15 days, with grade ≥3 neutropenia typically occurring 28 days after treatment initiation.
• Risk factors include baseline myelosuppression, recent antibiotic use, non-white race, and Asian ethnicity.

The patient, being non-white and of Asian ethnicity, aligns with these risk factors. Despite the recommended palbociclib dosage being 125 mg once daily for 21 days followed by a 7-day break in a 28-day cycle, the patient has been receiving a lower dose of 100 mg daily. Given this reduced dosage, further lowering is not advised to maintain therapeutic efficacy. Consideration may be given to using G-CSF to mitigate symptoms.

701352988

240307

[exam findings]

• 2023-10-19 MRI - pelvis
  • Clinical history: 73 y/o female patient with Peritoneal cancer post Subtotal hysterectomy + Bilateral salpingo-oopherectomy + Pelvic mass excision on 2023/09/18.
  • With and without contrast enhancement MRI: Pelvis:
    • S/P subtotal hysterectomy.
    • Large soft tissue tumors in the pelvic cavity, up to 11.3x7.4cm in the pelvic cavity, could be due to recurrent tumors.
    • Enlarged lymph nodes in the pelvic cavity (obturator, iliac regions and mesentery), r/o lymph nodes metastasis.
    • Unremarkable change of the liver, spleen, pancreas and both kidneys.
    • No ascites.
  • Impression:
    • S/P subtotal hysterectomy with recurrent tumors and metastatic lymph nodes.
• 2023-10-18 Pure Tone Audiometry
  • PTA: Reliability FAIR
  • Average RE 20 dB HL; LE 24 dB HL.
  • Bil normal to moderate.
• 2023-09-18 Patho - uterus (with or without SO) neoplastic (Y1)
  • PATHOLOGIC DIAGNOSIS
    • Tumor, right pelvic wall, excision — High-grade serous carcinoma
    • Ovary, bilateral, BSO — Free of tumor invasion, corpus albicans
    • Fallopian tube, bilateral, BSO — Free of tumor invasion
    • Endometrium, uterus, subtotal hysterectomy — Free of tumor invasion, endometrial polyps
    • Myometrium, uterus, ditto — Free of tumor invasion, leiomyomas
    • Cervix, uterus, ditto — Not received
    • Lymph node — Not received
    • Initial AJCC Pathologic staging — pT2, if cN0 and cM0, stage II
    • Revised diagnosis: AJCC Pathologic staging — pT2M1b, if cN0, stage IVB
    • Reason for revision: according to the report of S2023-14979 for rectum biopsy
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: subtotal hysterectomy + bilateral salpingo-oopherectomy + pelvic mass excision
    • Specimen type: partial uterus with bilateral adnexa and right pelvic wall tumor
    • Specimen size:
      • R’t ovary: 1.8 x 1.6 x 0.8 cm, normal appearance
      • R’t fallopian tube: 5.2 cm in length, 0.5 cm in diameter, normal appearance
      • Left ovary: 2.2 x 1.2 x 0.9 cm, normal appearance
      • Left fallopian tube: 5 cm in length, 0.4 cm in diameter, normal appearance
      • Uterus: 6.8 x 6.2 x 5.3 cm and 100 gm contains multiple myomas measure up to 4.2 x 3.7 cm and two endometrial polyps measure up to 2 x 0.4 cm
      • Right pelvic wall tumor: five fragments, up to 3.2 x 3.2 x 2.3 cm
    • Tumor site: peritoneum
    • Tumor size: five fragments, up to 3.2 x 3.2 x 2.3 cm
      
    • Tumor appearance: solid mass
      
    • Specimen integrity: fragmented
    • Lymph nodes: Not received
    • Representative sections as A1-A5: right pelvic wall tumor, B1: R’t F-tube, B2: R’t ovary, B3: L’t F-tube, B4: L’t ovary, B5-B6: myoma+ endometrial polyps
  • MICROSCOPIC EXAMINATION
    • Histologic type: high-grade serous carcinoma
    • Histologic grade: G3, high grade
    • Contralateral ovary involvement: absent
    • Tumor side ovarian surface involvement: absent
    • Contralateral ovary involvement: absent
    • Right tube involvement: absent
    • Left tube involvement: absent
    • In situ adenocarcinoma in right ＆/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: absent
    • Left adnexa soft tissue involvement: absent
    • Uterine serosa involvement: absent
    • Uterine Cervix involvement: not received
    • Endometrium involvement: absent
    • Myometrium involvement: absent
    • Lymph nodes metastasis: Not received
    • Immunohistochemistry: CK7(+), WT-1(+), PAX-8(+), P53(+, aberrant expression) and CDX2(-) for tumor
    • Ascites cytology: negative
• 2023-09-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 30) / 79 = 62.03%
    • M-mode (Teichholz) = 62
  • Conclusion:
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; mild TR; mild PR.
• 2023-08-04 CT - abdomen
  • Indication: rectal malignancy for staging
  • Findings:
    • There is a lobulated heterogeneous enhancing soft tissue mass in the pelvis, measuring 11 cm (the largest dimension), with directly attached the uterus and the rectum, and partial encasement the rectum.
      • Ovarian cancer with rectum invasion is highly suspected.
      • Please correlate with IHC stain of the rectal tumor and laparoscopy.
      • In addition, there are four enlarged nodes in the sigmoid mesocolon that are c/w metastatic nodes.
    • There are several gallstones (< 6 mm).
    • There is a heterogeneous soft tissue mass in left upper mediastinum with calcification component, measuring 9 cm (the largest dimension), that may be intrathoracic goiter.
      • Non-visualization of left lobe thyroid in left thyroid fossa is noted.
      • please correlate with clinical condition.
  • Impression:
    • Ovarian cancer with rectum invasion is highly suspected.
    • Please correlate with IHC stain of the rectal tumor and laparoscopy.
• 2023-07-28 Patho - colon biopsy (Y2)
  • Intestine, large, rectum, biopsy — adenocarcinoma
  • Microscopically, it shows adenocarcinoma composed of a proliferation of neoplastic cells with solid to glandular architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • IHC stain — CK(+), EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • IHC stain — CK20: negative, p53: aberrant-type, PAX-8: positive, WT-1: positive, CK7: positive,
  • NOTE: Based on the result of IHC stain, the tumor is compatible with non-colorectal origin and in favor of ovary origin. However, correlation with image study and clinical findings is recommended.

[MedRec]

• 2023-10-05 SOAP Hemato-Oncology Xia HeXiong
  • A:
    • Rectal tumor, adenocarcinoma, BUT colon origin is not likely
  • P:
    • for information of GYN combined surgery, had inform her and her family that may need a colostomy (ovary cancer involving low rectum)
    • TP +/- bevacizumab followed by bevacizumab +/- PARP inhibitor
    • Arrange admission for 24 hours CCr, Pelvis MRI, audiometry and then TP +/- bevacizumab
• 2023-09-16 ~ 2023-09-28 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Peritoneal cancer post Subtotal hysterectomy + Bilateral salpingo-oopherectomy + Pelvic mass excision on 2023/09/18
    • Female pelvic peritoneal adhesions (postinfective)
  • CC
    • Change in bowel habit with mucus passage and tenesmus for months, diarrhea 3-5 times
    • 202308 she was found colonoscope biopsy rectal adenocarcinoma, with elevated CA-125 level (451.3 U/mL); abdomen CT scan revealed ovarian cancer with rectum invasion is highly suspected.
  • Present illness
    • This 73-year-old, G2P2 (vaginal delivery) woman denied any medical history and surgical history.
    • This time, she came to our GI OPD on 2022/04/23 with the complaint of CHANGE IN BOWEL HABITS, WATEREY DIARRHEA 3-5 TIMES FOR SEVERAL MONTHS. She denied body weight loss, decreased appetite, progressively weakness or urinary frequency. Watery stool noted but no tarry or bloody stool. There was no fever, dyspnea, vaginal bleeding or other specific discomfort. No cancer family history was mentioned. Her symptoms didn’t relieved after medication, therefore, further survey was arranged as below:
      • 20230728 colonoscopy: One large polypoid lesion with overlaying mucosa noted at the rectum and parts of the surface had lost micro-surface and microvascular pattern. Rectal subepithelial lesion, R/O malignancy. Biopsy and pathology: adenocarcinoma.
      • 20230804 CEA and CA199: normal, CA125:451.3 U/mL (＜35).
      • 20230804 Abdomen CT: Ovarian cancer (enhancing soft tissue mass 11 cm in lengh) with rectum invasion is highly suspected.
    • Under the impression of PELVIC MASS IN WHICH OVARIAN CANCER CANNOT BE EXCLUDED, WITH RECTAL ADENOCARCINOMA, debulking surgery was suggested.
    • On arrival to our ward, the vital signs were stable. Blood test showed Hgb level as 13.9 g/dL, WBC level as 5,700 /uL and albumin level as 4.0 g/dL. We will arranged 2023/09/18 combined GYN (gynecology) debulking surgery with CRS (colon and rectal surgery), and consulted GU (division of urology) for double-J stenting insertion. We will closely follow her condition and complete pre-operation preparation.
  • Course of inpatient treatment
    • The patient was admitted on 2023-09-16 due to pelvic mass suspected ovarian cancer. She underwent subtotal hysterectomy and bilateral salpingo-oopherectomy + pelvic mass excision on 2023-09-18. The pathologic staging —Tumor, right pelvic wall, excision — High-grade serous carcinoma. stage IVB (pathology report: stage II if N0M0; after board conference, confirmed staging IVB).
    • The GYN tumor board conference suggest the patient to receive chemotherapy. Her postoperative course due to elevated D-dimer, Clexane was administered for prophylactic use. Self voiding was smooth. She was discharged on 2023-09-18. Her follow up appointment is scheduled on 2023-10-05.
  • Discharge prescription
    • MgO 250mg 2# QID
    • Acetal (acetaminophen 500mg) 1# QID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • cephalexin 500mg) 1# QID
    • plavix (clopidogrel 75mg) 1# QD
    • tetracycline 15mg/tube TID EXT

[Consultation]

• 2023-09-16 Urology
  • Q
    • Combined surgery GYN debulking surgery with CRS was arranged on 2023/09/18.
    • We need your help for double-J stenting insertion. Thank you very much!!
  • A
    • Dear doctor: we will stand by for the procedure.
• 2023-09-16 Colorectal Surgery
  • Q
    • This 73-year-old, G2P2 (vaginal delivery) woman denied any medical history and surgical history.
    • This time, she came to our GI OPD on 2022/04/23 with the complaint of diarrhea 3-5 times for more than 1 year. She denied body weight loss, decreased appetite, progressively weakness or urinary frequency. Watery stool noted but no tarry or bloody stool. There was no fever, dyspnea, vaginal bleeding or other specific discomfort. No cancer family history was mentioned. Her symptoms didn’t relived after medication, therefore further survey was arranged as below:
      • 20230728 colonoscopy: One large polypoid lesion with overlaying mucosa noted at the rectum and parts of the surface had lost micro-surface and microvascular pattern. Rectal subepithelial lesion, R/O malignancy.
      • Biopsy and pathology: adenocarcinoma.
      • 20230804 CEA and CA199: normal, CA125:451 U/mL (<35).
      • 20230804 Abdomen CT: Ovarian cancer (enhancing soft tissue mass 11 cm in lengh) with rectum invasion is highly suspected.
    • Under the impression of pelvic mass in which ovarian cancer cannot be excluded, surgical intervention was suggested.
    • Combined surgery GYN debulking surgery with CRS was arranged. We need your help for the operation.
  • A
    • CRS was consulted for combined surgery for large ovary ancer with rectum invasion..
    • DRE: palpable hard irregular mass lesion at anterior position of low rectum
    • A: Large ovary ancer with low rectum invasion
    • P:
      • We had informed the patient and her family at CRS OPD that the surgery of her cancer condition may need a colostomy (ovary cancer direct invading low rectum.)
      • LAR with protective colostomy or Hartmann operation may be performed depending on cancer condition (may require temporary or permanent enterostomy).

[surgical operation]

• 2023-09-18
  • Surgery
    • Bilateral ureter catheterization
  • Finding
    • Patent bilateral ureter orifices
    • No tumor was noted in the bladder
• 2023-09-18
  • Surgery
    • Diagnosis:
      • Pelvic mass, origin unspecified, r/o ovarian origin
      • Pelivc adhesion
    • Operation:
      • Subtotal hysterectomy + Bilateral salpingo-oopherectomy + Pelvic mass excision
  • Finding
    • Uterus: normal size, severe pelvic adhesion
    • LAD: grossly normal
    • RAD: grossly normal
    • Right pelvic wall mass, about 6 X 5 cm, papillary content
    • CDS: ascites(-), adhesion (+, severe)
    • Anti-adhesive agent: nil
    • Estimated blood loss: 150ml
    • Blood transfusion: nil
    • Complication: nil
• 2023-09-18
  • Surgery
    • Exploratory laparotomy
  • Finding
    • A huge hard tumor with irregular shape and densely invasion of pelvia side wall and whole rectum , which is unresectable and difficult to get R0 or R1 resection. We had informed her fanmily this condition, and GYN Dr had got some tissue for definite pathological report. No bowel trauma or leak was noted.

[chemotherapy]

• 2024-03-07 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-02-02 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-01-09 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-12-09 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-11-10 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-20 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-03-07

[considering a new MRI and reassessing the need for clopidogrel]

The decreasing CA125 levels indicate the efficacy of the treatment. The most recent MRI, conducted in 2023-10, is now 6 months old and could potentially be updated.

• 2024-02-02 CA125 64.1 U/mL
• 2024-01-09 CA125 111.8 U/mL
• 2023-12-09 CA125 194.2 U/mL
• 2023-10-31 CA125 351.9 U/mL
• 2023-10-19 CA125 401.6 U/mL
• 2023-08-04 CA125 451.3 U/mL

In the absence of recent d-dimer data and with PLT levels declining but still within the normal range, there seems to be no justification for the continued use of Plavix (clopidogrel). It may be prudent to reassess the necessity of this medication at this time.

• 2024-03-06 PLT 277 *10^3/uL
  

• 2024-02-01 PLT 322 *10^3/uL
  

• 2024-01-08 PLT 459 *10^3/uL

• 2023-12-08 D-dimer >10000 ng/mL(FEU)
  

• 2023-11-28 D-dimer >10000 ng/mL(FEU)
  

• 2023-11-10 D-dimer >10000 ng/mL(FEU)

700326470

240306

[exam findings]

• 2024-02-16 PD-L1 (SP142)
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • Tumor type: poorly cohesive carcinoma
    • Tumor location: stomach
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark ULTRA
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: [V]Pass, [ ]Fail
    • Adequate tumor cells present (>=50 viable tumor cells): [V] Yes, [ ] No
  • Result:
    • Tumor cell (TC) staining assessment:
      • TC category:
        • [V] TC <1%
        • TC >=1% and <5%
        • TC >=5% and <50%
        • TC >= 50%
      • Percentage of PD-L1 expressing tumor cells (%TC): <1%
    • Tumor-infiltrating immune cell (IC) staining assessment:
      • IC category:
        • [V] IC < 1%
        • IC >=1% and <5%
        • IC >=5% and <10%
        • IC >= 10%
      • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): <1%
  • Note:
    • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
    • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2024-02-16 PD-L1 IHC
  • Cellblock No. S2023-14710 A9
  • RESULTS
    • Combined Positive Score (CPS) assessment: CPS < 1
• 2023-11-22 CT - abdomen
  • History and indication: Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P gastric operation.
    • Colonic diverticula. Wall edema of A-colon.
    • A tumor (3.5cm) in uterus r/o myoma.
    • R/O right liver cyst (4mm).
    • Splenomegaly.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P gastric operation. No evidence of tumor recurrence.
• 2023-09-17 KUB
  • Scoliosis of L-spine with convex to left side.
  • S/P metalic autosuture projecting at left upper abdomen.
• 2023-09-14 ECG (ER)
  • Sinus rhythm with short PR
• 2023-07-28 Upper GI series
  • Indication: s/p total gastrectomy on 7/24
  • UGI series show
    • s/p total gastrectomy.
    • One linear structure at esophagointestinal junction. Nature?
• 2023-07-25 Patho - Stomach subtotal/total (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Stomach, total gastrectomy — Poorly cohesive carcinoma
    • Margins, frozen + bilateral cutting ends, ditto — Free of tumor invasion
    • Lymph nodes, LN 1, dissection — Free of  tumor metastasis (0/6)     - Lymph nodes, LN 2, ditto — Free of tumor metastasis (0/3)     - Lymph nodes, LN 3, ditto — Tumor metastasis (3/15) without extracapsular extension (0/3)     - Lymph nodes, LN 4, ditto — Tumor metastasis (4/14) with extracapsular extension (2/4), tumor deposition     - Lymph nodes, LN 5, ditto — Fat only     - Lymph nodes, LN 6, ditto — Tumor metastasis (3/13) without extracapsular extension (0/3), tumor deposition     - Lymph nodes, LN 7,8,9,11, ditto — Tumor metastasis (1/12) without extracapsular extension (0/1)     - Lymph nodes, LN 10, ditto — Fat only     - Lymph nodes, LN 12a, ditto — Free of tumor metastasis (0/2)  
    • Omentum, omentectomy — Tumor invasion, compatible with microscopically tumor seeding
    • AJCC Pathologic staging — pT4aN3aM1, stage IV
  • MACROSCOPIC EXAMINATION
    • Specimen type: stomach, lymph nodes and omentum
    • Specimen size: stomach: GC: 26.2 cm and LC: 14.2 cm
    • Number of lesions: solitary mass
    • Tumor site: from antrum to fundus
    • Tumor size: 13.2 cm in diameter
    • Tumor configuration: elevated or flat firm mass
    • Omentum: 45 x 9.5 x 1.1 cm, no obviously tumor grossly  
    • Representatively embedded for sections as A1: esophageal cutting end, A2: distal cutting end, A3-A8: tumor at fundus, A9-A12: tumor at body to antrum, A13: fat at lesser curvature, A14: non-tumor stomach, B: LN 1, C: LN 2, D1-D2: LN 3, E1-E2: LN 4, F: LN 5, G: LN 6, H1-H2: LN 7,8,9,11, I: LN 10, J: LN 12 and K: omentum. [Reference: F2023-00332 esophageal cutting end, one small piece measured 4.2 x 0.5 x 0.4 cm in size. All embedded]
  • MICROSCOPIC EXAMINATION
    • Histologic type: Poorly cohesive adenocarcinoma
    • Histologic grade: Grade 3
    • Depth of tumor invasion: serosa layer
    • Lymph nodes
      • Lymph nodes, LN 1: Free of  tumor metastasis (0/6)       - Lymph nodes, LN 2: Free of tumor metastasis (0/3)       - Lymph nodes, LN 3: Tumor metastasis (3/15) without extracapsular extension (0/3)       - Lymph nodes, LN 4: Tumor metastasis (4/14) with extracapsular extension (2/4) and tumor deposition       - Lymph nodes, LN 5: Fat only       - Lymph nodes, LN 6: Tumor metastasis (3/13) without extracapsular extension (0/3) and tumor deposition       - Lymph nodes, LN 7,8,9,11: Tumor metastasis (1/12) without extracapsular extension (0/1)       - Lymph nodes, LN 10: Fat only       - Lymph nodes, LN 12a: Free of tumor metastasis (0/2)  
    • Omentum: tumor invasion
    • AJCC Pathologic Staging: pT4aN3aM1
    • Bilateral cutting end: Free of tumor invasion
    • Additional pathologic findings: fat tissue deposition
    • Perineural invasion: Present
    • Lymphovascular space invasion: Present
    • Immunohistochemistry: CK(+) for isolet tumor cells of lymph node and tumor deposition at connective tissue
• 2023-06-26 CT - abdomen
  • History and indication: gastric tumor: biopsy proved poorly cohesive carcinoma; for staging
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of lower gastric body and antrum with regional LAP.
    • Left ovary cyst (2.5cm).
    • Colonic diverticula.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
• 2023-06-16 Patho - stomach biopsy
  • Stomach, low body, biopsy — Poorly cohesive carcinoma
  • Microscopically, the sections show a picture of poorly cohesive carcinoma with focal signet-ring cell differentiation characterized by individual tumor cells infiltrating in stroma.
  • Immunohistochemistry of CK(+) for tumor. Besides, colony of Helicobacter Pylori is identified in the submitted specimen.

[MedRec]

• 2023-09-15 ~ 2023-09-21 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24; status post intraperitoneal chemotherapy with 5FU on 2023/08/02~2023/08/06 and Immunity therapy with Nivolumab (200mg, self paid)/FOLFOX (Oxalip 75mg/m2, Covorin 300mg/m2, 5-Fu 300mg/m2, 5-Fu 2400mg/m2 ) on 2023/09/04~
    • Vomiting, unspecified
    • Chronic viral hepatitis B without delta-agent
    • Abnormal results of liver function studies
    • Hypokalemia
    • Cachexia
    • Neutropenia, unspecified
  • CC
    • Progression nausea with vomiting for 3 days.
  • Present illness
    • (Previously stated part omitted…)
    • Tumor marker on 2023/09/04 of CEA:1.21ng/mL. She denied fever, chills dizzness, body weight loss and tarry stool passage. Complain mild poor appetite and nausea was noted.
    • Immunity therapy with Nivolumab (200mg, self paid)/FOLFOX (Oxalip 75mg/m2, Covorin 300mg/m2, 5-Fu 300mg/m2, 5-Fu 2400mg/m2 ) on 2023/09/04(C1D1).
    • This time, progression nausea with vomiting and poor appetite with weakness for 3 days. No chills with fever, dyspnea, chest pain, abdominal pain and tarry stool passage was noted.
    • Therfore, she was snet to ER and Lab deta showed leukocytopenia (WBC:2860/uL, Neu:39.2%, ANC:1121.12), Abnormal results of liver function studies (GOT:136U/L, GPT:151U/L). Now, she was admitted to ward for further treatment.
  • Course of inpatient treatment
    • After admitted, IVF supplementation for poor appettie.
    • Primperan 1pc iv Q8H for nausea and vomiting.
    • Actein 1# po BID for sputum.
    • Leukocytopenia with delay chemotherapy.
    • Chronic viral hepatitis B without delta-agent (Anti-HBc(+)) with Baraclude 0.5mg 1# po QDAC.
    • Abnormal results of liver function studies (GOT: 136 -> 49 -> 37U/L, GPT: 151 -> 61 -> 36U/L) with Silymarin 2# po BID from 2023/09/15~.
    • Hypokalemia (K: 3.0 -> 4.2mmol/L) with 0.298% KCl in NS 500ml IVF BID from 2023/09/18~2023/09/21.
    • Cachexia with Megest 10ml po QD.
    • Patient tolerated the nausea and vomiting improving. With the stable condition, she was discharged on 2023/09/21 and OPD followed up later.     
  • Discharge prescription
    • Asthan (ketotifen 1mg) 1# BID (dermatologist suggested)
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Lactul (lactulose 666mg/mL, 60mL/bot) 10mL BID
    • Belolin ointment (clobetasol 0.5mg/gm, 7gm/tube) BID TOPI (dermatologist suggested)
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • BaoGan (silymarin 150mg) 2# BID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Through (sennoside 12mg) 2# HS
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2023-09-14 SOAP MER He Yaocan
  • S: Triage Level: 3 Nausea/Vomiting > Acute Persistent Vomiting. Chemotherapy ended on 9/6, currently experiencing severe vomiting.
    • CC: severe vomiting from 9/6 after chemotherapy
    • Hx: gastric ca status post total gastrectomy with lymph node dissection
    • allergy to drugs: ampicillin
    • no chest pain, abd pian, diarrhea
  • A/P
    • Preliminary impression: R11.10 Vomiting, unspecified
    • Lab
      • 2023/09/14 12:18 Creatinine = 0.47 mg/dL;
      • 2023/09/14 12:18 eGFR = 149.08;
      • 2023/09/14 12:18 S-GPT/ALT = 151 U/L;
      • 2023/09/14 12:18 S-GOT/AST = 136 U/L;
      • 2023/09/14 12:18 Na (Sodium) = 132 mmol/L;
      • 2023/09/14 12:18 K(Potassium) = 3.3 mmol/L;
      • 2023/09/14 12:08 WBC = 2.86 x10^3/uL;
      • 2023/09/14 12:08 Neutrophil = 39.2 %;
  • Prescription
    • Taita No.5 Injection (electrolyte solution) 500mL ST IVD 60cc/hr
    • Taita No.5 Injection (electrolyte solution) 500mL ST IVD
    • Vomstop (granisetron 1mg) ST IVD
    • Imperan (metoclopramide 10mg) ST IVD
    • Taita No.5 Injection (electrolyte solution) 500mL ST IVD 100cc/hr
• 2023-09-12 SOAP General and Gastroenterological Surgery Chen JiaHui
  • S: for Port-A insertion wound follow up. Besides, she vomits several times after chemotherapy for days
  • O: PE: 2 cm suture wound over L’t subclavian region
  • Prescription
    • Roumin (prochlorperazine maleate 5mg) 1# TID
• 2023-09-08 SOAP General and Gastroenterological Surgery Wu Chaoqun
  • Prescription
    • hydroxocobalamin 1mg IM 6 days
• 2023-09-04 ~ 2023-09-07 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24; status post intraperitoneal chemotherapy with 5FU on 2023/08/02-2023/08/06. ECOG:1
    • Chronic viral hepatitis B without delta-agent, Anti-HBc reactive
  • CC
    • for scheduled chemotherapy        
  • Present illness
    • This 50-year-old female was diagnosis Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24; status post intraperitoneal chemotherapy with 5FU on 2023/08/02-2023/08/06. Denied TOCC history in recent three months. Initially, she sufferred from acid regurgitation with chest burning, postprandial fullness and relieved by vomiting for many weeks. She came to our GI OPD for help. Panendoscope was performed which showed gastric giant rugae, suspicious malignancy (such as gastric cancer, Borrmann type 4), low body, status post biopsy. Duodenal shallow ulcers, bulb. Pathology showed poorly cohesive carcinoma on 2023/06/15. Further abdomen CT on 2023/06/26 which showed wall thickening of lower gastric body and antrum with regional lymphadenopathy. cT3N2M0 stage III.
    • As the result, she referred to our GS OPD for surgical intervention. Then, she received total gastrectomy with EJ Roux-en-Y anastomosis and LN dissection was processed successfully on 2023/07/24, UGI series was performed on 7/28 and no evidence of anastomosis leakage was found.
    • Final pathology showed poorly cohesive adenocarcinoma, pT4aN3aM1 stage IV. Then, further IP chemotherapy with 5Fu (920mg) for 5 days (2023/08/02-08/06), and Mitomycin-C (27mg) on 2023/08/03.
    • Tumor marker of CEA:1.21ng/mL. She denied fever, chills dizzness, body weight loss and tarry stool passage. Complain mild poor appetite and nausea was noted. Under impressed of gastric cancer, she was admitted to our service for chemotherapy.
  • Course of inpatient treatment
    • After admission, he received Nivolumab (200mg, self paid) plus FOLFOX (Oxalip 75mg/m2, Covorin 300mg/m2, 5-Fu 300mg/m2, 5-Fu 2400mg/m2 ) from 2023/09/04~2023/09/06(C1D1) smoothly.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for AntiHBc (+).
    • Patient tolerated the chemotherapy with mild nausea and vomiting. With the stable condition, she was discharged on 2023/09/07 and OPD followed up later.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2023-08-15 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • arranged abd CT scan on 6/26
    • refer to GS OPD Chief Wu on 6/27 for further management such as surgery or other further management.
    • Arrange admission for FOLFOX with or without Nivolumab, 1st line of CM649 (CheckMate649)
• 2023-07-23 ~ 2023-08-09 POMR General and Gastroenterological Surgery Wu Chaoqun
  • Discharge diagnosis
    • Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24; status post intraperitoneal chemotherapy with 5FU on 2023/08/02-2023/08/06. ECOG:1
  • CC
    • Acid regurgitation with chest burning, postprandial fullness and relieved by vomiting for many weeks
  • Present illness
    • This 50-year-old female denied of systemic disease before. She sufferred from acid regurgitation with chest burning, postprandial fullness and relieved by vomiting for many weeks. She came to our GI OPD for help. Panendoscope was performed which showed gastric giant rugae, suspicious malignancy (such as gastric cancer, Borrmann type 4), low body, status post biopsy. Duodenal shallow ulcers, bulb. Pathology showed poorly cohesive carcinoma.
    • Further abdomen CT on 2023/06/26 which showed wall thickening of lower gastric body and antrum with regional lymphadenopathy. cT3N2M0 stage III. As the result, she referred to our GS OPD for further management.
    • Tumor marker of CEA:1.31ng/mL. She denied fever, chills dizzness, poor appetite, nausea, body weight loss and tarry stool passage. Under impressed of gastric cancer, she was admitted to our service for surgical intervention.
  • Course of inpatient treatment
    • After admitted, she received total gastrectomy with EJ Roux-en-Y anastomosis and LN dissection was processed successfully on 7/24. Post operaively, we observed patient recovery and keep adequate fluid, nutrition support with PPN, empiric antibiotic, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed.
    • UGI series was performed on 7/28 and no evidence of anastomosis leakage was found. She try to introduced liquid diet with step by step until tolerate well for semi-liquid. Right side JP tube removal on 7/31. Final pathology showed poorly cohesive adenocarcinoma, pT4aN3aM1 stage IV.
    • Then, further IP chemotherapy with 5Fu (920mg) for 5 days (8/2-8/6), and Mitomycin-C (27mg) on 8/3 was performed smoothly.
    • Post chemotherpay with mild nausea and poor apppetite were noted, then promeran support since 8/4. Removal JP tube was done smoothly after finish of IP chemotherapy.
    • Her generally well beings and relativley stable. There were no nosocomial infection and other complications and vital signs were stable after the surgery. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Under stated improvement of clinical symptoms without vomit and appetite improved, she was allowed to discharge today then OPD follow up was arranged.
  • Diagnosis prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Through (sennoside 12mg) 2# HS
    • Celebrex (celecoxib 200mg) 1# QD
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • BaoGan (silymarin 150mg) 1# TID
• 2023-06-23 SOAP Gastroenterology Chen HongDa
  • S
    • easily fullness and nausea sensation after meals.
    • EGD: gastric tumor: biopsy proved poorly cohesive carcinoma;
    • DUs; CLO positive.
    • arranged abd CT scan on 6/26
    • refer to GS OPD Chief Wu on 6/27
    • we’ve informed possible side effect of HP eradication therapy: the patient understood and agreed
    • We’ve explained indication and possible complications, pros and cons of abd CT scan with contrast enhancement such as radiation exposure, allergic reaction to contrast media, contrast media related nephrotoxicity=> the patient understood and agreed with abdominal CT scan with contrast enhancement.
    • female patient: she denied pregnancy
  • O
    • 2023/06/16 PATHO - stomach biopsy
      • Stomach, low body, biopsy — Poorly cohesive carcinoma
    • PE abd soft no tenderness; no palpable mass.
    • past medical disease Hx: denied
    • allergy to drugs; denied
    • patient denied other medical disease such as chronic kidney disease; patient denied allergy to drugs; patient denied pregnancy
  • A/P
    • arranged abd CT scan on 6/26
    • refer to GS OPD Chief Wu on 6/27 for further management such as surgery or other further management.
  • Prescription
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Pariet (rabeprazole 20mg) 1# QNAC
    • Mopride (mosapride citrate 5mg) 1# TID
    • Klaricid (clarithromycin 500mg) 1# BID
    • Metrozole (metronidazole 250mg) 2# BID
• 2019-12-13 SOAP Family Medicine Xie QiPan
  • S
    • swelling pain of right dorsal hand for 4 days,
    • morning stiffness (+) duration 20 minutes
    • PH: IDA, anemia
  • O
    • BT 36.8 C, BP 140/96, HR 100
    • swelling tenderness of right MP joints of 2nd and 3rd
    • A: cellulitis or gout or OA or RA
    • P: check BCS, RF, Uric acid. Mx, f/u
  • Diagnosis
    • Osteoarthritis [M19.90]
    • Gout [M10.9]
    • Arthropathy associated with other bacterial diseases, unspecified site [M01.X0]
  • Prescription
    • cephalexin 500mg 1# Q6H
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
    • Ulstop (famotidine 20mg) 1# BID
    • Naposin (naproxen 250mg) 1# TID
    • Compesolon (prednisolone 5mg) 1# QD
    • colchicine 0.5mg 1# QD
• 2019-11-15 SOAP Family Medicine Lin ChunYu
  • S
    • intermittent chest tightness and palpitation for years
    • right hand numbness while wake up recently
    • had vivist Neuro OPD (EEG: ok)
      
    • Past hx: IDA s/p IV Fe, myoma
    • allergy: denied
  • Diagnosis
    • Chest tightness [R07.89]
    • Iron deficiency anemia, unspecified [D50.9]
    • Idiopathic insomnia [F51.01]
    • Neuralgia, neuritis, and radiculitis, unspecified [M79.2]
    • Palpitations [R00.2]
    • Acute nasopharyngitis [common cold] [J00]
    • HTN [I10]
    • Gout [M10.9]
    • Constipation [K59.00]
  • Prescription x3
    • Foliromin (sodium ferrous citrate 50mg) 1# BID
• 2018-03-21 SOAP Obstetrics and Gynecology Chen YiLing
  • S
    • 45y/o sex+ G2P0SA1AA1 LMP 2018/03/09 28 -> 21
    • IDA under iron supplement and tachycardia
    • large amount of MC for 1 year
    • OV cyst by health exam 2 years ago
    • Hx HTN
    • for pap smear
  • O
    • RTC on 6/13 for ergonovine effect; consider TAH in the furutre
    • 2018/03/09 Hb：8.9 g/dL
    • PV VD: scanty; Cx eroded
    • 2018/03/21 TVS: EM: 11.9mm Myoma : 2.9 x 2.4 , 4.7 x 4.5 cm
  • A
    • Excessive of frequent menstruation [N92.0]
    • Other disorders of menstruation and other abnormal bleeding from female genital tract [N92.5]
    • Screening for malignant neoplasms of cervix [Z12.4]
  • Prescription
    • Naposin (naproxen 250mg) 1# TID
    • ergometrine maleate 0.2mg 1# Q8H
    • Frotin (metronidazole 250mg) 1# HS
• 2018-03-12 SOAP Family Medicine Ye JiaZe
  • A: Iron deficiency anemia, unspecified [D50.9]
  • Prescription
    • Foliromin (sodium ferrous citrate 50mg) 1# BID
• 2018-03-05 SOAP Family Medicine Ye JiaZe
  • O: BP:142 80 mmHg; HR:70; Height: 160 cm; Weight: 77 Kg;
  • A
    • HTN [I10]
    • Gout [M10.9]
  • Prescription
    • Tonec (aceclofenac 100mg) 1# BID

[consultation]

• 2023-09-16 Dermatology
  • Q
    • This 50-year-old woman patient is a case of Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24; status post intraperitoneal chemotherapy with 5FU on 2023/08/02~2023/08/06 and chemotherapy with FOLFOX from 2023/09/04.
    • This time, abdominal redness rash. Now, for evaluate abdominal redness rash therapy. Thank you.
  • A
    • This patient suffered from multiple erytheamtous papules on trunk for days.
    • Imp: Miliaria rubra
    • Suggestion:
      • Zaditen 1/Bid (Ketotifen is a histamine H1 receptor blocker and mast cell stabilizer used to treat mild atopic asthma and allergic conjunctivitis.)
      • Clobatasol x 6 tubes/bid
• 2023-08-07 Hemato-Oncology
  • A
    • This 50 year old woman is a case of Poorly cohesive carcinoma of gastric cancer, pT4aN3aM1, stage IV, s/p total gastrectomy with LN dissection on 7/24, s/p  IP chemotherapy with 5Fu 500mg/m2 for 5 days (8/2-8/6), and Mitomycin-C 20mg/m2 on day 2 (8/3). We are consulted for further evaluation.
    • We had disucssed with patient about palliative chemotherapy with immunotherapy (Nivo + FOLFOX).
    • Arrange our OPD after discharge. Arrange port A insertion before treatment.

[surgical operation]

• 2023-07-24
  • Surgery
    • Total gastrectomy with LN1-12a dissection
    • EJ Roux-en-Y anastomosis with EndoGIA
  • Finding
    • Scirrhous type gastric ca with primary origin at distal stomach
    • multiple LN enlarge at 5,6,12,8
    • ascite (-)
    • seeding (-)
    • liver mets (-)
    • frozen section of distal esophagus: negative for ca

[immunochemotherapy]

• 2024-03-05 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL …………………………………….. + fluorouracil 2000mg/m2 3300mg 46hr (Opdivo + FOLFOX, Oxa 65mg/m2)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-15 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL …………………………………….. + fluorouracil 2000mg/m2 3300mg 46hr (Opdivo + FOLFOX, Oxa 65mg/m2)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-01-18 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL …………………………………….. + fluorouracil 2000mg/m2 3300mg 46hr (Opdivo + FOLFOX, Oxa 65mg/m2)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-25 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL …………………………………….. + fluorouracil 2000mg/m2 3300mg 46hr (Opdivo + FOLFOX, Oxa 65mg/m2)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-22 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL …………………………………….. + fluorouracil 2000mg/m2 3300mg 46hr (Opdivo + FOLFOX, Oxa 65mg/m2)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-18 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL …………………………………….. + fluorouracil 2000mg/m2 3300mg 46hr (Opdivo + FOLFOX, Oxa 65mg/m2 for severe vomiting)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-28 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL …………………………………….. + fluorouracil 2000mg/m2 3300mg 46hr (Opdivo + FOLFOX; due to neutropenia: Oxa 75 -> 65mg/m2, 5FU bolus DC and infusion 2400 -> 2000mg/m2)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-04 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 130mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL + fluorouracil 300mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg 46hr (Opdivo + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-02 - fluorouracil 500mg/m2 920mg 1hr IP D1-5 (fore IPEC via JP tube drip 1hr then retension 23hrs) + mitomycin-C 20mg/m2 37mg NS 500mL 2hr IP D2 (with pump on day 2) (IPEC)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2024-03-06

[check if iron sufficient]

In the CheckMate 649 trial, nivolumab was administered at a dosage of 360mg Q3W or 240mg Q2W, alongside the investigator’s choice of chemotherapy. Since 2023-09-04, nivolumab plus FOLFOX has been initiated with a reduced nivolumab dosage of 200 mg at intervals of 3 or 4 weeks in clinical practice. Given that nivolumab is not covered by the National Health Insurance and requires self-payment, administering the full dosage could impose a significant financial burden on the patient. Using a dosage lower than that specified in the trial protocol might result in a less optimal effect than the outcomes observed in the CheckMate 649 trial.

Aside from slight tachycardia observed in the vital signs, laboratory data (2024-03-05) remained largely within normal ranges.

The patient underwent gastrectomy on 2023-07-24. Post-gastrectomy, the absence of intrinsic factor - a protein essential for vitamin B12 absorption produced by the stomach - necessitates the use of B-Red (hydroxocobalamin).

Furthermore, iron deficiency anemia is a common complication following gastrectomy due to diminished iron absorption. Assessing the body’s iron stores is recommended to determine the need for iron supplementation.

2023-10-19

[hypokalemia, hypomagnesemia, hypoalbuminemia, hypocalcemia]

Lab data:

• 2023-10-18 K(Potassium) 2.5 mmol/L
• 2023-10-18 Mg (Magnesium) 1.4 mg/dL
• 2023-10-18 Ca (Calcium) 1.68 mmol/L
• 2023-10-18 Albumin(BCG) 2.8 g/dL

KCl and MgSO4 were given intravenously to treat hypokalemia and hypomagnesemia without any problems.

Lab results from 2023-10-18 indicated Ca 1.68 mmol/L, Albumin 2.8 g/dL. An estimated corrected serum calcium of 7.7 mg/dL, equivalent to 1.9 mmol/L, which is still beneath the normal range. Considering calcium and albumin supplements could be an optional course of action.

[severe delayed vomiting]

Severe vomiting persisted after the previous chemotherapy session (from 2023-09-04 to 2023-09-06), became intolerable, and led the patient to seek emergency care at our hospital on 2023-09-14. This type of vomiting is likely post-chemotherapy delayed vomiting.

For chemotherapy-induced delayed vomiting, NK-1 receptor antagonists (NK-1 RAs) may be preferred over 5-HT3 receptor antagonists (5-HT3 RAs). NK-1 RAs inhibit the effects of substance P, a neurotransmitter involved in vomiting, especially during the delayed phase. While 5-HT3 RAs block serotonin receptors and are most effective in the acute phase.

A study published in BMC Cancer found that the prolonged use of an NK-1 RA (fosaprepitant) in addition to a 5-HT3 RA and dexamethasone was more effective in preventing delayed Chemotherapy-Induced Nausea and Vomiting (CINV) compared to a regular dosage. The study showed a statistically significant lower incidence of nausea and slightly lower incidence of grade 1 vomiting in the delayed phase. Ref: https://bmccancer.biomedcentral.com/articles/10.1186/s12885-023-11070-3

Our hospital stocks Akynzeo, which includes netupitant, the NK-1 RA with the longest half-life at 96 hours.

701516762

240306

[exam findings]

• 2024-03-01 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Severe hypoplasia and see description
  • The specimen submitted consists of a core of gray-brown and hard bony tissue, measuring 3.0 x 0.2 x 0.2 cm. All for section after decalcification.
  • The sections show severe hypocellular marrow (<5%). All three lineages are markedly decreased with scattered plasma cells infiltrate in interstitium. The finding is compatible with aplastic anemia. Suggest further bone marrow smear evaluation and clinic correlation.
• 2024-03-01 Gynecologic ultrasonography
  • EDC: 2024-05-11
  • GWI(LMP): 29+6 wk
  • IMP: IUP at 29+6 wks

[MedRec]

• 2024-02-29 SOAP Medical Emergency Lu GuanLing
  • A/P
    • Phoned Dr. Gao, he said that she needs to be hospitalized for bone marrow biopsy, and the use of G-CSF is currently not recommended.
    • Patient Mobile Obstetrics and Gynecology Clinic App data:
      • 2024/01/25 Hb 9.9, PLT 61k, WBC 4k
      • 2023/10/30 WBC 10.3k, Hb 12.4, PLT 191k, anti-TPO 4881 U/ml, T4 12.9 ug/dL
• 2024-02-29 SOAP Hemato-Oncology Gao WeiYao
  • S
    • She was a pregnant woman 7 months+ but she was informed to have anemia and platelet problem during Obs predelivery work up. PLT 61K on 2024-01-25.
    • Gestational diabetes and suspected to have preeclampsia treated with aspirin since last Oct, 2028.
  • O
    • 20240229: BP 126/73; HR 116; BH 159; BW 54; BMI 21.4
    • Gum bleeding and oral ulcer having difficult to eat.
  • A
    • Bleeding diathesis, thrombocytopenia, nature ?
    • pregnancy 7 months
  • P
    • Refer to ER for admision and work up. ASAP
  • Diagnosis
    • Thrombocytopenia, unspecified [D69.6]
    • Gestational diabetes mellitus in pregnancy, unspecified control [O24.419]
    • Anemia, Unspecified [D64.9]

==========

2024-03-06

[aplastic anemia during pregnancy]

Epstein-Barr virus infection (no test result yet), seronegative hepatitis (AST 60, ALT 93 on 2024-03-04) are reported associating aplastic anemia.

It is suggested (Ref: Aplastic anemia during pregnancy: a review of obstetric and anesthetic considerations. Int J Womens Health. 2018 Feb 28;10:117-125. doi: 10.2147/IJWH.S149683):

• Identifying and addressing underlying causes and treating cytopenias while minimizing therapy side effects on both mother and fetus.
• Considering pregnancy termination if severe pancytopenia or bone-marrow suppression triggers, like drug reactions or infections, cannot be managed safely during pregnancy (this should not be applied in this patient’s case).
• Addressing severe thrombocytopenia due to its association with increased maternal and fetal complication rates, including risks of postpartum hemorrhage and adverse pregnancy outcomes such as preeclampsia and fetal death.
• Highlighting the need for optimal treatment, including transfusion management to avoid hemochromatosis and HLA alloimmunization, which can lead to platelet transfusion refractoriness.

Lab results from 2024-01-25 indicated WBC 4K, HGB 9.9, PLT 61K, compared to previous results on 2023-10-30 with WBC 10.3K, HGB at 12.4, and PLT at 191K. This could suggest the development of bone marrow hypoplasia over the recent months.

An elevated level of anti-TPO, like 4881 U/ml in this case (2023-10-30), can indicate the presence of autoimmune thyroiditis, also known as Hashimoto’s thyroiditis.

700828939

240305

[exam findings]

• 2024-02-16 CT - abdomen
  • History: Poorly cohesive carcinoma (signet-ring cell) of gastric with peritoneal seeding, cT4aN3aM1 stage IV, status post gastrojejunostomy with Hyperthermic Intraperitoneal Chemotherapy with Oxalip and Mitomycin on 2023/11/23. ECOG:1
  • Findings: Comparison: prior CT dated 2023/11/08.
    • Prior CT identified focal wall thickening with irregular contour at the gastric antrum is noted again, marked decreasing in wall thickness that is c/w adenocarcinoma of the stomach antrum S/P C/T with partial response or complete response.
      • Please correlate with gastroscopy.
      • In addition, Prior CT identified seven enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, decreasing in number that are c/w metastatic nodes S/P C/T with partial response.
    • Prior CT identified a soft tissue nodule 0.9 cm in right upper pelvis omentum area is not noted again that may be metastatic node S/P C/T with complete response. Follow up is indicated.
    • Prior CT identified few small lymph nodes in para-aortic space and para-cava space (up to 7 mm) are noted again, decreasing in number that may be non-regional metastatic nodes S/P C/T with partial response.
      • Follow up is indicated.
    • Tiny gallbladder stones.
    • Mild ascites in the pelvis is suspected.
    • S/P port-A implantation at RUQ abdominal wall and the catheter tip located in the upper pelvis midline omentum.
  • Impression:
    • Adenocarcinoma of the stomach antrum S/P C/T with partial response or complete response is highly suspected. Please correlate with gastroscopy.
    • Regional and non-regional metastatic nodes S/P C/T with partial response is highly suspected. Follow up is indicated.
• 2023-12-18 PD-L1 IHC 28-8
  • Immunostaining Result :28-8
  • Testing assay: pharmDx Assay (Agilent/Dako)
  • Cellblock No. F2023-00526FS
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS >= 1 and < 10
    • Combined Positive Score (CPS): 1
• 2023-11-24 Patho - uterus (with or without SO) neoplastic
  • Stomach, cardia and body, biopsy — poorly differentiated adenocarcinoma with signet-ring cell differentiation, seeding
  • Microscopically, sections show poorly differentiated adenocarcinoma with signet-ring cell diffferentiation and stromal fibrosis.
  • Immunohistochemical stains reveals CK7(+), CK20(+), CDX-2(+), CK(+). The tumor is compatible with gastrointestinal origin.
• 2023-11-15 Patho - stomach biopsy
  • Stomach, middle body, biopsy — Poorly cohesive carcinoma, signet-ring cell type
  • The sections show a picture of poorly cohesive carcinoma, composed of gastric body mucosal tissue with isolated or small aggregates of tumor cells, pleomorphic eccentric nuclei, abundant clear cytoplasm, and no well-fromed glands.
• 2023-11-15 Patho - stomach biopsy (Y1)
  • Stomach, angle, biopsy — Poorly cohesive carcinoma, signet-ring cell type
  • The sections show a picture of poorly cohesive carcinoma, composed of isolated and small aggregates of tumor cells with pleomorphic eccentric nuclei and abundant clear cytoplasm, without well-fromed glands.
  • IHC: HER2 — Negative (score = 0)
• 2023-11-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 17) / 53 = 67.92%
    • M-mode (Teichholz) = 67
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Mild to moderate MR, mild to moderate TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
• 2023-11-13 Flow Volume Chart
  • Mild obstructive ventilatory impairment
• 2023-11-10 ECG
  • Biatrial enlargement
  • Incomplete right bundle branch block pattern
  • Abnormal ECG
• 2023-11-08 CT - abdomen
  • CC: gastric cancer at antrum by EGD and pathology result at LMC.
  • History: Right ureteral stricture with hydronephrosis, S/P right ureterorenoscopy & internal dilatation of ureter with double-J stenting 
  • Findings:
    • There is focal wall thickening with irregular contour at the gastric antrum, 2.5 cm in wall thickness and 9 cm in size, causing marked dilatation of the proximal stomach.
      • Adenocarcinoma of the stomach antrum (T4a) with gastric outlet obstruction is highly suspected.
      • In addition, there are seven enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament.
      • Metastatic nodes (N3a) are highly suspected.
    • There is a soft tissue nodule 0.9 cm in right upper pelvis omentum area (Srs:301 Img:48) that may be metastatic node.
    • There are few small lymph nodes in para-aortic space and para-cava space (up to 7 mm). Please correlate with PET scan.
    • There is mild right side hydroureteronephrosis but no delayed contrast excretion of right kidney. However, the transition zone is hard to identify. Please correlate with retrograde pyelography.
    • Tiny gallbladder stones.
    • There is ascites in the pelvis, nature?
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N3a(N_value) M:M0(M_value) STAGE:III(Stage_value)
• 2023-09-13 ECG
  • Biatrial enlargement
  • Incomplete right bundle branch block
• 2023-09-07 CT - abdomen
  • History and indication: hydro: r/o radiolucent stone
  • Non-contrast CT of abdomen-pelvis revealed:
    • Right hydronephrosis.
    • Tiny gallbladder stones.
    • Atherosclerosis of aorta, iliac arteries.
    • Partial atelectasis at RML and left lingual lung.
  • IMP:
    • Right hydronephrosis.
    • Tiny gallbladder stones.

[MedRec]

• 2024-01-31 SOAP Hemato-Oncology He JingLiang
  • Prescription x3
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
• 2023-12-08 SOAP General and Gastrointestinal Surgery Wu ChaoQun
  • Prescription x3
    • Hepac Lock Flush (heparin sodium) 20mL ST IRRI
    • NS 20mL ST
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Amamet (glimepiride 2mg, metformin 500mg) 0.5# QDAC
    • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
• 2023-11-10 ~ 2023-12-02 POMR General and Gastrointestinal Surgery Wu ChaoQun
  • Discharge diagnosis
    • Poorly cohesive carcinoma (signet-ring cell) of gastric with peritoneal seeding, cT4aN3aM1 stage IV, status post gastrojejunostomy with Hyperthermic Intraperitoneal Chemotherapy with Oxalip and Mytomicin on 2023/11/23. ECOG:1
    • Encounter for adjustment and management of vascular access device with port-A insertion on 2023/11/23.
    • Encounter for antineoplastic immunotherapy with Nivoluamb (100mg) on 2023/12/1.
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Malnutrition
  • CC
    • Intermittent epigastric pain for 4 months, and abdomen fullness accompany vomit was noted since recent 1 month.
  • Present illness
    • This 69-year-old woman has history of
      • Hypertension under medication control for years;
      • Appendectomy;
      • Hysterectomy,
      • Right ureteral stricture with hydronephrosis, post right ureterorenoscopy and internal dilatation of ureter stricture with double-J stenting on 2023-09-14.
    • According for this patient statement, she sufferred from intermittent epigastric pain since 4 months ago. However, abdomen fullness accompany vomit was noted since recent 1 month. She visited to LMD for follow up, then UGI scope showed reddness of mucosa, submucosal infiltration lesion with surrounding mucosal swelling and superfial ulcerations from antrum to angularis biopsy then pathology showed malignancy.
    • Therefore, she came to our GI OPD for help. Further abdomen CT was performed which showed gastric cancer of stomach antrum (T4a) with gastric outlet obstruction is highly suspected. T4aN3aM0; stage: III. As the result, she refferred to our GS OPD for further evaluation.
    • Body weight loss 56kg to 47.5kg in recent 3 months was also noted. Tumor marker of CEA showed 1.55ng/ml. She denied fever, chills dizzness, poor appetite, nausea and tarry stool passage but less of stool passage was noted.
    • This time, she admitted to our ward for nutrition support first and further evaluate and management.
  • Course of inpatient treatment
    • After admitted, nutrtion support with TPN was given due to malnutrition. NG insertion with irrigation was also noted smoothly.
    • UGI scope was performed and showed advanced gastric cancer, Bormann type 4, body and angle, s/p biopsy. Final pathology showed poorly cohesive carcinoma, signet-ring cell type.
    • She received further operation on 2023/11/23 which revealed distal gastric cancer with peritoneal seeding at round ligament and lesser curvature (PCI:5/39), cancer direct invasion to posterior pancreas body.
    • Thus, Open GJ bypass with HIPEC Oxalip 300 mg/M2 (425 mg) + Mytomicin C 15 mg/M2 (21 mg) and port-A insertion was processed successfully on 2023/11/23.
    • Post operaively, we observed patient recovery and keep empiric antibiotic, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed. She try to introduced diet with step by step until well tolerate of semi-liquid diet. Her generally well beings and relativley stable. There were no nosocomial infection and other complications and vital signs were stable after the surgery. We consulted Oncology for further neoadjuvant chemotherapy with IP + IV chemotherapy then will be arrange at OPD. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Abdomen wound clean and was removal JP tube was done on 2023/11/30.
    • First IV immunotherapy with Nivolumab (100mg) was performed smoothly on 2023/12/01. The medication was applied and no significant discomfort was complained of.
    • Under a relative stable condition, she was allowed to discharge today and OPD follow up was arranged.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Amamet (glimepiride 2mg, metformin 500mg) 0.5# QDAC
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Takepron (lansoprazole 30mg) 1# QDAC
    • Exforge (amlodipine 5mg, valsatan 160mg) 1# QD
• 2023-06-27 SOAP Family Medicine Ye JiaQi
  • S
    • HTN, Home SBP 140, Diovan -> Exoforge
    • DM
    • Hematuria
    • skin itchiness and GI discomfort with metformin??
    • Past history HIVD with left S1 radiculpathy
  • Prescription x3
    • Exforge (amlodipine 5mg, valsatan 160mg) 1# QD
    • Uformin (metformin 500mg) 1# QDCC

[consultation]

• 2023-11-30 Hemato-Oncology
  • Q
    • For further bidirectional neoadjuvant chemotherapy with IP+IV chemotherapy
    • IP and IV port-a was performed
    • This 69-year-old woman has history of 1) Hypertension under medication control for years; 2) Appendectomy; 3) Hysterectomy, 4) diabetes.
    • This time, she sufferred from intermittent epigastric pain with fullness and vomiting in recent 2 months. Body weight loss almost for 10kg was noted in recent half year.
    • She came to LMD for help and UGI scope was follow up which revealed r/o gastric cancer with outlet obstruction.
    • She came to our OPD for help and was admitted on 2023/10/27. After admitted, nutrtion support with TPN was given due to malnutrition.
    • She received further operation on 2023/11/23 which revealed distal gastric cancer with peritoneal seeding at round ligament and lesser curvature (PCI:5/39), cancer direct invasion to posterior pancreas body.
    • Thus, Open GJ bypass with HIPEC Oxalip 300mg/M2 (425mg) + Mytomicin C 15mg/M2 (21mg) was processed successfully on 2023/11/23. Post operation course was smooth then try oral intake with step by step was tolerate well.
    • Under impressed of gastric cancer with peritoneal seeding, cT4aN3aM1 stage IV, we need your help for further bidirectional neoadjuvant chemotherapy (IP+IV) for this case. Thanks for your time!!
  • A
    • This 69 year old woman is a case of HTN, DM and newly diagnosis poorly cohesive carcinoma, signet-ring cell type of gastric cancer with peritoneal seeding, cT4aN3aM1, stage IV s/p open GJ bypass with HIPEC Oxalip 300mg/M2 (425mg) + Mytomicin C 15mg/M2 (21mg) on 2023/11/23. We are consulted for further evaluation.
    • For metastasis gastric cancer, we prefer Nivo+C/T, rather than IP/IV C/T. Thanks for your consultation.
• 2023-11-14 Gastroenterology
  • Q
    • nutrition support with TPN
    • This 69-year-old woman has history of 1) Hypertension under medication control for years; 2) Appendectomy; 3) Hysterectomy.
    • This time, she sufferred from intermittent epigastric pain with fullness and vomiting in recent 2 months. Body weight loss almost for 10kg was noted in recent half year.
    • She came to LMD for help and UGI scope was follow up which revealed r/o gastric cancer with outlet obstruction. She came to our OPD for help and was admitted for further management.
    • We need your help for TPN support for nutrition support first for this case. Thank your!!
  • A
    • A case of gastric cancer with obstruction who request pre-op nutrition support.
    • General appearance: ill looking
    • GI tract: Dysphagia (-), Abd pain (-), Abd distension (+), Nausea (-), Vomiting (+), Diarrhea (-), Poor appetite (+), Poor digestion (+), BW loss (+, 10kg/6M) , stool (+),
    • Feeding: try water
    • Allergy: NKA
    • Nutrition assessment:
      • BH 157cm BW 48.8kg
      • IBW 54.2kg 90%IBW BMI 19.8
      • BEE 1090kcal TEE 1700kcal
    • Lab data: Alb 3.6 preAlb 13.79 Transferrin 208.9 K 3.2 BS 171
    • According to the patient`s present conditions, parenteral nutrition will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
    • PN Use Suggestion:
      • DC SMOFkabiven peri 1440ml QD
      • SMOFkabiven central 1477ml QD, 61.5ml/hr
      • Lyo-Povigent 4ml/QD (add in TPN) (if out of stock, then add B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
      • Addaven 10ml/QD (add in TPN)
    • PN Use monitoring items:
      • TPN is a single route. Do not mix it with other drugs except TPN drugs.
      • Check BW QW5 and record I/O Q8H
      • Check one touch Q6H*2days, if stable QD check
      • Please control BS < 200 mg/dl with RI sliding scale
      • QW1 check CBC/DC
      • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
      • When TPN is not sufficient, use YF5 or D10W
      • The fat emulsion shold be temporarily held on the day of surgery
• 2023-11-13 Anesthesia
  • Q
    • CVC insertion for nutrition support
    • This 69 y/o female, a case r/o gastric cancer with gastric outlet obstruction was admitted for further management. BW loss for 10 kg then nutrition support with TPN was indicated. Thanks for your time!!
  • A
    • After positioning patient’s head left side with head down position, ultrasound was used to localize IJV.
    • After anesthetized with 1% lidocaine, we performed CVC insertion smoothly.
    • A 2-lumen CVC was placed at R’t IJV, under ultrasound guidance, fixed at 15 cm.
    • Vital sign were stable before and after the procedure. The patient stated no discomforts.
    • Please follow up CXR.
    • “It’s a better way to ask resident, CR or even the attending physician of surgical department for help first for such non-complex CVC placement before consultation.”
• 2023-05-23 Orthopedics
  • Q
    • Triage: 3 Blunt trauma to the upper limb > Swelling and deformation, suspected fracture/dislocation. Complaint of falling and fracture of right hand. Transferred from Guanshan TzuChi. NPO 0730AM TOCC(-)
  • A
    • Right wrist pain after falling down
    • Right wrist pain, swelling, ecchymosis, limited ROM
    • X-ray: Right distal ulnar fracture, minimally-displaced
    • Suggestion
      • Adequate pain control
      • Keep splint protection
      • OPD f/u
      • Explain the current condition and treatment plan to the patient and family

[surgical operation]

• 2023-11-23
  • Surgery
    • Open GJ bypass
    • HIPEC
      • Oxalip 300 mg/M2 (425 mg) for 30 mins at 42 C
      • Mytomicin C 15 mg/M2 (21mg) for 60 mins at 42 C
    • Intraabdoiminal Port-A insertion at subhepatic area
  • Finding
    • distal gastric ca with peritoneal seeding at round ligament and lesser curvature
    • PCI 5/39
    • cancer direct invasion to posterior pancreas body

[immunochemotherapy]

• 2024-03-04 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-02-15 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-01-18 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-01-03 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-12-18 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

• 2023-12-01 - nivolumab 2mg/kg 100mg NS 100mL 1hr (Wu ChaoQun)

• 2023-11-23 - [oxaliplatin 300mg/m2 425mg + mitomycin-C 15mg/m2 21mg] IP 1hr (HIPEC. Wu ChaoQun)

==========

2024-03-05

[positive imaging response to Opdivo + FOLFOX in gastric cancer; stability of vital signs and lab results during treatment]

The most recent imaging study, an abdominal CT conducted on 2024-02-16, revealed: 1) Suspected partial or complete response to chemotherapy/treatment (C/T) in adenocarcinoma located in the stomach’s antrum; 2) Suspected partial response in both regional and non-regional metastatic nodes following chemotherapy/treatment. These findings suggest that the Opdivo + FOLFOX regimen remains effective, as supported by the imaging results.

Throughout the duration of this hospital stay, the patient’s vital signs have been stable, and laboratory results as of 2024-03-04 were predominantly within normal ranges. No discrepancies in medication were noted.

2024-02-16

[reconciliation]

An abdominal CT scan performed on 2024-02-16 demonstrated a partial response of the signet-ring cell gastric cancer to the current treatment regimen of nivolumab plus FOLFOX. Vital signs remained stable throughout this hospitalization, and lab findings on 2024-02-15 were generally within normal limits. No medication discrepancies were identified.

2024-01-04

[nivolumab dosing recommendations for gastric cancer: optimization based on clinical research]

Clinical Evidence:

• The CheckMate 649 trial established nivolumab as a valuable treatment option for patients with advanced or metastatic gastric cancer or gastroesophageal junction cancer. The recommended dosing regimen, when combined with fluoropyrimidine- and platinum-containing chemotherapy (FOLFOX in this patient’s case), is either:
  • 240 mg every 2 weeks
  • 360 mg every 3 weeks
• This regimen should be continued until disease progression, unacceptable toxicity, or up to a maximum of 2 years.

Optimizing Treatment Efficacy:

• In this patient’s case, the current nivolumab dose falls below the recommended range. This may lead to a suboptimal treatment effect, meaning the medication might not be exerting its full potential against the cancer.

Ref: - First-line nivolumab plus chemotherapy versus chemotherapy alone for advanced gastric, gastro-oesophageal junction, and oesophageal adenocarcinoma (CheckMate 649): a randomised, open-label, phase 3 trial. Lancet. 2021 Jul 3;398(10294):27-40. doi: 10.1016/S0140-6736(21)00797-2. Epub 2021 Jun 5. PMID: 34102137; PMCID: PMC8436782).

700994040

240305

[exam findings]

• 2024-03-04 CTA - chest
  • History and indication: Chest pain/tightness
  • CTA of chest revealed:
    • Pancreatic body/ tail cancer with stomach/ splenic artery/ vein invasion, liver/ LNs/ lung metastases. Bil. pleural effusion and ascites. Some soft tissues in peritoneal cavity.
    • Left adrenal tumor (2.1cm).
    • Wall edema of stomach and colon.
    • Gallbladder stones (up to 1.1cm).
    • Patency of portal vein.
    • S/P hysterectomy.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion. S/P right THR without evidenced prothesis loosening.
  • IMP:
    • Pancreatic body/ tail cancer with stomach/ splenic artery/ vein invasion, liver/ LNs/ lung metastases. Bil. pleural effusion and ascites. Peritoneal carcinomatosis. Left adrenal tumor (2.1cm). Wall edema of stomach and colon.
• 2024-03-04 CXR erect
  • Increased infiltration in right lower lung zone
  • Blunting of right costophrenic angle
  • s/p port A insertion
• 2024-03-04 Emergency SONO - chest
  • Chest: Pleural effusion: Yes, R: +++
  • Procedure: Pleural effusion, Amount: 1000 ml, Color/Character: clear yellow, R
• 2024-02-18 CXR
  • Increased infiltration over RLL. May be active infection.
• 2024-01-08 Patho - stomach biopsy
  • Stomach, high body, PW, biopsy — Adenocarcinoma, poorly differentiated, origin?
  • Section shows gastric tissue infiltrated by irregular acinar glands.
  • The immunohistochemical stain of CK is positive. Please correlate with the clinical presentation and image study for primary tumor origin.
• 2024-01-05 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A (minimal)
    • Gastric ulcers, antrum, A2-H1
    • Antrum deformity
    • Gastric ulcer, high body, PW, s/p biopsy
    • Gastric varices
    • Superficial gastritis
    • Duodenal polyp, 2nd portion, GC/PW
  • CLO test: not done
  • Suggestion:
    • Pursue the pathology report
    • PPI usage
    • Causion for GV vleeding
• 2023-12-28 Body fluid cytology
  • 50 cc yellow turbid pleural effusion - suspicious malignancy
• 2023-12-28 SONO - chest
  • Symptoms: dyspnea
  • Indication: effusion, right side.
  • Special Procedure
    • echo-assisted
    • Pleural tapping 16 #-needle Right side 380 ml yellowish
  • Echo diagnosis
    • pleural effusion
  • Suggestion:
    • Watch out BP after tapping.
    • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
• 2023-12-25 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Pancreatic body/ tail cancer with stomach/ splenic artery/ vein invasion, liver/ LNs/ lung metastases. Bil. pleural effusion and ascites.
    • Left adrenal tumor (2.1cm).
    • Wall edema of stomach and colon.
    • Gallbladder stones (up to 1.1cm).
    • S/P hysterectomy.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion. S/P right THR without evidenced prothesis loosening.
  • IMP:
    • Pancreatic body/ tail cancer with stomach/ splenic artery/ vein invasion, liver/ LNs/ lung metastases. Bil. pleural effusion and ascites. Left adrenal tumor (2.1cm). Wall edema of stomach and colon.
• 2023-12-14 Tc-99m MDP bone scan
  • Mildly increased activity in the lower T-spines. Degenerative change is more likely.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Some faint hot spots in the skull and left rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, left hip and bilateral knees, compatible with benign joint lesions.
• 2023-12-11 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with metastatic pancreatic ductal adenocarcinoma
  • The sections show a picture of adenocarcinoma, moderately differentiated, composed of nests of polygonal neoplastic cells with clear cytoplasm, arranged in glandular and cribriform patterns with focal mucin secretion, embedded in fibrous stroma.
  • IHC shows: CK7(+), CK20(focal +), CA19-9(+), and DPC-4(-). The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
• 2023-12-08 CT - abdomen
  • CC: diffuse abdominal pain for 10 days, BW loss 6 kg in 1 year.
    • 20231205 US: Hypoechoic nodules (up to 3.20cm) in both hepatic lobes.
  • Findings:
    • There is a lobulated poor enhancing mass in the distal body and tail of the pancreas, measuring 6.5 cm in size (the largest dimension), and highly suggestive direct invasion the stomach fundus.
      • It is c/w adenocarcinoma of the pancreas (T3). Please correlate with CA199.
      • In addition, there is non-visualization of the splenic vein and narrowing of the splenic artery that is c/w tumor direct invasion and encasement.
    • There are four enlarged nodes in the gastrohepatic ligament and peripancreatic tail area that are c/w regional metastatic nodes (N2).
    • There are multiple poor enhancing lesions in both hepatic lobes (up to 2.6 cm in S2) that is c/w metastases (M1).
    • There is a mild heterogeneous poor enhancing mass in left adrenal gland, 2 cm in size. Adenoma is highly suspected.
      • The differential diagnosis includes metastasis.
    • There are several gallstones (up to 1.2 cm).
      
    • There is mild ascites in the cul-de-sac.
    • S/P hysterectomy. please correlate with clinical history.
    • There is a small soft tissue nodule at RML of the lung, directly attached the pleura (Srs:11 Img:4), 4 mm in size at lung window setting. Please correlate with chest CT.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:IV(Stage_value)
• 2023-12-05 SONO - abdomen
  • Sonography of hepatobiliary system revealed:
    • Hypoechoic nodules (up to 3.20cm) in both hepatic lobes.
    • Gallbladder stone (0.84cm, 0.86cm).
    • Patency of PV, HVs, IVC and aorta in hepatic portion.
    • A cystic lesion (0.64x0.75cm) at pancreatic head. The other portions of pancreas masked by gastric/ bowel gas.
      
    • Normal appearance of spleen.
    • No evidence of pleural effusion.
    • Left renal stones (0.59cm, 0.63cm).
  • IMP:
    • Hypoechoic nodules (up to 3.20cm) in both hepatic lobes.
    • Gallbladder stone (0.84cm, 0.86cm).
    • A cystic lesion (0.64x0.75cm) at pancreatic head. Left renal stones (0.59cm, 0.63cm).
• 2023-09-12 BMD
  • L-spines BMD performed by DXA revealed:
    • AP L-spines, BMD of L1-4 0.647 gms/cm2, about 3.9 SD below the peak bone mass (60%) and 0.8 SD below the mean of age-matched people (84%).
  • Impression
    • Osteoporosis

[MedRec]

• 2023-10-24 SOAP Metabolism and Endocrinology Guo XiWen
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
    • Chronic hepatits,unspecified [K73.9]
    • Other insomnia [G47.09]
  • Prescription x3
    • Kludone (gliclazide 60mg) 1# BID
    • Zulitor (pitavastatin 4mg) 1# QOD
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
    • Eurodin (estazolam 2mg) 1# HS
• 2017-01-25 SOAP Metabolism and Endocrinology Guo XiWen
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
    • Chronic hepatits,unspecified [K73.9]
  • Prescription x3
    • Silima (silymarin 150mg) 1# QD
    • Januvia (sitagliptin 100mg) 1# QD
    • NovoNorm (repaglinide 1mg) 2# TIDAC
• 2017-01-13 SOAP Orthopedics Huang MongRen
  • Diagnosis
    • Traumatic arthropathy, site unspecified [M12.50]
    • Osteoporosis, unspecified [M81.0]
    • OA, localized, primary, lower leg [M17.0]
  • Prescription x3
    • Evista (raloxifene 60mg) 1# QD

[consultation]

• 2024-02-20 Orthopedics
  • Q
    • for left shoulder pain for 2 weeks
    • This 67-year-old woman, a patient of Pancreatic body/tail with stomach and splenic artery/vein invasion, liver, lymph nodes, lung metastases, and malignant bilateral pleural effusion and ascites S/P C/T. She complained of left shoulder pain for 2 weeks and left shoulder x-ray was done. We need expertise to evaluate her condition thanks!
  • A
    • This 67-year-old woman, a patient of Pancreatic body/tail cancer , now under C/T. She complains of left shoulder pain after been moved by the EMT members 2 days ago.
    • Local findings :
      • left shoulder and axilla mild soreness
      • left shoulder ROM full and free
      • hypotrophy of shoulder girdle (+)
    • x-ray : no definite bony lesion around left shoulder ; Port-A catheter in situ
    • Imp :
      • left shoulder sprain
    • Suggestion :
      • warm packing, pain control with analgesic or local plaster
• 2024-02-06 Psychosomatic Medicine
  • Q
    • Suicidal ideation in cancer inpatients >= 2 points.
  • A
    • This woman, married and lived with husband, retired for many years, has sleep problem for years taking hypnotics from physical OPD, but denied previous mood problem and never visited psychiatrist.
      • She has suffered from abdominal pain and been diagnosed as pancreatic cancer stage IV 2 months ago.
      • Distressful mood, negative thinking, worthlessness feelings noted especially at pain.
      • Suicide attempt before admission by swallowing a large amount of Eurodin and hanging by stockings.
    • MSE: cachexia, frowning, low mood, poor spirit. low drive and motivation. suicide attempt and ideation.
    • IMP: Adjustment disorder with depressed mood.
    • r/o Major depressive disorder
    • Suggestion:
      • Mirtazapine 0.5# HS and Eurodin 1# HS (tapper to 0.5# HS if oversedation).
      • Safety plan discussion with family. It is recommended that family members accompany the patient 24 hours a day to prevent her suicide. Reduce dangerous items such as idle drip lines.
      • Arrange PSY OPD follow up.
• 2024-02-05 Psychosomatic Medicine
  • Q
    • Injury Level: 2, due to overdose with an intent towards self-harm or a well-defined plan. The individual reported ingesting over 30 Eurodin tablets around 40 minutes prior and attempted hanging using a stocking, which was unsuccessful as their feet touched the bathroom steps.
    • Past History:
      • Adenocarcinoma of pancreatic ductal, moderately differentiated, with liver metastasis, stage IV
      • suspected right malignant pleural effusion
    • Drug allergy: ibuprofen, pyrine, skinkenan
  • A
    • Imp: depressive diosrder, NOD, r/o major depressive disorder, single episode.
    • Past history: Pancrease Ca. s/p CT.
    • Long-term Eurodin was used but still failed to have better sleep, attempted suicide by swallowing a large amount of Eurodin.
    • low mood, poor appetite, body weight loss, and insomnia, negative thoughts were all found in recent one months.
    • P:
      • Zyprexa (olanzapine 5mg) 1# PO HS, Lexapro (escitalopram 10mg) 1# PO HS, and Stilnox (zolpidem 10mg) 1# PO HS.
      • OPD follow-up.
• 2023-12-27 Psychosomatic Medicine
  • Q
    • Cancer inpatients with suicidal thoughts score >= 2.
  • A
    • Psychiatric Impression:
      • Adjustment reaction
    • Clinical course:
      • This is a 67 y/o female, admitted on 2023/12/27 for abdominal pain management. She has underlying disease: Adenocarcinoma of pancreatic ductal, moderately differentiated, with liver metastasis, stage IV.
      • According to the patient, she deny previous psychiatric history. She has been taking Eurodin (estazolam 2mg) 1# HS as sleeping pills for a period of time, and report of good response. Severe intermittent abdominal pain became severe in recent 1 month, depressive mood reaction when suffering pain (report of no remarkable depressive mood if the pain is under control). Poor appetite, low mood, helplessness feeling associated with pain. Experiencing unbearable pain at home without immediate relief led to feelings of helplessness. Due to long waits at the clinic, the individual sought emergency and hospital services, hoping for pain alleviation. She also report constipation which troubles her a lot. She has tolerable night sleep under current Eurodin, and could sleep even better when pain is under control during admission.
      • MSE: kempt, smiley, polite and cooperative attitude, fluent speech, deny suicide thoughts.
    • Suggestion:
      • Adequate pain control as your expertise
      • Provide supportive psychotherapy
      • Agree with keeping current Eurodin (estazolam) 1# HS

[chemotherapy]

• 2024-02-19 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 175mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2024-02-07 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 178mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2024-01-30 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 183mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2024-01-16 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 183mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2024-01-09 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 183mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2024-01-02 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 186mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-12-21 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 186mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-03-05

[ketone elevation: starvation versus diabetes; significant weight loss]

The patient presented to our emergency department with chest pain and tightness on 2024-03-04, resulting in the drainage of approximately 1000 mL of pleural effusion. The Gram stain of the pleural effusion did not reveal any organisms. Brosym (cefoperazone, sulbactam) is currently being administered, with additional culture results awaited.

Recent urine analysis indicated elevated ketone levels, which in the context of this patient’s condition, could be attributed to:

• Starvation or carbohydrate restriction: The body resorts to metabolizing stored fats for energy when there is an inadequate supply of glucose from carbohydrates, producing ketones as a byproduct. This is common in patients with a diminished appetite.
• Diabetes: Individuals with uncontrolled diabetes experience ineffective insulin utilization, leading to elevated blood sugar levels. The body compensates by breaking down fats for energy, thereby increasing ketone levels.

Lab data:

• 2024-03-05 Urine KET 2+

• 2024-03-04 Urine KET 2+

• 2024-02-05 Urine KET 1+

• 2024-01-01 Urine KET 2+

• 2023-12-25 Urine KET 3+

• 2023-11-25 Urine KET -

• 2024-03-04 Glucose (serum) 219 mg/dL

• 2024-03-04 Glucose (serum) 222 mg/dL

• 2024-02-18 Glucose (serum) 163 mg/dL

• 2024-02-05 Glucose (serum) 174 mg/dL

• 2023-12-25 Glucose (serum) 328 mg/dL

• 2023-12-21 Glucose (serum) 272 mg/dL

• 2023-11-25 Glucose (serum) 218 mg/dL

On 2023-09-12, the patient’s weight was recorded at 58kg, which decreased significantly by more than 10kg to 45kg by 2024-02-20 over a span of 5 months. It is imperative to address the patient’s nutritional status. The patient is currently on TPN.

The addition of insulin might be beneficial to achieve better control of serum glucose.

2024-02-19

[responding to a glucose surge with insulin regulation]

A significant increase in serum glucose was observed, spiking to 310 mg/dL at 10:38 on 2024-02-19 from 166 mg/dL on 2024-02-18. Regular insulin has been administered since 2024-02-18. It may be necessary to adjust the dosage of regular insulin upward if the elevated glucose levels are not adequately controlled.

2024-02-06

[managing benzodiazepine overdose with flumazenil]

Lab findings from the urine analysis confirmed benzodiazepine toxicity.

• 2024-02-05 Benzodiazepines (BENZ) Positive
  
• 2024-02-05 Benzodiazepines (Value) 497 ng/mL

Flumazenil-hameln (at a concentration of 0.1 mg/ml in a 5 ml ampoule, available now in this hospital) is indicated for the treatment of benzodiazepine overdose. The initial intravenous dose is 0.2 mg administered over 2 minutes; if the desired level of consciousness is not achieved within 1 minute following the initial dose, an additional 0.2 mg may be administered at 1-minute intervals, up to a total of four times. The typical cumulative dosage ranges from 0.6 to 1 mg, with a maximum cumulative dose of 1 mg.

[more pain meds or hospice: addressing patient’s pain-driven death wish]

Based on the psychosomatic medicine consultation, the patient’s desire for death seems to stem from uncontrolled pain. Assuming this is the case, introducing additional analgesics may help alleviate the patient’s suffering. Alternatively, if the pain proves intractable, hospice palliative care may be recommended to both the patient and her family.

Currently, the patient is only being administered oral Tramacet (a combination of tramadol and acetaminophen) for pain management. To enhance analgesic efficacy, consideration could be given to the as-needed (PRN) use of morphine.

2023-12-22

Pathological confirmation of metastatic pancreatic ductal adenocarcinoma was obtained. Lab tests on 2023-12-12 revealed elevated tumor markers CA199 (14408.29 U/mL) and CEA (363.79 ng/mL).

No further results from driver mutation testing are currently available.

Instead of FOLFIRINOX regimen, the patient was initiated on gemcitabine + nab-paclitaxel on 2023-12-21. This combination is considered to have a little more favorable safety profile compared to FOLFIRINOX (NCCN guidelines, version 2023-06-19).

The patient has a long history of type 2 diabetes mellitus. The drugs prescribed by our endocrinologist have been integrated into the active medication list, confirming no discrepancies.

700024921

240304

[exam findings]

• 2024-03-01 ECG
  • Sinus rhythm with premature atrial complexes
    
  • Right bundle branch block
  • Septal infarct, age undetermined
  • Abnormal ECG
• 2024-02-28 CXR erect
  • Enlargement of cardiac silhouette.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
  • s/p anterior chest wall repair using metalic mesh is found.
  • S/P PICC catheter insertion via right forearm.
• 2024-02-28 ECG
  • Atrial fibrillation with rapid ventricular response
  • Right bundle branch block
  • Abnormal ECG
• 2024-02-27 CT - chest
  • Indication: Thymic moderately differentiated squamous cell carcinoma with lung, liver metastatic, highly suspected malignancy with sternum metastasis, AJCC 8th edition: pStage IIIB, pT4Nx(if cM0)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest
      • Necrotic tumors are found at right heart border (5.0m), right AP window (5.5cm) and right posterior chest wall measuring 4.68cm and left upper chest wall measuring 2.53cm in largest dimension. Diffuse meta is considered. In comparison with CT dated on 2023-12-15, the lesion progressed.
      • Mild to moderate bilateral pleural effusion is found.
      • s/p PICC. The SUPERIOR VENA CAVA is compressed and communicated with azygos vein.
      • s/p anterior chest wall repair with metalic plate fixation.
      • Increased pulmonary vasculature is found.
    • Visible abdomen:
      • Necrotic tumor at S4 of liver measuring 6.87cm in largest dimension. Liver meta is considered. In progression.
      • Cystic change at pancreatic tail measuring 2.62cm in largest dimension.
  • Imp:
    • thymic cancer s/p excision with recurrent/residual tumor at mediatsinum and bilateral chest wall, liver meta, in progression.
    • The SUPERIOR VENA CAVA is thrombosed with residual communication with azygos vein. The function of the PICC is deteriorated due to the thrombosis.
• 2024-02-25 ECG
  • Atrial fibrillation
  • Right bundle branch block
  • Abnormal ECG
• 2024-02-24 ECG
  • Wide QRS rhythm with occasional Premature ventricular complexes
  • Non-specific intra-ventricular conduction block
  • suspected sinus rhythm (poor baseline quality)
• 2024-02-07 SONO - chest
  • Pleural effusion, minimal, bilateral, left> right
  • Consolidation, LLL
• 2023-12-27 Bronchodilator Test
  • Diagnosis: Moderate restrictive pulmonary function impairment.
  • Conclusion: FVC: 56%.
• 2023-12-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (110 - 36.2) / 110 = 67.09%
    • M-mode (Teichholz) = 67.1
    • 2D (M-Simpson) = 68.5
  • Conclusion:
    • Thickened AV with mild AR (AVA 1.76)
    • s/p MVR with bio-prosthesis, increased pressure gradient, mild trans-valvular MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, mild to moderate TR, normal IVC size
• 2023-12-15 CTA - chest
  • CTA of chest revealed:
    • S/P PICC. Thrombosis of right subclavian vein and left proximal subclavian vein. A thrombus in SVC.
    • Some nodules at right lung. Right pleural effusion.
    • A poor enhancing lesion (2.4cm) at pancreatic tail.
    • Poor enhancing tumors (up to 5.6cm) in liver.
      
    • Some LNs at mediastinum.
    • Renal cysts (up to 1.6cm).
  • IMP:
    • S/P PICC. Thrombosis of right subclavian vein and left proximal subclavian vein. A thrombus in SVC.
    • LNs, liver and lung metastases.
    • A poor enhancing lesion (2.4cm) at pancreatic tail.
• 2023-10-31 Cardiac Catheterization
  • SvO2 was also check, it revealed only 45%.
  • Estimated Fick Cardiac index 1.86 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
  • Estimated Fick cardiac output 2.44 L/min. (nomral cardiac output range 5~6 L/min)
• 2023-10-12 CXR
  • Tortous aorta with calcification is noted.
  • Pleural effusion over right side is found.
• 2023-10-10 CXR
  • s/p aortic root valvular replacement
• 2023-10-06 CT - chest
  • 2023-07-31 CTA showed recurrent tumor as metastatic mediastinal LAP and metastatic tumor in RLL and Rt exudative pleural effusion with metastatic tumor. post op fluid collection over anterior mediastinum r/o abscess. For infection survey
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • s/p anterior chest wall repair with post op. change is found.
      • Lymphadenopathy at paracaval region of the mediastinum measuring 4.36cm is found.
      • Nodular lesions at left lower lobe measuring 0.54cm, right lower lobe measuring 2.17cm, 1.07cm are found. Lung meta is considered.
      • Right moderate pleural effusion is found. Fusiform pleural thickening is found. r/o pleura meta.
    • Visible abdomen:
      • Hepatic tumor at S8 of liver 3.8cm in largest dimension is found. Liver meta is considered.
      • Enlarged prostate up to 4.13cm in largest dimension is found.
      • Cystic change at pancreatic tail measuring 2.67cm in largest dimension.
  • Imp: metastatic mediatsinal lymph nodes and lung meta, liver meta.
• 2023-10-06 SONO - chest
  • Echo diagnosis: right pleural thickening with trivial amount of organized pleural effusion
• 2023-10-04 CXR
  • blunting bilateral costophrenic angles
• 2023-10-04 ECG
  • Sinus tachycardia with occasional Premature ventricular complexes
  • Right bundle branch block
• 2023-07-31 CTA - chest
  • Indication: 2023-04-03 sternal SCC s/p wedge resection + AsAO replacement. of post-op F/U
  • Comparison was made with CT on 2023/04/20
    • Lungs: septal thickening at anterior RUL and RML. a small rim-enhanced nodule over RLL-S7.
    • Mediastinum and hila:
      • a heterogeneous enhancing mass (28mm) at Rt paracaval region of mediastinum invading adjacent SVC.
      • moderate fluid accumulation in anterior mediastinal compartment.
      • mild pericardial thickening.
    • Vessels:
      • Thoracic aorta: s/p ascending aortic replacement. normal caliber of mild atherosclerotic change of aortic arch and descending thoracic aorta. patency of arch branches and replacement branch to the graft.
      • Central pulmonary arteries: normal caliber and well opacification.
      • Heart: normal size of cardiac chambers. s/p MVR. no filling defects.
    • Pleura:small Rt-sided effusion witha rim-enhanced central low density mass (32mm). associated pleural thickening.
    • Visible abdominal-pelvic contents:
      • several bilateral renal cysts measuring up to 1.6 cm.
      • multiple hepatic cysts measuring up to 1.9cm
      • unremarkable of the GB, spleen, both adrenal glands, pancreas, and no enlarged lymph node. no ascites.
  • Impression:
    • recurrent tumor as metastatic mediastinal LAP and metastatic tumor in RLL and Rt exudative pleural effusion with metastatic tumor.
    • post op fluid collection over anterior mediastinum r/o abscess.
• 2023-07-28 CXR
  • s/p sternotomy with metalic wire fixation of the sternum.
  • Pleural effusion over right side is found.
• 2023-07-12 ECG
  • Sinus tachycardia
  • Right bundle branch block
  • Abnormal ECG
• 2023-07-12 EGD
  • Diagnosis:
    • No bleeder or blood clot during exam
    • Reflux esophagitis LA Classification grade A (minimal)
    • Gastric ulcer, Forrest classification type III, prepyloric antrum
    • Superficial gastritis, antrum
  • Suggestion:
    • No bleeder or blood clot during exam
    • PPI use
• 2023-07-11 CXR
  • Surgical wires over the sternum.
  • S/P cardiac valve replacement.
  • Blunted bilateral costophrenic angles.
• 2023-04-20 CT - chest
  • Indication: SOB for days and palpitation
  • Chest CT with and without IV contrast ehnancement shows:
    • Bilateral massive pleural effusion is found.
    • Consolidation over both lungs is found.
    • Minimal air pockets at anterior and superior mediastinum is also noted. r/o residual abscess.
    • s/p chest wall graft at anterior chest is found.
  • Imp:
    • Massive bilateral pleural effusion with consoidation oat both lungs.
    • Minimal air pockets at anterior and superior mediastinum is also noted. r/o residual abscess.
    • Revision on 2023-04-24, minimal fluid collection at left inguia region measuring 4.05cm in largest dimension. Suggest further evaluation.
• 2023-04-20 CXR
  • Artifacts over the chest.
  • Bilateral pleural effusion, more severe at right side.
  • Cardiomegaly.
• 2023-04-20 ECG
  • Sinus tachycardia
  • Right bundle branch block
  • Inferior infarct, age undetermined
• 2023-04-10 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • s/p chest tube placement at left and right hemithorax.
  • Pleural effusion over left side is found.
• 2023-04-06 Patho - aneurysm
  • DIAGNOSIS:
    • Bone and soft tissue, mediastinum, bilateral clavicle head, upper sternum, bilateral 1st and 2nd ribs, wide excision — Squamous cell carcinoma, moderately differentiated, in favor of thymic origin, if no other primary tumor is found; AJCC 8th edition: pStage IIIB, pT4Nx(if cM0)
    • Lung, RUL, wedge resection — Squamous cell carcinoma, by direct invasion
    • Ascending aorta, excision — Squamous cell carcinoma, by direct invasion
    • Superior vena cava, excision — Squamous cell carcinoma, by direct invasion
    • F2023-00148, Soft tissue, peristernum, biopsy — Negative for malignancy
  • GROSS DESCRIPTION:
    • Specimen submitted in formalin consists of a piece of wide excision of sternal tumor measuring 15.0 x 9.0 x 7.5 cm.
    • The specimen is including, mediastinum, bilateral clavicle head, upper sternum, bilateral 1st and 2nd ribs, overlying skin, measuring 15 x 4 cm, wedge resection of RUL of lung, measuring 10.0 x 3.5 x 2.0 cm, a segment of ascending aorta, measuring 8.7 cm in length, a portion of superior vena cava, measuring 3.2 x 1.4 cm.
    • On cutting, a white, invasive and necrotic tumor measuring 9.0 x 5.5 x 5.0 cm is seen. The tumor has invaded to the sternum, ribs, mediastinum, subcutaneous soft tissue, RUL of lung, ascending aorta, and superior vena cava. The tumor is 0.1 cm, 0.8 cm, 0.15 cm, and 0.1 cm away from the superior, inferior, right, and left resection margins, respectively.
    • The resection margin of RUL of lung is 0.6 cm.
    • Representative sections are taken and labeled as: A1: resection margin of RUL of lung; A2-4: tumor with superior margin (A3: with large vein; the same level); A5-7: tumor with ascending aorta (the same level); A8-9: tumor with ascending aorta; A10-11: tumor with lung; A12: ink right resection margin; A13-14: tumor with inferior resection margins (the same level); A15: tumor with thymus; A16: tumor with left resection margin; A17-A20: tumor with sternum and ribs; X1: tumor with superior vena cava.
      
    • F2023-00148 - The specimen submitted in fresh consists of 2 pieces of tan, irregular tissue measuring up to 3.5 x 2.6 x 0.5 cm. All for section in 2 cassettes FsA1-2, for frozen examination.
  • MICROSCOPIC DESCRIPTION:
    • Sections show moderately differentiated keratinized squamous cell carcinoma with invasion through the sternal bone to subcutaneous soft tissue, ribs, mediastinal soft tissue, RUL of lung tissue, ascending aorta, and superior vena cava. The resection margins are free of malignancy. Lymphovascular invasion is seen. Peri-neural invasion is not found. If no other primary tumor is found, the morphology is consistent with thymic squamous cell carcinoma. Please correlate with the clinical presentation.
      
    • F2023-00148 - Sections show fibroadipose tissue and a lymph node without malignancy.
• 2023-04-03 2D transthoracic echocardiography
  • Conclusion:
    • Adequete LV systolic function, EF 43.3%
    • Moderate AR (Vena contracta width = 5.8 mm), Trivial TR
    • s/p bioprothetic MVR, mild MR, and remaining chordae
    • Minimal pericardial effusion
• 2023-03-27 Tc-99m MDP bone scan
  • Several hot/faint hot spots in the sternum, highly suspected malignancy with sternum metastasis.
  • Suspected benign lesions in both rib cages, some C-, T- and L-spine, bilateral shoulders, S-I joints, and hips.
• 2023-03-24 EGD
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
  • Gastric erosions, body, antrum, and cardia
• 2023-03-22 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • s/p sternotomy with metalic wire fixation of the sternum.
    • Abnormal air pockets at superior and anterior mediastinum is found. Abscess formation cannot be excluded.
  • IMp:
    • Abnormal air pockets at superior and anterior mediastinum is found. Abscess formation cannot be excluded
• 2023-03-13 Patho - mediastinum mass
  • Mediastinum, superior mass, resection — moderately differentiated squamous cell carcinoma with necrosis
  • Microscopically, sections show moderately differentiated squamous cell carcinoma consisting of nests of squamous tumor cells in infiltrative growth pattern with keratin pearls.The tumor cells have abundant eosinophilic cytoplasm, prominent nucleoli, pleomorphism, nuclear hyperchromasia, and mitiotic activity. The stroma shows focal necrosis and fibrosis.
  • Immunohistochemical stain reveals p63(+), CD117(-), CK(+), S100(-), and Myosin(-).
• 2023-03-11 CT - chest
  • Indication: sternal wound infection
  • Chest CT with and without IV contrast ehnancement shows:
    • Necrotic mass like lesion at anterior mediastinum encircling ascending aorta is found about 8.4cm is found. Smaller lesion at subcutaneous tissue just anterior to the manubrium is found measuring 2.09cm is found. abscess is favored. Suggest surgical drainage.
    • Cystic change at pancreatic tail measuring 2.52cm is found.
  • Imp:
    • Necrotic mass like lesion at anterior mediastinum encircling ascending aorta is found about 8.4cm is found. Smaller lesion at subcutaneous tissue just anterior to the manubrium is found measuring 2.09cm is found. abscess is favored. Suggest surgical drainage.
• 2023-03-10 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 26) / 80 = 67.50%
    • M-mode (Teichholz) = 67
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • s/p bioprothetic MVR with adequate function, mild MR, and remaining chordae
    • Grade 1 LV diastolic dysfunction
    • Moderate AR, mild TR
• 2023-03-09
  • Sinus rhythm with 1st degree A-V block
  • Right bundle branch block
  • Abnormal ECG
• 2022-06-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 31.9) / 111 = 71.26%
    • M-mode (Teichholz) = 69.3 - 71.3
    • 2D (M-Simpson) = 56.2
  • Conclusion:
    • Thickened AV with mild AR
    • s/p MV replacement, with bio-prosthesis MV, mild trans-valvular MR, no MS (with remaining cordae)
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
• 2021-08-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (81.39 - 30.88) / 81.39 = 62.06%
    • LVEF (%) = 50
    • M-mode (Teichholz) = 62.06
  • Conclusion:
    • Thickened AV with mild AR
    • S/p MVR, with bio-prosthesis, with mild trans-valvular MR, no MS, possible remaining chordae connecting to prosthesis strut at anteroseptal side
    • Concentric LVH
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size

[MedRec]

• 2023-12-16 ~ 2023-12-28 POMR Hemato-Oncology Yang MuJun
  • Discharge diagnosis
    • Thymic moderately differentiated squamous cell carcinoma with lung, liver metastatic, highly suspected malignancy with sternum metastasis, AJCC 8th edition: pStage IIIB, pT4Nx(if cM0), paliactive chemotherapy with cisplatin(30mg/m2) plus docetaxel(25mg/m2) weekly form 2023/12/20~
    • Reflux esophagitis LA Classification grade A (minimal)
    • Chronic viral hepatitis B without delta-agent
    • Anemia in neoplastic disease
    • Acute embolism and thrombosis of deep veins of right upper extremity suspected and D-dimer > 10000
    • Wheezing possibly asthma
  • CC
    • face swelling on 2023/12/11
  • Present illness
    • This 78-year-old male had history of:
      • Anterior mediastinal squamous cell carcinoma status post surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13, s/p radiotherapy (4500cGy/25+15 fractions) on 2023/08/22 ~ 2023/09/08.
      • Infective endocarditits post Mitral valve replacement with 33mm Medtronic Hancock II tissue valve on 2020/08/10.
      • Hypertension.
      • S/P
        • wide excision of sternal SCC + AsAo replacement;
        • Pericardiectomy;
        • wedge resection of RUL;
        • reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws;
        • bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/4/3.
    • Patient received radiotherapy (4500cGy/25+15 fractions) on 2023/08/22 ~ 2023/09/08.
    • He sufferred from mild chest wall pain noted for 1 month. Sternal notch area fluid collecting and pain radiation to right shoulder area noted for 3 days.
    • Followed-up Chest CT (2023/03/11) revealed Necrotic mass like lesion at anterior mediastinum encircling ascending aorta about 8.4cm is found. Smaller lesion at subcutaneous tissue just anterior to the manubrium measuring 2.09cm is found, abscess is likely.
    • The surgical of resection of anterior mediastinum tumor on 2023/03/13, the biopsyshowed moderately differentiated squamous cell carcinoma with necrosis, Immunohistochemical stain reveals p63(+), CD117(-), CK(+), S100(-),and Myosin(-) on 2023/03/13.
    • Then, he suffered from Anterior mediastinum squamous cell carcinoma was reported, pus discharge noted from sternum wound was noted for 1 day, so he was admitted on 2023/03/23.
    • Followed-up chest CT (2023/03/22) revealed abnormal air pockets at superior and anterior mediastinum is found. Abscess formation cannot be excluded.
    • Panendoscopy (2023/03/24) disclosed Reflux esophagitis LA Classification grade A-,Superficial gastritis,and Gastric erosions, body, antrum, and cardia.
    • The Tc-99m MDP bone scan (2023/03/27) disclosed several hot/faint hot spots in the sternum, highly suspected malignancy with sternum metastasis.
    • Cancer combine meeting (Hematology Oncology, Plasty, CVS) was done on 2023/03/28, consulted ENT was consulted for evaluation of head and neck tumor who suggested no finding suggestive of tumor in nasal cavity, oral cavity, pharynx, and larynx. Plasty was consulted for flap after tumor excision.
    • After fully explain to patient about surgical indication he and his family agree to received.
    • He underwent
      • wide excision of sternal SCC + AsAo replacement;
      • Pericardiectomy;
      • wedge resection of RUL;
      • reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws;
      • bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/04/03.
    • The biopsy showed:
      • Bone and soft tissue, mediastinum, bilateral clavicle head, upper sternum, bilateral 1st and 2nd ribs, wide excision — Squamous cell carcinoma, moderately differentiated, in favor of thymic origin, if no other primary tumor is found; AJCC 8th edition: pStage IIIB, pT4Nx(if cM0)
      • Lung, RUL, wedge resection — Squamous cell carcinoma, by direct invasion
      • Ascending aorta, excision — Squamous cell carcinoma, by direct invasion
      • Superior vena cava, excision — Squamous cell carcinoma, by direct invasion
      • F2023-00148 - Soft tissue, peristernum, biopsy — Negative for malignancy.
    • Followed-up transthoracic echocardiography (2023/04/03) showed LVEF(%) = 43.3%. Adequete LV systolic function, EF 43.3%. Moderate AR (Vena contracta width = 5.8 mm), Trivial TR. s/p bioprothetic MVR, mild MR, and remaining chordae. Minimal pericardial effusion.
    • Chest CT (2023/04/20): Massive bilateral pleural effusion with consoidation oat both lungs. Minimal air pockets at anterior and superior mediastinum is also noted. r/o residual abscess. Revision on 2023-04-24, minimal fluid collection at left inguia region measuring 4.05cm in largest dimension. Suggest further evaluation. Pleural effus cytology: negative.
    • Anti-HBc: POSITIVE on 2023/05/06, s/p Vemlidy 1tab QD since 2023/10/31~.
    • Panendoscopy (2023/07/12): No bleeder or blood clot during exam. Reflux esophagitis LA Classification grade A(minimal). Gastric ulcer, Forrest classification type III, prepyloric antrum. Superficial gastritis, antrum.
    • Chest CTA (2023/07/31) showed: several bilateral renal cysts measuring up to 1.6 cm, multiple hepatic cysts measuring up to 1.9cm, unremarkable of the GB, spleen, both adrenal glands, pancreas, and no enlarged lymph node. no ascites. Impression: recurrent tumor as metastatic mediastinal LAP and metastatic tumor in RLL and Rt exudative pleural effusion with metastatic tumor, post op fluid collection over anterior mediastinum r/o abscess, s/p Right chest tube with drainge bloody pleural effusion 200ml. Chest echo (2023/10/06) revealed right pleural thickening with trivial amount of organized pleural effusion. Consulted 放射腫瘤科 for radiotherapy with 4500cGy/25+15 fractions on 8/22 ~ 9/8/2023.
    • Chest CT (2023/10/06) revealed metastatic mediatsinal lymph nodes and lung meta, liver meta.
    • This time, he complaomed of face swelling on 2023/12/11 then blood transfusion with LPRBC 2U was given on 2023/12/12. Fever without chills was noted post blood transfusion and took Acetal 1# po st then without more fever. Right hand swelling, reddish and right arm circumferencev from 23cm increase to 25cm were found on 2023/12/15 and he came to our ER.
    • At ER, the chest CTA showed S/P PICC. Thrombosis of right subclavian vein and left proximal subclavian vein. A thrombus in SVC. LNs, liver and lung metastases. A poor enhancing lesion (2.4cm) at pancreatic tail.
    • The laboratory revealed D-dimer >10000 ng/mL, CRP = 6.8 mg/dL, HGB = 7.3 g/dL. He was admitted for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, Laboratory shows D-dimer > 10000 and chest CTA showed S/P PICC. Thrombosis of right subclavian vein and left proximal subclavian vein. A thrombus in SVC. LNs. Anticoagulant with Clexance 45mg sc q12h x 7 days (12/16-12/22).
    • The empirical antibiotic with Augmentin 1200mg ivd q8h for right hand erythema & swelling R/O cellulitis due to right hand PICC line.
    • For anemia, HGB 7.3 g/dL and blood transfusion with LPRBC 2U on 2023/12/16. We explained his condition to his family and disscuss treatment on 2023/12/19.
    • Due to cancer in progression, thus shift to paliactive chemotherapy with Cisplatin(30mg/m2) plus docetaxel(25mg/m2) weekly (2 weeks of treatment and 1 week of rest) form 2023/12/20(C1D1), 2023/12/27(C1D8).
    • Steroid with compeslon 5mg/tab 1# bid was give for 2days(12/20~12/21). The Clexance SC shift to lixiana 30mg qd po since 12/23.
    • For DOE intermittent and PFT shows FVC 56%, add MDI with foster 2puff bid.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/12/28 and OPD followed up later.
  • Discharge prescription
    • Antica (orciprenaline, bromhexine, doxylamine) 10mL Q12H
    • Eurodin (estazolam 2mg) 1# PRNHS if insomnia
    • Fudecough (dextromethorphan 15mg) 1# TID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
    • Lixiana (edoxaben 30mg) 1# QD
    • MgO 250mg 2# TID
    • Megest (megestrol 40mg/mL) 10mL QD
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Through (sennoside 12mg) 1# HS
    • Ulstop (famotidine 20mg) 1# QD
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-10-05 ~ 2023-10-17 POMR Infectious Disease Hong BoBin
  • Discharge diagnosis
    • Malignant neoplasm of overlapping sites of heart, mediastinum and pleura
    • Pyothorax without fistula
    • Nonrheumatic mitral (valve) insufficiency
  • CC
    • Fever up to 40 degree for one week.
  • Present illness
    • This 78-year-old male had history of:
      • Anterior mediastinal squamous cell carcinoma status post surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13.
      • Infective endocarditits post Mitral valve replacement with 33mm Medtronic Hancock II tissue valve on 2020/08/10.
      • Hypertension.
      • S/P 1.wide excision of sternal SCC + AsAo replacement; 2.Pericardiectomy; 3.wedge resection of RUL; 4. reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws; 5.bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/04/03.
      • Patient received radiotherapy since 8/22 ~ 9/8/2023.
      • This time, he suffered from Fever up to 40 degree for one week and productive cough in recent days. He was brought to our emergency department for help.
      • At ED, conscious clear, vital signs showed fever, tachcyadria (BP:117/55; HR:105; BT:38.6’C; RR:18). Laboratory examination revealed leukocytosis (WBC:13660/uL), anemia (Hb:8.6 g/dl), elevated CRP (CRP:16.5 mg/dl).
      • Chest x-ray showed no acute pulmonary lesion.
      • Under the impression of fever cause unknown, he is admitted to the Infection ward for evaluation and management on 2023-10-05.
  • Course of inpatient treatment
    • During the hospital stay, we use parenteral cefuroxime for empirical treatment of lung abscess. The sputum is submitted for sputum culture, TB culture, atypical pneumonia. Chest CT was arrange for lung abscess survey. Chest CT revealed metastatic mediatsinal lymph nodes and lung meta, liver meta. Streptococcus pneumoniae urine Antigen showed Negative. Acid-fast stain showed not found.
    • Sputum culture showed mixed normal flora. Urine culture showed after 48 hours 1000 CFU/mL. We also arrange chest sonography for excluded lung empyema or malignancy. Chest sonography revealed right pleural thickening with trivial amount of organized pleural effusion. Urine culture showed after 48 hours 1000 CFU/mL. No bacterial growth on blood culture is noted. He sudden of fever noted, fever survey was done. Laboratory examination revealed leukocytosis stationary, CRP become better, but anemia is noted. Urinalysis shows no pyuria. No bacterial growth on blood culture is noted.
    • Tumor marker showed elevated SCC, CA125 noted.
    • Naproxen was given for suspect tumor fever.
    • Mucolytics, antitussives and laxatives for relieve symptoms.
    • Blood transfusion with LPRBC one unit for two days.
    • Laxative supp. was given for relieve constipation.
    • Laboratory examination are in improvement. Room air saturation showed 92% without dyspnea. Smooth breath pattern. He is discharged on 2023-10-17.
  • Discharge prescription
    • naproxen 250mg 1# QW14
    • Ulstop (famotidine 20mg) 1# QD
    • Through (sennoside 12mg) 2# HS
    • Cough Mixture (platycodon) 15mL Q12H
    • Actein Effervescent (acetylcysteine 600mg) 1# BID

[consultation]

• 2024-02-15 Family Medicine
  • Q
    • for combine hospice care.
    • This 78-year-old male had history of:
      • Anterior mediastinal squamous cell carcinoma status post surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13, s/p radiotherapy (4500cGy/25+15 fractions) on 2023/08/22 ~ 09/08.
      • Infective endocarditits post Mitral valve replacement with 33mm Medtronic Hancock II tissue valve on 2020/08/10.
      • Hypertension.
      • S/P 1. wide excision of sternal SCC + AsAo replacement; 2. Pericardiectomy; 3. wedge resection of RUL; 4. reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws; 5. bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/04/03.
    • Patient received radiotherapy (4500cGy/25+15 fractions) on 2023/08/22 ~ 09/08.
    • He sufferred from mild chest wall pain noted for 1 month. Sternal notch area fluid collecting and pain radiation to right shoulder area noted for 3 days. Followed-up Chest CT (2023/03/11) revealed Necrotic mass like lesion at anterior mediastinum encircling ascending aorta about 8.4cm is found. Smaller lesion at subcutaneous tissue just anterior to the manubrium measuring 2.09cm is found, abscess is likely. The surgical of resection of anterior mediastinum tumor on 2023/03/13, the biopsyshowed moderately differentiated squamous cell carcinoma with necrosis, Immunohistochemical stain reveals p63(+), CD117(-), CK(+), S100(-),and Myosin(-) on 2023/03/13, s/p paliactive chemotherapy with Cisplatin (30mg/m2) plus docetaxel (25mg/m2) weekly form 2023/12/20~.
    • This time. he suffered from SHORTNESS OF BREATH, DYSPNEA AND GENERALIZED MALAISE FOR 2 DAYS. Chest PA view shows enlargement of cardiac silhouette with suspect right pleura effusion and nodular opacity in RLL. Lab cardiac enzyme elevation (NT-proBNP 2528.3, hs-Troponin I 37.0), CRP 2.7mg/dL, eGFR 73.41mL/min, Hb 10g/dL, vein gas pH7.29 with pCO2 59.4 and HCO3 27.9. EKG sinus tachycardia with RBBB. He was admitted for further management. The patient, and family signs DNR, so we need your help for combine hospice care, thanks a lot!!
  • A
    • When I visited, the patient lied on bed, and his wife stood by him. His consciousness was clear, and he felt better after admission. After discussion, I decided to arrange hospice combine care for this patient. Thanks for your consultation.
    • Indication for hospice combine care: Anterior mediastinal squamous cell carcinoma
    • Plan: hospice combined care
• 2023-10-31 Cardiology
  • Q
    • for PICC insertion.
    • This 78-year-old male had history of:
      • Anterior mediastinal squamous cell carcinoma status post surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13.
      • Infective endocarditits post Mitral valve replacement with 33mm Medtronic Hancock II tissue valve on 2020/08/10.
      • Hypertension.
      • S/P
        • wide excision of sternal SCC + AsAo replacement;
        • Pericardiectomy;
        • wedge resection of RUL;
        • reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws;
        • bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/04/03.
    • This time, he is admitted for chemotherapy, so we need your help for PICC insertion, thanks a lot!!
  • A
    • I’m consulted for PICC.
    • SvO2 was also check, it revealed only 45%.
      • Estimated Fick Cardiac index 1.86 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
      • Estimated Fick cardiac output 2.44 L/min. (nomral cardiac output range 5~6 L/min)
    • impression
      • Anterior mediastinal squamous cell carcinoma status post surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13
      • Low cardiac output
    • Suggestion
      • We complete PICC smoothly. and low cardiac output was noted.
• 2023-05-05 Hemato-Oncology
  • Q
    • For anterior mediastinal squamous cell carcinoma chemotherapy survey
    • This 78 year-old male is a care of Anterior mediastinal squamous cell carcinoma
      • s/p surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13.
      • S/P 1.wide excision of sternal SCC + AsAo replacement; 2.Pericardiectomy; 3.wedge resection of RUL; 4. reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws; 5.bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/04/03.
    • He was admitted due to right side massive pleural effusion.We need your help for further treatment.
  • A
    • We had discuss with patient about further adjuvant chemotherapy due to pT4Nx and lymphvascular invastion.
    • May consider adjuvant chemotherapy after complete RT (old age).
    • Please check Anti-HBc, Anti-HBs, HBsAg, Anti HCV and 24 urine CCR. Arrange port A insertion.
    • Please arrange our OPD after discharge.
• 2023-04-28 Radiation Oncology
  • Q
    • for anterior mediastinal squamous cell carcinoma treatment
  • P
    • Radiotherapy is indicated for this patient with the following indicators: stage pT4Nx(cM0).
    • Goal: curative
    • Treatment target and volume: anterior mediastinal tumor bed and peripheral involved area
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 4500cGy/25 fractions of the anterior mediastinal tumor bed and peripheral involved area.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family (wife and sister). They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0930, 2023-05-09.
• 2023-03-24 Plastic and Reconstructive Surgery
  • Q
    • anterior mediastinum SCC for flap after tumor excision
    • He was admitted due to anterior mediastinum SCC.
  • A
    • Methods of flap surgery is considered for this patient.
    • For wound closure of the thorax only, pectoris major myocutaneous flaps can be chosen. If there is a space which needs filling, rectus abdomins muscle flap and split-thickness skin graft on the flap surface can achive the need of spcae filling and wound resurfacing.
• 2020-08-03 Cardiac Surgery
  • Q
    • This 75 y/o man admitted due to IE. Mitral valve flail. So we need your help for assessment surgery. Thanks!!
  • A
    • This 75 y/o man was a case of IE with Mitral valve flail.
    • If patient’s family agreed to proceed, then I will take over this case and arrange operation.
• 2020-07-30 Cardiology
  • Q
    • This 75 years old patient is admitted under the diagnosis of Streptococcus gordonii bacteremia.
    • Echocardiography revealed LVEF 66, no vegetation; but degenerative changes of mitral valve with flail posterior mitral leaflet (P3) due to chordae rupture; severe MR (multiple jets). We need youe help for management of chordae rupture. Thank you.
  • A
    • This patient admitted due to sepsis, he had heart murmur since Jun′2018. 2D echo ih 2018 revealed Typical MVP, posterior leaflet with chordal rupture, severe MR.
      • Becaues of 2D echo severe MR, I’m consuled for it
      • Patient denied shortness of breath
    • PE: systolic murmur, Gr III
    • Impression
      • severe MR since 2018
      • sepsis
    • Suggestion:
      • Because of patient without symptoms, CxR no pulmonary edema, familes and patient not favor operation right now
      • If worried about MR related subclinical heart failure, to perform treadmill with Naughton is another choice.

[surgical operation]

• 2023-04-21
  • Surgery
    • Insertion of Right chest tube
  • Finding
    • bloody pleural effusion 200ml
• 2023-04-03
  • Surgery
    • reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws
    • bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax
  • Finding
    • about 25cm X 10cm X 3cm skin, whole-layer (bone and soft tissue) defect over sternal region owing to ablasion of cancer
    • missing manubrium, upper-two-thirds-of-body, and xiphoid process of sternum; also mission medial ends of bilateral clavicles; and also missing anterior ends of bilateral 1st~4th ribs; thus only the wired-fixed, lower one-third of sternal body keeping the lower half of the bony thoracic cage fixed
    • exposed heart, artificial aortic segments, and both lungs before my recontruction surgery
    • released structures for flap advancement: origin sites of bilateral pectoris major muscles over medial clavicles, medial ribs, and low part of sternum
    • titanium implants for fixation of clavicles and ribs: BIOPLATE PREFORMED FIXATION SYSTEM - MESH + SCREWS
      • size of mesh before and after trimming: 20cm X 20cm and about 15cm X 15cm
    • distance of cutting ends of bilateral clavicles after reducion and fixation: 8.5cm
• 2023-04-03
  • Surgery
    • wide excision of sternal SCC + AsAo replacement
    • Pericardiectomy
  • Finding
    • sternal SCC with capsualization involved ascending aorta, brachial-cephalic trunk, SVC. Tumor adhesionof RUL of lung
• 2023-04-03
  • Surgery
    • Wedge resection of RUL
  • Finding
    • Perioperative consultation
    • A large mediastinal tumor with mediastinal and RUL invasion
    • Wedge resection of RUL was done using endo-GIA
    • No residual tumor or active bleeding noted
• 2023-03-13
  • Surgery
    • Resection of anterior mediastinum tumor
  • Finding
    • Capsuled mass over upper sternal region extended to anterior mediastinum space with pus accumunation.
• 2020-08-10
  • Surgery
    • Mitral valve replacement with 33mm Medtronic Hancock II tissue valve.        
  • Finding
    • Ruptured chordae tendineae of P2.
    • Vegetation on anteriior leaflet of mitral valve.    

[radiotherapy]

• 2023-08-22 ~ 2023-09-11 - 2700cGy/15 fractions of the metastatic tumor in RLL.
• 2023-05-19 ~ 2023-06-23 - 4500cGy/25 fractions of the anterior mediastinal tumor bed and peripheral involved area.

[chemotherapy]

• 2024-02-19 - docetaxel 25mg/m2 30mg NS 100mL 1hr + cisplatin 30mg/m2 30mg NS 350mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-02-07 - docetaxel 25mg/m2 30mg NS 100mL 1hr + cisplatin 30mg/m2 30mg NS 350mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-31 - docetaxel 25mg/m2 30mg NS 125mL 1hr + cisplatin 30mg/m2 30mg NS 350mL 3hr + NS 250mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-17 - docetaxel 25mg/m2 34mg NS 125mL 1hr + cisplatin 30mg/m2 40mg NS 350mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-13 - docetaxel 25mg/m2 34mg NS 125mL 1hr + cisplatin 30mg/m2 40mg NS 350mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-27 - docetaxel 25mg/m2 34mg NS 125mL 1hr + cisplatin 30mg/m2 40mg NS 350mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-20 - docetaxel 25mg/m2 34mg NS 125mL 1hr + cisplatin 30mg/m2 40mg NS 350mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-05 - paclitaxel 60mg/m2 80mg NS 250mL 2hr + carboplatin AUC 2 120mg NS 200mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-28 - paclitaxel 60mg/m2 80mg NS 250mL 2hr + carboplatin AUC 2 120mg NS 200mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-14 - paclitaxel 60mg/m2 80mg NS 250mL 2hr + carboplatin AUC 2 120mg NS 200mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-07 - paclitaxel 60mg/m2 80mg NS 250mL 2hr + carboplatin AUC 2 120mg NS 200mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-31 - paclitaxel 60mg/m2 80mg NS 250mL 3hr + carboplatin AUC 2 120mg NS 200mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

Clinical presentation and management of thymoma and thymic carcinoma - 2023-11-01 - https://www.uptodate.com/contents/clinical-presentation-and-management-of-thymoma-and-thymic-carcinoma

• The same regimens are used in the neoadjuvant setting for potentially resectable disease as in the treatment of unresectable disease. Although several regimens are acceptable, cyclophosphamide, doxorubicin, and cisplatin (CAP) and cisplatin and etoposide (PE) have been used successfully for thymomas or thymic carcinomas. The combination of carboplatin and paclitaxel is also used extensively, especially in patients with thymic carcinoma. If chemotherapy is given concurrently with RT, our preferred regimens are PE or carboplatin and paclitaxel.
  • CAP
    • Cyclophosphamide (500 mg/m2 intravenous [IV] day 1), doxorubicin (50 mg/m2 IV day 1), and cisplatin (50 mg/m2 IV day 1), repeated every three weeks. In a United States intergroup study, 29 patients with metastatic or progressive thymoma were treated with CAP. The overall and complete response rates were 50 and 10 percent, respectively, and the median survival was 38 months.
  • PE
    • Cisplatin (60 mg/m2 IV day 1) and etoposide (120 mg/m2 IV days 1 to 3), repeated every three weeks [60]. In a European Organisation for Research and Treatment of Cancer (EORTC) study, 16 patients with advanced thymoma received etoposide plus cisplatin every three weeks. The overall and complete response rates were 56 and 31 percent, respectively, and the median progression-free and overall survival durations were 2.2 and 4.3 years, respectively.
  • CAP with prednisone
    • Cyclophosphamide (500 mg/m2 IV day 1), doxorubicin (20 mg/m2/day as a continuous infusion, days 1 to 3), cisplatin (30 mg/m2 IV days 1 to 3), and prednisone (100 mg/day on days 1 to 5), repeated every three weeks. In a series of 22 patients given induction chemotherapy with the CAP with prednisone regimen, partial responses were observed in 14 cases and complete responses in three cases for an overall 77 percent response rate.
  • Carboplatin (area under the curve [AUC] 6) and paclitaxel (225 mg/m2 IV) every three weeks
    • In a prospective, multicenter study of patients with advanced disease, three complete responses and six partial responses were observed in 21 patients with thymoma (overall response rate, 43 percent). There were five partial responses and no complete responses among the 23 patients with thymic carcinoma (overall response rate, 22 percent).
  • ADOC
    • Cisplatin (50 mg/m2 IV day 1), doxorubicin (40 mg/m2 IV day 1), vincristine (0.6 mg/m2 IV day 3), and cyclophosphamide (700 mg/m2 IV day 4), repeated every three weeks. In another series, 37 patients with advanced disease were treated with ADOC. The overall and complete response rates were 92 and 43 percent, respectively, and the median survival was 15 months.
  • VIP
    • Etoposide (75 mg/m2 IV days 1 to 4), ifosfamide (1.2 g/m2 IV on days 1 to 4), and cisplatin (20 mg/m2 IV days 1 to 4), repeated every three weeks. In an intergroup trial that included 28 patients with advanced thymoma or thymic carcinoma, nine partial responses (32 percent) were observed.

==========

2024-03-04

[tube administration of Nexium and Concor: guidelines for the simple suspension method]

All oral medications currently listed as active are suitable for administration via tube feeding. Nonetheless, for specific medications like Nexium (esomeprazole) and Concor (bisoprolol), the manufacturers advise against crushing the tablets. In such cases, the Simple Suspension Method (SSM) is recommended for preparing these medications for tube feeding.

The Simple Suspension Method, involves dispersing solid oral medications into a liquid form to facilitate administration through a nasogastric (NG) tube. This approach is particularly beneficial for patients who are unable to swallow tablets or capsules due to conditions such as dysphagia, or for those who have a feeding tube or are in a comatose state.

To utilize the Simple Suspension Method:

• Place the medication in a small container.
• Add warm water to the container, ensuring the medication is fully submerged.
• Stir or agitate the solution until the medication has either dissolved or broken down into sufficiently small particles for tube administration.
• Use a syringe or feeding pump to introduce the medication mixture through the NG tube.

Considerations when applying the Simple Suspension Method:

• Employing warm water can aid in dissolving the medication more effectively.
• Ensure thorough stirring or shaking of the mixture to achieve complete dispersion of the medication.
• For medications contained within capsules, it may be necessary to open the capsule and extract its contents prior to dissolution.

[PACs & RBBB on ECG: management options & bisoprolol continuation]

ECG on 2024-03-01 showed: 1. Sinus rhythm with premature atrial complexes (PACs); 2. right bundle branch block (RBBB).

PACs are common and often benign, especially in healthy individuals. Treatment may not be needed unless PACs are frequent and symptomatic, in which case the following approaches might be considered:

• Lifestyle Modifications: Reducing caffeine and alcohol intake, managing stress, and quitting smoking can decrease the frequency of PACs.
• Beta-Blockers: These can be used to reduce palpitations associated with PACs by slowing down the heart rate.
• Calcium Channel Blockers: Non-dihydropyridine calcium channel blockers, like diltiazem or verapamil, may also be used to control heart rate and reduce symptoms.
• Antiarrhythmic Drugs: In more symptomatic cases, medications like flecainide or propafenone might be considered, usually under the guidance of a cardiologist.

RBBB is a pattern seen on an ECG where the electrical impulse in the heart is delayed or blocked along the right bundle branch. Treatment for RBBB is usually not necessary unless it is associated with other underlying heart conditions. The management focuses on the underlying cause, if identified:

1. Underlying Heart Disease: If RBBB is associated with conditions like heart failure or ischemic heart disease, treatment will focus on managing these underlying conditions.
2. Pacemaker: In cases where RBBB contributes to significant heart conduction problems or is part of a more complex conduction disorder, a pacemaker might be indicated to help coordinate heartbeats.

The patient has experienced recent episodes of heart rate elevation, reaching up to 155 bpm with significant variability. He is currently taking 2.5 mg of bisoprolol daily. Should atrial fibrillation (as seen on the ECG dated 2024-02-28) recur, the addition of an antiarrhythmic medication might be considered.

2024-02-20

[chronic anemia worsens with chemo: LPRBC transfusion for the patient]

Lab data on 2024-02-19 showed HGB 7.5 g/dL and an immediate LPRBC transfusion was performed. Vital signs are currently stable.

This patient has a long history of anemia even before the initiation of chemotherapy, but the chemotherapy treatment dose associated with lowered HGB level on a long-term basis.

2024-01-12

[regimen change prompts eGFR decline: further monitoring needed]

Following a switch to docetaxel + cisplatin on 2023-12-20 from the previous paclitaxel + carboplatin regimen, the patient has experienced a preliminary decline in eGFR.

While the current eGFR remains within the acceptable range, further monitoring is necessary to track potential changes.

• 2024-01-09 eGFR 83.52 ml/min/1.73m^2
  
• 2023-12-27 eGFR 114.04 ml/min/1.73m^2
  
• 2023-12-25 eGFR 117.87 ml/min/1.73m^2

[observing potential thrombosis after previous event]

A thrombotic event previously occurred in mid-Dec 2023, and a recent slight elevation in D-dimer levels has been observed. Monitoring for any signs of potential thrombosis is recommended.

• 2024-01-09 D-dimer 2638.00 ng/mL(FEU)
  
• 2023-12-25 D-dimer 2152.00 ng/mL(FEU)
  
• 2023-12-15 D-dimer >10000 ng/mL(FEU)

2023-11-01

The tumor marker SCC has consistently been elevated throughout the year.

• 2023-10-12 SCC 122.0 ng/mL
• 2023-03-24 SCC 125.5 ng/mL

In 2023Q3, radiation therapy of 2700cGy/15 was administered to the metastatic tumor in the right lower lobe (RLL). Additionally, in 2023Q2, a dose of 4500cGy/25 was directed to the anterior mediastinal tumor bed and the surrounding affected area.

The treatment regimen of paclitaxel combined with carboplatin commenced on 2023-10-31.

No discrepancies in medication were identified.

700556004

240304

[lab data]

2023-06-13 Anti-HBs 0.00 mIU/mL
2023-06-13 HBsAg Reactive
2023-06-13 HBsAg (Value) 6203.60 S/CO
2023-06-13 Anti-HCV Nonreactive
2023-06-13 Anti-HCV Value 0.17 S/CO
2023-05-23 HBeAg Nonreactive
2023-05-23 HBeAg (Value) 0.949 S/CO
2023-05-23 HBsAg Reactive
2023-05-23 HBsAg (Value) 5353.06 S/CO

2023-05-02 P.jiroveci DNA-Sp Undetectable
2023-05-02 CMV viral load assay <35 IU/mL
2023-05-02 EBV DNA PCR Not deteceted copies/mL

2023-04-29 Gamma 25.9 %
2023-04-28 B2-Microglobulin 6183 ng/mL

2023-04-27 HIV Ab-EIA Nonreactive
2023-04-27 Anti-HIV Value 0.04 S/CO

2023-04-27 LDH 344 U/L

[exam findings]

• 2024-03-01 ECG
  • Poor data quality
  • Sinus tachycardia with Premature ventricular complexes or Fusion complexes
  • Inferior infarct , age undetermined
  • Abnormal ECG
• 2024-01-02 ECG
  • Sinus tachycardia
• 2023-12-22 CXR
  • S/P port-A implantation.
  • Multiple lung metastases.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-12-07 Patho - breast simple/partial mastectomy
  • Diagnosis
    • Breast, left, simple mastectomy — invasive carcinoma, NST, no special type.
    • Margin: free
    • Lymph node, no tissue submitted
    • ypT4a pNx (if cM1); anatomic stage: IV , pathology prgnostic stage group: IV
  • Gross Description
    • Procedure - simple mastectomy: breast: 11 x 8 x 5.5 cm with skin grossly invaded by tumor. Skin: 10 x 8 cm.
    • Lymph node sampling (if lymph nodes are present in the specimen)- no tissue submitted
    • Specimen laterality - Left
      • Sections are taken and labeled as: Tissue for formalin fixation: S2023- 24591: A1-2: peripheral margin; a3: deep margin; A4-8: tumor
  • Microscopic Description
    • For Invasive Carcinoma
      • Histologic type: Invasive carcinoma
      • Size of invasive carcinoma (mm): 70 x 70 x 40 mm.
      • Histologic grade (Nottingham histologic score): grade II (score 6,7)
      • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: Present (with ulceration )
        • Chest wall invasion deeper than pectoralis muscle: Absent
    • For Ductal Carcinoma In Situ- multiple folci
      • Tumor size (mm): 3 x 2 x 2 mm
      • Nuclear grade: 2
      • Architectural pattern: Comedo
      • Tumor necrosis: Present
    • Margins: Negative, Closest margin (2 mm from deep margin)
    • Nodal status: no tissue submitted
    • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
      • In the Breast - Probable or definite response to presurgical therapy in the invasive carcinoma
      • In the Lymph nodes - no tissue submitted
    • Immunohistochemical Study - S2023-24591A3
      • ER (Ab): Positive (5%, strong); PR (Ab): Negative (0%); Her-2/neu : Positive (3+); Ki-67: 40-50%; p53: 95%
• 2023-11-10 CT - abdomen
  • History: left breast cancer with multiple lung metastases.
    • 20231106 US: a faint heterogenous hypoechoic lesion at S5 near surface: size about 1.6cm(?)
    • HBV related cirrhosis, child A with splenomegaly
  • Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
  • Findings:
    • Prior CT identified left breast cancer (4.0cm) is noted again, increasing in size to 6.1 cm that is c/w progressive disease.
      • In addition, prior CT identified multiple metastases on bilateral lungs are noted again, marked increasing in size and number that is c/w multiple lung metastases with progressive disease.
    • There are two poor enhancing lesion 0.7 cm in S5 sub-capsule area. and 0.8 cm in S4 of the liver. Follow up is indicated. Otherwise, please correlate with MRI.
    • Prior CT identified Cirrhosis of the liver with portal hypertension (splenomegaly) is noted again, stationary.
    • Prior CT identified some calcifications in the uterus are noted again, stationary that is c/w fibroids.
  • Impression:
    • Left breast cancer with multiple lung metastases show progressive disease.
    • There are two poor enhancing lesion 0.7 cm in S5 sub-capsule area. and 0.8 cm in S4 of the liver. Follow up is indicated. Otherwise, please correlate with MRI.
• 2023-11-09 PET scan
  • In comparison with the previous study on 2023/02/15, the glucose-hypermetabolism in the left breast is a little less evident and the previous glucose hypermetabolic lesions in the left axillary region and left 1st rib disappeared. However, more new bilateral lung lesions are noted, suggesting multiple lung metastases in progression.
    
  • Glucose hypermetabolism in the right shoulder joint and in the right hip joint. Inflammtion may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological accumulation of FDG.
• 2023-11-06 SONO - abdomen
  • Findings:
    • Coarse liver parenchyma with uneven surface, increased brightness of liver parenchyma with far attenuation was noted. some parts of liver obscured by bowel gas: incomplete exam of liver.
      • a faint heterogenous hypoechoic lesion was noted at S5 near surface: size about 1.6cm.
    • a high echoic lesion was noted in the gallbladder, size about 0.4cm; diffuse gallbladder wall thickening was noted.
    • mild splenomegaly
  • Diagnosis:
    • Liver cirrhosis (incomplete exam of liver: please see description), fatty liver (moderate)
    • liver hypoechoic lesion: suspected liver tumor
    • mild splenomegaly
    • gallbladder stone
    • gallbladder wall thickening
  • Suggestion:
    • suggest further image study: such as CT scan
• 2023-10-31 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 14) / 88 = 84.09%
    • M-mode (Teichholz) = 84
  • Conclusion:
    • Mild septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; mild PR.
    • Dilated proximal ascending aorta (35 mm).
• 2023-08-14 SONO - abdomen
  • Findings
    • Coarse liver parenchyma with uneven surface, increased brightness of liver parenchyma.
      • some parts of liver obscured by bowel gas: incomplete exam of liver.
      • Lesion could be masked due to cirrhosis background.
    • a high echoic lesion was noted in the gallbladder, size about 0.5cm; diffuse gallbladder wall thickening was noted.
    • mild splenomegaly
  • Diagnosis:
    • Liver cirrhosis (incomplete exam of liver: please see description), fatty liver
    • mild splenomegaly
    • gallbladder stone
    • gallbladder wall thickening
• 2023-07-12 ENT Hearing Test
  • Tymp bil type B
  • ART bil ansent
  • PTA:
    • Reliability FAIR
    • Average RE 39 dB HL; LE 41 dB HL
    • RE mild to moderate SNHL
    • LE midl to moderately severe SNHL
• 2023-06-30 CT - brain
  • no evidence of brain metastasis.
• 2023-06-13, -05-17, -05-11 CXR
  • Multiple nodules at bil. lungs.
• 2023-05-08, -05-05, -05-02, -04-27, -04-24, -04-20 CXR
  • Multiple nodules in both lungs due to metastases.
• 2023-04-25 Esophagogastroduodenoscopy, EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Mild oozing lesion, antrum, GC, s/p hemostasis with argon plasma coagulation
  • Suggestion:
    • High dose PPI use
    • Coagulopathy correction
    • 2nd look maybe indicated, if active bleeding present
• 2023-04-24 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Hypercellularity
  • Immunohistochemical stains:
    • MPO: positive for myeloid series
    • CD71: positive for erythroid series
    • CD61: positive for megakaryocytes
    • CD34 & CD117: positive for blast
    • CD138: positive for plasma cells
    • Kappa & lambda light chain: polyclonality
    • CK: negative for carcinoma cell
  • Microscopically, the section shows pictures as follows:
    • Hypercellularity for her age, 70%
    • M/E ratio > 10, hyperplasia of myeloid series and marked hypoplasia of erythroid series
    • Adequate megakaryocytes with focal mononucleation and hyposegmentation
    • No increase of blast
    • Increase of plasma cells (about 10%) with polyclonality of kappa and lambda light chains
  • According to above histopathologic findings, it maybe either therapeutic effect or myelodysplastic syndrome. Please correlate with clinical finding and bone marrow smear for conclusive diagnosis.
• 2023-04-17 CXR
  • Multiple nodules of variable sizes in both hypoinflated lungs due to metastases.
• 2023-04-17 SONO - chest
  • Findings
    • Left-side of thorax:
      • There was no pleural effusion in the left hemithorax. The pleural gliding and diaphragm excursion were adequate.
    • Right-side of thorax:
      • There was no pleural effusion in the right hemithorax. The pleural gliding and diaphragm excursion were adequate. Large amount of ascites was also noted in the abdominal cavity. We tried echo-assisted ascites tapping first but failed because of too thick of skin and soft tissue to approach ascites. We then performed echo-assisted pig-tail insertion from RLQ for ascites tapping under her son’s agreement. After local anaesthesia, Fr 10 pig-tail was inserted smoothly and total 1000cc yellowish turbid fluid was drained immediately. The specimen was submitted for routine, biochemistry, TB, bacterial culture and cell block. The whole procedure was smoothly.
  • Special Procedure
    • Insertion of pig-tail catheter fr.10 through the RLQ abdomen
  • Echo diagnosis
    • No pleural effusion.
    • Massive ascites post pig-tail insertion for ascites drainage.
• 2023-04-15 Gynecologic ultrasonography
  • Findings
    • Uterus Position : AVF
      • Myoma: Myoma: 11 x 8 mm,
        
    • Endometrium:
      • Thickness: 15.7 mm
    • CUL-DE-SAC: with fluid
      
    • Other: Asites >1000ml
  • IMP:
    • EM: 15.7mm, blood clot
    • Ascites
• 2023-04-06 CT - abdomen
  • History and indication: Sepsis
  • Non-contrast CT of abdomen-pelvis revealed:
    • Left breast cancer (4.0cm) with calcification.
    • Multiple nodules at bilateral basal lungs.
    • Liver cirrhosis with splenomegaly.
    • Some calcifications in uterus.
    • S/P foley catheter indwelling. S/P Port-A infusion catheter insertion.
  • IMP: Left breast cancer with lung metastases. Liver cirrhosis with splenomegaly.
• 2023-04-05 CT - brain
  • Brain atrophy.
• 2023-04-05 ECG
  • Sinus tachycardia
  • Poor wave progression
  • Abnormal ECG
• 2023-02-17 SONO - abdomen
  • Liver cirrhosis with suspected muliple regeneration noules
• 2023-02-15 PET
  • Glucose-hypermetabolism in the left breast and several left axillary lymph nodes, compatible with the primary left breast cancer with regional lymph nodes metastases.
    
  • Glucose-hypermetabolism in bilateral lung fields and the left 1st rib, highly suspected cancer with distant metastases.
    
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    
  • Left breast cancer with regional lymph nodes, bilateral lungs and left 1st rib metastases, cTxN2M1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-02-14 ECG
  • Normal sinus rhythm
  • Low voltage QRS
  • Inferior infarct, age undetermined
• 2023-02-14 Spirometry
  • mild restrictive impairment
• 2023-02-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (68 - 17) / 68 = 75%
    • M-mode (Teichholz) = 75
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Trivial TR
• 2023-02-06 CT - chest
  • Indication: Left breast palpable tumor noted for several days. Left breast heterogenous hypoechoic lesion under the nipple, size: 5.0x5.0cm
  • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Lungs: multiple randomly distributed pulmonary nodules of varying sizes due to metastases. mosaic attenuation changes in both lower lobes may be due to obstructive airway disease
    • Mediastinum and hila: no enlarged LN or mass.
    • Aorta: normal caliber, mild atherosclerotic change of aortic arch.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no effusion or nodule.
    • Chest wall and visible lower neck: an ill-defined large soft-tissue tumor (52mm in longest dimension) with areas of cystic or necrotic change, and thickening of overlying skin, and with multiple metastaic LAP at left axilla.
    • Visible abdominal contents: appearance of liver cirrhosis and moderate splenomegaly. normal appearance of gall bladder. unremarkable of the, both adrenal glands, pancreas, and both kidneys. no enlarged lympode.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression: Lt breast cancer T3N2M1
• 2023-02-03 Patho - breast biopsy
  • Breast tumor, left, core needle biopsy — Invasive carcinoma of no special type
  • Microscopically, the sections show a picture of invasive carcinoma of no special type characterized by tumor nests infiltrating in the sclerotic stroma with tumor necrosis.
  • Immunohistochemistry shows P63(-), ER(80%, 2~3+), PR(50%, 2+), Her2/neu(+, Dako score 3+) and Ki-67: 70% for tumor.
• 2023-02-02 Mammography
  • Impression:
    • R/O left breast malignancy with axillary lymph nodes metastasis.
    • Group hetergeneous calcifications in UIQ of right breast (posterior third portion). Malignancy?
  • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
• 2021-04-16 Nerve Conduction Velocity, NCV
  • Findings
    • The results of NCV study showed (1) prolonged distal motor latency and decreased sensory nerve conduction velocity in bilateral median nerves, (2) decreased motor nerve conduction velocity in left median nerve, (3) reduced CMAP amplitude in left peroneal nerve.
    • The results of F-wave and H-reflex studies were within normal limits.
    • The thermal QST study showed normal cold and warm threshold in upper and lower limbs.
  • Conclusion
    • The above findings suggest (1) bilateral median distal neuropathy, more severe in the left side, (2) left peroneal neuropathy. Advise clinical correlation.

[consultation]

• 2024-02-19 Family Medicine

  • Q
    • Request for Palliative Care Assessment/ Hospice combined care
    • Dear Family Medicine Department,
      • Greetings from the Hematology Oncology Department. We are reaching out to request a consultation for a 66-year-old female patient under our care, with a history of left breast cancer diagnosed following the discovery of a palpable mass in June 2022.
      • Despite initial neglect, the patient sought medical attention in January 2023 due to an increase in the size of the tumor and associated mastalgia. Diagnostic imaging confirmed the suspicion of left breast malignancy with axillary lymph node metastasis. Core needle biopsy indicated invasive carcinoma with high proliferation index and positive hormone receptor status.
      • Following an explanation of her condition and treatment options, the patient commenced neo-adjuvant chemotherapy with EC in February 2023 but had to discontinue after only two cycles due to severe side effects and complications, including neutropenia, thrombocytopenia, sepsis with septic shock. A subsequent treatment regimen included dual blockade therapy and aromatase inhibitors; however, the patient continued to experience significant disease burden and underwent palliative surgery in December 2023.
      • Her condition has been further complicated by progressive lung metastases and a recent episode of neutropenic fever post-chemotherapy, necessitating hospital admission. Given the clinical progression and the complexity of her condition, we kindly request a thorough evaluation by your team to determine her candidacy for palliative care services or potential transfer to a hospice facility.
    • We appreciate your assistance in managing this challenging case and look forward to your expert assessment to improve her quality of care.
    • Warm regards! Thank you for your support!!
  • A
    • Dear Dr:
      • Cons: clear
      • ECOG: 3
    • Patient and her son felt no somait complaints, including cough, while I visited.
    • They anticipated further chemotherapy. If no more therapy will be arranged, please tell the truth.
    • We will arrange share care to follow up.
    • Indication: breast cancer with lung mets

• 2023-05-12 Rehabilitation

  • A
    • Assessment
      • Malignant neoplasm of unspecified site of left female breast, cT3N1M1, stage IV with axillary lymph node and lung metastasis
      • Secondary malignant neoplasm of unspecified lung
      • Bacteremia, blood culture: Klebsiella pneumoniae
      • Pneumonia due to Methicillin susceptible Staphylococcus aureus
      • Pneumonia, sputum culture: Carbapenem resistant Acinetobacer nosocomialis
      • Urinary tract infection, urine culture: Klebsiella pneumoniae
      • Pneumocystosis
      • Severe sepsis with septic shock
      • Hypoxic respiratory failure post intubation on 112-04-08
      • Acute gastric ulcer with hemorrhage
      • Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
      • Agranulocytosis secondary to cancer chemotherapy
      • Thrombocytopenia
      • Hyperlipidemia, unspecified
      • Hyperosmolality and hypernatremia
      • Gastro-esophageal reflux disease without esophagitis
      • Liver cirrhosis, HBV related
      • Herpesviral gingivostomatitis and pharyngotonsillitis
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation programs
      • Goal: recondition, improve endurance and muscle strength

• 2023-04-28 Hemato-Oncology

  • Q
    • For bone marrow
    • Dear Dr, This 66-year-old female patient has past history of 1) Hypertension 2) Type 2 diabetes mellitus. 3) Covid-19 infection on 2022/10/15. 4) Left breast cancer with axillary lymph nodes, lung , left 1st rib metastasis, cT3N2M1, stage IV. ER(80%, 2~3+), PR(50%, 2+), Her2/neu(+, Dako score 3+) and Ki-67:70% status post right subclavian vein port-a implantation on 2023/02/16. ECOG performance: 0. 5) hepatitis B without hepatic coma.
    • According to the statement of ER and family record. She just finished 2nd neo-adjuvant chemotherapy with Epirubicin 90mg/m2 + Endoxan 600mg/m2 on 2023/03/29.
    • This time she suffered from sorethroat and poor appetite in recent three days. The symptom progression therefore she came to our ER for help. At ER, The vital sign showed: BP:108/51mmHg; HR:164; BT:38.7’C; RR:22;SPO2 over 93%. PE revealed Conscious: E2V2M5, BS: clear and bil. Ext: freely movable, no limitation and limb pitting edema 1+.
    • The lab data revealed leukopenia and thrombectocytopnia with elevated of CRP and lactic acid.
    • Hyperglycemia plus positive ketone body and elevated of osmolality with hypernatremia.
    • Acute kidney injury.
    • CSF PCR revealed negative.
    • Abdominal CT showed Left breast cancer with lung metastases. Liver cirrhosis with splenomegaly.
    • Under impress of 1) Sepsis with spetic shock; 2) Suspect post chemotherapy related leukopenia and thrombectocytopnia with secondary infection; 3) Hyperglycemia with diabetic ketoacidosis. She was admitted to our MICU for further treatment.
    • After admission, GCSF for corect leukopenia. Empirical antibiotic with Cefepim, Targocid, Mycamin(4/6-) for infection control.
    • Neuro doctor was consulted for consciousness disturbance, labor lumbar puncture was done, CSF study no special finding, exclued meningitis. Well explained her unstable condition to her family members (daughter, son and son in law), they can understand her poor prognosis and decided not to resuscitation if condition downhill, DNR was signed on 2023/04/08.
    • The NG tube was inserted on 2023/04/11.
    • The Neutropenia and thrombocytopenia got improved after blood transfusion and GCSF injection.
    • Baktar(oral, 4/12-) was prescribed due to PJP positive.
    • We removed nasal Merocel on 2023/04/13 and no epistaxis was noted.
    • Vigina bleeding and blood clot was noted on 2023/04/16, we consulted GYN who replied bleeding might related to low platelet and poor coagulation condition and LRP was transfused.
    • On 2023/04/17, severe diarrhea was noted and we follow up stool cultiure (c. difficile: negative).
    • Smecta plus Imolex was given and feeding pump used.
    • Abdomen echo was performed on 2023/04/18 and much ascites was noted, we explained to her son and he agreed pig-tail placement.
    • Thus, RLQ pig-tail placement was done on 2023/04/18 and kept drainage amount < 500ml/Q8H.
    • We tried weaninig ventilator on 2023/04/20 with PSV mode and tried T-piece QD on 2023/04/21.
    • At present, for pancytopenia with Hb:5.8, PLT:42000, WBC: 1810, well explain her condition and about bone marrow indicated, they were understood, so we need your help for bone marrow and evatulated, Thanks!
  • A
    • Dear doctor: This 66 year old woman is a case of 1. Left breast cancer, Invasive carcinoma of no special type, with axillary lymph nodes, lung , left 1st rib metastasis, cT3N2M1, stage IV. ER(80%, 2~3+), PR(50%, 2+), Her2/neu(+, Dako score 3+) and Ki-67:70% status post right subclavian vein port-a implantation on 2023/02/16. s/p Epirubicin 90mg/m2 + Endoxan 600mg/m2 on 2/17, 3/29. 2. hepatitis B with crrhosis and splenomegaly, 3. HTN, 4. DM. She was admiited due to neutropenia fever, septic shock, DKA, HHS, AKI, PJP, Bilateral pneumonia with acute respiratory failure and hypoxia s/p ETT on 2023/04/08, Epistaxis (2023/04/06 Sputum culture: Staphylococcus aureus (OSSA); 2023/04/12 PJP positive), KP bacteremia and UTI (2023/04/06 U/C: KP), Euthyroid sick syndrome. We are consulted for pancytopenia.
    • Pancytopenia may be caused by bone marrow aplasia, marrow infiltration/replacement, ineffective hematopoiesis, and/or excessive blood cell destruction or sequestration. Please check autoimmune profile (ANA, C3, C4, anti ds DNA, RF, anti Ro/La), nutrition profile (vitamin B12, folic acid), LDH, HIV, EBV,CMV, serum EP, serum IFE, IgG, IgA, IgM, B2 microglobulin, albumin, Total protein. We will also arrange bone marrow aspiration and biopsy. Thanks for your consultation.
  • A1 2023/04/28
    • bone marrow biopsy show no evaidance of breast cancer bone marrow metastasis. It maybe either therapeutic effect or myelodysplastic syndrome.
    • Keep Best supportive care. May arrange our OPD after discharge. Thanks for your consultation.

• 2023-04-15 Obstetrics and Gynecology

• 2023-04-08 Ear Nose Throat

• 2023-04-08 Gastroenterology

• 2023-04-08 Metabolism and Endocrinology

• 2023-04-06 Infectious Disease

• 2023-04-06 Neurology

• 2023-02-15 Gastroenterology

  • Q
    • For HBsAg postivite
    • This 66-year-old female patient has past history of 1) Hypertension 2) Type 2 diabetes mellitus.
    • Under the impression of left breast invasive carcinoma with axillary LN, lung metastsis, cT3N1M1, stage IV.
    • This time, she was admitted to our ward for implantation port-a catheteriplatation and arrange 1st neo-adjuvant chemotherapy.
    • Due to HBsAg data showed reactive, we need your profressional assisstance, thank you!
  • A
    • P:
      • Check CBC, AST/ALT, PT, ALB, T.BIL, AFP, HbeAg, HBV DNA
      • Arrange abdominal sonography
      • Vemlidy 25mg QD (GFR > 15 no dose adjustment; GFR < 15 contraindicated; HD: no dose adjustment, after HD)
      • GI OPD follow up
    • NHI
      • HBV carrier (HbsAg (+) or HbsAg (-) but anti-Hbc ab (+))
        • Chemotherapy：Start paying 1 week before chemotherapy and continue until 6 months after the end of chemotherapy.

[immunochemmotherapy]

• 2024-02-24 - ……………………… docetaxel 75mg/m2 100mg NS 250mL 2hr (Gao WeiYao)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2024-01-23 - trastuzumab 600mg SC 3min + docetaxel 75mg/m2 110mg NS 250mL 2hr (Gao WeiYao)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-12-26 - trastuzumab 600mg SC 3min + docetaxel 75mg/m2 116mg NS 250mL 2hr (Gao WeiYao)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-12-19 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

  • SOAP: The patient reported vomiting and nausea, so she refused to take Perjecta. Only Herceptin administered today.

• 2023-11-28 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

• 2023-10-31 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

• 2023-10-12 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

• 2023-09-21 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

• 2023-09-07 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

• 2023-07-04 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

• 2023-06-13 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr (Wang ShengLin)

• 2023-03-29 - epirubicin 90mg/m2 157mg NS 100mL 30min + cyclophosphamide 600mg/m2 1044mg NS 500mL 1hr (EC(90) Q3W)

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL + Granocyte (lenograstim 250ug) SC

• 2023-02-17 - epirubicin 90mg/m2 155mg NS 100mL 30min + cyclophosphamide 600mg/m2 1033mg NS 500mL 1hr (EC(90) Q3W)

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

• 2023-05-23 ~ Femara (letrozole)

• 2023-05-19 ~ 2023-05-24 - Cytotec (misoprostol)

Pertuzumab - Adult Dosing - 2024-01-03 - https://www.uptodate.com/contents/pertuzumab-drug-information

• Breast cancer, metastatic, HER2+
  • IV: 840 mg over 60 minutes followed by a maintenance dose of 420 mg over 30 to 60 minutes every 3 weeks until disease progression or unacceptable toxicity (in combination with trastuzumab [or trastuzumab/hyaluronidase] and docetaxel).
• Breast cancer, early HER2+, adjuvant treatment
  • IV: 840 mg over 60 minutes followed by a maintenance dose of 420 mg over 30 to 60 minutes every 3 weeks for a total of 1 year (up to 18 cycles) or until disease progression or unacceptable toxicity (whichever occurs first); as part of a combination regimen containing trastuzumab (or trastuzumab/hyaluronidase) and including standard anthracycline- and/or taxane-based therapy; pertuzumab and trastuzumab (or trastuzumab/hyaluronidase) should begin on day 1 of the first taxane-containing cycle.
• Breast cancer, early HER2+, neoadjuvant treatment
  • IV: 840 mg over 60 minutes followed by a maintenance dose of 420 mg over 30 to 60 minutes every 3 weeks for 3 to 6 cycles; may be administered as one of the regimens below. Postoperatively, continue pertuzumab and trastuzumab (or trastuzumab/hyaluronidase) to complete 1 year of treatment (up to 18 cycles); refer to specific protocol for details.
    • Four preoperative cycles of pertuzumab, trastuzumab (or trastuzumab/hyaluronidase), and docetaxel, followed by 3 postoperative cycles of fluorouracil, epirubicin, and cyclophosphamide (FEC) or
    • Three or four preoperative cycles of FEC (alone) followed by 3 or 4 preoperative cycles of pertuzumab, trastuzumab (or trastuzumab/hyaluronidase), and docetaxel or
    • Six preoperative cycles of pertuzumab, trastuzumab (or trastuzumab/hyaluronidase), docetaxel, and carboplatin
    • Four preoperative cycles of dose-dense doxorubicin and cyclophosphamide alone, followed by 4 preoperative cycles of pertuzumab, trastuzumab (or trastuzumab/hyaluronidase), and paclitaxel.
• Missed doses or delays: If <6 weeks has elapsed, administer pertuzumab 420 mg (maintenance dose) as soon as possible; do not wait until the next planned dose. If >= 6 weeks has elapsed, readminister pertuzumab 840 mg (loading dose) over 60 minutes, and then follow with a maintenance dose of pertuzumab 420 mg (over 30 to 60 minutes) every 3 weeks thereafter.
• Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Docetaxel - 2024-03-04 - https://www.uptodate.com/contents/docetaxel-drug-information

• Breast cancer:
  • Locally advanced or metastatic: IV:
    • 60 to 100 mg/m2 every 3 weeks (as a single agent) until disease progression or unacceptable toxicity for at least 6 cycles or
    • 100 mg/m2 every 3 weeks (as a single agent) for a maximum of 7 or 10 cycles.
  • Operable, node-positive (adjuvant treatment): IV:
    • TAC regimen: 75 mg/m2 every 3 weeks for 6 courses (in combination with doxorubicin and cyclophosphamide).
  • Adjuvant treatment (off-label dosing): IV:
    • 75 mg/m2 every 21 days (in combination with cyclophosphamide) for 4 cycles or
    • 75 mg/m2 every 21 days (in combination with carboplatin and trastuzumab) for 6 cycles or
    • 75 mg/m2 every 21 days (in combination with cyclophosphamide and trastuzumab) for 4 cycles.
  • Neoadjuvant treatment (off-label dosing): IV:
    • 75 mg/m2 (cycle 1; if tolerated, may increase to 100 mg/m2 in subsequent cycles) every 21 days for a total of 4 cycles (in combination with trastuzumab and pertuzumab) or
    • 75 mg/m2 every 21 days for 6 cycles (in combination with carboplatin and WBC growth factor support) or
    • 75 mg/m2 every 21 days for 6 cycles (in combination with carboplatin, trastuzumab, and pertuzumab) or
    • 75 mg/m2 initially (if tolerated, may increase to 100 mg/m2 in subsequent cycles) every 21 days for 3 cycles (following 3 cycles of fluorouracil, epirubicin, and cyclophosphamide and in combination with trastuzumab and pertuzumab).
  • Metastatic treatment (off-label dosing):
    • Every-3-week administration: IV:
      • 75 mg/m2 (cycle 1; may increase to 100 mg/m2 in subsequent cycles) every 21 days for at least 6 cycles (in combination with trastuzumab and pertuzumab) or
      • 100 mg/m2 every 21 days (in combination with trastuzumab) for at least 6 cycles or 75 mg/m2 every 21 days (in combination with capecitabine) until disease progression or unacceptable toxicity or
      • 60 mg/m2, 75 mg/m2, or 100 mg/m2 every 21 days for at least 6 cycles until disease progression, unacceptable toxicity, or discontinuation.
    • Weekly administration: IV:
      • 40 mg/m2 once a week (as a single agent) for 6 weeks followed by a 2-week rest, repeat until disease progression or unacceptable toxicity or
      • 35 mg/m2 once weekly for 3 weeks, followed by a 1-week rest, may increase to 40 mg/m2 once weekly for 3 weeks followed by a 1-week rest with cycle 2 or
      • 35 mg/m2 once weekly (in combination with trastuzumab) for 3 weeks followed by a 1-week rest; repeat until disease progression or unacceptable toxicity.

==========

[neutropenia after docetaxel, culture pending while maintaining ABX & Mg supplementation]

Both tumor markers CA-153 and CEA remain elevated. The last dose of docetaxel was administered on 2024-02-24, followed by grade 4 neutropenia observed on 2024-03-01. G-CSF was administered to address the neutropenia.

• 2024-02-23 CA-153 49.6 U/mL
  

• 2024-02-02 CA-153 (NM) 98.764 U/ml
  

• 2024-02-02 CA-153 (NM) 89.900 U/ml
  

• 2024-01-22 CA-153 (NM) 116.675 U/ml
  

• 2023-12-26 CA-153 (NM) 118.131 U/ml
  

• 2023-12-12 CA-153 (NM) 110.748 U/ml
  

• 2023-06-20 CA-153 (NM) 44.155 U/ml
  

• 2023-04-03 CA-153 (NM) 64.922 U/ml
  

• 2023-02-06 CA-153 50.7 U/mL

• 2024-02-23 CEA 63.31 ng/mL
  

• 2024-02-02 CEA (NM) 69.720 ng/ml
  

• 2024-02-02 CEA (NM) 62.090 ng/ml
  

• 2024-01-22 CEA (NM) 23.710 ng/ml
  

• 2023-12-26 CEA (NM) 12.156 ng/ml
  

• 2023-12-12 CEA (NM) 17.145 ng/ml
  

• 2023-06-20 CEA (NM) 27.607 ng/ml
  

• 2023-04-03 CEA (NM) 35.020 ng/ml
  

• 2023-02-06 CEA 24.89 ng/mL

• 2024-03-01 WBC 0.42 x10^3/uL ***

• 2024-03-01 WBC 0.81 x10^3/uL **

• 2024-02-24 WBC 21.33 x10^3/uL - docetaxel 75mg/m2

• 2024-02-23 WBC 1.61 x10^3/uL *

• 2024-02-20 WBC 3.33 x10^3/uL

Culture results are still pending. Tapimycin (piperacillin/tazobactam) is currently being used. Magnesium sulfate (MgSO4) is being administered for hypomagnesemia, as evidenced by a serum magnesium level of 1.4 mg/dL on 2024-03-02. No medication discrepancies were identified.

2024-01-22

[prophylactic G-CSF for post-chemotherapy leukopenia]

This patient is scheduled to receive her second session of trastuzumab + docetaxel on 2024-01-23. Following her first session on 2023-12-26, she experienced a nadir WBC count of 0.48K/uL on 2024-01-02, one week later. G-CSF (filgrastim) 300mg daily from 2024-01-03 to 2024-01-05 successfully mitigated the leukopenia. However, due to a recent downward trend in WBC counts across the past three data points, prophylactic G-CSF is recommended for potential standby use.

• 2024-01-20 WBC 3.42 x10^3/uL *
• 2024-01-18 WBC 4.02 x10^3/uL
• 2024-01-08 WBC 5.07 x10^3/uL
• 2024-01-06 WBC 17.95 x10^3/uL
• 2024-01-04 WBC 1.19 x10^3/uL ** 1/3-1/5 G-CSF
• 2024-01-02 WBC 0.48 x10^3/uL *** nadir
• 2023-12-26 WBC 6.86 x10^3/uL trastuzumab + docetaxel
• 2023-12-25 WBC 1.94 x10^3/uL **
• 2023-12-21 WBC 6.00 x10^3/uL 12/19 G-CSF
• 2023-12-06 WBC 3.56 x10^3/uL *

2024-01-03

[Neutropenia and Febrile Episode]

The patient recently experienced an episode of grade 4 neutropenia (severely low white blood cell count) on 2024-01-02. This is likely due to the combined effects of the chemotherapy medications trastuzumab and docetaxel, with docetaxel likely playing a stronger role.

• 2024-01-02 WBC 0.48 x10^3/uL
  

• 2023-12-26 WBC 6.86 x10^3/uL

• 2024-01-02 Neutrophil 0.0 %
  

• 2023-12-26 Neutrophil 82.2 %

To address the neutropenia, the patient received:

• A single dose of Granocyte (lenograstim 250ug) on 2024-01-02.
• G-CSF (filgrastim) 600mg daily starting on 2024-01-03.

Additionally, the patient experienced a fever with a peak temperature of 39°C in the night of 2023-01-02. This fever has been successfully controlled with the administration of Cefim (cefepime 2g Q8H).

No identification of medication reconciliation issues.

2023-06-16

• The chronological data for the patient’s WBC levels is organized in the following table, with asterisks (*) denoting instances when the WBC count fell below 3K/uL. According to the available HIS5 data, there were three episodes of leukopenia, where the WBC count fell below 3K/uL. These instances occurred in late Feb to early Mar, early Apr, and late Apr. The first two episodes could potentially be attributed to the chemotherapy regimen of epirubicin and cyclophosphamide. However, the cause of the third episode is less certain as there was a full recovery between the second and third episode, and no chemotherapy treatment was administered during this period.
  • 2023-06-13 WBC 4.68 x10^3/uL 2023-06-13 trastuzumab + pertuzumab
  • 2023-05-17 WBC 3.88 x10^3/uL
  • 2023-05-12 WBC 4.74 x10^3/uL
  • 2023-05-11 WBC 3.52 x10^3/uL
  • 2023-05-10 WBC 3.95 x10^3/uL
  • 2023-05-08 WBC 5.11 x10^3/uL
  • 2023-05-05 WBC 7.37 x10^3/uL
  • 2023-05-02 WBC 8.82 x10^3/uL
  • 2023-04-29 WBC 5.39 x10^3/uL
  • 2023-04-27 WBC 4.56 x10^3/uL
  • 2023-04-26 WBC 4.85 x10^3/uL
  • 2023-04-25 WBC 6.28 x10^3/uL
  • 2023-04-24 WBC 1.81 x10^3/uL * cause unknown
  • 2023-04-20 WBC 1.51 x10^3/uL * cause unknown
  • 2023-04-17 WBC 3.36 x10^3/uL
  • 2023-04-13 WBC 7.86 x10^3/uL
  • 2023-04-10 WBC 1.37 x10^3/uL *
  • 2023-04-08 WBC 0.13 x10^3/uL *
  • 2023-04-05 WBC 0.06 x10^3/uL *
  • 2023-03-29 WBC 7.28 x10^3/uL 2023-03-29 chemo
  • 2023-03-16 WBC 5.07 x10^3/uL
  • 2023-03-09 WBC 6.67 x10^3/uL
  • 2023-03-05 WBC 13.05 x10^3/uL
  • 2023-03-03 WBC 1.87 x10^3/uL *
  • 2023-03-02 WBC 0.48 x10^3/uL *
  • 2023-02-23 WBC 2.32 x10^3/uL *
  • 2023-02-16 WBC 3.66 x10^3/uL 2023-02-17 chemo
  • 2023-02-14 WBC 3.86 x10^3/uL

In continuation of the previous pharmacist note.

• According to Taiwan’s NHI reimbursement guidelines, the administration of G-CSF is approved for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL after chemotherapy. In this specific case of the patient, these criteria have been met, suggesting that if the use of G-CSF is deemed beneficial, it will be covered by the NHI.
• Granocyte (lenograstim) was administered concurrently with the chemotherapy regimen on 2023-03-29. It’s recommended for primary and secondary prophylaxis that G-CSF administration typically starts 24 to 72 hours after the end of chemotherapy treatment (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation). ref(1): Delayed Granulocyte Colony-Stimulating Factor (G-CSF) Administration after Chemotherapy Reduces Total G-CSF Doses without Affecting Neutrophil Recovery in a Randomized Clinical Study in Children with Solid Tumors. Pediatr Hematol Oncol. 2020;37(8):665-675. ref(2): Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Exp Hematol. 2008;36(1):9-16.

700947003

240304

[exam findings] (not completed)

• 2024-02-29 PET scan
  • As compared with the previous study on 2023-08-28, the glucose hypermetabolism in two nodular lesions in the left lower pelvic region and in soft tissue in the posterior aspect of the left abdomen is slightly less evident. Please correlate with other imaging modalities for further evaluation.
  • The glucose hypermetabolism in the region about rectum is a little more evident. Malignancy can not be ruled out. Please also correlate with other imaging modalities for further evaluation.
    
  • Increased FDG uptake/accumulation in bilateral neck muscles, diaphragm and left kidney. Physiological FDG uptake/accumulation is more likely.
• 2024-02-22 Abdomen - standing (diaphragm)
  • High grade mechanical small bowel obstruction is suspected. Please correlate with contrast enhanced CT to evaluate the location, etiology and complication.
  • Fecal material store in the colon.
• 2024-02-19 Abdomen - standing (diaphragm)
  • Presence of ileus.
  • Degeneration of T-L spine.
• 2024-02-05 CT - abdomen
  • Adenocarcinoma of descending colon with lymph nodes metastasis and intestinal obstruction, pT4aN1aM0; Stage IIIB, EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+), status post colonoscopic stenting following laparoscopic left hemicolectomy, on 2021/07/16 s/p Biweekly HDFL until 2022-02
  • Abdominal CT with and without enhancement revealed:
    • s/p left hemicolectomy.
    • s/p ATH.
    • Calcified dots at left psoas muscle region are found Chains of ureter stones are favored.
    • Fusiform soft tissue at left iliac crest is found measuring 2.0cm in largest dimension. r/o ovary. In comparison with CT dated on 2023-08-18, the lesion is stationary in size
    • Calcified coronary arteries is found.
    • Tree in bud appearance at right lower lobe is found.
  • Imp:
    • s/p left hemicolectomy.
    • s/p ATH.
    • Left psoas calcified dots, r/o ureter stones.
• 2023-08-28 PET scan
  • The glucose hypermetabolic lesion around the stent in the descending colon disappears compared with the previous study on 2021-07-08, compatible with D-colon cancer s/p treatment.
  • A glucose hypermetabolism at the rectal region, the nature is to be determined (recurrent tumor or other nature ?), suggesting colon fibroscopy for investigation.
    
  • Increased FDG uptake in two nodular lesions in the left lower pelvic region and in soft tissue in the post. aspect of the left abdomen, respectively, the nature is to be determined also (metastatic lymph nodes or other nature ?), suggesting biopsy (the lesion in the post. aspect of left abdomen) for investigation.
  • Increased FDG uptake in myocardium of the right ventricle, suggesting pulmonary dysfunction.
  • Increased FDG uptake in soft tissue in the right suprarenal space, the nature is to be determined, suggesting follow-up.
  • D-colon cancer s/p teatment, suspected tumor recurrence with lymph nodes metastasis, by this F-18 FDG PET scan.
• 2023-08-18 CT - abdomen
  • history: D-colon cancer s/p OP and C/T.
  • Findings:
    • S/P left hemicolectomy and S/P hysterectomy.
    • Prior CT identified soft tissue with dense calcifications anterior to left psoas muscle is noted again, mild increasing in size. please correlate with clinical condition.
    • Prior CT identified a hepatic cyst 8 mm at S4/2 dome is noted again, stationary.
  • Impression:
    • Prior CT identified soft tissue with dense calcifications anterior to left psoas muscle is noted again, mild increasing in size. please correlate with clinical condition.

[MedRec]

• 2023-09-05 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • Already discuss with family, the PET revealed recurrence. Suggest CT. But family would like not to let patient know and would like to rest for some time (maybe after 2024-02) and then decide to take C/T or not.

[chemotherapy]

• 2022-02-08 - leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 160mL 48hr (infusor)
  • dexamethasone 4mg + NS 250mL
• 2022-01-25 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3950mg NS 160mL 48hr (infusor)
  • dexamethasone 4mg + NS 250mL
• 2022-01-11 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3950mg NS 500mL 46hr
  • dexamethasone 4mg + NS 250mL
• 2021-12-28 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + NS 250mL
• 2021-12-15 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + NS 250mL
• 2021-12-03 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + NS 250mL
• 2021-11-19 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + NS 250mL
• 2021-11-08 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr
  • dexamethasone 4mg + NS 250mL
• 2021-10-20 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr
  • dexamethasone 4mg + NS 250mL
• 2021-10-06 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr
  • dexamethasone 4mg + NS 250mL
• 2021-09-22 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3920mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-09-07 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + NS 250mL
• 2021-08-24 - leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3920mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-03-04

[rising tumor markers & adjusting ileus medication]

Both CEA and CA19-9 tumor markers have reached their highest levels documented in the lab data. Chemotherapy was discontinued in mid-Feb 2022. Recent imaging suggests that complete remission of the colon cancer is unlikely. Therefore, further treatment is recommended.

• 2024-02-26 CEA 12.68 ng/mL **

• 2024-02-05 CEA 8.07 ng/mL *

• 2023-12-12 CEA 6.30 ng/mL

• 2023-08-18 CEA 9.09 ng/mL

• 2023-07-10 CEA 9.58 ng/mL

• 2023-04-19 CEA 4.36 ng/mL

• 2023-03-16 CEA 4.14 ng/mL

• 2023-02-16 CEA 4.61 ng/mL

• 2022-11-29 CEA 4.21 ng/mL

• 2022-09-26 CEA 3.70 ng/mL

• 2024-02-26 CA199 149.71 U/mL **

• 2024-02-05 CA199 55.18 U/mL *

• 2023-12-12 CA199 47.40 U/mL

• 2023-08-18 CA199 45.83 U/mL

• 2023-07-10 CA199 38.65 U/mL

• 2023-04-19 CA199 35.58 U/mL

• 2023-03-16 CA199 48.07 U/mL

• 2023-02-16 CA199 37.36 U/mL

• 2022-11-29 CA199 31.49 U/mL

• 2022-09-26 CA199 31.97 U/mL

Lactul (lactulose), Through (sennoside) and Bisadyl (bisacodyl) are currently being used to manage ileus. While the stool records show passage on 6 and 7 occasions on 2024-03-02 and 2024-03-03, respectively, it is recommended to review the necessity and potential for dose adjustments of these medications.

700551138

240301

{serous carcinoma of right fallopian tube with peritoneal and pleural invastion with tumor recurrent, pT3cN1aM1a, stage IVA}

[diagnosis] - 2023-03-30 discharge note

• Right fallopian tube carcinoma, pT3N1aM1a, FIGO stge IVA s/p Debulking surgery + CRS HIPES s/p IP C/T with Taxol/CDDP and Peripheral C/T with Taxol and Carboplatin with pseudomyxoma peritonei with liver and spleen metastases s/p C/T with Avastin/Taxotere/Carboplatin and IO therapy with Keytruda s/p mild progressive disease of pseudomyxoma peritonei with liver and spleen metastases with IO therapy with Q3W Keytruda and C/T with Avastin/Lipo-Dox/Carboplatin
• Essential (primary) hypertension
• Insomnia
• Chronic viral hepatitis B without delta-agent

[past history]

• Hypertension more than 10years with regular medical at our CV OPD
• Goiter post subtotal thyroidectomy at VGH-Taipei 10years ago.

                                                        

[allergy]

• Drug adverse event: never occurred
• Food allergy: never occurred
• Transfusion adverse event: never received transfusion                                                         

[family history]

• Non contributory to the psychiatric disorders.
• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2024-02-29 CXR erect
  • Cardiomegaly and tortuosity of the thoracic aorta.
  • Widening of the mediastinum.
  • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
  • Bilateral pleural effusion.
• 2024-02-01 KUB
  • Spondylosis with scoliosis of the L-spine with convex to left side.
  • S/P LAR with autosuture retention over the the rectosigmoid junction.
• 2024-01-27 CXR erect
  • No cardiomegaly
  • Increased lung markings over both lungs.
  • Blunting of bilateral costophrenic angles are noted, may be due to pleural effusion or pleural thickening.
• 2024-01-12 KUB
  • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition. Follow up is indicated.
  • Spondylosis with scoliosis of the L-spine with convex to left side.
  • S/P LAR with autosuture retention over the the rectosigmoid junction.
• 2024-01-12 CXR erect
  • S/P nasogastric tube insertion
  • Enlargement of cardiac silhouette.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Scoliosis of the T-spine with convex to right side.
• 2024-01-08 CT - abdomen
  • History and indication: abdominal pain
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation. Some soft tissues in peritoneal cavity.
    • S/P mammoplasty. Some poor enhancing nodules (up to 4.9cm) in liver and spleen.
    • Small bowel ileus.
    • Bil. pleural effusion and pericardial effusion
  • IMP:
    • S/P operation. In favor of peritoneal seeding, liver and spleen metastases. Small bowel ileus.
• 2023-10-27 CT - abdomen
  • FINDINGS: Comparison prior CT dated 2023/08/17.
    • The small intestine shows mild dilatation that is c/w obstruction.
    • Prior CT identified two focal fluid collection in the mesentery of the pelvis are noted again, mild increasing in size.
    • Prior CT identified lobulated cystic lesion in Rt subphrenic space with S8 liver invasion, Rt lower medial perihepatic space with S6 invasion, gastrohepatic ligament, lesser sac, and the medial perisplenic space with spleen invasion are noted again, mild increasing in size.
      • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease.
    • S/P hysterectomy
      • S/P LAR with autosuture retention over the rectosigmoid junction.
      • S/P water bag breast implantation, bilateral.
    • There is no focal lesion in both lung and mediastinum.
      • There is mild pericardial effusion.
  • IMP:
    • The small intestine shows mild dilatation that is c/w obstruction.
    • Prior CT identified two focal fluid collection in the mesentery of the pelvis are noted again, mild increasing in size.
    • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease. please correlate with clinical condition.
• 2023-10-27 CXR
  • Cardiomegaly is noted.
  • S/p port-A placement with its tip at Superior vena cava
  • Scoliotic alignment of the thoracolumbar spine is noted.
  • Pleural effusion over right side is found.
• 2023-08-02, -07-26 KUB
  • Fecal material store in the colon.
  • S/P metalic autosuture at the rectosigmoid junction
• 2023-07-18 KUB
  • Radiopaque spots at pelvic region.
  • Presence of ileus.
• 2023-07-18 CXR (erect)
  • Blunted bilateral costophrenic angles.
  • Presence of ileus.
• 2023-06-07 All-RAS + BRAF mutation
  • Tissue Block No: S2019-12133 Fs
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-08 CT - abdomen
  • History and indication: Right fallopian tube cancer s/p OP and C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy and colon operation.
    • Some low attenuations at liver and spleen (up to 1.8cm). Focal thickening of peritoneum.
    • S/P mammoplasty.
    • Absence left thyroid gland. A nodule (7mm) at right thyroid gland.
  • IMP:
    • S/P hysterectomy and colon operation.
    • Some low attenuations at liver and spleen (up to 1.8cm) r/o metastases.
    • Focal thickening of peritoneum r/o tumor seeding.
• 2023-04-17 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (90.5 - 35.0) / 90.5 = 61.33%
    • M-mode (Teichholz) = 61.3
  • Conclusion
    • Normal AV with mild AR
    • Normal MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
• 2023-03-29 Foot Lt
  • Fracture of 5th MT base of left foot is highly suspected. please correlate with clinical condition.
  • Osteoporotic change
• 2022-12-02 ECG
  • Sinus bradycardia
  • Moderate voltage criteria for LVH, may be normal variant
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2022-12-02 PET scan
  • Glucose hypermetabolism in multiple focal areas in the right lobe of the liver, in a small focal area in the left lobe of the liver, in two focal areas in the spleen and in a focal area in the anterior aspect of the upper midline abdominal cavity, compatible with multiple metastatic lesions.
  • A glucose hypermetabolic lesion in the posterior aspect of the left upper thigh. The nature is to be determined (a metastatic lesion? inflammation or infection?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the right shoulder and in the esophagus. Inflammation may show this picture.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
• 2022-12-01 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (66 - 20) / 66 = 69.70%
    • M-mode (Teichholz) = 70
  • Concentric LVH with normal LV systolic function.
  • Mild RV hypertrophy with normal RV systolic function.
  • Mild aortic valve sclerosis; mild MR; mild PR.
  • Minimal amount pericardial effusion (<50ml).
  • poor apical echo window
• 2022-11-18 CT - abdomen
  • History: Serous carcinoma of Rt fallopian tube with peritoneal and pleural invasion with tumor recurrent, pT3cN1aM1a; Stage IVA
    • 20220128 CT: Pseudomyxoma peritonei is highly suspected.
    • 20220224 CT guided biopsy: liver metastasis
  • FINDINGS:
    • Prior CT identified lobulatd cystic lesion in Rt subhphrenic space, S8 liver invasion, Rt lower medial perihepatic space with indentation the liver capsule, gastrohepatic ligament, lesser sac, and the medial perisplenic space with indentation the splenic capsule are noted again.
      • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease.
    • S/P hysterectomy
    • S/P LAR with autosuture retention over the rectosigmoid junction.
    • S/P water bag breast implantation, bilateral.
    • There is no focal lesion in both lung and mediastinum.
    • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
    • There is no ascites or lymphadenopathy.
    • There is no bowel wall thickening, and no bowel obstruction.
    • The abdominal aorta and IVC are grossly unremarkable.
      
    • There is no evidence of intrinsic or extrinsic bladder mass.
    • There is no focal lesion in the mesentery.
  • IMP:
    • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease. please correlate with clinical condition.
• 2022-11-18 CXR
  • Scoliosis of the T-spine with convex to right side.
  • Enlargement of cardiac silhouette.
• 2022-10-19 Sonography - right shoulder
  • Findings
    • Thickening and inhomogeneous echogenesity of right supraspinatus tendon. No definite discontinuity.
    • Prominent fluid in subacromial-subdeltoid bursa.
  • Impression
    • Supraspinatus tendinosis and subacromial-subdeltoid bursitis
    • suspected subacromial impingement. Suggest radiography correlation.
• 2022-08-27 CT - abdomen
  • Focal low attenuation at right kidney r/o nephritis.
  • S/P mammoplasty.
• 2022-08-27 CXR
  • Blunted bilateral costophrenic angles.
  • Presence of scoliosis of the T-spine.
• 2022-07-22 CT - abdomen
  • History: Serous carcinoma of Rt fallopian tube with peritoneal and pleural invasion with tumor recurrent, pT3cN1aM1a; Stage IVA
    • 20220128 CT: Pseudomyxoma peritonei is highly suspected.
    • 20220224 CT guided biopsy: liver metastasis
  • FINDINGS:
    • Prior CT identified lobulatd cystic lesion in Rt subhphrenic space, S8 liver invasion, Rt lower medial perihepatic space with indentation the liver capsule, gastrohepatic ligament, lesser sac, and the medial perisplenic space with indentation the splenic capsule are not noted again, except a small cystic lesion in the spleen.
      • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T with near complete response are suspected.
    • S/P hysterectomy
    • S/P LAR with autosuture retention over the rectosigmoid junction.
    • S/P water bag breast implantation, bilateral.
  • IMP:
    • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T with near complete response are suspected. please correlate with clinical condition.
• 2022-04-13 Panendoscopy
  • Reflux esophagitis LA grade A
  • Superficial gastritis
  • Gastric erosions, antrum
• 2022-04-12 CT - abdomen
  • Clinical history: 64 y/o female patient with Serous carcinoma of right fallopian tube with peritoneal and pleural invasion with tumor recurrent, pT3cN1aM1a; Stage IVAFor tumor f/u.
  • Findings
    • Post-op at the colon. S/P hysterectomy.
    • There are subphrenic and subhepatic soft tissue tumors, regression as compare with CT study on 2022-03-02.
    • Wall edema of the cecum.
    • Spleen tumor, 0.97cm.
  • Impression:
    • Post-op at the colon. S/P hysterectomy.
    • Pseudomyxoma peritoneum with liver and spleen involvement, regression as compare with CT study on 2022-03-02.
    • Wall edema of the cecum.
• 2022-04-11 Patho - colon biopsy
  • Transverse colon, biopsy — Nonspecific active colitis
• 2022-04-07 KUB
  • S/P metalic autosuture at the the rectosigmoid junction
• 2022-03-02 CT - abdomen, pelvis
  • Pseudomyxoma peritonei with liver and spleen metastases show stationary.
• 2022-02-24 Needle aspiration cytology - liver
  • Smears show histiocytes and clusters of atypical hyperchromatic papillary tumor. Malignancy is favored.
• 2022-02-23 CT - lung/mediastinum/pleura
  • no lung metastasis. pseudomyxoma peritonei and splenic lesion.
• 2022-01-28 CT - abdomen, pelvis
  • Pseudomyxoma peritonei is highly suspected. Please correlate with aspiration cytology.
• 2021-11-04 SONO - abdomen
  • Right liver cyst (1.75x2.10cm).
• 2021-08-10 CT - abdomen, pelvis
  • s/p LAR and autosuture. No evidence of recurrent/residual tumor in the current study.
• 2021-05-11 SONO - abdomen
  • A hepatic cyst measuring 1.81 cm in S6 is noted.
• 2021-02-09 CT - abdomen, pelvis
  • Post-op at the colon. S/P hysterectomy and oophorectomy.
• 2020-11-19 Whole body PET scan
  • Mild glucose hypermetabolism in a right axillary lymph node. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in bilateral shoulders and in the soft tissues around bilateral hips. Inflammatory process may show this picture.
  • Mildly increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
• 2020-11-13 CT - abdomen, pelvis
  • No Abscess or lymphocele in right pelvic sidewall is noted.
• 2020-09-18 CT - abdomen, pelvis
  • Abscess 3.5 x 2.8 cm in right pelvic sidewall is suspected.
  • The differential diagnosis include lymphocele.
• 2020-09-08 CT - abdomen, pelvis
  • Post op. change of the rectum.
  • Cystic change at right pelvic side wall, stable.
• 2020-05-25 CT - abdomen, pelvis
  • S/P hysterectomy.
  • Some LNs (up to 1.1cm) at bil. inguinal regions.
  • A cystic lesion (3.8cm) at right pelvic cavity.
• 2019-12-24 CT - abdomen, pelvis
  • S/P pigtail catheter drainage, right lower abdomen.
  • S/P CAPD catheter in the pelvic cavity, with focal loculated fulid in pericatheter region.
  • Cystic lesion, 3.8cm in right pelvic cavity, r/o lymphocele.
  • Post-op at the colon.
  • Bilateral pleural effusion with basal atelectasis.
• 2019-07-25 Patho Level VI - sigmoid colon
  • pathologic diagnosis
    • Sigmoid colon, radical proctectomy? — Serous carcinoma, metastatic
      
    • Faciform ligament, excision — Serous carcinoma, metastatic
      
    • Soft tissue over rectum, excision — Serous carcinoma, metastatic
      
    • Lymph nodes, mesocolic, dissection — Metastatic serous carcinoma (4/4)
  • microscopic examination
    • Histology: Serous carcinoma, metastatic
      
    • Histology Grade: High grade
    • Depth of invasion: Subserosal tumor with muscularis propria invasion
    • Angiolymphatic invasion: Present
      
    • Perineural invasion: Not identified
      
    • Lymph node metastasis, mesocolic: Positive (4/4)
    • Faciform ligament: Serous carcinoma, metastatic
      
    • Soft tissue over rectum: Serous carcinoma, metastatic
• 2019-07-25 Patho Level VI - BSO, hysterectomy
  • pathologic diagnosis
    • Fallopian tube, right, BSO — Serous tubal intraepithelial carcinoma and serous carcinoma, consistent with right fallopian tube is primary site
      
    • Ovaries, bilateral, BSO — Involved by serous carcinoma
      
    • Fallopian tube, left, BSO — Involved by serous carcinoma
      
    • Uterus, corpus, total hysterectomy — Involved by serous carcinoma
      
    • Uterus, cervix, total hysterectomy — Free of carcinoma
      
    • Omentume, omentectomy — Involved by serous carcinoma
      
    • Peritoneum, right, excision — Involved by serous carcinoma
      
    • Bladder, biopsy — Involved by serous carcinoma
      
    • Lymph nodes, external iliac, left, PLND — Metastatic serous carcinoma
      
    • Pathologic Stage: pT3cN1aM1a; Stage IVA at least
  • microscopic examination
    • Histologic type: Serous carcinoma
      
    • Histologic grade: High grade
    • Bilateral ovaries involvement: Present
    • Bilateral ovarian surface involvement: Present
    • Right tube involvement: Present
    • Left tube involvement: Present
    • Serous tubal intraepithelial carcinoma in right fallopian tube: Present
    • Uterine serosa involvement: Present
    • Omentum involvement: Present
    • Uterine Cervix: Chronic cervicitis, Nabothain cyst and squamous metaplasia
    • Endometrium involvement: Atrophy
    • Myometrium: Leiomyoma and adenomyopsis
    • Largest Extrapelvic Peritoneal Focus: 5.0 x 3.5 x 2.0 cm
    • Peritoneal/Ascitic Fluid: Malignant (positive for malignancy)
    • Pleural Fluid: Malignant (positive for malignancy)
    • Regional Lymph Nodes: Positive for metastasis
    • Other organs or specimens involvement: Present, specify: Bladder and sigmoid colon (S2019-12175)
    • Additional Pathologic Findings: Brenner tumor in right ovary
    • IHC for tumor cells (S2019-12133FS): WT1(+), PAX8(+), p53(+ aberrant expression), calretinin(-)

[MedRec]

• 2023-10-27 ~ 2023-11-02 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Right fallopian tube carcinoma, pT3N1aM1a, FIGO stge IVA s/p Debulking surgery + CRS HIPES s/p IP C/T with Taxol/CDDP and Peripheral C/T with Taxol and Carbplatin with pseudomyxoma peritonei with liver and spleen meta s/p C/T with Avastin/Taxotere/Carboplatin and IO therapy with Keytruda s/p mild PD of pseudomyxoma peritonei with liver and spleen meta with IO therapy with Q3W Keytruda and C/T with Avastin/Lipo-Dox/Carboplatin with liver and spleen meta and peritoneum seeding
    • Ileus, suspect partial obstruction or paralytic ileus
    • Secondary malignant neoplasm of retroperitoneum and peritoneum
    • Secondary malignant neoplasm of liver and intrahepatic bile duct
    • Essential (primary) hypertension
    • Insomnia
    • Chronic viral hepatitis B without delta-agent
    • Constipation, unspecified
    • Anemia due to antineoplastic chemotherapy
    • Cachexia
  • CC
    • For lower abdominal pain and nausea with vomiting since three days ago
  • Present illness
    • The 65-years-old female has had past histories of 1. Hypertension more than 10 years with regular medical at our CV OPD, 2. Goiter post subtotal thyroidectomy at VGH-Taipei 10 years ago.
    • According to the statement by herself, she suffered from on and off dry cough and progresstion SOB for 20 days. She ever visited LMD for help. But there was no obvious improvement. CXR revealed Bilateral pleural effusions. Chest echo was done, right side 1100 ml serosangunous and left side 600 ml.
    • 2D echo on 2019/07/15 showed 1. Septal hypertrophy with normal LV amnd RV systolic function. 2. Mild AV sclerosis; mild aortic root calcification. 3. Some left pleural effusion.
    • Chest cheo tapping on 2019/07/15 and 2019/7/17. Pleural effusion pathology showed positive for adenocarcinoma. Pleural effusion pathology showed suspicious for malignancy IHC satin: TTF-1(-), Napsin-A(-), CK7(+), CK5/6(+), CK(+), Calretinin (+), CK20(-), P40(focal+).
    • Lung CT on 2019/07/16 showed bilateral pleural effusion and ascites formation. Tumor mark CA-125:1902.5 U/ml. Removed right pig-tail on 2019/07/22
    • GYN echo on 2019/07/18 showed 1. Uterine myoma 2. RT adnexa mass. Abdominal CT on 2019/07/19 showed 1. Cystic adenocarcinoma of the ovary with carcinomatosis is highly suspected. Please correlate with ascites cytology and CA-125. 2. Detailed findings, please see description.
    • Abdominal echo on 2019/07/19 showed mild ascites, mild pleural effusion, left, suspected fatty infiltration of pancreas and suboptimal examination of liver due to poor echo window. Ascites pathology showed poistive for malignancy.
    • Under the impression of ovarian cancer with peritoneal and invasion. She underwent operation of Debulking surgery (ATH + BSO + Cytoreduction surgery + infracolic omentectomy + Appendectomy) + CRS HIPES on 2019-07-19.
    • #1 IP chemotherapy with Intaxel 60mg + Cisplatin 60mg and Peripheral chemotherapy with Intaxel 200mg and CARBOPLATIN 300 mg with Cisplatin and Intaxel were prescribed on 8/20 19, #2 on 9/11 19, #3 on 10/15 19, #4 on 11/11 19, #5 chemotherapy with Taxol/Carboplatin on 12/9 19. #6 on 2/3 20.
    • Follow-up abdominal CT (9/20 19) showed local recurrent cystic adenocarcinoma of the fallopian tube is highly suspected. Moderate right side hydroureteronephrosis is noted.
    • Abdomianl CT on (10/16 19) showed minimal right hydronephrosis, s/p LAP, ATH and BSO and bilateral pleural effusion.
    • Abd CT (5/25 20) showed s/p hysterectomy. Some LNs (up to 1.1cm) at bil. inguinal regions. A cystic lesion (3.8cm) at right pelvic cavity. CXR (5/26 20) revealed two nodular opacity projecting in R upper lung. Chest CT (6/4 20) revealed no evidence of pulmonary mass in the study.
    • The tumor marker showed CEA / CA-125: 0.5 / 23.9.CEA / CA-125: 0.2 / 19.3. Abd sono & CXR (9/1 20): negative.
    • Chect CT was performed and showed no lung metastasis. pseudomyxoma peritonei and splenic lesion was noted. CT guided biopsy for liver tumor tissue proof then final pathology showed atypical hyperchromatic papillary tumor.
    • Abdominal CT (3/2 22) showed Pseudomyxoma peritonei with liver and spleen metastases show stationary.
    • #1 Chemotherapy with Taxol (160mg/m2)  plus CArboplatin (AUC:5, 450mg) was given on 2/3 22.
    • #1 chemotherapy with Taxotere/Carboplatin on 3/2 22. #2 chemotherapy with Taxotere/Carboplatin & (#1) Avastin (self-paid) on 3/28 22. #3 chemotherapy with Carboplatin & (#2) Avastin (self-paid)/(#1) Keytruda (self-paid) on 4/26 22, #4 chemotherapy with Carboplatin & (#3) Avastin (self-paid)/(#2) Keytruda (self-paid) on 5/17 22, #5 chemotherapy with Carboplatin & (#4) Avastin (self-paid)/(#3) Keytruda (self-paid) on 6/8 22, #6 chemotherapy with Carboplatin & (#5) Avastin (self-paid)/(#4) Keytruda (self-paid) on 6/30 22, #7 chemotherapy with Carboplatin & (#6) Avastin (self-paid)/(#5) Keytruda (self-paid) on 7/21 22, #8 chemotherapy with Carboplatin & (#7) Avastin (self-paid)/(#6) Keytruda (self-paid) on 8/23 22.
    • Abd CT (8/27 22) showed focal low attenuation at R kidney r/o nephritis. S/P mammoplasty. Abd CT (11/18 22) revealed pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease.
    • We explain to pt & her daughter-in-law & son about resumption of palliative C/T.
    • Will give palliiative Tx with Keytruda 100mg (self-paid) / & Avastin ( #2 ) (self-paid) / Carboplatin IV Q3W x 4~6. will consider to add Gem ( non-hair loss agent )
    • PET scan (12/2 22): Lesions at in R liver, in a small one in L liver, in two lesion at spleen & a focal lesion at anterior upper midline abdominal cavity, c/w mets lesions. Lesion in the posterior aspect of the L upper thigh. nature ? (a metastatic lesion? inflammation or infection?).
    • #1 palliiative Tx wt Keytruda 100mg (self-paid) / & Avastin (self-paid) / Lipo-Dox (self-paid)/ Carboplatin IV Q3W x 6 on 12/1 22, #2 palliiative Tx wt Keytruda 100mg (self-paid) / & Avastin (self-paid) / Lipo-Dox (self-paid)/ Carboplatin IV Q3W x 6 on 01/05 23, #3 palliiative Tx wt Keytruda 100mg (self-paid) / & Avastin (贈品, 打2送1) / Lipo-Dox (self-paid)/ Carboplatin IV Q3W x 6 on 2/8 23, #4 palliiative Tx with Keytruda 100mg (self-paid) / & Avastin (self pay) / Lipo-Dox (self-paid)/ Carboplatin IV Q3W x 6 on 3/6 23, #5 palliiative Tx with Keytruda 100mg (self-paid) / & Avastin (self pay) / Lipo-Dox (self-paid)/ Carboplatin IV Q3W x 6 on 3/29 23.
    • 2D echo on 2023/04/17 showed M-mode(Teichholz) = 61.3, 1. Normal AV with mild AR 2. Normal MV with mild MR 3. Normal LV chamber size and wall thickness 4. Preserved LV and RV systolic function 5. Mild PR, mild TR, normal IVC size. Abdominal CT on 2023/05/08 showed S/P hysterectomy and colon operation, some low attenuations at liver and spleen (up to 1.8cm) r/o metastases and focal thickening of peritoneum r/o tumor seeding. Tumor mark on 2023/05/16 showed (CA-125:83.3 U/mL, CA-199:22.29 U/mL, CEA:1.02 ng/mL).
    • Palliative chemotherapy with weekly Topotecan(3.75mg/m2)(self pay) was given on 2023/05/22(C1D1), 2023/06/07(C1D8), 2023/06/20(C1D15), 2023/07/13(C2D1), 2023/08/02(C2D8). Leukocytopenia with dely chemotherapy. Tumor mark on 2023/05/30 showed increased (CA-125:145.7 U/mL, CA-199:28.82 U/mL, CEA:1.05 ng/mL). Palliative chemotherayp with weekly Gemzar(800mg/m2)(self pay) on 2023/06/26(C1D1), 2023/07/13(C1D8), 2023/08/02(C1D15). Now, she was admitted to ward for follow-up, Abdominal CT and palliative chemotherayp with weekly Gemzar(800mg/m2)(self pay)(C2D1)/Topotecan(3.75mg/m2)(self pay)(C2D15).
    • According to the patient’s statement and medical record, She suffered from lower abdominal pain and nausea with vomiting since three days ago, and she had stool passage in these days, and complained poor appetite for 3 days. She denied fever, chillness, headache,conscious disturbance, dyspnea, cough, sputum, chest pain or chest tightness, dysuria, burning sensation, diarrhea, constipation, tarry stool, bloody stool, coffee ground emesis, or change of bowel habits recently. She also denied general weakness, cold sweating, recent weight loss. She didnot had recent travelling history and history of contact to sick people. According to the above, the patient came to our ER for help.
    • The blood test and images/examination of abdominal CT was performed. Lab data showed CKD, mild hypokalemia, no leukocytosis, elevated CRP level. The abdominal CT showed small intestine shows mild dilatation that is c/w obstruction. Physical examination was done at ward and revealed normal to hyperactive bowel sound and no obvious tenderness.
    • Under the impression of Ileus, suspect partial obstruction or paralytic ileus , and intraabdominal infection, the patient was admitted to our ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, suspect partial obstruction or paralytic ileus, IAI infection, empirical antibiotic with Loforan 2gm/vial 2000mg IVD Q8H for IAI from 2023/10/27~2023/10/31.
    • IVF for poor appetite supportive.
    • Imperan 10mg/2mL/amp 1amp Q8H for nausea and vomiting.
    • Through 12mg/tab 2# PO HS, MgO 250mg/tab 1# PO TID.
    • Bisadyl supp 10mg/pill 2pill RECT for no stool passage.
    • Limadol 100mg/2mL/amp 50mg IVD PRNQ6H for pain control.
    • Explain to patient and family for disease condition on 2023/10/30.
    • Hypertension with Carvedilol HEXAL 6.25mg/tab 1# PO QD, Exforge F.C. 5mg & 160mg/tab 0.5# PO QD.
    • Insomnia with Alpraline 0.5mg/tab 1# PO PRNQN if insomnia, Lexapro 10mg/tab 1# PO QN.
    • Cachexia with Megejohn 160mg/tab 1# PO QD.
    • Chronic viral hepatitis B with (Anti-HBc reactive) with Baraclude 0.5mg/tab 1# po QDAC.
    • Anemia was noted, BT LRBC 2 unit for 2 days on 2023/11/01 and 2023/11/02.
    • Due to she feels her symptoms get improved, want to discharge. With the stable condition, she was discharged on 2023/11/02 and OPD followed up later.
  • Discharge prescription
    • Through (sennoside 12mg) 2# HS
• 2023-09-27 SOAP Cardiology Zhang HengJia
  • Prescription x3
    • Exforge (amlodipine, valsartan) 0.5# QD
    • carvedilol 6.25mg 1# QD
• 2023-09-27 SOAP Psychosomatic Medicine Li JiaFu
  • Prescription x3
    • Lexapro (escitalopram 10mg) 1# QN
    • Alpraline (alprazolam 0.5mg) 1# PRNQN
• 2023-07-05 SOAP Psychosomatic Medicine
  • Diagnosis
    • Generalized anxiety disorder [F41.1]
    • Major depressive disorder single episode,unspecified [F32.9]
    • Nonorganic sleep disorder,unspecified [F51.9]
    • Malignant neoplasm of right fallopian tube [C57.01]
  • Prescription x3
    • Anxiedin (lorazepam 0.5mg) 1# QN
    • Lexapro (escitalopram 10mg) 1# QN
    • Stilnox (zolpidem 10mg) 1# HS
    • Alpraline (alprazolam 0.5mg) 1# PRNQN
• 2023-07-05 SOAP Cardiology Zhang HengJia
  • P: change CCB to Exforge, F/U blood biochemistry.
  • Prescription x3
    • Exforge (amlodipine, valsartan) 0.5# QD
    • carvedilol 6.25mg 1# QD
• 2023-05-16 SOAP Hemato-Oncology Xia HeXiong
  • P: Already mention the slow progression of liver and peritoneum comparing 2023-05 vs 2023-02 vs 2022-11 and 2022-08. -> RTC 4 weeks
• 2023-04-18 SOAP Hemato-Oncology Xia HeXiong
  • P: Admission on 2023-04-18 for heart echo then decide the next 6th Lipo-Dox / Carboplatin -> Becasue patient can not tolerate the C/T AE and LVEF drop from 70 to 61, she would not like to take the 6th dose of Lipo-Dox / Carboplatin.
    • Abd/Pelvis plus Chest CT will be arranged two weeks later (on 2023-05-02).
• 2023-04-17 SOAP Cardiology
  • A/P: Malignant neoplasm of right fallopian tube; Bilateral pleural effusion; HCVD, HLD, B hepatitis
    • A: need to R/O pericardioal effusion w/u for right pleural effusion
    • P: need to keep BB and CCB, 2D and CT of chest are indicated, watch for pancytopenia
• 2023-04-12 SOAP Hemato-Oncology
  • P: Admission on 2023-04-18 for heart echo then decide the next 6th Lipo-Dox / Carboplatin
• 2019-10-24 SOAP Psychosomatic Medicine
  • S
    • 1st time visiting come to my clinical due to insomia, dysphoric mood, anxiety, depression, cannot control emotion and ……..
    • 1st time visiting come alone. She claimed she cannot sleep well for a while.
  • O
    • Psychiatric impression:
      • Neurotic depression
      • Insomnia
    • Present illness:
      • This 61 y/o female suffered from serous carcinoma of right fallopian tube with peritoneal and pleural invasion, pT3cN1aM1a and was admitted to our hospital for chemotherapy. Severe insomnia was told and we were consulted for drug adjustment. Upon visit, the patient was coherent and relevant, cooperative attitude and mild anxiousness. According to herself, she started to have sleep disturbance with middle type insomnia ever since she was informed that she had cancer in 2019-07.
      • However, she didn’t seek psychiatric help due to she believed that the cancer treatment also caused insomnia. She received Alpraline 0.5mg/tab 1# HS, Eurodin 2mg/tab 1# HS, rivotril 0.5mg/tab 1# HS but in vain, and would switch to isolated ward due to she felt sensitivity to the environment at night. She claimed that she had low mood but denied suicidal thoughts or hopelessness sensation, decreased appetite was told. She is hesitate to adjust psychotropics in fear that the medications may cause renal impairment. There were no previous psychiatric history, no substance use history.
    • Suggestion:
      • D/C Eurodin 1# and Alpraline 1# HS
      • Add Mirtapine 1# HS for depressed mood
      • May titrate Rivotril dosage if the patient agrees
      • Arrange OPD follow-up
  • Diagnosis
    • Generalized anxiety disorder [F41.1]
    • Major depressive disorder single episode,unspecified [F32.9]
    • Nonorganic sleep disorder,unspecified [F51.9]
    • Malignant neoplasm of right fallopian tube [C57.01]
  • Prescription
    • Lexapro (escitalopram 10mg) 0.5# QN
    • Rivotril (clonazepam 0.5mg) 0.5# QN
    • Alpraline (alprazolam 0.5mg) 1# PRNQN
    • Eurodin (estazolam 2mg) 1# HS
• 2019-09-19 SOAP Hemato-Oncology
  • O:
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2019-08-01
      • Diagnosis: Tubal cancer
      • Staging: pT3cN1aM1a; at least Stage IVA
      • Treatment: Post-operative chemotherapy is recommended.
    • AE: Hair loss: Grade 2: Total hair loss.
    • 20190910 prescription: Taxol/Carboplatin IP with Taxol/Carboplatin C/T
• 2017-01-03 SOAP Cardiology
  • Diagnosis
    • Other and unspecified angina pectoris [I20.9]
    • HCVD, unspecified, without CHF [I11.9]
    • Mixed hyperlipidemia [E78.2]
    • Cardiac dysrhythmia, unspecified [I49.9]
    • Chest pain, other [R07.89]
    • Generalized anxiety disorder [F41.1]
  • Prescription
    • Algitab (alginic acid, MgCO3, Al(OH)3, 200mg) 1# TID
    • Alpraline (alprazolam 0.5mg) 0.5# HS
    • Pitator (pitavastatin 2mg) 1# QD
    • Syntrend (carvedilol 6.25mg) 1# QD
    • Bokey (aspirin 100mg) 1# QOD

[surgical operation]

• 2019-07-19
  • Debulking surgery (ATH + BSO + cytoreduction + infracolic omentectomy + appendectomy)
  • CRS HIPES

[chemoimmunotherapy]

• 2024-01-03 - gemcitabine 800mg/m2 1200mg NS 100mL 30min (He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-12-20 - gemcitabine 800mg/m2 1200mg NS 100mL 30min (He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-12-11 - gemcitabine 800mg/m2 1200mg NS 100mL 30min (He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-08-18 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-08-02 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-07-13 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-26 - gemcitabine 800mg/m2 1200mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + NS 250mL
• 2023-06-20 - topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-07 - topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-05-23 - topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-03-29 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (2023-04-12 WBC 1.46K/uL) (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-06 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-10 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-05 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-02 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1
• 2022-08-23 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-07-21 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-06-30 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-06-08 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-05-17 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 400mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-04-26 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 400mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-03-28 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-03-02 - + docetaxel 60mg/m2 90mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1
• 2020-02-03
• 2019-12-09
• 2019-11-11
• 2019-10-15
• 2019-09-11
• 2019-08-20 - paclitaxel 160mg/m2 240mg 3hr + carboplatin AUC 5 300mg 2hr + [paclitaxel 60mg + cisplatin 60mg] IP

Primary Systemic Therapy Regimens - Primary Therapy for Stage II–IV Disease - Epithelial Ovarian/Fallopian Tube/Primary Peritoneal (Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN guidelines version 5.2022 20220916, OV-C 6 OF 11, p43)

• High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
  • Preferred Regimens
    • Paclitaxel/carboplatin q3weeks
    • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
  • Other Recommended Regimens
    • Paclitaxel weekly/carboplatin weekly
    • Docetaxel/carboplatin
    • Carboplatin/liposomal doxorubicin
    • Paclitaxel weekly/carboplatin q3weeks
  • Useful in Certain Circumstances
    • IP/IV paclitaxel/cisplatin (for optimally debulked stage II–III disease)
    • For carcinosarcoma:
      • Carboplatin/ifosfamide
      • Cisplatin/ifosfamide
      • Paclitaxel/ifosfamide (category 2B)

Acceptable Recurrence Therapies for Epithelial Ovarian (including LCOC)/Fallopian Tube/Primary Peritoneal Cancer (Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN guidelines version 5.2022 20220916, OV-C 9 OF 11, p51)

• Recurrence Therapy for Platinum-Resistant Disease (alphabetical order)
  • Preferred Regimens
    • Cytotoxic Therapy
      • Cyclophosphamide (oral)/bevacizumab
      • Docetaxel
      • Etoposide, oral
      • Gemcitabine
      • Liposomal doxorubicin
      • Liposomal doxorubicin/bevacizumab
      • Paclitaxel (weekly)
      • Paclitaxel (weekly)/bevacizumab
      • Topotecan
      • Topotecan/bevacizumab
    • Targeted Therapy (single agents)
      • Bevacizumab
  • Other Recommended Regimens
    • Cytotoxic Therapy
      • Capecitabine
      • Cyclophosphamide
      • Doxorubicin
      • Ifosfamide
      • Irinotecan
      • Melphalan
      • Oxaliplatin
      • Paclitaxel
      • Paclitaxel, albumin bound
      • Pemetrexed
      • Sorafenib/topotecan
      • Vinorelbine
    • Targeted Therapy (single agents)
      • Niraparib (category 3)
      • Olaparib (category 3)
      • Pazopanib (category 2B)
      • Rucaparib (category 3)
    • Hormone Therapy
      • Aromatase inhibitors (anastrozole, exemestane, letrozole)
      • Leuprolide acetate
      • Megestrol acetate
      • Tamoxifen
  • Useful in Certain Circumstances
    • Immunotherapy
      • Dostarlimab-gxly (for dMMR/MSI-H recurrent or advanced tumors)
      • Pembrolizumab (for patients with MSI-H or dMMR solid tumors, or TMB-H tumors >=10 mutations/megabase)
    • Hormone Therapy
      • Fulvestrant (for low-grade serous carcinoma)
    • Targeted Therapy
      • Entrectinib or larotrectinib (for NTRK gene fusion-positive tumors)
      • Dabrafenib + trametinib (for BRAF V600Epositive tumors)
      • For low-grade serous carcinoma:
        • Trametinib
        • Binimetinib (category 2B)

==========

2024-03-01

[declining renal function, cardiopulmonary findings emerge on CXR]

Comparing the CXR from 2024-01-27 and 2024-02-29, reveals significant new developments. While the January X-ray showed normal heart size and no confirmed fluid buildup, the February X-ray indicates an enlarged heart (cardiomegaly), abnormal twisting of the aorta (tortuosity), and confirmed fluid accumulation in the space around the lungs (bilateral pleural effusion). Additionally, the February X-ray reveals enlarged lymph nodes near the lungs (engorgement of bilateral hilar regions) and widening of the area between the lungs (mediastinum), which weren’t seen in the previous X-ray.

The patient’s renal function is in decline as evidenced by elevated serum creatinine and BUN.

• 2024-02-29 Creatinine 2.15 mg/dL

• 2024-02-21 Creatinine 1.39 mg/dL

• 2024-02-07 Creatinine 1.85 mg/dL

• 2024-02-01 Creatinine 1.34 mg/dL

• 2024-01-27 Creatinine 1.11 mg/dL

• 2024-02-29 BUN 38 mg/dL

• 2024-02-21 BUN 31 mg/dL

• 2024-02-07 BUN 25 mg/dL

• 2024-02-01 BUN 13 mg/dL

The patient is currently taking furosemide, albumin (serum level 3.1 g/dL on 2024-02-29), and carvedilol. PRN normal saline has also been prescribed. Vital signs are currently stable.

If the patient’s urine output is sufficient, benzbromarone may be considered for the treatment of her hyperuricemiaserum (uric acid level of 8.0 mg/dL on 2024-02-29).

2024-01-29

[reconciliation]

Baraclude (entecavir), Stilnox (zolpidem), and Alpraline (alprazolam) were prescribed on 2024-01-17, while Norvasc (amlodipine), Exforge (amlodipine, valsartan), and Carvedilol were prescribed on 2023-12-20 by our OPD. These medications are currently being used without any noted issues.

2023-12-11

The patient obtained repeat prescriptions for Exforge (amlodipine, valsartan) and Hexal (carvedilol) from our cardiologist, and Lexapro (escitalopram) and Alpraline (alprazolam) from our psychiatrist on 2023-09-27. These medications are accurately listed as the patient’s active medication, and no issues with medication reconciliation have been detected.

2023-08-17

This patient received repeat prescriptions from our cardiologist (for Exforge (amlodipine, valsartan) and Hexal (carvedilol)) and our psychiatrist (for Anxiedin (lorazepam), Lexapro (escitalopram), Stilnox (zolpidem), and Alpraline (alprazolam)) on 2023-07-05. These drugs are well included in the active formulary and no reconciliation issues were identified.

2023-07-14

On 2023-07-08, the patient refilled her prescription for Baraclude (entecavir) at a local pharmacy. In addition, on 2023-07-05, our cardiologist wrote a prescription for Exforge (amlodipine, valsartan) and Carvedilol. On the same day, our psychosomatic medicine specialist also prescribed Anxiedin (lorazepam), Lexapro (escitalopram), Stilnox (zolpidem), and Alpraline (alprazolam) for the patient. These medications were appropriately added to the patient’s active medication list with no reconciliation issues identified.

2023-05-23

• According to the PharmaCloud database, it seems that the patient has only received medical care at our hospital for the past three months. No discrepancies or issues have been identified during the medication reconciliation process for this patient upon her current admission.
• The patient has been unable to tolerate the adverse events associated with chemotherapy and her LVEF has decreased from 70% to 61%. Therefore, she decided not to receive the 6th dose of the Lipo-Dox and Carboplatin chemotherapy regimen.
• The patient is currently receiving topotecan, a medication which is reimbursable by the National Health Insurance (NHI) for use as a second-line chemotherapy treatment for ovarian cancer and small cell lung cancer. The eligibility for this is conditional on the first-line treatment including platinum compounds.
• The patient’s body surface area (BSA) is 1.56 m2, based on a height of 157 cm and weight of 56 kg. The administered dose of topotecan is 4mg, which is approximately 2.5mg/m2. The recommended dose of topotecan for ovarian cancer and small cell lung cancer is 1.5 mg/m2/day for five consecutive days every 21 days. Our current regimen administers a more concentrated dose in a single day. This warrants monitoring for potential myelosuppression and other adverse reactions.
• The patient experienced an episode of leukopenia on 2023-04-12, with a WBC count of 1.46K/uL, after the previous regimen of lipo-dox and carboplatin administered on 2023-03-29. However, the patient’s WBC count has since recovered to 3.56K/uL on 2023-05-22, making topotecan administration not contraindicated.
• The patient’s SBP exceeds 200mmHg several times and remains around 190mmHg 2023-05-23 08:33 this morning even she is taking Norvasc (amlodipine 5mg 0.5# QD) and Hexal (carvedilol 6.25mg 1# QD), it might be beneficial to double Norvasc to 1# QD first and monitor if the high SBP being mitigated.

2023-03-30

• Consecutive 3 days of granocyte (lenograstim) is scheduled approximately 1 week after the patient received chemotherapy to prevent them from leukopenia without an issue.

2022-12-02

• Several SBP data points exceeded 200mmHg in this patient while taking the self-care medications Norvasc (amlodipine) and Carvedilol (carvedilol) these two days. In order to mitigate her hypertension, the addition of an ARB, such as valsartan, losartan, might be beneficial.

2022-04-06

• This patient was diagnosed with serous carcinoma of the right fallopian tube with peritoneal and pleural invasion with recurrent tumors, received [paclitaxel + carboplatin] 6 times in the period from 2019-08-20 to 2020-02-03 following debulking surgery on 2019-07-19, now she is on [docetaxel + carboplatin] since 2022-03-02 (plus bevacizumab since 2022-03-28).

700346981

240229

[MedRec]

• 2024-01-28 ~ 2024-02-02 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Gastric cancer adenocarcinoma, with suspect left adrenal metastasis, stage IV, s/p FOLFOX
    • Chronic viral hepatitis B without delta-agent
    • xerotic dermatitis with lichen simplex cohronicus
    • suspect lichen amyloidosis
  • CC
    • for chemotherapy with C1D1 FOLFOX Q2W.
  • Present illness
    • This is a 75 year-old man who has the history of hypertension for 7 years without medication control.
    • According to the statement of the patient’s families record. He suffered from epigastric fullness, general maliaise, and hemopty for two days, so he came to GI OPD at Cardinal Tien Hospital on 2023-08. The endoscopic was done on 2023/08/22, the report showed: Gastroesophageal reflux disease, Rule Out cancer of stomach hight body ulcer in tumor. The stomach biopasy (2023/08/24) revealed Adenocarcinoma, Immunostains: CK(+) for stromal invasion p53: (-) mCEA: (+) CDX-2: (+) Her-2: Negative (1+, Incomplete membrane staining > 10%), Mucin: Few cells (+) Giemsa stain: (-) for Helicobacter Pylori PAS: (-) for neoplastic cells infiltration). He denide have the body weight loss, fever, weakness.
    • He came to our Hema OPD for cancer evaluation due to personal reason. The port-a catheter was insertion on 2024/01/25. Anti-HBc: reactive on 2024/01/29, s/p Vemlidy.
    • This time, he is admitted for C1D1 chemotherapy with FOLFOX on 2024/01/28.
  • Course of inpatient treatment
    • After be admitted, he suffered from cough with white sputum noted, so gave antitussive treatment. Then, he complaints skin rash, itchy, and skin tag at abdomen, back, limbs for 2-3 months, and the symptom not become better, so consulted dermatology, and suggested Biomycin onit for wound lesions.
    • Clobestol onit for itchy papules.
    • Sinphraderm cream mix-up with CB.
    • Orolisin 1# tid po for pruritus control.
    • Consideer further NB-UVB at Dermatology OPD after patient discharge.
    • After treatment, the symptom improved, so he received C1D1 chemotherapy with FOLFOX on 2024/01/31-02/02, hydration, Vemlidy for Anti-HBC: reactive, Imperan for vomiting.
    • After chemotherapy, he denide having a fever, vomiting, diarrhea, or any complaints. He can be discharged on 2024/02/02, the OPD follow-up will be arranged.
  • Discharge prescription
    • Cough Mixture (platycodon) 5mL TID
    • Actein (acetylcysteine 200mg) 1# TID
    • Norvasc (amlodipine 5mg) 1# QD
    • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# TID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD

[consultation]

• 2024-02-27 Orthopedics
  • Q
    • for suspect degenerative arthritis.
    • He suffered from right knee pain and swelling for 2-3 days, then the symptom become worse, so we need your help, thanks a lot!!
  • A
    • This is a case r/o OA knee, please check knee standing x-ray first and i will check osteoarthritis stage and discuss treatment and education to Paitnet, Thanks alot.
• 2024-01-30 Dermatology
  • Q
    • He suffered from skin rash, itchy, and skin tag at abdomen, back, limbs for 2-3 months, and the symptom become worse, so we need your help, thanks a lot!!
  • A
    • The patient had sufferred from diffuse verrucous leisons with lichenificaiton over expose area.
      
    • Under the impression of xerotic dermatitis with lichen simplex cohronicus r/o lcihen amyloidosis.
      
    • The following sugeetion:
      • for wound lesions, biomycin onit 1 tube topical bid use first.
      • for itchy papules, Clobestol onit 3 tube otpical bid use.
      • for dry scaling lesions, SInphraderm cream 1 tube mix-up with CB. Strong 4 tube topical bid use.
      • Orolisin 1# tid po for pruritus control.
      • consideer further NB-UVB at Dermatology OPD after patient discharge.
• 2023-12-24 Ophthalmology
  • Q: right eye pain for 3 days
    • Chief Complaint: FBS OD for 3 days
    • denied BV, stinging pain, itchy, discharge(-)
    • stated that just came back from taitung, may contact with
    • dirty bed sheet
    • NKDA
    • Medication: antihypertensive
    • OPH hx: cata s/p OP OU 10+ yrs ago
    • Past history: HTN under meds control
    • Surgical history: BPH s/p TURP
    • Exposure (TOCC): nil
  • A
    • O
      • VAcNC od 20/30
      • IOP soft by digit
      • Pupil 3/3 +/+
      • No periorbital swelling
      • conj od upper tarsal injected and tender when palpate, inf tarsal cyst and multiple lithiasis os multiple non-protruded lithiasis
      • K clear ou peripheral thinning ou, dellen??, Pooling at thinning site, Staining negative
      • AC D/cl ou
      • PCIOL ou
    • A
      • Internal hordeolum od
    • P
      • Cravit 1gtt qid + tetracycline ointment 1qs bid od
      • inform the risk of infection progression, if increased pain/swelling, come back asap
      • opd f/u on W2

[chemotherapy]

• 2024-02-27 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3190mg NS 500mL 46hr (70% FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-01-31 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (70% FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

==========

2024-02-29

[reconciliation]

The FOLFOX regimen was initiated on 2024-01-31. A subsequent evaluation on 2024-02-27 revealed an elevated CA-199 level. This finding might suggest the possibility of disease in the distal stomach (closer to the small intestine).

• 2024-02-27 CA-199 (NM) 85.264 U/ml
  
• 2024-01-22 CA-199 20.66 U/mL

Additionally, the CRP level on 2024-02-27 was 15.5 mg/dL, while the PCT level was within normal limits. Elevated CRP can indicate various conditions, including inflammation, autoimmune disorders, tissue injury, or even certain cancers. Therefore, further monitoring or investigations may be prudent to elucidate the cause of the elevated CRP.

No medication discrepancies were found after review of HIS5 and PharmaCloud records.

700801871

240229

==========

2024-02-29

[reconciliation - potential medication discrepancy: refills not aligned with active list]

A potential medication discrepancy has been identified for this patient. While the patient has recently refilled a 28-day supply of lorazepam, escitalopram, and ginkgo biloba extract (ginkgoflavonglycosides) on 2024-02-26 according to the PharmaCloud database, these medications are not currently included in the active medication list. Please verify if these refilled medications are still deemed necessary and consider updating the active medication list accordingly.

700995209

240229

[exam findings]

• 2024-01-24 SONO - neurology
  • Chronic parenchymal renal disease
  • Right renal stone
• 2024-01-08 CXR
  • multifocal areas of GGOs in both lungs further in regression
• 2024-01-02 CXR
  • multifocal areas of GGOs in both lungs in regression as compared with previous chest image
• 2023-12-29 CT - chest
  • Indication
    • Other pneumonia, unspecified organism
    • Malignant neoplasm of unspecified site of left female breast
    • Fever, unspecified
    • suspected Pneumonia
  • Chest CT without IV contrast ehnancement shows:
    • Diffuse mosaic ground glass opacities scattered at both lungs is found.
    • S/p port-A placement with its tip at Superior vena cava
    • No evidence of bilateral pleural effusion.
    • Patent airway is found.
    • There is no evidence of mediastinal LAP
    • The liver, spleen, pancreas, both kidneys and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
    • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Diffuse mosaic ground glass opacities scattered at both lungs is found. Pneumonia is considered.
• 2023-12-29 CXR erect
  • Diffuse opacities over both lungs is found.
• 2023-12-08 CXR erect
  • patchy consolidation and ground-glass opacities over RUL
  • recticular opacities over left lung and Rt midlung zone?
  • Surgical clips over the Lt lower chest
• 2023-09-06 Patho - breast mastectomy with regional lymph nodes
  • PATHOLOGIC DIAGNOSIS
    • Breast, left, partial mastectomy — Mixed invasive carcinoma of no special type and mucinous carcinoma
    • Resection margin, breast, left, partial mastectomy — Free
    • Lymph node, axillary sentinel and axillary, left, axillary LN dissection — Metastatic carcinoma (1/4)
    • AJCC 8 th edition, Pathology stage: pT2N1(cM0); Anatomic stage IIB; Prognostic stage IB
  • MACROSCOPIC EXAMINATION
    • Breast Size: 7.3 x 4.2 x 2.4 cm and 2.5 x 2.0 x 1.5 cm (4’-6’ re-excision)
    • Skin Size: 5.8 x 1.2 cm
    • Nipple: Not included
    • Tumor Size: 2.5 x 2.0 x 1.5 cm
      
    • Resection Margin: Free
    • Lymph node: Axillary
    • Representative parts are taken for section and labeled: F2023-00398: FSA1= 12’ 3’, 6’ margins, FSA2= 9’ and deep margins, A1= skin, A2-A5= tumor, A6= non-tumor, FSB= sentinel LNs, FSC and C= 4’-6’ re-excision. S2023-17825: A1-A3= axillary lymph nodes
  • MICROSCOPIC EXAMINATION
    • Histology
      • Histologic type: Mixed invasive carcinoma of no special type (60%) and mucinous carcinoma (40%)
      • Size of invasive carcinoma: 2.5 x 2.0 x 1.5 cm
        
      • Histologic grade (Nottingham histologic score): Grade 2 (score= 6)
      • Skin involvement: Absent
      • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
    • Margins: Negative, Closest margin: > 10 mm
      • 6” margin invovlved by carcinoma (frozen section specimen A), and free of carcinoma in “4’-6’ re-excision” (frozen section specimen C)
    • Nodal status: Metastatic carcinoma (1/4)
      • number of lymph node examined: 2 (sentinel), 2 (axillary)
      • number with macrometastases (>2mm): 1 (sentinel)
      • number with micrometastases (>0.2~2mm and/or >200 cells): 0
      • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
    • Treatment Effect: No presurgical therapy received
    • Lymphovascular invasion: Present
    • Perineural invasion: Absent
  • IMMUNOHISTOCHEMICAL STUDY (S2023-16485)
    • ER (Ab): Positive (95%, strong intensity)
    • PR (Ab): Positive (2%, moderate intensity)
    • HER-2/Neu (Ab): Negative (score = 1+ in both mucinous carcinoma component and invasive carcinoma of no special type component) (F2023-00398A1)
    • Ki-67: 10%
    • E-cadherin: Positive (F2023-00398A1)
• 2023-09-04 SONO - abdomen
  • mild fatty liver
  • fatty infiltration of pancreas
• 2023-08-25 Tc-99m MDP bone scan
  • Mildly increased activity in the middle T-spines and L3-4 spines. Degenerative change may show this picture.
  • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2023-08-18 Patho - breast biopsy (no need margin)
  • Breast, left, core neddle biopsy — Mucinous carcinoma
  • The sections show a picture of mucinous carcinoma, composed of breast tissue with nests and cords of polygonal neoplastic cells with focal micropapillary pattern, floating in mucinous pools. Focal calcification is present.
  • IHC shows following features:
    • ER (Ab): Positive (95%, strong intensity)
    • PR (Ab): Positive (2%, moderate intensity)
    • HER-2/Neu (Ab): Negative (score = 0)
    • Ki-67: 10%
• 2023-08-18 SONO - breast
  • Left breast 4’ region tumor, suggest biopsy.
    
  • BI-RADS: Category 4b: suspicious abnormality-biopsy should be considered.
• 2023-08-18 Mammography
  • Digital mammography of both breasts with MLO and CC views:
  • Old mammographic study: 2015-12-30 (BIRADS 1)
    • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
    • Focal asymmetry in LOQ of left breast, suggest sonographic correlation.
    • No obvious architectural distortion.
      
    • No periareolar skin thickening.
    • Non-specific bilateral axillary lymph nodes.
  • Impression:
    • Dense breast. Focal asymmetry in LOQ of left breast, suggest sonographic correlation.
  • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)

[MedRec]

• 2023-12-29 ~ 2024-01-08 POMR Chest Medicine Wu YaoGuang
  • Discharge diagnosis
    • Bilateral pneumonia, sputum culture pending
    • Interstitial pulmonary disease, unspecified
    • Left breast invasive carcinoma with axillary lymph nodes metastasis. pT2N1M0, stage IIB. ER (95%), PR (5%), Ki67 10%, ECOG 0.
  • CC
    • dyspnea for two days
  • Present illness
    • This is a 55 years old female patient with past history of Left breast invasive carcinoma with axillary lymph nodes metastasis. pT2N1M0, stage IIB. ER (95%), PR (5%), Ki67 10%, ECOG 0.
    • She denied other systemic diseases including DM, HTN,or heart disease. HBV was noted since 2023/08. She denied any drug use recently.
    • She suferred from dyspnea for two days accompanied with productive cough. Fever up to 38.9’C was noted. No rhinorrhea or sorethroat. Due to above symptoms, she came to our ER for help.
    • At ER, the temperature was 40’C, pulse beats 150 per minute, blood pressure 140/79 mmHg, respiratory rate 18 breaths per minute, and the oxygen saturation 91%, consciousness was E4V5M6.
    • The laboratory data showed leukocytosis (12290/ul) with bandemia and elevated CRP level (28.9mg/dl).
    • Chest CT revealed diffuse mosaic ground glass opacities scattered at both lungs is found. Pneumonia is considered.
    • Under the impression of pneumonia, she was admitted for further evaluation and management.
  • Course of inpatient treatment
    • After admission, antibiotics with brosym, her underlying medication or other symptomatic drugs were kept using.
    • She developed fever on 2024/01/03 and the fever last two days to 01/04.
    • We checked two set of blood cultures and check sputum culture. We also prescribed Targocid for infection control.
    • We also checked Aspergillus serum antigen on 01/04 and the result showed negative.
    • Recent lab data results of autoimmune related all showed no abnormalities.
    • Pathogen like HSV, mycoplasma IgM showed negatuve results. We titrated Codeine use from TID to Q6H due to her more frequent cough on 2024/01/03 night.
    • We also Swicth Hydrocortisone to oral Compesolon due to his improving chest CXR on 01/02 compared with last film on 2023/12/29.
    • Lab datas and chest CXR followed on 2024/01/08 showed improving,acceptable results.
    • Her O2 saturation were stable during this hospitalization.
    • Due to her much improving clinical condtions, improving lab datas and CXR, she was allowed discharge today.
  • Discharge prescription
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Compesolon (prednisolone 5mg) 1# BID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
• 2023-12-29 SOAP Medical Emergency
  • S: Self-reported fever, upper respiratory tract symptoms, and shortness of breath for 2 days, denied TOCC
    • fever was noted for 2 days
    • cough with sputums
    • Hx of Lt breast ca (mucinous ca) proved by CNB on 2023-08-18
    • Lt breast ca s/p partial mastectomy+ALND on 2023-09-05
    • adjuvant C/T with E(Lipodox) C -> T since on 2023-09-19
  • O: Vital signs: BP 140/79; HR: 150; BT 40’C; RR 18;
    • Con’s: E4V5M6
    • SpO2: 91%
    • General appearance: not in distress
    • Conj: not pale
    • Sclera: not icteric
    • BS: clear and bil. symmetrical breathing sound, no tender over chest wall, no obvious skin rash
    • Heart: RHB, no JVE
    • Abdomen: soft and oviod, no obvioius tenderness, no muscle guarding,
    • Extremities: freely movable,
  • Preliminary Impression
    • J18.8 Other pneumonia, unspecified organism
    • PN, bil, fever, SOB, Hx Lt breast Ca s/p op, C/T, WBC 12.3K, CRP 29, U/A(-), COVID, Flu(-), Brosym, OA CM
  • Prescription
    • Acetal (acetaminophen 500mg) 1# ST
    • Brosym (cefoperazone, sulbactam) 4g ST IVD
    • Brosym (cefoperazone, sulbactam) 4g Q12H IVD
    • NS 500mL ST IVD
    • Lyacety (lysine acetylsalicylate) 500mg ST IVD

[consultation]

• 2024-01-17 Nephrology
  • Q
    • poor renal function
    • This is a 55 years old female patient. She denied any underlying systemic diseases including DM, HTN or heart disease. HBV was noted since 2023/08. She denied any drug use recently.
    • Under the impression of left breast invasive carcinoma with axillary lymph nodes metastasis. She was admission for 6th adjuvant chemotherapy with nab Taxol.
    • She just discharged from chest ward due to ILD. However, BUN:27mg/dl, Cr:1.62 mg/dl, eGFR: 35.06ml/min were noted on 2023/01/17. We need your help for renal function assessment. Thank you so much!!
  • A
    • This 55 y/o female was admitted to GS ward due to left breast invasive carcinoma with axillary lymph nodes metastasis for 6th adjuvant chemotherapy.
    • Hx: DM, HTN or heart disease. HBV was noted since 2023/08.
    • BW 53.8 kg
    • Lab
      • 2024-01-17 BUN 27 mg/dL
        
      • 2024-01-17 Creatinine 1.62 mg/dL
        
      • 2024-01-17 eGFR 35.06 ml/min/1.73m^2
        
      • 2024-01-17 Alkaline phosphatase 131 U/L
        
      • 2024-01-17 K (Potassium) 4.4 mmol/L
        
      • 2024-01-17 Na (Sodium) 139 mmol/L
        
      • 2024-01-17 WBC 12.97 x10^3/uL
        
      • 2024-01-17 HGB 11.7 g/dL
        
    • Urinalysis ??
    • Renal echo ??
    • Medication history:
      • Chemo: Nab-paclitaxel, pending 6th course
    • Consciousness: E4V5M6
    • Previously admitted to CM due to aspergillosis
    • Baseline renal function was normal
    • Impression: Pre-renal AKI may due to dehydration
    • Recommendation:
      • Please titrate fluid supplement (e.g. N/S, D5W) slightly more than maintainence dosage (> 25-30 ml/kg/Day), that is at least around 1500 mL/day, or divided separately via mouth and IV, avoid dehydration especially in the scenario of active cancer under chemotherapy susceptible to infection
      • Please record U/O on a daily basis, and check body weight BIW or TIW if necessary
      • Please obtain URINALYSIS and LIPID profile given lipemia
      • Regular f/u BUN/CRE, electrolyte, VBG, CXR
      • Arrange renal echo to r/o post-renal factor
      • Please feel free to contact us if any inquiries.
      • Thanks for consultation.
• 2023-09-18 Gastroenterology
  • Q
    • This is a 55 years old woman patient. Due to left breast cancer, she was admitted for chemotherapy. However, Anti-HBc and Anti-HBs positive. We need your help for medicine. Thank you so much!
    • First adjuvant chemotherapy on 2023/09/20
    • MBD on 2023/09/20
    • arrange OPD on 2023/09/27
  • A
    • 55 years old female with breast cancer and admitted for chemotherapy. For anti-HBc(+), we are consulted.
    • Lab
      • 2023-09-18 S-GPT/ALT 17 U/L
        
      • 2023-09-18 S-GOT/AST 16 U/L
        
      • 2023-09-18 Bilirubin total 0.26 mg/dL
        
      • 2023-09-12 Anti-HCV (NM) Negative
        
      • 2023-09-12 Anti-HBs (NM) Positive
        
      • 2023-09-12 HBsAg (NM) Negative
        
      • 2023-09-04 Alkaline phosphatase 121 U/L
        
      • 2023-09-04 Albumin 4.0 g/dL
        
    • impression
      • Resolved HBV infection
      • Left breast cancer, plan for chemotherapy
    • suggestion
      • The prophylactive antiviral treatment of HBV is indicated during the chemotherapy
      • Arrange abdominal sonography and check HBV DNA
      • GI OPD follow-up is indicated
      • We would prescribe the antiviral agent when the chemotherapy is to be launched
• 2023-09-04 Rehabilitation
  • A
    • Rehabilitation programs: arrange bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education.
    • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[surgical operation]

• 2023-09-05
  • Surgery
    • Partial mastectomy + axillary lymphnode dissection        
  • Finding
    • a 2.5x2x1.5 cm slight firm mass in lt breast
    • SLN 1/2 (+) 

[chemotherapy]

• 2024-02-29 - nab-paclitaxel 260mg/m2 390mg 30min (Abraxane)
  • diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-02-07 - nab-paclitaxel 260mg/m2 390mg 30min (Abraxane)
  • diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-01-17 - nab-paclitaxel 260mg/m2 390mg 30min (Abraxane)
  • diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-12-14 - docetaxel 75mg/m2 110mg NS 250mL 1hr (D Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-11-22 - cyclophosphamide 600mg/m2 885mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL
• 2023-11-01 - cyclophosphamide 600mg/m2 870mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL
• 2023-10-11 - cyclophosphamide 600mg/m2 860mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL
• 2023-09-20 - cyclophosphamide 600mg/m2 835mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL

700999655

240229

[exam findings]

• 2024-02-21 Patho - breast simple/partial mastectomy
  • PATHOLOGIC DIAGNOSIS
    • Breast tumor, left, simple mastectomy (s/p neoadjuvant C/T) —- Residual ductal carcinoma in situ, high grade
    • Resection margins, ditto — Free of tumor invasion
    • Sentinel lymph nodes, L’t axillary, frozen section — Free of tumor metastasis (0/3)
      
    • Nipple and skin, left breast — Free of tumor invasion
    • AJCC Pathologic Anatomic Stage — ypTisN0, if cM0, stage 0; Prognostic Stage — Stage 0
  • MACROSCOPIC EXAMINATION
    • Breast: 20 x 15 x 5.3 cm
    • Skin: 19.5 x 5.1 cm, no ulcer
    • Nipple: 1.3 x 0.9 cm, retracted
    • Tumor: 1.1 x 0.7 cm
    • Resection Margins: free
    • Lymph node: left axillar sentinel lymph nodes for frozen (F2024-00060)
    • Representatively embedded for sections as A1: unlabelled four peripheral margins, A2: lesion 1, A3-A5: lesion 2, A6-A7: lesion 3, A8: lesion 4, A9: lesion 5, A10: lesion 6, A11: lesion 7 and A12-A16: nipple + skin + breast tissue and X1-X20: breast tissue [Reference: F2024-00060 FSA1 and FSA2: L’t axillary SLNs]
  • MICROSCOPIC EXAMINATION
    • Histologic type: residual ductal carcinoma in situ with central necrosis
    • Histologic grade: grade 3, high grade
    • Margins: free of tumor invasion
    • Nodal status: free of tumor metastasis (0/3)
    • Treatment Effect:
      • In the Breast: no residual invasive carcinoma is present in the breast after presurgical therapy
      • In the Lymph nodes: no lymph node metastases and no prominent fibrous scar
    • Lymphovascular invasion: absent
    • Perineural invasion: absent
    • Non-tumor breast: fibrocystic change with adenosis, microcalcification, usual ductal hyperplasia, intraductal papillomas, fibroadenomas and sclerosing adenosis
  • IMMUNOHISTOCHEMISTRY
    • For DCIS (S2024-03260X17): P63 shows preserved outer myoepithelial cell
    • For UDH (S2024-03260A8): CK5/6 and P63 show positive for myoepithelial cell
• 2024-02-16 MRI - breast
  • Clinical history: 61 y/o female patient with Rt breast microcalcification s/p needle localization excision on 2013-04-16, pathology showed DCIS with positive margin.
    • Rt breast DCIS s/p simple mastectomy on 2013-05-07
    • Lt breast mass noted for days on 2023-08-09
    • Lt breast ca proved by CNB on 2023-08-11
    • NEOADJUVANT C/T WITH EC -> THP SINCE 2023-08-22
    • Changed to VNB + H + P since 6th C/T due to ILD.
  • With and without enhancement MRI of breast (axial T1, T1FS, sagittal T2, T2FS, axial and sagittal T1FS contrast, dynamic study):
    • S/P right mastectomy.
    • Regression of left breast malignancy.
    • No periareolar skin thickening.
    • Small right axillary lymph nodes.
  • Impression:
    • S/P right mastectomy.
    • Left breat malignancy with axillary lymph node s/p neoadjuvant, moderate regression.
  • BI-RADS: Category 6 - proven malignancy.
• 2023-11-26 CT - abdomen
  • Findings
    • S/P right breast operation.
    • Mild small bowel ileus.
    • A lipoma (2.0cm) at left thigh.
    • Retroversion of uterus.
    • Grade 4 fatty liver.
    • Atherosclerosis of aorta, iliac arteries.
    • Compression fracture of L1.
  • IMP:
    • S/P right breast operation.
    • Mild small bowel ileus.
• 2023-08-23 MRI - breast
  • Clinical history: 60 y/o female patient with left breast cancer
  • With and without enhancement MRI of breast:
    • S/P right mastectomy.
    • There is large irregular tumor, 6.5cm in left breast, with prominent enhancement, c/w malignancy.
      
    • Presence of left periareolar skin thickening.
    • Enlarged left axillary and internal mammary lymph nodes, could be due to metastatic lymph nodes.
  • Impression:
    • S/P right mastectomy.
    • Left breast malignancy with axillary and internal mammary lymph nodes metastasis.
  • BI-RADS: Category 6: proven malignancy.
• 2023-08-22 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 28) / 100 = 77.00%
    • M-mode (Teichholz) = 72
  • Conclusion:
    • Indeterminated LV filling pressure; severely dilated LA.
    • Normal LV and RV systolic function.
    • Trivial MR.
    • Prominent epicardial fat.
• 2023-08-21 PET
  • Glucose hypermetablic lesions in the left breast, left axilla, and bilateral SCF lymph nodes, compatible with left breast cancer with regional lymph nodes metastases.
    
  • Glucose hypermetablic lesions in bilateral lower neck and bilateral mediastinal lymph nodes, T6 spine and left humeral shaft, highly suspected breast cancer with distant metastases.
    
  • Increased FDG uptake in the right lobe of the thyroid gland, highly suspected the other primary malignancy, suggesting biopsy, if necessary, for further evaluation.
    
  • Left breast cancer, cTxN3cM1, stage IV (AJCC 8th ed.); highly suspected the other primary thyroid cancer in the right lobe, by this F-18 FDG PET scan.
• 2023-08-11 Patho - lymphnode biopsy
  • Lymph node axillary, left, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (-, 0%), PR (-, 0%), Her2/neu: positive (score = 3+), Ki-67 (40%), E-cadherin (+).
  • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.
• 2023-08-11 Patho - breast biopsy
  • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (-, 0%), PR (-, 0%), Her2/neu: positive (score = 3+), Ki-67 (80%), E-cadherin (+).
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2023-08-11 Mammography
  • Dense breast.
  • S/P right mastectomy.
  • Left breast plemorphic microcalcifications with enlarged left axillary lymph nodes, r/o malignancy.
  • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
• 2023-08-10 Tc-99m MDP bone scan
  • Increased activity in some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, elbows, wrists, hips, knees and feet, compatible with benign joint lesions.
• 2019-04-23 SONO - abdomen
  • Mild fatty liver
  • A hepatic hemangioma measuring 1.08 cm in S8 is noted.

[MedRec]

• 2023-11-26 ~ 2023-12-06 POMR Integrative Medicine Rao LunYu
  • Discharge diagnosis
    • Left breast invasive carcinoma with axillary lymph nodes, cT3N1M0, stage IIIA. IHC stains: ER (-, 0%), PR (-, 0%), Her2/neu: positive (score = 3+), Ki-67 (80%). ECOG: 0.
    • Acute respiratory failure with hypoxia
    • Pneumonia, unspecified organism
    • Urinary tract infection, urine culture:Escherichia coli
    • Agranulocytosis secondary to cancer chemotherapy
    • Interstitial pulmonary disease, suspect Taxotere related
    • Type 2 diabetes mellitus
    • Hypertension
    • Carrier of viral hepatitis B
  • CC
    • fever up to 39.5 degree since this today
  • Present illness
    • This is a 61-year-old male/female with past history of (1) Left breast invasive carcinoma with multiple lymph nodes metatstais, cT3N3cM1, stage IV, under neoadjuvant chemotherapy (2) HBV (3) DM (4) HTN .
    • This time, according to patient statement, she was suffered from fever up to 39.5 degree since this today. Diarrhea was her chronic problem after chemotherapy.
    • She denied URI symptoms(-), dyspnea(-), decrease urine output(-).
    • Due to the symptom, she went to our ER for help. In ER, her vital sign was showed BP:140/71 mmHg, HR: 108bpm, BT:39.5’C, RR:18/min, conscious E4V5M6, and SpO2:98% under room air. Physical examination showed bilateral clear breathing sound and no abdominal tenderness, no CV angle knocking pain(-). Laboratory data revealed leukopenia, hypokelamia, hyponatremia and elevated CRP level. The urinalysis showed pyuria and bacteriuria. Under the impression of neutropenic fever, chemotherapy related, she was admitted for further management. 
  • Course of inpatient treatment
    • After admission, empiric antibiotics with Tapimycin was administered on 2023/11/26-28 due to neutropenic fever, add Targocid on 11/27-12/06.
    • However, desaturation was noted on 11/30 night and followed the chest film disclosed suspect interstitial lung disease.
    • We add the Dexamethasone on 11/30-12/06 and shifted the antibiotics to Mepem on 11/30-12/06 for suspect interstitial lung disease, blood culture no growth.
    • Add Baktar 2 tab Q12H for PJP prevention.
    • Patient become better after the medication treatment. With the relatively stable condition,she was discharged on 2023/12/06 and will OPD follow up
  • Discharge prescription
    • loperamide 2mg 2# PRNQ8H if watery diarrhea
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
    • Ulstop (famotidine 20mg) 1# BID
    • ZCough (benzonatate 100mg) 1# TID
    • Morcasin (sulfamethoxazole 400mg, trimethoprim 80mg) 2# Q12H
    • Ceficin (cefixime 100mg) 2# Q12H
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Limeson (dexamethasone 4mg) 1# BID
• 2023-08-21 ~ 2023-08-23 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Left breast invasive carcinoma with axillary lymph nodes status post port A insertion on 2023/08/22. cT3N1M0, stage IIIA.ECOG:0.
    • Encounter for antineoplastic chemotherapy
    • Intraductal carcinoma in situ of right breast status post simple mastectomy on 2013/05/07
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Carrier of viral hepatitis B
  • CC
    • noted a palpable mass at left breast on 2023/08/09.
  • Present illness
    • This 61-year-old female patient has past history of hypertension over 10 years with regular medicine control. DM over 5 years with regular medicine control. HBV was noted on 2023/08. Right breast DCIS status post simple mastectomy on 2013/05/07. She denied any TOCC histories in recent 3 months.
    • She noted a palpable mass at left breast on 2023/08/09. She came to our OPD for help. Breast sono showed a lesion, Left 10/0.62 cm , size: 3.76x1.4 cm, r/o malignancy with left axillary lymph nodes metastasis suggest biopsy. Left breast and axillary lymph nodes core needle biopsy revealed invasive carcinoma, ER (-, 0%), PR(-, 0%), Her2/neu positive (score= 3+), Ki-67(80 %), CA-153 10.768 U/ml, CEA 2.393 ng/ml.
    • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss. PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at left breast around 9x9 cm without discharge. The nipple was dimping without exudative nor bloody discharge and no retraction. The left breast skin had no cellulitis change.
    • SDM for this patient in OPD. Neo-adjuvant chemotherapy was her choose. Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 + Herceptin 600mg SC + Perjeta 420mg for 4 cycles was plan.
    • Under the impression of left breast invasive carcinoma with axillary lymph nodes metastasis, she was admitted for surgery of port A insertion. Arrange 1st neoadjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 on 2023/08/23. 
  • Course of inpatient treatment
    • After admission, port A insertion was performed on 2023/08/22. 1st neo-adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 were given. The wound is clean and dry. No discomfort after chemotherapy.
    • Under the stable condition, she was discharged today, wound will be follow up on 2023/08/30. And arrange next admission three weeks later.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Emend (aprepitant 125mg) 1# QD on 8/24, 8/25
    • Promeran (metoclopramide 3.84mg) 1# TIDAC on 8/26, 8/27, 8/28
    • loperamide 2mg 2# PRNQ8H if watery stool > 2 per day

[surgical operation]

• 2024-02-20
  • Surgery
    • left breast simple mastectomy and sentinel lymph node biopsy
  • Finding
    • lef breast tumor 1.5cm, 10”/1.5cm
    • left axillary sentinel lymph nodes biopsy: 3, all negative

[chemotherapy]

• 2024-02-19 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr
• 2024-01-29 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + vinorelbine 30mg/kg 45mg NS 50mL 10min
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2024-01-08 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + vinorelbine 30mg/kg 45mg NS 50mL 10min
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-12-18 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + vinorelbine 30mg/kg 40mg NS 50mL 10min
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-16 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 60min + docetaxel 75mg/m2 113mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-10-25 - cyclophosphamide 600mg/m2 910mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-10-04 - cyclophosphamide 600mg/m2 905mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-09-13 - cyclophosphamide 600mg/m2 908mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-08-22 - cyclophosphamide 600mg/m2 919mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

701492916

240229

[exam findings]

• 2023-12-13 CT - chest
  • Indication
    • breast lump Lt breast ca proved by CNB on 2023-07-14 at ZhongXiao Hospital
    • Lt breast ca (TNBC) and NACT with E(Lipodox)C -> T since 2023-08-16 and adding Keytruda since 2023-08-16.
  • Findings: Comparison was made with CT on 2023/12/03
    • Lungs: inferior lingular segment atelectasis with bronchiectasis. patchy ground-glass opacities at both upper lobes and interlobular septal thickening at both lungs.
      • ground glass solid nodule at RUL RML RLL LUL LLL (mm in largest
    • Mediastinum and hila: no enlarged LN or mass.
    • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: a 5mm dense calcification
    • at left breast, and no abnormal enhancing nodule and no enlarged LN at axilla.
    • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • residual interstitial fibrosis sequela of prior drug-related toxicity? lingula collapse with bronchiectasis
• 2023-12-08 Bronchodilator Test
  • Normal pulmonary function
• 2023-12-06 CXR
  • Presence of ileus.
  • S/P Port-A infusion catheter insertion.
  • Ground glass opacity in LLL.
  • Normal appearance of trachea and bil. main bronchus.
  • Normal size of heart.
  • Suggest clinical correlation.
• 2023-12-03 CTA - chest
  • Findings
    • No intimal flap, nor intramural hematoma of aorta.
    • No filling defect of pulmonary artery.
    • Ground-glass opacities with superimposed interlobular septal thickening of both lung fields, more severe at upper lobes.
    • No enlarged mediastinal lymph node.
    • No pleural lesion.
    • Unremarkable change of the visible liver, spleen, pancreas, adrenal glands, and kidneys.
    • No bony destructive lesion on these images.
  • Impression
    • No CT-evidence of aortic dissection or pulmonary embolism
    • Crazy paving of both lung fields. The differential diagnosis includes, but is not limited to pulmonary edema, ARDS, and acute interstitial pneumonia.
• 2023-11-07 CT - chest
  • Indication: fever, cause unknown, ILD???
  • Findings
    • Lungs: partial atelectasis of inferior lingular segment and RML.
    • several lobular ground glass opacities at RUL.
    • normal appearance of both lower lobes.
    • Mediastinum and hila: no enlarged LN or mass.
    • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: an enhancing lesion (22mm) in left breast with a central high density focus.
    • suspect duodenal diverticuulm, 2nd portion.
    • marginal spurs of multiple vertebrae due to spondylosis. no destructive lytic or blastic lesion.
  • Impression:
    • no evidence of interstitial lung disease or pneumonia.
• 2023-11-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (46 - 15) / 46 = 67.39%
    • M-mode (Teichholz) = 65
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
• 2023-08-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (49.8 - 17.3) / 49.8 = 65.26%
    • M-mode (Teichholz) = 65.3
    • 2D (M-Simpson) = 73.7
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
• 2023-08-14 SONO - abdomen
  • Findings
    • Liver: Increased brightness of liver parenchyma was noted. A sonolucent lesion was noted in S6-S6, with posteriore enhancement, in S6-S7: size about 0.5cm.
    • Pancreas: Some parts of pancreas blocked by bowel gas, especially head and tail; increased brightness of pancreas parenchyma
  • Diagnosis:
    • mild fatty liver
    • liver cyst
    • fatty infiltration of pancreas
• 2023-08-11 MRI - breast
  • Clinical history: 71 y/o female patient with breast lump, Lt breast ca proved by CNB on 2023-07-14 at ZhongXiao Hospital.
  • With and without enhancement MRI of breast (axial T1, T1FS, sagittal T2, T2FS, axial and sagittal T1FS contrast, dynamic study):
    • There is irregular tumor,, 2.5cm in left subareolar region, with prominent enhancement, c/w malignancy.
    • Irregular tumor, 1.5cm in deep breast of 10-11’region of left breast.
    • No periareolar skin thickening.
    • No enlarged axillary lymph node.
      
  • Impression:
    • Left breast subareolar and 10-11region tumors, r/o malignancy.
  • BI-RADS: Category 6 - proven malignancy.
• 2023-08-07 PD-L1 (22C3)
  • Cellblock No. STQ2304637 (Taipei City Hospital ZhongXiao Branch)
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS >= 1 and <10
      
    • Combined Positive Score (CPS): 1
• 2023-08-04 Tc-99m MDP bone scan
  • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, elbows, wrists, hips and knees, compatible with benign joint lesions.
• 2023-08-04 SONO - breast
  • Diagnosis:
    • Bil. fibroadenomas as described
    • Left breast cancer
  • BI-RADS: 6. known biopsy-proven malignancy
• 2023-08-04 Mammography
  • Digital mammography of both breasts with MLO and CC views:
    • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
    • Focal asymmetry in subareolar region of left breast.
  • Impression:
    • Dense breast. Focal asymmetry in subareolar region of left breast.
      
  • BI-RADS: Category 6 - proven malignancy.

[MedRec]

• 2024-02-06, 2023-11-17, -08-25 SOAP Gastroenterology Zhan WeiYu
  • O: 2023/08/07 HBsAg (NM) = Positive;
  • A: HBV carrier under chemotherapy
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-12-03 ~ 2023-12-09 General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Left breast cancer, cT2N0M0, stage IIA. ER(-), PR(-), HER-2(1+), Ki-67:40%. ECOG:1.
    • Immune-Related Adverse Events with bilateral pneumonitis
  • CC
    • Dry cough with mild dyspnea at last night, SpO2 measured 70-80% at home.
  • Present illness
    • This 71-year-old female patient has past history of insomnia and hyperdislipidemia with regular medicine control at ZhongXiao Hospital. She is a HBV carrier. Her TOCC history was travel to Okinawa from 7/24 to 7/29.
    • Under the impression of left breast invasive carcinoma, chemotherapy with weekly Taxotere on 11/22. However, dry cough with mild dyspnea at last night, SpO2 measured 70-80% at home. Cough started 2-3 days ago.
    • She was came to our EF for help. In ER, vital sign BP:109/59mmhg; PR:131 bpm/min; BT:37.1’C; RR:24;
    • Con’s:E4V5M6, SPO2:94%.
    • Chest CTA reaveled ground-glass opacities with superimposed interlobular septal thickening of both lung fields, more severe at upper lobes, suspect ILD (caused by chemotherapy). Respiratory patten shallow and minimal of yellow sputum.
    • Under the impression of pneumonitis suspect ILD, she was admitted for further survey and management.
  • Course of inpatient treatment
    • After admission, Medason 40mg IVD Q12H and A+B INHL for ILD. (why “A+B” stands for Ipratran (ipratropium bromide) and Butanyl (terbutaline)?)
    • Cravit for pneumonia.
    • O2 N/C 3L support.
    • Under staable condition, she was discharged today, OPD will be arrange.
    • Chemotherapy change to weekly nab-Taxol + Carboplatin 450mg at next time.
  • Discharge prescription
    • Cravit (levofloxacin 500mg) 1.5# QDAC 7D
    • Trimbow (beclometasone 100ug, formoterol 5ug, glycopyrronium 12.5ug; per dose) 2 puff BID INHL
    • Methylone (methylprednisolone 4mg) 1# TID 2D 12/9-10
    • Methylone (methylprednisolone 4mg) 1# BID 2D 12/11-12
• 2023-08-14 ~ 2023-08-16 General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Left breast cancer, cT2N0M0, stage IIA status post port A insertion on 2023/08/15. ER(-), PR(-), HER-2(1+), Ki-67：40%. ECOG：0.
    • Encounter for antineoplastic chemotherapy
    • Hyperlipidemia
    • Other insomnia
    • Type 2 diabetes mellitus without complications
    • Chronic viral hepatitis B without delta-agent
  • CC
    • Palpable breast lump for 1 month
  • Present illness
    • This 71-year-old female patient has past history of insomnia and hyperdislipidemia with regular medicine control at ZhongXiao Hospital. She is a HBV carrier. She denied cancer history. Her TOCC history was travel to Okinawa from 7/24 to 7/29.
    • She noted a palpable mass at left breast for 1 month. A hard, nontender, movable mass with irregular margin at left breast around 5x5 cm without discharge. Her body weight was decreased from 51.5kg in January to 49kg in August. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, nor bowel habit change. physical exmaination showed symmetrical of bilateral breasts. There were no thickening or swelling of part of the breast, irritation or dimpling of breast skin, redness or flaky skin in the nipple area or the breast, pulling in of the nipple, nipple discharge other than breast milk or blood, or change in the size or the shape of the breast.
    • She came to local ObGyn OPD for help and was told a left irregular 2x3cm lesion by breast sonography. Therefore, she went to ZhongXiao Hospital for further management. Core needle biopsy was done on 2023/07/14 and breast cancer was proved by pathological report. Then, the patient came to Doctor Zhang’s out patient clinic for help. Mammography on 8/4 showed focal asymmetry in subareolar region of left breast with BI-RADS: Category6-proven malignancy. Breast sonography on 8/4 showed bilateral fibroadenomas as described and left breast cancer. Tc-99m MDP whole body bone scan on 8/4 showed no obvious lesion for metastasis. Breast MRI on 8/11 showed left breast subareolar and 10-11region tumors, r/o malignancy. CA-153：8.704 U/ml, CEA：2.088 ng/ml.
    • Under the impression of left breast invasive carcinoma, she was admitted for surgery of abdominal sonography, port-A insertion, and chemotherapy.        
  • Course of inpatient treatment
    • After admission, port A insertion was performed on 2023/08/15. 1st neo-adjuvant chemotherapy with Lipo dox + Endoxan + Keytruda were given. The wound is clean and dry. No discomfort after chemotherapy. Under the stable condition, she was discharged today, wound will be follow up on 8/23. And arrange next admission three weeks later.
  • Discharge prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Acetal (acetaminophen 500mg) 1# QID
    • Emend (aprepitant 125mg) 1# QD for 8/17, 8/18
    • Lemeson (dexamethasone 4mg) 1# BID for 8/17 ~ 8/19
    • loperamide 2mg 2# PRNQ8H if watery diarrhea > 2

[immunochemotherapy]

• 2024-02-29 - nab-paclitaxel 100mg 30min
  • diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-02-21 - nab-paclitaxel 100mg 30min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-02-15 - nab-paclitaxel 100mg 30min + carboplatin AUC 2 450mg NS 250mL 2hr
  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-01-31 - nab-paclitaxel 100mg 30min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-01-24 - nab-paclitaxel 100mg 30min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-01-17 - nab-paclitaxel 100mg 30min + carboplatin AUC 2 450mg NS 250mL 2hr
  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2024-01-03 - nab-paclitaxel 100mg 30min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-12-27 - nab-paclitaxel 100mg 30min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-12-20 - nab-paclitaxel 100mg 30min + carboplatin AUC 2 450mg NS 250mL 2hr
  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-11-22 - ……………………………… docetaxel 40mg/m2 58mg NS 150mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-11-15 - pembrolizumab 200mg NS 100mL 30min + docetaxel 40mg/m2 58mg NS 150mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-10-18 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 875mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W) Zhang YaoRen
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
• 2023-09-28 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W) Zhang YaoRen
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
• 2023-09-06 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W) Zhang YaoRen
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
• 2023-08-15 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W) Zhang YaoRen
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL

==========

2023-11-06

[leukopenia]

The patient received the Keytruda (pembrolizumab) with AC(Lipo) regimen on 2023-08-15, 2023-09-06, 2023-09-28, and 2023-10-18, with episodes of leukopenia noted in early Sep and early Oct.

• 2023-11-06 WBC 1.70 x10^3/uL **
• 2023-11-04 WBC 1.50 x10^3/uL **
• 2023-11-03 WBC 1.91 x10^3/uL **
• 2023-10-18 WBC 4.06 x10^3/uL
• 2023-09-28 WBC 4.50 x10^3/uL
• 2023-09-06 WBC 2.89 x10^3/uL *
• 2023-08-23 WBC 8.61 x10^3/uL
• 2023-08-09 WBC 9.17 x10^3/uL

The frequency of the immunochemotherapy was Q3W, and the second episode of leukopenia was more severe than the first. This may indicate that the patient’s recovery capacity is not keeping pace with the immunosuppressive effects of the medication.

Under the National Health Insurance drug reimbursement regulations, short-acting injectables G-CSF such as filgrastim and lenograstim can be used in non-hematologic malignancy patients post-chemotherapy if they have experienced white blood cell counts below 1000/cumm or absolute neutrophil counts (ANC) below 500/cumm. The patient’s lab values have not yet reached these thresholds. If there is a consideration of increased risk of infection, it may be advisable for the patient to use these medications at their own expense.

Compared to other options such as lowering the dose of chemotherapy or increasing the administration interval, the use of G-CSF appears to be a more effective approach in managing neutropenia caused by chemotherapy. Lowering the dose of chemotherapy may reduce the occurrence of neutropenic complications, but it can also compromise the effectiveness of the treatment (Lyman et al., 2005). Similarly, increasing the administration interval of chemotherapy may reduce the frequency of neutropenia, but it can also lead to delays in treatment and potentially compromise treatment outcomes (Okera et al., 2010). On the other hand, the use of G-CSF has been shown to effectively prevent and manage neutropenia, reducing the risk of febrile neutropenia, infections, and the need for dose reductions or delays in treatment (Ar, 2004; Crawford, 2003; Mizuno et al., 2017; Flores & Ershler, 2010).

• Ref:
  • Risk models for predicting chemotherapy-induced neutropenia. The Oncologist, 10(6), 427-437. https://doi.org/10.1634/theoncologist.10-6-427
  • A prospective study of chemotherapy-induced febrile neutropenia in the south west london cancer network. interpretation of study results in light of ncag/ncepod findings. British Journal of Cancer, 104(3), 407-412. https://doi.org/10.1038/sj.bjc.6606059
  • Pegfilgrastim: a recent advance in the prophylaxis of chemotherapy-induced neutropenia. European Journal of Cancer Care, 13(4), 371-379. https://doi.org/10.1111/j.1365-2354.2004.00503.x
  • Safety and efficacy of pegfilgrastim in patients receiving myelosuppressive chemotherapy. Pharmacotherapy, 23(8 Part 2), 15S-19S. https://doi.org/10.1592/phco.23.9.15s.32889
  • Efficacy of reduced dose of pegfilgrastim in japanese breast cancer patients receiving dose-dense doxorubicin and cyclophosphamide therapy. Japanese Journal of Clinical Oncology, 47(1), 12-17. https://doi.org/10.1093/jjco/hyw152
  • Managing neutropenia in older patients with cancer receiving chemotherapy in a community setting. Clinical Journal of Oncology Nursing, 14(1), 81-86. https://doi.org/10.1188/10.cjon.81-86

700022241

240227

[exam findings]

• 2024-02-26 CT - abdomen
  • History and indication: gastric cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Gastric cancer (low body and antrum) with adjacent liver, pancreas, hepatic artery, portal vein and SMV invasion. Some LNs around stomach. Some soft tissue in peritoneal cavity with ascites. S/P CBD stenting.
    • Patchy densities (up to 2.9cm) at RLL.
    • Liver and renal cysts (up to 2.8cm).
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Progression of gastric cancer (low body and antrum) with adjacent liver, pancreas, hepatic artery, portal vein and SMV invasion. Some LNs around stomach. Peritoneal carcinomatosis with ascites. S/P CBD stenting.
    • Patchy densities (up to 2.9cm) at RLL (stable).
• 2023-11-28 CT - abdomen
  • History and indication: Malignant neoplasm of stomach
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Gastric cancer (low body and antrum) with adjacent liver, pancreas, hepatic artery, portal vein and SMV invasion. Some LNs around stomach. Some soft tissue in peritoneal cavity. S/P CBD stenting.
    • Patchy densities (up to 2.9cm) at RLL.
    • Liver and renal cysts (up to 2.8cm).
    • Distention of gallbladder.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Gastric cancer (low body and antrum) with adjacent liver, pancreas, hepatic artery, portal vein and SMV invasion (stable). Some LNs around stomach. Some soft tissue in peritoneal cavity. S/P CBD stenting.
    • Patchy densities (up to 2.9cm) at RLL (stable).
• 2023-08-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (87.2 - 10.1) / 87.2 = 88.42%
    • M-mode (Teichholz) = 88.4-78.4
• 2023-08-23 CT - abdomen
  • Findings: Comparison prior CT dated 2023/05/29.
    • Prior CT identified lobulated circumferential irregular wall thickening at the gastric low body and antrum is noted again, stable in size that is c/w adenocarcinoma S/P C/T with stable disease.
      • Prior CT identified the stomach lesion direct invasion the liver and pancreas is noted again, stationary.
      • There is smudgy appearance of the omentum that may be metastases (tumor seeding).
    • S/P biliary stent implantation in between IHD and duodenum.
      • However, mild IHDs dilatation is still noted.
    • Prior CT identified three calcified masses in RLL of the lung are noted again, stationary. Old granulomas are highly suspected.
    • Prior CT identified bilateral renal cysts (up to 2.8cm) are noted again, stationary.
  • Impression:
    • Adenocarcinoma of the stomach S/P C/T show stable disease.
    • There is smudgy appearance of the omentum that may be metastases (tumor seeding).
• 2023-08-15 ECG 24hr
  • Baseline was sinus rhythm
  • A few isolated VPCs
  • Rare isolated APCs / burst APCs
  • No long pause
  • No significant tachyarrhythmia
• 2023-06-08 All-RAS + BRAF mutation
  • Cellblock No. S2023-10706
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-06-08 PD-L1 IHC
  • Cellblock No. S2023-10706
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS >= 1 and <10
    • Combined Positive Score (CPS): 1
• 2023-06-08 PD-L1 22C3
  • Cellblock No. S2023-10706
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS < 1
    • Combined Positive Score (CPS): 0
• 2023-06-08 PD-L1 SP142
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • S2023-10706
    • Tumor type: signet-ring cell carcinoma
    • Tumor location: stomach
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark XT
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: Pass,
      
    • Adequate tumor cells present (>=50 viable tumor cells): Yes
  • Result:
    • Tumor cell (TC) staining assessment: TC category: TC < 1%
    • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
  • Note:
    • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
    • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2023-06-02 CT - chest
  • Indication: gastric cancer favor lung metastasis
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lobulated calcified mass at right lower lobe measuring 2.8cm in largest dimension is found. Old insult is considered.
      • Small lymph nodes are found at paratracheal region.
    • Visible abdomen:
      • Huge mass lesion at gastric body measuring 11.6cm with liver invasion is found. Gastric cancer is considered. Some lymph nodes are found around the gastric body.
      • s/p biliary stent placement.
      • Dilated IHDs and CBD is found.
      • Mild pneumobilia is found.
  • Imp:
    • Huge gastric cancer with biliary tree obstruction s/p biliary stent placement.
    • Right lower lobe calcified mass. Old insult is considered.
• 2023-05-31 Patho - stomach biopsy
  • Stomach, antrum, biopsy — Signet-ring cell carcinoma
  • Section shows fragments of gastric tissue infiltrated by signet-ring cells.
  • The immunohistochemical stains reveal CK(+) and Her-2/neu (Ab): Negative (0).
• 2023-05-31 Endoscopic Retrograde Cholangiopancreatography, ERCP
  • Indication: Gastric cancer, obstructive jaundice, rule out metastic tumor with hepatic hilar compression
  • Symptoms: Jaundice
  • Premedication: Buscopan IV + Gascon po
  • Anesthesia: IV anesthesia
  • Findings
    • Duodenum
      • Since advanced gastric cancer involve gastric body and antrum had been known from previous study, upper GI endoscopic GIF-H260 was used before ERCP to exam the route from gastric body to 2nd portion. A huge ulcerative mass was noted from lower body to pyloric ring. Juxtapapillary diverticulum (type 2) was noted.
    • Common bile duct
      • Cholangiogram showed dilated proximal CBD measured 1.5 cm in max diameter. About 2.5 cm stricture was noted middle CBD
  • Management during examination
    • Unintended pancreatic duct guide wire cannulation happened on initial cannulation. After 45 minute trial to stanadard cannulation, needle knief precut fistulotomy (Boston) was applied followed by successful bile duct cannulation. About 10 ml yellowish bile was aspirated. ERBD (Boston, Advenix,8.5 Fr. 9 cm) was inserted with good bile drainage
  • Diagnosis
    • Middle common bile duct stricture, status post needle knife precut fistulotomy + ERBD
    • Non-visualized GB
    • Juxtapapillary diveritculum
    • Advanced gastric cancer, type IV, lower body to pylorus
  • Suggestion
    • NSAID (Voltaren 100mg supp) was used to post ERCP pancreatitis prevention
• 2023-05-30 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Gastric lesion, suspect gastric cancer, Borrmann type IV (infiltration type), s/p biopsy
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
  • Suggestion
    • Pursue pathology report
    • PPI use
• 2023-05-29 CT - abdomen
  • History and indication: favor a tumor in upper abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of stomach (low body and antrum) with adjacent liver, pancreas, CBD, hepatic artery, portal vein and SMV invasion causing biliary dilatation. Some LNs around stomach. Some soft tissue in peritoneal cavity.
    • Nodules (6.4mm, 7.2mm) at RLL.
    • Liver and renal cysts (up to 2.8cm).
    • Distention of gallbladder.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • In favor of gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases.
• 2023-05-29 CXR
  • Multiple nodules at bil. lower lung zones.
• 2023-05-27 SONO - abdomen
  • Diagnosis
    • favor a tumor in upper abdomen (origin to be determined: pancreas or stomach?)
    • suspected liver parenchymal disease
    • gallbladder distention, dilatation of CBD and bilateral IHD
    • gallbladder sludge, sludge in left IHD
    • bilateral renal cysts
  • Suggestion
    • 4 phase CT scan

[MedRec]

• 2024-01-16 SOAP Hemato-Oncology He JingLiang
  • Prescription x2
    • NS 10mL ST IVD
    • Hepac Lock Flush 100 USP units/mL 10mL ST IRRI
    • Xeloda (capecitabine 500mg) 2# BID
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Nexium (esomeprazole 40mg) 1# QDAC

[consultation]

• 2023-06-05 Hemato-Oncology
  • Q
    • for management of gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases.
    • This 67-year-old male denied systemic disease in the past.
    • This time, due to favor gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases. He was admitted to our GI ward for management and further survey
      • Abdominal CT:gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases.
      • upper GI endoscopy was performed that showed Gastric lesion, suspect gastric cancer, Borrmann type IV(infiltration type), s/p biopsy. NGS was also done *
    • ERCP was also done revealed Middle common bile duct stricture, status post needle knife precut fistulotomy + ERBD; Non-visualized GB; Juxtapapillary diveritculum and Advanced gastric cancer, type IV, lower body to pylorus.
    • AFP: 3.3 ng/mL; CA199: 3.37 U/mL; CEA: 149.83 ng/mL      
      
    • Now, we pending pathology and need your further survey.
    • Thanks a lot!
  • A
    • Dear doctor: This 67 year old is a case of suspect gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases, pending gastric lesion biopsy result.
    • Please check HBsAg, Anti HBc, Anti HBs, Anti HCV and arrange chest CT (+/- contrast). Check HER2 and PD-L1 testing if metastatic adenocarcinoma is documented/suspected. Testing for MSI by PCR/nextgeneration sequencing (NGS) or MMR by IHC. Arrange port A insertion. We will take over this case if you agree. Thanks for your consultation.
  • A1 2023/06/02 10:42
    • The patient lives in Banqiao. He is a CiCheng member. He has a wife and a daughter. His niece is a nurse at Cathay General Hospital.
    • Initial presentation: palpable upper abdominal mass, abdominal fullness, body weight loss 3kg in one month, bilirubin noted
    • ERCP show middle common bile duct stricture, tumor compression related s/p status post needle knife precut fistulotomy + ERBD

[chemotherapy]

• 2023-11-14 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-10-31 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-10-11 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-09-26 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-09-12 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-29 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-15 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-02 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-18 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-04 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-20 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-08 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-02-27

[Xeloda (capecitabine) tube feeding]

Steps to dissolve the Xeloda tablets (Ref: https://www.enherts-tr.nhs.uk/wp-content/uploads/2019/10/Capecitabine-v1-final.pdf)

• Fill a cup with approximately 200ml of warm (not hot) water. Ensure that this cup, as well as the spoon, are not used by anyone else or for anything else.
• The exact number of capecitabine tablets needed should be popped out from the blister and added to the water.
• Allow the tablets to dissolve in the water and use the spoon to mix the solution periodically. This process takes around 15 minutes.
• Once the tablets have completely dissolved, you may add raspberry squash or other strong flavouring (not fruit juice) to disguise the bitter taste.
• The whole contents of the cup must be drunk immediately. It is advisable to rinse the cup with water and drink this to ensure the entire contents are ingested.

Important - Capecitabine tablets should never be crushed - this creates a dangerous dust.

Protection - The person preparing the solution should wear non-sterile gloves and a non-sterile plastic apron (supplied by the hospital).

Capecitabine can be slowly but completely dissolved. It can be used with a gastric or jejunal feeding tube. (Ref: Developing guidance for feeding tube administration of oral medications. JPEN J Parenter Enteral Nutr. 2023 May;47(4):519-540. doi: 10.1002/jpen.2490)

2023-06-09

• Trastuzumab is recommended to be included in the first-line chemotherapy for advanced gastric adenocarcinoma with HER2 overexpression. The National Health Insurance (NHI) covers the use of trastuzumab (specifically the IV formulation) in metastatic gastric cancer when used in conjunction with capecitabine (or 5-fluorouracil) and cisplatin for the treatment of HER2 overexpressing (IHC3+ or FISH+) metastatic gastric adenocarcinoma that hasn’t been previously treated with chemotherapy.
• However, the patient’s stomach biopsy pathology dated 2023-05-31 showed negative results for Her-2/neu(Ab)(0). Therefore, this patient does not meet the criteria for the use of trastuzumab covered by NHI.
• The patient has begun his initial dose of the FOLFOX regimen today, without a bolus of 5-FU and with a reduced dosage of oxaliplatin. As of the current moment, there have been no complaints of adverse reactions. The patient’s TPR readings are stable, and there are no concerns with the currently active prescription.

2023-06-08

[patient education]

After attending a family meeting with the patient’s relatives at 11:00 this morning, I visited the patient at 12:30. At that time, the patient and his wife had left the bed to walk nearby, only the patient’s daughter was present. I told the patient’s daughter that if immunotherapy is to be used, it is better to use it sooner rather than later. The patient’s daughter also asked about the possible prognosis of the disease and the possible side effects of the drugs. I elaborated based on the content of this morning’s family meeting. The patient’s daughter indicated that she will decide whether to use immunotherapy in the near future.

700877253

240227

[exam findings]

• 2023-12-02 CT - abdomen
  • Indication: High-grade B-cell lymphoma, stage IV, over left pelvis, extending to L5 level and compression of nerve root of left sacrum, swelling and paralysis of left lower limb; osteolytic lesion over left sacrum and SI joint, ECOG 2.
  • Abdominal CT with and without enhancement revealed:
    • Thickening of pyriformis muscle is found. Recurrent/residual lymphoma is compatible. In comparison with CT dated on 2023-08-25, the lesion regressed.
    • Tiny GB polyp measuring 0.3cm is found. There is no evidence of paraarotic LAPs.
  • Imp:
    • Recurrent/residual left pyriformis muscle soft tissue mass. Residual lymphoma is compatible. Suggest further treatment.
• 2023-10-24 MRI - pelvis
  • History and indication: High-grade B-cell lymphoma
  • With and without contrast MRI of pelvis revealed:
    • Mild regression of left pelvic lymphom with adjcent structures invasion and central necrosis.
    • No ascites. Small lymph nodes at retroperitoneum.
    • Mild left hydronephrosis.
  • IMP:
    • Mild regression of left pelvic lymphom with adjcent structures invasion and central necrosis.
• 2023-10-13 Motor Nerve Conduction Velocity (MNCV) & Sensory Nerve Conduction Velocity (SNCV)
  • Lower limb MNCV study:
    • Absence of signal in Lt peroneal nerve & Lt tibial nerve.
    • Normal distal latency, Normal CMAP amplitude & Normal MNCV in Rt peroneal nerve & Rt tibial nerve.
  • SNCV study:
    • Absence of signal in Lt sural nerve.
    • Prolonged distal latency, Normal SNAP amplitude & Normal SNCV in Rt sural nerve.
  • F wave study:
    • Prolonged F wave-latency in Rt peroneal nerve & Rt tibial nerve.
    • Absence of signal in Lt peroneal nerve & Lt tibial nerve.
  • H reflex study:
    • Normal H reflex latency in Rt tibial nerve.
    • Absence of signal in Lt tibial nerve.
  • These findings suggest
    • Absence of signal in left peroneal, tibial & sural nerve, in favor of left Lumbosacral plexopathy
    • Lumbosacral radiculopathy, right side.
    • Advise clinical correlation.
• 2023-08-25 CTA - abdomen
  • CC: left lower leg pain since 8/8 23
    • Sudden onset of Lt lower leg pain & unable to walk, she went to FuJen Catholic University Hospital ER 20230809 CT: soft tissue mass in left pelvic side wall with total encasement of left common and internal iliac artery and vein.
    • Explorative laparoscopic surgery pathology: high-grade B-cell lymphoma.
  • Findings - Comparison: prior CT from FuJen Catholic University Hospital dated 2023/08/09.
    • Prior CT identified lobulated soft tissue masses in left side pelvis with total encasement of left common, internal, and external iliac artery and vein is noted again, mild increasing in size that is c/w malignant lymphoma.
      • In addition, there is filling defects at left common iliac vein, left external iliac vein, and left superficial femoral vein that are c/w thrombosis.
    • There is mild left side hydroureteronephrosis that is c/w malignant lymphoma with left M3 ureter encasement.
    • There are enlarged nodes in para-aortic space and para-cava space that are c/w malignant lymphoma.
    • There is mild ascites and smudgy appearance of the omentum.
      • Please correlate with ascites cytology.
    • The urinary bladder shows mild right lateral deviation and S/P Foley’s catheter insertion.
    • The gallbladder shows distension and a linear calcification (1 cm in length) within the wall.
    • There is small amount right side Pleura effusion.
  • Impression:
    • Malignant lymphoma in left side pelvis.
    • There is mild left side hydroureteronephrosis that is c/w malignant lymphoma with left M3 ureter encasement.
    • There are enlarged nodes in para-aortic space and para-cava space that are c/w malignant lymphoma.
    • There is mild ascites and smudgy appearance of the omentum. Please correlate with ascites cytology.
• 2023-08-24 CXR (erect)
  • Hypo-inflation of both lung is noted.
  • Atherosclerotic change of aortic arch
• 2023-08-24 ECG
  • Sinus tachycardia
  • Nonspecific ST and T wave abnormality
• 2023-08-24 CXR (erect)
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
• 2023-08-24 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (70 - 27) / 70 = 61.43%
    • M-mode (Teichholz) = 61
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Mild MR, trivial TR
    • Preserved RV systolic function
• 2023-08-22 PET scan
  • A large glucose hypermetabolic lesion in the pelvic cavity with extension to the sacrum and the soft tissue of left upper thigh, compatible with lymphoma.
  • Glucose hypermetabolism in some paraaortic and common iliac lymph nodes, in a focal area in the right anterior upper abdominal cavity and in the T9 spine. Lymphoma should be considered first.
  • Mild glucose hypermetabolism in the right anterior pelvic wall. The nature is to be determined (inflammatory process? lymphoma? other nature?). Please correlate with other clinical findings for further evaluation.
• 2023-08-21 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 2.3 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
  • Section shows piece(s) of bone marrow with 45% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.

[MedRec]

• 2023-10-21 SOAP Neurology Zou ChuYin
  • S: CC: tingling senssation and numbness for 3 weeks
  • O: NCV:
    • Absence of signal in left peroneal, tibial & sural nerve, in favor of left Lumbosacral plexopathy
    • lumbosacral radiculopathy, right side.
• 2023-10-14 SOAP Dermatology Wang ChunHua
  • S
    • dyskeratotic nails on bil feet and hands for yrs, scaling(+), itching(+), local painful(+)
    • Erythematous patches on trunk and inguinal area for yrs, ringwarm(+)
    • T unguin was Dx and Tx at LMD for yrs, poor response to topical drugs
    • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching
  • Prescription
    • Asthan (ketotifen 1mg) 1# BID
    • Zalain Cream (sertaconazole nitrate) BID TOPI
• 2023-10-06 ~ 2023-10-14 POMR Hemato-Oncology He JingLiang
  • Course of inpatient treatment
    • After be admitted, she received C1 R-DA-EPOCH Q3W on 2023/10/06-10/10, Imperan for vomiting, Vemlidy for Anti-HBc: positive, the lab of GPT level elevation (GPT: 54 U/L), so gave Bao-gan treatment.
    • She suffered from fever without chillness (BT: 38’C), CRP level elevation (CRP: 9.1 mg/dl) before chemotherapy, so inform to the visiting staff about the patient’s condition, CRP level elevation, and fever noted, then the visiting staff expressed tumor fever high likely, so the chemotherapy kept going.
    • Followed-up urine routine not urinary tract infection signs. After chemotherapy, she denied having a fever, chillness, vomiting, or diarrhea. Consulted Chinese Medicine for Comprehensive protocol of integrated Chinese and western medicine. She suffered from hoarseness, and left foot walk lamely noted, so eduation to drink more water, and consulted Rehabilitation Department for rehabilitation, Neurology for Neurological physical examination, followed-up MNCV (lower limbs), SNCV, F wave, H reflex was done on 2023/10/13, the report pending.
    • The symptom of hoarseness improved. The lab of BSC showed poor liver function (ALT: 67U/L), so gave Bao-gan treatment. After treatment, the symptom of poor liver function improved (ALT: 67 -> 48U/L).
    • She suffered from pustules around anus, so gave Excelderm plus Mycomb using.
    • The GCSF 250mcg will given for 3 days (2023/10/14-10/16) due to prevention leukocytopenia.
    • Under the stable stable, she can be discharged on 2023/10/14, the OPD follow-up will be arranged.
  • Discharge prescription
    • Exelderm Cream (sulconazole nitrate) BID EXT
    • Mycomb Cream (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
    • Ulstop (famotidine 20mg) 1# BID
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Through (sennoside 12mg) 2# HS
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
    • diphenidol 25mg 1# TID
    • Eurodin (estazolam 2mg) 1# HS
    • BaoGan (silymarin 150mg) 1# TID
• 2023-08-19 ~ 2023-09-22 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • High-grade B-cell lymphoma over left pelvis, extending to L5 level and compression of nerve root of left sacrum, swelling and paralysis of left lower limb; osteolytic lesion over left sacrum and SI joint, ECOG 2.
    • Other bacterial infections of unspecified site
    • Tinea corporis
    • port-a catheter insertion at left subclavicular on 2023/8/24.
    • hypokalemia
    • hypomagnesemia
    • Port-a insertion at left superior vena cava on 2023/8/24
  • CC
    • left lower leg pain since 2023-08-08
  • Present illness
    • This is a 65 years old female patient, denied any systemic disease.
    • Beacuse of sudden onset of left lower leg pain and unable to walk, she went to see FuRen Univ Hospital ER and suspected of abdominal abscess and she was admitted.
    • 2023/08/18 lab data at FuRen U Hospital: WBC 11.25k, Hb: 9.6, Plt: 324k, ALT: 22, Bil: 0.49, LDH: 607, Cr: 0.8, Na: 133, K: 3.6, Ca: 8.2, CRP 16
    • Patho S2310863 (at FuRen U Hospital)
      • DIAGNOSIS
        • Soft tissue, pelvis, left side, explorative laparoscopic surgery, high-grade B-cell lymphoma
      • MACROSCOPY
        • Specimen size: 5 fragments, up to 1.4 x 1 x 0.6 cm
        • Specimen features: brown and soft All for section.
        • Jar 0 Immunostain for CD3, CD20, Ki-67, CD10, BCL6, Mum1, BCL2, c-Myc, CD5, CD30, cyclin D1, TdT are performed.
      • MICROSCOPY
        • Sections show fibroadipose tissue diffusely infiltrated by abnormal lymphoid cells. There is prominent and extensive crush artifact. In the areas where cellular morphology are better preserved, the abnormal cells are found to be medium to large sized, moderately pleomorphic, with fine to vesicular chromatin and one to three nucleoli.
        • The tumor cells are positive for CD20 while negative for CD3, and Ki-67 labeling index is 95%. It is consistent with high-grade B-cell lymphoma.
        • The tumor cells are positive for CD10, while a few cells are positive for BCL6 or Mum1. It is consistent with germinal center phenotype.
        • The tumor cells are positive for BCL2, and 90% of the tumor cells are positive for c-Myc. Considering the high grade feature, germinal center phenotype, high Ki-67 and c-Myc labeling, some Burkitt-like features are present; however, the cells are not typical blastoid in morphology, and they are BCL2 positive, favoring DLBCL. A high-grade B-cell lymphoma with MYC and BCL2 rearrangements cannot be excluded.
        • FISH analysis for BCL2, BCL6 and MYC are performed, and the result will be sissued in an addendum.
        • The tumor cells are negative for CD5, CD30, cyclin D1 and TdT.
    • She had intermittent low grade fever during admission there. Because of difficult urination, foley was indwelled at that time. She denied abdominal pain, nausea, vomiting nor changes in stool color. She had loss of appetite but currently no weight loss. She also had a habit of constipation and need to use laxative.
    • After doing laparoscopic exploration, B-cell lymphoma was diagnosed at the pathology report. So, she was transferred to our hospital. She denied At our ER, vital signs showed BP 178/98 mmHg; HR 125 bpm; BT 37.5’C; RR 20 bpm; Con’s: E4V5M6, SPO2 96%, antibiotic treatment with Brosym.
    • Under the impression of B-cell lymphoma. she was admitted to our ward for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, Brosym was administered as prophylaxis due to high CRP level. Then, check blood tests and imaging tests including Cardiac echo and PET scan.
    • PET (2023/08/22) revealed
      • A large glucose hypermetabolic lesion in the pelvic cavity with extension to the sacrum and the soft tissue of left upper thigh, compatible with lymphoma.
      • Glucose hypermetabolism in some paraaortic and common iliac lymph nodes, in a focal area in the right anterior upper abdominal cavity and in the T9 spine. Lymphoma should be considered first.
      • Mild glucose hypermetabolism in the right anterior pelvic wall. The nature is to be determined (inflammatory process? lymphoma? other nature?).
      • Please correlate with other clinical findings for further evaluation.
    • Heart echo (2023/08/24): LVEF(%): 61%.
      • Adequate LV systolic function with normal resting wall motion.
      • Mild MR, trivial TR.
      • Preserved RV systolic function.
    • Then, palliative radiotherapy to left pelvic mass, left sacrum and SI joint for 2500cGy/10 fx was started 2023-08-23 for pain and symptom control. CT simulation is arranged on Aug 21 13:30. Possible side effect is told.
    • Self-paid Calcium carbonate 1# TID, self-paid Febuxostat 1# QD, Calgon 1 vial stat and supplement hydration NS 1# QD to 1# BID were given for prophylactic tumor lysis syndrome.
    • Record lower legs circumference daily.
    • Vemlidy 1# QD was added due to anti-HBc reactive.
    • Port-A installation was done on 2023-08-24.
    • Then, Chemotherapy R-CEOP regimen was started on 2023-08-25.
    • After first cylce, a sudden onset of abdominal pain, chills during mabthera infusion occurred.
    • The emergent CT abdomen revealed malignant lymphoma in left side pelvis.
      • There is mild left side hydroureteronephrosis that is c/w malignant lymphoma with left M3 ureter encasement.
      • There are enlarged nodes in para-aortic space and para-cava space that are c/w malignant lymphoma.
      • There is mild ascites and smudgy appearance of the omentum.
    • Therefore, acute infusion reaction ws noted. The mabthera infusion was stopped. The chemotherapy was still ongoing.
    • Due to elevation of D-dimer, we added Lixiana (edoxaban) 1# QD on 2023/08/26-08/31.
    • Febuxostat was discontiuned on 2023-08-28 after urine acid dropped.
    • Bed-side PT rehabilitation was consulted.
    • The lab of CBC/DC showed neutropenia, and anemia (WBC: 450/uL, band: 2.4%, neutrophil: 28.1%, ANC: 137.25, Hb:8.6mg/dL), so gave blood transfusion with LPRBC, Granocyte 250mcg SC QD x3 days (9/5-9/7 23), Cefim 2000 mg IVD Q8H for prevention infection, and protective isolation.
    • The complaints abdomen bloating, so the radiotherapy (2500cGy, 8/10 fx) was stopped due to severe gastrointestinal discomfort, and neutropenia on 2023/09/05.
    • The lab of eletrolecty showed imblance (K: 3.1mmol/L, Mg: 1.8mg/dL), so gave 0.298% KCL in N/S 500ml QD, Const-K 1# QD. MgO 1# TID. Education diet with orange juice, banana.
    • She complaints dry cough, gave Z-cough plus Cough Mixture 5ml PRNQ8H.
    • After treatment, the symptom of neutropenia, and anemia improved (BC: 450 -> 4600/uL, band: 2.4 -> 4.2%, neutrophil: 28.1 -> 48.90%, ANC: 137.25 -> 2442, Hb:8.6 -> 9.9mg/dL), and the gastrointestinal discomfort became better.
    • She received C2 R-CHOP on 2023/09/12, and gave GCSF 250mcg x3 days (9/14-9/16 23).
    • When the GCSF 250mcg was given once, the lab of WBC level up to 41140/uL (9/15 23), so stopped to give GCSF.
    • And she complaints dry cough, so gave antitussives treatment. After treatment, the symptom of dry cough improved.
    • Then, re followed-up the lab of WBC level drop to 1530/uL (9/20 23), so gave GCSF 250mcg x3 days on 2023/9/20-9/22.
    • Now, the lab of WBC level up to 2110/uL (9/22 23), and complaints shortness of breathing when she is walking hard, but take a rest, the respiratory pattern become smooth, followed-up chest x-ray not pneumonia, not pleural effusion.
    • The patient, family request to discharge. Under the condition become smooth, she can be discharged on 2023/09/22, the OPD follow-up will be arranged.
  • Discharge prescription
    • Cardiolol (propranolol 10mg) 0.5# QD
    • Cough Mixture (platycodon) 5mL PRNQ8H
    • diphenidol 25mg 1# TID
    • Eurodin (estazolam 2mg) 1# PRNHS
    • Gaslan (dimethylpolysiloxane 40mg) 2# TID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
    • Lactul (lactulose 666mg/mL) 10mL QD
    • Through (sennoside 12mg) 2# HS
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Norvasc (amlodipine 5mg) 1# QN
    • Ulstop (famotidine 20mg) 1# BID
• 2023-08-18 SOAP Medical Emergency Wu MengYu
  • S: 8/18 lab data at FuRen Uni Hosp: WBC 11.25k, Hb: 9.6, Plt: 324k, ALT: 22, Bil: 0.49, LDH: 607, Cr: 0.8, Na: 133, K: 3.6, Ca: 8.2, CRP 16
    • Pathology S2310863
      • DIAGNOSIS
        • Soft tissue, pelvis, left side, explorative laparoscopic surgery, high-grade B-cell lymphoma
      • MACROSCOPY
        • Specimen size: 5 fragments, up to 1.4 x 1 x 0.6 cm
        • Specimen features: brown and soft All for section.
        • Jar 0 Immunostain for CD3, CD20, Ki-67, CD10, BCL6, Mum1, BCL2, c-Myc, CD5, CD30, cyclin D1, TdT are performed.
      • MICROSCOPY
        • Sections show fibroadipose tissue diffusely infiltrated by abnormal lymphoid cells. There is prominent and extensive crush artifact. In the areas where cellular morphology are better preserved, the abnormal cells are found to be medium to large sized, moderately pleomorphic, with fine to vesicular chromatin and one to three nucleoli.
        • The tumor cells are positive for CD20 while negative for CD3, and Ki-67 labeling index is 95%. It is consistent with high-grade B-cell lymphoma.
        • The tumor cells are positive for CD10, while a few cells are positive for BCL6 or Mum1. It is consistent with germinal center phenotype.
        • The tumor cells are positive for BCL2, and 90% of the tumor cells are positive for c-Myc. Considering the high grade feature, germinal center phenotype, high Ki-67 and c-Myc labeling, some Burkitt-like features are present; however, the cells are not typical blastoid in morphology, and they are BCL2 positive, favoring DLBCL. A high-grade B-cell lymphoma with MYC and BCL2 rearrangements cannot be excluded.
        • FISH analysis for BCL2, BCL6 and MYC are performed, and the result will be sissued in an addendum.
        • The tumor cells are negative for CD5, CD30, cyclin D1 and TdT.
  • A: Preliminary Impression: C85.10 Unspecified B-cell lymphoma, unspecified site

[consultation]

• 2023-10-12 Neurology
  • Q
    • for Neurological physical examination
    • This is a 65 years old female patient with diagnosis of high grade B lymphoma, s/p chemotherapy, radiotherapy. Due to tumor on pelvis, so her left leg swelling, and muscle power: RL/LL 5/4+, she can walk with walker. But left foot walk lamely. Therefore, please kindly refer this patient for Neurological physical examination.
  • A
    • left leg weakness since 2023/08/08, partially improved
      • Muscle power of left leg: proximal:3, distal:0
      • DTR: (-)
    • Plan:
      • arrange MNCV (lower limb), SNCV, F wave, H reflex
• 2023-09-01 Dermatology
  • Q
    • for skin impetigo over left knee & buttock
    • This 65-year-old woman, a patient of large B cell lymphoma S/P C/T. She complained of skin impetigo over left knee & buttock for days. We need expertise to evaluate her condition thanks !
  • A
    • This patient suffered from multiple erytehamtous papules on buttock and limbs for days.
    • Imp:
      • Tinea corporis
    • Suggestion:
      • Excelderm x 1 tubes/bid
      • Mycomb x 2 tubes/bid

[immunochemotherapy]

• 2024-02-27 - rituximab 375mg/m2 550mg NS 500mL 8hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincrestine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mb BID PO D1-5 (R-da-EPOCH Q3W)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1,4 + palonosetron 250ug D1,4 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1,4
• 2024-01-24 - rituximab 375mg/m2 550mg NS 500mL 8hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincrestine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mb BID PO D1-5 (R-da-EPOCH Q3W)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1,4 + palonosetron 250ug D1,4 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1,4
• 2023-12-26 - rituximab 375mg/m2 550mg NS 500mL 8hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincristine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mb BID PO D1-5 (R-da-EPOCH Q3W)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1,4 + palonosetron 250ug D1,4 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1
• 2023-11-27 - rituximab 375mg/m2 550mg NS 500mL 8hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincristine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mb BID PO D1-5 (R-da-EPOCH Q3W)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1,4 + palonosetron 250ug D1,4 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1
• 2023-11-02 - rituximab 375mg/m2 540mg NS 500mL 6hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincristine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mg BID PO D1-5 (R-da-EPOCH Q3W)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1,4,5 + palonosetron 250ug D1,4,5 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1,5
• 2023-10-06 - rituximab 375mg/m2 540mg NS 500mL 6hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincristine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mg BID PO D1-5 (R-da-EPOCH Q3W)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1-5 + palonosetron 250ug D1-5 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1,5
• 2023-09-12 - rituximab 375mg/m2 530mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + epirubicin 60mg/m2 80mg NS 100mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (RCHOP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL
• 2023-08-24 - rituximab 375mg/m2 530mg NS 500mL 8hr + cyclophosphamide 750mg/m2 900mg NS 250mL 30min + epirubicin 60mg/m2 70mg NS 100mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (RCHOP Q3W, Endoxan and Epicin 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL

dose-adjusted (da)-R-EPOCH - Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma - 2024-01-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F88411

• Cycle length:
  • 21 days.
• Regimen
  • Rituximab
    • 375 mg/m2 IV
    • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. In the absence of an initial infusion reaction, for subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count ≥5000/microL.
    • Day 0 or 1
  • Etoposide
    • 50 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Doxorubicin
    • 10 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Vincristine
    • 0.4 mg/m2 per day IV (dose not capped)
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Cyclophosphamide
    • 750 mg/m2 IV
    • Dilute with 250 mL NS or D5W and administer over 30 minutes.
    • Day 5
  • Prednisone
    • 60 mg/m2 orally twice daily
    • Administer first dose 30 minutes prior to chemotherapy on day 1.
    • Days 1 to 5
  • Granulocyte colony stimulating factor (G-CSF)
    • Start day 6

==========

2024-02-27

[anemia]

Lab results obtained on 2024-02-26 were unremarkable except for a stool occult blood test 1+ and anemia (HGB 7.7 g/dL). The anemia was subsequently addressed with a LPRBC transfusion.

No lab findings were identified that would preclude administration of the R-da-EPOCH regimen.

2024-01-25

[monitoring iron levels in this frequent transfusion patient]

The laboratory results suggest a consistent pattern of microcytosis/microcytic anemia. This patient has been receiving multiple blood transfusions approximately monthly since Sep 2023. Given this history, it is advisable to assess iron storage to evaluate for potential iron overload if clinically necessary.

• 2024-01-24 RBC 3.67 x10^6/uL
  
• 2024-01-24 HGB 8.8 g/dL
  
• 2024-01-24 HCT 28.1 %
  
• 2024-01-24 MCV 76.6 fL

2023-12-27

[reconciliation]

Lab results obtained on 2023-12-26 revealed no significant abnormalities that would contraindicate the continuation of the R-da-EPOCH regimen. Additionally, comprehensive medication reviews using HIS5 and PharmaCloud identified no discrepancies in the current medication list.

2023-11-28

[prophylactic G-CSF for post-chemotherapy leukopenia]

The patient was admitted to begin the 3rd cycle of R-da-EPOCH chemotherapy on 2023-11-27. Based on the experiences from cycles 1 and 2 of this regimen, leukopenia may occur following this administration. Prophylactic G-CSF can be prescribed for standby use.

• 2023-11-27 WBC 4.93 x10^3/uL
• 2023-11-15 WBC 0.46 x10^3/uL ** R-da-EPOCH C2 on 11/02
• 2023-11-09 WBC 3.51 x10^3/uL
• 2023-11-02 WBC 6.38 x10^3/uL
• 2023-10-24 WBC 8.79 x10^3/uL
• 2023-10-17 WBC 0.83 x10^3/uL ** R-da-EPOCH C1 on 10/06
• 2023-10-13 WBC 6.96 x10^3/uL
• 2023-10-11 WBC 4.58 x10^3/uL

2023-10-09

There are no medication reconciliation issues after review of PhamaCloud and HIS5 records.

The patient has received two cycles of R-CHOP treatment and has then transitioned to DA-R-EPOCH treatment as of 2023-10-06. It is believed that the new treatment, R-DA-EPOCH, is more effective but also carries a higher risk of toxicity. As the patient has recently started this new regimen, please closely monitor for any signs of adverse reactions. Ref: DA-R-EPOCH vs R-CHOP in DLBCL: How do we choose? Clin Adv Hematol Oncol. 2021 Nov;19(11):698-709. PMID: 34807015; PMCID: PMC9036549.

2023-09-12

An episode of leukopenia was observed on 2023-09-05, approximately two weeks after the patient’s initial R-CHOP regimen administered on 2023-08-24. Prompt intervention with a consecutive 3-day course of G-CSF was initiated, and since then, no further instances of leukopenia have been detected.

• 2023-09-11 WBC 6.10 x10^3/uL
• 2023-09-08 WBC 4.60 x10^3/uL
• 2023-09-05 WBC 0.45 x10^3/uL * Granocyte (lenograstim 250ug) x 3 days
• 2023-09-01 WBC 4.23 x10^3/uL
• 2023-08-28 WBC 4.91 x10^3/uL
• 2023-08-25 WBC 15.59 x10^3/uL
• 2023-08-24 WBC 15.94 x10^3/uL
• 2023-08-21 WBC 20.57 x10^3/uL

701025993

240227

[lab data]

2023-12-06 P.jiroveci DNA-Sp Positive
2023-12-04 CMV viral load assay Target not detecetedIU/mL
2023-11-30 Aspergillus Ag Negative
2023-11-30 Aspergillus Ag Value 0.1 Ratio
2023-11-29 ANA Negative
2023-11-29 Mycoplasma pneumonia IgG Negative AU/mL
2023-11-29 Mycoplasma IgG Valu <10 AU/ml
2023-11-28 Anti-ds DNA Antibody <0.6 IU/ml
2023-11-28 Anti-ENA SS-A (Ro) <0.4 EliA U/ml
2023-11-28 Anti-ENA SS-B (La) <0.3 EliA U/ml
2023-11-28 Anti Jo-1 antibody <0.3 EliA U/ml
2023-11-28 Anti-ENA Scl-70 Ab <0.6 EliA U/ml
2023-11-28 Anti-ENA Sm <0.8 EliA U/ml
2023-11-28 Anti-ENA RNP <0.5 EliA U/ml
2023-11-28 Cryptococcus Ag Negative
2023-11-28 RF <10 IU/mL
2023-11-26 COVID19 fast screen Negative
2023-11-26 Influenza A Ag Negative
2023-11-26 Influenza B Ag Negative

2023-08-08 Anti-HCV (NM) Negative
2023-08-08 Anti-HCV Value (NM) 0.042
2023-08-08 Anti-HBc (NM) Negative
2023-08-08 Anti-HBc Value (NM) 2.360
2023-08-08 Anti-HBs (NM) Positive
2023-08-08 Anti-HBs value (NM) 210.000 mIU/mL
2023-08-08 HBsAg (NM) Negative
2023-08-08 HBsAg Value (NM) 0.432

[exam findings]

• 2024-02-19 Bone densitometry - spine
  • L-spines BMD performed by DXA revealed:
    • AP L-spines, BMD of L1-4 is 0.900 gms/cm2, about 1.1 SD below the peak bone mass (88%) and 0.3 SD below the mean of age-matched people (95%).
  • Impression:
    • Osteopenia
• 2024-01-22 Bone densitometry - spine
  • L-spines BMD (AP view) performed by DXA revealed:
    • AP L-spines, BMD of L1-4 0.880 gms/cm2, about 1.3 SD below the peak bone mass (86%) and 0.5 SD below the mean of age-matched people (93%).
  • IMP: osteopenia
• 2024-01-16 Gynecologic Ultrasonography
  • IMP: Uterine myoma
• 2024-01-03 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 19) / 80 = 76.25%
    • M-mode (Teichholz) = 77
  • Conclusion:
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
• 2023-12-14 CXR + Lat Rt
  • Scoliotic alignment of the thoracolumbar spine is noted.
• 2023-12-12 CT - chest
  • Indication
    • Lt breast ca s/p partial mastectomy + ALND on 2023-07-28
    • adjuvant C/T with E(lipodox)C ->T, since 2023-08-16
  • Findings: comparison prior CT on 2023/11/26
    • lungs: normal appearance of both lungs.
    • Mediastinum and hila: no enlarged LNs or mass.
      
    • Thoracic aorta: normal caliber,Central pulmonary arteries: normal caliber.
    • Heart: normal size of cardiac chambers. well myocardial enhancement.
    • Pleura: no effusion.
    • Chest wall and visible lower neck: no abnormal enhancing lesion in the breasts. no enlarged LN.
    • Visible abdominal contents: unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
    • no enlarged lymph node. no ascites.
    • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • no abnormality of both lungs in this F/U CT.
• 2023-12-02, -11-29, -11-26 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2023-11-29 Bronchodilator Test
  • Mild restrictive ventilatory impairment
  • without significant bronchodilator response
  • please correlated with clinical condition
• 2023-11-27 CT - chest
  • Indication: left breast cancer s/p chemotherapyr/o ILD
  • Findings
    • lungs: extensive, upper lung predominant, extensive ground glass opacity and consolidation, in both lungs, assoicated septal thickening.
    • Mediastinum and hila: a few slighlty enlarged LNs in the visceral space.
    • Thoracic aorta: normal caliber,Central pulmonary arteries: normal caliber.
    • Heart: normal size of cardiac chambers. well myocardial enhancement.
    • Pleura: trace Rt-sided effusion.
    • Chest wall and visible lower neck: abnormal enhancing lesion in the breasts
    • unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
    • arginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • Lung parenchymal and interstial proces, drug-related toxicity r/o infection.
• 2023-11-26 ECG
  • Sinus tachycardia
  • Possible Left atrial enlargement
• 2023-10-16 Patho - endometrium curretage/biopsy
  • Uterus, endometrium, D&C — endometrial hyperplasia,without atypia
• 2023-10-05 ECG
  • Normal sinus rhythm
  • Increased R/S ratio in V1, consider early transition or posterior infarct
  • Abnormal ECG
• 2023-09-27, -09-02 Gynecologic Ultrasonography
  • IMP: Uterine myoma
• 2023-07-28 Patho - breast mastectomy with regional lymph nodes
  • PATHOLOGIC DIAGNOSIS
    • Tumor, left breast, frozen + partial mastectomy —- Invasive carcinoma of no special type, multifocal
      • Resection margins, ditto — Free of tumor invasion
    • Sentinel lymph node, L’t axilla, frozen — Tumor metastasis (1/6)
      • Non-sentinel lymph node, L’t axilla, frozen — Fat only
    • Left axilla LNs, dissection — Free of tumor metastasis (0/5)
    • AJCC Pathologic Anatomic Stage — pT2N1a, if cM0, stage IIB and Prognostic Stage — Stage IB
  • MACROSCOPIC EXAMINATION
    • Breast size: 7.2 x 4.8 x 3.0 cm
    • Skin size: 5.4 x 1.3 cm
    • Nipple: Not received
    • Tumor: 2.1 x 2.0 cm
    • Resection margins: Free, 0.9 cm from closest 6 o’clock margin
    • Lymph node: L’t axillary lymph nodes
    • All embedded for sections as A1-A2: L’t axillary LNs [Reference: F2023-00339 frozen, FSA: 6 o’clock margin (ink) + base and A1-A3: tumor, A4: non-tumor, A5: skin and X: 12 o’clock (blue ink) + 3 o’clock + 9 o’clock (yellow ink) margin, FSB: L’t axillary sentinel lymph node, FSC: L’t axillary non-sentinel lymph node]
  • MICROSCOPIC EXAMINATION
    • Histologic type: multifocal invasive carcinomas of no special type
    • Size of invasive carcinoma: up to 2.1 x 2.0 cm
    • Histologic grade (Nottingham histologic score): Grade II (score 6) including [(A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1]
    • Margins: Free of tumor invasion
    • Nodal status: tumor metastasis (1/11) in total number, without extracapsular extension (0/1)
    • Treatment Effect: N/A
    • Lymphovascular space invasion: Present
    • Perineural invasion: Present
    • Immunohistochemistry: ER(2~3+, 90%), PR(1~2+, 30-40%), HER2/neu(-, Dako score 1+) and Ki-67: 5-10% and P63(-) for tumor
• 2023-07-08 Frozen Section
  • Margins, left breast, frozen — Free of tumor invasion, 0.9 cm from closest 6 o’clock margin
  • Sentinel lymph node, frozen — Tumor metastasis (1/6)
  • Non-sentinel lymph node, frozen — Fat only
• 2023-07-28 Lymphoscintigraphy
  • Probably two sentinel lymph nodes at the left axillary region.
• 2023-07-27 MRI - breast
  • Left breast malignancy.
  • Left internal mammary lymph node, r/o lymph node metastasis.
    • Round right axillary lymph nodes, suggest further study.
  • Right breast subareolar region oval shaped cystic tmor, 3x1.6cm.
  • Round right axillary lymph nodes, suggest further study.
  • BI-RADS: Category 6-proven malignancy.
• 2023-07-27 SONO - abdomen
  • Diagnosis:
    • Fatty liver, mild
    • Suspected fatty infiltration of pancreas
  • Suggestion:
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2023-07-25 Tc-99m MDP bone scan
  • Increased activity in the lower L-spines and bilateral S-I joints. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips, knees and feet, compatible with benign joint lesions.

[MedRec]

• 2024-02-21 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • Prescription x3
    • NS 10mL ST IVD
    • Hepac Lock Flush 100 USP units/mL 10mL ST IRRI
    • Evista (raloxifen 60mg) 1# QD
    • MgO 250mg 1# TID
    • Stilnox (zolpidem 10mg) 1# HS
• 2024-01-31 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • S: consider TAM 5 years (raloxifen since today)
  • Prescription
    • Evista (raloxifen 60mg) 1# QD
    • MgO 250mg 1# TID
    • Stilnox (zolpidem 10mg) 1# HS
• 2023-12-13 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • S:
    • breast lump
    • Lt breast ca(4/2) proved by CNB at ZhongShan Hospital on 2023-07-05
    • VABB for rt breast tumor (atypical ductal papilloma) at ZhongShan Hospital on 2023-07-14
    • Lt breast ca s/p partial mastectomy + ALND on 2023-07-28
    • adjuvant C/T with E(lipodox)C then T, since 2023-08-16
    • ILD after 5th adjuvant C/T
• 2023-12-07 SOAP Chest Medicine
  • S: just discharge, still dyspean, cough, DOE less but not subsided, itching thorat few, lump thorat, GERD, rhirnohea few
  • O:
    • 2023/11/27 CT: Lung/Mediastinum/Pleura
      • Lung parenchymal and interstial proces, drug-related toxicity r/o infection.
    • 2023/11/29 Bronchodilator Test
      • Mild restrictive ventilatory impairmentwithout significant bronchodilator response (FVC 62%, FEV1 62%)
    • 2023/12/06 P.jiroveci DNA-Sp = Positive;
    • 2023/12/04 CMV viral load assay = Target not deteceted IU/mL;
    • 2023/11/30 Aspergillus Ag = Negative;
    • 2023/11/30 Aspergillus Ag Value = 0.1 Ratio;
    • 2023/11/29 ANA = Negative;
    • 2023/11/28 Anti-ds DNA Antibody = <0.6 IU/ml;
    • 2023/11/28 Anti ENA (Ro,La): Anti-ENA SS-A(Ro) = <0.4 EliA U/ml; Anti-ENA SS-B(La) = <0.3 EliA U/ml;
    • 2023/11/28 Anti-ENA (Jo-1): Anti Jo-1 antibody = <0.3 EliA U/ml;
    • 2023/11/28 Anti-ENA (Scl-70): Anti-ENA Scl-70 Ab = <0.6 EliA U/ml;
    • 2023/11/28 Anti-ENA (Sm/RNP): Anti-ENA Sm = <0.8 EliA U/ml; Anti-ENA RNP = <0.5 EliA U/ml;
    • 2023/11/28 Cryptococcus Ag = Negative;
    • 2023/11/28 RF = <10 IU/mL;
    • 2023/11/27 ESR = 15 mm/hr;
  • Prescription
    • Methylone (methylprednisolone 4mg) 1# BID
    • Allegra (fexofenadine 60mg) 1# BID
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • Morcasin (sulfamethoxazole 400mg, trimethoprim 80mg) 2# BID
    • Stilnox (zolpidem 10mg) 1# HS
• 2023-11-27 ~ 2023-12-04 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Left breast invasive carcinoma with left axillary lymph node metastasis. pT2N1a, if cM0, stage IB. ER(90%), PR(30-40%), HER2/neu( 1+) and Ki-67: 5-10%. ECOG:1.
    • Interstitial pulmonary disease due to chemotherapy
  • CC
    • dyspnea and severe dry cough for 3 days.
  • Present illness
    • This 44-year-old female patient denied any past history including hypertension, diabetes mellitus, hepatitis B virus or heart disease. She denied any TOCC histories in recent 3 months.
    • She was under 5th adjuvant chemotherapy on 11/16 due to left breast invasive carcinoma with left axillary lymph node metastasis. However, dyspnea and severe dry cough for 3 days. She went to ER for help. In ER, vital sign: BP:154/76mmhg; PR:151 bpm/min; BT:37.6 ℃; RR:26 bpm/min; Con’s:E4V5M6, Spo2:93%. CXR revealed ground glass opacities in bilateral lungs.
    • Under impression of pneumonia suspect interstitial pulmonary disease after chemotheray. She was admitted for treatment. Lung CT will be arrange.
  • Course of inpatient treatment
    • After admission, lung CT revealed lung parenchymal and interstial proces, drug-related toxicity r/o infection. Medason 40mg IVD Q12H and Cravit was given. O2 support due to dyspnea.
    • After condition improved, she was discharged today. OPD will be follow up.
  • Discharge prescription
    • Actein (acetylcysteine 200mg) 1# TID 7D
    • Fudecough (dextromethorphan 15mg) 1# TID 7D
    • Stilnox (zolpidem 10mg) 1# HS 7D
    • Methylone (methylprednisolone 4mg) 1# TID 2D
    • Methylone (methylprednisolone 4mg) 1# BID 2D since 2023-12-06
    • Cravit (levofloxacin 500mg) 1.5# QDAC 7D
    • Trimbow (beclometasone 100ug, formoterol 6ug, glycopyrronium 12.5ug; per dose) 2 pull BID INHL
• 2023-11-26 SOAP Medical Emergency Li XuanQing
  • S: Triage: 2 Shortness of breath > Fever (immune function deficiency) the patient had chemotherapy last Thursday and had fever, shortness of breath, and general malaise for days.
  • O: Vital signs: BP:154/76; HR:151; BT:37.6’C; RR:26;
    • Con’s:E4V5M6
    • SpO2:93%
  • A: Preliminary impression: R50.9 Fever, unspecified
  • Prescription
    • Actein (acetylcysteine 200mg) 1# TID
    • Cravit (levofloxacin) 750mg ST & QD IVD
    • NS 500mL ST IVD run 100cc/hr
    • Acetal (acetaminophen 500mg) 1# ST
• 2023-08-23 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • O: Conclusion of the Multidisciplinary Cancer Team Meeting, Meeting Date: 2023-08-11
    • Recommendation: Initiate treatment with EC followed by T, then R/T + H/T.
• 2023-07-27 ~ 2023-07-29 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Left breast invasive carcinoma status post Partial mastectomy + axillary lymph node dissection  on 2023/07/28. cT2N1M0, stage IIA.ECOG:0
  • CC
    • noted a palpable mass at left breast over 2 months.
  • Present illness
    • This 44-year-old female patient denied any past history including hypertension, diabetes mellitus, hepatitis B virus or heart disease. She denied any TOCC histories in recent 3 months.
    • She noted a palpable mass at left breast over 2 months. She went to ZhongShan hospital for help. Left breast core neddle biopsy showed invasive carcinoma on 2023/07/05. ER(90%), PR(70%), HER(-),Ki67:5%. Right breast papilloma status post Vacuum-assisted breast biopsy on 2023/07/14.
    • Due to personal reason, she came to our OPD for help. Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis.
    • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
    • PE: symmetrical of bilateral breasts. Old op scar at right breast. A hard, nontender, movable mass and irregular margin at left breast around 2x2 cm without discharge. The nipple was dimping without exudative nor bloody discharge and no retraction. The left breast skin had no cellulitis change.
    • Under the impression of left breast invasive carcinoma, she was admitted for surgery of partial mastectomy + SLNB.
  • Course of inpatient treatment
    • After admission, left breast partial mastectomy + ALND was performed on 2023/07/28. The wound is clean and dry.
    • Under the stable condition, she was discharged today, wound will be follow up in OPD.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Ulstop (famotidine 20mg) 1# BID

[consultation]

• 2024-01-03 Radiation Oncology
  • Q
    • Under impression of left breast invasive carcinoma with axillary lymph node metastasis, she was admitted for 7th adjuvant chemotherapy with 5FU 500mg/m2 + Lipo dox 35mg/m2 + Endoxan 600mg/m2. We need your help for radiotherapy schedule. Thank you so much!!
  • A
    • Objective:
      • General Condition-ECOG: 1.
      • PE, 2024/1/03: No SCF LAPs.
      • Pathology, 2023/07/28: Tumor, left breast, frozen + partial mastectomy —- Invasive carcinoma of no special type, multifocal, 2.1 x 2.0 cm, LVSI(+), PNI(+), ER(2~3+, 90%), PR(1~2+, 30-40%), HER2/neu(-, Dako score 1+) and Ki-67: 5-10%.
        • Resection margins, ditto — Free of tumor invasion; 0.9cm form 6 o’clock margin.
        • Sentinel lymph node, L’t axilla, frozen — Tumor metastasis (1/6);
        • Left axilla LNs, dissection — Free of tumor metastasis (0/5);
        • AJCC Pathologic Anatomic Stage — pT2N1a, if cM0, stage IIB and Prognostic Stage — Stage IB.
      • Images:
        • Breast MRI, 2023/07/27: There are irregular hypervascular tumor (2x1.7cm) in LOQ of left breast, 5cm from the nipple near chest wall, c/w breast malignancy. There are oval shaped tumors, 1.2cm in UIQ of left breast and 1.4cm in LIQ of left breast, suggest close follow up. Right breast subareolar region oval shaped cystic tumor, 3x1.6cm. Presence of left internal mammary lymph node (1.8cm), r/o lymph node metastasis. Left axillary lymph node. Round right axillary lymph nodes, suggest further study. IMP: 1. Left breast malignancy. 2. Left internal mammary lymph node, r/o lymph node metastasis. Round right axillary lymph nodes, suggest further study. 3. Right breast subareolar region oval shaped cystic tmor, 3x1.6cm. 4. Round right axillary lymph nodes, suggest further study.
        • CXR, Liver sonogram & Bone scan, 2023/07: negative for metastases.
        • Chest CT, 2023/11/27: Lung parenchymal and interstitial process, drug-related toxicity.
        • CA-153: 9.143 U/ml, CEA: 0.857 ng/ml. (2023/07/25)
    • Diagnosis: Left breast cancer, invasive carcinoma, pT2N1a cM0, s/p partial mastectomy + axillary lymph node dissection on 2023/07/28 s/p adjuvant C Lipo-Dox F x 4; Taxotere x 1, C Lipo-Dox F x 2, ECOG 1.
      • Interstitial lung disease due to Taxotere in 2023/11.
    • Plan: I suggested adjuvant RT to left breast & SCF lymphatics for 5000cGy/25 fx, boost scar for 1000cGy/5 fx for locoregional control.
      • CT simulation on 2024/01/16 08:30 (if chemotherapy is delayed, it will be postponed); RT will be started 2 days later. Psychosocial support and diet education.
• 2023-11-28 Chest Medicine
  • Q
    • Surgery of left breast invasive carcinoma status post partial mastectomy + axillary lymph node dissection on 2023/07/28. Pathology report showed left breast invasive carcinoma, left axillary lymph node metastasis, Grade II, pT2N1a, if cM0, Stage IB. ER(2~3+, 90%), PR(1~2+, 30-40%), HER2/neu(-, Dako score 1+) and Ki-67: 5-10%. Adjuvant chemotherapy with Lipo dox 35mg/m2+ Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles were suggest. 5th adjuvant chemotherapy with Taxotere 75mg/m2 on 11/16.
    • However, dyspnea and severe dry cough for 3 days. She went to ER for help. Arrange lung CT revealed pneumonia, suspect ILD?? We need your help for assessment. Thank you so much!!
  • A
    • Suggestions:
      • Survey:
        • Chest CT scan (done) and c/w ILD, DDX including drug related, infection and pulmonary edema.
        • Arrange pulmonary function test if condition permit
        • Survey other cause of ILD such as autoimmune: ANA, dsDNA, SSA, SSB, Scl70, Jo-1, smRNP, RF. If positive, suggest to consult Rheumatologits
        • Survey possibility of infection such as bacteria, aspergillus, Cryptococcus, PJP, CMV
        • f/u routine blood test (CBC and biochemistry) + ESR
      • Treatment:
        • Treat underlying condition as your expert
        • Oxygen therapy to keep adequate SpO2.
        • Corticosteroids: parental methylprednisolone during acute phase. Shift to oral steroid after stable condition.
        • Bronchodilator with A+B to treat dyspnea. Shift to trimbow after stable condition and maintain during OPD treatment.
        • Prevent fluid overload
• 2023-09-27 Obstetrics and Gynecology
  • Q
    • This 44-year-old female patient under the impression of left breast invasive carcinoma, she was admitted for chemotherapy. Due to vaginal bleeding was noted for days, we need your help for assessment. Thank you so much!!      
  • A
    • This 44-year-old menopaused woman was admitted for chemotherapy under the impression of left breast invasive carcinoma. No Tamoxifen used. We were consulted for vaginal bleeding was noted for days.
    • PV: bloody vaginal discharge, cervix: grossly normal, no mass lesion
    • TVUS IMP: Multiple myomas, Endometrium Thickness: 6.6 mm
      
    • Suggestion:
      • Symptomatic treatment firstly: Transamin 500mg Q8H till symptom improve
      • GYM OPD f/u after discharged.
      • Diagnostic D&C may be considered if persistent symptoms.
• 2023-08-14 Dentistry
  • Q
    • This 44-year-old female patient under the impression of left breast invasive carcinoma, she was admitted for chemotherapy.
    • Complaint of upper gum pain. We need your help for assessment before chemotherapy. Thank you so much!!
  • A
    • S: complaint gum boil over UA area off and on.
    • O:
      • FM chrinic periodontiutis with calculus deposition,
      • #22: post endo-tx without crown protection,
      • #26: ill-fitting crown.
    • A: 522.6
    • P:
      • take panox1 for check up.
      • #22: suggest micro-re-endo-tx at endo-OPD.
      • #26: suggest remove and further evalaution and tx.
      • suggest keep f/u every 6 months.

[chemotherapy]

• 2024-01-04 - fluorouracil 500mg/m2 870mg NS 100mL 30min + liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 500mg/m2 870mg NS 500mL 1hr (FAC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO
• 2023-12-13 - fluorouracil 500mg/m2 870mg NS 100mL 30min + liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 500mg/m2 870mg NS 500mL 1hr (FAC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO
• 2023-11-16 - docetaxel 75mg/m2 129mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + famotidine 20mg + NS 250mL (D Q3W)
• 2023-10-25 - cyclophosphamide 600mg/m2 1025mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 59mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-09-27 - cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-09-06 - cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-08-16 - cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(Lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-11-30

[addressing post-chemotherapy respiratory distress and leukopenia]

Currently, there are no recent daily progress notes in HIS5 found.

Should there be recent occurrences of dyspnea, respiratory distress, or shortness of breath, it’s important to note that the last chemotherapy session with docetaxel was on 2023-11-16, about two weeks ago. Therefore, it is less probable that these symptoms are directly caused by the chemotherapy (hypersensitivity). However, docetaxel has also been linked to pulmonary disease, unspecified, with a reported incidence rate of 41% (Ref: UpToDate).

Another potential cause that cannot be overlooked is the earlier administration of cyclophosphamide, a component of the AC(Lipo) regimen. This drug has been associated with pulmonary toxicity, manifesting in various forms such as pneumonitis, pulmonary fibrosis, pulmonary veno-occlusive disease, and acute respiratory distress syndrome. Identifying pulmonary toxicity can be challenging due to overlapping pulmonary conditions in the same patient population, including infections and pulmonary malignancies. Symptoms of this toxicity typically include dyspnea, fever, cough, parenchymal infiltrates, abnormal pulmonary function tests, and pleural thickening.

If nonspecific interstitial pneumonia (NSIP) has been confirmed (and assuming that infection has been completely excluded as a cause), it is recommended to begin with prednisone 0.5 to 1 mg/kg ideal body weight per day up to a maximum of 60 mg/day for one month followed by 30 to 40 mg/day for an additional two months.

For patients with severe NSIP, pulse intravenous methylprednisolone may be preferred for initial therapy. A typical regimen is 1000 mg/day for three days followed by oral prednisone as dosed above. Rarely, patients need additional pulse doses.

Additionally, there was an episode of leukopenia in late Nov (WBC counts 1.69K/uL on 2023-11-22 and 2.84K/uL on 2023-11-26), which might have been caused by the administration of docetaxel. It may be an option to prepare prophylactic G-CSF for use after the next chemotherapy session.

701343379

240227

[exam findings]

• 2024-02-15 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2024-01-17 CT - abdomen
  • Findings: Comparison prior CT dated 2023/08/01.
    • Prior CT identified a soft tissue nodule 6 mm in the omentum at left middle pelvis is noted again, mild increasing in size to 9 mm (Srs:301 Img:91). Follow up is indicated.
    • S/P hysterectomy
    • Prior CT identified a well-defined homogeneous soft tissue mass 2.4 x 1.8 cm in left adrenal gland is noted again, stationary.
      • Adenoma is highly suspected. Follow up is indicated.
        
  • Impression:
    • Prior CT identified a soft tissue nodule 6 mm in the omentum at left middle pelvis is noted again, mild increasing in size to 9 mm. Follow up is indicated.
• 2023-08-30 All-RAS + BRAF mutation
  • Cellblock No.: F2023-00362 Fs
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-08-16 CXR erect
  • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
  • s/p left chest tube in place,its tip directed superiorly projecting over 4th intercostal space
  • small Lt hemithorax, decreased pulmonary vascularity, small hilum, due to post operative change of LUL lobectomy
  • Linear band subsegmental atelectasis at Rt lower lung zone
• 2023-08-14 Patho - lung total/lobe/segmental
  • Diagnosis
    • Lung, left lower lobe, 3D VATS lobectom — Moderately differentiated squamous cell carcinoma, HPV-associated, metastatic
    • Lymph node, LN 5, RLND — Negative for malignancy
      
    • Lymph node, LN 7, RLND — Negative for malignancy
    • Lymph node, LN 9, RLND — Negative for malignancy
      
    • Lymph node, LN 10, RLND — Negative for malignancy
    • Lymph node, LN 11, RLND — Negative for malignancy
      
    • Lymph node, LN 12, RLND — Negative for malignancy
      
    • AJCC 8th edition pathology stage for Cervix Uteri: pTxN0M1; AJCC stage IVB
  • Gross Description
    • Specimen received:
      • Lung, size:16 x 8 x 2.5 cm and 186 gm in weight 
      • Lymph nodes, 6 bottles, maximal size: 0.8 cm
    • Tumor Site: Near hilar of left lower lobe
    • Gross Tumor Size: Solitary 1.7x 1.5 cm     - Gross tumor patterns: poorly defined
    • Representative sections are taken and labeled as: FS: frozen control, A1: margin, A2-4: tumor, A5: non-tumor, A6: hilar, A7: LN 5, A8: LN 7, A9: LN 9, A10: LN 10, A11: LN 11, A12: LN 12
  • Microscopic Description
    • Tumor Size: Greatest dimension (centimeters): 1.7 cm + Additional dimensions (centimeters): 1.5 x 1.3 cm
    • Tumor Focality - Single tumor
    • Histologic Type (select all that apply) — squamous cell carcinoma, HPV-associated, metastatic
    • Histologic Grade (according to the main histological type) — G2: Moderately differentiated
    • Visceral Pleura Invasion — Not identified
    • Lymphovascular Invasion (select all that apply) — Not identified
    • Margins (select all that apply)
    • Note: Use this section only if all margins are uninvolved and all margins can be assessed. — All margins are uninvolved by carcinoma
    • Distance of invasive carcinoma from closest margin (centimeters): 0.7 cm from closest bronchial Margin
    • Regional Lymph Nodes
      • Lymph Node Examination (required only if the lymph nodes present in the specimen) - N1 (Number involved / Number examined)           - group 10 (Hilar), left:  0 / 5           - group 11 (Interlobar): 0 / 6           - group 12 (lobar): 0 / 2     - N2 (Number involved / Number examined)          - group 5: 0 / 8           - group 7: 0 / 1
        • group 9:  0 / 3
    • Additional Pathologic Findings (select all that apply) — None identified
    • Ancillary Studies: Immunostains — TTF-1 (-), CD56 (-), P40 (+), P16 (+, strong, diffuse, >80%)
• 2023-08-13 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Left axis deviation
  • Abnormal ECG
• 2023-08-07 Nasopharyngoscopy
  • smooth nasopharynx, oropharynx and hypopharynx, no finding of lesion over bilateral palatine tonsils.
• 2023-08-04 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 13 dB HL; LE 13 dB HL.
  • Bil normal to mild SNHL.
• 2023-08-02 MRI - larynx
  • Indication: increased FDG uptake in bilateral palatine tonsils, for survey
  • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed showed:
    • susceptibility artifacts in the left oral cavity
    • a smooth-margined nodular lesion, about 31mm, in the right thyroid gland.
    • symmetric increased soft tissue in the bilateral oropharyngeal tonsils. Homogeneous enhancement was noted.
    • no neck LAP.
  • IMP:
    • prominent soft tissue in the bilateral oropharyngeal tonsils
• 2023-08-01 CT - abdomen
  • Findings
    • Post-op change at right abdominal wall.
    • S/P hysterectomy.
    • Peritoneal nodules in the peritoneum, r/o carinomatosis.
    • Left adrenal tumor, 2.3cm, stationary.
    • Left lower lung tumor, 1.7cm near hilar region, r/o malignancy.
  • Impression:
    • Post-op change at right abdominal wall.
    • S/P hysterectomy.
    • Peritoneal nodules in the peritoneum, r/o carinomatosis.
    • Left lower lung tumor, 1.7cm near hilar region, r/o malignancy, primary or metastasis?
• 2023-07-19 PET scan
  • Increased FDG uptake in the peritoneum of the right abdomen, compatible with the recurrent tumor.
    
  • Increased FDG uptake in the left adrenal region, probably benign in nature.
    
  • Increased FDG uptake in a focal lesion in the left upper lung, highly suspected the other primary (lung) or seconary (from cervical cancer) cancer, suggesting biopsy for investigation.
  • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, probably reactive (priority) or metastatic nodes.
  • Increased FDG uptake in the left 4th rib, probably post-traumatic change (priority) or cancer with bone mets.
    
  • increased FDG uptake in bilateral palatine tonsils, probably inflammation process.
    
  • Cervical cancer s/p treatment with tumor recurrence and highly suspected the other primary cancer in the left upper lung, by this F-18 FDG PET scan.
• 2023-07-03 Patho - soft tissue tumor, extensive resection
  • Soft tissue, anterior peritoneum, debulking surgery —- metastatic squamous cell carcinoma, moderately differentiated, consistent with cervical origin
  • Sections show fibroadipose tissue with metastatic keratinized squamous cell carcinoma.
  • The immunohistochemical stains reveal p16(+) and p40(+). The results are consistent with metastatic cervical squamous cell carcinoma. The tumor is 0.1 cm away from the closest peripheral resection margin. The small piece of fibroadipose tissue is free of malignancy.
• 2023-06-29 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Left axis deviation
  • Abnormal ECG
• 2023-05-09 MRI - pelvis
  • Findings
    • S/P hysterectomy.
    • Focal enhanced soft tissue, 2.9cm in right abdominal wall, r/o recurrent tumor.
    • Presence of gallbladder stone.
    • Minimal ascites in the pelvic cavity.
    • Left adrenal tumor, 2cm.
  • Impression:
    • S/P hysterectomy.
    • GB stone.
    • Left adrenal tumor, 2cm.
    • R/O recurrent tumor in right abdominal wall.
• 2023-02-20 Gynecologic ultrasonography
  • No obvious uterine or ovarian lesion
• 2023-02-01 CT - abdomen
  • S/P hysterectomy. There is no evidence of tumor recurrence.
  • Adenoma measuring 2.4 x 1.8 cm in left adrenal gland is suspected. please correlate with clinical condition.
• 2022-11-21 Gynecologic ultrasonography
  • No obvious uterine or ovarian lesion
• 2022-10-27 MRI - pelvis
  • Findings
    • S/P hysterectomy.
    • Non-enhancing nodule, 0.6cm in left kidney, r/o renal cyst.
    • Unremarkable change of the liver, spleen, pancreas and right kidney.
    • Presence of gallbladder stone.
    • Left adrenl tumor, 2.2cm, stationary.
  • Impression:
    • S/P hysterectomy, suggest follow up.
    • Left adrenal tumor, stationary.
    • R/O left renal cyst.
    • Gallbladder stone.
• 2022-08-31 CT - abdomen
  • S/P hysterectomy. There is no evidence of tumor recurrence.
  • Adenoma measuring 2.4 x 1.8 cm in left adrenal gland is suspected. please correlate with clinical condition.
• 2022-08-29 Gynecologic ultrasonography
  • No obvious uterine or ovarian lesion
• 2022-06-25 SONO - abdomen
  • Findings
    • Increase brightness of liver parenchyma with fat attenuation. No focal lesion is found.
    • A 0.77 cm hyperechoic lesion with acoustic shadow was noted in the gallbladder.
  • Dignosis
    • GB stone
    • Fatty liver, moderate
• 2022-06-09 MRI - pelvis
  • Findings
    • S/P hysterectomy.
    • Non-enhancing nodule, 0.58cm in left kidney, r/o renal cyst.
    • Diffuse thickening wall at superior wall of urinary bladder, suggest clinical correlation.
      
    • Left adrenl tumor, 2.2cm, stationary.
  • Impression
    • S/P hysterectomy, suggest follow up.
    • Left adrenal tumor, stationary.
    • R/O left renal cyst.
    • Diffuse thickening wall at superior wall of urinary bladder, cystitis? suggest clinical correlation.
• 2022-05-30 Gynecologic ultrasonography
  • No obvious uterine or ovarian lesion
• 2022-03-02 CT - abdomen
  • S/P hysterectomy. There is no evidence of tumor recurrence.
    
  • Adenoma measuring 2.4 x 1.8 cm in left adrenal gland is suspected. please correlate with clinical condition.
• 2021-11-08 Patho - uterus (with or without SO) neoplastic
  • PATHOLOGIC DIAGNOSIS
    • Uterus, cervix, laparoscopic radical hysterectomy — squamous cell carcinoma, HPV-associated
      
    • Uterus, endometrium, laparoscopic radical hysterectomy — squamous cell carcinoma, by direct invasion
      
    • Uterus, myometrium, laparoscopic radical hysterectomy — squamous cell carcinoma, by direct invasion
      
    • Ovaries and fallopian tubes, bilateral, BSO — Negative for malignancy
      
    • Lymph nodes, left ilac, lymphadenectomy — Negative for malignancy (0/5)
      
    • Lymph nodes, left obturator, lymphadenectomy — Negative for malignancy (0/9)
      
    • Lymph nodes, right ilac, lymphadenectomy — Negative for malignancy (0/3)
      
    • Lymph nodes, right obturator, lymphadenectomy — Negative for malignancy (0/10)
      
    • AJCC 9th edition: pStage IIB, pT2bN0(if cM0); FIGO Stage: IIB
      
  • MACROSCOPIC EXAMINATION
    • Size of uterus: 9.5 x 5.5 x 4.0 cm
      
    • Tumor size: 4.5 x 3.0 x 2.5 cm; involving the whole cervix and invasion to endometrium, myometrium, upper vagina
      
    • Tumor depth: 1.5 cm
      
    • Parametrium: Microscopically, tumor invasion is seen.
      
    • Endometrium: 4.0 x 3.5 x 0.4 cm; invaded by tumor
      
    • Myometrial wall: several leiomyomas, measuring up to 4.5 x 3.8 x 2.7 cm, adenomyosis, and invaded by tumor
      
    • Adnexa: Included
      
    • Right ovary: 2.4 x 1.4 x 0.8 cm,
    • Left ovary: 1.8 x 1.2 x 0.5 cm,
      
    • Right fallopian tube: 6.5 cm in length and 0.3 cm in diameter
      
    • Left tube: 5.8 cm in length and 0.3 cm in diameter
      
    • Bilateral adnexa appear unremarkable.
      
    • Lymph nodes: 4 groups of lymph nodes, labeled right iliac, obturator and left iliac, obturator
      
    • Representative sections are taken and labeled as: A1: right ovary and fallopian tube; A2: left ovary and fallopian tube; A3-4: leiomyoma and adenomyosis; A5: endometrium, non-tumor; A6-14: tumor (A7-8; A9-10: the same level); B: lymph node, left iliac; C: lymph node, left obturator; D: lymph node, right iliac; E: lymph node, right obturator.
      
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Squamous cell carcinoma, HPV-associated
      
    • Histologic Grade: G2: Moderately differentiated
      
    • Stromal invasion: Depth of stromal invasion: 15 mm, entire cervical wall
      
    • Silva Pattern of Invasion (applicable only to invasive endocervical adenocarcinomas): Not applicable
      
    • Other Tissue/ Organ Involvement (select all that apply):
      • Parametrium, side not specified
        
      • Vagina: location not specified
        
    • Margins:
      • Ectocervical/Vaginal cuff Margin: Not Free (Cancer present)
        
      • Radial (Circumferential) Margin: Not Free
        
    • Lymphovascular Invasion: Present
      
    • Regional Lymph Nodes:
      • Pelvic Lymph Nodes:
        
      • Right iliac: Negative: 0/ 3
        
      • Left iliac: Negative: 0/ 5
        
      • Right obturator: Negative: 0/ 10
        
      • Left obturator: Negative: 0/ 9
        
      • Para-aortic Lymph Nodes: not received
        
    • Distant Metastasis: Not applicable
      
    • Additional Pathologic Findings: None identified
      
    • Special Study: p16 immunohistochemistry: Positive (S2021-16493)
      
    • Several leiomyoma with calcification and adenomyosis are seen in myometrium.
• 2021-10-21 Patho - cervix biopsy
  • Labeled as “cervix”, biopsy — carcinoma.
  • Section shows nests of neoplastic epithelium with polygonal appearance.
  • IHC stain: p16 (+, 100%), Ki-67: 95%, p40 (+). GATA-3 (+).
    
  • NOTE: Although the pattern p16 (+) and p40 (+) is compatible with cervical squamous cell carcinoma. A normal serum level of SCC marker and IHC stain of GATA-3 (+) is not typical. Please check urinary bladder to exclude other possibility.
• 2021-10-18 Gynecologic ultrasonography
  • cervical mass 35 x 32 mm (blood flow)
  • Uterine myoma
  • EM 11.6mm (+fluid)

[MedRec]

• 2023-06-29 ~ 2023-07-05 POMR Obstetrics and Gynecology Chen GuoHu
  • Discharge diagnosis
    • cervical cancer (squamous cell carcinoma, stage II), post radical hysterectomy + BSO + BPLND and CCRT –> right abdominal tumor 4.5x4cm at ant peritoneum, suspected cervical cancer recurrence
    • right abdominal tumor 4.5x4cm at ant peritoneum, suspected cervical cancer recurrence s/p debulking surgery (abdominal tumor excision for suspected cervical cancer recurrence) and enterolysis on 2023-06-30
    • cervical cancer (squamous cell carcinoma, stage IIb), post radical hysterectomy + BSO + BPLND and CCRT –> right abdominal tumor 4.5x4cm at ant peritoneum, suspected cervical cancer recurrence s/p debulking surgery (abdominal tumor excision for suspected cervical cancer recurrence) and enterolysis on 6/30/2023
  • CC
    • She found a mass at right abdominal wall WITH PELVIC MRI FINDINGS OF RIGHT ABDOMINAL TUMOR, SUSPECTED CANCER RECURRENCE when UNDERGOING regular f/u on 2023/05/09     
  • Present illness
    • This 58 y/o woman, G1P0AA1, menopauseD at 53 y/o, menstral cycle regular with duration/interval of 5/28 days, had no dysmenorrhagia. She had a past history of CERVICAL CANCER, STAGE II (squamous cell carcinoma of cervix) POST RADICAL HYSTERECTOMY + BSO + BPLND + adhesiolysis on 2021/11/05, AND POST-OP CCRT (C/T on 2021/12/2, 9, 16, 23, 29, 2022/1/5 and RT on 2021/12/3~2022-1-27 WITH 4500cGy/25 fractions of the pelvic, 4860cGy/27 fractions of the cuff to parametrium, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT. SHE Denied any food or drug allergy, and denied anticoagulants or hormone use.
    • AFTER THE SURGERY AND CCRT, No palpable mass was noted UNTIL THIS MAY, AND THERE WAS no significant body weight change, no abdominal discomfort, no constipation, no diarrhea, no urinary frequency, no nausea or vomitting, no decreased appetite. She turned to our GYN OPD for help because of a mass was noted in her right abdominal wall, and some examinations were done. She found a mass at right abdominal wall WITH PELVIC MRI FINDINGS OF RIGHT ABDOMINAL TUMOR 3X3CM, SUSPECTED CANCER RECURRENCE when UNDERGOING regular f/u on 2023/05/09. The transabdominal sono on 2023.06.26 revealed no ascites, BUR right abd mass 2.9cm -> 3.5cm. THE Tumor marker was examinated on the same day and showd SCC LEVEL 0.8~1.0 ng/ml; CEA LEVEL 1.88 ng/mL.
    • Under the impression of RIGHT ABDOMINAL TUMOR, SUSPECTED recurrent cervical cancer WITH POSSIBLE PELVIC ADHESION, she was admitted on 2023/06/29 for exploratory laparotomy (TUMOR DEBULKING SURGERY), ENTEROLYSIS and postoperative care.      
  • Course of inpatient treatment
    • The patient was admitted on 2023-06-29 and underwent debulking surgery (abdominal tumor excision for suspected cervical cancer recurrence) and enterolysis the next day. Her postoperative course was uneventful. After flatus, her eating and urination by self voiding, defecation was smooth. The vital sign was stable after surgery. She is discharged on 2023-07-05 and her followup appointment is scheduled on next week.
  • Discharge prescription
    • MgO 250mg 2# QID
    • Acetal (acetaminophen 500mg) 1# QID
    • cephalexin 500mg 1# QID
• 2023-05-10 SOAP Hemato-Oncology Xia HeXiong
  • P: Already discuss with Chief Chen for the possibility of recurrence over right abdominal wall based on MRI on 2023-05-09
• 2022-03-03 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • CCRT with weekly CDDP on 2021-12-30 followed by C/T with PF later
    • Encourage respiratory exercise
    • RTC on 2022-02-09, then discuss with adjuvant C/T (margin not free)
    • After discussion with patient about adjuvant TP, patient trend not to receive adjuvant chemotherapy.
    • Port-A flush Q3M, next on 2022-04-05
• 2021-11-25 SOAP Radiation Oncology Huang JingMin
  • A: Squamous cell carcinoma, HPV-associated, of the uterine cervix, AJCC 8th edition: pStage IIB, pT2bN0(cM0); FIGO Stage: IIB, s/p 3D laparoscopic radical hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + adhesiolysis.
  • P: Postoperative CCRT is indicated for this patient with the following indicators: stage IIB, margin involed.
    • Goal: curative
    • Treatment target and volume: pelvis
    • Technique: VMAT/IGRT and IVRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, 4860cGy/27 frcations of the parametrium, and another 1200cGy/3 fractions to vagnal cuff mucosa surface.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient. She understand and would like to receive radiotherapy, The treatment planning of ardiotherapy will be started at 2:30 PM, 2021-11-30.
• 2021-11-25 SOAP Hemato-Oncology Xia HeXiong
  • P
    • CCRT with weekly CDDP followed by C/T with PF
    • Encourage respiratory excersie
    • Port-A insertion
• 2021-11-25 SOAP Obstetrics and Gynecology Chen GuoHu
  • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 20210118
    • CCRT and C/T
• 2021-11-04 POMR Obstetrics and Gynecology Chen GuoHu
  • Discharge diagnosis
    • Cervical cancer (C53.9) post laparoscopic radical hysterectomy + bilateral salpingo-oophorectomy + bilateral lymph node dissection on 2021/11/05
    • Malignant neoplasm of endometrium
    • Myoma uteri
    • Female pelvic peritoneal adhesions (postinfective)
  • CC
    • intermittent menopausal bleeding for almost 2 years.  
  • Present illness
    • This is a 56 year-old female, G0P0, SEX(+), AND she denied any medical history and surgical history. Her menstral cycle was in interval of 28 days and in duration of 5 days. Menopause was NOTED on her age of 52 y/o. SHE Ever took estrogen by herself in 2019.
    • This time, she complained of intermittent menopausal bleeding for almost 2 years, but she didn’t pay attention to it. However, the vaginal bleeding got more frequent and the blood loss amount also got more and more, blood clot was also noted in recent monthS. Anemic symptoms, such as general malaise, dizziness and tachycardia were noted since 2021.09. Thus, she turned to ShuangHe hostpital on 2021.10, andD lab data of Hb 7 was noted, ferrous agent was also perscribed and the symptoms improved. Some work-out was done there.
    • She then brought the examination results found in ShuangHe hostpital to our OPD for second opinion. The GYN sonar on 110.10.18 revealed EM 1.16cm with fluid, 3 myomas (3x3cm ; 2.8x2.5cm ; 2.3x2cm), and A cervical mass 3.5x3cm, with abduantWITH abundant flow(+), The abdominal CT scan (done in ShuangHe) revealed endometrium thickening with irregular marginS, SUSPECTED ENDOMETRIAL CANCER with extending to cervix. A 2.4 cm adrenal nodule was also noted. The lab data on 110.10.18 revealed SCC level was 1.5, and CEA level was 4.93 ng/mL. The cervical biopsy showed carcinoma, nature to be determined. with IHC stain: p16 (+, 100%), Ki-67: 95%, p40 (+), GATA-3 (+). The endocervical biopsy, ECC revealed high grade dysplastic epidermoid.
    • Under the impression of cervical cancer with endometrial involvement or suspected endometrial cancer with extending to cervix, she was admitted for 3D laparoscopic radical hysterectomy, BSO and BPLND. Cystoscope + DBJ insertion will be arranged prior to the major surgery.
  • Course of inpatient treatment
    • The patient was admitted on 2021/11/04 and underwent 3D laparoscopic radical hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + adhesiolysis (by Prof. Chen) + cystoscopy + Bilateral DBJ insertion by GU Dr. on 2021/11/05.
    • We gave her Cefazolin and Gentamycin IV form for 3 days and then shifted her antibiotics to Cephalexin oral form. Post-operation wound was dry and clean without dehiscence, discharge, or oozing. Her lab data on 2021/11/06 also showed no specific positive findings. There was no special complaint nor fever, with improved condition 3 days after the LSC radical hysterectomy surgery. After flatus, her eating and self voiding, defecation were all ok. JP drain was removed on 11/12 with stable condition. Since all her general conditions were all improved and relatively stable, we arranged discharge for her on 2021-11-13 for further OPD follow up of her recovery status and surgical wound conditions.     
  • Discharge prescription
    • Anxiedin (lorazepam 0.5mg) 1# PRNHS
    • Gaslan (dimethylpolysiloxane 40mg) 2# TID
    • cephalexin 500mg 1# QID
    • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

• 2023-08-14
  • Surgery
    • 3D VATS LUL lobectomy + RLND.
  • Finding
    • One tumor was noted over LUL, central located, size about 1.5cm in diameter.
    • Frozen section: squamous cell carcinoma.
    • One 24 Fr. straight chest tube was inserted via left 8th ICS.
• 2023-06-30
  • Surgery
    • debulking surgery (abdominal tumor excision for suspected cervical cancer recurrence) and enterolysis
  • Finding
    • prevical cervical cancer (SCC, stage II), post radical hysterectomy + BSO + BPLND and CCRT
      • -> right abdominal tumor 4.5x4cm at ant peritoneum (5cm distance to umbulicus), suspected cervical cancer recurrence
      • -> abdominal tumor excision
    • abdominal cavity:
      • no ascites, but pelvic adhesion (due to previous radical hysterectomy + BSO + BPLND?) was noted between ant peritoneum, abdominal tumor, omentum and bowels s/p enterolysis
• 2021-11-05
  • Surgery
    • 3D laparoscopic radical hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + adhesiolysis
  • Finding
    • Uterus: 12x8x5 cm, corpus – multile myomas 2~4cm
    • prev cervical biopsy – carcinoma, nature?
    • cervix – eroded with cauderflower mass 3x3cm, suspected residual cancer
    • endometrium – multiple soft fungating mass, suspected cancer
      • -> R/O endometrial cancer with isthmus and cervical invasion, or cervical cancer with endometrial invasion?
    • vagina (upper 1/2) – eorded with soft, necrotic mass, suspected cancer invasion
    • parametrium (including uterus artery) – seemed free of invasion
    • bil adnexa: normal-looking
    • bowels, omentum – seemed free of cancer invasion
    • cystoscopy – smooth bladder and ureter contour
    • Bilateral pelvic iliac and obturator LNs was removed
    • CDS: 20c.c ascites (washing cytology was sent), some pelvic adhesion was noted between US ligaments and rectum s/p lysis
    • A 7mm JP drain was placed in CDS

[radiotherapy]

• 2021-12-03 ~ 2022-01-27 - 4500cGy/25 fractions of the pelvic, 4860cGy/27 fractions of the cuff to parametrium, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.

[chemotherapy]

• 2024-02-27 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-02-01 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2024-01-09 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-12-12 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-11-14 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-16 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-20 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
• 2023-09-13 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
• 2023-09-06 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
• 2023-08-30 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
• 2022-01-06 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
• 2021-12-30 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
• 2021-12-24 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
• 2021-12-17 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 1000mL 2hr
• 2021-12-09 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 1000mL 2hr
• 2021-12-02 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr

==========

2024-02-27

[reconciliation]

Vital signs during this hospital stay and labs on 2024-02-27 showed stable and normal values, no medication discrepancy found after reviewing HIS5 and PharmaCloud.

2024-02-02

[reconciliation]

Lab data from 2024-02-01 and vital signs assessed through the TPR panel during this hospital stay were overall within normal limits. A thorough review of the HIS5 and PharmaCloud databases did not reveal any discrepancies in medication.

2024-01-09

[gradual eGFR change: current dose safe, continued monitoring]

There appears to be a gradual downward trend in eGFR in this patient, and no dose adjustment is required at this time.

• 2024-01-08 eGFR 66.41 ml/min/1.73m^2
• 2023-12-11 eGFR 78.03 ml/min/1.73m^2
• 2023-11-09 eGFR 55.38 ml/min/1.73m^2
• 2023-10-16 eGFR 65.01 ml/min/1.73m^2
• 2023-09-25 eGFR 69.24 ml/min/1.73m^2
• 2023-09-19 eGFR 72.03 ml/min/1.73m^2
• 2023-09-12 eGFR 68.35 ml/min/1.73m^2
• 2023-09-05 eGFR 67.48 ml/min/1.73m^2
• 2023-08-28 eGFR 84.36 ml/min/1.73m^2
• 2023-08-13 eGFR 77.19 ml/min/1.73m^2
• 2023-08-03 eGFR 91.35 ml/min/1.73m^2

700029486

240226

==========

2024-02-26

[tube feeding: Const-K extended-release tab 750mg/10mEq/tab (KCl); Detrusitol SR 4mg prolonged-release cap (tolterodine); Wellbutrin XL 150mg/tab (bupropion)]

Const-K is an extended-release potassium supplement tablet that is not intended to be crushed, as this would compromise its slow-release properties. However, in situations where oral administration is not feasible and intravenous potassium is not preferred, crushing the tablet for tube feeding might be considered the only option, despite the loss of extended-release functionality.

Each Const-K tablet delivers 10 mEq of potassium, equating to the potassium content of approximately a 10 cm banana, which contains about 2.2 mEq/inch (0.9 mEq/cm) in bananas (N Engl J Med. 1985;313(9):582.)

Similarly, other extended-release medications such as Detrusitol SR and Wellbutrin XL are not recommended to be crushed. Disrupting their extended-release mechanism can lead to more variable serum concentrations, potentially affecting their efficacy and safety.

700165811

240226

[exam findings]

[MedRec]

• 2024-01-04 ~ 2024-01-06 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Adenocarcinoma of the vagina with severe adhesion to bladder, status post staging operation (BSO + BPLND + vaginal tumor excision), with bladder injury status post repair,  pT2bN1, stage III, if cM0/FIGO stage III with progression.
    • Postive of anti-HBc
  • CC
    • for C4 chemotherapy with Abraxance (self-paid) Q3W
  • Present illness
    • This is a 56-year-old female, G2P2, with past history of
      • adenomyosis and uterine myoma s/p laparoscopic hysterectomy in Tzu Chi Hospital in 2012/03
      • bilateral ureter obstruction s/p extracorporeal shock wave lithotripsy (ESWL) in Carinal Tien Hospital (CTH) in 2020
      • left hydronephrosis and ureteral stricture s/p double J-stent placement in CTH in 2021/10
      • right hydronephrosis and ureteral stricture s/p double J-stent placement in CTH in 2021/11
      • endometriosis related recurrent bilateral ureteral stricture and hydronephrosis s/p right laparoscopic ureteroneocystostomy (UNC), laparoscopic ureterolysis and laparoscopic adhesionolysis in CTH on 2022/01/06
    • She denied systemic disease, including DM, hypertension or allergic history. Her father has pancreatic cancer and DM, her mother had no underlined diseases.
    • According to her statement, she had adenomyosis and leiomyoma s/p laparoscopic hysterectomy, laparoscopic pelvic adhesion lysis and P repair in Tzu Chi Hospital on 2012/03. She had regular OPD follow-up but stopped a few years later. She had intermittent lower abdominal pain since 2020, and she visited GU OPD for treatment. Bilateral ureter obstruction was noted, and ESWL was done in CTH in 2020. Her lower abdominal and back pain recurred in 2021/10, so she visited ER in CTH for treatment.
    • Left hydronephrosis and ureteral stricture was noted, and left double J-stent placement was done in 2021/10. Left double J-stent was removed 1 week after discharge. However, her lower abdominal and back pain recurred again in 2021/11, so she still visited ER in CTH for treatment. Right hydronephrosis and ureteral stricture was noted, and right double J-stent placement was done in 2021/10. right double J-stent was removed 1 week after discharge. After discharge, she still have intermittent lower abdominal pain and and visited ER in CTH in 2021/12.
    • The GU doctor noted a mass attached to bladder, suspected causing recurrent bilateral ureteral stricture and hydronephrosis, so right laparoscopic ureteroneocystostomy (UNC), laparoscopic ureterolysis and laparoscopic adhesionolysis was done in CTH on 2022/01/06. The mass was suspected endometiosis related.
    • During operation, a mass around vagina was noted, and biopsy was suggested. Then, colposcopic was done and adnenocarcinoma was suspected, origin unspecified.
    • Immunostain of vagina biopsy showed CK7, p53 positive, PAX8 weakly positive and MIB-1 increased.
    • Thus, colonoscopy was done to exclude colonorectal cancer, but there was no tumor noted except colitis at a-colon s/p biposy and hemorrhoid.
    • PET scan was done on 2022/03/22 and revealed undertemined lesion in proximal rectum. Surgery was not suggested by gynecologist in CTH.
    • Thus, she visited Gynecologist Dr. Hung in Tzu Chi Hospital for second opinion. Endometriosis was suspected and medication was prescribed. However, her lower abdominal pain and low back pain persisted. Then, she visited NTUH for further evaluation of her diseases. Viginal biopsy, MRI and lab data were done. Vaginal biopsy showed adenocarcinoma, PAC8 positive and increased Ki-67 index. MRI revealed a 2.2cm focal enhancing lesion at the vaginal stump or cervix with diffusion restrition, neoplasm cannot be excluded. Gynecologist in NTUH suggested that radiotherapy had poorer effect to adenocarcinoma than squamous cell carcinoma (SCC), and the bladder impairment of radiotherapy complication should be considered as well. Thus, she visited radiologist in NTUH, but the radiologist in NTUH had different opinion with Gynecologist in NTUH.
    • She then visited Dr. Huang in Tzu Chi Hospital for second opinion, and Dr. Huang decided to discuss this patient’s management in gynecologic cancer meeting. After the meeting, CCRT was suggested. However, the patient was concern about poor radiotherapy effect to adenocarcinoma and bladder impairment caused by radiotherapy. So gynecologist Dr. Huang suggested her to visit our radiologist Dr. Huang for treatment evaluation. Radiologist Dr. Huang suggested vaginectomy and lymphadenectomy, combined with radiotherapy for consolidation later.
    • She underwent staging surgery (BSO + BPLND + vaginal tumor excision) and bilatearl neocystostomy orifice s/p DBJ insertion & bladder injury s/p repair on 2022/6/15.The pathology showed pT2bN1,stage III, if cM0 / FIGO stage III.Port-A insertion on 2022/7/7.
    • Under th diagnosis of Adenocarcinoma of the vagina with severe adhesion to bladder, status post staging operation (BSO + BPLND + vaginal tumor excision), with bladder injury status post repair, pT2bN1, stage III, if cM0/FIGO stage III. DBJ removal on 2022/7/11.
    • CCRT with selfpaid of C1 Taxol (selfpaid) plus Cisplatin was administered on 2022/7/19. Weekly cisplatin on 2022/8/16-9/13.
    • Radiotherapy started on 2022/08/01 with 4500cGy/25 fractions of the pelvic, 5040cGy/28 fractions of the vaginal tumor bed, and 5400cGy/30 fractions of the reduced vaginal tumor bed.
    • After completion of CCRT, she received chemotherapy with Avastin (selfpay) + Taxol (selfpaid) + Cisplatin since 2022/09-2023/04.
    • Follow up CT showed 1. Prior CT identified a soft tissue mass-like lesion in the vagina, measuring 5 x 3.3 cm, is noted again, stationary, 2. Prior CT identified diffuse mild wall thickening of the urinary bladder is not noted again and 3. Prior CT identified small size and mild hydroureteronephrosis but no delayed contrast excretion of left kidney is noted again, stationary.
    • Last time. she received hydronephrosis /p bilateral tumor stent insertion on 2023/11/23, without complication during hospitalization. Newly chemotherapy as C1 Abraxane by selfpay QW for diaease progress on 2023/11/24, C2 Abraxane on 2023/12/08, C3 on 2023/12/22.
    • This time, she she was admitted for C4 Abraxane on 2024/01/04.
  • Course of inpatient treatment
    • After admission, chemotherapy with Abraxance (125mg/m2, self-paid) was given on 2024-01-05, smoothly without obvious side effect.
    • She was discharged on 2024-01-06 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • none

[chemotherapy]

• 2024-02-26 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-02-02 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-01-25 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2024-01-05 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-12-22 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-12-08 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-11-24 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-04-07 - bevacizumab 15mg/kg 800mg NS 250mL 90min + paclitaxel 175mg/m2 280mg NS 250mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-03-16 - bevacizumab 15mg/kg 800mg NS 250mL 90min + paclitaxel 175mg/m2 280mg NS 250mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-02-07 - bevacizumab 15mg/kg 800mg NS 250mL 90min + paclitaxel 175mg/m2 280mg NS 250mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-12-20 - bevacizumab 15mg/kg 800mg NS 250mL 90min D1 + paclitaxel 175mg/m2 280mg NS 250mL 3hr D2 + NS 500mL 1hr D2 (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr D2 + NS 500mL 1hr D2 (after cisplatin)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D2 + famotidine 20mg D2+ palonosetron 250ug D2 + NS 250mL D1-2
• 2022-11-01 - paclitaxel 175mg/m2 275mg NS 250mL 3hr + NS 500mL (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr + NS 500mL (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-10-04 - paclitaxel 175mg/m2 275mg NS 250mL 3hr + NS 500mL (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr + NS 500mL (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-09-14 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
  • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
• 2022-09-07 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
  • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
• 2022-08-31 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
  • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
• 2022-08-24 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
  • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
• 2022-08-17 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
  • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
• 2022-08-10 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
  • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
• 2022-07-19 - paclitaxel 175mg/m2 275mg NS 250mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-02-26

[nab-paclitaxel and renal function]

Post-administration of nab-paclitaxel, serum creatinine levels have consistently remained above 1.5 mg/dL. Although there hasn’t been a rapid increase, continuous monitoring is still advised.

• 2024-01-12 Creatinine 1.64 mg/dL
• 2024-01-04 Creatinine 1.60 mg/dL
• 2023-12-29 Creatinine 1.52 mg/dL
• 2023-12-22 Creatinine 1.77 mg/dL
• 2023-12-14 Creatinine 1.56 mg/dL
• 2023-12-08 Creatinine 1.54 mg/dL
• 2023-11-30 Creatinine 1.58 mg/dL nab-paclitaxel 20231124 initialized
• 2023-11-22 Creatinine 1.36 mg/dL
• 2023-11-17 Creatinine 1.66 mg/dL
• 2023-10-20 Creatinine 1.24 mg/dL
• 2023-10-06 Creatinine 1.21 mg/dL
• 2023-09-15 Creatinine 1.18 mg/dL
• 2023-09-08 Creatinine 1.00 mg/dL
• 2023-09-01 Creatinine 1.12 mg/dL
• 2023-08-11 Creatinine 1.01 mg/dL

Nab-Paclitaxel for patients with altered kidney function, there are no dosage adjustment recommendations for those with a Creatinine Clearance (CrCl) ≥30 mL/minute. Furthermore, there are no pharmacokinetic studies available for severe kidney impairment in patients with a CrCl <30 mL/minute.

700184828

240226

[past history]

• Medical history:
  • Hypertension
  • Goiter
  • Gall bladder stone
  • Mixed hyperlipidemia
  • Left adrenal hemanigioma status post laparoscopic adrenalectomy
  • Diabetes, suspicious subclinical Cushing.
  • Acom aneurysm rupture s/p TAE at ShuGuang Hospital in ShangHai, 20160326
  • Non rupture right MCA aneurysm.
• Operative history:
  • Left adrenal hemanigioma status post laparoscopic adrenalectomy
  • Acom aneurysm rupture s/p TAE at ShuGuang Hospital in ShangHai, 20160326
  • Port-A insertion on 2022-10-13
• Neoadjuvent chemotherapy with
  • Lipo-dox 35mg/m2 + Endoxan 600mg/m2 since 2022/10/22~2022/12/26.
  • Taxotere 75mg/m2 since 2023/01/31~ .
  • Herceptin 600mg SC + Perjeta 420mg for 6 cycles since 2023/01/31~

[allergy]

• NKDA                 

[family history]

• There is no family history of mental diseases or asthma.
• Father: lung cancer; Mother: hypertension.

[exam findings]

• 2023-01-31 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 21) / 80 = 73.75%
    • M-mode (Teichholz) = 73
  • Preserved LV and RV systolic function with normal wall motion
  • Mildly dilated LA, grade 1 LV diastolic dysfunction
  • Mild MR, TR
• 2022-10-14 Patho - breast biopsy (no need margin)
  • Breast, left, biopsy — fibroadenoma
  • Microscopically, the breast shows fibroadenoma composed of intracanalicular growth pattern of elongated and branching mammary ductules surrounded by fibrous stroma.
• 2022-10-13 SONO - neck (lymph node)
  • Sonography of neck revealed some LNs in bil. neck.
• 2022-10-12 SONO - breast
  • Diagnosis
    • uncertain breast tumor, in favor of benign
    • fibroadenoma (FA) suspect malignancy from PET
  • Suggestion and Plan
    • regular OPD follow-up.
    • A breast tumor located at L’t (1, 0) noted from sonography.
    • We use 16 guage needle to puncture the tumor for 3 times.
• 2022-09-30 Whole body PET scan
  • There was increased FDG uptake in multiple focal areas in the right breast (SUVmax early: 18.22, delay: 20.27), in multiple right axillary lymph nodes (SUVmax early: 17.81, delay: 24.89), in a small focal area in the left breast (SUVmax early: 17.33, delay: 23.16), in a focal area in the right parotid gland (SUVmax early: 7.93, delay: 7.69), in some bilateral neck lymph nodes (SUVmax early: 5.17, delay: 6.25) and in the right adrenal gland (SUVmax early: 7.32, delay: 9.92).
  • IMPRESSION:
    • Multiple glucose hypermetabolic lesions in the right breast, compatible with multiple malignant breast tumors.
    • A small glucose hypermetabolic lesion in the left breast. Breast malignancy should be watched out. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in multiple right axillary lymph nodes, suggesting metastatic lymph nodes.
    • A glucose hypermetabolic lesion in the right parotid gland. Some kind of parotid lesion may show this picture. Please correlate with other clinical findings for further evaluation
    • Mild glucose hypermetabolism in some bilateral neck lymph nodes. Inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Glucose hypermetabolism in the right adrenal gland. Either hyperplasia or adenoma may show this picture. Please also correlate with other clinical findings for further evaluation
• 2022-09-29 Patho - breast biopsy (no need margin)
  • Lymph node, right axillary, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains (using block: S2022-16632): ER (-, 0%), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67( 70%), E-cadherin (+).
  • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.
• 2022-09-29 Patho - breast biopsy (no need margin)
  • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains (using block: S2022-16631): ER (-, 0%), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67( 70%), E-cadherin (+).
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2022-09-27 Mammography
  • Screening digital mammography of both breasts with MLO and CC views:
  • Old mammographic study: 2013-08-09 (BIRADS 1)
  • Impression:
    • Dense breast. Right breast tumors with enlarged right axillary lymph nodes, suspected malignancy with lymph nodes metastasis.
  • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.

[chemoimmunotherapy]

• 2024-01-02 - trastuzumab emtansine 3.6mg/kg 243mg NS 250mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-12-13 - trastuzumab emtansine 3.6mg/kg 243mg NS 250mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-11-06 - trastuzumab emtansine 3.6mg/kg 244mg NS 250mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-10-16 - trastuzumab emtansine 3.6mg/kg 251mg NS 250mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-09-25 - trastuzumab emtansine 3.6mg/kg 251mg NS 250mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-09-04 - trastuzumab emtansine 3.6mg/kg 254mg NS 250mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-08-14 - trastuzumab emtansine 3.6mg/kg 255mg NS 250mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-07-24 - trastuzumab emtansine 3.6mg/kg 256mg NS 250mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-06-26 - trastuzumab emtansine 3.6mg/kg 256mg NS 250mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-05-17 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr
• 2023-04-27 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr
• 2023-04-06 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 133mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-03-14 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 133mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-02-21 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 133mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-01-31 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr + docetaxel 75mg/m2 132mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-12-26 - cyclophosphamide 600mg/m2 1046mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2022-12-05 - cyclophosphamide 600mg/m2 1048mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2022-11-14 - cyclophosphamide 600mg/m2 1048mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2022-10-22 - cyclophosphamide 600mg/m2 1053mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

==========

2024-02-26

[guidelines for platelet transfusion addressing thrombocytopenia in Kadcyla therapy]

The patient has been on Kadcyla (trastuzumab emtansine) therapy since 2023-06-26, following a previous regimen that included Herceptin (trastuzumab) and Perjeta (pertuzumab), with the last dose administered on 2023-05-17.

Post-initiation of Kadcyla, there has been a temporal association with an increase in both the frequency and severity of thrombocytopenia episodes, indicating that the thrombocytopenia could be attributed to Kadcyla. Literature indicates that trastuzumab emtansine is associated with thrombocytopenia, with incidences ranging from 29% to 31%, and grades 3/4 thrombocytopenia occurring in 6% to 15% of cases, including a higher incidence in patients of Asian descent, where grades 3/4 thrombocytopenia ranges from 19% to 45%.

• 2024-02-23 PLT 87 x10^3/uL **
• 2024-02-22 PLT 44 x10^3/uL ***
• 2024-01-16 PLT 55 x10^3/uL **
• 2024-01-06 PLT 51 x10^3/uL **
• 2024-01-02 PLT 61 x10^3/uL **
• 2023-12-13 PLT 116 x10^3/uL *
• 2023-11-27 PLT 69 x10^3/uL **
• 2023-11-06 PLT 95 x10^3/uL **
• 2023-10-16 PLT 110 x10^3/uL *
• 2023-09-25 PLT 144 x10^3/uL *
• 2023-09-04 PLT 177 x10^3/uL
• 2023-08-14 PLT 248 x10^3/uL
• 2023-07-24 PLT 251 x10^3/uL
• 2023-07-04 PLT 84 x10^3/uL **
• 2023-06-26 PLT 239 x10^3/uL
• 2023-05-25 PLT 212 x10^3/uL
• 2023-04-27 PLT 285 x10^3/uL
• 2023-04-06 PLT 232 x10^3/uL
• 2023-03-14 PLT 284 x10^3/uL
• 2023-02-21 PLT 264 x10^3/uL
• 2023-02-07 PLT 273 x10^3/uL
• 2023-01-31 PLT 243 x10^3/uL

Prophylactic platelet transfusions are recommended to prevent spontaneous bleeding in afebrile patients with platelet counts below 10K/uL due to bone marrow suppression. This recommendation aligns with guidelines from the International Society on Thrombosis and Haemostasis published in 2023 (Reference: J Thromb Haemost. 2024;22(1):53).

In patients presenting with fever, infection, or inflammation, platelet transfusions are generally advised at counts of ≤ 15K to 20K/uL due to the heightened risk of bleeding (Reference: Clin Lab Med. 2021;41(4):621).

2023-02-22

There are currently no bowel movement records for this hospital stay in HIS5. However, the records from the patient’s previous hospital stay (between 2023-01-31 and 2023-02-01) indicated that the patient had one bowel movement per day.

According to the review of systems in the admission note for this hospital stay, the patient experienced diarrhea and had 8 to 9 bowel movements per day.

It might be noted that docetaxel is known to cause gastrointestinal adverse reactions, including diarrhea (with a frequency of 23% to 43%, and severe diarrhea occurring in 6% or less of cases), and the incidence of diarrhea with pertuzumab and trastuzumab is 60% (ref: UpToDate).

The use of loperamide is recommended as a means of alleviating diarrhea and Loperamide (2mg/cap) is available in this hospital.

Loperamide usage: Oral, Initial: 4 mg, followed by 2 mg every 2 to 4 hours or after each loose stool; for diarrhea persisting >24 hours, administer 2 mg every 2 hours (or 4 mg every 4 hours). Continue until 12 hours have passed without a loose bowel movement. Doses >16 mg/day may not provide benefit; consider alternative therapy for diarrhea persisting >=48 hours.

700738641

240226

[MedRec]

• 2024-02-22 SOAP Metabolism and Endocrinology Liao YuHuang
  • Prescription x3
    • Relinide (repaglinide 1mg) 0.5# TIDAC15
    • Januvia (sitagliptin 100mg) 1# QD
    • Zulitor (pitavastatin 4mg) 0.5# QD
    • Doxaben (doxazosin 4mg) 1# QD
• 2024-01-25 SOAP Orthopedics Zen XiaoZu
  • Prescription x3
    • TieShrShuPap (flurbiprofen 40mg/patch) 1# QD EXT
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# BID
• 2023-12-07 SOAP Urology Wu ShuYu
  • A: BPH, OAB, urolithiasis
  • Prescription x2
    • Minirin Melt (desmopressin 60ug) 1# HS
    • Avodart (dutasteride 0.5mg) 1# QD

==========

2024-02-26

[reconciliation]

According to the PharmaCloud database, there are no outstanding prescriptions issued by other healthcare provider.

Two drugs, Relinide (repaglinide) and Januvia (sitagliptin), prescribed by our endocrinologist on 2024-02-22, are not reflected in the active medication list. It is recommended to verify whether these medications are no longer required.

700335981

240223

[exam findings]

• 2023-12-28 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Consolidation of left lower lobe and posterior segment of left upper lobe is found.
    • S/p port-A placement with its tip at Superior vena cava.
    • There is stone at dependent portion of GB. GB stone(s) are noted.
    • Loculated cystic change at pancreatic body measuring 2.8cm in largest dimension. Suggest follow up.
  • Imp:
    • Consolidation of left lower lobe and posterior segment of left upper lobe is found. Suggest closely follow up.
• 2023-11-13 CXR (erect)
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Increased lung markings on left middle lung and both lower lung are noted.
• 2023-10-26 Bladder Sonography
  • PVR 26.88mL
• 2023-07-27 SONO - abdomen
  • Diagnosis:
    • Suspected chronic liver parenchyma disease
    • Suspected GB stone
    • Pancreas not shown
    • Suboptimal examination of liver, especially the subcostal view due to poor echo window
  • Suggestion:
    • OPD f/u
    • Please correlate with liver function test and follow AFP
    • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
• 2023-07-11 Neurosonology
  • Occlusion in R proximal CCA to CCA bifurcation; tight stenosis with trace flow in R ICA; reversed R ECA flow; mild to moderate atheromatous lesions in L CCA bifurcation and ICA; mild atheromatous lesions in L proximal to distal CCA.
  • Normal extracranial L carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • Poor bilateral temporal windows for transcranial insonation.
  • Normal bilateral ophthalmic arterial flows.
  • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
• 2023-06-17 CT - chest
  • LLL small cell carcinoma with lung to lung metastases, T2N2M0, stage IIIA s/p radiotherapy to the Lt lung tumor and LAPs from 2023/03/22~ and chemotherapy with EP (Etoposide 80mg/m2(D1~D3), Carboplatin AUC:4(D1)) from 2023/03/27~
  • Chest CT with and without IV contrast ehnancement shows:
    • Centrilobular Emphysematous change over both lungs is found.
    • Interstitial change at both lungs more on the dependent lung is found.
    • Minimal infiltration over left lower lobe is found. In comparison with CT dated on 2023-01-28, the lesion decreased in size markedly.
    • There is mild bilateral pleural effusion.
    • Calcified coronary arteries is found.
  • Imp:
    • left lower lobe lung cancer s/p C/T with almost complete remission.
    • COPD
    • Interstitial change at both lungs. Cancer Treatment related change cannot be fully excluded.
• 2023-05-11, -04-20 CXR
  • Atherosclerotic change of aortic arch
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2023-03-22 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 28 dB HL; LE 59 dB HL.
  • RE normal to severe SNHL. (BC masking dilemma at 4k Hz)
  • LE moderate to profound mixed type HL.
• 2023-03-16 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopharynx, right, biopsy — Lymphoid hyperplasia
  • Section shows a piece of respiratory epithelium lined tissue with lymphoid hyperplasia.
  • The immunohistochemical stain of CK reveals no invasive tumor. The immunohistochemical stains of CD3 and CD20 show relatively preserved lymphoid architecture. The immunohistochemical stain of CD56 is negative.
• 2023-03-16 Nasopharyngoscopy
  • Bx of R NP PET + lesion
  • smooth bulging
  • CT-guided Bx = L poor diff ca, favor small cell ca
• 2023-03-06 PET
  • Glucose hypermetabolism in the left lower lung with left pulmonary lymph nodes involvement, highly suspected the primary lung cancer with regional lymph nodes metastases. Some small nodular lesions in the right lower lung, however, show no increased FDG uptake.
    
  • Increased FDG uptake in bilateral mediastinal and right pulmonary hilar lymph nodes, probably reactive or metastatic nodes, suggesting further evaluation.
  • Increased FDG uptake in the in the post. wall (submucosa layrer ?) of the right nasopharynx, the nature is to be determined (another NPC, inflammation process or other nature ?), suggesting biopsy for investigation.
  • Increased FDG uptake in soft tissue of bilateral buccal regions, inflammation process may show this picture.
  • Decreased FDG uptake in the left fronto-parieto-temporal regions of the cerebral cortex, compatible with cerebral infarction.
    
  • Left lower lung cancer, cTxN1-3M0 (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-02-13 Portable 24hr ECG
  • Baseline was sinus rhythm with paroxysmal AFIB
  • 2 episodes of sustained pAFIB noted (13~16PM, 8~12AM)
  • Rare isolated VPCs / VPC couplet
  • Frequent isolated APCs / APC couplets (Burden 2%)
  • 19 episodes of short-run AT, max 6 beats
• 2023-02-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (95 - 25) / 95 = 73.68%
    • M-mode (Teichholz) = 73
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR, mild AR, trivial TR
    • Impaired LV relexation
    • Preserved RV systolic function
• 2023-02-10 Tc-99m MDP bone scan
  • Increased activity in some L-spines and sacrum. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Some hot and faint hot spots in the posterior aspect of bilateral rib cages and increased activity in the left frontal area of the skull and left tibia. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and knees, compatible with benign joint lesions.
• 2023-02-06 CXR
  • Lung markings: a nodular lesion in the left perihilar lung field
• 2023-02-06 Patho - lung transbronchial biopsy
  • Lung, left, CT-guide biopsy — poorly differentiated carcinoma, in favor of small cell carcinoma
  • Sections show large nests of small hyperchromatic tumor cells with scanty cytoplasm and crushing artifact.
  • The immunohistochemical stains reveal CK(+), CK7(focal +), CK20(-), CD56(focal +), Synaptophysin(-), Chromogranin A(-), TTF-1(-), Napsin A(-), p40(-), GATA3(-), and CDX2(-). The Ki-67 is about 80%. The results and morphology are in favor of small cell carcinoma. Please correlate with the clinical presentation and image study.
• 2023-01-31 CT - abdomen
  • With and without contrast enhancement CT of abdomen:
    • Presence of gallbladder stone.
    • Left upper lung tumor (3.1cm), r/o lung malignancy.
    • Right lower lung nodule, r/o lung to lung metastasis.
    • Emphysematous change of lungs.
  • Impression:
    • GB stone.
    • Left upper lung tumor, r/o lung malignancy.
    • RLL nodule, r/o lung to lung metastasis.
    • Emphysematous change of lungs.
• 2023-01-31 Electroencephalography, EEG
  • This EEG study recorded background alpha rhythm (8-9) and beta activity with intermittent transient diffuse slow waves. more on the left.
  • No epileptiform discharges.
  • Please correlate with clinical features.
• 2023-01-28 CT - chest
  • Indication: for left lung nodular?
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Moderate to severe Emphysematous change over both lungs is found.
      • Mass like lesion at left upper lobe measuring 3.33cm in largest dimension. r/o lung cancer.
      • Minimal peribronchial opacity oveer right lower lobe and left lower lobe is found.
      • Some lymph nodes are found at bialteral paratracheal region.
    • Visible abdomen:
      • There is stone at dependent portion of GB. GB stone(s) are noted.
  • IMP:
    • COPD with one mass at left upper lobe measuring 3.33cm. Lung cancer is suspected.
    • Mediatinal lymphadenopathy
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-01-27 Neurosonology
  • Occlusion in R proximal CCA to CCA bifurcation; tight stenosis with trace flow in R ICA; reversed R ECA flow; mild atheromatous lesions in L CCA bifurcation and ICA.
  • Normal extracranial L carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • Poor bilateral temporal windows for transcranial insonation.
  • Reversed R ophthalmic arterial flows.
  • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
• 2023-01-26 MRA - brain
  • Subacute infarcts involving left frontotemporal lobe and basal ganglion as described. Stenosis of right ICA. Mild general brain atrophy.
• 2023-01-23, -01-19 CXR
  • Lung markings: a nodular lesion in the left perihilar lung field

[MedRec]

• 2024-02-22 SOAP Chest Medicine Lan ZhouJin
  • Prescription x3
    • Xanthium (theophylline 200mg) 1# BID
    • Mecater (procaterol 25ug) 1# QD
    • Concor (bisoprolol 1.25mg) 1# PRNQD if SBP > 140
    • Berotec-N (fenoterol 0.1mg/pull) 1 puff PRNQID INHL
    • Spiolto (tiotropium 2.5ug, olodaterol 2.5ug; per puff) 2 puff QD INHL
• 2024-02-02 SOAP Neurology Chen PeiYa
  • Prescription x3
    • Syntam (piracetam 1200mg) 1# QD
    • Lixiana (edoxaban 30mg) 1# QD
    • Mesyrel (trazodone 50mg) 1# HS
• 2024-01-24 SOAP Cardiology Zhan ShiRong
  • Prescription x3
    • Cartil (diltiazem 30mg) 1# BID hold if SBP < 100
    • Cordaron (amiodarone 200mg) 1# QD
• 2024-01-18 SOAP Urology Wu ZhuYu
  • A: NVD (Bard: Neurogenic? or Night? Voiding Dysfunction), urine retention
  • Prescription x3
    • Urief (silodosin 8mg) 1# QD
    • Wecoli (bethanechol 25mg) 1# TIDAC
• 2023-11-23 SOAP Neurology Chen PeiYa
  • Prescription x3
    • Syntam (piracetam 1200mg) 1# QD
    • Lixiana (edoxaban 30mg) 1# QD
    • Mesyrel (trazodone 50mg) 0.5# HS
• 2023-10-11 ~ 2023-10-13 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Left lower lung small cell carcinoma with lung to lung metastases, T2N2M0, stage IIIA s/p radiotherapy to deliver 66~70 Gy/ 33~35 fx to the Lt lung tumor and LAPs from 2023/03/22~06/20 and chemotherapy with EP (Etoposide 80mg/m2(D1~D3), Carboplatin AUC:4(D1)) from 2023/03/27~
    • Chronic obstructive pulmonary disease, unspecified
    • Left distal ICA and left MCA occlusion with infarction s/p IV rt-PA therapy and EVT
    • Atrial fibrillation
    • Constipation, unspecified
    • Chronic viral hepatitis B without delta-agent
    • Anxiety disorder, unspecified
    • Hyperlipidemia, unspecified
    • Hypomagnesemia
    • Hypokalemia
    • Enlarged prostate with lower urinary tract symptoms
    • Other difficulties with micturition
    • Neuromuscular dysfunction of bladder, unspecified
    • Cachexia
  • CC
    • for chemotherapy plus immunity therapy
  • Present illness
    • This 74 year-old man suffered found lying on the ground with speechlessness on 2023/01/14.
    • Brain CT on 2023/01/14 was performed revealed suspect hyperdensity at left distal ICA and proximal MCA, suggest CTA study to clarify.
    • The neurology was consulted. Who suggest r-tPA was indication.
    • After Brain CTA on 2023/01/14 was performed revealed occlusion of left ICA and proximal MCA, r/o ICA dissectio and suspect occlusion of right CCA.
    • Impression of left distal ICA and left MCA occlusion with infarction s/p r-tPA, EVT + IA thrombectomy on 2023/01/14.
    • Brain VT on 2023/01/15 showed no definite intracranial hemorrhage and acute infarct in left insular cortex and frontal lobe.
    • Brain MRA on 2023/01/26 showed subacute infarcts involving left frontotemporal lobe and basal ganglion as described, stenosis of right ICA and mild general brain atrophy.
    • Dopscan + CPA on 2023/01/27 showed 1) Occlusion in R proximal CCA to CCA bifurcation; tight stenosis with trace flow in R ICA; reversed R ECA flow; mild atheromatous lesions in L CCA bifurcation and ICA. 2) Normal extracranial L carotid, vertebral, and intracranial vertebral, basilar arterial flows. 3) Poor bilateral temporal windows for transcranial insonation. 4) Reversed R ophthalmic arterial flows. 5) Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
    • Chest CT on 2023/01/28 showed COPD with one mass at left upper lobe measuring 3.33cm, Lung cancer is suspected and mediatinal lymphadenopathy, T2N2M0, stage IIIA.
    • Abdominal CT on 2023/01/31 showed GB stone, left upper lung tumor, R/O lung malignancy, RLL nodule, R/O lung to lung metastasis and emphysematous change of lungs.
    • Awake or Sleep EEG on 2023/01/31 showed this EEG study recorded background alpha rhythm (8-9) and beta activity with intermittent transient diffuse slow waves. more on the left, no epileptiform discharges and please correlate with clinical features.
    • LLL lung mass CT-guided biopsy on 2023/02/06 and pathology showed poorly differentiated carcinoma, in favor of small cell carcinoma, immunohistochemical stains reveal CK(+), CK7(focal +), CK20(-), CD56(focal +), Synaptophysin(-), Chromogranin A(-), TTF-1(-), Napsin A(-), p40(-), GATA3(-), and CDX2(-), the Ki-67 is about 80% and the results and morphology are in favor of small cell carcinoma.
    • Whole body bone scan on 2023/02/10 showed degenerative of L-spines and sacrum, no bone metastasis. 2D echo on 2023/02/13 showed M-mode (Teichholz) = 73, 1. Adequate LV systolic function with normal resting wall motion 2. Trivial MR, mild AR, trivial TR 3. Impaired LV relexation 4. Preserved RV systolic function.
    • Whole body PET scan on 2023/03/06 showed left lower lung with left pulmonary lymph nodes involvement, highly suspected the primary lung cancer with regional lymph nodes metastases, some small nodular lesions in the right lower lung, bilateral mediastinal and right pulmonary hilar lymph nodes, probably reactive or metastatic nodes, left lower lung cancer, cTxN1-3M0.
    • Port-A catheter implantation on 2023/03/06.
    • Nasopharyngoscopy on 2023/03/16 with nasopharynx right biopsy lymphoid hyperplasia.
    • He received PTA on 2023/03/22 showed Reliability FAIR, Average RE 28 dB HL; LE 59 dB HL, RE normal to severe SNHL. (BC masking dilemma at 4k Hz) and LE moderate to profound mixed type HL.
    • 24hrs CCr. on 2023/03/23 showed 54.5ml/min.
    • Radiotherapy to deliver 66~70 Gy/ 33~35 fx to the Lt lung tumor and LAPs from 2023/03/22~2023/03/23, 2023/03/29~.
    • Chemotherapy with EP(Etoposide 80mg/m2(D1~D3), Carboplatin AUC:4(D1)) was given on 2023/03/27(C1), on 2023/06/01(C2).
    • Follow up Chest CT on 2023/06/17 showed left lower lobe lung cancer s/p C/T with almost complete remission, COPD, interstitial change at both lungs. Cancer Treatment related change cannot be fully excluded.
    • Extensive discussion with treatment strategy, suggest IO plus C/T.
    • Chemotherapy plus immunity therapy with Carboplatin + Etoposide + Durvalumab (C1) on 2023/09/11.
    • This time, he was admitted to our ward for chemotherapy plus immunity therapy with Carboplatin + Etoposide + Durvalumab (free) (C2).
  • Course of inpatient treatment
    • After admission, he received chemitherapy with Carboplatin (AUC:4)/ Etoposide(100mg/m2, D1-D3)/ Durvalumab(1500mg, C2 Free(Buy one Free one)), post last chemotherapy, weakness still noted, discussion with wife, reduce Etoposide(100mg/m2, D1-D3), and decrease Carboplatin (AUC:4->2) on 2023/10/12.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • Chronic obstructive pulmonary disease with Mecater 25mcg/tab 1# PO QD, ROMICON-A 20,20,90mg/cap 1# PO QD for cough, Xanthium 200mg/cap 1# PO BID, Shitan 8mg/tab 1# PO BID, Spiolto 60 puff/box 2puff INHL QD.
    • Left distal ICA and left MCA occlusion with infarction s/p IV rt-PA therapy and EVT with Syntam Granules 1200mg/pk 1pk PO QD.
    • Atrial fibrillation with Lixiana F.C. 30mg 1# po QD, Concor 1.25mg/tab 1# PO PRNQD if SBP > 140mmHg and Cartil 30 mg/tab 1# PO BID Hold if SBP < 100mmHg.
    • For chemotherapy, Baraclude 0.5mg 1# po QDAC was given for Anti-HBc showed Reactive.
    • Hyperlipidemia with CRESTOR 10mg/tab 1# PO QD.
    • Hypomagnesemia with Magnesium Sulfate 10%, 20mL/amp 1amp IVD for support.
    • Hypokalemia with 0.298% KCl in 0.9% NaCl Injection 500mL/bot IVD for support.
    • Neuromuscular dysfunction of bladder, Uro OPD follow up, was treated with Urief F.C 8mg/tab 1# PO QD, Wecoli 25mg/tab 1# PO TIDAC.
    • Constipation with Through 12mg/tab 1# PO HS.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/10/13 and OPD followed up later.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QLAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • BaoGan (silymarin 150mg) 2# BID
    • Crestor (rosuvastatin 10mg) 1# QD
    • Actein Effervescent (acetylcisteine 600mg) 1# BID
    • Through (sennoside 12mg) 1# HS
    • Megest (megestrol 40mg/mL) 10mL QD
• 2023-08-31 SOAP Neurology Chen PeiYa
  • Prescription x3
    • Syntam (piracetam 1200mg) 1# QD
    • Lixiana (edoxaban 30mg) 1# QD
    • Mesyrel (trazodone 50mg) 0.5# QODHS
• 2023-08-31 SOAP Chest Medicine Lan ZhouJin
  • Prescription x3
    • Xanthium (theophylline 200mg) 1# BID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# BID
    • Mecater (procaterol 25ug) 1# QD
• 2023-08-09 SOAP Cardiology Zhan ShiRong
  • Prescription x3
    • Cartil (diltiazem 30mg) 1# BID
• 2023-05-25 SOAP Psychosomatic Medicine
  • S: The patient comes with son and wife. Less anxiety, less dysphoria, and more speech. It seems response to the additional sertraline.
• 2023-05-11 SOAP Psychosomatic Medicine
  • S: MAJOR ILLNESS CARD: [Diagnostic interview 45085] C.C. & P.I.: The first time visit, the patient comes with wife and son. He initilally focus on left lower leg and ankle area. He then hesitately to talk about something wrong, about his wife and son. left cerebral stroke. In addition, lung cancer diagnosis at the same time. Low self-esteem, hypotalkativeness.
• 2023-02-23 SOAP Chest Medicine
  • A/P
    • visit for asking about cancer Tx, for his stage III and poor performance, surgey was not suggested, refer to Oncology for possible clinical trial of IO
    • Tx COPD with Mx,
    • P: ultibro, xanthium, medicon
  • Prescription
    • Xanthium (theophylline 200mg) 1# QD
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Ultibro Breezhaler (indacaterol 100ug, glycopyrronium 50ug) 1# QD INHL

[consultation]

• 2024-01-03 Radiation Oncology
  • Q
    • for increase infiltration of lung after radiotherapy
  • A
    • The consolidation of left lower lobe and posterior segment of left upper lobe shown on the latest chest CT are comparable to the irradiated volume (2023-03-23 ~ 2023-06-20: 66 Gy/ 33 fx), which indicates fibrotic change. The fibrotic change is less likely to interfere systemic Tx such as IO if active infection has been ruled out.
• 2023-06-23 Cardiology
  • Q
    • The patient is an 74-year-old male with a history of Left lower lung small cell carcinoma with lung to lung metastases, T2N2M0, stage IIIA s/p radiotherapy to deliver 66~70 Gy/ 33~35 fx to the Lt lung tumor and LAPs from 2023/03/22~ and chemotherapy with EP (Etoposide 80mg/m2(D1~D3), Carboplatin AUC:4(D1)) from 2023/03/27~, last time C/T on 2023/06/01, now under R/T.
    • For heart disease history, he presented with tachycardia for days, we need your further evaluation and management.
  • A
    • S: 74 year-old male had the history of Left distal internal carotid artery and left middle cerebral artery occlusion with infarction post intravenous recombinant tissue plasminogen activator and endovascular thrombectomy on 2023-01-14, atrial fibrillation and left lung cancer stage IIIA.
      • The patient just had the recovery of pancytopenia after chemotherapy.
    • O
      • LAB 6/23 Hb10.9 PLT231l Cre0.90 ALT54 K4.6; 6/15 albumin 3.0
      • ECG 20230612 Af, VR118bpm
      • CXR 230616 no cardiomegaly,
      • CT of chest 20230617
        • Centrilobular Emphysematous change over both lungs is found.
        • Interstitial change at both lungs more on the dependent lung is found.
        • Minimal infiltration over left lower lobe is found. In comparison with CT dated on 2023-01-28, the lesion decreased in size markedly.
        • There is mild bilateral pleural effusion.
        • Calcified coronary arteries is found.
      • Echocardiogram 20230213
        • Findings
          • AO(mm) = 34; LA(mm) = 35
          • IVS(mm) = 10; LVPW(mm) = 7
          • LVEDD(mm) = 45; LVESD(mm) = 26
          • TAPSE(mm) = 19
          • M-mode(Teichholz) = 73
          • TR: Trivial; Max pressure gradient = 21 mmHg
          • IVC size 7 mm with respiratory collapse > 50%
        • Conclusion:
          • Adequate LV systolic function with normal resting wall motion
          • Trivial MR, mild AR, trivial TR
          • Impaired LV relexation
          • Preserved RV systolic function
    • Impression
      • Atrial fibrillation
    • Suggestion
      • Give regular bisoprolol 1.25mg QD if no bronchospasm
      • Keep rosuvastatin, edoxaban 30mg QD
      • Watch fluid status and any sepsis (might induce HR increasing)
      • Holter ECG evaluation
      • Consider diltiazem 30mg QD or BID for ventricular rate control
• 2023-06-20 Infectious Disease
  • Q
    • The patient is an 74-year-old male with a history of Left lower lung small cell carcinoma with lung to lung metastases, T2N2M0, stage IIIA s/p radiotherapy to deliver 66~70 Gy/ 33~35 fx to the Lt lung tumor and LAPs from 2023/03/22~ and chemotherapy with EP (Etoposide 80mg/m2(D1~D3), Carboplatin AUC:4(D1)) from 2023/03/27~, last time C/T on 2023/06/01, now under R/T.
    • he presented with herpes of lip since 6/17 night, we need your further evaluation and management.
  • A
    • Hx review as mentioned above and Lab data
    • Suggestion: keep topic acyclovir ointment for lip herpes and follow-up
• 2023-02-02 Diagnostic Radiology
  • A: This 74-year-old patient is a case of LLL lung mass, r/o malignancy. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
• 2023-01-30 Chest Medicine
  • Q
    • This 74 y/o man has a history of HTN and hyperuricemia. He was normal at 6pm when going to toilet but was found lying on the ground with speechlessness at 6:30pm. He denied of any aura, urinary or faecal incontinence, history of recent URI symptoms, headaceh, taking OC pills, unknown medications, similar disease in family history. He was sent to our ER for help. Arrival our ER around 19PM. Initail GCS E4V2M6. Physical examination shoed right limb weakness (muscle power 0), left gaze deviation, right hemianopia and right central facial palsy. Brain CT was performed revealed suspect hyperdensity at left distal ICA and proximal MCA. The neurology was consulted. Who suggest r-tPA was indication. After Brain CTA was performed revealed occlusion of left ICA and proximal MCA, r/o ICA dissectio and suspect occlusion of right CCA. Impression of left distal ICA and left MCA occlusion with infarction s/p r-tPA + IA thrombectomy then admission to SICU for neurologicalo monitor.
    • After admission, the brain CT was follow-up on 2023-01-15, it revealed No definite intracranial hemorrhage, acute infarct in left insular cortex and frontal lobe. The Plavix was added at that time. After general condition stable, he will transfer to ward on 2023/01/19. at ward, his conscious E4VA(dysarthria + breathy sound)M6. motor aphasia, MP general 4-5. s/p NG with Foley and remove sucess. the bronchdilator for wheezing.
    • Brain MRA showed Subacute infarcts involving left frontotemporal lobe and basal ganglion as described. Stenosis of right ICA. Mild general brain atrophy. For chest x-ray found a nodular lesion in the left perihilar region. chest CT was done and showed COPD with one mass at left upper lobe measuring 3.33cm. Lung cancer is suspected. Mediatinal lymphadenopathy. we arranged Abdomen CT+C afternoon, so your was consulted.
  • A
    • For his CT scan with emphysema with one mass at left upper lobe measuring 3.33cm. Lung cancer is suspected. Suggested to perform CT guided biospy. If he is proved to be case of lung cancer, further study of brain MRI and bone scan should be done.
    • For his emphysema, Spiolto inhaler is suggested.
    • I will like to follow this case if pathology available.
• 2023-01-14 Neurology
  • Q
    • CVA Call
    • Triage Level: 2, Limb Weakness > Symptom onset time <4.5 hours. At 18 PM, patient was normally using the toilet. At 18:30 PM, patient was unable to move in the toilet, exhibiting right side limb weakness and both eyes looking to the left. Fasting sugar is 74 mg/dL by EMT. Denies TOCC (Time of onset, Characteristics, Circumstances).
  • A1
    • This 74 y/o man has a history of HTN and hyperuricemia. He was normal at 6pm when going to toilet but was found lying on the ground with speechlessness at 6:30pm.
    • NE E4VaM5 aphasia
      • CNs:
        • left gaze deviation, right hemianopia
        • right central facial palsy
      • MP upper 0/5 lower 2-3 /5
      • sensation: poor response of right limbs
      • NIHSS 022 111 0402 01320 (18) at 19:25
    • brain CT: no ICH, left dense MCA sign
    • impression: acute left MCA territory infarct
    • suggestion:
      • rt-PA therapy was indicated (71.2kg, 0.9mg/kg, total 64mg, loading 6.4mg)
      • arrange CTA to rule out LVO and consider EVT if indicated
      • neurology ICU admission
  • A2 2023-01-14 20:46:44
    • s/p rt-PA therapy (loading at 19:53)
    • NIHSS 122 111 0302 01220 (18) at 20:40
    • brain CTA: left ICA/MCA occlusion; right CCA occlusion
    • EVT is indicated after discussion with intervention radiologist
    • explained to the family about the EVT and the family agreed
    • tight control BP and arrange EVT

[chemotherapy]

• 2024-01-31 - durvalumab 1500mg NS 250mL 1hr + carboplatin AUC 2 150mg NS 250mL 2hr (Carbo AUC 4 -> 2. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-01-03 - durvalumab 1500mg NS 250mL 1hr + carboplatin AUC 2 150mg NS 250mL 2hr (Carbo AUC 4 -> 2. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-11 - durvalumab 1500mg NS 250mL 1hr + carboplatin AUC 2 150mg NS 250mL 2hr (Carbo AUC 4 -> 2. He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-14 - durvalumab 1500mg NS 250mL 1hr + carboplatin AUC 2 150mg NS 250mL 2hr (Carbo AUC 4 -> 2. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-12 - durvalumab 1500mg NS 250mL 1hr + carboplatin AUC 2 150mg NS 250mL 2hr (Carbo AUC 4 -> 2. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-11 - durvalumab 1500mg NS 250mL 1hr + etoposide 100mg/m2 135mg NS 500mL 2hr D1-3 + carboplatin AUC 4 300mg NS 250mL 2hr D1 (VP16 80mg/m2, Carbo AUC 4. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-01 - etoposide 100mg/m2 135mg NS 500mL 2hr D1-3 + carboplatin AUC 4 300mg NS 250mL 2hr D1 (VP16 80mg/m2, Carbo AUC 4) (CCRT. Xia HeXiong)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-27 - etoposide 100mg/m2 135mg NS 500mL 2hr D1-3 + carboplatin AUC 4 300mg NS 250mL 2hr D1 (VP16 80mg/m2, Carbo AUC 4) (CCRT. Xia HeXiong)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

Small Cell Lung Cancer NCCN Evidence Blocks - Version 1.2024 - 2023-09-05

• PRIMARY OR ADJUVANT THERAPY FOR LIMITED-STAGE SCLC - SCL-E, 1 OF 6
  • Principles
    • Four cycles of systemic therapy are recommended.
    • Planned cycle length should be every 21–28 days during concurrent RT. During systemic therapy + RT, cisplatin/etoposide is recommended (category 1).
    • The use of myeloid growth factors is not recommended during concurrent systemic therapy plus RT (category 1 for not using GM-CSF).
  • Preferred Regimens
    • Cisplatin 75 mg/m2 day 1 and etoposide 100 mg/m2 days 1, 2, 3
    • Cisplatin 60 mg/m2 day 1 and etoposide 120 mg/m2 days 1, 2, 3
  • Other Recommended Regimens
    • Cisplatin 25 mg/m2 days 1, 2, 3 and etoposide 100 mg/m2 days 1, 2, 3
    • Carboplatin area under the curve (AUC) 5–6 day 1 and etoposide 100 mg/m2 days 1, 2, 3
• PRIMARY THERAPY FOR EXTENSIVE-STAGE SCLC - SCL-E, 1 OF 6
  • Principles
    • Four cycles of therapy are recommended, but some patients may receive up to 6 cycles based on response and tolerability after 4 cycles.
  • Preferred Regimens
    • Carboplatin AUC 5 day 1 and etoposide 100 mg/m2 days 1, 2, 3 and atezolizumab 1200 mg day 1 every 21 days x 4 cycles followed by maintenance atezolizumab 1200 mg day 1, every 21 days (category 1 for all)
    • Carboplatin AUC 5 day 1 and etoposide 100 mg/m² days 1, 2, 3 and atezolizumab 1200 mg day 1 every 21 days x 4 cycles followed by maintenance atezolizumab 1680 mg day 1, every 28 days
    • Carboplatin AUC 5-6 day 1 and etoposide 80-100 mg/m2 days 1, 2, 3 and durvalumab 1500 mg day 1 every 21 days x 4 cycles followed by maintenance durvalumab 1500 mg day 1 every 28 days (category 1 for all)
    • Cisplatin 75–80 mg/m2 day 1 and etoposide 80–100 mg/m2 days 1, 2, 3 and durvalumab 1500 mg day 1 every 21 days x 4 cycles followed by maintenance durvalumab 1500 mg day 1 every 28 days (category 1 for all)
  • Other Recommended Regimens
    • Carboplatin AUC 5–6 day 1 and etoposide 100 mg/m2 days 1, 2, 3
    • Cisplatin 75 mg/m2 day 1 and etoposide 100 mg/m2 days 1, 2, 3
    • Cisplatin 80 mg/m2 day 1 and etoposide 80 mg/m2 days 1, 2, 3
    • Cisplatin 25 mg/m2 days 1, 2, 3 and etoposide 100 mg/m2 days 1, 2, 3
  • Useful in Certain Circumstances
    • Carboplatin AUC 5 day 1 and irinotecan 50 mg/m2 days 1, 8, 15
    • Cisplatin 60 mg/m2 day 1 and irinotecan 60 mg/m2 days 1, 8, 15
    • Cisplatin 30 mg/m2 days 1, 8 and irinotecan 65 mg/m2 days 1, 8
• SCLC SUBSEQUENT SYSTEMIC THERAPY (PS 0–2) - SCL-E, 3 OF 6
  • Principles
    • Consider dose reduction or growth factor support for patients with PS 2.
  • CHEMOTHERAPY-FREE INTERVAL (CTFI) >6 MONTHS
    • Preferred Regimens
      • Clinical trial enrollment
      • Re-treatment with platinum-based doublet
    • Other Recommended Regimens
      • Lurbinectedin
      • Topotecan oral (PO) or intravenous (IV)
      • Irinotecan
  • CTFI <=6 MONTHS
    • Preferred Regimens
      • Clinical trial enrollment
      • Lurbinectedin
      • Topotecan oral (PO) or intravenous (IV)
      • Irinotecan
      • Re-treatment with platinum-based doublet may be considered for CTFI 3–6 months
    • Other Recommended Regimens
      • Nivolumab or pembrolizumab (if not previously treated with an ICI)
      • Paclitaxel
      • Temozolomide
      • Cyclophosphamide/doxorubicin/vincristine (CAV)
      • Docetaxel
      • Gemcitabine
      • Oral etoposide
• Response Assessment - SCL-E - 4 OF 6
  • Limited stage  - For patients receiving adjuvant therapy, response assessment is recommended only after completion of adjuvant therapy; do not repeat scans to assess response during adjuvant treatment.  - Response assessment after adjuvant therapy involves C/A/P CT with contrast and brain MRI (preferred) with contrast or brain CT with contrast (SCL-6).  - For patients receiving systemic therapy + concurrent RT, response assessment is recommended only after completion of initial therapy; do not repeat scans to assess response during initial treatment.  - For patients receiving systemic therapy alone or sequential systemic therapy followed by RT, response assessment by C/A/P CT with contrast is recommended after every 2–3 cycles of systemic therapy and at completion of therapy.
  • Extensive stage -During systemic therapy, response assessment by C/A/P CT with contrast is recommended after every 2–3 cycles of systemic therapy and at completion of therapy.  - For patients with asymptomatic brain metastases receiving systemic therapy before brain RT, it is recommended that brain MRI (preferred) or CT with contrast is repeated after every 2 cycles of systemic therapy and at completion of therapy.
  • Subsequent systemic therapy -Response assessment by C/A/P CT with contrast is recommended after every 2–3 cycles of systemic therapy.
  • Transformed SCLC from NSCLC with an Oncogenic Driver -This is a rare population of patients with very limited data to guide treatment. -Systemic cytotoxic chemotherapy is recommended using the NCCN Guidelines for Small Cell Lung Cancer. -The role of immunotherapy in this setting is unclear based on limited data. -If TKI is continued, ICI should be avoided, due to known toxicity. -Consider referral to a center with experience managing transformed SCLC.

Carboplatin plus etoposide for chemotherapy-naïve extensive-stage small cell lung cancer 2023-06-02 https://www.uptodate.com/contents/image?topicKey=ONC%2F4633&imageKey=ONC%2F75586

• Cycle length: 21 days, for a maximum of six cycles.

• Regimen

  • Carboplatin
    • AUC = 5 mg/mL × min IV (AUC is converted to a patient-specific carboplatin dose (in mg) according to renal function by using the Calvert formula. The Calvert formula is total dose (mg) = (target AUC) × (GFR + 25). If using measured serum creatinine, limit the maximal GFR for the calculation to 125 mL/min)
    • Dilute in 250 mL NS and administer over 30 minutes.
    • Day 1
  • Etoposide
    • 100 mg/m2 IV
    • Dilute in 500 mL NS or D5W to final concentration <0.4 mg/mL. Infuse over 30 to 60 minutes; if infused more rapidly, severe hypotension may occur.
    • Days 1, 2, and 3

• Pretreatment considerations:

  • Emesis risk
    • MODERATE on day 1 and LOW on days 2 and 3.
  • Vesicant/irritant properties
    • Carboplatin and etoposide are irritants.
  • Infection prophylaxis
    • Routine primary prophylaxis with hematopoietic growth factors is not recommended (incidence of febrile neutropenia is about 5%).
  • Dose adjustment for baseline liver or renal dysfunction
    • Each carboplatin dose should be calculated based upon renal function by use of the Calvert formula. A lower starting dose of etoposide may be needed for patients with renal or liver impairment.

• Monitoring parameters:

  • CBC with differential and platelet count weekly during treatment.
  • Electrolytes and liver and renal function prior to each cycle of chemotherapy.

• Suggested dose modifications for toxicity:

  • Myelotoxicity
    • Dose adjustment based on myelotoxicity was not reported in the final publication. Per protocol, cycles were delayed for up to 42 days to allow neutrophils to return to >=1500/microL and platelets to >=100,000/microL. However, the United States Prescribing Information recommends that the dose of carboplatin be reduced by 25% if platelets are <50,000/microL and/or ANC is <500/microL.
  • Nonhematologic toxicity
    • Chemotherapy should be held for grade 3 and 4 nonhematologic toxicities (except for neurotoxicity) and is only restarted after the toxicity has resolved to patient’s baseline.
  • Hepatotoxicity
    • No formal etoposide dosing recommendations were reported in this publication. However, accepted dose reductions per product information may be found in the literature.
  • Nephrotoxicity
    • Alterations in renal function during therapy may require a recalculation of the carboplatin dose.
  • If there is a change in body weight of at least 10%, doses should be recalculated.

==========

2024-02-23

[evaluating elevated conjugated bilirubin and potential obstructions]

The level of conjugated bilirubin is elevated, which may indicate obstructions such as gallstones or strictures in the bile ducts, hindering the excretion of bilirubin into the gastrointestinal tract. Abdominal ultrasonography conducted on 2023-07-27 revealed potential chronic liver parenchymal disease and a suspected gallbladder stone. The examination of the liver, particularly the subcostal view, was suboptimal due to a poor echo window.

• 2024-02-22 Bilirubin direct 0.22 mg/dL
• 2024-01-31 Bilirubin direct 0.22 mg/dL
• 2024-01-02 Bilirubin direct 0.16 mg/dL
• 2023-12-11 Bilirubin direct 0.15 mg/dL

It may be advisable to request a follow-up abdominal ultrasonography and an Alpha-Fetoprotein (AFP) test for further evaluation.

2024-02-01

[monitoring pneumonitis risk: durvalumab/carboplatin for stable patchy consolidation]

Comparing the CXR 2024-01-03, to 2024-01-31, the patchy consolidation in the left middle lung has not become more pronounced. On 2024-01-31, a new session of durvalumab combined with carboplatin was administered. Continuous monitoring of the pulmonary condition is recommended.

Pneumonitis includes acute interstitial pneumonitis, interstitial lung disease, pneumonitis, pulmonary fibrosis is associated with Imfinzi (durvalumab), according to the package insert (https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/761069s035lbl.pdf page 12-13; all grades 34%, grade 3/4 3.4%).

Vital signs and lab results were grossly normal except for elevated AST, ALT and bilirubin levels, no medication discrepancies noted.

2024-01-03

[reconciliation]

The admission note dated 2024-01-02 recorded an ECOG PS of 2. The original regimen was designed as “carboplatin AUC 5-6 on day 1 and etoposide 80-100 mg/m2 on days 1, 2, 3, along with durvalumab 1500 mg on day 1 every 21 days for 4-6 cycles, followed by maintenance durvalumab 1500 mg on day 1 every 28 days.” However, due to the patient’s apparent frailty, since Oct 2023, the regimen was modified to a reduced dose version with carboplatin AUC 2 and etoposide omitted. The CT results from 2023-12-28 still indicate an effective disease control.

Lab data from 2024-01-02 showed slightly elevated ALT (42 U/L) and creatinine (1.32 mg/dL) levels. Current medications do not require dose adjustments based on these readings.

2023-10-12

The patient is currently taking several medications with no discrepancies noted: From our neurologist (as of 2023-08-31) for Syntam (piracetam), Lixiana (edoxaban), and Mesyrel (trazodone); from the chest physician (as of 2023-08-31) for Xanthium (theophylline), Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), and Mecater (procaterol); and from the cardiologist (as of 2023-08-09) for Cartil (diltiazem).

The previously observed spikes in AST and ALT levels in May and July/August of this year have now disappeared. Renal function tests show normal results and no drug dose adjustments are required based on liver and kidney function.

The serum potassium level dropped to 3.1 mmol/L on 2023-10-05, the lowest level recorded in the last three months. This may warrant further monitoring.

2023-09-12

Per the HIS5 records, medications issued as repeat prescriptions by our departments of Neurology, Chest Medicine, and Cardiology on 2023-08-31, 2023-08-31, and 2023-08-09 respectively, are all accounted for in the active medication list. No discrepancies in medication reconciliation have been found.

2023-06-02

• The patient visited our Psychosomatic Medicine OPD on 2023-05-11 and 2023-05-25, where he was prescribed Zoloft (sertraline), which was duly added to the list of active medications. In addition, the patient has a refillable prescription for Lixiana (edoxaban) from our Neurology OPD dated 2023-04-13, which also appears on the active medication list.

• It’s advised to note that selective serotonin reuptake inhibitors (SSRIs), such as sertraline, can potentially increase the risk of bleeding, especially when used with antiplatelet and/or anticoagulant medications. There have been several observational studies linking the use of SSRIs to a variety of bleeding complications, ranging from minor problems such as bruising, hematoma, petechiae, and purpura to more serious conditions such as stroke, upper gastrointestinal bleeding, intracranial hemorrhage, postpartum hemorrhage, and perioperative bleeding. In light of this, it is prudent to monitor this patient closely for any signs of bleeding.

• The liver-associated enzymes ALT and AST, particularly ALT, have both shown an increasing trend in this patient. The patient is currently being treated with Baogan (silymarin) and Baraclude (entecavir), which are appropriate given the patient’s liver status and HBV carrier state.

  • 2023-06-01 S-GPT/ALT 116 U/L
    
  • 2023-05-04 S-GPT/ALT 140 U/L
    
  • 2023-04-20 S-GPT/ALT 75 U/L
    
  • 2023-04-06 S-GPT/ALT 51 U/L
    
  • 2023-03-27 S-GPT/ALT 20 U/L
    
  • 2023-03-22 S-GPT/ALT 31 U/L
    
  • 2023-02-06 S-GPT/ALT 30 U/L
    
  • 2023-06-01 S-GOT/AST 46 U/L
    
  • 2023-05-18 S-GOT/AST 64 U/L
    
  • 2023-05-11 S-GOT/AST 62 U/L
    
  • 2023-05-04 S-GOT/AST 60 U/L
    
  • 2023-04-27 S-GOT/AST 49 U/L
    
  • 2023-04-13 S-GOT/AST 40 U/L
    
  • 2023-02-06 S-GOT/AST 26 U/L
    
  • 2023-02-01 S-GOT/AST 22 U/L

• Etoposide has been associated with hepatotoxicity, but the incidence is low (<= 3%) and therefore it is less likely to be the primary cause of the elevated liver enzymes. On the other hand, carboplatin is reported to be associated with increased serum alkaline phosphatase (24% to 37%) and increased serum aspartate aminotransferase (15% to 19%). This suggests that carboplatin might be a more likely cause of the observed liver enzyme elevation.

• Given that the patient’s current regimen has already been dose-reduced since initiation (etoposide from 100mg/m2 to 80mg/m2, carboplatin from AUC 5 to AUC 4), it may not be necessary to further reduce the dose immediately unless the liver enzymes rapidly increase.

701050910

240223

[exam findings]

• 2023-07-06 SONO - abdomen
  • Diagnosis:
    • Splenic fossa tumor, enlarged compared to 2022/08 (DDx: lymphoma?, accessory spleen hyperplasia?)
    • Post splenectomy
    • Parenchymal liver disease, mild
    • Pancreatic cystic lesion, body, size similar
    • Renal cysts, both
  • Suggestion:
    • Consider other image studies for the enlaring splenic tumor
• 2023-07-05 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Hairy cell leukemia, relapsed
  • The sections show hypercellular marrow (60%). Diffuse sheets of monotonous neoplastic cells (80% marrow cells) with oval nuclei surrounded by abundant clear or light pink cytoplasm, and decreased trilineage hematopoiesis are present. Mild marrow fibrosis can be identified.
  • IHC, the neoplastic cells show: CD3(-), CD20(+), DBA 44(+) and Annexin A1(+). The finding is consistent with relapsed hairy cell leukemia.
• 2023-07-05 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2022-08-24 SONO - abdomen
  • Parenchymal liver disease, mild
  • Suspected Pancreatic cystic lesion, body (stationary)
  • Renal cysts
  • Chronic kidney disease (left)
  • Post splenectomy
  • Probable Accessary spleen (2.91 cm)
• 2021-03-15 CXR
  • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
  • Borderline cardiomegaly
• 2021-03-01 SONO - abdomen
  • Fatty liver, mild
  • s/p splenectomy with small residue spleen
  • Renal cyst, bilateral
• 2021-03-08 CXR
  • Consolidation in right lower lung zone, r/o pneumonia
• 2021-03-08 CT - abdomen
  • Partial consolidation at RLL. R/O pneumonia
  • S/P splenectomy with a accessory spleen ?
  • Bil. renal cysts (up to 6.3cm). Left renal stone (3mm).
• 2020-12-15 Patho - bone marrow biopsy (Y1)
  • Bone marrow, iliac, biopsy — B cell leukemina.
  • Section shows piece(s) of bone marrow with 100% cellularity and M:E ratio of approximately 10:1. There is a predominant small to medium size atypical lymphoid population present.
  • IHC stains: CD3: 2%, CD20: 95%, CD5: 2%, CD19: 95%; CD23: ＜1%.

[MedRec]

• 2021-03-25 ~ 2021-04-02 POMR Hemato-Oncology
  • Discharge diagnosis
    • Chronic lymphocytic leukemia of B-cell type not having achieved remission
    • Relapsed HAIR CELL LEUKEMIA s/p Leustatin (cladribine)
    • Carrier of viral hepatitis B
    • Thrombocytopenia, unspecified
  • CC
    • for scheduled chemotherapy
  • Present illness
    • This 65 year-old male patient has the history of 1. HBV carrier 2. s/p splenectomy on 2016-11-16 3.CLL s/p C/T Splenomegaly was told during routine GI OPD f/u. Thrombocytopenia was also noticed. Thus, splenectomy was performed 2016-11-16. However, leukocytosis and anemia were found recent 2 months. He deined any body weight loss, appetite change, fever and abdominal disconfortable. He then visited our OPD and was admiited for bone marrow pucture on 2016/01/03. The pathology result showed Lymphocytic leukemia, B cell type. Flow cytometry at NTUH and TSGH revealed TRAP (+). Hairy cell leukemia was diagnosed. Evaluation of Abdominal echo was arranged for previous history of HBV and the reprot showed suspect retroperitoneal lesion. Furtehr abdominal CT was performed and the result revealed left renal stone & cyst and accesory spleen on 2016-01-30. Bone morrow aspiration and biopsy were done smoothly on 2020/12/15, pathology showed B cell leukemina.
    • Leustatin (cladribine) from 2016/2/20-2/26 6mg in 500ml saline drip for 24 hrs (10ml/vial, 1mg/1ml)
    • This time, he was admitted for scheduled chemotherapy
  • Course of inpatient treatment
    • After admission, chemotherapy with Leustatin 6g QD was administered from 2021/03/25-31. Fever without chills was noted on 3/25, follow up blood culture yielded negative and Acetaminophen prn used. Blood transfusion with LRP or LPRBC if necessary. With the relatively stable condition, he was discharged on 2021/04/02 and will OPD follow up later.
    • take Lenograstim 250mcg on 4/3, 4/4
  • Discharge prescription
    • Granocyte (lenograstim 250mcg) QD SC 2D on 4/6, 4/7
• 2020-12-13 ~ 2020-12-15 POMR Hemato-Oncology
  • Discharge diagnosis
    • Chronic lymphocytic leukemia of B-cell type not having achieved remission
    • Carrier of viral hepatitis B
    • Chronic viral hepatitis B without delta-agent
    • Neoplasm of unspecified behavior of digestive system
    • Thrombocytopenia, unspecified
  • CC
    • Thrombocytopenia noted for week
  • Present illness
    • This 60 year-old male patient has the history of 1. HBV carrier 2. s/p splenectomy on 2016-11-16 3. CLL s/p C/T Splenomegaly was told during routine GI OPD f/u. Thrombocytopenia was also noticed. Thus, splenectomy was performed 2016-11-16. However, leukocytosis and anemia were found recent 2 months. He deined any body weight loss, appetite change, fever and abdominal disconfortable. He then visited our OPD and was admiited for bone marrow pucture on 2016-01-03. The pathology result showed Lymphocytic leukemia, B cell type. Flow cytometry at NTUH and TSGH revealed TRAP (+). Hairy cell leukemia was diagnosed. Evaluation of Abdominal echo was arranged for previous history of HBV and the reprot showed suspect retroperitoneal lesion. Furtehr abdominal CT was performed and the result revealed left renal stone & cyst and accesory spleen on 2016-01-30. Today, he was admitted for Anemia and thrombocytopenia and further chemotherapy of Leustatin.
  • Course of inpatient treatment
    • After admission, thrombocytopenia was noted. Bone morrow aspiration and biopsy were done smoothly on 12/15. Peripheral blood example was collected for smear. There was no soreness or active bleeding noted. Since relative stable condition, he was discharged on 2020/12/15 and OPD follow up.

[immunochemotherapy]

• 2024-02-21 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1370mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)
  • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30m D1-2 + palonosetron 250ug D2 + NS 250mL D1-2
• 2024-01-17 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 650mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP, Endoxan 50% off)
  • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30m D1-2 + palonosetron 250ug D2 + NS 250mL D1-2
    
• 2023-11-01 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)
  • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30m D1-2 + palonosetron 250ug D2 + NS 250mL D1-2
• 2023-09-07 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cladribine 6mg NS 500mL 24hr D2-8
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-8 + betamethasone 4mg D2-8
• 2023-07-07 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cladribine 6mg NS 500mL 24hr D2-8
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-8 + betamethasone 4mg D2-8
• 2021-03-25 - cladribine 6mg NS 500mL 24hr D1-7
  • [diphenhydramine 30mg + NS 250mL] D1-7

[note]

Hairy Cell Leukemia SUGGESTED TREATMENT REGIMENS - NCCN Evidence Blocks - Version 1.2023 - 2022-10-13 — HCL-A 1 OF 2, p7

• Initial Therapy
  • Preferred Regimens
    • Purine analogs
      • Cladribine ± rituximab
      • Pentostatin
  • Useful in Certain Circumstances (consider for patients who are unable to tolerate purine analogs including frail patients and those with active infection)
    • Vemurafenib + obinutuzumab
• Relapsed/Refractory Therapy
  • Less than complete response after initial treatment OR Relapse < 2 years
    • Preferred Regimens
      • Clinical trial
      • Alternative purine analog + rituximab
      • Vemurafenib ± rituximab
    • Other Recommended Regimens
      • Peginterferon-alfa 2a
      • Alternative purine analog
    • Useful in Certain Circumstances
      • Rituximab, if unable to receive purine analog
  • Relapse >= 2 years
    • Preferred Regimens
      • Retreat with initial purine analog + rituximab
      • Alternative purine analog + rituximab
    • Other Recommended Regimens
      • none
    • Useful in Certain Circumstances
      • Rituximab, if unable to receive purine analog
• Progressive Disease After Relapsed/Refractory Therapy
  • Preferred Regimens
    • Clinical trial
    • Moxetumomab pasudotox
    • Vemurafenib ± rituximab (if not previously given)
  • Other Recommended Regimens
    • Ibrutinib

Cladribine 2023-07-13 https://www.uptodate.com/contents/cladribine-drug-information

• Adult Dosing - Hairy cell leukemia:
  • IV:
    • 0.14 mg/kg/day over 2 hours for 5 days for 1 cycle or
    • 0.1 mg/kg/day continuous infusion for 7 days for 1 cycle or
    • 0.09 mg/kg/day continuous infusion for 7 days for 1 cycle or
    • 0.15 mg/kg/day over 2 hours on days 1 to 5 as a single course (in combination with concurrent or delayed rituximab) or
    • 5.6 mg/m2 over 2 hours once daily for 5 days as a single course, followed 28 days later by rituximab.
  • SUBQ (off-label route):
    • 0.1 to 0.14 mg/kg/day for 5 days for 1 cycle.

Rituximab 2023-07-13 https://www.uptodate.com/contents/rituximab-intravenous-including-biosimilars-drug-information

• Adult Dosing - Hairy cell leukemia (off-label use):
  • In combination with cladribine (as initial treatment or after first relapse): IV:
    • 375 mg/m2 once weekly (beginning 28 days ± 4 days after initiation of 5 days of cladribine) for 8 doses or
    • 375 mg/m2 once weekly (beginning concurrently with cladribine) for 8 doses.
  • In combination with vemurafenib (relapsed or refractory disease): IV:
    • 375 mg/m2 on days 1 and 15 every 6 weeks (in combination with vemurafenib) for 2 induction cycles, followed by 375 mg/m2 once every 2 weeks for 4 rituximab monotherapy consolidation doses (total of 8 rituximab doses).

==========

2024-02-23

Anemia with HGB at 7.6 was observed on 2024-02-19, LPRBC transfusion was then carried out.

• 2024-02-19 HGB 7.6 g/dL
• 2024-02-15 HGB 8.3 g/dL
• 2024-02-05 HGB 8.3 g/dL
• 2024-02-01 HGB 8.7 g/dL
• 2024-01-29 HGB 9.5 g/dL
• 2024-01-22 HGB 9.7 g/dL
• 2024-01-16 HGB 8.7 g/dL
• 2024-01-15 HGB 9.3 g/dL
• 2024-01-08 HGB 9.6 g/dL

2023-09-14

[thrombocytopenia]

The patient’s thrombocytopenia was present even before the two most recent rounds of immunochemotherapy (rituximab with cladribine administered on 2023-07-07 and 2023-09-07). The primary treatment has been blood transfusions, which were conducted on the following dates: 2023-07-04, 2023-07-22, 2023-07-27, 2023-07-31, 2023-08-07, 2023-08-28, 2023-09-09, and 2023-09-13.

2023-09-13 PLT 43 10^3/uL 2023-09-11 PLT 34 10^3/uL 2023-09-09 PLT 38 10^3/uL 2023-09-06 PLT 41 10^3/uL 2023-09-05 PLT 43 10^3/uL 2023-08-28 PLT 42 10^3/uL 2023-08-23 PLT 29 10^3/uL 2023-08-22 PLT 26 10^3/uL 2023-08-15 PLT 25 10^3/uL 2023-08-09 PLT 120 10^3/uL 2023-08-07 PLT 26 10^3/uL 2023-08-03 PLT 91 10^3/uL 2023-08-01 PLT 24 10^3/uL 2023-07-31 PLT 31 10^3/uL 2023-07-27 PLT 36 10^3/uL 2023-07-25 PLT 50 10^3/uL 2023-07-21 PLT 25 10^3/uL 2023-07-19 PLT 50 10^3/uL 2023-07-18 PLT 92 10^3/uL 2023-07-16 PLT 120 10^3/uL 2023-07-14 PLT 23 10^3/uL 2023-07-12 PLT 40 10^3/uL 2023-07-10 PLT 75 10^3/uL 2023-07-07 PLT 122 10^3/uL 2023-07-05 PLT 19 10^3/uL 2023-07-04 PLT 23 10^3/uL 2023-06-29 PLT 23 10^3/uL 2023-04-06 PLT 87 10^3/uL 2023-02-09 PLT 132 10^3/uL 2022-11-03 PLT 180 10^3/uL

2023-07-13

[leukopenia]

The recent WBC nadir was noted on 2023-07-10 with a count of 0.88K/uL, and by 2023-07-12, an increase to 1.21K/uL was evident.

• 2023-07-12 WBC 1.21 x10^3/uL **
• 2023-07-10 WBC 0.88 x10^3/uL ***
• 2023-07-07 WBC 3.56 x10^3/uL
  
• 2023-07-05 WBC 2.23 x10^3/uL *
• 2023-07-04 WBC 3.61 x10^3/uL

The patient received the regimen of cladribine plus rituximab on 2023-07-07. It’s well known that cladribine injection often leads to dose-dependent myelosuppression (manifested as neutropenia, anemia, and thrombocytopenia), typically reversible. Additionally, rituximab is associated with an incidence of neutropenia (8% to 14%; grades 3/4: 4% to 49%). As such, the regimen could be the primary cause of the patient’s recent leukopenia.

Given the current trend of increasing WBC count without the administration of G-CSF, it would be advisable to continue monitoring over the next few days to verify if the developed leukopenia is resolved.

[thrombocytopenia]

(this pharmacist note is a continuation of the previous one)

Even as the WBC count gradually recovers, platelet levels continue to decline, noted at 40K/uL on 2023-07-12. If this decrease continues, it is typically recommended to consider transfusion if the platelet count drops to or below a threshold of 10K/uL. If fever, sepsis, or coagulopathy is present, higher thresholds may be needed.

• 2023-07-12 PLT 40 x10^3/uL
  
• 2023-07-10 PLT 75 x10^3/uL
  
• 2023-07-07 PLT 122 x10^3/uL

700030390

240222

• 2024-02-21 CXR erect
  • Increase bilateral lung markings.
  • Nodular densities in bilateral lungs, r/o lung metastasis.
  • Tortuous thoracic aorta with intimal calcification.
  • Thoracic spondylosis.
• 2024-02-21 EGD
  • Diagnosis
    • Esophageal varices, F2CbL1, RCS (-), s/p variceal ligation x 2
    • Gastric varices, cardia
    • Superficial gastritis
    • Duodenal ulcers, bulb
  • Suggestion
    • PPI, terlipressin use
• 2024-01-16 KUB
  • marginal spurs of multiple vertebral bodies due to spondylosis.
• 2024-01-12 CXR
  • Multiple nodules in both lungs due to metastases.
  • Rt pleural effusion
  • A poorly defined mass over peripheral of RUL
  • Old fibrocalcified change at Rt apical lung
• 2024-01-09 SONO - abdomen
  • Diagnosis:
    • Parenchymal liver disease
    • Hepatic tumor, probably hepatoma with bilateral and main trunk portal vein thrombosis
    • GB sludge
    • Ascites
  • Suggestion:
    • Please correlate with other image study and AFP level
• 2024-01-06 CT - chest
  • Indication: RLL pneumonia
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Several nodular lesions are found at both lungs are found. Metastatic lesion is considered.
      • Consolidation of right upper lobe is found.
      • Bilateral pleural effusion more on right side is found.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Fibrocalcified lesions are noted at right upper lobe and left upper lobe. Old TB is considered.
    • Visible abdomen:
      • Splenomegaly and ascites formation is found. r/o liver cirrhosis.
      • One soft tissue heterogeneous tumor at S7 of liver measuring 6.05cm in largest dimension. HCC is suspected. Suggest contrast enhanced study.
  • Imp:
    • Hepatic tumor at S7 of liver measuring 6.05cm with bilateral lung meta and bone meta. r/o HCC. Suggest contrast enhanced study.

[MedRec]

• 2023-12-30 ~ 2024-01-19 POMR Chest Medicine Huang JunYao
  • Discharge diagnosis
    • Pneumonia right middle lobe, sputum culture :Mixed normal flora
    • Hemoptysis
    • Hepatic cell carcinoma,r/o T4NxM1,stage IVB; ECOG2
    • Malignant neoplasm of prostate
    • Chronic obstructive pulmonary disease, unspecified
    • Type 2 diabetes mellitus without complications
    • Major depressive disorder, single episode, unspecified
    • Constipation, unspecified
    • Essential (primary) hypertension
    • Mixed hyperlipidemia
    • Gastro-esophageal reflux disease with esophagitis
    • Suspect UGI bleeding (tarry stool and stool OB 4+)
  • CC
    • dyspnea and productive cough since 2023/12/28, hemoptysis in recently 2 days
  • Present illness
    • This 92 year old male had history of type 2 DM, COPD, old TB. BPH s/p laser TURP with cystostomy (Heish) on 2016/12/06, s/p RT, cT1-2N0M0, stage IIB. He was regular in our CM, Meta and Uro OPD for medication treatment.
    • According to his family statement, he went to our ER due to chest pain when coughing, dyspnea, chillness and dysuria for 2 days ago. This time, he suffered from hemoptysis was noted since yesterday, blood clot was also noted. Therefore he was brought to our ER for help. In ER, vital signs: Temp: 37.3’C, pulse: 96/min, respiration: 18/min and blood pressure: 114/54 mmHg, Spo2:97%. Laboratory data showed no leukocytosis with left shifted (WBC 8450, N.seg 86.8), mild elevated CRP. CXR film showed Increased infiltration over both lower lungs. May be active infection. COVID rapid screening and influenza A+B agents showed negative result. Under the impression of pneumonia and hemoptysis, he was admitted to CM ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, empiric antibiotic with Brosym IV and Colimycin inhalation were used for pneumonia control. Antitussive, mucolytic agents and other palliative treatment were given for symptomatic relief. Transamin IV used for hemoptysis.
    • Do sputum culture, sputum TB culture and blood culture evalution to identify pathogen.
    • In addition, dysuria occured on admission, highly suspect BPH related adn added Urief 1# QD.
    • Consult GU Dr and non-invasive evaluation such as uroflowmetry and residual urine is recommended.
    • After treatment, no more fever or hemoptysis noted, we tappered IV from Transamin to oral form use.
    • The hemogram, renal function and electrolyte were followed up and showed improvement, and CXR showed r/o right side pleural effusion.
    • Arranged chest echo on 2024/01/05, it revealed 1. Right trivial subpulmonary pleural effusion. 2. Right lower lung consolidation.
    • Follow up chest CT, which chowed Hepatic tumor at S7 of liver measuring 6.05cm with bilateral lung meta and bone meta. r/o HCC. Suggest contrast enhanced study.
    • Arranged abdominal echo for evaluation, Parenchymal liver disease, Hepatic tumor, probably hepatoma with bilateral and main trunk portal vein thrombosis, GB sludge, Ascites was shown and check AFP dislcosed >303000 ng/mL.
    • Due to highly suspect HCC, we consulted G-I doctor, who was impression of suspect HCC, T4NxM1, stage IVB, BCLC C-D: 1. Check HBsAg, anti-Hbs Ab, anti-Hbc Ab, Anti HCV Ab, CEA, CA199; 2. arrange image studies: liver, spleen MRI with/without contrast or triphase liver CT were suggested. Apply HCC Major Illness already.
    • Bedsides, passage tarry stool occured on admission, check stool OB revealed postive 4+. PPI with Pantolac IV was applied for highly suspect UGI bleeding.
    • B-fluid IVF supplement prescribed for poor oral intake.
    • After treatment, no more passage tarry stool, we tappered IV form PPI to oral form Nexium use.
    • Due to his familes further hospice care to HCC termitinal stage, we consulted FMH Dr and combined care at first.
    • Prescried Silymarin for abnormal liver function.
    • The CXR, hemogram, ranal function and electrolyte were followed up and showed improvement.
    • Under stable condition, he was discharged on 2024-01-19. Further Chest OPD followed up was arranged.
  • Discharge prescription
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Urief (silodosin 8mg) 1# QD
    • BaoGan (silymarin 150mg) 1# TID
• 2023-11-20 SOAP Chest Medicine Huang JunYao
  • Diagnosis
    • Malignant neoplasm of prostate [C61]
    • Chronic airway obstruction(COPD), NEC [J44.9]
    • Mucopurulent chronic bronchitis [J41.1]
    • Reflux esophagitis [K21.0]
    • Arthralgia of temporomandibular joint [M26.62]
    • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
    • Constipation [K59.00]
    • OA, localized, not specified whether primary or secondary, unspecified site [M19.90]
    • Hypertrophy (benign) of prostate [N40.1]
    • Spondylosis of unspecified site, with mention of myelopathy [M47.10]
    • Atherosclerosis of arteries of the extremities with intermittent claudication [I70.92]
    • Depression [F32.9]
    • Lumbosacral spondylosis without myelopathy [M47.27]
    • Cervical spondylosis without myelopathy [M47.22]
  • Prescription x3
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Xyzal (levocetirizine 5mg) 1# HS
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# BID
    • Spiolto (tiotropium 2.5ug, olodaterol 2.5ug; per puff) 1 puff BID INHL
    • Stilnox (zolpidem 10mg) 1# HS

[consultation]

• 2024-01-11 Gastroenterology
  • Q
    • Due to HCC termitinal stage and apply HCC Major Illness, we sincerly your special evaluation and help. TKS !!
  • A
    • This 92-year-old male was a case of type 2 DM, COPD, old TB. BPH s/p laser TURP with cystostomy (Heish) on 2016/12/6, s/p RT, cT1-2N0M0, stage IIB. He was regular in our CM, Meta and Uro OPD for medication treatment. This time, he was admitted for hemoptysis. And, abdomen CT revealed suspect HCC with distal meta. We are consulted for further evaluation.
    • O
      • At bedside, stable vital signs
      • Lab
        • 2024-01-09 AFP >303000 ng/mL
          
        • 2024-01-08 WBC 11.11 x10^3/uL
          
        • 2024-01-08 HGB 9.9 g/dL
          
        • 2024-01-08 PLT 268 *10^3/uL
          
        • 2024-01-05 ALT 40 U/L
          
        • 2024-01-05 AST 61 U/L
          
        • 2024-01-05 Creatinine 0.59 mg/dL
          
        • 2024-01-05 CRP 7.7 mg/dL
          
        • 2023-12-30 APTT 33.3 sec
          
        • 2023-12-30 PT 11.7 sec
          
        • 2023-12-30 INR 1.14
          
      • CT: Hepatic tumor at S7 of liver measuring 6.05cm with bilateral lung meta and bone meta. r/o HCC.
      • Abdomen echo:
        • Parenchymal liver disease
        • Hepatic tumor, probably hepatoma with bilateral and main trunk portal vein thrombosis
        • GB sludge
        • Ascites
    • A:
      • Suspect HCC, T4NxM1, stage IVB, BCLC C-D
    • P:
      • Check HBsAg, anti-Hbs Ab, anti-Hbc Ab, Anti HCV Ab, CEA, CA199
      • Arrange image studies: liver, spleen MRI with/without contrast or triphase liver CT
      • Please contact us for the survey above complete
• 2024-01-10 Family Medicine
  • Q
    • Follow up chest CT for evaluation, it revealed hepatic tumor at S7 of liver measuring 6.05cm with bilateral lung meta and bone meta. r/o HCC. Suggest contrast enhanced study. Arranged abdominal echo for evaluation and parenchymal liver disease, Hepatic tumor, probably hepatoma with bilateral and main trunk portal vein thrombosis, GB sludge and Ascites. We checked AFP and result revealed > 303000.
    • We well explined the present condition of HCC, his families asked further hospice care, so we sincerly your special evaluation and help. TKS !!
  • A
    • This is a 92 y/o male has history of COPD, old TB, prostate cancer s/p. He was admitted with a diagnosis of pneumonia and hemoptysis.
    • During this admission, he was incidentally diagnosed with liver cancer with bilateral lung and bone metastases.
      • Cons E4V5M6, ECOG4, DNR(-)
      • Patient dose not know his current status.
    • Hospice team has provided an explanation of hospice care and will coordinate combined care for him.
    • Indication: liver cancer with lung and bone metastasis
    • Plan: Hospice Combined Care

==========

2024-02-22

[variceal bleeding, hepatic encephalopathy & hypokalemia: multifaceted management approach]

Variceal bleeding has resulted in low hemoglobin (7.6 g/dL on 2024-02-22). Symptomatic anemia might necessitate LPRBC transfusion.

Currently, the patient is receiving IV Glypressin (terlipressin acetate), Hemoclot (tranexamic acid), and Panzolec (pantoprazole).

Serum ammonia level reached 92 µmol/L on 2024-02-21, indicating hepatic encephalopathy. Lactul (lactulose) is being administered to reduce ammonia levels.

Serum potassium measured 3.5 mmol/L on 2024-02-22, placing it at the lower end of the reference range. Studies have demonstrated that hypokalemia can increase renal tubular ammonia production, leading to elevated levels in both the tubular lumen and peritubular capillaries. This effect is partially attributed to intracellular acidosis within renal tubular cells, which stimulates ammonia production from glutamine. While appropriate in the context of metabolic acidosis, this mechanism can become clinically significant in patients with advanced cirrhosis, potentially contributing to hepatic encephalopathy.

Therefore, maintaining serum potassium levels within the middle of the reference range may be beneficial in patients with hepatic encephalopathy to minimize this potential complication.

700704015

240221

[exam findings]

• 2024-02-19 CT - chest
  • Findings
    • massive Lt pleural effusion with nodular thickening and minimal Rt pleural effusion.
    • lungs: partail relaxation atelectasis of LLL. large consolidation with air-bronchogram and extensive ground glass opacity as well as nodules at Lt lung. multiple nodules of variable sizes in Rt lung due to metastasis.
    • liver: multiple tumors of variable sizes (some of which have necrotic part) throughout in both lobes of liver.
    • marked enlarged necrotic tumors in the pancreas especially at tail part. extensive lymphadenopathy in the retroperitoneum with thickening of renal fasciae. moderate abdominal ascites and dilated biliary tree.
    • diffuse subcutaneous edema of abdominal wall and left chest wall.
  • Impression:
    • cholangiocarcinoma with hepatic, pancreas, retroperitoneal LNs, lung, and pleural metastases.
    • partial volume loss and consolidation of left lung and massive Lt pleural effusion.
• 2023-10-25 SONO - abdomen
  • Multiple liver metastatic tumor, bilateral lobes
  • Hepatic cyst, S4
  • Status post cholecystectomy.
  • Pancreatic tumors, pancreatic body and tail
  • Boderline splenomegaly
  • Suspicious accessory spleen
  • Suspect enlarged lymphnodes, around the aorta
• 2023-10-18 Patho - stomach biopsy
  • Stomach, remnant, biopsy — chronic gastritis with intestinal metaplasia and Helicobacter infection
  • Microscopically, it shows chronic gastritis with leukocytic and lymphoplasmacytic infiltrate and focal intestinal metaplasia. Helicobacter-like bacilli are seen.
• 2023-10-12 CT - abdomen
  • Findings
    • S/P Whipple operation.
    • A poor enhancing tumor (2.3x4.3cm) at pancreatic body and tail with splenic vein invasion. Enlarged LNs around pancreas and along aorta.
    • A nodule (0.7cm) at RLL.
    • Some poor enhancing tumors in liver.
    • Left renal cyst (0.8cm).
    • Disc space narrowing at L2/3.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P Whipple operation.
    • A poor enhancing tumor (2.3x4.3cm) at pancreatic body and tail with splenic vein invasion. Enlarged LNs around pancreas and along aorta.
    • Some poor enhancing tumors in liver.
    • A nodule (0.7cm) at RLL.
• 2023-10-12 CXR erect + L-spine Lat
  • Post-op with metallic materials in LUQ.
  • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation
  • Disc space narrowing at L2-3 level.
  • Gr I spondylolisthesis at L3-4 level.
  • Lumbar spondylosis.
• 2023-10-04 SONO - abdomen
  • Hepatic tumors, compatible with hepatic metastases
  • Hepatic cyst
  • Post cholecystectomy
  • Pancreatic body-tail region tumor, in favor of retroperitoneal tumor rather than pancreatic origin
  • Para-aortic lymphadenopathy
• 2023-09-28 Patho - lymphnode biopsy
  • Labeled as “lymph node, retroperitoneum”, CT guided needle biopsy — adenocarcinoma.
  • Section shows lymph node with adenocarcinoma.
  • IHC stains: CK7 (+), CK20 (-), CA19-9 (-), CK19 (+), hepatocyte (+).
  • An adenocarcinoma arising from pancreato-biliary system might be considered. Please correlate with clinical and imaage findings.
• 2023-09-25 KUB
  • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, L-spine.
  • suture materials over the LUQ region of abdomen
  • increased air in nondistended loops of small bowel over LUQ, RUQ, could be ileus, adhesive?
• 2023-09-18 CT - abdomen
  • History and indication: Ampulla vater cancer s/p whipple operation on 2011-05-07
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P Whipple operation.
    • A poor enhancing tumor (3.3x5.1cm) at pancreatic body and tail with splenic vein invasion. Enlarged LNs around pancreas and along aorta.
    • Small poor enhancing tumors in liver.
    • Normal appearance of spleen, adrenals and kidneys.
    • Disc space narrowing at L2/3.
  • Addendum Imaging Report Form for Cholangiocarcinoma
    • Impression ( Imaging stage ) : T:T2(T_value) N:N0(N_value) M:M1(M_value) STAGE:IVB(Stage_value)

[MedRec]

• 2023-09-27 ~ 2023-10-06 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Intrahepatic bile duct carcinoma of adenocarcinoma. IHC stains: CK7 (+), CK20 (-), CA19-9 (-), CK19 (+), hepatocyte (+) with with LNs and liver metastases.
    • History fof Ampulla of Vater Adenocarcnoma, moderately differentiated; pT3N0 cM, pStage IIA S/P operation on 2011/05/07
    • Chronic viral hepatitis B without delta-agent anti-Hbc: positive
    • Unspecified abdominal pain
  • CC
    • fatigue, poor appeitte, body weight loss 7kg, abdominal distension, fullness and pain and back pain for 3-4 months.
  • Present illness
    • This 66-year-old man, had history of ampula of Vater of adenocarcnoma, moderately differentiated; pT3N0 cM, pStage IIA by pathology S/P Whipple`s operation on 2011/05/07 by Dr Lai JieWen without any treatment and follow-up at OPD for 7 years ago. In recent 3-4 month, he suffered from fatigue, poor appeitte, body weight loss 7kg and abdominal distension, fullness and pain and back pain were also noted and he visited to our GS OPD for aid and transferred to our ER on 9/27 23. At arrival to ER, the abdominal CT (9/18 23) showed S/P Whipple operation, In favor of pancreatic body/ tail tumor with LNs and liver metastases. the laboratory showed CRP:19.3mg/dl, WBC: 12890, seg:78, CEA:6.539ng/ml, CA-199:9.775U/ml.
    • Under the impression of suspected pancreatic body/tail tumor with LNs and liver metastases. He was admitted for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, antibiotic with Loforan 2000mg ivd q8h was given for fever and abdominal pain since 9/27 to 9/29 23, owing to fever without chills persistent was noted and antibiotic shifted to Tapimycin 4.5mg ivd q6h since 9/29 23 for infection control. The blood culture x 2 set & urine culture yielded no growth for 5 days aerobically & anaerobically. We will arrange abdominal sono for fever surey. Naproxen 1# po qd was added for rule out tumor fever. The abdominal CT (9/18 23) showed S/P Whipple operation. In favor of pancreatic body/ tail tumor with LNs and liver metastases. (10/3 revised report) showed A poor enhancing tumor (3.3x5.1cm) at pancreatic body and tail with splenic vein invasion. Enlarged LNs around pancreas and along aorta. Small poor enhancing tumors in liver. T:T2(T_value) N:N0(N_value) M:M1(M_value) STAGE:IVB(Stage_value) and radiologist was consulted for CT-guide biopsy evaluation.
    • CT-guide biopsy was done on 9/29 23. The pathology of Labeled as “lymph node, retroperitoneum”, CT guided needle biopsy (10/3 23) adenocarcinoma. IHC stains: CK7 (+), CK20 (-), CA19-9 (-), CK19 (+), hepatocyte (+). Port-A was inserted on 10/3 23.
    • The abdominal sono (10/4 23) revealed hepatic tumors, compatible with hepatic metastases, hepatic cyst, Post cholecystectomy, pancreatic body-tail region tumor, in favor of retroperitoneal tumor rather than pancreatic origin.
    • C1D1 chemotherapy with Gemzar (1000mg/m2) plus Cisplatin (30mg/m2) were given on 10/5 23, smoothly without obvious side effect. He was discharged on 10/6 23 under stable condition and will follow-up at OPD on 10/12 23.
  • Discharge prescription
    • Through (sennoside 12mg) 2# HS
    • Ulstop (famotidine 20mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# PRNQ6H if BT > 38’C
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H if abdominal pain or back pain VAS > 3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-09-22 SOAP General Surgery Lai JieWen
  • O: 2023/09/18 CT ABD: In favor of pancreatic body/tail tumor with LNs and liver metastases.
• 2023-09-15 SOAP General Surgery Lai JieWen
  • O: loss forllow up for nearly 3 years. arrange cancer surveillence.
• 2020-02-07 SOAP General Surgery Lai JieWen
  • O: Left liver cyst (0.50x0.98cm). Right renal stone (0.65cm). S/P cholecystectomy.
• 2017-05-01 SOAP General Surgery Lai JieWen
  • O: Ampulla vater cancer s/p whipple operation on 2011-05-07
  • Diagnosis
    • Malignant ampulla of Vater neoplasm [C24.1]

[surgical operation]

[chemotherapy]

• 2024-02-07 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2024-01-23 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2024-01-16 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2024-01-02 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2023-12-19 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2023-12-05 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2023-11-28 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2023-11-15 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2023-11-09 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
• 2023-11-03 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 500mL
• 2023-10-19 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2023-10-05 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL

==========

2024-02-26

[evaluating appetite stimulants in patient care]

Social service staff member Luo YuQuan visited the patient on 2024-02-22 and observed that the patient reported recent feelings of lethargy and fatigue. Additionally, the patient’s wife indicated that he has experienced a loss of appetite.

Considering these symptoms, the addition of the appetite stimulant megestrol could be beneficial for improving the patient’s condition, provided there are no contraindications to its use.

700132281

240220

[exam findings]

• 2024-01-10 Tc-99m MDP bone scan
  • A hot area at a upper T-spine and faint hot spots in the sternum and right rib cage, the nature is to be determined (early bone mets, post-traumatic change, or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, bilateral shoulders, hips, knees, and tibiae.
• 2024-01-04 SONO - abdomen
  • Liver tumors, bil. Propable metastases
  • Propable pancreatic tumor, body with enlarged pancreas
  • Propable intra-abdominal lymphadenopathy
• 2023-12-29 CT - abdomen
  • Findings:
    • There is lobulated wall thickening at the gastric fundus, 5.2 x 2.2 cm in size (base width x wall thickness). Loss of normal fat plane between stomach fundus and pancreatic body is noted.
      • Adenocarcinoma of the stomach fundus with direct pancreatic invasion (T4b) is suspected. Please correlate with gastroscopy.
    • There is an ill-defined poor enhancing mass lesion in the pancreatic body and tail, measuring 6.8 x 2.6 cm in size, with suggestive celiac trunk invasion and splenic vein encasement.
      • Adenocarcinoma of the pancreatic body and tail (T4) is suspected.
      • The differential diagnosis includes adenocarcinoma of the stomach with direct pancreatic invasion.
      • Please correlate with EUS-guided biopsy.
    • There are several enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament that are c/w regional lymph node metastases.
    • There is a poor enhancing mass 5.4 cm in S8/4 of the liver that is c/w metastasis (M1).
      • In addition, there is one enlarged node 1.87 cm in left para-aortic space that is c/w non-regional lymph node metastasis (M1).
  • Impression:
    • Adenocarcinoma of the stomach fundus with direct pancreatic invasion (T4b) is suspected. Please correlate with gastroscopy.
    • Adenocarcinoma of the pancreatic body and tail (T4) is suspected.
      • The differential diagnosis includes adenocarcinoma of the stomach with direct pancreatic invasion.
      • Please correlate with EUS-guided biopsy.
    • Liver metastasis 5.4 cm in S8/4.
      • CT-guided biopsy is indicated to R/O gastric or pancreatic origin.

[MedRec]

• 2018-06-07, -03-15, 2017-07-03 SOAP Family Medicine Lin ChunYu
  • Diagnosis
    • IDA, unspecified [D50.9]
    • Other abnormal blood chemistry [R73.9]
  • Prescription x3
    • Foliromin (sodium ferrus citrate 50mg) 1# QD

[immunochemotherapy]

• 2024-02-19 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 80mg D5W 250mL 2hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (Opdivo + 80% FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-02-06 - ………………………… oxaliplatin 85mg/m2 80mg D5W 250mL 2hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2000mg NS 500mL 46hr (80% FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-17 - ………………………… oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-02-20

[monitoring leukopenia in FOLFOX patient, G-CSF not used, dose reduction initiated]

The initial administration of FOLFOX occurred on 2024-01-17. Subsequently, an episode of leukopenia developed in late Jan and early Feb, with a nadir WBC count of 2.67 K/uL. No record of G-CSF administration was found in the HIS5. The patient then recovered, with a WBC count of 12.17 K/uL on 2024-02-18. As of today, no further evidence of leukopenia has been observed.

• 2024-02-18 WBC 12.17 x10^3/uL
  
• 2024-02-05 WBC 2.67 x10^3/uL
  
• 2024-01-30 WBC 2.67 x10^3/uL
  
• 2024-01-19 WBC 9.53 x10^3/uL
  
• 2024-01-09 WBC 10.34 x10^3/uL

Due to the leukopenic episode, the FOLFOX dose has been reduced by approximately 20% since the second administration, which commenced on 2024-02-06.

[long-term Foliromin for iron deficiency: re-check ferritin (MCV trend down) to guide future supplementation]

The patient has a long-standing history of Foliromin (sodium ferrous citrate) prescription by our family medicine specialist for iron deficiency anemia, dating back to at least 2017.

A ferritin level of 12.1 ng/mL was measured on 2023-11-29, which falls within the lower end of the reference range. However, MCV continues to show a slowly downward trend.

• 2023-11-29 Ferritin 12.1 ng/mL

• 2024-02-18 MCV 85.4 fL

• 2024-02-05 MCV 87.0 fL

• 2024-01-30 MCV 87.9 fL

• 2024-01-19 MCV 86.1 fL

• 2024-01-09 MCV 87.5 fL

• 2023-11-29 MCV 89.0 fL

• 2023-09-06 MCV 88.6 fL

• 2023-06-13 MCV 94.9 fL

• 2022-12-19 MCV 97.7 fL

• 2022-09-19 MCV 96.8 fL

• 2022-06-25 MCV 96.9 fL

• 2022-03-29 MCV 97.7 fL

• 2022-01-05 MCV 98.1 fL

Given that previous ferritin measurements were performed approximately every 3 months, it is recommended to consider a repeat test to obtain an updated iron storage level. This will inform the decision regarding whether to re-administer iron supplements.

700293834

240220

[exam findings]

• 2024-02-20 Sigmoidoscopy
  • Findings
    • up to 10cm, lumen narrowing, and radation procitis is seen.
    • check from distal T colstomy and stool obstruction
  • Diagnosis
    • rectum stenosis, can not evaluate primary site
• 2024-02-08 CT - abdomen
  • Findings
    • S/P operation. Progression of live metastases.
    • Multiple lung metastases.
    • A nodule (2.8cm) in right thyroid gland.
    • A cystic lesion (3.5x4.8cm) in left perineum.
    • Retroversion of uterus. Nodules (up to 2.4cm) in uterus.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P operation. Progression of live metastases.
    • Multiple lung metastases.
• 2023-11-01 CT - abdomen
  • Prior CT identified liver metastases on both lobes are noted again, mild decreasing in size that are c/w stable disease.
• 2023-07-31 CT - abdomen
  • Rectal cancer s/p colostomy with liver meta, lung meta. The metastatic lesion regressed slightly. The primary tumor is statinary or minimally regressed.
  • Cystic lesionat left perineum measuring 5.9cm in largest dimension, r/o bartholin cyst.
• 2023-04-24 All-RAS + BRAF mutation
  • Cellblock No. S2023-05853
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-04-22 CT - chest
  • Left lower lobe lung meta. 1.75cm
  • Thyroid metastatic lesion at right lobe. 3.1cm
  • Liver meta at both lobes.
• 2023-04-10 PET scan
  • Increased FDG uptake in the rectal region, compatible with the primary rectal cancer.
    
  • Increased FDG uptake in both left and right lobes of the liver, highly suspected rectal cancer with distant metastases.
    
  • Increased FDG uptake in the left lower lung, highly suspected cancer (rectal or thyroid cancer with distant mets ?), suggesting biopsy for investigation; increased FDG uptake in the left upper lung, the nature is to be determined (inflammation process or cancer with lung mets ?), suggesting follow-up.
  • Increased FDG uptake in both right and left lobes of the thyroid gland, highly suspected another pirmary thyroid cancer, suggesting biopsy (right lobe) for investigation. .
  • Rectal cancer with liver and lung metastasis, cTxNxM1b, stage IVB (AJCC 8th ed.) and highly suspected another primary thyroid cancer, by this F-18 FDG PET scan.
• 2023-03-29 Patho - colon biopsy
  • Colorectum, upper rectum, biopsy — Adenocarcinoma.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2023-03-21 Gynecologic Ultrasonography
  • Subserosal myoma 37.3 x 26.2 mm, posterior
  • Bilateral ovarian cysts

[MedRec]

• 2023-04-18 ~ 2023-04-25 POMR Colorectal Surgery Lv ZongRu
  • Discharge diagnosis
    • Rectal cancer with multiple liver and left lung metastasis, cT4aN2aM1b, stage IVb status post T loop colostomy and port-a insertion, left after left cephalic vein exploration on 2023/04/19. ECOG：0.
    • Secondary malignant neoplasm of unspecified lung
    • Secondary malignant neoplasm of liver and intrahepatic bile duct
  • CC
    • for enterostomy and Consult GS for Port-A implantation.
  • Present illness
    • This is a 54 year old woman with the history of 1) bilateral breast fibroadenomas, 2) rectum adenocaircinam with lumen narrowing was diagnosed in 2023-03.
    • She was just discharged from our CRS ordinary ward on 2023/03/31 under the tentative diagnosis as rectal cancer with multiple liver and lung metastasis.
    • The pathology showed adenocarcinoma. Arrange whole body PET scan showed rectal cancer with liver and lung metastasis, cTxNxM1b, stage IVB and highly suspected another primary thyroid cancer.
    • After discussion, neoadjuvant CCRT was suggested. This time, she is admitted to our ward for enterostomy and Consult GS for Port-A implantation.
  • Course of inpatient treatment
    • After admittion, she was under surgery of T loop colostomy and Port-A insertion on 2023/04/19.
    • NPO with adequate IV fluid supplement and empirical antibiotic treatment with Soonmelt was use after operation.
    • Surgical wound pain was under the medications control. Tolerable oral diet was noted after operation and intravenous fluid supplement was tappered down.
    • Education on care of colostomy was done. Consulted radiation oncology and hematology oncology for neo-adjuvant CCRT. Suggest arrange Chest CT was perfromed on 2023/04/22. The report showed left lower lobe lung meta about 1.75cm; thyroid metastatic lesion at right lobe about 3.1cm; liver meta at both lobes.
    • The post-operative course was relatively smooth without complication. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. She was discharged today and OPD follow-up was arranged.
  • Discharge prescription
    • Deflam-K (diclofenac 25mg) 1# TID
    • Foliromin (ferrous sodium citrate 50mg) 1# QD
    • MgO 250mg 1# TID
• 2023-03-22 ~ 2023-03-31 POMR Colorectal Surgery Lv ZongRu
  • Discharge diagnosis
    • Rectal cancer with local abscess, and multiple liver with lung metastasis, stage IVb
  • CC
    • Lower abdominal pain for 5 days.
    • Noticed granular bloody stool since 2 months ago
  • Present illness
    • This is a 54 year old woman with the history of bilateral breast fibroadenomas. This time, was admitted due to lower abdominal pain for 5 days.
    • The patient noticed granular bloody stool since 2 months ago. There was no abdominal discomfort then. However, she encountered sudden dull pain at lower abdomen on the following days 5 days ago. It was a suprapubic pain with radiation to right flank with shaking chills for 2 days. She had nausea and vomitted once. Thus, she came to our ER on 2023/03/21 for help.
    • At ER, chills and fever up to 38.2 was noted. PE showed periumbilical tenderness without rebounding pain. Lab data revealed neutrophil predominant leukocytosis WBC 17660/ul with elevated CRP 11.59. Anemia Hb 8.3.
    • ABD CT showed thickening wall of rectosigmoid colon with focal loculated fluid, r/o colon malignancy with rupture and abscess, suspect metastasis to liver. LLL tumor, r/o malignancy. GB stone. and a soft tissue tumor, 6.5cm, r/o uterine myoma.
    • She was referred to CRS OPD next day with blood test showed CEA 186.2ng/mL and highter CRP level to 13.97.
    • Thus, under the impression of abscess of intestine r/o malignancy, she was admitted for further treatment and evaluation.
  • Course of inpatient treatment
    • After admission with ward routine and blood examination were done. NPO and nutrition support by PPN and IV fluids hydration, antibiotic treatment. On full liquid diet was started on 2023/03/27 after abdominal discomfort and general condition subsided. Arrange sigmoidfiberscopy for biopsy was performed on 2023/03/28. No nausea and no vomiting, stools and flatus passage. On semi-liquid diet was started on 2023/03/30. Well bowel movement and stools passage with diet fair tolerant. Now, the patient no fever and no complication. Discharged in general condition stable on 2023/03/31 and will follow up in our out-patient department next week.
  • Discharge prescription
    • MgO 1# TID
    • Through (sennoside 12mg) 1# HS
    • Transamin (tranexamic acid 250mg) 1# BID
    • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# Q12H

[surgical operation]

[radiotherapy]

[chemotherapy]

• 2024-02-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3820mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-01-24 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3840mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2024-01-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3850mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-12-06 - (Avastin + FOLFOX)
• 2023-11-09 - (Avastin + FOLFOX)
• 2023-10-20 - (Avastin + FOLFOX)
• 2023-10-04 - (Avastin + FOLFOX)
• 2023-09-13 - (Avastin + FOLFOX)
• 2023-08-21 - (Avastin + FOLFOX)
• 2023-07-28 - (Avastin + FOLFIRI)
• 2023-07-12 - (Avastin + FOLFIRI)
• 2023-06-20 - (Avastin + FOLFIRI)
• 2023-05-30 - (Avastin + FOLFIRI)
• 2023-05-08 - (FOLFIRI)

==========

2024-02-20

On 2024-02-19, the patient received Avastin + FOLFOX during her current hospital stay. Lab values obtained on the same date were unremarkable except for an elevated alkaline phosphatase level at 154 U/L.

A subsequent sigmoidoscopy performed on 2024-02-20 revealed luminal narrowing up to 10cm from the anal verge. This finding suggests rectal stenosis and precluded evaluation of the primary tumor site.

No medication discrepancies were identified during the review.

700360174

240220

[lab data]

2023-07-14 Anti-HBc Reactive
2023-07-14 Anti-HBc-Value 7.77 S/CO
2023-07-14 Anti-HBs 437.04 mIU/mL
2023-07-14 HBsAg Nonreactive
2023-07-14 HBsAg (Value) 0.26 S/CO

[exam findings]

• 2023-12-29 SONO - thyroid gland
  • Enlargement of right thyroid gland with some nodules (up to 2.72cm) and calcification (0.65cm).
• 2023-12-29 CT - abdomen
  • Findings: Comparison prior CT dated 2023/07/03.
    • Prior CT identified wall thickening of the rectum and regional LAP are noted again, decreasing in size that is c/w rectal cancer S/P CCRT with partial response.
    • Prior CT identified a hypodense lesion in left adrenal gland, 2.5 cm x 1.8 in size and 9 HU at non-enhanced CT, is noted again, stationary.
      • Adenoma of left adrenal gland is highly suspected.
    • There are several gallstones.
    • Bil. renal cysts (up to 3.1cm). Tiny calcifications in both kidneys.
    • Abdominal aorta shows atherosclerosis and ectasia 2.4 cm.
    • Absence of left thyroid gland.
      • Enlargement of right lobe thyroid with poor enhancing nodules (up to 1.7 cm). Please correlate with sonography to R/O nodular goiter.
    • There is aneurysmal dilatation of ascending thoracic aorta, 5 cm in diameter.
    • There are several enlarged LNs at the mediastinum and axillary regions, and some of them show calcification component.
      • Old inflammatory process is highly suspected.
      • In addition, there are several small calcifications in LUL of the lung that are c/w old granulomas.
    • The urinary bladder shows small contracted and diffuse wall thickening. please correlate with clinical condition.
      
  • Impression:
    • Prior CT identified wall thickening of the rectum and regional LAP are noted again, decreasing in size that is c/w rectal cancer S/P CCRT with partial response. Please correlate with colonoscopy.
• 2023-11-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 26) / 79 = 67.09%
    • M-mode (Teichholz) = 66
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA and aortic root, thickening of LVPW
    • Grade 1 LV diastolic dysfunction
    • Mild AR
• 2023-11-16 Cardiac Catheterization
  • Finding Summary
    • Left Radio cephalic AVF, draining left innominate vein: 68% stenosis. AV fistula.
  • Intervention Summary
    • Left Radio cephalic AVF, draining left innominate vein, Pre-DS = 68%
      • MLD/RVD=8.8/17.88 mm -> 21.58/26.81 mm, Post-DS = 20%.
      • Guide Wire: Terumo Radifocus 0.035 150cm.
      • Balloon: Bard ATLAS. 16.0 X 40 mm. Pressure: 10 atmospheres.
  • In conclusion :
    • S/P PTA for left radiocephalic AVF, drainig left innominate vein stenosis, successful, from 68% to 20% residual stenosis
  • Recommendation :
    • PTA Intervention
    • treatment: Antegrade
• 2023-11-16 Peropheral Vascular Test: AV fistula
  • Clinical diagnosis: AVF dysfunction
  • Result:
    • The venous Duplex study revealed a left radiocephalic AVF. Aneuruysmal dilatation at the cannulation sites were detected, with venous diameter at A cannulation site and V cannulation site around 19.1mm and 20.9mm respectively. The draining cephalic vein was small but patent. The draining basilic vein to axillary vein were also patent.
    • The estimated flow volume measured at the feednig radial artery was 3207 ml/min.
    • Subcutaneous tissue edema at left forearm was noticed.
    • The measured MVO/SVC ratio at right arm level was 100%, indicated no significant right central venous stenosis or obstruction.
    • Right side:
      • SVC: 10.2 mmHg ;
      • MVO/SVC: 100 % ;
      • Average MVO/SVC: 100 %
  • Suggestion
    • Left central venous stenosis is highly suspected according the clinical presentation and past history.
    • IV DSA and PTA prn will be arranged.
    • Suggestion: PTA
• 2023-07-06 PercutaneousTransluminal Angioplasty, PTA
  • Past Medical History
    • The patient has a history of CAD s/p PCI and thoracic aorta aneurysm.
  • Indication
    • The patient was referred with marked swelling of left arm and left forearm. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
  • Approach
    • Percutaneous access was performed through the av shunt fistula where a 8F sheath was inserted.
  • Procedure
    • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 40cc. The patient was treated with dormicum (Dosage=2.5 mg).
  • Finding Summary
    • Left Radio cephalic AVF, left innominate vein : 81% stenosis. AV fistula.
  • Intervention Summary
    • Left Radio cephalic AVF, draining left innominate vein, Pre-DS = 81%
    • MLD/RVD=4.5/23.5 mm → 20.3/22.6 mm, Post-DS = 10%.
    • Guide Wire: Terumo Radifocus 0.035 150cm.
    • Balloon: Bard ATLAS. 16.0 X 40 mm. Pressure: 10 atmospheres.
  • In conclusion :
    • S/P PTA for left radiocephalic AVF, draining left innominate vein, successful, from 81% to 10% residual stenosis
  • Recommendation :
    • PTA Intervention Treatment: Antegrade
• 2023-07-04 Patho - colon biopsy
  • Large intestine, lower rectum, 3-5 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2023-07-03 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent fat stranding and regional LAP.
    • Absence of left thyroid gland. Enlargement of right thyroid gland with nodules (up to 9mm).
    • Some LNs at mediastinum, axillary regions.
    • Left adrenal nodule (2.5cm).
    • Enlargement of prostate.
    • Bil. renal cysts (up to 3.1cm). Tiny calcifications in both kidneys.
    • Normal appearance of liver, spleen, pancreas.
    • Tiny gallbladder stones.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • Some calcifications at bilateral lungs.
  • Addendum Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2023-02-22 CTA - chest
  • Indication: aortic root dilatation hx, acute pul. edema, r/o aortic disseciton
  • With and without contrast enhancement CT of chest shows:
    • No intimal flap, nor intramural hematoma of aorta. Dilatation of aortic root, 5.0cm.
    • No filling defect of pulmonary artery.
    • Suspect stenosis of coronary artery, left anterior descending artery (Srs:8;Img:62).
    • No definite lung consolidation.
    • Small mediastinal lymph nodes.
    • No pleural lesion.
    • Polycystic kidney disease.
    • No bony destructive lesion on these images.
  • Impression
    • No CT-evidence of aortic dissection or pulmonary embolism
    • Aortic root dilatation
    • Suspect coronary artery stenosis, LAD

[MedRec]

• 2023-07-20 SOAP Radiation Oncology
  • P: Admission for infusional or oral 5-FU (UFUR)
  • Prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QW135 (after dialysis on QW1,3,5)
• 2023-07-14 SOAP Radiation Oncology
  • Plan: CT-simulation will be arranged on 7/18. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 7/20 or 21.
• 2023-07-13 SOAP Hemato-Oncology
  • O: Will decide what regimen
  • A: Now on HD on W1, 3, 5, Noon time
• 2023-07-13 SOAP Colorectal Surgery
  • A/P: Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-07-11
    • CCRT (TNT) then OP
• 2023-07-03 ~ 2023-07-05 POMR Colorectal Surgery
  • Discharge diagnosis
    • Rectal cancer with bleeding, cT4aN2aM0, STAGE:IIIC
    • End stage renal disease
    • Chronic ischemic heart disease, unspecified
    • Chronic systolic (congestive) heart failure
    • Thoracic aortic aneurysm (50 mm)
    • Enlargement of prostate
    • Left adrenal nodule
    • Pure hypercholesterolemia
  • CC
    • Bloody stool for 1 day
  • Present illness
    • This is a 70-year-old male with underlying history of ESRD QW135, CHF, and CAD s/p stent placement. He was admitted this time due to bloody stool for 1 day.
    • He was in his usual status of health until 1 days ago at midnight, when he started to defecate blood clot about 300ml. Then during hemodialysis, another episode of bloody stool was noted, therefore he was sent directly to our ER. After arrival at our ER, no bloody stool was noted. He was currently taking Bokey due to CAD s/p stent status. He denied history of peptic ulcer disease, HBV, HCV infection history,dizziness, abdominal pain, chest tightness or pain.
    • At ER, T/P/R: 36.6/107/18. BP:153/93mmHg. Con’s:E4V5M6. SpO2:95%. PE showed pink conjunctiva, no abdominal tenderness. Lab data showed hyperkalemia, BUN/Cr 107/10.1, WBC 9.34. Sigmoidoscopy showed several 0.2-0.3 cm IIa polyps at sigmoid colon. An ulcerative tumor was noted at lower rectum about 3-5 cm above anal verge, and Internal hemorrhoid. Abdominal CT showed rectal wall thickening r/o tumor. Under the impression of rectal ulcerative tumor bleeding, he was admitted for supportive treatment.
  • Course of inpatient treatment
    • After admission, abdominal CT showed rectal wall thickening r/o tumor. Sigmoidoscopy showed several 0.2-0.3 cm IIa polyps at sigmoid colon. An ulcerative tumor was noted at lower rectum about 3-5 cm above anal verge, and Internal hemorrhoid. The patient had no bloody stool after admission. Due to stable condition, and the patient requested for AV shunt occlusion management, the patient was discharged on 2023/7/5. Regular OPD f/u is arranged. Subsequent chemotherapy may be arranged after definite staging could be done after pathology report.
• 2023-05-10 SOAP Cardiology
  • A: In stationary condition now, no subjective complaints, asked for drug refill, acceptable BP control, keep on current medications
  • Prescription
    • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QD
    • Bokey (aspirin 100mg) 1# QD
    • Coxine (isosorbide-5-mononistrate 20mg) 1# BID
    • Nebilet (nebivolol 5mg) 0.5# BID
• 2017-09-14 SOAP Cardiology
  • S: A case of chronic GN with ESRD under regular hemodialysis since 2013, QW1,3,5 night
  • Diagnosis
    • Chronic ischemic heart disease, unspecified [I25.9]
    • Chronic systolic (congestive) heart failure [I50.22]
    • End stage renal disease [N18.6]
    • Dependence on renal dialysis [Z99.2]
    • Pure hypercholesterolemia [E78.0]
  • Prescription
    • Vytorin (ezetimibe 10mg, simvastatin 20mg) 0.5 HS
    • Plavix (clopidogrel 75mg) 1# QD
    • Hexal (carvedilol 25mg) 0.5# QD
    • Bokey (aspirin 100mg) 1# QD
• 2017-01-06 SOAP Nephrology
  • S: ESRD on HD 3
  • O: regular HD 3
  • Diagnosis: Chronic renal failure [N18.6]
• 2017-01-04 SOAP Nephrology
  • S: ESRD on HD 2
  • O: regular HD 2
  • Diagnosis: Chronic renal failure [N18.6]
• 2017-01-02 SOAP Nephrology
  • S: ESRD on HD 1
  • O: regular HD 1
  • Diagnosis: Chronic renal failure [N18.6]

[consultation]

• 2023-12-28, -12-12, -11-10, -10-17, -09-22, -08-24, -07-27, -07-03 Nephrology
  • A: We will arrange hemodialysis QW135 for the patient during the course of hospitalization. Please prescribe EPO 5000 IU QW if Hb < 11.
• 2023-01-16 Cardiology
  • Q
    • SOB since last night, denied chest pain, denied inadequate H/D recently
    • Allergy: AZ COVID Vaccine
    • PH:
      • CAD, CAG was arranged next month
      • ESRD, H/D QW135
      • Thoracic aneurythm
  • A
    • 69 year-old male had the history of :
      • heart failure
      • CAD, s/p LAD stent
      • ESRD
      • AsAo aneurysm, 48mm noted since 2020 (AsAo grafting had been discussed with the patient)
    • ECG 20230116 sinus, Q wave at inferior wall?
    • Echocardiogram 20230104
      • AO(mm) = 40.7
      • LA(mm) = 34.8
      • IVS(mm) = 13.2
      • LVPW(mm) = 12.5
      • LVEDD(mm) = 55.4
      • M-mode(Teichholz) = 43.7
      • TR: mild; Max pressure gradient = 26 mmHg
      • Conclusion:
        • Dilated LA and LV
        • Concentric LV hypertrophy
        • Global LV hypokinesis with impaired LV systolic function
        • Adequate RV systolic function
        • Possibly impaired LV relaxation
        • Calcified mitral annulus with mild MR, mild AR, TR and PR
    • SPECT 20221229
      • Probably mild myocardial ischemia at the apex, anteroseptal wall and anterolateral wall.
      • Mild reverse redistribution of radioactivity to the inferolateral wall, either normal variant or myocardial ischemia may show this picture.
    • The patient visited emergency department on 2023/01/16 morning due to dyspnea for one night. Elevating NTproBNP level was found. Chest film showed lung infiltration, suspected lung edema.
    • impression
      • Acute lung edema, CRP 0.93
      • heart failure
    • plan
      • as Scheduled hemodialysis
      • repeat TnI and ECG after dialysis
      • oxygen supplement and monitor breath pattern
      • book ICU for respriatory distress
        • If lung edema improves after hemodialysis, may re-evaluate the clinic condition
      • echocardiogram and SPECT done recently

[radiotherapy]

[chemotherapy]

• 2024-02-19 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-02-02 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2024-01-16 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-29 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-12 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-10 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-18 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 1090mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-23 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 1000mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-25 - [fluorouracil 400mg/m2 700mg NS 100mL 10min + leucovorin 20mg/m2 35mg NS 100mL 10min] D1,4,6-7 (CCRT)
• 2023-08-02 - [fluorouracil 400mg/m2 700mg NS 100mL 10min + leucovorin 20mg/m2 35mg NS 100mL 10min] D1,3-6 (CCRT)

==========

2024-02-20

[uremic pruritus management in hemodialysis: potential safety concerns with levocetirizine, examining ketotifen possibility]

This hemodialysis patient reports insufficient itch relief with Allegra (fexofenadine), potentially indicating uremic pruritus. Consequently, Allegra has been replaced with Xyzal (levocetirizine).

Caution is warranted, as levocetirizine undergoes minimal metabolism (85.8% excreted unchanged). Additionally, it is nondialyzable (<10% removed during a standard 4-hour dialysis session, three times weekly). Therefore, its use is generally contraindicated in hemodialysis patients.

Even in exceptional circumstances where its use is considered, short-term administration is highly recommended to minimize drug accumulation.

One potentially safer alternative therapy to consider is ketotifen. Notably, the manufacturer’s labeling does not include specific dosage adjustments for hemodialysis patients.

Despite the lack of specific guidance, ketotifen offers several potential advantages: it undergoes extensive metabolism in humans, resulting in only three identifiable metabolites detected in urine. Additionally, reported cases of oral ingestion at up to 60 times the recommended dose did not result in fatalities. These factors suggest a potentially favorable safety profile compared to levocetirizine in this patient population.

2024-01-16

The patient’s current medication, as listed in the active medication list, is appropriately adjusted for his hemodialysis schedule of QW135.

2023-09-25

This patient’s PharmaCloud is currently inaccessible. After reviewing the HIS5 records, no medication reconciliation issues were identified.

2023-08-30

Our cardiologist provided a repeat prescription for Atozet (ezetimibe, atorvastatin), Bokey (aspirin), Coxine (isosorbide-5-mononitrate), and Nebilet (nebivolol). All of these drugs are currently listed in the active medication record, and no issues with medication reconciliation have been identified.

2023-08-09

[optimal dosage adjustment of metoclopramide for intermittent hemodialysis patients]

Metoclopramide is not effectively removed during dialysis. Therefore, it is advisable to administer approximately one-third (or less) of the standard total daily dose for patients undergoing intermittent (three times weekly) hemodialysis. ref: Metoclopramide kinetics in patients with impaired renal function and clearance by hemodialysis. Clin Pharmacol Ther. 1985;37(3):284-289. doi:10.1038/clpt.1985.41

700506064

240220

[exam findings]

• 2021-11-09 Patho
  • Diagnosis
    • Ovary, bilateral, debulking surgery - Residual high grade serous carcinoma
    • Fallopian tube, bilateral, ditto - High grade serous carcinoma
    • Endometrium, uterus, ditto - Free from tumor, endometrial polyp
    • Myometrium, uterus, ditto - Tumor invasion, focal
    • Tumor on bladder, ditto - Tumor present
      
    • Tumor on rectum, ditto - Tumor present
      
    • Lymph node, L’t iliac artery, dissection - Tumor metastasis (1/4) without extracapsular extension (0/1)
    • Lymph node, R’t iliac artery, ditto - Tumor metastasis (1/3) without extracapsular extension (0/1)
    • Lymph node, R’t obturator nerve, ditto - Tumor metastasis (1/6) without extracapsular extension (0/1)
    • AJCC Pathologic staging: ypT3cN1a, if cM0; stage IIIC
      
  • Microscopic Exam
    • Histologic type: high-grade serous carcinoma (refer to S2021-05715)
    • Histologic grade: high grade
    • Contralateral ovary involvement: present
      
    • Tumor side ovarian surface involvement: present
      
    • Contralateral ovary involvement: present
      
    • Right tube involvement: present
      
    • Left tube involvement: present
      
    • Right adnexa soft tissue involvement: present
      
    • Left adnexa soft tissue involvement: present
      
    • Uterine serosa involvement: present
      
    • Endometrium involvement: absent, endometrial polyp
      
    • Myometrium involvement: present, focal
      
    • Lymph nodes metastasis: tumor metastasis (3/19) without extracapsular extension (0/3) in total number
    • Lymphovascular space invasion: present
      
    • Tumor on bladder: high grade serous carcinoma with necrosis and microcalcification
    • Tumor on rectum: high grade serous carcinoma with necrosis and microcalcification
  • 2021-04-15 Patho - peritoneum biopsy
    • Peritoneum, debulking -Metastatic serous carcinoma, compatible with fallopian tube or ovarian origin
    • The sections show metastatic serous carcinoma, high grade, compatible with fallopian tube or ovarian origin, composed of nests of pleomorphic neoplastic cells with numerous mitotic figures, arranged in solid and papillary patterns. Scattered psammoma bodies and tumor necrosis are noted.
    • IHC: ER(+), WT1(+), PAX8 (+), p53(+ with aberrant expression).
• 2021-04-14 Ascites
  • Smears show clusters of pleomorphic tumor cells. Malignancy is favored.
• 2021-04-14 Frozen Section
  • Peritoneal tumor, frozen section - Malignant, favor serous carcinoma.

[consultation]

• 2024-01-21 General and Gastrointestinal Surgery
  • Q
    • Abdominal pain > Transferred from another hospital. ABC CT diagnosed ileus
    • abd. pain and vomiting +
    • no fever
    • no chest pain
    • PH: ovarian cancer s/p C/T
    • NKA
  • A
    • impression
      • mechanical ileus, suspect ovarian cancer with peritoneal carcinomatosis related, or adhesion related
      • no signs of bowel strangulation
    • suggest
      • NPO
      • IVF supply
      • NG decompression if necessary

[chemotherapy]

• 2024-01-16 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr IVF

  • dexamethasone 2mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

• 2023-12-19

• 2023-11-16

• 2023-10-18

• 2023-09-20

• 2023-08-23

• 2023-07-25

• 2023-07-04

• 2023-06-21

• 2023-05-24

• 2023-05-09

• 2023-04-25

• 2023-04-11

• 2023-03-28

• 2023-03-15

• 2023-03-07

• 2023-02-21

• 2023-02-27

• 2023-01-31

• 2023-01-10

• ……….

• 2021-12 ~ 2023-04 - Paclitaxel + Carboplatin

• 2021-11 ~ 2021-11 - Liposome Doxorubicin + Carboplatin

• 2021-09 ~ 2021-10 - Paclitaxel

• 2021-05 ~ 2021-09 - Paclitaxel + Carboplatin

==========

2024-02-20

[tube feeding]

There are 2 oral drugs - Norvasc and Alpraline included in the active medicatin list. Both of them can be tube fed.

2022-01-26

• Paclitaxel + Carboplatin is preferred as an primary systemic therapy regimen for high-grade serous stage II-IV disease.
• Albumin-bound paclitaxel could be substituted for patients experiencing a hypersensitivity reaction to paclitaxel.
• Bevacizumab (or its biosimilar) might be an optional component to the aforementioned regimen.
• for elderly patients and/or those with comorbidities and/or intolerence, the following adjustment might be considered.
  • paclitaxel 60mg/m2 IV over 1 hour followed by carboplatin AUC 2 IV over 30 minutes
  • days 1, 8, 15; repeat every 21 days
• no issue found in active medication.

700953527

240220

[MedRec]

• 2023-11-21 SOAP Cardiology Liu ZhiRen
  • Diagnosis
    • HCVD, benign without CHF [I11.9]
    • Anxiety state, unspecified [F41.9]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Mixed hyperlipidemia [E78.2]
  • Prescription x3
    • Tulip (atorvastatin 20mg) 1# QW14
    • Diovan (valsartan 160mg) 1# QD
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# QD
• 2022-12-01 SOAP Hemato-Oncology Xia HeXiong
  • Prescription
    • Tagrisso (osimertinib 80mg) 1# QD
• 2022-11-17 SOAP Hemato-Oncology Xia HeXiong
  • S
    • EGFR: Exon 19 deletion (+)
    • ALK (-)
    • ROS1 (-)
    • 22C3 TPS 2%
    • 28-8 TC < 1%
    • SP142 TC 0%, IC 0%
• 2022-10-20 SOAP Ear Nose Throat Huang TongCun
  • O
    • 2022/10/14 PATHO - lymphnode biopsy
      • Labeled as “right lower neck”, core needle biopsy — soft tissue with invasive carcinoma.
      • IHC stains: TTF-1 (+), Napsin-A (+), S-100 (-), Dog-1 (-), p63 (-), CK7 (+), Ki-67: 10%.
• 2022-10-03 SOAP Ear Nose Throat Huang TongCun
  • S: tumor board suggest tumor marker test and sono guided biopsy
  • O:
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-09-30
      • test tumor marker: CA125, CA153, CA199, CEA, etc.
      • arrange image guided biopsy (neck LN)
• 2022-01-18 SOAP Ear Nose Throat Huang TongCun
  • O
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2021-12-17
      • Please ask the Pathology Department to reconfirm the pathological results. Is it a local in situ carcinoma, or an invasive cancer that has metastasized to the neck from another site?
  • A/P
    • Left lower neck mass (noted since 2016), favor benign nature because stable size (only increase a little) during follow up
    • size increase noted in 2021-10, excision on 2021-11-30 showed compatible with low-grade intraductal carcinoma of salivary gland
• 2021-12-21 SOAP Radiation Oncology Huang JingMin
  • O
    • Lymphnode aspiration, 2021-11-3: Left lower neck mass — Atypia.
      
    • MRI: Nasopharynx (2021-11-13): Post operative appearance in and around the area of left parotid gland, seems stationary.
    • Operation (2021-11-30): Excision of left neck mass
    • Pathology (S2021-17525, 2021-12-02): Soft tissue, lower neck, left, excision — Compatible with low-grade intraductal carcinoma of salivary gland. Surgical margins: Free of tumor.
• 2018-10-30, -08-07, -05-15, -02-20, 2017-11-28, -09-05, -06-13, -03-21 SOAP Cardiology Liu ZhiRen
  • Diagnosis
    • HCVD,benign without CHF [I11.9]
    • Anxiety state, unspecified [F41.9]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Pure hyperglyceridemia [E78.1]
  • Prescription x3
    • Uformin (metformin 500mg) 1# QD
    • Diovan (valsartan 160mg) 1# QD
• 2017-02-22 SOAP Radiation Oncology Huang JingMin
  • O:
    • Pathology (S2008-09410, 2008-07-22): nasopharynx,biopsy — negative for malignancy – lymphoid hyperplasia.
    • Pathology (S2008-06278, 2008-05-14): salivary gland, parotid, left ,total parotidectomy — acinic cell carcinoma.
      • Surgical margin, parotid, left, total parotidectomy — free (2~3mm away from tumor). The surgical margin is free and 2 to 3 mm away from tumor.
    • A: Acinic cell carcinoma of the Lt parotid gland, stage T4aN0M0 (IVA), s/p Lt total parotidectomy, with facial N adhesion, and s/p radiotherapy.
  • Diagnosis
    • Malignant parotid gland neoplasm [C07]

[consultation]

• 2024-02-20 Radiation Oncology
  • Q
    • This 72 year old female due to LUL cancer with bony and liver metastasis, she was admitted to our oncology ward for management. This time, she suffered from legs weakness and numbness till difficult walking for one week. She was brought to our ER for help.
    • At ER, blood test showed no leukocytosis nor anemia found, no electrolyte imbalance.
    • T-spine MRI was performed which revealed multiple bone metastasis at the T-spine vertebral body and S1.
    • NS man was consulted and informed poor prognosis of the disease, already discussed with patient and family.
    • Now, we will be keep target therapy with Tagrisso treatment and given pain control.
    • Family talked about they decided do further survey by NS doctor suggested.
    • Monitor U/O for dysuria and considered Foley insertion.
    • For the metastasis of T-spine and S-spine, we sincerely need your expertise for RT. Thanks a lot.
  • A
    • ON CALL
• 2024-02-16 Neurosurgery
  • Q
    • legs weakness and numbness till difficult walking for 1+ weeks
    • no fever
    • PH:
      • left parotid cancer (acinic cell carcinoma) s/p op by Dr Yen. on 2008-05-14 and post-op RT
      • Left lower neck mass, excision on 2021-11-30 compatible with low-grade intraductal carcinoma of salivary gland
    • 2024-01-30 pain over T spine, Xray: compression, arrange bone scan
    • 2024-02-07 multiple bony mets, add Xegeva x1, continue Tagrisso
    • 2024/02/02 Tc-99m MDP whole body bone scan IMPRESSION:
      • The scintigraphic findings suggest multiple bone metastases. In comparison with the previous study on 2023/01/31, some of the previous bone lesions in the skull, midlde T-spines, adjacent right costovertebral junctions, left acetabulum, sacrum and adjacent right S-I joint are a little more evident
  • A
    • a case of lower limbs weakness and numbness with difficulty in walking for 1+ week
    • back pain
    • lower limbs weakness and numbness
    • MRI multiple heterogeneous enhancing lesions c/w bone metastasis in the T4, T5, T6, T7, T8 and S1, causing epidural extension and moderate indentation on the T7 cord.
    • bone scan suggest multiple bone metastases. In comparison with the previous study on 2023/01/31, some of the previous bone lesions in the skull, midlde T-spines, adjacent right costovertebral junctions, left acetabulum, sacrum and adjacent right S-I joint are a little more evident.
    • CT LUL cancer with bony metastasis, stationary. obstructive airway disease in lungs.
    • Plan: poor prognosis of the disease well discussed with patient and family

[radiotherapy]

• 2008-06-18 ~ 2008-08-01 - 6600cGy/33 fractions of the Lt parotid to neck area.

[chemotherapy]

• 2022-12-01 ~ undergoing - Tagrisso (osimertinib 80mg) 1# QD

==========

2024-02-20

[priority issue: bone metastases impacting gait & sensation]

It appears that the bone metastases causing lower limb weakness and numbness with difficulty walking is the most important medical problem for this patient now. Radiation oncologist has been consulted. No medication discrepancy was found.

700393370

240219

[lab data]

Examination of Bone Marrow

• 2023-12-17 clinical diagnosis leukocytosis /blast
  
• 2023-12-17 Gross: Marrow +
  
• 2023-12-17 Cellularity Hyper-extreme
  
• 2023-12-17 Fat componemt +(Normal)
  
• 2023-12-17 Megakaryocyte dist absent.
  
• 2023-12-17 M/E ↑
  
• 2023-12-17 M/E(/) 86/14
  
• 2023-12-17 sites lliac. post. R
  
• 2023-12-17 type Aspiration
  
• 2023-12-17 specimen condition adequate
  
• 2023-12-17 smear fair
  
• 2023-12-17 Myeloblast 32 %
  
• 2023-12-17 N.Myeloblast 0 %
  
• 2023-12-17 N.Meta 12 %
  
• 2023-12-17 N.Band 0 %
  
• 2023-12-17 N.Seg. 2 %
  
• 2023-12-17 Eo.Myeloblast 0 %
  
• 2023-12-17 Eo.Meta 0 %
  
• 2023-12-17 Eo.Band 0 %
  
• 2023-12-17 Eo.Seg. 0 %
  
• 2023-12-17 Baso 0 %
  
• 2023-12-17 Promyelo. 0 %
  
• 2023-12-17 Mono. 0 %
  
• 2023-12-17 Mo.blast 42 %
  
• 2023-12-17 Mo.promono. 0 %
  
• 2023-12-17 Mo.mature 0 %
  
• 2023-12-17 Lympho 0 %
  
• 2023-12-17 Lym.blast 0 %
  
• 2023-12-17 Lym.promono. 0 %
  
• 2023-12-17 Lym.mature 0 %
  
• 2023-12-17 Plasma Cell 0 %
  
• 2023-12-17 Pro-eyth. B 0 %
  
• 2023-12-17 Normoblast 0 %
  
• 2023-12-17 Nor.Baso 0 %
  
• 2023-12-17 Nor.polych 6 %
  
• 2023-12-17 Nor.ortho. 8 %
  
• 2023-12-17 Peroxidase Positive
  
• 2023-12-17 LAP NA
  
• 2023-12-17 CAE Positive
  
• 2023-12-17 ANAE Positive
  
• 2023-12-17 Iron stain NA
  
• 2023-12-17 PAS NA
  
• 2023-12-17 Other stains NA
  
• 2023-12-17 Description see comment
  
• 2023-12-17 Comments see comment

2023-12-15 FLT3-D835 (bone marrow) Undetectable
2023-12-15 FLT3/ITD (bone marrow) Presence of mutation
2023-12-15 NPM1 (qualitative, BM) Undetectable

2023-12-07 Anti HTLV I/II Nonreactive
2023-12-07 Anti HTLV I/II Value 0.06 S/CO

2023-12-05 Anti-HCV Nonreactive
2023-12-05 Anti-HCV Value 0.30 S/CO
2023-12-05 HBsAg Reactive
2023-12-05 HBsAg (Value) 4397.98 S/CO

[exam findings]

• 2024-01-23 Microsonography
  • Conclusion: borderline glaucoma
  • Report: disc OCT
  • OD 84um/0.64
  • OS85um/0.58
  • macular OCT
  • OD252
  • OS257um
• 2024-01-17 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — acute myelogenous leukemia.
  • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 1:2. Three cell lineages are present with left shift of leukocytes.
  • IHC stains: CD117: 10 %; CD34: 25 %; MPO: 35-40 %, CD61: 5 %; CD71: 55-60% (of the nucleated cells).
• 2024-01-14 CXR
  • S/P nasogastric tube insertion
  • S/P PICC catheter insertion via right forearm.
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2024-01-14 KUB
  • S/P nasogastric tube insertion
  • Fecal material store in the distal descending colon, sigmoid colon, and rectum.
  • A calcification projecting at left middle pelvis is noted. Please correlate with CT.
• 2023-12-21 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A(minimal)
    • Gastric erosions, antrum
    • Pangastritis
    • Duodenal ulcer scar, bulb
  • CLO test: not done
  • Suggestion: PPI use
• 2023-12-21 ElectroEncephaloGram, EEG
  • Abnormal, continuing generalized slowing with theta waves 5-6 Hz, indicated moderate cortical dysfunction bilaterally, suggest clinical correlation.
• 2023-12-20 CT - brain
  • Indication: AML
  • Head CT without contrast enhancement shows:
    • brain atrophy with prominent sulci, fissures and dilated ventricles.
    • confluent hypodensity at bilateral periventricular white matter, indicating leukoaraiosis.
    • bilateral paranasal sinusitis change.
  • Impression:
    • Brain atrophy and leukoaraiosis.
    • Bilateral paranasal sinusitis.
• 2023-12-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (86.8 - 25.1) / 86.8 = 71.08%
    • M-mode (Teichholz) = 71.1
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnrmality at resting state
    • Mild MR, TR and PR
    • Mildly thick IVS
    • Sinus tachycardia during the exam, HR 103-109bpm during the exam
• 2023-12-05 Patho - bone marrow biopsy
  • DIAGNOSIS:
    • Bone marrow, iliac, biopsy — see description.
  • GROSS DESCRIPTION:
    • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 0.6 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
  • MICROSCOPIC DESCRIPTION:
    • Section shows piece(s) of bone marrow with 40% cellularity and M:E ratio of approximately 3:1. A predoimant lymphoid subpopulation is present in the marrow
    • IHC stains:
      • CD117: <1 %; CD34: <1 %; MPO: 2 %, CD61: <1 %; CD71: <1 % (of the nucleated cells).
      • The hemogram shows up to 58% blasts. The marrow smear shows many blasts.
      • These findings suggest biopsy specimen might not be representative.
      • Considering the hemogram and smear findings, acute leukemia is considered.

[chemotherapy]

• 2023-12-07 - daunorubicin 45mg/m2 76mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 170mg NS 500mL 24hr D1-7
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-7

==========

2024-02-19

[tube-feeding]

The 2 drugs in the active medication list - Anxiedin (lorazepam) and Brintellix (vortioxetine) can both be tube-fed.

[AML suppression & transfusion: prophylactic approach at 10K PLT & beyond petechiae]

Patients with AML can have suppressed bone marrow from AML and/or chemotherapy. It is generally recommended to use standard dose prophylactic transfusion of these patients at a threshold platelet count of 10K/uL, and transfusion for any bleeding greater than petechial bleeding.

• 2024-02-18 PLT 20 *10^3/uL
• 2024-02-15 PLT 7 *10^3/uL
• 2024-02-05 PLT 9 *10^3/uL
• 2024-01-31 PLT 70 *10^3/uL
• 2024-01-30 PLT 27 *10^3/uL
• 2024-01-29 PLT 77 *10^3/uL
• 2024-01-28 PLT 12 *10^3/uL
• 2024-01-23 PLT 9 *10^3/uL
• 2024-01-18 PLT 22 *10^3/uL
• 2024-01-16 PLT 23 *10^3/uL
• 2024-01-15 PLT 27 *10^3/uL

2024-01-29

[assessing anemia progression after recent LPRBC use]

The anemia observed appears to have intensified, following the administration of Leukocyte-Poor Red Blood Cells (LPRBC) on 2024-01-28. Should this condition persist, further LPRBC transfusions might be necessary.

• 2024-01-29 HGB 7.8 g/dL
• 2024-01-28 HGB 8.5 g/dL
• 2024-01-23 HGB 9.0 g/dL

[considering additional induction for inconsistent blast reduction]

Given that the blast count has not consistently remained below 5% (2024-01-17 bone marrow biopsy pathology IHC MPO 35-40 %) following the initial administration of the standard 7+3 regimen (2023-12-07 started) combined with Rydapt (midostaurin) for FLT3 mutation, it is advisable to proceed with a second cycle of induction therapy promptly, provided the patient’s condition allows for it.

• 2024-01-29 Blast 5.1 %
  
• 2024-01-28 Blast 2.0 %
  
• 2024-01-23 Blast 4.0 %
  
• 2024-01-18 Blast 4.1 %
  
• 2024-01-16 Blast 3.2 %
  
• 2024-01-14 Blast 5.3 %
  
• 2024-01-09 Blast 10.0 %
  
• 2024-01-05 Blast 1.0 %

[implementing simple suspension for esomeprazole tube feeding]

All oral medications listed as active can be administered via tube feeding. However, for Nexium (esomeprazole), it is recommended not to crush the tablets due to manufacturer guidelines. Instead, a simple suspension method (SSM) should be used to prepare the medication for tube administration.

The simple suspension method, also known as the water bath method, is a technique used to disperse solid oral medications into a liquid for administration through a nasogastric (NG) tube. This method is often used for patients who are unable to swallow tablets or capsules, such as those with dysphagia, a feeding tube, or a coma.

To perform the simple suspension method:

• Place the medication in a small cup or bowl.
• Add enough warm water to cover the medication.
• Stir or shake the mixture until the medication is dissolved or dispersed into small enough particles or completely dissolved.
• Administer the mixture through the NG tube using a syringe or feeding pump.

Tips for using the simple suspension method:

• Use warm water to help dissolve the medication.
• Stir or shake the mixture vigorously to ensure that the medication is completely dispersed.
• If the medication is a capsule, you may need to open it and remove the contents before dissolving it.

2023-12-18

[anemia and neutropenia]

Blood product transfusion is recommended for anemia. For anticipated severe neutropenia (absolute neutrophil count [ANC] < 500 for more than 7 days), prophylactic antibiotics such as ciprofloxacin or levofloxacin may be considered as a preventive measure.

[Rydapt (midostaurin) underdosed]

On 2023-12-05, the patient tested positive for HBsAg, indicating a current infection. Baraclude (entecavir 0.5mg) has been prescribed at a dosage of 1# QDAC.

The FLT3/ITD mutation was detected on 2023-12-15. Rydapt (midostaurin) is recommended at a dosage of 50 mg twice daily from days 8 to 21 of each induction cycle, in combination with daunorubicin and cytarabine. A second induction cycle is advised if there is clear evidence of significant residual leukemia. Presently, Rydapt (midostaurin) is being administered at 25mg BID, which is half the recommended dose. It is therefore suggested to increase the dosage to the recommended 50mg BID.

701060745

240219

[MedRec]

• 2019-08-04 ~ 2019-08-10 POMR Thoracic Surgery Xie MinXiao
  • Discharge diagnosis
    • C34.92 Left lower lung adenocarcinoma, pT1aN0 pStage IA1 status post robotic video-assisted thoracic surgery left lower lobectomy and radical lymph node dissection on 2019/08/07
    • C30.0 Left sinonasal cancer recurrent status post left total maxillectomy, left posterolageral neck dissection, excision of intranasal malignant tumor and Da Vinci surgery on 2018/08/21
    • G47.01 Insomnia due to medical condition
  • CC
    • LUL lung nodule, 1.82cm
  • Present illness
    • This 69-year-old female patient has history of
      • Left sinonasal cancer stage III s/p Da Vinci surgery at Tong general hospital in 2016 s/p L DaVinci ND + L transnal endoscopic (+/-Midfacial excision) + L ora-nasal fistula repair (Ho = R vocal polyp), rpT2N3bMx (NK-SCC) on 2018/08/21
      • Uterine prolapse post Da Vinci robotic hysterectomy and bilateral salpingo-oophorectomy on 2018/04/27
    • She was under regular ENT OPD follow up. Neck CT on 2019/05/20 revealed
      • C/W left sinunasal cancer with post-operation changes and abscess formation as aforementioned. Malignant nodule (19 mm) in LLL.
      • Gall stones.
      • Hepatic cysts, left lobe.
    • No dyspnea, cough or fever was noted. After discussing with the patient and her family on the benefits of surgical treatment as well as subsequent risks and possible complications, she was admitted for RATS LLL wedge, if ca. lobectomy + RLND.
  • Course of inpatient treatment
    • After admission, pre-op assessment was done. Operation of robotic video-assisted thoracic surgery left lower lobectomy and radical lymph node dissection was performed smoothly on 2019/08/07. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Left chest tube with LPS -18 cmH2O was done. Chest tube was removed on 2019/08/09. She was discharged under stable hemodynamics on 2019/08/10.
  • Discharge prescription
    • Actein (acetylcysteine 200mg) 1# TID
    • MgO 250mg 1# TID
    • Lactam (acetaminophen 500mg) 1# QID
    • Sindine 10% PRN EXT
• 2018-08-20 ~ 2018-08-27 - POMR Ear Nose Throat Su WanYu
  • Discharge diagnosis
    • C30.0 Left sinonasal cancer recurrent status post left total maxillectomy, left posterolageral neck dissection, excision of intranasal malignant tumor and Da Vinci surgery on 2018-08-21
    • R03.0 Eevated blood pressure reading without diagnosis of hypertension
    • G47.09 Insomnia
  • CC
    • Left sinonasal cancer post Da Vinci surgery in 2016, complicated with left oronasal fistula. Followed MRI showed recurrent.
  • Present illness
    • This 68-year-old female has history of left sinonasal cancer stage III post Da Vinci surgery at Tong general hospital in 2016 and uterine prolapse post Da Vinci robotic hysterectomy and bilateral salpingo-oophorectomy on 2018/04/27.
    • She suffered from complicated with left oronasal fistula since 2016. Easy left nasal obstruction was also noted. She visited our ENT OPD for help. Physical examination revealed a fistula at left hard palate around 0.7x0.3cm. Scope showed left nasal floor focal smooth bulging, a fistula at left nasal floor, left nose post medial maxillectomy, and no tumor found. MRI followed on 2018-08-02 which revealed tumors in left posterior maxillary region extending to pterygoid plates and muscles, and multiple left posterior neck LAPs. After discussion with the patient, we suggest her to receive tumor wide excision. She ask for Da Vinci surgery. Operation details and risks were explained.
    • Under the impression of left sinonasal cancer recurrent, she was admitted to our ward for the operation.
  • Course of inpatient treatment
    • After admission, the surgery of left total maxillectomy, left posterolageral neck dissection, excision of intranasal malignant tumor and Da Vinci robotic - neck malignant tumor resection surgery were performed smoothly on 2018/08/21. Post op condition of no nasal oozing, no headache, E.O.M. were free and full, vision as usual, mild nasal wound pain, left neck wound no oozing with H/V drainage and mild wound pain.
    • After the operation, she was transferred to SICU for post-op intensive care and return to ordinary ward on 8/22. The H/V drainage amount gradually less then removed it on 8/24. Under stable condition, we let her discharged today and arranged OPD follow schedule.
  • Discharge prescription
    • cephalexin 500mg 1# QID
    • Antica Syrup 10mL TID
    • Actein (acetylcysteine 200mg) 1# TID
    • Allegra (fexofenadine 60mg) 1# BID
    • Paran (acetaminophen 500mg) 1# QID
• 2018-04-26 ~ 2018-04-30 - POMR Obstetrics and Gynecology Chen GuoHu
  • Discharge diagnosis
    • N81.9 Uterine prolapse, cystocele and rectocele
    • N39.3 Stress incontinence
    • R35.0 Urinary frequency
    • Da Vinci robotic hysterectomy and bilateral salpingo-oophorectomy
    • Transvaginal pelvic floor reconstruction on 2018-04-27
  • CC
    • A mass dropping out of vagina for 3 months
  • Present illness
    • This is a 67-year-old female, and she has history of nasopharyngeal carcinoma cancer stage III post Da Vinci surgery at Tong general hospital in 2016. She suffered from a mass dropping out of vagina for 3 months, otherwise she had the symptoms of stress urinary incontinence (SUI) and urinary frequency. She visited our OPD for help, which PV examination revealed uterine prolapse, cystocele and mild rectocele. She was suggested for surgical intervention. Therefore she was admitted for Da Vinci surgery for hysterectomy, BSO and pelvic reconstruction on 2018-04-27.

[surgical operation]

• 2019-08-07
  • Operation
    • Da Vinci assisted lobectomy
    • Pneumonolysis, intrapleural (extrapleural)
  • Finding
    • One nodular lesion was noted over LB6, size about 2.2cm in diameter.
    • Frozen section: adenocarcinoma
    • One 24 Fr. straight chest tube was inserted via left 9th ICS.
• 2018-08-21
  • Operation
    • Maxillectomy - total, left
    • posterolageral neck dissection, left
    • Endoscopic-assisted excision of intranasal malignant tumor
    • Da Vinci robotic - neck malignant tumor resection surgery (complexity)
  • Finding
    • MRI = (1) L nasal and maxillary sinus lesion with invasion of pterygoid muscles, (2) cervical LAP over L level II and posterolateral neck.
    • L sinonasal cancer (stage III told) s/p da Vinci op at Tong general hospital in 2016 (Dr. Cai QingShao), complicated with left oronasal fistula (refuse post-op R/T, refuse open op suggested at other hospitals).
    • tumor over L OMC + PE with E-tube invasion, lateral and inferior maxillary sinus wall and nasal floor.
• 2018-04-27
  • Operation
    • Da Vinci robotic hysterectomy
    • Da Vinci robotic bilateral salpingo-oophorectomy
    • Transvaginal pelvic floor reconstruction
    • Resection of Uterus, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance
  • Finding
    • Uterus: elongated, 12x5x3cm
    • cervix eroded, prolapsed
    • uterine prolapse, cystocele and rectocele(+) with prolapsed vaginal epithelium
    • bil adnexa: atrophic changes
    • CDS: no fluid
  • Course of inpatient treatment
    • She was arranged to admit for Da Vinci surgery with hysterectomy and bilateral salpingo-oophorectomy & transvaginal pelvic floor reconstruction, which were performed smoothly on 2018-04-27. Her postoperative course was uneventful. Abdominal wound was clear without discharge and healing was well. Her self voiding and eating were OK after adjustiong drugs. So she was discharged and her OPD follow-up appointment is scheduled on next week.

2024-02-19

[tube-feeding]

Tube feeding is available for all oral medications on the active drug list.

701119127

240219

[exam findings] (not completed)

• 2024-06-23, -06-21, -06-17 CXR erect

  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Linear infiltration over both lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
  • Bilateral pleura effusion.
  • S/P pigtail catheter implantation at left CP angle.

• 2024-06-20 ECG

  • Sinus tachycardia
  • Right superior axis deviation
  • Poor wave progression in precordial leads
  • Abnormal ECG

• 2024-06-18 ECG

  • Atrial fibrillation with rapid ventricular response
  • Right superior axis deviation

• 2024-06-14 SONO guiding aspiration - thoracocentesis

  • Sono- and fluoro-guide drainage of left pleural effusion

• 2024-06-14 CT - chest

  • Indication: shortness of breath
  • Chest CT with and without IV contrast ehnancement shows:
    • There is massive bilateral pleural effusion.
    • Consolidation of right upper lobe with mediastinal lymphadenopathy is found. In comparison with CT dated on 2024-01-19, the lesion progressed.
    • Consolidation of right lower lobe and left lower lobe is found.
    • Left axillary lymphadenopathy is also noted.
    • Calcified coronary arteries is found.
    • S/p port-A placement with its tip at Superior vena cava
    • Esophageal wall thickening is found at upper and middle third esophagus. Nature?
  • Imp:
    • Bilateral cancer seeding and mediatsinal lymphadenopathy
    • left axillary lymphadenopathy
    • Right upper lobe lung collapse and esophageal wall thickening.

• 2024-06-12 CXR

  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Linear infiltration over both lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?

• 2024-06-09 CXR

  • Consolidation in left lower lung zone. DDx: pneumonia, mass

• 2024-06-09 CT - brain

  • Findings
    • Encephalomalacia in left frontal lobe.
    • Prominent sulci, fissures, and ventricles.
  • Impression
    • Encephalomalacia due to old insult

• 2024-06-09 ECG

  • Sinus tachycardia with Premature atrial complexes
  • Right axis deviation
  • Low voltage QRS of limb leads
  • Borderline ECG

• 2024-04-09 CXR (erect)

  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.

• 2024-03-11 Bronchodilator Test

  • Diagnosis: If COPD, GOLD stage II
  • Conclusion: FVc:81%, FEV1: 66, FEV1/FVC:63%.

• 2024-03-04 CXR

  • Port-A catheter inserted into cavo-atrial junction via right subclavian vein.
  • reticular opacities over both lungs
  • mild enlarged cardiac silhoutte
  • Thoracic aortic arch calcified atheriosclerotic plaque

• 2024-03-04 Bladder Sonography

  • PVR: 13.9mL

• 2024-02-02 CXR erect

  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?

• 2024-01-19 CT - chest

  • Chest CT with and without IV contrast ehnancement shows:
    • Diffuse tree in bud and Bronchiectatic change over both lungs is found.
    • Confluent lymphadenopathy in the mediastinum is found. In comparison with CT dated on 2023-10-14, the lesion regressed.
    • Calcified coronary arteries is found.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
  • Imp:
    • Bone meta.
    • Mediastinal lymphadenopathy, in regression.

• 2024-01-12 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (76 - 12.1) / 76 = 84.08%
    • M-mode (Teichholz) = 84
  • Conclusion:
    • Dilated LA
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild MR, TR, AR

• 2024-01-10, 2023-12-11, -11-16 CXR

  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Linear infiltration over left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.

• 2023-10-26 Cell Block

  • 50 cc red cloudy pericardial fluid — Positive for metastatic squamous cell carcinoma - Malignancy
  • The smears and cell block show lymphocytes, PMNs, reactive mesothelial cells and some atypical cells, which immunocytochemistry shows TTF-1(-) and P63(+) for tumor cell. According to clinical information and cytomorphologic findings, it is compatible with metastatic squamous cell carcinoma.

• 2023-10-25 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (82.6 - 13.6) / 82.6 = 83.54%
    • M-mode (Teichholz) = 83.5
  • Conclusion:
    • Normal chamber size
    • Large pericardial effusion with diastolic RA and RV compression with cardiac tmponade signs
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR , mild TR and PR
    • Calcified mitral annulus with mild MR
    • No regional wall motion abnormalities

• ……….

• 2019-09-03 CT - abdomen

  • Clinical history: 71 y/o female patient with rectal cancer post CCRT and C∕T. 108∕8∕27: Persistent elevating CEA. FU CT scan. 2019∕04∕29
    • CEA elevated noted by oncologist; gastric wall thickening suspected by oncologist, abd CT scan: mild rectal wall thickening.
    • Rectal cancer post CCRT and C∕T, Persistent elevating CEA up to 12. => FU CT scan.
  • With and without contrast enhancement CT of abdomen–whole:
    • Thickening wall at the rectum.
    • Presence of gallbladder stone.
    • Cystic lesion, 4.3cm in left adenxa, r/o left ovarian cyst.
    • Right renal cyst, 0.6cm.
    • Generalized low density over liver parenchyma, suggesting fatty liver.
    • Small right lower lung nodules, suggest further study.
  • Impression:
    • Thickening wall at the rectum. Stationary.
    • GB stone.
    • Left ovarian cyst.
    • Right renal cyst.
    • Fatty liver.
    • Small right lower lung nodules, suggest further study.

• 2019-05-27 EUS

  • No paraesophageal lesion or mural lesion at cardia or lower esophagus

• 2019-05-27 CT - chest

  • Indication: for f∕u of colon cancer
  • Impression: no lung nodule.

• 2019-05-03 Surgical pathology Level IV

  • Clinical diagnosis: Abnormal CEA level; suspected colon lesion; Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation; Malignant neoplasm of rectum
  • Pathological DIAGNOSIS:
    • Esophagus, biopsy — Squamous hyperplasia with mild acute inflammation.

• 2019-04-23 CT - abdomen

  • FINDINGS:
    • There is mild wall thickening in the rectum. Please correlate with colonoscopy.
    • Asymmetrical wall thickening in the gastric fundus (Srs:301, Img:17) is noted that may be adenocarcinoma or normal variation secondary to inadequate distension. Please correlate with gastroscopy.
    • There is fatty density in the pancreatic head and body that is compatible with fatty replacement of the pancreatic parenchyma.
    • Left side ovarian cyst measuring about 3.8 x 3.2 cm is noted. Please correlate with GYN. sonography.
  • Impression:
    • There is mild wall thickening in the rectum. Please correlate with colonoscopy.

[MedRec]

• 2024-02-01 ~ 2024-02-05 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Recurrent squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, rcT2N2M1, stage IV s/p concurrent chemoradiotherapy with FOLFOX with progressive disease of mediastinal lymphadenopathy s/p palliative chemotherapy with mDCF (selfpaid of Docetaxel) from 2022/11/29
    • Postive of anti-HBc
    • Paroxysmal atrial fibrillation
    • Right 1st toe paronychia
    • Insomnia
    • Constipation
  • CC
    • for chemotherapy
  • Present illness
    • This 74-year-old female patient has past history of squamous cell carcinoma of rectum cancer, cT2N2M1, stage IV status post concurrent chemoradiotherapy (MMC/5Fu) at KFSYSCC in 2013, C4 PF at TzuChi in 2014. She visited our oncologist OPD for regular follow-up. Followed abdominal CT scan on 2022-03-22 revealed enlarged lymph nodes (up to 3.2cm) at mediastinum. She denied any poor appetite, body weight loss, easy cough, shortness of breath or dyspnea. After discussing with the patient and her family on the benefits of surgical treatment as well as subsequent risks and possible complications.
    • Operation of right video-assisted thoracoscopic surgery lymph node sampling and pneumolysis was performed smoothly on 2022-04-14.pathology showed metastatic squamous cell carcinoma, CD56(-), P40 (+), CK20 (-). PET was performed on 2022/4/23 revealed increased FDG uptake in some right paratracheal and precarinal lymph nodes, an A-P window lymph node, bilateral pulmonary hilar regionsand right lateral chest wall. Besides, there was increased FDG accumulation in the colon, rectum, both kidneys and left ureter.
    • Under the impression of Metastatic squamous cell carcinoma of the mediastinal lymph node from rectum cancer, cT2N2M1, stage IV status post concurrent chemoradiotherapy
    • CCRT with FOLFOX (selfpaid of Oxaliplatin) C1D1 on 2022/05/12, C1D15 on 2022/06/08, C2D1 on 2022/06/23, C2D15 on 2022/07/19.
    • Follow-up abdominal CT on 2022/07/22 showed there is mild wall thickening in the rectum.
    • C3D1 on 2022/07/31. C3D15 on 2022/08/12. C4D1 on 2022/09/02. C4D15 on 2022/09/16. C5D1 on 2022/10/03. C5D15 on 2022/10/20. C6D1 FOLFOX on 2022/11/14.
    • Followed up, CT of chest to abdominal on 2022/11/04 revealed Rectal cancer s/p C/T with mediastinal lymphadenopathy, in progression. Foca recal wall thickening. Stationay. Followed up laboratory test revealed elevated tumor marker (CEA:303ng/ml) on 2022/11/17.
    • Palliative chemotherapy with mDCF (Docetaxel 40mg/m2, self pay, CDDP 40mg/m2, LV 400mg/m2, 5FU 1200mg/m2) C1D1 on 2022/11/29. C1D15 on 2022/12/14.
    • Followed up laboratory test revealed elevated tumor marker (CEA:447.69ng/ml) on 2022/11/29, (CEA:231.89ng/ml) on 2022/12/13.
    • Palliative chemotherapy with mDCF (Docetaxel 40mg/m2, self pay, CDDP 40mg/m2, LV 400mg/m2, 5FU 1200mg/m2) C2D1 on 2023/1/02.   
    • This time, she was admitted due to pericardial effusion seen on CT during regular OPD follow up. According to the patient herself and her family, she had been suffering from progressive exertional dyspnea during the past half year, and had exaggerated in recent 1-2 months. Comparison of CT in July and in October this year revealed increased amount of pericardial effusion and mediastinal lymphadenopathy in progression. Emergency echocardiography showed large pericardial effusion with diastolic RA and RV compression with cardiac tmponade signs. CV was consulted for drainage. During cardiac catheterization, puncture of left chest wall, s/p pericardiocentesis around 170ml. Episode Af was developed on 2023/10/27, so anticoagulant Lixiana and antiarrhythmic agent with Propafenone. Precardial effusion pathology showed positive for metastatic squamous cell carcinoma.
    • C1D1 Cetuximab + FOLFIRI on 2023/11/2-11/4.
    • C1D15 Cetuximab + FOLFIRI on 2023/11/16-18.
    • C2D1 Cetuximab + FOLFIRI on 2023/12/11-12/13.
    • C2D15 Cetuximab + FOLFIRI on 2023/12/25-12/27.
    • C3D1 Cetuximab (self-paid) + FOLFIRI on 2024/01/11-2024/01/13.
    • This time, she has mild chest tightness for 1 day and right toe wound for 1 week. She denied fever, so she was admitted for C3D15 Cetuximab + FOLFIRI on 2024/2/1.
  • Course of inpatient treatment
    • After admission, she received C3D15 FOLFIRI and Cetuximab since 2024/02/02 - 02/04.
    • Mosapin 5mg/tab (Mosapride Citrate) 1# tid for prevent vomit.
    • Baraclude 0.5mg/tab (Entecavir) 1# qdac for anti-HBc postive.
    • Under the stable condition, she can be discharged on 2024/02/05. OPD follow up is arranged.
  • Discharge prescription
    • Actein (acetylcysteine 200mg) 1# TID
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • codeine phosphate 15mg 1# Q6H
    • Dinco Syrup (codeine phosphate) 10mL QID
    • diphenidol 25mg 1# TID
    • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# TID
    • Lixiana (edoxabam 30mg) 1# QD
    • MgO 250mg 1# TID
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Rytmonorm (propafenone 150mg) 1# BID hold if HR < 60
    • Megejohn (megestrol acetate 160mg) 1# QD
    • Rivotril (clonazepam 0.5mg) 1# HS
    • Through (sennoside 12mg) 2# HS
    • Diclocin (dicloxacillin 250mg) 2# Q6H
• 2023-08-04, -05-10, -02-08 SOAP Neurology
  • A: r/o CT induced polyneuropathy
  • Prescription x3
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
• 2017-02-02 SOAP Hemato-Oncology Wan XiangLin
  • S
    • A patient of low rectal cancer (Squamous cell carcinoma) with multiple pelvic, inguinal, paraaortic metastasis, (lung meta?) stage T2N3M1
      
    • treated at Koo Foundation Sun Yat-Sen Cancer Center s/p CCRT (201311 - 201312)
    • S/P chemotherapy with PF (C4) (201401 - 201404).
    • Skin itching. leg cramping and pain. diarrhea, S/P lab. test.
  • O
    • 20160414 chest CT showed: no lung metastasis.
  • Diagnosis
    • Malignant rectum neoplasm [C20]
    • Peristent disorder of initiating or maintaining sleep [F51.09]
  • Prescription
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Imolex (loperamide 2mg) 1# BID
    • Paran (acetaminophen 500mg) 1# QID
    • Agglutex (heparin 25000U/5mL) 5mL ST
    • NS 20mL ST

[consultation]

• 2024-06-20 Cardiology
  • Q
    • For Paroxysmal atrial fibrillation
    • This is a 76 year old female with underlying disease of
      • Recurrent squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, rcT2N2M1, stage IV s/p concurrent chemoradiotherapy with FOLFOX with progressive disease of mediastinal lymphadenopathy s/p palliative chemotherapy with mDCF (selfpaid of Docetaxel) from 2022/11/29, Cetuximab + FOLFIRI from 2023/11/2 to 2024/05/28
        
      • Paroxysmal atrial fibrillation
    • This time she was admitted due to consciousness drowsy and shortness of breath for one day.
      
    • According to her family statment, she suffered from consciousness drowsy and shortness of breath for one day. Due to above symptoms, she wa brought to our ER for help on 2024/06/09. At ER, vital sign showed BP:144/106; PR:167; BT:36.6’C; RR:22; Con’s:E1V2M5, SPO2:84%. PE showed left hand swelling and local heat, bilateral coarse breathing sound and irregular heart beat. Lab data showed WBC:7100, CRP:16.5, Cr:2.03, PT pro BNP:12987.5 and D-dimer:7525. Urine analysis showed positrive nitrite, bacteriuria and pyuria (WBC:>100/HPF, bacteria:2+). Chest x ray showed LLL infiltration. Under the impression of LLL pneumonia, urinary tract infection, left hand cellulitis, she was admitted for further treatment.
    • After admission, we kept ceftazoline as antibiotics. However, shortness of braeth was noted on 6/14 and Chest CT showed bilateral pleural effusion and pigtail was done on 6/14. And her symptoms of shortness of breath and consciousness had improved. However, paroxysmal atrial fibrillation happened on 06/16, 06/18, 06/20. Her underlying medication were lixiana 1# QD and rytmonorm 1# BID.
    • We need your expertise for this condition. Thank you very much!
  • A
    • O
      • ECG
        • 20220505 normal sinus rhythm
        • 20231020 normal sinus rhythm
        • 20231024 Atrial fibrillation with rapid ventricular response
        • 20231211 Sinus rhythm with 1st degree AV block
        • 20240609 Sinus tachycardia with PACs
        • 20240618 Atrial fibrillation with rapid ventricular response 168bpm
        • 20240620 sinus tachycardia HR111bpm
      • LAB
        • 20240618 CRP2.2 albumin3.4 Na139 K3.7 Ca2.38 CK28 hsTnI25.1 Hb10.1 WBC13190 PLT588k
        • 20231026 TSH 4.47
      • CT 20240614
        • Bilateral cancer seeding and mediatsinal lymphadenopathy
        • left axillary lymphadenopathy
        • Right upper lobe lung collapse and esophageal wall thickening.
      • CXR 20240617
        • left pigtail at pleural space
    • Impression
      • Atrial fibrillation, documented ECG on 20231024, 20240618
        
      • Recurrent squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, rcT2N2M1, stage IV s/p concurrent chemoradiotherapy with FOLFOX with progressive disease of mediastinal lymphadenopathy s/p palliative chemotherapy with mDCF (selfpaid of Docetaxel) from 2022/11/29, Cetuximab + FOLFIRI from 2023/11/2 to 2024/05/28
        
    • Suggestion
      • for rate/rhythm control, may give amiodarone 200mg QD to BID
      • because of advanced cancer status with bleeding risk, edoxaban as anticoagulant should be prescribed cautiously.
      • recheck TSH/FT4; if abnormal thyroid function, may change to propafenone 150mg bid for rate/rhythm control
• 2024-06-14 Diagnostic Radiology
  • Q
    • After admission, we kept ceftazoline as antibiotics. However, shortness of braeth was noted on 6/14 and CHest CT showed bilateral pleural effusion. We need your expertise for pig tai insertion. Thank!
  • A
    • According to the clinical condition and imaging findings, drainage is indicated.
• 2023-10-25 Cardiology
  • Q
    • This 74-year-old female has recurrent squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, rcT2N2M1, stage IV. Due to large pericardial effusion with diastolic RA and RV compression with cardiac tmponade signs, so we meed your help for drainage.
  • A
    • because of cardiac tamponade, I’m consulted for it
    • I epxlain the indication of emergency drainage for pericardiac effusion and tamponade. It will be arrange right now.
• 2023-10-24 Cardiology
  • Q
    • This 74-year-old female has recurrent squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, rcT2N2M1, stage IV s/p concurrent chemoradiotherapy with FOLFOX(selfpaid of Oxaliplatin) from 2022/05/12~2022/11/14 for 11 cycles, progressive disease of mediastinal lymphadenopathy s/p palliative chemotherapy with mDCF(selfpaid of Docetaxel) from 2022/11/29.
    • Due to pericardial effusion, so we need your help for management.
  • A
    • A 74 years old woman with recurrent squamous carcinoma of anorectum and multiple metastasis s/p C/T.
      • Dyspnea on exertion noted for half a year with cardiomegaly seen on CXR, and ECG showed normal sinus rhythm with low voltage QRS in limb leads, and CT scan showed moderate pericardial effusion.
      • Physically, JY flat, BP 136/94 mmHg, HR 92/min and gr 2-3/6 SEM over LSB, leg edema (-). Now she is consulted for further management.
      • also dyspnea (+), chest discomfrot (+)
    • Impression:
      • recurrent squamous carcinoma of anorectum and multiple metastasis s/p C/T
      • pericardial effusion cause to be determined
    • Suggestion:
      • please arrange echocardiography first to evaluate the degree of pericardial effusion and any evidence of cardiac tamponade.
      • contact with us after echocardiography.
• 2023-01-03 Neurology
  • Q
    • This 74-year-old woman patient is a case of Recurrent squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, rcT2N2M1, stage IV s/p concurrent chemoradiotherapy with FOLFOX (selfpaid of Oxaliplatin) from 2022/05/12~2022/11/14 for 11 cycles, progressive disease of mediastinal lymphadenopathy s/p palliative chemotherapy with mDCF (selfpaid of Docetaxel) from 2022/11/29.
    • She was admitted for prepare chemotherapy. This time, bilateral lower limbs weakness with trembling developed. Now, for evaluate bilateral lower limbs weakness with trembling examination and therapy. Thank you.
  • A
    • NE:
      • CN: intact
      • MP: full
      • Gait: wide based
      • FNF: No dysmetria
      • Romberg test: positive
    • Imp:
      • r/o sensory ataxia
    • Suggestion:
      • Arrange NCV (upper and lower limbs MNCV + SNCV + H reflex + F wave) and SSEP (upper and lower limbs)
• 2022-05-10 Radiation Oncology
  • Q
    • This 74-year-old female patient has past history of squamous cell carcinoma of rectum cancer, cT2N2M1, stage IV status post concurrent chemoradiotherapy in 2013-2014 at Koo Foundation Sun Yat-Sen Cancer Center.
    • She visited our oncologist OPD for regular follow-up. Followed abdominal CT scan on 2022-03-22 revealed enlarged lymph nodes (up to 3.2cm) at mediastinum. She denied any poor appetite, body weight loss, easy cough, shortness of breath or dyspnea.
    • After discussing with the patient and her family on the benefits of surgical treatment as well as subsequent risks and possible complications.Operation of right video-assisted thoracoscopic surgery lymph node sampling and pneumolysis was performed smoothly on 2022-04-14.
    • Pathology showed metastatic squamous cell carcinoma, CD56(-), P40 (+),CK20 (-).
    • PET was performed on 2022/04/23 revealed increased FDG uptake in some right paratracheal and precarinal lymph nodes, an A-P window lymph node, bilateral pulmonary hilar regionsand right lateral chest wall. Besides, there was increased FDG accumulation in the colon, rectum, both kidneys and left ureter.
    • Under the impression of 1) Metastatic squamous cell carcinoma of the mediastinal lymph node from rectum cancer, cT2N2M1, stage IV status post concurrent chemoradiotherapy in 2013-2014 at Koo Foundation Sun Yat-Sen Cancer Center.
    • She was admitted for further management. port-A insertion on 2022/05/06
    • We need your experise for radiotherapy evaluation, thanks
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For radiotherapy due to metastatic squamous cell carcinoma of the mediastinal lymph nodes.
      • PI: The patient has past history of squamous cell carcinoma of anorectum, stage cT2N2M1, stage IV status post concurrent chemoradiotherapy in 2013-2014 at Koo Foundation Sun Yat-Sen Cancer Center. Operation of right video-assisted thoracoscopic surgery lymph node sampling and pneumolysis was performed smoothly on 2022-04-14. Pathology showed metastatic squamous cell carcinoma,CD56(-), P40 (+),CK20 (-). PET (2022-4-28) showed glucose hypermetabolism in some right paratracheal and precarinal lymph nodes and an A-P window lymph node. Metastatic lymph nodes should be considered.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM(-); HTN(-)
        • Allergy(-)
        • Travel Hx(-)
      • Previous RT (2013-11-20 ~ 2014-01-03): 4500cGy/25 fractions of the paraaortic, pelvic, bilateral inguinal, 5040cGy/28 fractions of the LN, and 6000cGy/30 fractions of the anorectal tumor at Koo Foundation Sun Yat-Sen Cancer Center.
    • O:
      • ECOG: 0
      • PE: neck and bil SCF: neg.
      • Pathology (P001325380, 1021101, TSGH): rectum, “5cm”, biopsy - microinvasive squamous cell carcinoma.
      • CT scan of abdomen (2022-03-12): Mild wall thickening of rectum (stable). Enlarged LNs (up to 3.2cm) at mediastinum.
      • CXR (2022-04-13): elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta. Clean lung fields based on plain image. Normal shape and size of heart. Normal appearance of both hila. Costophrenic angles are preserved.
      • Operation (2022-04-14): Right VATS lymph node sampling and pneumolysis
      • Pathology (S2022-06359, 2022-04-20): ADDENDUM: IHC stain — CD56(-), P40 (+). ADDENDUM: IHC stain — CK20 (repeat): negative. DIAGNOSIS: (revise) Right paratracheal lymph node, VATS excision — metastatic squamous cell carcinoma.
      • PET (2022-04-28): Glucose hypermetabolism in some right paratracheal and precarinal lymph nodes and an A-P window lymph node. Metastatic lymph nodes should be considered. Please correlate with other clinical findings for further evaluation.
      • 2022/04/29 CA-199 (NM) = 10.120 U/ml;
      • 2022/04/29 CEA (NM) = 4238.1 ng/ml;
    • A: Squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, stage cT2N2M1, stage IV, s/p CCRT (at Koo Foundation Sun Yat-Sen Cancer Center), with progression of metastatic mediastinal lymph nodes.
    • P: Radiotherapy is indicated for this patient with the following indicators: progression of metastatic mediastinal lymph nodes.
      • Goal: palliation
      • Treatment target and volume: metastatic mediastinal lymph nodes
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5400cGy/27 fractions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2022-05-12.
• 2022-04-07 Thoracic Surgery
  • Q
    • The 74 y/o woman has recurren SCC of rectum cancer with enlarged LNs (up to 3.2cm) at mediastinum. We need your help for tissue proof for genetic testing. Thanks!
  • A
    • The patient had Hx of colon cancer. Mediastinal LNs enlargement noted. VATS with biopsy for therapeutic planning is indicated

[radiotherapy]

• 2022-05-19 ~ 2022-06-28 - 5400cGy/27 fractions of the metastatic mediastinal lymph nodes area.

[chemmotherapy]

• 2024-01-11- 2023-12-25 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 525mg NS 250mL 2hr + fluorouracil 2800mg/m2 3680mg NS 500mL 46hr (Erbitux + 80% FOLFIRI; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-12-25 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 525mg NS 250mL 2hr + fluorouracil 2800mg/m2 3680mg NS 500mL 46hr (Erbitux + 80% FOLFIRI; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-12-11 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 525mg NS 250mL 2hr + fluorouracil 2800mg/m2 3675mg NS 500mL 46hr (Erbitux + 80% FOLFIRI; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-11-16 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 525mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + 80% FOLFIRI; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-11-02 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 525mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + 80% FOLFIRI; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2022-12-14 - docetaxel 40mg/m2 60mg NS 100mL 1hr + NS 500mL 1hr (before CDDP) + cisplatin 40mg/m2 65mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 1200mg/m2 1800mg NS 500mL 48hr (mDCF)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-11-29 - docetaxel 40mg/m2 60mg NS 100mL 1hr + NS 500mL 1hr (before CDDP) + cisplatin 40mg/m2 65mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 1200mg/m2 1800mg NS 500mL 48hr (mDCF)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-11-14 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 3850mg NS 500mL (old age 20% off) (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-10-20
• 2022-10-03
• 2022-09-15
• 2022-09-02
• 2022-08-12
• 2022-08-01
• 2022-07-19
• 2022-06-23
• 2022-06-08 -
• 2022-05-12 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (old age 20% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-06-24

[tube feeding - Dulcolax (bisacodyl 5mg)]

Dulcolax (bisacodyl 5mg):

• Swallowing Whole: Due to the enteric coating designed to release the medication in the intestines, Dulcolax tablets should be swallowed whole and not split or crushed.
• Alternative Option: Bisacodyl suppositories (10mg) are available as an alternative and contain the same active ingredient.

2024-02-19

[proactive potassium supplementation for heart patients on propafenone]

Laboratory findings revealed the development of hypokalemia.

• 2024-02-16 K(Potassium) 3.1 mmol/L
• 2024-02-02 K(Potassium) 3.6 mmol/L
• 2024-01-10 K(Potassium) 3.8 mmol/L

Hypokalemia typically manifests with serum potassium concentrations between 3.0 and 3.4 mEq/L, often remaining asymptomatic. However, individuals with pre-existing cardiac conditions, particularly those receiving digitalis or certain antiarrhythmic medications, may experience symptoms at these potassium levels.

Therefore, potassium supplementation is recommended throughout propafenone therapy to proactively address potential hypokalemia.

2024-01-22

Lab data from 2024-01-22 indicated that the tumor markers CEA and SCC continued their previous upward trend. Other lab parameters, such as blood cell counts, electrolytes, and liver and kidney functions, were within acceptable ranges. No discrepancies in medication were identified.

2024-01-11

[evolving disease activity? CEA & SCC levels raise concerns]

Since mid-Dec 2023, an initial upward trend has been observed in both CEA and SCC levels. This may suggest possible disease progression or decreased effectiveness of the current treatment regimen (Erbitux + FOLFIRI, initialized early Nov 2023).

• 2024-01-09 CEA (NM) 4604.100 ng/ml

• 2023-12-26 CEA (NM) 3546.800 ng/ml

• 2023-12-15 CEA (NM) 3143.700 ng/ml

• 2023-12-01 CEA (NM) 6128.400 ng/ml

• 2023-11-17 CEA (NM) 15774.500 ng/ml

• 2023-10-20 CEA (NM) 20331.000 ng/ml

• 2023-10-03 CEA (NM) 29059.500 ng/ml

• 2023-07-11 CEA (NM) 11534.600 ng/ml

• 2023-06-20 CEA (NM) 5571.400 ng/ml

• 2023-05-16 CEA (NM) 2113.400 ng/ml

• 2023-03-21 CEA (NM) 194.380 ng/ml

• 2023-02-15 CEA (NM) 31.804 ng/ml

• 2024-01-09 SCC (NM) 2.64 ng/mL

• 2023-12-15 SCC (NM) 1.76 ng/mL

• 2023-12-01 SCC (NM) 1.46 ng/mL

• 2023-11-17 SCC (NM) 2.18 ng/mL

• 2023-10-20 SCC (NM) 3.31 ng/mL

• 2023-10-03 SCC (NM) 3.08 ng/mL

2023-11-17

Repeat prescriptions that are still valid currently within the past 3 months are not shown in PharmaCloud.

Slight hyponatremia, hypocalcemia, and hypomagnesemia were observed in the laboratory results from 2023-11-16. Close monitoring is recommended.

An episode of leukopenia occurred on 2023-11-10, approximately 1 week after the patient’s first dose of Erbitux + FOLFIRI (reduced dose). The patient’s WBC before the second administration of the regimen was even lower than before the first administration. Therefore, there is a possibility of developing another episode of leukopenia after the second administration. Careful monitoring is advised.

• 2023-11-16 WBC 3.14 x10^3/uL
• 2023-11-10 WBC 2.04 x10^3/uL *
• 2023-10-31 WBC 6.67 x10^3/uL

700152280

240216

[lab data]

• 2022-04-08
  • HBsAg negative, value 0.384
  • Anti-HCV negative, value 0.0336
  • Anti-HBc positive, value 0.00706
  • Anti-HBs positive, value 34

[exam findings]

• 2023-12-12 CXR erect
  • Few metastases in both lungs are noted after correlate with CT.
• 2023-12-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 23) / 88 = 73.86%
    • LVEF (%) = 74
    • M-mode (Teichholz) = 76
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • LV posterior wall thickening; normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild aortic valve sclerosis.
• 2023-12-01 Tc-99m MDP bone scan
  • Mildly increased activity in the lower L-spines. Degenerative change may show this picture.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • A hot spot in the lateral aspect of right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders and knees, compatible with benign joint lesions.
• 2023-11-01 CXR erect
  • Multiple randomly distributed pulmonary nodules of varying sizes s/p wedge-resections and areas increased opacity
• 2023-10-30 Patho - lung wedge biopsy
  • A
    • Lung, right, lower lobe, wedge resection —- Consistent with metastatic endometrioid carcinoma
      • Lymph node, right, group 7, dissection —- Negative for malignancy (0/6)
      • Lymph node, right, group 9, dissection —- Negative for malignancy (0/1)
    • Microscopic Description
      • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes
      • Histologic Type (select all that apply): Consistent with metastatic endometrioid carcinoma; The immunohistochemical stains reveal CK7(+), CK20(-), PAX8(+), TTF-1(focal +), p40(-), CD56(focal +).
        
      • Histologic Grade: G3: Poorly differentiated
      • Spread Through Air Spaces (STAS): Present
      • Visceral Pleura Invasion: Present (PL2)
      • Lymphovascular Invasion (select all that apply): Present, Lymphatic
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.2 cm
  • B
    • Lung, right, middle lobe, wedge resection —- Consistent with metastatic endometrioid carcinoma
  • C
    • Lung, right, upper lobe, wedge resection —- Consistent with metastatic endometrioid carcinoma
• 2023-10-30, -10-29 CXR
  • Multiple randomly distributed pulmonary nodules of varying sizes.
• 2023-10-04 CT - chest
  • Impression: bilateral pulmonary metastatic lesion, in progression as compared with CT on 2023/03/21.
• 2023-07-29 CT - abdomen
  • S/P hysterectomy.
  • R/O liver cyst, stationary.
  • Progression of bilateral lung metastasis.
• 2023-03-21 CT - chest
  • Impression: bilateral pulmonary metastatic lesions.
• 2023-03-11 CT - abdomen
  • S/P hysterectomy.
  • R/O liver cyst.
  • Newly developed RML nodule, r/o lung metastasis.
• 2022-12-16 Pap Smear
  • Atypical squamous cells (ASC-US)
• 2022-10-11 CT - abdomen
  • S/P hysterectomy. No evidence of tumor recurrence.
• 2022-07-01 CT - abdomen
  • Primary lung cancer 7 mm in RUL is suspected.
• 2022-03-23 Patho - lumph node region resection
  • pathologic diagnosis
    • Endometrium, uterus, frozen and LSC staging surgery — Endometrioid carcinoma, grade 3
    • Myometrium, uterus, ditto — Tumor invasion, greater than half thickness
    • Cervix, uterus, ditto — Free from tumor, atrophy with Nabothian cysts
    • Left ovary, ditto — Free from tumor, corpus albicans
    • Left fallopian tube, ditto — Free from tumor, paratubal cysts
    • Right ovary, ditto — Free from tumor, corpus albicans
    • Right fallopian tube: free from tumor, paratubal cysts
    • Lymph node, left iliac, dissection — Free from tumor metastasis (0/12)
    • Lymph node, left oburator, ditto — Tumor metastasis (1/19)
    • Lymph node, right iliac, ditto — Free from tumor metastasis (0/11)
    • Lymph node, right oburator, ditto — Tumor metastasis (1/16)
    • Parametrium, bilateral — Free from tumor
    • AJCC Pathologic stage — pT1bN1a, if cM0, stage IIIC1 / FIGO stage IIIC1
  • macroscopic examination
    • Operation Procedure: frozen section and LSC staging surgery (TAH, BSO and BPLND)
    • Specimens include: Uterus, bilateral ovaries, fallopian tubes and pelvic LNs
    • Tumor site: endometrium
    • Tumor size: 4.2 x 3.7 cm
    • The myometrium: up to 1.3 cm in thickness
    • The cervix : mucoid cyst
    • Adnexa (bilateral): bilateral ovaries and bilateral tubes are not invaded by tumor
    • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs and right obturator LNs
    • Representative sections as follows: [Reference: F2022-00124 FS: endometrial mass, A1: R’t ovary + F-tube, A2: L’t ovary + F-tube, A3-A5: uterus from fundus to cervix, A6-A8: tumor + serosa(ink), A9: tumor + endocervix, A10: cervix, A11: R’t parametrium, A12: L’t parametrium]
      • A1-A2: left iliac LNs;
      • B1-B2: left obturator LNs;
      • C1-C3: right iliac LNs;
      • D1-D2: right obturator LNs.
  • microscopic examination
    • Histology type: Endometrioid carcinoma
    • Histology grade: Grade 3
    • Depth of invasion: greater than half thickness of myometrium, less than 0.1 cm away from serosa
    • Lymphovascular invasion: present
    • The cervical stroma involvement:: absent
    • Resection margins of the cervix: Free, 2.8 cm away from tumor
    • Additional pathologic findings: focal tumor necrosis
    • Lymph nodes:
      • left iliac LNs: free from tumor metastasis (0/12)
      • left oburator LNs: tumor metastasis (1/19) without extracapsular extension (0/1)
      • right iliac LNs: free from tumor metastasis (0/11)
      • right oburator LNs: tumor metastasis (1/16) without extracapsular extension (0/1)
    • Immunohistochemistry: WT-1(-), CK(+), ER(-), PR(-) and vimentin(+. focal) for tumor
• 2022-03-23 Frozen section
  • Mass, endometrial cavity, frozen section — Adenocarcinoma
• 2022-03-20 CT - abdomen, pelvis
  • A mass lesion (4.6cm) in uterus.
  • Left liver cyst (6.5mm).
• 2022-03-20 Gynecologic ultrasonography
  • A 54 x 42 mm mass with flow was noted in endometrial cavity, submucosal myoma with degeneration or endometrial malignancy need to be ruled out
  • Bilateral adnexae: free
• 2021-11-16 CT - lung/mediastinum/pleura
  • Lungs:
    • areas of patchy expiratory air-trapping in both lower lobes, indicating small airways disease.
    • an ill-defined ground glass nodule at posterobasal segment of LLL (about 7 mm in largest axial dimension) as compared with previous CT study.
  • Impression:
    • LLL-S10 ill-defined GGO 7 mm, suggest f/u LDCT at 12 months later. (GGO: ground glass opacity; LDCT: low dose CT)
    • small airways disease in both lower lobes of lungs.
• 2021-11-02 SONO - breast
  • Bilateral breasts fibroadenomas. Suggest follow up.
  • BI-RADS category 2, Benign finding.

[MedRec]

• 2024-01-15 ~ 2024-01-17 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Endometrioid carcinoma of endometrium, grade 3, pT1bN1aM0, stage IIIC1/FIOGO stage IIIC1 with bilateral lung multiple nodules status post three-dimensional video-assisted thoracoscopic surgery right upper, middle and lower lobe lung wedge resection and lymph node dissection on 2023/10/30
    • Chronic viral hepatitis B without delta-agent anti-HBC:positive
  • CC
    • for C3 chemotherapy with Avastin (#2, self-paid) /Taxol/Cisplatin
  • Present illness
    • This is a 71 year-old female had operation history of appendicitis s/p appendectomy.
    • She also had endometrioid carcinoma of endometrium, grade 3, pT1bN1aM0, stage IIIC1/FIOGO stage IIIC1 status post Paclitaxel+Carboplatin since 2022/4-2022/8. It was until March 2023s, she was suspected to have lung metastases but she hesitated to receive tissue proof at that time.
    • CT was done which revealed multiple lung mets in progress on 2023/10/04. Surgical intervention as three-dimensional video-assisted thoracoscopic surgery right upper, middle and lower lobe lung wedge resection and lymph node dissection was performed on 2023/10/30. Pathology showed the findings were consistent with metastatic endometrioid carcinoma. The immunohistochemical stains reveal CK7(+), CK20(-), PAX8(+), TTF-1(focal +), p40(-), CD56(focal +).
    • Anti-HBc: reactive and Baraclude was ordered.
    • Echocardiagraphy (2023/12/04): LVEF(%) = 74. 1. Normal LV systolic function with normal wall motion. 2. LV posterior wall thickening; normal LV diastolic function. 3. Normal RV systolic function. 4. Mild MR; mild TR; mild aortic valve sclerosis.
    • C1 Palliative chemotherapy with Taxol + Cisplain on 2023/12/5, C2 on 2023/12/25 + C1 Avastin (self-paid).
    • Tumor marker showed CA-125: 11.324U/ml on 2023/05/15, 10.87U/ml on 2023/07/11, 15.622U/ml on 2024/01/11.
    • This time, she is admitted for C3 chemotherapy with Taxel + Cisplain + (C2) Avastin self-paid) on 2024/01/15.
  • Course of inpatient treatment
    • After admission, she received pre-medication as Dexamethasone 20mg q6h twice dose and then gave chemotherapy with self paid of Avastin (15mg/kg) + Taxol + Cisplatin on 1/16 24 , smoothly without obvious side effect. She was discharged on 1/17 24 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2023-10-29 ~ 2023-11-02 POMR Thoracic Surgery Xie MinXiao
  • Discharge diagnosis
    • Metastatic endometrical carcinoma over right lung field status post three-dimensional video-assisted thoracoscopic surgery right upper, middle and lower lobe lung wedge resection and lymph node dissection on 2023/10/30.
    • Bilateral lung multiple nodules status post three-dimensional video-assisted thoracoscopic surgery right upper, middle and lower lobe lung wedge resection and lymph node dissection on 2023/10/30
    • Endometrioid carcinoma of endometrium, grade 3, pT1bN1aM0, stage IIIC1/FIOGO stage IIIC1
  • CC
    • Lung metastasis was noted.        
  • Present illness
    • This is a 71 year-old female had operation history of appendicitis s/p appendectomy.
    • She also had endometrioid carcinoma of endometrium, grade 3, pT1bN1aM0, stage IIIC1/FIOGO stage IIIC1 status post chemotherapy. Chemotherapy-related agranulocytosis happened after 3rd chemotherapy. Lung metastasis was noted, and therefore she was transfer to chest surgery for tissue proof of lung tumors. CT was done which revealed multiple lung nodules.
    • After well explaination to the patient and her family of current conditions and treatments, she decided to undergo a surgery. The patient was admitted on 2023/10/29. 3D vedio-assisted thoracic surgery of right upper, middle and lower lobe wedge was arranged on 2023/10/30.
  • Course of inpatient treatment
    • After admission, pre-op assessment was done. Operation of three-dimensional video-assisted thoracoscopic surgery right upper, middle and lower lobe lung wedge resection and lymph node dissection was performed smoothly on 2023/10/30. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Right chest tube with low pressure suction -18 cmH2O was done. Chest tube was removed on 2023/11/01. She was discharged under stable hemodynamics and chest surgery clinic follow up will be arranged.
  • Discharge prescription
    • Actein (acetylcysteine 200mg) 1# TID
    • MgO 250mg 1# TID
    • Sindine (povidone iodine aq soln) QD EXT
    • Acetal (acetaminophen 500mg) 1# PRNQID
• 2022-03-22 ~ 2022-03-31 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of endometrium
    • Malignant neoplasm of endometrium => laparoscopic staging (total hysterectomy + bilateral salpingo-oophorectomy + bilateral Pelvic Lymph nodes Dissection) on 2022/03/23.
    • Female pelvic peritoneal adhesions (postinfective)
    • Abnormal uterine and vaginal bleeding
  • CC
    • Right lower quadrant abdominal dull pain with great mount of vaginal bleeding for 2 days
  • Present illness
    • This is a 70 year-old female, with menstural history G1P1, and menopause when she was 50 y/o. Besides, she also had operation history of appendicitis s/p appendectomy wen she was 13 years ago, and CT image finding of GGO about 0.8cm at LLL. Her ADL is totally independent.
    • According to her statement and medical record, she suffered from Right lower abdominal dull pain for 2 days. There was no relieving nor exaggerate factors. No refer pain, no fever with chillness, no nausea nor vomitus, no recent abdominal trauma history, no constipation, no tarry stool nor bloody stool, no vaginal spotting was noted then. Thus, she visited Dr.祝’s OPD for help at first. At OPD, her vital sign was stable and physcial examination showed no remarkable finding. Transvaginal sonography found a uterine myoma 2.4*2.1cm. Painkiller was prescibed, and no episode of was found in recent half years. However, she was brought to our emergency room on 3/20 due to severe right lower abdominal dull pain with great mount of vaginal bleeding noted.
    • At our triage, her vital sign was stable and physcial examination showed no obvious tenderness, no muscle guarding nor rebounding pain. Laboratory data were all in normal limit, but elevated of tuomr marker CA125(114.7). Abdominal Ct found a A mass lesion (4.6cm) in uterus. Transvaginal sonography showed a 5 x 4 cm poor marginal mass lesion with fluid in uterus with flow(+),suspected submucosal myoma with degeration, but endometrial malignancy need to be ruled out. After we had well explain to the patient and her family of current conditions and treatments, she decided to undergo a surgery.
    • Under the impression of right lower abdominal pain with vaginal bleeding, suspect uterine myoma related, she was admitted to our ward for LAVH+ BSO.
  • Course of inpatient treatment
    • The patient was admitted on 2022/03/22 and underwent Laparoscopic gynecologic oncology staging surgery (LAVH +BSO+ bilateral pelvic lymphectomy) the next day and 2022/03/30 on 1. Port-A, left Fluoroscopy. Her postoperative course was uneventful. her eating and self viding,as well as defecation were both ok. She is to be discharged on 2022/03/31. Her followup appointment is scheduled on 2022/04/07.
  • Discharge prescription
    • cephalexin 500mg 2# QID
    • MgO 250mg 2# QID
    • naproxen 250mg 1# QID
    • Anxiedin (lorazepam 0.5mg) 1# HS for insomnia use

[surgical operation]

• 2023-10-30 - Op Method:
  • 3D VATS RUL wedge + RML wedge + RLL wedge + LND.
  • Finding:
    • Multiple lung nodules over RML, RUL and RLL, size about 0.8cm.
    • One 20 Fr. stragith chest tube was inserted via right 8th ICS.
  • Procedure:
    • Under DLGA, the patient was put in left lateral decubitus position. The operative field was sterilized and draped as usual. One incision was made over right 8th ICS and entered the pleural cavity carefully. Under the 3D thoracoscope, another incision was made over right 5th ICS in the anterior axillary line. Wedge resection was performed for lesions over RUL, RML and RLL. Lymph node sampling was also performed. After sure the lung can be expanded, massive warm normal saline was irrigated the whole pleural cavity. One chest tube was inserted via camera port. The other wound was closed with 2-0 and 4-0 vicryl layer by layer. After extubated of ETT, she was sent to POR under stable condition.
• 2022-03-23
  • Diagnosis:
    • Endometrial cancer (Frozen section: Adenocarcinoma)
    • Intra-abdominal adhesions (right site, surgical history: s/p appendectomy)
  • Operation:
    • Laparoscopic gynecologic oncology staging surgery (LAVH + BSO + bilateral pelvic lymphectomy)
  • Finding
    • Uterus: normal size, smooth surface, papillary mass in uterus cavity
    • Bilateral adnexa: grossly normal
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
    • CDS: free
    • Adhesion over right abdominal wall
• 2018-11-06
  • Intracapsular (extracapsular) lens extractionunder microscope + IOL insertion

[chemotherapy]

• 2024-02-16 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 258mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-01-16 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 260mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-12-25 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 260mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-12-05 - …………………………………… paclitaxel 175mg/m2 257mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-08-23 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-07-25 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-07-02 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-06-08 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 575mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-05-09 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 575mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2022-04-19 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 575mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2024-02-16

As of 2024-02-16, the patient demonstrates stable vital signs and grossly normal laboratory values (2024-02-15). Entecavir (Baraclude) is currently utilized for the management of Anti-HBc positivity. No medication discrepancies were identified.

2022-05-10

• For this post-operative endometrial cancer patient, the current regimen is preferred, and the patient was able to tolerate the regimen during last hospitalization.
• Laboratory results on 2022-05-09 indicated that liver and kidney function, CBC and electrolytes were generally normal.
• Baraclude (entecavir 0.5mg) QDAC is used for the management of heptatitis virus B.

700152752

240216

[lab data]

2023-06-19 RPR/VDRL Nonreactive
2023-06-19 HIV Ab-EIA Nonreactive
2023-06-19 Anti-HIV Value 0.05 S/CO
2023-06-19 Anti-HBs >1000.00 mIU/mL
2023-06-19 HBsAg Nonreactive
2023-06-19 HBsAg (Value) 0.30 S/CO
2023-06-19 Anti-HCV Nonreactive
2023-06-19 Anti-HCV Value 0.07 S/CO
2023-06-06 HBsAg Nonreactive
2023-06-06 HBsAg (Value) 0.27 S/CO
2023-06-06 Anti-HCV Nonreactive
2023-06-06 Anti-HCV Value 0.08 S/CO
2023-06-06 Anti-HBc Reactive
2023-06-06 Anti-HBc-Value 4.98 S/CO
2023-05-30 CEA (NM) 1908.200 ng/ml

[exam findings]

• 2024-02-07, -01-19, 2023-12-29, -11-16, -10-12, -08-15, -07-21, -06-08, -06-02, -06-01 CXR
  • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Old fracture of right clavicle S/P long screw fixation shows good alignment and good union.
• 2024-01-16 L-spine flex. & ext. (including sacrum)
  • Disc space narrowing with marginal osteophyte formation of L4-5.
• 2024-01-23 Tc-99m MDP bone scan with SPECT
  • Increased activity in the sacrum and lower portion of bilateral S-I joints. The nature is to be determined (bone metastases? degenerative or post-traumatic change? other nature?). Please correlate with other imaging modalities for further evaluation.
  • Some hot spots in the skull. The nature is to be determined. Please also correlate with other imaging modalities for further evaluation.
  • Mildly increased activity in the lower C-spine, lower T-spine and L5 spine, compatible with degenerative change.
  • Some hot spots in bilateral rib cages in linear arrnagement. Post-traumatic change is more likely.
  • Increased activity in the mandible. Dental problem may show this picture. Please also correlate with other clinical findings.
  • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
• 2024-01-18 MRA - brain
  • Findings
    • An intra-axial enhancing lesion, about 23 mm, with necrotic change and extensive perifocal edema in left temporal lobe, causing effacement of adjacent cortical sulci and mild mass effect. Metastasis is first considered. Abscess is less likely.
    • Well-defined T2-hyperintensities with diffusion elevation in left cerebellar hemisphere, indicating old infarcts.
    • No intracranial hemorrhage, nor acute/subacute infarct.
    • No remarkable finding of skull base and bony structures.
    • No remarkable finding of nasopharynx visible in these images.
    • Segmental narrowing of bilateral MCA segments.
    • Engorged and tortuous VA, indicating dolichoectasia.
  • IMP:
    • Left temporal lobe tumor. Metastasis is considered. Abscess is less likely.
    • Old infarcts in left cerebellum.
• 2024-01-03 T- L-spine AP + Lat.
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon at right lateral aspect of L4-5.
• 2023-12-06 CT - abdomen
  • S-colon cancer with regional LAP and lung metastases (mild progression).
• 2023-11-20 Nasopharyngoscopy
  • Findings: smooth nasopharynx, oropharynx, hypopharynx, sticky post nasal drip, erosion wound over left caudal septum
  • Diagnosis: sticky post nasal drip, erosion wound over left caudal septum
• 2023-11-01 Bladder Sonography
  • PVR: 14 mL
• 2023-09-22 ENT Hearing Test
  • PTA
    • R’t : 39 dB HL
    • L’t : 41 dB HL
    • Bil normal to severe SNHL
  • Tymp
    • Bil Type Ad
  • ART
    • Bil absent.
• 2023-08-28 CT - chest
  • sigmoid colon cancer with stationary of lung metastases and regression regional metastatic LAP compared with CT on 2023/05/19 and 2023/05/26
• 2023-07-31 T-L spine Lat
  • Increased kyphosis of thoracolumbar spine.
  • Degenerative change of the spine with marginal spur formation.
• 2023-06-09 All-RAS + BRAF mutation
  • Tissue Block No.: S2023-11068
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-06-05 Patho - colon biopsy (Y1)
  • Intestine, large, sigmoid colon, 30 cm AAV, cm from anal verge, biopsy — Adenocarcinoma
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2023-06-05 Colonoscopy
  • Mixed hemorrhoid was noted.
  • A tumor lesion is loacted at S-colon (30cm AAV) with nearly lumen obstruction
• 2023-06-02 Patho - lung transbronchial biopsy
  • Lung, ? side, CT-guide biopsy — consistent with metastatic moderately differentiated adenocarcinoma from colorectal origin
  • Sections show alveolar lung tissue with infiltration of cribriform tumor glands.
  • The immunohistochemical stains reveal CK7(-), CK20(focal +), CDX2(+), and TTF-1(-). The results are consistent with metastatic moderately differentiated adenocarcinoma from colorectal origin.
• 2023-05-26 CT - chest
  • Indication: multiple lung nodules, nature?
  • Chest CT with and without IV contrast ehnancement shows:
    • Diffuse necrotic nodules are found at both lungs up to 2.4cm at right lower lobe. lung meta is considered.
    • Small lymph nodes are found at mediastinum.
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • Imp: Bilateral lung meta. Colon cancer meta is favored.
• 2023-05-25 Lower G-I Series (Colon filling study)
  • Administration of contrast medium from anus. Opacification of rectosigmoid colon. Fistula formation with urinary bladder.
  • Impression: Fistula between sigmoid colon and urinary bladder.
• 2023-05-19 CT - abdomen
  • CC: urine turned sticky with bubbles
    • Urine Culture: Enterococcus faecalis and Escherichia coli: >100000. suspect fistula between intestine and urinary bladder
    • History: menopause, ATH
  • Findings:
    • There is segmental wall thickening of the sigmoid colon, measuring 6 cm in size, with caudal extension into the urinary bladder (diffuse wall thickening and gas content c/w fistula formation).
      • Adenocarcinoma of the sigmoid colon with urinary bladder invasion (T4b) is highly suspected.
      • Please correlate with colonoscopy and cystoscopy.
    • There are seven enlarged nodes in the adjacent mesocolon that are c/w metastatic nodes (N2b).
    • There are multiple variable size soft tissue masses on both lungs, the largest one 2.1 cm at RLL, that are c/w lung metastases (M1a).
      • There are several kissing metastatic nodes in retrocaval space (M1b).
      • In addition, there is a soft tissue nodule 2 cm in the omentum at right upper pelvis that is c/w tumor seeding (M1c).
    • Right renal stones (< 5mm). There are several renal cysts on left kidney and the largest one measuring 2 cm in size at left middle pole para-pelvic area.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M1c(M_value) STAGE:IVC(Stage_value)
• 2022-11-28 CT - abdomen
  • History and indication: insist on confirm renal stone before go abroad
  • Non-contrast CT of abdomen-pelvis revealed:
    • Some nodules (up to 9mm) at bil. basal lungs.
    • Right renal stones (3-4mm). Nodules (5mm, 7mm) at left kidney.
    • Atherosclerosis of iliac arteries.
  • IMP:
    • Some nodules (up to 9mm) at bil. basal lungs.
    • Right renal stones (3-4mm). Nodules (5mm, 7mm) at left kidney.
• 2022-09-28 MRA - brain
  • Old insults (ischemic?) in left cerebellum. Nasopharyngeal mucosal thickening. Suggest ENT check-up.
• 2022-05-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (103 - 24) / 103 = 76.70%
    • M-mode (Teichholz) = 76.6
  • Conclusion:
    • Dilated Ao
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Poor echo window
• 2022-02-15 Bone densitometry - spine
  • L-spines BMD (AP view) performed by DXA revealed:
    • AP L-spines, BMD of L1-4 0.657 gms/cm2, about 3.3 SD below the peak bone mass (65%) and 0.4 SD below the mean of age-matched people (93%).
  • IMP: osteoporosis
• 2022-02-15 L spine Ap + Lat. (including sacrum)
  • Maintained bony alignment
  • Disc space narrowing at L4/5
  • Facet degeneration of lumbar spine

[consultation]

• 2023-06-13 Radiation Oncology
  • Q
    • For evaluation of RT
    • This is a 71 female, had past history of Colon-vesicle fistula; Hypertension; Psoriasis (regular OPD f/u at NTUH)
    • This time was admitted to our ward for cancer survey. CT guide Biopsy and colon scope biopsy had proven maligancy last week.
    • Colon Ca with lung metastasis (Colorectal Carcinoma, Imaging stage T4bN2bM1c, STAGE:IVC)
    • We need your expertise for evaluation of RT, thank you
  • A
    • A: Adenocarcinoma of the sigmoid colon, EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)C, stage T4bN2bM1c (IVC), with colon-vesicle fistula and lung metastases.
    • P: The treatment modality and the possible effects of radiotherapy were well explained. I need to further discuss with the patient and her family.
      • Addendum (2023-06-14): Concern the possible effects of radiotherapy on fistula, after discussed with the patient and her family (younger brother and son), radiotherapy was not planned.
• 2023-06-12 Urology
  • Q
    • For colon-vesicle fistula before chemotherapy.
    • This is a 71 female, had past history of Colon-vesicle fistula; Hypertension; Psoriasis (regular OPD f/u at NTUH)
    • This time was admitted to our ward for cancer survey. CT guide Biopsy and colon scope biopsy had proven maligancy.
    • Colon Ca with lung metastasis (Colorectal Carcinoma, Imaging stage T4bN2bM1c, STAGE:IVC)
  • A
    • The aim of surgical excision of fistula is to reduce infection rate during chemotherapy
    • There is still large amount of metastatic lymph and lung lesion
    • There is high risk of residual tumor on urinary bladder or urine leakage after fistula resection
    • The more urinary bladder resection will reduce residual cancer but increase risk of urine leakage after bladder repair
    • Colonstomy may reduce fecal contamination to urinary bladder
    • colonstomy may be a feasible alternative
    • The benefit and risk of procedure will explain to her

[surgical operation]

• 2023-06-15
  • Surgery
    • T loop colostomy
  • Finding
    • dilatation of T colon
    • omentum adhesion to low abdomen.
  • Procedure
    • After GA, abdomen skin is prepare.
    • Incision over RUQ and check bleeding.
    • Lysis of omentum adn free T colon
    • Fix T colon to skin.
    • clean stool in colon and suture.

[radiotherapy]

RT (2024-01-26 ~ 2024-02-08): 3000cGy/10 fractions (6MV photon) of the metastatic brain tumor. RT (2024-02-05 ~ undergoing): 1500cGy/5 fractions (10MV photon) of the metastatic sacrum area.

[chemotherapy]

• 2024-01-03 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-11-16 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-10-25 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-09-14 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-08-24 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-08-03 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4650mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-07-21 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-07-09 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-06-27 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

==========

2024-02-16

[reconciliation]

Treatment for the patient’s UTI commenced on 2024-02-15 with Flumarin (flumoxef sodium) 1000mg Q8H IVD. Additionally, on 2024-02-05, the patient initiated radiotherapy of the metastatic sacrum area with a total dose of 1500 cGy delivered in 5 fractions using 10MV photons. Baraclude (entecavir) is used to prevent HBV from becoming reactivated. No medication discrepancies were identified.

2023-08-24

After examining both PharmaCloud and HIS5 records, no medication discrepancies were found.

Erbitux (cetuximab) was first administered on 2023-08-03 in conjunction with the 4th dose of the FOLFIRI regimen which began on 2023-06-27 (2023-06-09 no variant detect in the KRAS/NRAS gene). Based on the CEA lab data, the decreasing trend suggests that the regimen has been effective so far.

2023-08-23 CEA (NM) 457.140 ng/ml 2023-08-04 CEA (NM) 962.760 ng/ml 2023-07-14 CEA (NM) 1473.200 ng/ml 2023-07-14 CEA (NM) 1508.900 ng/ml 2023-05-30 CEA (NM) 1908.200 ng/ml

2023-07-24

As of the current date, the patient’s oral Alinamin-F (vitamin B complex) and Bokey (aspirin) prescriptions, which were refilled for 30 days on 2023-07-15, are not listed in the active medication list. To ensure patient appropriate treatment, it is advisable to recheck the necessity of these medications.

2023-06-26

• According to the PharmaCloud records, the patient received treatment for acute sinusitis from a local ENT clinic on 2023-05-25 and was provided with a 3-day short-term prescription that is no longer valid. This does not pose a medication reconciliation issue.

• On 2023-05-08, the patient was prescribed Evista (raloxifene 60mg) 1# QD and Celebrex (celecoxib 200mg) 1# QD by our hospital’s orthopedic department, both on a refillable basis. Currently, Evista is included in the patient’s active medication list. Celebrex has been replaced by Deflam-K (diclofenac 25mg) 1# QD, which does not seem to present any medication reconciliation issues. The adjustments are in alignment with the patient’s current health status.

• A fistula between the sigmoid colon and the bladder was seen on 2023-05-25 in the lower GI series. A urine culture obtained on 2023-06-13 confirmed the presence of both Enterococcus faecalis and Escherichia coli, both greater than 100,000 CFU/cc. After a T-loop colostomy on 2023-06-15, the stool culture on 2023-06-19 showed only the presence of normal flora, with no non-intestinal pathogens identified.

• The lab results from 2023-06-06 and 2023-06-19 indicated that the patient tested positive for Anti-HBc and Anti-HBs, suggesting a past HBV infection. Given this, if immunosuppressive chemotherapy is planned, prophylactic antiviral therapy with either Baraclude (entecavir 0.5mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25mg) 1# QD is recommended, at least for the duration of the chemotherapy. This measure can help prevent potential reactivation of the HBV infection due to the immunosuppressive effects of chemotherapy.

  • ref: “Pharmacy FAQ - Hepatitis B reactivation and screening” http://www.bccancer.bc.ca/pharmacy-site/Documents/Pharmacy%20FAQs/Pharmacy-FAQ-Hepatitis-B.pdf

700546273

240216

[exam findings]

• 2024-01-27 CT - abdomen
  • s/p ATH and BSO with post op. change of the pelvis
  • s/p C/T
  • No evidence of abnormal recurrent/residual tumor in the study.
• 2023-08-28 F-18 Fluorodeoxyglucose (FDG) PET scan
  • No previous study for comparison.
  • Increased FDG uptake in the lower pelvis, compatible with cervical cancer s/p surgical change.
  • Increased FDG uptake in three nodular lesions in bilateral pelvic regions and in the peritonium of LLQ of abdomen, the nature is to be determined (s/p surgical reaction, metastatic lymph nodes or other nature ?), suggesting biopsy (the nodular lesion in the peritonium of LLQ of abdomen) for investigation.
  • Increased FDG accumulation in bilateral pulmonary hilar regions, kidneys, and ureters, probably physiological uptake of FDG.
    
  • No prominent abnormal focal FDG uptake is noted elsewhere.
• 2023-08-21 Patho - uterus (with or without SO) neoplastic (Y1)
  • Diagnosis:
    • Cervix, radical hysterectomy — Moderately differentiated squamous cell carcinoma, HPV -associated
    • Endometrium, radical hysterectomy — Negative for malignancy
    • Myometrium, radical hysterectomy — Involved by tumor
    • Parametrium, right, radical hysterectomy — Involved by tumor＆ margin free
    • Parametrium, left, radical hysterectomy — Negative for malignancy
    • Vaginal cuff, radical hysterectomy — Negative for malignancy; Margin positive for severe dysplasia
    • Ovary, bilateral, radical hysterectomy— Negative for malignancy
    • Fallopian tube, bilateral, radical hysterectomy — Negative for malignancy
    • Lymph node, right iliac, dissection — metastatic carcinoma
    • Lymph node, right obturator, dissection — Negative for malignancy
    • Lymph node, left iliac, dissection — Negative for malignancy
    • Lymph node, left obturator, dissection — Negative for malignancy
    • Lymph node, paraaortic, dissection — Mature fat tissue only
    • AJCC 8th edition pathology stage:pT2bN1(if cM0); AJCC stage IIB
    • AJCC 9th edition Cervix Uteri:pT2bN1a(if cM0); FIGO stage IIIC1; AJCC stage IIIC1
  • Gross description:
    • Procedure (select all that apply)
      • Radical hysterectomy + BSO + BPLND + PALNS
      • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
    • Tumor Size:
      • Greatest dimension: 3.5 cm
      • Additional dimensions (centimeters): 3 x 1.4 cm
    • Tumor Site (select all that apply)
      • Left superior (anterior) quadrant (12 to 3 o’clock), left inferior (posterior) quadrant (3 to 6 o’clock), right inferior (posterior) quadrant (6 to 9 o’clock), right superior (anterior) quadrant (9 to 12 o’clock)
    • Sections are taken and labeled as: A1:right iliac LN, A2:right obturator LN, A3:left obturator LN, A4:left iliac LN, A5-6:right adnexae, A7-8:left adnexae, A9-10:right parametrium, A11-12:left parametrium, A13-23:cervical tumor, A24-25:lower segment, A26-27:upper segment, A28:paraaortic LN
  • Microscopic Description:
    • Histologic Type
      • Squamous cell carcinoma, HPV-associated
    • Histologic Grade:
      • G2: Moderately differentiated
    • Stromal invasion:
      • Depth of stromal invasion: 10 mm, entire (The fractions of stromal invasion can be replaced by reporting “depth of stromal invasion in mm / cervical wall thickness in mm” as needed.)
    • Silva Pattern of Invasion (applicable only to invasive endocervical adenocarcinomas): Not applicable
      
    • Other Tissue/ Organ Involvement (select all that apply):
      • Right parametrium
      • Myometrium, lower segment
    • Margins:
      • Vaginal cuff Margin: Positive for severe dysplasia
      • Parmetrial Margin: Free, 3 mm of closest margin distance at right side
    • Lymphovascular Invasion: Present
    • Regional Lymph Nodes: described as follows
      • Site: (Positive: positive nodes number/total number) (Negative: 0/total number)
      • Pelvic Lymph Nodes:
      • Right iliac: Positive: 2/8
        
      • Left iliac: Negative: 0/6
      • Right obturator: Negative: 0/9
      • Left obturator: Negative: 0/5
    • Greatest dimension of largest nodal metastatic deposit (required only if macrometastasis or micrometastasis present):4 mm
      • Isolated tumor cells (0.2 mm or less and not more than 200 cells) (required only in the absence of macrometastasis or micrometastasis in other lymph nodes): Absent
        
    • Para-aortic Lymph Nodes: N/A (fat tissue only)
      • Greatest dimension of largest nodal metastatic deposit (required only if macrometastasis or micrometastasis present): N/A
      • Isolated tumor cells (0.2 mm or less and not more than 200 cells) (required only in the absence of macrometastasis or micrometastasis in other lymph nodes): Absent
        
    • Distant Metastasis:
      • This excludes metastasis to pelvic or para-aortic lymph nodes, or vagina: Not applicable
    • Additional Pathologic Findings
      • severe dysplasia at vaginal cuff
    • Special Study: immunohistochemistry: p16: Positive (strong, diffuse, >90%), P40(+)
    • Comment(s): None
• 2023-07-15 CT - pelvis-bone
  • With and without contrast enhancement CT of abdomen–whole:
    • There is enhanced soft tissue tumor, 3.5cm in the uterine cevical region, r/o cervical malignancy.
    • Segmental wall edeman at hepatic flexure of colon.
    • Thickening wall at gastric antrum.
  • Imaging Report Form for Cervical Carcinoma
    • Impression (Imaging stage) : T:T1b2(T_value) N:N0(N_value) M: M0_(M_value) STAGE:IB2(Stage_value)
  • Impression:
    • Cervical tumor, r/o malignancy, cstage T1b2N0M0.
    • Wall edema of hepatic flexure of colon.
    • Wall thickening at gastric antrum, suggest further study.
• 2023-07-14 Patho - cervix biopsy
  • Uterus, cervix, LEEP conization — Squamous cell carcinoma in situ (CIS), at least, with glandular involvement. Endocervical margin is positive for CIS. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
  • Specimen submitted in formalin consists of one piece of tan, cone-shaped tissue measuring 2.0 x 0.9 x 0.3 cm. The surface is eroded. Entire tissue is serially sectioned in a clockwise fashion from 12 O’clock position and submitted in 1 cassette.
  • Sections show cervical tissue with squamous cell carcinoma in situ (CIS) at least. The dysplastic epithelium shows nuclear hyperchromasia, enlargement and crowding in the entire thickness of the squamous epithelium. The endocervical glands are involved. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
• 2023-07-14 Patho - cervix biopsy
  • Uterus, endometrium, D＆C — squamous cell carcinoma in situ (CIS), at least. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
  • Specimen submitted in formalin consists of blood clots and tissue measuring 0.9 x 0.7 x 0.3 cm. All for section in one cassette.
  • Section shows blood clots and squamous cell carcinoma in situ (CIS), at least. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
• 2023-07-14 Patho - cervix biopsy (Y1)
  • Uterus, endocervix, ECC — squamous cell carcinoma in situ (CIS), at least. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
  • Specimen submitted in formalin consists of mucin, blood clots, and scanty tissue measuring 1.5 x 0.5 x 0.4 cm. All for section in one cassette.
  • Section shows squamous cell carcinoma in situ (CIS), at least. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
• 2023-06-27 Patho - endocervix curretage/biopsy
  • Uterus, endocervix, ECC — squamous cell carcinoma is situ (CIS).
  • Specimen submitted in formalin consists of mucin and scanty tissue measuring 0.1 x 0.1 x 0.1 cm. All for section in one cassette.
  • Section shows mucin and scanty squamous cell carcinoma is situ (CIS).
• 2023-06-27 Patho - cervix biopsy
  • Uterus, endocervix, ECC — squamous cell carcinoma is situ (CIS).
  • Specimen submitted in formalin consists of mucin and scanty tissue measuring 0.1 x 0.1 x 0.1 cm. All for section in one cassette.
  • Section shows mucin and scanty squamous cell carcinoma is situ (CIS).

[MedRec]

• 2023-08-17 ~ 2023-09-02 POMR Obstetrics and Gynecology Shao ZhiXiuan
  • Discharge diagnosis
    • Malignant neoplasm of cervix uteri, unspecified
    • Malignant neoplasm of cervix uteri (Moderately differentiated squamous cell carcinoma, pT2bN1 (if cM0); AJCC stage IIIC1, FIGO pStage IIIC1, post Radical hysterectomy on 2023/08/18
  • CC
    • Intermittent vaginal spotting since mid June this year
  • Present illness
    • This is a 61y/o woman, G1P1 (C/S), without underlying disease. Her gynecology history as follow: Menopause at 57 y/o, HPV vaccine (-), routine pap smear screen (-). She denied any food or drug allergy, denied anticoagulants or hormone use but taking chinese medicine regularly for 4 years.
    • This time, she noted vaginal spotting for 1 day since 2023/06/19. She denied abdominal pain, purulent vaginal discharge, vaginal irritation/pruritus, nausea or vomiting, tarry/bloody stoool, constipation, unintentional body weight loss or postcoital bleeding. She visited our GYN OPD for evaluation, pelvic examination showed mild hypertrophic cervix deviated to 3’, no active bleeding, R/O mosaic pattern around 11’.
    • Pap smear revealed CIN3. The sonography showed endometrial thickness as 13.8mm, suspected EM polyp (8x6mm) and a cervical mass (35x29mm) with minimal cul-de-sac fluid. Lab data showed elevated tumor marker SCC 2.8 ng/mL.
    • The CT scan reported cervical tumor, r/o malignancy, cstage T1b2N0M0, wall edema of hepatic flexure of colon, wall thickening at gastric antrum. We then arranged LEEP cone + ECC + D&C on 2023/07/14, pathology report revealed at least squamous cell carcinoma in situ (CIS), with glandular involvement and endocervical margin is positive for CIS.
    • After well explanation to the patient and under the impression of cervical squamous cell carcinoma in situ (cT1b2), she was admitted to our ward for radical hysterectomy + BILATERAL SALPINGO-OOOPHORECTOMY + BILATERAL PELVIC LYMPH NODE DISSECTION + PARA-AORTIC LYMPH NODE SAMPLING and further management.
  • Course of inpatient treatment
    • After admission, radical hysterectomy + bilateral salpingo-oophprectomy + bilateral pelvic lymph node dissection + para-aortic lymph node dissection + double-J insertion were proceeded smoothly on 2023/08/18. Post-op condition was stable without complication.
    • Pathology result showed as above on 2023/08/23, with cervical carcinoma FIGO stage IIIC1; AJCC stage IIIC1. Concurrent chemoradiotherapy was suggested by guideline. After discussion with oncology specialist, PET scan was done on 2023/08/28, and report showed FDG uptake in lower pelvis compatible with cervix cancer s/p surgical change and three nodular lesions in bilateral pelvic region and peritonium of LLQ abdomen AND NATURE TO BE DETERMINED. We removed vaccum ball on 08/25, and tried removing foley on 08/25 and 08/30 but failed, voiding difficulty with postvoided residual volume around 600mL thus foley was re-inserted.
    • Under relatively stable condition, the patient was dischraged on 2023/09/02 with OPD follow up and further CCRT treatment discussed with radiologist and oncology specialist.
  • Discharge prescription
    • MgO 250mg 2# QID
    • Wecoli (bethanechol 25mg) 1# TIDAC
    • Eurodin (estazolam 2mg) 1# PRNHS

[surgical operation]

• 2023-08-18
  • Surgery
    • Diagnosis:
      • R/O cervical SCC, cstage IB2
    • Surgery:
      • Radical hysterectomy + BSO + BPLND + PALNS
      • Bilateral double J insertion by GU Dr
  • Finding
    • Uterus: Avfl, 7*4 cm, cervix mass 3.5x2x2cm with endocervical region involved
    • RAD: grossly normal.
    • LAD: grossly normal.
    • CDS: no ascites, no adhesion bands.
    • Right parametrium: size : 2cm, Induration (-);
    • Left parametrium: size : 2cm, Induration (-);
    • Vagina cuff: 2 cm , gross tumor (-), section margin free
    • Bilateral pelvic lymphnodes: Normal, Induration (-)
    • Right external iliac (-)
    • Right obturatorand and hypogastric (-)
    • Left external iliac(-)
    • Left obturator and hypogastric (-)
    • Paraortic lymphnodes: Normal, induration (-)
    • Estimated blood loss: 350ml
    • Blood transfusion: nil
    • Complication: nil
• 2023-07-14
  • Surgery
    • Impression:
      • Cervical tumor, squamous cell carcinoma in situ (CIS), cstage T1b2N0M0.     - Procedure:
      • Endocervical curretage   
      • Dilatation and curettage
      • Loop eletrosurgical excision procedure (LEEP).
  • Finding
    • Uterus: Anteversion, 7 cm.
    • Cervix: Hypertrophic cervix with eroded surface. One 1x0.5 cm strip of cervix was electrocauterized.
    • Some endocervical and endometrial tissue, with papillary-like were curetted out.
    • Episiotomy was performed (1cm perineal wound) due to narrow vaginal introitus, s/p suturing repair with 3-0 vicryl material.
    • Estimated blood loss: 10 mL,
    • Blood transfusion: nil,
    • Complication: nil.

[radiotherapy]

[chemotherapy]

• 2024-02-16 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 50mg/m2 80mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
• 2024-01-27 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 50mg/m2 80mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
• 2023-12-30 - paclitaxel 175mg/m2 275mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 50mg/m2 75mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
• 2023-12-04 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + cisplatin 50mg/m2 70mg NS 500mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-19 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited with NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-10-12 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited with NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-10-04 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited with NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-09-27 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited with NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-09-20 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited with NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2024-02-16

[gabapentin and duloxetine in neurotoxicity management]

Grade 2 neurotoxicity has been recorded in the patient’s progress notes. Neurontin (gabapentin) is currently being administered for management. Should the neurological symptoms persist, the use of duloxetine may be considered as a potential therapeutic option.

Ref: Platinum-induced neurotoxicity and preventive strategies: past, present, and future. Oncologist. 2015 Apr;20(4):411-32. doi: 10.1634/theoncologist.2014-0044. Epub 2015 Mar 12. PMID: 25765877; PMCID: PMC4391771.

2023-12-04

[Dipeptiven administration]

To the primary nurse,

Dipeptiven 100 mL (alanyl glutamine 20g) can be diluted with NS 250-1000 mL. After dilution, it can be stored at room temperature for 24 hours.

If the patient is still on port-A, based on her body weight of about 56kg, IV infusion is recommended not less than 3.6 hours (20g / (0.1g/kg/hr x 56kg)), 4 to 6 hours would be even better.

700591359

240216

[chemotherapy]

• 2024-02-16 - liposome doxorubicin 35mg/m2 51mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 870mg NS 500mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-26 - liposome doxorubicin 35mg/m2 51mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 872mg NS 500mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-05 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-12-15 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-02-16

[leukopenia]

It appears that the patient’s WBC level has been in a downward trend even with G-CSF. G-CSF is still the appropriate agent for this patient’s leukopenia episodes.

• 2024-02-16 WBC 1.87 x10^3/uL
• 2024-01-26 WBC 2.49 x10^3/uL
• 2024-01-05 WBC 2.01 x10^3/uL
• 2023-12-22 WBC 4.40 x10^3/uL
• 2023-12-15 WBC 6.01 x10^3/uL

700757783

240216

[exam findings]

• 2023-11-27 Patho - bone marrow biopsy (Y1)
  • DIAGNOSIS:
    • Bone marrow, iliac, biopsy — myelodysplastic syndrome with excess blast type 2 (10-19%)
    • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular cytogenetic study, flow cytometery and clinical findings is recommended.
  • Gross description:
    • The specimen submitted consists of 1 bone marrow tissue fragment measuring 2.4x 0.2x 0.2 cm in size, fixed in formalin. Grossly, it is brownish and elastic to hard.
  • MICROSCOPIC DESCRIPTION:
    • Microscopically, section shows hypercellularity marrow (>90%), and myeloid cell proliferation with dysplasia. Blasts (highlighted by CD34 and CD117) are increased in numbers (10-19%). CD61 highlights megakaryocytes (3~4 per HPF) and multinucleation.
      
    • Immunohisotchemical stain reveals CD68 (+), MPO (+), CD138 (focal+, 1~2%), MPO (+), CD71 (focal+, <=5%), TdT (focal+, <=5%).
• 2022-11-17 Patho - bone marrow biopsy
  • DIAGNOSIS:
    • Bone marrow, iliac, biopsy — hypercellularity, see description. IHC stains: CD117: 5%; CD34: 5%; MPO: 50%, CD61: 5%; CD71: 30% (of the nucleated cells).
  • GROSS DESCRIPTION:
    • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 1.9 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
  • MICROSCOPIC DESCRIPTION:
    • Section shows piece(s) of bone marrow with 90% cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number.
    • IHC stains: CD117: 5%; CD34: 5%; MPO: 50%, CD61: 5%; CD71: 30% (of the nucleated cells). The possobility of myelodysplastic syndrome is considered.
• 2022-07-25 lung perfusion scan4-
  • Multiple sub- or non-segmental perfusion defects in the left upper lung field, the probability of PE is low (5-19%, by modified PIOPED criteria).
  • Cardiomegaly is noted.
• 2022-06-28 Tl-201 stress myocardial perfusion SPECT
  • Probably mild myocardial ischemia at the anteroapical wall, basal lateral wall and posterior wall.
  • Mild reverse redistribution of radioactivity to the apical lateral wall, either normal variant or myocardial ischemia may show this picture.

[MedRec]

• 2023-11-26 ~ 2023-11-28 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Refractory anemia, unspecified
    • Myelodysplastic Syndrome suspect leukemic transformation, due to Blast: 13.3%
    • anemia
    • thrombocytopenia
    • hyperuricemia
  • CC
    • for bone marrow examination and further treatment.
  • Present illness
    • This 67 yeasr old female is a case of MDS suspect leukemic transformation. She was regularly follow up and blood transfusion with LPRBC monthly at ONC OPD. However, the laboratory test revealed blast increased on 2023/11/22 consider leukemic transformation.
    • This time, she was admitted for bone marrow examination and further treatment.
  • Course of inpatient treatment
    • After be admitted, she received blood transfusion with LPRBC, LRP for anemia, thrombocytopenia treatment, and the bone marrow was done on 2023/11/27, pending the report. She can be discharged on 2023/11/28, the OPD follow-up will be arranged.
  • Discharge prescription
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Feburic (febuxostat 80mg) 1# QD

[chemotherapy]

• 2024-02-07 - Vidaza (azacitidine) 100mg SC 3min D1-2
• 2024-01-31 - Vidaza (azacitidine) 100mg SC 3min D1-3
• 2024-01-17 - Vidaza (azacitidine) 100mg SC 3min D1-3
• 2024-01-10 - Vidaza (azacitidine) 100mg SC 3min D1-3
• 2023-12-20 - Vidaza (azacitidine) 100mg SC 3min D1-3
• 2023-12-13 - Vidaza (azacitidine) 100mg SC 3min D1-3

==========

2024-02-16

[adapting Vidaza (azacitidine) dosing in MDS treatment]

The patient, weighing 59kg with a height of 159cm, has a BMI of 23.3 kg/m2 and a BSA of 1.61 m2.

For MDS, azacitidine administration is typically recommended as follows:

• Initial treatment cycle involves administering 75 mg/m2/day for 7 consecutive days within a 28-day cycle. In subsequent cycles, the same dosage is continued every 4 weeks. If no improvement is observed after two cycles and the only side effects are nausea and vomiting, the dosage may be escalated to 100 mg/m2/day. A minimum of 4 to 6 cycles is recommended, with the option to extend treatment if the patient derives ongoing benefit.

Alternative dosing schedules include:

• Administering 75 mg/m2/day for the first 5 days (Monday to Friday), followed by a 2-day break (Saturday and Sunday), and then 75 mg/m^2/day for the next 2 days (Monday and Tuesday), with the cycle repeating every 28 days.
• Administering 50 mg/m2/day for the first 5 days (Monday to Friday), followed by a 2-day break, and then 50 mg/m^2/day for another 5 days, with the cycle repeating every 28 days.
• Administering 75 mg/m2/day for 5 days (Monday to Friday), with the cycle repeating every 28 days.

For this patient, Vidaza (azacitidine) was administered at an approximate dosage of 62 mg/m2/day (100mg/day) for 3 or 2 days, with intervals varying from 1 to 3 weeks. This represents a lower dosage (mg/kg/day), shorter duration (reduced from the recommended 7 or 5 days to 3 or 2 days), and a more frequent dosing schedule (shorter cycle intervals). Deviating from the standard recommended regimen could potentially yield different therapeutic outcomes from the original regimen’s design.

[transfusion-dependent patient: elevated ferritin suggests iron overload, deferasirox considered]

Given the patient’s history of receiving multiple blood transfusions monthly for an extended period, lab data from 2023-12-13 revealed a serum ferritin level of 2261.8 ng/mL, suggesting the possibility of iron overload. Jadenu (deferasirox), the sole iron chelator available at this institution, could be considered as a treatment option. As of 2024-02-16, the patient’s ALT level was 14 U/L and the eGFR was 60.88 ml/min/1.73m^2, indicating no contraindications for using this medication. Jadenu treatment may be initiated at a dosage of 14 mg/kg daily, with subsequent dose adjustments every 3 to 6 months, depending on serum ferritin levels.

Jadenu (deferasirox) at a daily dose of 360 mg has been administered since Dec 2023. This dosage is below the suggested level of 14 mg/kg for a 59 kg individual, which would amount to 826 mg daily.

701333841

240216

[lab data]

• 2022-08-13 Ferritin 694.9 ng/mL
  
• 2022-08-13 Folic Acid 9.65 ng/mL
  
• 2022-08-13 Vitamin B12 948 pg/mL
  
• 2022-08-13 Reticulocyte count 0.360 %
  
• 2022-08-13 Fe (Iron-bound) 47 ug/dL
  
• 2022-08-13 TIBC 143 ug/dL
  
• 2022-08-13 UIBC 96 ug/dL
  
• 2022-08-13 DBI/TBI 21.88 %

[exam findings]

• 2023-05-23 CT - brain
  • No brain infarct or mass
  • Intracranial ICAs and VAs atherosclerosis.
  • Brain atrophy. Chronic Rt mastoiditis and oititiis media.
  • Sagittal plane C-spine images show:
  • Disc space narrowing and marginal spurs of vertebral bodies at C5-C6 and C6-C7 levels due to spondylosis.
  • Mild anterolithesis of C6 vertebra.
  • C2-C3, C3-4, C4-C5, and C5-C6 facets hypertrophy
• 2023-05-15 SONO - abdomen
  • GB stones and sludge
  • Splenomegaly
• 2023-03-27, 2022-12-26, -11-25 CXR
  • Atherosclerotic change of aortic arch
• 2023-03-14 CT - abdomen
  • Clinical history: 71 y/o male patient with RLQ pain for 2 days, constant pain, precipitated by positional change, no related to meal, no bowel movement change, no fever, no nausea
  • PH: Oral cancer s/p OP
  • WITHOUT contrast enhancement CT of abdomen - whole:
    • Presence of gallbladder stones.
    • Presence of splenomegaly.
      
    • No enlarged lymph node in the paraaortic region.
    • Minimal ascites.
    • Right lower lung nodule, 0.8cm.
    • Tree-in-bud infiltrates in left lower lung.
  • Impression:
    • Gallbladder stones.
    • Splenomegaly.
    • Tree-in-bud infiltrates in left lower lung.
    • Right lower lung nodule, 0.8cm.
• 2023-03-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (128.9 - 68.9) / 128.9 = 46.55%
    • M-mode (Teichholz) = 46.6
    • 2D (M-simpson) = 50.1
  • Conclusion
    • Borderline LV systolic function with mildly global hypokinesia
    • Mitral valve prolapse (anterior leaflet) with mild mitral regurgitation
    • Trivial tricuspid regurgitation, mild pulmonic regurgitation
    • Impaired LV relaxation
    • Dilated LA and aortic root; thick IVS and LVPW
• 2022-11-10, -11-04 CXR
  • Enlargement of cardiac silhouette.
  • Atherosclerotic change of aortic arch
  • Peri-bronchial wall thickening of the right and left lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2022-10-31 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Meylodysplasia syndrome (refractory anemia with excess blast-I).
  • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 2.6 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
  • Section shows piece(s) of bone marrow with 90% cellularity and M:E ratio of approximately 8:1. Three cell lineages are present with left shift of leukocytes. Megakaryocytes are adequate in number with mild nucleat atypia.
  • IHC stains: CD117: 10%; CD34: 5%; MPO: 80-85%, CD61: 5 %; CD71: 10 % (of the nucleated cells).
• 2022-10-04 KUB
  • There is splenomegaly.
  • Spondylosis of the L-spine is noted.
• 2022-09-28 CXR
  • Lung markings: consolidation in the right lower lung field.
• 2022-09-28 ECG
  • Sinus rhythm with Premature atrial complexes
  • Possible Left atrial enlargement
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2022-09-15, -09-08 CXR
  • Enlargement of cardiac silhouette.
  • Atherosclerotic change of aortic arch.
  • Increased lung markings on both lower lung are noted.
• 2022-09-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (135 - 66) / 135 = 51.11%
    • M-mode (Teichholz) = 50
  • Dilated LA and LV; mildly abnormal LV systolic function with global hypokinesia
  • Septal hypertrophy; LV diastolic dysfunction, Gr 1
  • Trivial MR, mild AR, mild TR and trivial PR
  • Preserved RV systolic function
  • Rare isolated premature atrial beat (PAC) at the exam
• 2022-08-29 CXR
  • Increase bilateral lung markings.
  • Mild cardiomegaly.
  • Thoracic spondylosis.
  • Post-op with metallic clips in right neck.
• 2022-08-15 CXR
  • Crowding of vascular markings over both lungs
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • Normal heart size
  • Rt and Lt subpulmonary effusion
  • Marginal spurs of multiple vertebral bodies
  • Compression fracture of L1 vertebral body
• 2022-08-11 MRI - kidney, adrenals
  • Splenomegaly with compression on left kidney.
  • Focal T2 hyperintensity in the spleen, suspected splenic infarct.
  • Left pleural effusion.
• 2022-08-11 SONO - nephrology
  • bilateral chronic change of both kidneys.
• 2022-08-10 CXR
  • Bilateral parahilar infiltrates, suspected lung edema.
    
  • No cardiomegaly.
  • Intimal calcification of thoracic aorta.
  • Thoracic spondylosis.
• 2022-08-09 CT - abdomen
  • Splenomegaly with low attenuations.
  • Compression fracture of L1.
  • Tiny gallbladder stones.
• 2022-08-08 ECG
  • Normal sinus rhythm
  • Prolonged QT
  • Abnormal ECG
• 2022-08-03 Transrectal Ultrasound of Prostate, TRUS-P
  • benign prostatic hyperplasia
• 2022-06-01 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with myelodysplastic syndrom with myelodysplastic/myeloproliferative neoplasm transformation
  • The sections show hypercellular marrow (95%). Marked granulocytic proliferation with left shift in MPO stain. CD61+ megakaryocytes are increased and occasional atypical and small megakaryocytes are present. Decreased in number of CD71+ erythroid precursors. A few CD34+ blasts (2%) and scattered CD117+ immature cells (15%) in paratrabecular and interstitial areas. The finding is compatible with MDS with myelodysplastic/myeloproliferative neoplasm transformation. Suggest bone marrow smear evaluation and clinic correlation.
• 2022-05-31 CT - abdomen
  • Splenomegaly with low attenuations suspected infarcts.
  • Some LNs (up to 1.5cm) at bil. inguinal regions.
  • Compression fracture of L1.
  • Tiny gallbladder stones.
• 2022-05-31 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (149 - 49) / 149 = 67.11%
    • M-mode (Teichholz) = 67
  • Gr I LV diastolic dysfunction and impaired RV relaxation.
  • Dilated LV with normal LV and RV systolic function.
  • Aortic valve sclerosis; mild MR; mild PR.
  • Mildly dilated aortic root with mild calcification.
• 2022-05-30 KUB
  • Increased density of left abdomen.
  • Compression fracture of L1.
• 2022-04-09 X Ray
  • Rt 7th-9th ribs fracture
• 2022-03-07 Patho - bone marrow biospy
  • Bone marrow, iliac, biopsy — hypercellular marrow.
  • IHC stains: CD117: <2 %; CD34: <2 %; MPO: 60-70 %, CD61: 5 %; CD71: 15-20 % (of the nucleated cells).
  • Section shows piece(s) of bone marrow with 100 % cellularity and M:E ratio of approximately 4-5:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number with mild nuclear atypia. IHC stains: CD117: ＜2 %; CD34: ＜2 %; MPO: 60-70 %, CD61: 5 %; CD71: 15-20 % (of the nucleated cells). The findings are compatible with myelodysplastic syndrome.
• 2022-03-04 ECG
  • Normal sinus rhythm
  • Prolonged QT
  • Abnormal ECG
• 2021-12-06 CT - brain
  • Swelling of left parietal scalp.
  • A soft tissue nodule (1.2cm) at right parotid region.
  • Fat tissue at right deep neck.
• 2021-12-06 CXR
  • Nasogastric tube in place, proper position
  • Consolidation in Rt lung, in regression as compared with the previous image
  • Elevation of both hemidiaphragms
  • Right internal jugular venous catheter with tip in the SVC
• 2021-11-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (133 - 54) / 133 = 59.34%
    • M-mode (Teichholz) = 58
  • Adequate LV systolic function with normal resting wall motion
  • Dilated LA, septal hypertrophy; impaired LV systolic function
  • Trivial MR adn trivial TR
  • Preserved RV systolic function
• 2021-09-23 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Hypercellular marrow, favor myelodysplastic syndrome
  • The sections show hypercellular marrow (80%). M/E ratio = 5:1 in MPO and CD71 stains. The erythoid precursors are dispersed and scattered. The myeloid cells show left shift with neutrophilia. The CD61+ megakaryocytes are increased in number and occasional abnormal and small megakaryocytes are present. Slightly increased CD34+ and/or CD117+ blasts, accout for 3% of marrow cells. Myelodysplastic syndrom can be considered. Suggest further bone marrow smear evaluation and clinic correlation.
• 2021-09-23 CT - liver, spleen, biliary duct, pancreas
  • Splenomegaly.

[MedRec]

• 2023-12-07 SOAP Cardiology Zhan ShiRong
  • Prescription x3
    • Concor (bisoprolol 1.25mg) 1# QD
    • Spiron (spironolactone 25mg) 1# QD
• 2023-12-06 SOAP Neurology Wang YiChun
  • Prescription x3
    • sodium bicarbonate 300mg 1# QOD
    • Tricozide (trichlomethiazide 2mg) 1# QOD
• 2023-05-24 ~ 2023-05-31 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Refractory anemia with excess of blasts 1
    • Staphylococcus haemolyticus urinary tract infection
    • Acute kidney failure, unspecified
    • Thrombocytopenia, unspecified
    • Anemia
  • CC
    • For dizziness and fever since 2023/05/23           
  • Present illness
    • This is 71 year-old man with past history of MDS, splenomegaly, antiphospholipid syndrome, malignant neoplasm of upper gum, thrombocytopenia, BPH.
    • Last time, kidney sono and MRI for AKI progression on 2022/08/12, echo showed bilateral chronic change of both kidneys and MRI report showed 1. Splenomegaly with compression on left kidney, 2. Focal T2 hyperintensity in the spleen, r/o splenic infarct and 3. Left pleural effusion. Emergency HD in MICU and suspect HUS.
    • Encocardiography showd LVEF: 50%, Dilated LA and LV; mildly abnormal LV systolic function with global hypokinesia 2. Septal hypertrophy; LV diastolic dysfunction, Gr 1 3. Trivial MR, mild AR, mild TR and trivial PR 4. Preserved RV systolic function 5. Rare isolated premature atrial beat (PAC) at the exam.
    • PCR positive Covid-19 infection on 2022/10/08.
    • He was regularly followed up at ONC OPD. The laboratory test revealed severe anemia and thrombocytopenia, leukocytosis. There were no fever, no chest pain, no abdominal pain nor dysuria. Under the impression of MDS with severe anemia and thrombocytopenia, leukocytosis. He receive targeted therapy with Vidaza from 2022/11/26~2022/12/02(C1), 2022/12/26~2023/01/01(C2). 2023/1/30-2023/2/5(C3). 2023/2/27-3/5(C4). 2023/3/28-4/3(C5). 2023/5/10-5/16(C6). Abdominal echo showed splenomegaly. Scabies was diagnosis last time.
    • This time, he has fall down and hit head at home. He sent to OPD for PL 6000/uL and blood transfusion. After blood transfusion, he had fatigue and fever, so he refered to ED for on 2023/05/23. The lab data showed PL showed 4000/uL, so the LRP transfusion again, but recheck just 7000/uL. He denied vomit, diarrhea or abdominal pain, but malaise and dizziness bother him. His legs more patachiae and ecchymosis noted. Under the impression of MDS in porgression and fever cause unknown, so he was admitted on 2023/05/24.
  • Course of inpatient treatment
    • After admission, he received antibiotic as Rocephin for fever control at first. U/C yield Staphylococcus haemolyticus. Critical care for PLT 4000/uL. Frequency blood transfusion as LPRBC and LRP. Check HLA-ABC low resolusion for LRP choice. Under the stable condition without bleeding sign, so he can be discharged on 2023/05/31. OPD follow up is arranged.
  • Discharge prescription
    • Stogamet (cimetidine 300mg) 1# BID
    • Allegra (fexofenadine 60mg) 1# BID
    • Alpraline (alprazolam 0.5mg) 1# HS
    • calcium carbonate 500mg 1# TID
    • Feburic (febuxostat 80mg) 1# QD
    • Mirtapine Orally Disintegrating (mirtazapine 30mg) 0.5# HS
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q12H
    • Utapine (quetiapine 25mg) 1# HS
    • Sinpharderm Cream (urea) BID TOPI
    • Topsym Cream (fluocinonide 0.05%) BID EXT
    • loperamide 2mg 1# PRNQ8H if diarrhea

[chemotherapy]

• 2023-05-10 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
• 2023-03-28 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
• 2023-02-27 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
• 2023-01-30 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
• 2022-12-26 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
• 2022-11-25 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7

==========

2024-02-16

[navigating anemia treatment for MDS with iron overload]

Azacitidine and decitabine are commonly known as hypomethylating agents (HMA) due to their ability to inhibit DNA methyltransferase. However, it remains uncertain whether this inhibition fully explains their therapeutic action in Myelodysplastic Syndromes (MDS). Comparative studies between azacitidine and decitabine in lower-risk MDS cases have not definitively shown one HMA to be superior to the other. This patient underwent 6 sessions of Vidaza (azacitidine) treatment from Nov 2022 to May 2023, approximately on a monthly basis. For patients who do not sufficiently respond to one HMA, the likelihood of responding to the other is minimal.

Laboratory results on 2024-02-01 revealed a serum ferritin level of 1811 ng/mL, suggesting possible iron overload, likely due to repeated blood transfusions. Should this diagnosis be confirmed, Jadenu (deferasirox), the sole iron chelator available at this hospital, might be considered as a viable treatment option. However, its use is contraindicated in patients with an eGFR < 40. Given the patient’s creatinine level of 6.03 mg/dL, eGFR of 9.82 ml/min/1.73m^2, and BUN of 104 mg/dL on 2024-02-16, it is advisable to minimize the frequency of LPRBC transfusions. Moreover, treatment with erythropoiesis-stimulating agents (ESA) to alleviate anemia associated with MDS is generally more efficacious in patients with serum erythropoietin (EPO) levels below 500 mU/mL. For patients with an adequate response to ESA therapy, it is recommended to continue treatment and adjust administration to minimize transfusions and maintain HGB 10 to 12 g/dL.

2023-05-10

The patient’s reliance on blood transfusions to maintain HGB and PLT levels is a critical aspect of his clinical history and care. The levels of both HGB and PLT have been consistently below the lower limit of normal since 2021, according to available laboratory data in HIS5. Anemia and thrombocytopenia are present prior to the initiation of azacitidine treatment, suggesting that these conditions are unlikely to be due solely to the drug. However, azacitidine may exacerbate these conditions because it can cause myelosuppression. The most update PLT level on 2023-05-09 was 21K/uL. In circumstances where the PLT count dips below 25K/uL, a dose reduction of 50% for the upcoming treatment cycle is typically recommended.

2023-03-28

The patient’s serum creatinine level has remained below 2mg/dl until late March 2023, and there is currently an obvious upward trend in the level.

• 2023-03-27 Creatinine 2.52 mg/dL
  
• 2023-03-24 Creatinine 2.21 mg/dL
  
• 2023-03-20 Creatinine 1.95 mg/dL
  
• 2023-03-16 Creatinine 1.71 mg/dL

Deferasirox can cause acute renal failure and death, particularly in patients with comorbidities and those who are in the advanced stages of their hematologic disorders. Deferasirox is contraindicated in patients with eGFR less than 40mL/min/1.73m2.

• 2023-03-27 eGFR 26.95
  
• 2023-03-24 eGFR 31.35
  
• 2023-03-20 eGFR 36.22
  
• 2023-03-16 eGFR 42.15

Other iron chelators are available in the market, but this hospital does not procure deferiprone and deferoxamine is currently out of stock.

To prioritize kidney function over iron overload, an alternative option could be to reduce or hold the dose of deferasirox to prevent the serum creatinine from exceeding 2mg/dL. (eGFR 40 to 60 mL/minute/1.73m2: Reduce initial deferasirox dose by 50%. ref: UpToDate)

2023-03-01

Transfusional iron overload occurs when transfusions are given for anemia not caused by iron deficiency. Despite the administration of Jadenu (deferasirox) since early December 2022, the patient’s ferritin level has been consistently fluctuating at a high level since that time.

• 2023-02-24 Ferritin (NM) 2013.24 ng/ml
  
• 2023-02-21 Ferritin (NM) 1844.19 ng/ml
  
• 2023-01-05 Ferritin (NM) 1838.62 ng/ml
  
• 2022-12-16 Ferritin (NM) 2051.18 ng/ml
  
• 2022-12-01 Ferritin 1554.2 ng/mL
  
• 2022-08-13 Ferritin 694.9 ng/mL

Vidaza (azacitidine) to treat MDS: Subsequent cycles 75 mg/m2/day for 7 days every 4 weeks; dose may be increased to 100 mg/m2/day if no benefit is observed after 2 cycles and no toxicity other than nausea and vomiting have occurred. Patients should be treated for a minimum of 4 to 6 cycles; treatment may be continued as long as patient continues to benefit.

Since the patient has been admitted to receive his 4th cycle of azacitidine during this hospitalization, it would be appropriate to evaluate the effectiveness of the treatment in the next few follow-up visits.

2022-12-23

Lab data (2022-12-23) showed low HGB (8.4g/dL, grade 3) and PLT (33K/uL, grade 3). Jadenu (deferasirox) 360mg PO DQAC is applied to lower the excess iron storage in this patient following times of LPRBC transfusion. Since September 20, 2022, Feburic (febuxostat 80mg) has been successful in lowering the patient’s serum uric acid. Rare excess ULN events have been observed since then. The recommended initial dose of febuxostat is 40 mg once daily, as the patient is senior aged, his hyperuricemia has been well-controlled, and his renal function readings are outside the normal limits, it is recommended to adjust the febuxostat dose to 40mg QD. It appears that Allegra (fexofenadine), Feburic (febuxostat), Jadenu (deferasirox), Smecta (dioctahedral smectite), Stogamet (cimetidine), Utapine (quetiapine) have been prescribed twice (one of each drug marked as a self-carried item). Please confirm the need for multiple prescriptions.

2022-11-28

2022-11-25 albumin 3.2g/dL. The patient is receiving azacitidine for the first time. In a study, it was suggested that the use of azacitidine is not recommended when albumin levels are lower than 3 g/dL. (ref: Dose recommendations for anticancer drugs in patients with renal or hepatic impairment. Lancet Oncol. 2019;20(4):e200-e207. doi:10.1016/S1470-2045(19)30145-7). A closer monitor might be necessary.

2022-09-30

Allogeneic hematopoietic cell transplantation (HCT) is the treatment with the highest potential to cure MDS. However, because of advanced age, comorbid conditions, lack of adequately matched donors, and/or patient preferences, only a small subset of patients with MDS are candidates for allogeneic HCT. Ferritin 694.9ng/mL (2022-08-13, normal 23.9~336.2). A high level of iron in the blood might lead to hemochromatosis. The clinical manifestations of iron overload can be influenced by the amount of tissue iron and the presence of other conditions that lead to organ dysfunction. Cardiac iron overload can lead to the following complications: dilated cardiomyopathy, diastolic dysfunction, heart failure, conduction disturbances, sinus node dysfunction. (NT-proBNP 14016 pg/mL 2022-09-28 <- 5491 pg/mL 2022-09-16) There is no further deterioration in kidney function during Sep 2022 as ceatinine remains around 1.5 mg/dL and eGFR remains around 45-50 mg/dL.

2022-03-04

[drug identification]

requesting drug identification for 2 items.

all the 2 items are identified as following…

• allegra (fexofenadine 60mg) - antiallergic agent, antihistamine, second generation
• orolisin (orotic acid 30mg + glycyrrhizinate extract 50mg + chlorpheniramine maleate 5mg) - antiallergic agent, antihistamine, second generation

these drugs will be sent back to ward by an in-hospital porter.

701515147

240216

[exam findings]

• 2024-02-14 CXR
  • S/P NG tube indwelling.
  • S/P Port-A infusion catheter insertion.
  • Left pleural effusion.
  • Ground glass opacities in bil. lungs.

[MedRec]

• 2024-02-15 Multi-disciplinary Team Recommendations - Palliative Care
  • Referral Date: 2024-02-15
  • Response Content:
    • The patient was diagnosed with gastric cancer at a Taipei Hospital in December last year and sought a second opinion at Taipei Veterans General Hospital. Due to respiratory distress, jaundice, and acute renal failure, chemotherapy was not feasible, and palliative care was recommended.
    • The eldest brother still wished to pursue aggressive treatment, hence the transfer to our hospital. During the combined hospice caregiver’s visit, the patient’s wife mentioned the difficulty of seeing the patient with intubation and ECMO, with many tubes inserted, causing much distress.
    • The family (patient’s wife, daughter, mother, sister, and second brother) reached a consensus on opting for palliative care, except for the eldest brother. Now, disregarding the eldest brother’s opinion, the family wishes to spare the patient further suffering, consenting to palliative ward transfer without the use of vasopressors and minimal morphine for breath control. The patient, fully conscious, expressed a desire not to be resuscitated and agreed to the palliative ward transfer.
    • Assistance was provided to complete the Advance Palliative Care Directive (missing one witness, to be filled by the patient’s daughter in the evening). The combined hospice caregiver informed the patient’s wife that the thoughts would be conveyed to Dr. Shen from family medicine, awaiting the palliative consent form from Dr. Shen and also reminded of preparations for eventualities, providing a supportive handbook.
  • Conclusion and Recommendations: Palliative co-care and follow-up on the Advance Palliative Care Directive.
  • Responder: Chen Hui
  • Response Date: 2024-02-15 17:22
  • Doctor’s Response: 02/15 18:29 He Jingliang Response: Acknowledged
• 2024-02-14 SOAP Medical Emergency Chen YuLong
  • S: Injury Severity Level: 3, Referral > Acute Peripheral Severe Pain (8-10).
    • The patient’s family transferred him from Taipei Veterans General Hospital to our hospital on their own. In early January, the patient was diagnosed with gastric cancer at MOHW Taipei Hospital.
    • The family took the patient to the outpatient clinic of Taipei Veterans General Hospital for a transfer to inpatient care, stating that Taipei Veterans General Hospital only administered antibiotics and bile drainage without any other treatment and even suggested hospice care.
    • Therefore, the family decided to transfer the patient to our hospital for a reevaluation and treatment.
    • 2023/12 diagnosed stage IV gastric cancer
    • pulmonary embolism s/p ECMO
    • AKI s/p H/D
    • NKA
    • PH denied
  • P: preliminary impression C16.9 Malignant neoplasm of stomach, unspecified
    • (DNR, Critical) stage IV gastric cancer, oa Onco. Septic shock, mutiple organ failure.
    • Levophed, Sintrix, CRP11.8 BUN116 Cr5.6 GFR11 GPT71 GGT65 dBI 14 Ti 40 CKMB 1.6

==========

2024-02-16

[tube feeding]

There are currently no oral drugs on the active medication list.

700472307

240210

[lab data]

• 2023-02-10 HBsAg Nonreactive
  
• 2023-02-10 HBsAg (Value) 0.36 S/CO
  
• 2023-02-10 Anti-HBc Nonreactive
  
• 2023-02-10 Anti-HBc-Value 0.05 S/CO
  
• 2023-02-10 Anti-HCV Nonreactive
  
• 2023-02-10 Anti-HCV Value 0.06 S/CO

[exam findings]

• 2024-01-31 ECG
  • Sinus tachycardia
  • Poor wave progression v1~3
  • Abnormal ECG
• 2024-01-31 SONO - chest
  • Echo diagnosis
    • Pleural effusion, minimal, left
    • Consolidation, LLL
• 2024-01-30 Ascites Tapping
  • 2000 ml yellowish color ascites were drained.
• 2024-01-30 SONO - abdomen
  • Findings
    • Liver: Fine echotexture. Several hypoechoic lesions at both lobes, the biggest one measured 12 cm at left lobe
    • Bile: Echogenic substance in GB
    • Pancreas: Part of head and part of tail masked
    • Spleen: Measured 8.3 x 4 cm
  • Diagnosis:
    • Hepatic tumor, mulitple, probably metastatic tumor
    • GB sludge
    • Ascites, massive
    • Splenomegaly
• 2024-01-17 SONO - chest
  • Echo diagnosis
    • Pleural effusion, moderate, right
    • Atelectasis, LLL, RLL
• 2024-01-15 SONO - chest
  • Echo diagnosis
    • left side small amount of pleural effusion over dependent portion, 430cc serosangious flujd was aspirated for analysis.
• 2024-01-11 EGD
  • Suboptimal study of the gastric body and fundus due to much residual food
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
  • Gastric ulcerative tumor, body
  • Status post ND tube placement
• 2024-01-05 MRA - T-aorta
  • Indication: D-dimer 7894, NT-proBNP 27988 R/O pulmonary embolism
  • Chest MRI without IV contrast enhancement shows:
    • Moderate left pleural effusion is found.
    • Left hilar lymphadenopathy is noted.
    • No significant pulmonary embolism is found. However, the non-contrast study is limited in the sensitivity of detecting pulmonary embolism.
    • Huge Soft tissue mass at mid-abdomen measuring 14.8cm in largest dimension. In comparison with CT dated on 2023-10-06, the lesion enlarged markedly.
    • Diffuse gastric wall thickening is found.
    • Lymphadenopathy at paraaortic region is found.
    • Mild ascites formation is found.
    • There is no evidence of destructive bone lesion.
  • Imp:
    • Diffuse lymphadenopathy at abdominal cavity and probably left pulmonary hilar region. Recurrent/residual lymphoma is considered.
    • No significant pulmonary embolism is found. However, the non-contrast study is limited in the sensitivity of detecting pulmonary embolism.
• 2024-01-05 ECG
  • Normal sinus rhythm
  • Septal infarct, age undetermined
  • Prolonged QT
  • Abnormal ECG
• 2024-01-05 CXR
  • S/P port-A implantation.
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2024-01-02 SONO - nephrology
  • Interpretation:
    • Parenchymal change of bilateral kidneys, cause to be determied
    • Presence of ascites
    • Splenomegaly
• 2023-12-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (95.9 - 37.6) / 95.9 = 60.79%
    • 2D (M-Simpson) = 60.8
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild AR, MR and TR
    • Dilated LA, thick IVS and LVPW
    • Tachycardia during the exam, around 120bpm
• 2023-12-27 ECG
  • Sinus tachycardia with Premature atrial complexes
  • Septal infarct, age undetermined
  • Abnormal ECG
• 2023-12-25 KUB
  • Splenomegaly.
  • Ascites is highly suspected. Please correlate with sonography.
• 2023-12-20 ECG
  • Sinus tachycardia
  • Poor wave progression V1~4
  • Abnormal ECG
• 2023-12-07 CXR
  • S/P Port-A infusion catheter insertion.
  • Bilateral pleural effusion.
• 2023-12-06 ECG
  • Normal sinus rhythm
  • poor R wave progression
• 2023-12-06 EGD
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
  • Gastric ulcerative tumor, middle body to cardia, AW and GC site with easily touch bleeding.
  • Gastric ulcer scar, antrum, GC
• 2023-11-17 ENT Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 20 dB HL, WNL except 6k-8k Hz
    • L’t : 23 dB HL, normal to moderate SNHL
  • Tymp
    • Bil Type A
  • ART
    • Bil Ipsi 4k Hz absent, contra absent.
• 2023-11-07 MRA - brain
  • No evidence of brain metastasis.
• 2023-10-06 CT - abdomen
  • Findings: Comparison: prior CT dated 2023/08/23.
    • Prior CT identified diffuse wall thickening of the stomach is noted again, stationary. It is c/w stable disease.
      • Prior CT identified regional LAP are not noted again.
      • Please correlate with contrast enhanced CT with oral water to full distension the stomach.
    • There is splenomegaly (the greatest anterior-posterior dimension: 14.8 cm).
  • Impression:
    • Gastric lymphoma S/P C/T show stable disease. Please correlate with contrast enhanced CT with oral water to full distension the stomach.
• 2023-08-29 Patho - stomach biopsy
  • Stomach, body, biopsy — Gastric ulcer with residual diffuse large B-cell lymphoma
  • The specimen submitted consists of two small pieces of gray-white soft tissue, labeled body, AW and GC site, measuring up to 0.2 x 0.2 x 0.1 cm. All for section.
  • The sections show mucosal tissue with necrosis, fibrinous exudate, granulation tissue, and moderate acute and chronic inflammatory cells infiltration. Clusters of large to medium-sized atypical lymphoid cells in the lamina propria with crush artifact can be found.
  • IHC, the atypical lymphoid cells reveals: CD79a(+), PAX5(+), CD20(-) and CD3(-). the finding is compatible with residual diffuse large B-cell lymphoma.
• 2023-08-28 Patho - bone marrow biopsy
  • Bone marrow, iliac, clinical history of lymphoma, R-CHOP from 2023/2/17~2023/06/20 (6th dose), biopsy — Negative for malignancy.
  • IHC stains: CD3: <1%; CD20: <1 %; bcl-2: <1%, bcl-6: <1 % (of the nucleated cells).
  • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
• 2023-08-23 CT - abdomen
  • Gastric wall thickening, c/w gastric lymphoma
  • Splenomegaly
• 2023-07-14 PET scan
  • In comparison with the previous study on 2023/02/13, the previous glucose hypermetabolism in the gastric region and lymph nodes in bilateral thigh regions are less evident, suggesting partial response to the therapy.
    
  • The glucose hypermetabolism in the the bone marrow of the skeleton is also less evident.
• 2023-06-10 KUB
  • Degeneration of bony structures.
• 2023-06-10 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2023-06-02 CT - abdomen
  • CC: nausea and poor appetite for 1 month. Persist poor intake due to pain after intake. BW loss 7-8 kgs since 2023-01
    • 20230129 CT: Wall thickening of stomach & regional LAP r/o malignancy.
    • 20230130 gastroscopy: Diffuse ulcerative lesions with blood clot on surface were noted at antrum, body, fundus and cardia, s/p biopsy.
      • Pathology: Gastric lymphoma.
  • Findings: Comparison prior CT dated 2023/01/29.
    • Prior CT identified diffuse wall thickening of the stomach and regional LAP is noted again, mild decreasing in wall thickness and lymph nodes size that is c/w gastric lymphoma S/P C/T with partial response.
    • There is splenomegaly and the greatest anterior-posterior dimension measuring about 14.8 cm.
  • Impression:
    • Gastric lymphoma S/P C/T show partial response.
• 2023-04-03, -03-06 CXR
  • Increased lung markings on both lower lung are noted.
• 2023-02-28 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2023-02-15 CXR
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2023-02-14 CT - chest
  • Indication: Large B cell lymphoma, non-geminal center type, Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-).
  • MDCT (128-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
  • Comparison was made with previous abdomimal CT dated on 2023/01/29
    • Lungs:
      • Linear band subsegmental atelectasis at both lower lobes,
        • inferior lingular segment, and RML.
        • mosaic attenuation changes in both lower lobes too.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal-pelvic contents:
      • large region infiltrative lesion and wall thickening of the stomach, with ulceration at antral, body, and fundal regions. small LNs at perigastric region.
      • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • enlarged prostate.
    • Visualized bones:marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • no LAP or mass in the chest and visible lower neck.
    • gastric lypmhoma with perigastric LAP.
• 2023-02-13 Whole body PET scan
  • There was increased FDG uptake in the gastric region (SUVmax early: 33.94, delay: 41.31), and lymph nodes in bilateral thigh regions (SUVmax early: 4.37). In addition, diffusely increased FDG uptake was also noted in bone marrow including sternum, both rib cags, scapulae, spines, sacrum, pelvic bones, humeri and femurs.
  • IMPRESSION:
    • Glucose-hypermetabolism in the gastric region (Deauville score 5), compatible with large B-cell lymphoma.
      
    • Glucose-hypermetabolism in lymph nodes in bilateral thigh regions (Deauville score 4), highly suspected lymphoma with involvement of lymph node regions.
      
    • Diffusely increased FDG uptake in bone marrow including sternum, both rib cags, scapulae, spines, sacrum, pelvic bones, humeri and femurs, probably severe anemia. However, lymphoma with involvement of bone marrow may be excluded, suggesting follow-up.
      
    • Large B-cell lymphoma with involvement of stomach and lymph nodes in bilateral thigh regions, by this F-18 FDG PET scan.
• 2023-02-10 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 24) / 104 = 76.92%
    • M-mode (Teichholz) = 77.2
  • Dilated LA
  • Adequate LV, RV systolic function with normal wall motion
  • LV hypertrophy, Impaired LV relaxation
  • Mild AR (aortic regurgitation is the diastolic flow of blood from the aorta into the left ventricle)
• 2023-01-31 Patho - stomach biopsy
  • Stomach, body, biopsy — Lymphoma, B cell type, diffuse pattern. High grade.
  • IHC stains: CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +).
  • Addtional IHC stains: C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-). Diffuse large B cell lymphoma, non-geminal center type is considered.
  • Section shows gastric glandular mucosal tissue with diffuse infiltration by round blue neoplastic cells.
• 2023-01-30 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Diffuse ulcerative lesions, antrum, body, fundus and cardia, highly suspected malignancy, suspected lymphoma, s/p biopsy
    • Reflux esophagitis LA Classification grade A
• 2023-01-29 CT - abdomen
  • History and indication: abdominal pain
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of stomach with regional LAP r/o malignancy.
    • Normal appearance of liver, spleen, pancreas, adrenals and kidneys.
    • Normal appearance of gallbladder.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • No abnormal density at bilateral basal lungs.
  • IMP:
    • Wall thickening of stomach with regional LAP suspected malignancy.
• 2023-01-08 CT - abdomen
  • Normal appearance of the appendix.
  • The both kidneys show normal contrast excretion, size, and contour without evidence of renal stone or tumors.
  • The liver parenchyma reveals no evidence of focal lesion.
  • The gallbladder is normal in size and wall thickness.
  • The pancreas & spleen appears normal in size and contour.
  • No evidence of ascites or intra-abdominal fluid collection.
  • No evidence of paraaortic or pericaval lymphadenopathy in this study.

[MedRec]

• 2023-12-20 ~ 2024-02-10 POMR Chest Medicine Wu ZhiWei
  • Admission diagnosis
    • Gastro-esophageal reflux disease with esophagitis with Gastric ulcerative tumor, middle body to cardia, AW and GC site with easily touch bleeding by 2023/12/06 EGD report
    • Double hit, Gastric lymphoma with large B cell lymphoma, stage IV, non-geminal center type CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-), R-CHOP from 2023/02/17~2023/06/20 (6th dose)
    • Essential (primary) hypertension
  • Discharge diagnosis
    • Severe sepsis with septic shock
    • Acute respiratory failure s/p intubation and mechanical ventilator support.
    • Bilateral bacterial pneumonia (sputum culture: stenotrophomonas maltophilia)
    • Acute kidney failure
    • Double hit, Gastric lymphoma with large B cell lymphoma, stage IV with liver and intra-abdominal lymph node metastasis, non-geminal center type CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-), R-CHOP from 2023/2/17~2023/06/20 (6th dose)
    • Neutropenia ANC:249
  • CC
    • Tarry stool passage since 2023/12/17
  • Present illness
    • This 59-year-old male patient has the history of 1) HTN for 30 years under medical treatment just 2 years and 2) gout for years.
    • According to himself and his wife, he sufferred nausea and poor appetite for about 1 month. BW loss 7-8 kg in 1+ months and poor intake. Upper GI endoscopy was performed on 2023/01/30 and pathology showed Lymphoma, B cell type, diffuse pattern. High grade. IHC stains: CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +), C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-). Diffuse large B cell lymphoma, non-geminal center type is considered.
    • Abd CT on 2023/01/29, report showed wall thickening of stomach with regional LAP r/o malignancy. EGD showed 1. Diffuse ulcerative lesions, antrum, body, fundus and cardia, highly suspected malignancy, r/o lymphoma, s/p biopsy and 2. Reflux esophagitis LA Classification grade A, PPI used.
    • Heart echo was done showed LVEF 70%. Follow up abd CT showed no LAP or mass in the chest and visible lower neck and gastric lypmhoma with perigastric LAP.
    • The PET for staging, report showed large B-cell lymphoma with involvement of stomach and lymph nodes in bilateral thigh regions on 2023/02/14.
    • 2023/02/13 Bone marrow showed negative for malignancy.
    • He received chemotherapy with R-CHOP 6th since on 2023/02/17-2023/06/20 (by Dr Hsia).
    • 2023/07/14 PET showed in comparison with the previous study on 2023/02/13, the previous glucose hypermetabolism in the gastric region and lymph nodes in bilateral thigh regions are less evident, suggesting partial response to the therapy, The glucose hypermetabolism in the the bone marrow of the skeleton is also less evident.
    • 2023/07/18 PES showed reflux esophagitis LA Classification grade A (minimal), gastric ulcer, lower body, GC, s/p biopsy (A), gastric polyps, antrum, PW, gastric polypoid lesion with ulceration, fundus, upper body, AW, s/p biopsy (B), and pathology showed Ulcer, H pylori NOT present. IHC stain of cytokeratin (CK) highlights preserved glands.
    • 2023/08/23 Abd CT: Gastric wall thickening, c/w gastric lymphoma and splenomegaly
    • 2023/08/28 BM: Negative for malignancy. IHC stains: CD3: <1%; CD20: <1 %; bcl-2: <1%, bcl-6: <1 % (of the nucleated cells).
    • 2023/08/29 EGD showed Esophageal lesion, lower esophagus, s/p biopsy (C), Superficial gastritis, Gastric ulcerative tumor, body, AW and GC, s/p biopsy (B) and Gastric scar, antrum, GC, s/p biopsy (A).
    • 2023/08/29 Esophagus, lower, 38 cm biopsy — Compatible with large B-cell lymphoma with esophageal involvement.
    • 2023/08/29 Stomach, body, biopsy — Gastric ulcer with residual diffuse large B-cell lymphoma.
    • Under the impression of Gastric Diffuse large B cell lymphoma, non-geminal center type stage IV post R-CHOPx6 with residual lymphoma, so he was referred and admitted to Dr Kao for future treatment.
    • He received C1 R-DHAP since 9/26-9/29, C2 on 12/7-12/9 23 for his refractory lymphoma.
    • Follow-up abdominal CT (2023/10/6)showed Gastric lymphoma S/P C/T show stable disease. Tarry stool passage and stool OB 4+ were noted, R/O GI bleeding or tumor bleeding. Intravenous PPI was added and EGD showed Reflux esophagitis LA Classification grade A, Superficial gastritis, Gastric ulcerative tumor, middle body to cardia, AW and GC site with easily touch bleeding. He complained of tachycardia and EKG showed possible anterior infract coronary artery disease suspected.
    • This time, he suffered from tarry stool passage on 12/17 23 and epigastric pain was also noted. Owing to tarry stool passage, watery diarrhea, epigastric discomfort and poor appetite were also noted in recent 2 days and visited to OPD on 12/19 23 and blood transfusion with LPRBC2U & LRP 2PH was given. Epigastric pain progression and tarry stool passage remain and vomiting were developed and came to our ER on 12/20 23. At ER, the laboratory showed WBC:760, Hb:8.3, seg:32.8, ANC:249, PL:22K, PCT:11.71, CRP:34.4, TBI:2.19, Cr:2.03. Under the impression of neutropenia and GI bleeding or tumor bleeding suspected and he was admitted for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, NPO except drugs/hydration and antibiotic with Cefim, primperan and PPI therapy were given for nausea with vomiting, stool OB 4+ R/O GI bleeding or tumor progression related and infection control. The blood culture x 2 set showed negative.
    • Owing to poor appetite and nausea with vomiting and general weakness, fatigue were also noted and PPN support was added.
    • Tramtor 100mg ivd prnq6h was given for pain control.
    • Tachycardia was found on 12/26 and EKG showed sinus tachycardia with premature atrial complexes septal infarct, age undetermined.
    • Owing to poor appetite was noted and PPN was added for cachexia.
    • Tramtor was given for pain control.
    • The heart echo showed LVEF 60.8%. 1. Adequate LV systolic function with no regional wall motion abnormality at resting state. 2. Mild AR, MR and TR. 3. Dilated LA, thick IVS and LVPW. 4. Tachycardia during the exam, around 120bpm.
    • Concor and Norvasc were given for tachycardia and hypertension control.
    • General weakness & fatigue and high CRP:19.4 were found R/O severe sepsis without septic shock.
    • Septic work-up was performed and antibiotic with Tapimycin was given.
    • Acute kindey injury (cr:3.13) was noted on 1/2 and renal sono showed parenchymal change of bilateral kidneys, cause to be determied.
    • Presence of ascites and splenomegaly. Hydration were given for cachexia and AKI.
    • Antibiotic with Brosym was administered for infection control, correct hypomagnesaemia & hypokalemia.
    • Antibiotic shifted to Imipenem since 2024/01/05 for infection control.
    • NG tube was inserted on 2024/01/08 but the patient self-removal of nasogastric tube on 2024/01/09.
    • Owing to elevation D-dimern and NT-proBNP was found R/O pulmonary embolism and MRA: T-aorta showed diffuse lymphadenopathy at abdominal cavity and probably left pulmonary hilar region.
    • Recurrent/residual lymphoma is considered. No significant pulmonary embolism is found. However, the non-contrast study is limited in the sensitivity of detecting pulmonary embolism. We explained his poor condition to his family and on critical.
    • Intravenous PPI was added due to stool OB 4+ and tarry stool passage R/O GI bleeding or tumor bleeding.
    • Dyspnea was noted and CXR showed bilateral pleural effusion and chest tapping about 430cc yellowish fluid was done on 2024/01/15 and report showed transudate.
    • The cytology & cell block report lymphoma. Dyspnea progression was noted on 2024/01/17, ABG shwoed metabolic acidosis.
    • Jusonin 60mg ivd was given. Follow-up CXR revealed bilateral pleural effusion progression and pig-tail drainage was inserted on 2024/01/17 (removed on 2024/01/26).
    • Owing to disease progression noted and we explained his poor condition to his family (son, daughter, wife and sister). The patient’s condition was explained to the family, and the possibility of intubation and resuscitation in case of deterioration was discussed. However, the patient had already expressed a wish not to be resuscitated and had signed an advance medical directive to this effect.
    • Cytology & cell block of pleural effusion showed negative for malignancy. Target therapy with Gazvay on 2024/01/18, smoothly with dyspnea improved. Intravenous PPI, Transamin and blood transfusion for tarry stool passage and symptom relief. EGD shwoed suboptimal study of the gastric body and fundus due to much residual food, reflux esophagitis LA Classification grade A, gastric ulcerative tumor, body, status post ND tube placement on 2024/01/11. Follow-up CXR showed massive pleural effusion and pig-tail drainage was inserted on 2024/01/17.
    • Immunotherapy with Columiv 2.5mg in N/S 100ml IVF 4hrs was administered on 2024/01/25, smoothly without CRS symptoms. Albumin and Lasix to keep I/O balance.
    • Abdominal dullness was noted and 2000 ml yellowish color ascites were drained.
    • Abdominal sono showed Hepatic tumor, mulitple, probably, metastatic tumor, Ascites, massive, splenomegaly on 2024/01/30.
    • Septic work-up was performed and antibiotic with Cefim was added for sepsis.
    • Owing to dyspnea progression and metabolic acidosis were noted and we explained his poor condition to his family and endotracheal tube was inserted on 2024/02/01. Jusonin was given to correct acidosis. Midatin pump titration. He was transferred to MICU on 2024/02/01.
    • After transferred to MICU, the patient received ventilator support and dormicum pump infusion. Antibiotic with meropenem (2/1-2/9), Cravit (2/9-) and Targocid (2/3-) were used for infection control. We added anti-fungal with Eraxis (2/5-) for sputum culture yield candida troicalis.
    • We consulted the nephrologist for CKD and AKI with metabolic acidosis ==> the suggestions: keep I/O and electrolyte balance, follow kidney function. Aggressive fluid hydration with H/S infusion.
    • Vasopressin and albumin injection were given for shock status.
    • We well explained with family about poor prognosis (gastric diffuse large B cell lymhpoma with liver and abdominal lymph node metastasis), and they understood and decided refuse cardiac massage and defibrillation.
    • Persistent oliguria and hypotension were noted. The nephrologist suggestion: not recommended hemodialysis due to terminal stage.
    • Family physician was consulted for hospice combine care.
    • The family requested hospice extubation on 2024/02/10.
    • After withdrawl endotracheal tube and ventilator machine support, few minutes later, bradycardia and EKG showed standstill. So, announced expired at 10:46, 2024/02/10.

[consultation]

• 2024-01-24 Rheumatology and Immunology
  • Q
    • for Glofitamab infusion with CRS happened will given Tocilizumab used to CRS
    • This 59-year-old man, a patient of Double hit, Gastric lymphoma with large B cell lymphoma, stage IV, non-geminal center type CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-).
    • R-CHOP from 2023/2/17~2023/06/20 (6th dose) and R-DHAP x 2 time. He was admitted due to tarry stool passage and neutropenia.
    • Target therapy with Gazyva was given on 2024-01-18. We will given Glofitamab infusion on 2024-01-24. We need expertise to evaluate his condition thanks!
  • A
    • History review was performed. Patient was admitted due to gastric lymphoma & received R-CHOP from 2023/2/17~2023/06/20 (6th dose) and R-DHAP x 2 time. He began to receive Gazyva since 2024-01-18. Glofitamab will be scheduled infusion on 2024-01-24. I was consulted for CRS.
    • Suggestion:
      • Grading for CRS.
      • If CRS happen, corticosteroid may be use first (low dose to pulse dosage dependent on it’s severity).
      • If not effective, please consider tocilizumab (4-8mg/kg).
• 2024-01-04 Neurology
  • Q
    • for acute kindey injury evaluation
    • This 59-year-old man, a patient of Double hit, Gastric lymphoma with large B cell lymphoma, stage IV, non-geminal center type CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-), R-CHOP from 2023/2/17~2023/06/20 (6th dose) and R-DHAP x 2 time. He was admitted due to tarry stool passage and neutropenia.
    • Owing to elevated Cr index from 3.13 -> 3.75 on 2024-01-04. The renal sono showed Parenchymal change of bilateral kidneys, cause to be determied. Presence of ascites. Splenomegaly. We need expertise to evaluate his condition thanks!
  • A
    • We are consulted for AKI
    • 59/M. Double hit, Gastric lymphoma with large B cell lymphoma, stage IV, non-geminal center type.
    • Info:
      • Cre: 1.7 -> 3.1 -> 3.7
      • BUN: 23 -> 40 -> 46, within 1 week
      • Na/K: 134/2.9
      • PCT 5.97, CRP 19.4
      • Urinalysis: RTE cell 10-19/HPF, PRO 1+
      • U/B Culture: NIL
      • Renal echo: Parenchymal change of bilateral kidneys, cause to be determied. Presence of ascites. Splenomegaly
      • Abx: Tapimycin 4.5gm Q8H x 7 days
      • No obvious renal toxic medication usage, except cisplatin
      • BW: 66.9 kg
      • U/O: ~ 2300-2600/day, non-oliguric
      • Poor oral intake recently, on TPN
      • Increased skin turgor, frequent diarrhea recently
      • C. difficile in 2023-10
    • Impression:
      • AKI on CKD KDIGO stage 2, non-oliguric, suspect acute tubular necrosis, r/i dehydration and infection related (prerenal AKI due to diarrhea and poor oral intake is more favored).
      • Our recommendation as below:
        • Please treat infection as your expertise, may keep antibiotic as brosym (Tazocin may exacerbate diarrhea) escalate if necessary
        • Please titrate fluid hydration to around 2000-2500mL/day (slight I/O positive) to keep adequate renal perfusion, prevent diarrhea and dehydration.
        • Please check FENA (Serum and urine sodium/Serum and urine creatinine) and FEUric acid (Serum and urine uric acid)
        • Please follow BUN/CRE, electrolytes, VBG, CBC/DC regularly.
        • Please record I/O on a daily basis and BW at least BIW or TIW
    • We will follow-up this case.
• 2023-12-28 Cardiology
  • Q
    • He complained of tachycardia and chest discomfort for days and EKG (2023/12/20) shwoed sinus tachycardia, poor wave progression V1-V4. EHG (2023/12/27) revealed sinus tachycardia with premature atrial complexes septal infarct. We need expertise to evaluate his condition thanks!
  • A
    • I was consulted for sinus tachycardia. The patient was admitted due to stage IV lymphoma.
    • O
      • EKG showed new PRWP since this December.
      • CXR: cardiomegaly?
      • TTE 2023/02: no structural heart disease
      • Lab: anemia
    • Impression: sinus tachycardia, r/o cancer therapy related, r/o underlying diseases related
    • Suggestion:
      • Follow an echocardiography.
      • Treat underlying diseases as your expertise.
  • A 2023-12-29 16:18:38
    • An echocardiography showed no overt structural heart disease or pulmonary hypertension.
    • Please survey and treat underlying diseases, since sinus tachycardia is usually secondary to noncardiac diseases.
    • If the patient was still symptomatic, may consider beta blocker or non-DHP CCB for symptom relief.

[surgical operation]

• 2022-01-04
  • Surgery
    • Hemorrhoidectomy        
  • Finding
    • Prolasped hemorrhoids at 3,7,11 o’clock        
  • Procedure
    • Under IVGA, Patient was placed on modified Jack-Knife position
    • Tap anus apart
    • Disinfected perianal area with aqueous Beta-Iodine and draped perianal area as usual
    • Local anesthesia applied with mixture of 20ml Marcaine 0.5% and 1% Xylocaine 20ml + E
    • Expose anal canal retractor and identified of hemorrhoid
    • Skin incision was made longitudinally the sites as figure to just above the level of internal sphincter
    • Elevate all tissue above sphincter plant. Turn it over and trimmed away hemorrhoid plexuses
    • Check bleeders and suture mucosa and skin back to sphincter with 4-0 Vicryl
    • Identical procedures were done as figure below
    • Wash anal canal and apply Neomycine ointment
    • Pack wound with gauze 

[chemoimmunotherapy]

• 2024-01-25 - glofitamab 2.5mg NS 100mL 4hr (Columvi)

  • methylprednisolone 80mg + diphenhydramine 50mg + acetaminophen 1000mg PO + NS 250mL

• 2024-01-18 - obinutuzumab 1000mg NS 500mL 5hr (Gazyva)

  • dexamethasone 20mg + diphenhydramine 50mg + acetaminophen 1000mg PO + NS 250mL

• 2023-12-07 - rituximab 375mg/m2 650mg NS 500mL 8hr D1 + carboplatin AUC 5 300mg 24hr D2 + dexamethasone 40mg/m2 20mg BID PO D2-5 + cytarabine 2000mg/m2 3500mg NS 500mL 3hr Q12H D3 (R-DHAP Q3W. Gao WeiYao)

  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2

• 2023-09-26 - rituximab 375mg/m2 679mg NS 500mL 8hr D1 + cisplatin 100mg/m2 180mg NS 500mL 24hr D2 + dexamethasone 40mg/m2 20mg BID PO D2-5 + cytarabine 2000mg/m2 3600mg NS 500mL 3hr Q12H D3 (R-DHAP Q3W. Gao WeiYao)

  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + NS 250mL D1-3 + acetaminophen 500mg PO D1 + palonosetron 250ug D2-3

• 2023-06-20 (R-CHOP Q3W. Xia HeXiong)

• 2023-05-30 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)

  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2

• 2023-04-03 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)

  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2

• 2023-03-09 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)

  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2

• 2023-02-17 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)

  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2

(R)DHAP - Cisplatin, Cytarabine and Dexamethasone +/- Rituximab - 2024-01-08 - https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2018/11/RDHAP.pdf

• Indication
  • Salvage chemotherapy for relapsed/refractory Hodgkin’s or Non-Hodgkin’s Lymphoma
  • First line therapy in combination with alternating R-CHOP in patients with Mantle Cell Lymphoma with stage III/IV disease up to 65 years of age.
• ICD-10 codes
  • Code with prefix C81-86
• Regimen details
  • dexamethasone
    • 40mg
    • IV or PO
    • D1-4
  • rituximab
    • 375mg/m2
    • IV infusion
    • D1
    • for B cell Non Hodgkin’s lymphoma patients only
  • cisplatin
    • 100mg/m2
    • IV infusion
    • D1
  • cytarabine
    • 2g/m2 BD (12 hours apart)
    • IV infusion
    • D2
  • Consider starting GCSF (according to local policy, dose based on weight) either to shorten the duration of neutropenia (days 3-9) or to facilitate peripheral bloods stem cell collection (days 6-12).
• Cycle frequency
  • Repeated every 21-28 days - as soon as blood counts recovered i.e. neutrophils > 1.0 x 10^9/L and platelets (unsupported) > 100 x 10^9/L (unless cytopenias related to disease).
• Number of cycles
  • Relapse setting: 2 cycles - then reassess disease for suitability for consolidation with stem cell transplant.
  • Non-transplant eligible: up to 6 cycles (total).
  • Mantle cell lymphoma: 3 cycles alternating with R-CHOP followed by consolidation with autograft.
• Administration
  • Day 1
    • Rituximab is administered in 500mL sodium chloride 0.9%.
      • The first infusion should be initiated at 50mg/hour and if tolerated the rate can be increased at 50mg/hour every 30 minutes to a maximum of 400mg/hour.
      • Subsequent infusions should be initiated at 100 mg/hour and if tolerated increased at 100mg/hour increments every 30 minutes to a maximum of 400 mg/hour.
    • Cisplatin is administered in 1000mL sodium chloride 0.9% over 2 hours following the pre and post hydration as per protocol below:
      • Infusion Fluid & Additives - Volume - Infusion Time
        • [Sodium Chloride 0.9% - 1000mL - 1 hour]
        • [Mannitol 20% - 200mL - 30 minutes] or [Mannitol 10% - 400mL - 30 minutes]
      • Ensure urine output > 100mL / hour prior to giving cisplatin. Give a single dose of furosemide 20mg IV if necessary.
        • [Cisplatin in Sodium Chloride 0.9% - 1000mL - 2 hours]
        • [Sodium Chloride 0.9% + 2g MgSO4 + 20mmol KCl - 1000mL - 2 hours]
      • Total - 3200mL or 3400mL - 5 hours 30 minutes
      • Note:
        • Additional pre hydration may be given as per local policy or required for individual patients.
        • Patients with low magnesium levels (< 0.7 mmol/L) should have an additional 2g magnesium sulphate added to the pre-hydration bag.
        • An accurate fluid balance record must be kept.
        • All patients must be advised to drink at least 2 litres of fluid over the following 24 hours
  • Day2
    • Cytarabine is administered in 1000mL sodium chloride 0.9% over 3 hours.
      • Start time of each infusion must be 12 hours apart.
      • A total of 2 doses are given.
• Pre-medication
  • Rituximab premedication:
    • Paracetamol 500mg-1g PO 30-60 minutes prior to rituximab infusion
    • Chlorphenamine 10mg IV bolus 15-30 minutes prior to rituximab infusion
    • Dexamethasone 8mg IV bolus or hydrocortisone 100mg IV bolus 15 minutes prior to rituximab infusion (may be omitted if day 1 dexamethasone has been taken at least 30 minutes prior to the start of the rituximab infusion)
• Emetogenicity
  • This regimen has high emetic potential.
• Additional supportive medication
  • Allopurinol 300mg OD (100mg OD if CrCl < 20mL/min) for the first 2 weeks.
  • Antiemetics as per local policy
  • Antiviral prophylaxis as per local policy.
  • Prophylactic antibiotics may be required e.g. ciprofloxacin (or as per local policy) when neutrophil count < 0.5 x 10^9/L.
  • Consider antifungal and PCP prophylaxis as per local policy.
  • Mouthwashes as per local policy.
  • H2 antagonist or proton-pump inhibitor if required.
  • Prednisolone 0.5% eye drops 1 drop QDS to both eyes (to avoid chemical conjunctivitis from high dose cytarabine) to start on day 2 for 5-7 days.
  • If magnesium/potassium levels < normal reference range, replace as per local policy.
• Extravasation
  • Rituximab and cytarabine are neutral (Group 1)
  • Cisplatin is an exfoliant (Group 4)
• Investigations - pre first cycle
  • Investigation - Validity period
    • FBC - 14 days
    • U&Es - 14 days
    • LFTs - 14 days
    • Magnesium - 14 days
    • Calcium - 14 days
  • Other pre-treatment investigations:
    • Hepatitis B sAg & core antibody
    • Hepatitis C antibody
    • HIV antibody
    • Immunoglobulin levels (IgG, A, M)
    • HbA1c
    • LDH
• Investigations - pre subsequent cycles
  • Investigation - Validity period
    • FBC - 72 hours
    • U&Es - 72 hours
    • LFTs - 72 hours
    • Magnesium - 72 hours
    • LDH - If clinically indicated
• Standard limits for administration to go ahead
  • If blood results not within range, authorisation to administer must be given by prescriber/consultant - Unless cytopenias are disease related.
  • Investigation - Limit
    • Neutrophils ≥ 1.0 x 10^9/L
    • Platelets ≥ 100 x 10^9/L
    • Creatinine Clearance (CrCl) ≥ 60 mL/min
    • Bilirubin < 1.5 x ULN
• Dose modifications
  • Haematological toxicity
    • There is no dose adjustment for haematological toxicity.
    • If neutrophils < 1.0 x 10^9/L and/or platelets (unsupported) < 100 x 10^9/L delay treatment until recovery (unless cytopenias are disease-related).
  • Renal impairment
    • Cisplatin CrCl (mL/min) - Cisplatin dose
      • ≥ 60 - 100%
      • 45-59 - 75%
      • <45 - Consider substitution with carboplatin
      • note: Consider omission of platinum at lesser renal impairment / ototoxicity in mantle cell lymphoma, as the most important component of the regimen is cytarabine.
    • Cytarabine CrCl (mL/min) - Cytarabine dose

      • 60 - 100%

      • 46-60 - 60%
      • 31-45 - 50%
      • < 30 - Omit/Contraindicated
  • Hepatic impairment
    • Cytarabine dose should be reduced to 50% if bilirubin > 1.5 x ULN. Doses may be escalated in subsequent cycles in the absence of toxicity (consultant decision).
  • Other toxicities
    • Cisplatin
      • Neurotoxicity including ototoxicity
        • Grade 1 - 100%
        • Grade 2 - 50%
        • Grade 3 - Omit
        • Grade 4 - Discontinue
      • Stomatitis/Mucositis
        • Grade 1 - 100%
        • Grade 2 - Omit until <= grade 1 then 75% dose
        • Grade 3 - Omit until <= grade 1 then 50% dose
        • Grade 4 - Discontinue or omit until <= grade 1 then 50% dose
    • Other toxicities (except alopecia or nausea and vomiting)
      • Grade 3
        • Cisplatin - Interrupt treatment until resolved then consider dose reduction
        • Cytarabine - Interrupt treatment until resolved then consider dose reduction
      • Grade 4
        • Cisplatin - Interrupt treatment until resolved
        • Cytarabine - 75% dose
• Adverse effects
  • Serious side effects
    • Myelosuppression
    • Infertility
    • Secondary malignancy
    • Anaphylactoid reaction
    • Nephrotoxicity
    • CNS toxicity (cytarabine)
    • Neurotoxicity including ototoxicity
    • Nephrotoxicity including electrolyte disturbance
    • Hepatotoxicity
  • Frequently occurring side effects
    • Myelosuppression
    • Gastrointestinal toxicity
    • Rash
    • Conjunctivitis (cytarabine)
    • Arrhythmia
  • Other side effects
    • Cytarabine syndrome (fever, myalgia, rash)

==========

2024-02-08

[kidney decline and fluid concern: edema check recommended]

Kidney function is deteriorating.

• 2024-02-08 Creatinine 5.73 mg/dL
  
• 2024-02-05 Creatinine 5.36 mg/dL
  
• 2024-02-02 Creatinine 4.04 mg/dL

The patient’s body weight increased from 70.4kg on 2024-02-02 to 75.1kg on 2024-02-08. It is advisable to assess for any indicators of fluid accumulation or edema.

When furosemide is used, higher doses may be required to achieve the desired diuretic response due to decreased secretion into the tubular fluid.

Additionally, the absence of acidosis is confirmed by blood gas analysis on 2024-02-08. If the underlying causes of the acidosis have been resolved, then it would be appropriate to consider discontinuing sodium bicarbonate therapy at an opportune moment.

2024-02-02

[strategic Jadenu administration: addressing high ferritin level]

On 2024-02-01, a ferritin level of 10238 ng/mL was observed, potentially indicative of iron overload, possibly from multiple blood transfusions. Confirmation of this could lead to the consideration of Jadenu (deferasirox) as a treatment option, the only iron chelator available in this hospital. Its use is contraindicated for patients with eGFR < 40. (2024-02-01 eGFR 19.94 ml/min/1.73m^2)

Upon recovery of kidney function to eGFR > 40, an initial 50% dose reduction is recommended. No dosage adjustment is needed for eGFR > 60.

For patients with moderate liver impairment (Child-Pugh class B), a 50% dose reduction is advised initially, with vigilant monitoring for efficacy and adverse reactions that might necessitate further dosage adjustments. Jadenu use is not recommended for severe liver impairment (Child-Pugh class C).

In cases with no liver or kidney impairments, Jadenu may be started at 14 mg/kg daily, with dose adjustments every 3 to 6 months based on serum ferritin levels, and tailored to individual responses and treatment goals. If control is insufficient at 21 mg/kg/day, doses may be increased up to 28 mg/kg/day for persistently high serum ferritin levels above 2500 ng/mL. Doses above 28 mg/kg/day are not advised. A reduction in dose is considered if serum ferritin levels drop below 1000 ng/mL on two consecutive assessments, especially for doses above 17.5 mg/kg/day. Therapy should be paused if levels fall below 500 ng/mL, with monthly monitoring thereafter.

2024-01-26

[monitoring for CRS during these 2 or 3 days]

The last R-DHAP treatment was administered on 2023-12-07, with an expectation that the bone marrow suppression effect would almost diminish by the end of the year. However, since the beginning of 2024, the patient’s HGB levels have continued to remain low, ranging from just over 6 to 8 g/dL, indicating persistent anemia.

• 2024-01-26 HGB 7.8 g/dL
• 2024-01-24 HGB 7.9 g/dL
• 2024-01-22 HGB 7.1 g/dL
• 2024-01-20 HGB 8.2 g/dL
• 2024-01-19 HGB 7.1 g/dL
• 2024-01-18 HGB 8.9 g/dL
• 2024-01-17 HGB 7.4 g/dL
• 2024-01-16 HGB 6.7 g/dL
• 2024-01-15 HGB 6.1 g/dL
• 2024-01-13 HGB 7.3 g/dL
• 2024-01-12 HGB 8.8 g/dL
• 2024-01-11 HGB 7.0 g/dL
• 2024-01-10 HGB 6.3 g/dL
• 2024-01-08 HGB 7.7 g/dL
• 2024-01-05 HGB 8.8 g/dL
• 2024-01-04 HGB 8.4 g/dL
• 2024-01-02 HGB 7.6 g/dL

Gazyva (obinutuzumab) was administered on 2024-01-18, and 8 days later today 2024-01-26, the patient’s HGB had dropped by approximately 1 g/dL, necessitating a transfusion today. While the incidence of anemia with Gazyva is 12% to 39% (grades 3/4: 5% to 10%), it was administered only once as per the regimen schedule. Attention should now be directed towards the potential impact of Columvi (glofitamab) administered on 2024-01-25, as it has a higher incidence of decreased hemoglobin (72%; grades 3/4: 8%).

Close monitoring for cytokine release syndrome (CRS) is advised during these 2 or 3 days while Columvi (glofitamab) is being initiated.

For continuing the Columvi (glofitamab) regimen, the next 10mg dose should be scheduled for 2024-02-01 (C1D15).

[grading and managing CRS in glofitamab therapy]

Cytokine release syndrome (CRS) - 2024-01-26 - https://www.uptodate.com/contents/cytokine-release-syndrome-crs

In the event of cytokine release syndrome (CRS) caused by glofitamab, grading can be aligned with the NCI CTCAE v5.0 criteria.

• Grade 1 - Fever, with or without constitutional symptoms.
• Grade 2 - Hypotension responding to fluids. Hypoxia responding to <40 percent FiO2.
• Grade 3 - Hypotension managed with one pressor. Hypoxia requiring ≥40 percent FiO2.
• Grade 4 - Life-threatening consequences; urgent intervention needed.

Regardless of the underlying cause of mild CRS, it is suggested symptomatic treatment with antihistamines, antipyretics, intravenous fluids, and close monitoring. For patients with mild CRS, the balance of benefit and toxicity with symptomatic treatment is more favorable than with high dose glucocorticoids, tocilizumab, or interruption of the infusion. The goal of management is to prevent life-threatening toxicity from CRS while sustaining the antitumor effects of the immunotherapy.

For grade 3/4 CRS caused by glofitamab, administer dexamethasone 8 mg (or 5 mg/m2 if <45 kg; maximum: 8 mg) IV or PO Q8H for up to 3 days, then taper over 4 days. In addition, for patients with an inadequate response, tocilizumab (8 mg/kg IV) can be given.

2024-01-15

[Bestnem 500mg Q6H too high for eGFR 18.47, consider 200mg Q6H or 500mg Q12H]

The eGFR level of 18.47 measured on 2024-01-15 falls within the 15-30 range for which the Sanford Guide recommends Imipenem/Cilastatin dosing of 200mg Q6H or 500mg Q12H. As the current regimen of Bestnem 500mg IVD Q6H exceeds the recommended Sanford Guide guidance, a dose adjustment to either 200mg Q6H or 500mg Q12H is recommended to potentially reduce the risk of adverse effects.

2024-01-09

[Feburic dose modification for lower eGFR]

As of 2024-01-08, the patient’s uric acid level was 6.0mg/dL and eGFR was 19.54mL/min/1.73m².

While currently taking Feburic (febuxostat 80mg) 1# QD, this dosage exceeds the recommended limit of 40mg daily for patients with CrCl below 30mL/minute.

Therefore, a dose reduction to 0.5# QD is advisable to ensure safe and effective management.

2024-01-08

[prioritizing kidney recovery: temporary hold on R-DHAP]

The patient’s eGFR has significantly declined over the past six months, dropping from over 80 to below 20 (as of 2024-01-08). This concerning decline occurred despite receiving only three immunochemotherapy sessions during this period:

• 2023-06-20: R-CHOP
• 2023-09-26: R-DHAP
• 2023-12-07: R-DHAP (with carboplatin replacing cisplatin)

Lab results for eGFR

• 2024-01-08 eGFR 19.54
• 2024-01-05 eGFR 17.36
• 2024-01-04 eGFR 17.62
• 2024-01-02 eGFR 21.79
• 2023-12-29 eGFR 44.06
• 2023-12-25 eGFR 52.94
• 2023-12-21 eGFR 40.22
• 2023-12-20 eGFR 35.91
• 2023-12-19 eGFR 40.22
• 2023-12-14 eGFR 41.79
• 2023-12-04 eGFR 35.11
• 2023-12-03 eGFR 35.30
• 2023-12-01 eGFR 29.74
• 2023-11-24 eGFR 26.63
• 2023-11-06 eGFR 44.37
• 2023-11-02 eGFR 37.61
• 2023-10-17 eGFR 46.26
• 2023-10-09 eGFR 43.47
• 2023-10-06 eGFR 31.72
• 2023-10-02 eGFR 39.48
• 2023-09-25 eGFR 61.69
• 2023-09-13 eGFR 61.69
• 2023-08-28 eGFR 59.52
• 2023-08-20 eGFR 58.49
• 2023-07-12 eGFR 67.82
• 2023-07-05 eGFR 81.29
• 2023-06-19 eGFR 70.60
• 2023-06-16 eGFR 84.20

It is important to note that the R-DHAP regimen is not recommended for patients with creatinine clearance (CrCl) below 30mL/min.

[tube feeding]

Concor 5mg - Utilize the Simple Suspension Method (SSM) for administration. This method requires dissolving the tablet in warm drinking water for 5-10 minutes, occasionally stirring or gently shaking the container until complete dissolution. Once dissolved, it is suitable for administration via a feeding tube. The SSM is effective for dissolving tablets and capsules in warm water, preparing them for suspension and tube feeding.

2023-06-12

• The patient has been regularly visiting a local healthcare provider primarily for the management of his hypertension. The most recent consultation was on 2023-06-06, during which the patient was prescribed bisoprolol, valsartan, atorvastatin, and febuxostat. The current active medication list includes Concor (bisoprolol), Feburic (febuxostat), Atozet (ezetimibe + atorvastatin), and Exforge (amlodipine + valsartan). So far during this hospitalization, there have been no observations of elevated blood pressure readings. No discrepancies have been identified in the medication reconciliation process.

• Leukopenia was detected with the lowest WBC count dropping to 420/uL on 2023-06-10, 11 days after the last R-CHOP regimen was initiated on 2023-05-30. To address this, G-CSF (filgrastim 150ug) was administered for 3 consecutive days beginning on 2023-06-10, which led to a noticeable increase in WBC count by 2023-06-12.

  • 2023-06-12 WBC 0.69 x10^3/uL
    
  • 2023-06-10 WBC 0.42 x10^3/uL
    
  • 2023-06-06 WBC 6.74 x10^3/uL
    
  • 2023-05-30 WBC 3.68 x10^3/uL
    
  • 2023-05-16 WBC 8.06 x10^3/uL

• Possible leukopenia-related bilateral ground-glass opacity in the lower lungs was revealed in the CXR performed on 2023-06-10, potentially indicating respiratory infections. This might also be substantiated by an elevated CRP level of 8.9mg/dL and a fever of 39.2°C recorded on the same day. Following the initiation of Cefim (cefepime 2000mg every 8 hours), the patient’s fever seems to have been managed effectively.

• Recent lab results have shown that the patient’s hs-Troponin I, total bilirubin, and BUN levels have exceeded the upper limit of normal. The root causes of these elevated levels might require further investigation.

  • 2023-06-10 hs-Troponin I 17.7 pg/mL
    
  • 2023-06-10 Bilirubin total 1.24 mg/dL
    
  • 2023-06-06 Bilirubin total 0.67 mg/dL
    
  • 2023-06-06 BUN 34 mg/dL
    
  • 2023-05-30 BUN 22 mg/dL

2023-03-06

• Since 2023-02-28, the patient has been receiving consecutive doses of Granocyte (lenograstim 250ug) for several days and no leukopenia is observed now.
  • 2023-03-06 WBC 10.64 x10^3/uL
    
  • 2023-03-04 WBC 15.66 x10^3/uL
    
  • 2023-03-02 WBC 1.44 x10^3/uL
    
  • 2023-02-28 WBC 0.51 x10^3/uL
    
  • 2023-02-22 WBC 5.49 x10^3/uL
    
  • 2023-02-20 WBC 7.31 x10^3/uL
    
  • 2023-02-19 WBC 9.48 x10^3/uL
    
  • 2023-02-17 WBC 9.66 x10^3/uL
    
  • 2023-02-16 WBC 11.02 x10^3/uL
• The patient received blood transfusions on 2023-02-16 ~ 19 and 2023-03-02 ~ 03, and the latest record shows that the hemoglobin level is close to normal.
  • 2023-03-06 HGB 10.5 g/dL
    
  • 2023-03-04 HGB 11.8 g/dL
    
  • 2023-03-02 HGB 7.8 g/dL
    
  • 2023-02-28 HGB 9.9 g/dL
    
  • 2023-02-22 HGB 9.4 g/dL
    
  • 2023-02-20 HGB 9.7 g/dL
    
  • 2023-02-19 HGB 8.6 g/dL
    
  • 2023-02-17 HGB 7.8 g/dL
    
  • 2023-02-16 HGB 5.9 g/dL
• Currently, the platelet count is within the normal range.
  • 2023-03-06 PLT 212 x10^3/uL
    
  • 2023-03-04 PLT 216 x10^3/uL
    
  • 2023-03-02 PLT 112 x10^3/uL
    
  • 2023-02-28 PLT 114 x10^3/uL
    
  • 2023-02-22 PLT 239 x10^3/uL
    
  • 2023-02-20 PLT 248 x10^3/uL
    
  • 2023-02-19 PLT 267 x10^3/uL
    
  • 2023-02-17 PLT 265 x10^3/uL
    
  • 2023-02-16 PLT 320 x10^3/uL
• The patient seems to be prone to developing pancytopenia after the first R-CHOP treatment from 2023-02-17. The lowest blood counts were observed one to two weeks after treatment according to the data. Therefore, measures such as G-CSF might be prepared ahead of the next chemotherapy.

2023-03-02

• Lab data
  • 2023-03-02 Procalcitonin(PCT) 3.75 ng/mL
    
  • 2023-03-02 WBC 1.44 x10^3/uL
    
  • 2023-02-28 WBC 0.51 x10^3/uL
    
  • 2023-02-22 WBC 5.49 x10^3/uL
    
  • 2023-02-19 WBC 9.48 x10^3/uL
    
  • 2023-02-16 WBC 11.02 x10^3/uL
• The patient’s temperature has not exceeded 37.3 degrees Celsius since 2023-03-02, following the administration of piperacillin and tazobactam and Granocyte (lenograstim), indicating initial control of febrile neutropenia.
• According to the current National Health Insurance drug reimbursement regulations, short-acting injection of granulocyte-colony stimulating factor (G-CSF) such as filgrastim and lenograstim can be used for patients with hematological malignancies after receiving intravenous chemotherapy.
• The patient has B cell lymphoma and started his first cycle of R-CHOP on 2023-02-17. Leukopenia was observed on 2023-02-28, and the aforementioned national health insurance drug reimbursement regulations could be applied.

2023-02-13

• The patient was unable to take in a sufficient amount of food due to pain after intake. As a result of the poor response to acetaminophen and the development of anorexia following use of Nexium, Pariet has been prescribed. In the event that poor intake persists in this patient, Tramacet 2 hrs before prandial might be considered.
• As a PPI, Panzolec (pantoprazole) is duplicated by self-carried Pariet (rabeprazole). If two PPIs are necessary, please confirm.

701320703

240208

[exam findings]

[MedRec]

• 2021-08-04 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • S
    • Lt breast locally advanced ca (TNBC)
    • neoadjuvant C/T with TC -> EC since 2021-07-31
  • Diagnosis
    • Malignant neoplasm of unspecified site of left female breast [C50.912]
  • Prescription
    • Silverzine (silver sulfadiazine 10mg/g) BID EXT
• 2021-07-29 ~ 2021-07-31 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Left breast cancer with lymph node metastasis cT4N1M0 stage IIIB status post left breast biopsy and port-A implacement
    • ECOG performance score: 0
    • Encounter for antineoplastic chemotherapy
  • CC
    • palpable a mass at left breast and associated with ulceration and serous discharge
  • Present illness
    • This 60-year-old female patient denied any past history including DM, HBV or hypertension. She denied any TOCC histories in recent 3 months. She palpable a mass at left breast last June but she ignored it. Until, the mass grew larger quickly and associated with ulceration and serous discharge since this April. She received Traditional Chineses medicine first but the symptom didn’t improved. She went to Dr. Chang OPD for further survey. After physical examination, palpable a 12x9x5 cm protruding mass with skin ulceration at left breast and left axillar lymph node up to 4 cm in size. Breast sono revealed left breast malignancy with axillary lymph nodes metastasis; #5Location: Left 12/0.2 cm, Size: 4.76x5.58 cm; #6 Location: Left 3/2.19 cm, Size: 1.58x1.62 cm. Tc-99m MDP whole body bone scan showed a hot spot in the sternum, bone metastasis should be watched out.
    • Under the impression of left breast invasive carcinoma with lymph node metastasis cT4N1M0 stage IIIB. After well explain the possible treatment modality were well explained to the patient. She was admitted to our ward for implantation port-a catheteriplatation and arrange neo-adjuvant chemotherapy with 1st TC (Taxotere 75mg/m2 + Carboplatin 450mg) for every three weeks.
  • Course of inpatient treatment
    • After admittion, she underwent of left breast tumor biopsy + Port-A catheter implatation on the right side on 2021/07/30. The post-operative course was relatively smooth without complication. The wound is clean and dry.
    • Taxotere 101mg in NS 250/ml IV 1hr and Carboplatin 450mg were performed on 2021/07/31, there was no special complain.
    • Under the stable condition, she was discharged today and will be arrange next neo-adjuvent chemotherapy treatment.
  • Discharge prescription
    • Silverzine (silver sulfadiazine 10mg/g) BID EXT
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Limeson (dexamethasone 4mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# PRNTID
• 2021-07-26 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • S
    • Lt breast protruding mass with axillar LN
    • noted for 1+ yr
    • at least locally advanced breast cancer
  • O
    • postmenopausal 45 y/o
    • menarche 13 y/o
    • G0P0
    • FH of breast ca (+) grandmother and aunt
    • HRT (+) 3M
    • A 12x9x5 cm protruding mass with skin ulceration at left breast
    • Lt axillar LN up to 4 cm in size
  • Diagnosis
    • Unspecified lump in breast [N63]
  • Prescription
    • Silverzine (silver sulfadiazine 10mg/g) BID EXT

[immunochemotherapy]

• 2024-02-08 - vinorelbine 25mg/m2 48mg NS 50mL 10min + carboplatin AUC 5 450mg NS 250mL 2hr

  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL + acetaminophen 500mg PO

• 2024-01-19 - vinorelbine 30mg/m2 55mg NS 250mL 10min + carboplatin AUC 5 450mg NS 250mL 2hr

  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL

• 2023-11-27 - Trodelvy (sacituzumab govitecan) 10mg/kg 180mg NS 100mL 3hr

  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL

• 2023-11-08 - Trodelvy (sacituzumab govitecan) 10mg/kg 180mg NS 100mL 3hr

  • Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL

• 2023-03-24 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-02-24 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-02-10 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-01-27 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-01-09 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2022-12-26 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-12-12 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 693mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-11-28 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-11-14 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-10-26 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-10-12 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-09-21 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-09-08 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 678mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-08-23 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 665mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-07-20 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-07-06 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-06-22 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-05-23 - Keytruda (pembrolizumab) 200mg NS 100mL 30min

• 2022-04-27 - Keytruda (pembrolizumab) 200mg NS 100mL 30min

• 2022-04-07 - Keytruda (pembrolizumab) 200mg NS 100mL 30min

• 2022-03-17 - Keytruda (pembrolizumab) 200mg NS 100mL 30min

• 2022-02-23 - Keytruda (pembrolizumab) 200mg NS 100mL 30min

• 2022-01-04 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 154mg NS 100mL 30min + cyclophosphamide 600mg/m2 1030mg NS 500mL 1hr (Keytruda + EC(90) Q3W)

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO

• 2021-12-07 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 157mg NS 100mL 30min + cyclophosphamide 600mg/m2 1047mg NS 500mL 1hr (Keytruda + EC(90) Q3W)

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO

• 2021-11-16 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 160mg NS 100mL 30min + cyclophosphamide 600mg/m2 1060mg NS 500mL 1hr (Keytruda + EC(90) Q3W)

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO

• 2021-10-26 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 160mg NS 100mL 30min + cyclophosphamide 600mg/m2 1066mg NS 500mL 1hr (Keytruda + EC(90) Q3W)

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2021-10-05 - pembrolizumab 200mg NS 100mL 30min + docetaxel 75mg/m2 135mg NS 250mL 60min + carboplatin AUC 2 450mg NS 250mL 2hr

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2021-09-14 - docetaxel 75mg/m2 134mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2021-08-24 - docetaxel 75mg/m2 135mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2021-07-30 - docetaxel 75mg/m2 135mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Treatment protocols for breast cancer - 2024-02-08 - https://www.uptodate.com/contents/treatment-protocols-for-breast-cancer

• Regimens for HER2-negative breast cancer (including HER2-low cancers)
  • TC (docetaxel plus cyclophosphamide)
  • AC-T, dose dense (doxorubicin plus cyclophosphamide followed by paclitaxel)
  • AC (doxorubicin plus cyclophosphamide)
  • TAC (docetaxel, doxorubicin, and cyclophosphamide)
  • Oral CMF (oral cyclophosphamide plus methotrexate and fluorouracil)
  • IV CMF (IV cyclophosphamide plus methotrexate and fluorouracil)
  • FEC (fluorouracil, epirubicin, plus cyclophosphamide)
  • FEC followed by weekly paclitaxel
  • FEC followed by weekly docetaxel
  • Trastuzumab deruxtecan
• Regimens for HER2-positive breast cancer
  • TH (paclitaxel and trastuzumab)
  • TCH (docetaxel, carboplatin, and trastuzumab)
  • TCHP (trastuzumab, pertuzumab, carboplatin, and docetaxel)
  • AC-TH (doxorubicin plus cyclophosphamide followed by paclitaxel plus trastuzumab)
  • AC-THP (doxorubicin and cyclophosphamide followed by paclitaxel, trastuzumab, and pertuzumab)
  • FEC-THP (FEC followed by docetaxel, pertuzumab, and trastuzumab)
  • THP-FEC-H (neoadjuvant docetaxel, trastuzumab, and pertuzumab followed by adjuvant FEC, followed by trastuzumab
  • THP (docetaxel, trastuzumab, and pertuzumab)
  • Ado-trastuzumab emtansine

==========

2024-02-08

[precautions for chemotherapy during holidays]

The final two treatments of the vinorelbine plus carboplatin regimen occurred on 2024-01-19 and 2024-02-08, with the nadir of leukopenia and thrombocytopenia recorded on 2024-01-26, roughly one week after the initial treatment.

• 2024-02-07 WBC 9.93 x10^3/uL

• 2024-02-01 WBC 12.25 x10^3/uL

• 2024-01-29 WBC 1.11 x10^3/uL **

• 2024-01-26 WBC 0.68 x10^3/uL ***

• 2024-01-22 WBC 11.94 x10^3/uL

• 2024-01-17 WBC 13.18 x10^3/uL

• 2024-02-07 PLT 56 *10^3/uL **

• 2024-02-01 PLT 41 10^3/uL **

• 2024-01-29 PLT 74 *10^3/uL **

• 2024-01-26 PLT 12 10^3/uL **

• 2024-01-22 PLT 38 10^3/uL **

• 2024-01-17 PLT 114 10^3/uL

Following the administration of Granocyte (lenograstim), leukopenia has ceased. However, there was slight thrombocytopenia present even before the first treatment, which worsened post-medication.

On 2024-02-08, the second treatment day coinciding with the Lunar New Year holiday, the vinorelbine dose was reduced by approximately 15% compared to the first session. Despite this reduction, the risk of leukopenia and thrombocytopenia cannot be entirely dismissed, suggesting the preemptive preparation of G-CSF and platelet transfusions might be prudent.

[declining liver function: considering GaoGan (silymarin) in absence of contraindications]

Lab results showed that the patient’s liver function deteriorated in these 7 days, it might be beneficial to add BaoGan (silymarin) as a hepatoprotective agent if there is no contraindication.

• 2024-02-07 ALT 56 U/L
  

• 2024-02-01 ALT 31 U/L

• 2024-02-07 AST 87 U/L
  

• 2024-02-01 AST 44 U/L

• 2024-02-07 Bilirubin total 3.62 mg/dL
  

• 2024-02-01 Bilirubin total 2.33 mg/dL

• 2024-02-07 Bilirubin direct 2.30 mg/dL
  

• 2024-02-01 Bilirubin direct 1.36 mg/dL

700027657

240207

[exam findings]

[MedRec]

• 2023-07-05 SOAP Hemato-Oncology Xia HeXiong

  • A/P
    • C-spine MRI will be done on 2023-07-15, RTC on 2023-07-19 for the decision of further treatment.
    • Paitent can’t afford A+B (atezolizumab + bevacizumab). May apply ramucirumab plus self pay FOLFOX.

• 2023-06-14 SOAP Dermatology Zhou WeiTing

  • Prescription
    • Royalsense (clindamycin 10mg/g) BID TOPI
    • doxycycline 100mg 1# BID
    • fusidic acid 20mg/g BID EXT
    • doxycycline 100mg 1# BID (self-paid)

• 2023-06-14 SOAP Hemato-Oncology Xia HeXiong

  • A/P
    • Although the CT showed stable, the AFP level is still increasing.
    • Will arrange C-spine MRI and shift sorafenib (TKI, VEGF inh) to regorafenib (TKI, VEGF inh) or ramucirumab (VEGF inh, VEGFR2 inh) by NHI (or 1. Atezolizumab (anti-PD-L1) + Bevacizumab (VEGF inh); 2. FOLFOX)

• 2023-06-02 SOAP Hemato-Oncology Wan XiangLin

  • Prescription
    • Nexavar (sorafenib 200mg) 2# BIDAC 28D
    • loperamide 2mg 1# BID

• 2023-05-05, -04-07, -03-08 SOAP Hemato-Oncology Wan XiangLin

  • Prescription
    • Nexavar (sorafenib 200mg) 2# BIDAC 28D

• 2023-04-06 SOAP Dermatology Zhou WeiTing

  • S
    • hand-foot syndrome.
    • seocndary infection was noted.
  • Prescription
    • Sinpharderm Cream (urea) QN TOPI
    • cephalexin 500mg 1# TID
    • Transamin (tranexamic acid 250mg) 1# TID
    • tetracycline ointment TID EXT
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID

• 2023-03-22, -03-08 SOAP Dermatology Zhou WeiTing

  • O
    • tapper down oral medication frequency.
  • Prescription
    • doxycycline 100mg 1# BID
    • Ulstop (famotidine 20mg) 1# BID
    • Broen-C (bromelain 20000units, L-cysteine 20mg) 1# BID
    • Biomycin Ointment (neomycin, tyrothricin) BID TOPI
    • Sinpharderm Cream (urea) QN TOPI
    • Mycomb Cream (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI

• 2023-02-07, -01-10, 2022-12-13 SOAP Hemato-Oncology Zhang ShouYi

  • Prescription
    • Nexavar (sorafenib 200mg) 2# BIDAC 28D

• 2023-02-01 SOAP Dermatology Zhou WeiTing

  • S: improved and dry out.
  • Prescription
    • doxycycline 100mg 1# BID
    • Ulstop (famotidine 20mg) 1# BID
    • Biomycin Ointment (neomycin, tyrothricin) BID TOPI
    • Sinpharderm Cream (urea) BID TOPI
    • Allegra (fexofenadine 60mg) 1# BID

• 2023-01-18 SOAP Dermatology Zhou WeiTing

  • S
    • severe bullae papules and plaques erupition over hands and feet after medication
  • O
    • drug induced.
    • hand-foot skin erpution.
    • Suspect related medication: sorafenib
  • Plan:
    • education about drug side effec and explain
    • Strongly suggested OPD f/u
  • Prescription
    • Silverzine (silver sulfadiazine 10mg/g) BID EXT
    • Acetal (acetaminophen 500mg) 1# PRNQID
    • Compesolon (prednisolone 5mg) 1# BID
    • doxycycline 100mg 1# BID
    • Topsym Cream (fluocinonide 0.05%) BID EXT
    • Ulstop (famotidine 20mg) 1# BID

• 2022-11-22 SOAP Radiation Oncology Huang JingMin

  • S
    • For radiotherapy due to HCC with C spine metastases.
    • PI: 72 y/o male, a pt of HCC s/p TACE x 6 from 2020.04 to 2021.06 & s/p Op x 2 in 2021.03 & 2022.09 by Dr Wu ChaoQun & recurrence wt bone mets Dx in Nov 2022.
    • Family history: (father: HCC)
    • Cancer site specific factors: Alcohol (quit); Smoking (+); Betel nut (quit).
    • Personal Hx: DM(-); HTN(-)
    • Allergy(-)
    • Previous RT Hx: (-)
  • O:
    • ECOG: 0
    • PE: neck and bil SCF: neg; but paitn of the low neck area.
    • TAE (2022-06-10): HCC at RIGHT hepatic lobe s/p TACE.
    • CT scan of abdomen (2022-07-08): 1. Viable HCC 0.8 cm in S4 liver is highly suspected. 2. Detailed findings, please see description.
    • Operation (2022-08-11): Laparoscope S4b partial reection
    • pathology (S2022-13192, 2022-08-12): 1. Liver, S4b, partial resection — Hepatocellular carcinoma. 2. Pathologic Staging: ypT1aNx; Stage IA if cM0.
      
    • CT scan of lung (2022-10-21): Fibrocalcified lesions are noted at right upper lobe and left upper lobe, old TB is considered. NO evidence of recurrent/residual HCC in the study.
    • CT scan of C spine (2022-11-11): Probably multiple bone metastases, cervical spine, with C5 pathological fracture.
    • Bonne scan (2022-11-18): 1. Increased activity in the upper and lower C-spines. Either bone metastases or degenerative spine disease may show this picture. 2. Mildly increased activity in the L4-5 spines. Degenerative change may show this picture. 3. Some hot spots in the sternum and right rib cage and increased activity in the left iliac bone. The nature is to be determined (post-traumatic change? bone metastases?).
    • C-spine AP+ Lat (2022-11-19): 1. mild retrolisthesis at C4-5. 2. Unremarkable change in the width of the bony spinal canal. 3. compression fracture at C5 vertebrla body with blurred vertebral cortical margins.
  • A:
    • Hepatocellular carcinoma, s/p TAE and laparoscope S4b partial reection, Pathologic Staging: ypT1aNx(cM1), with multiple bone metastases and C5 pathological fracture.
      
  • P:
    • Radiotherapy is indicated for this patient with the following indicators: C spine metastases with C5 pathological fracture
    • Goal: palliation
    • Treatment target and volume: C5 and peripheral involved spine area
    • Technique: IMRT
    • Preliminary planning dose: 3000cGy/15 ractions
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-11-28.
    • Suggest the patient visit ortho or NS for evaluation of surgery first. The patient and his wife would like to visit ortho (Dr. Zen) first and then make a decision.

• 2021-08-10 ~ 2021-08-16 POMR General and Gastrointestinal Surgery Wu ChaoQun

• 2021-06-09 ~ 2021-06-11 POMR General and Gastrointestinal Surgery Wu ChaoQun

• 2021-03-30 ~ 2021-04-03 POMR General and Gastrointestinal Surgery Wu ChaoQun

  • Discharge diagnosis
    • Hepatocellular carcinoma, ypT1bN0M0, Stage:IB , Barcelona Clinc Liver Cancer stage A, ECOG: 1, status post laparoscopic S5 resection and laparoscopic cholecystectomy on 2021/03/31
    • Alcoholic liver cirrhosis, Child A
    • Liver cell carcinoma
  • CC
    • Liver tumor was noted by MRI.
  • Present illness
    • This 71 years old male has history of
      • 1. Hepatocellular carcinoma, initial cT2N0M0, stage II, Barcelona Clinc Liver Cancer stage A, status post transarterial chemoembolization *5 on 2020/04/20, 07/01, 09/14, 12/01 and 2021/03/03.
      • 2. Alcoholic liver cirrhosis, Child A
      • 3. Gout
      • 4. non HBV or HCV
    • He was regularly followed up at our GI OPD. The follow up abdomen CT was done on 2021/02/25 which revealed (1) Right HCCs s/p TACE with viable tumors (up to 3.9cm). (2) Liver and renal cysts (5.0cm). (3) A LN (1.1cm) at hepatic hilar region. (4) Liver cirrhosis. Tumor marker showed incerease of AFP:749.2ng/mL. He reffered to GS Dr. Wu’s OPD for help. Arrange Liver MRI was performed which revealed HCC 4 x 3.3 cm in S5 of the liver, no evidence of ascites or lymphadenopathy on 03/24. ICG test showed 12.4%. He denied fever, nausea, dyspnea, abdominal pain, frequent urinary, and tarry stool. Physical examination showed abdomen soft and ovoid, no palpable mass, no tenderness. Under impressed of HCC, he was admitted to our ward for surgical intervention.
  • Course of inpatient treatment
    • After admission, he received laparoscopic cholecystectomy and S5 hepectectomy was processed successfully on 2021/03/31. Post operaively, we observed patient recovery and keep empiric antibiotic, stool softener, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed. He try to introduced soft diet and can tolerate well. His generally well beings and relativley stable without other complications and vital signs were stable after the surgery. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Abdomen wound clean and was removal JP tube was done on 2021/04/02. Under improved general condition, he was allowed to discharge today and OPD follow up was arranged.
  • Discharged prescription
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
    • Through (sennoside 12mg) 2# HS
    • MgO 250mg 1# TID

• 2021-03-03 ~ 2021-03-05 POMR Gastroenterology Chen JianHua

  • CC: for scheduled 5th TACE.

• 2020-11-30 ~ 2020-12-03 POMR Gastroenterology Chen JianHua

  • CC: HCC s/p embolization with recurrence admitted for the 4th TACE

• 2020-09-14 ~ 2020-09-16 POMR Gastroenterology Chen JianHua

  • CC: Hepatoma s/p embolization with recurrence admitted for the 3rd TACE    

• 2020-07-01 ~ 2020-07-03 POMR Gastroenterology Chen JianHua

  • Discharge diagnosis
    • Hepatocellular carcinoma, cT2N0M0, stage II, Barcelona Clinc Liver Cancer stage A, status post 2nd transarterial chemoembolization
    • Alcoholic liver cirrhosis, Child A
    • Gout
    • Liver cell carcinoma
  • CC
    • for 2nd TACE
  • Present illness
    • This 70 years old male had history of 1) Alcoholic liver cirrhosis, Child A; 2) Gout; 3) Hepatocellular carcinoma, cT2N0M0, stage II, Barcelona Clinc Liver Cancer stage A, status post 1st transarterial chemoembolization.
    • He was regular followed up at our GI OPD. Abdominal CT was perfromed on 2020/06/18 and revealed 1) Right HCCs s/p TACE with viable tumors (up to 2.9cm); 2) A LN (1.1cm) at hepatic hilar region; 3) Liver cirrhosis.
    • Alpha-feto-protein (AFP) was 268.5ng/dl on 2020/06/18. There was no fever, chills, nausea, vomiting, poor appetite, abdomen pain, bloody or tarry stool passage, tea color urine. He was admitted to GI ward for 2nd TACE.
  • Course of inpatient treatment
    • After admission, the 2nd transarterial chemoembolization for hepatocelluar carcinomas was performed smoothly on 2020/07/01. There was no fever episode, no abdominal pain after procedure. Follow-up liver function tests revealed mild elevation of ALT (59 U/L) and no hyperbilirubinemia were found.
    • Under stable condition, he was discharged on 2020/07/03 and GI OPD follow up was arranged later.
  • Discharge prescription
    • Lactam (acetaminophen 500mg) 1# PRNQ6H if BT > 38.2 or chills post TACE

• 2020-04-20 ~ 2020-04-22 POMR Gastroenterology Chen JianHua

  • Discharge diagnosis
    • Hepatocellular carcinoma T2N0M0 stage II status post transarterial chemoembolization
    • Alcoholic liver cirrhosis, Child A
    • Gout
  • CC
    • for first TACE
  • Present illness
    • This 70 years old male had history of alcoholic hepatitis and gout for years which were regular follow up at our OPD.
    • Serum alphafeto protein on 2020/03/16 was 64.523 ng/ml. Follow-up abdominal echography on 2020/04/02 showed liver tumor, S5, 3.3 cm. Computed tomography of the abdomen revealed liver cell tumor, T2N0M0, Stage:II and liver cirrhosis. Informed the benefit and risk of TACE.
    • The patient was arranged admitted for first TACE on 2020-04-20. He denied fever, cough, loss appetite, chest pain, tarry stool passage, oliguria, nor limbs edema.
  • Course of inpatient treatment
    • At ward, the liver reserve was Child A. We informed the risk and benefit of TACE to the patient and the family. They understood and signed the permit.
    • TACE was done on 2020-04-20 and there was no complication. Puncture wound was clear and no bleeding. Pain control and IV fluid were given. Follow up ALT/Total bil/CBC/DC were checked on 2020/04/22 which showed stationary.
    • Under the stable vital sign, the patient was discharged on 2020-04-22. OPD follow up was arranged.

[surgical operation]

[radiotherapy]

[immunochemotherapy]

• 2024-02-05 - ramucirumab 8mg/kg 600mg NS 250mL 60min + oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 500mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL (Cyramza + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2024-01-11 - ramucirumab 8mg/kg 600mg NS 250mL 60min + oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 500mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL (Cyramza + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-12-18 - ramucirumab 8mg/kg 600mg NS 250mL 60min + oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 500mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL (Cyramza + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-11-21 - ramucirumab 8mg/kg 600mg NS 250mL 60min + oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 500mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL (Cyramza + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-01 - ramucirumab 8mg/kg 600mg NS 250mL 90min + oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 500mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL (Cyramza + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

2024-02-07

[marked AFP suppression following current chemotherapy initiation]

Lab data on 2024-02-02 were generally within normal limits, with the exception of a notably elevated AFP level, which significantly deviated from the reference range.

Since initiating ramucirumab plus FOLFOX on 2023-11-01, the previously increasing trend in AFP levels has been markedly suppressed, even showing a slight decrease, indicating the continued efficacy of this treatment regimen.

• 2024-01-11 AFP 1890.8 ng/mL
• 2023-12-19 AFP 2110.6 ng/mL
• 2023-11-30 AFP 1855.1 ng/mL
• 2023-11-02 AFP 2331.8 ng/mL
• 2023-08-16 AFP 2310.7 ng/mL
• 2023-07-01 AFP 1096.1 ng/mL
• 2023-06-09 AFP 610.7 ng/mL
• 2023-05-29 AFP 405.1 ng/mL
• 2023-05-02 AFP 120.1 ng/mL
• 2023-04-07 AFP 133.9 ng/mL

Medication not found to be missing.

700556472

240207

[MedRec]

• 2024-02-05 ~ 2024-02-07 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Recurrence pancreatic head adenocarcinoma, pT2N1 with small intestine and CBD invasion, complicated with obstructive jaundice - s/p classical Whipple procedure with SMV-portal reconstruction on 20210629, with peritoneal carcinomatosis (2021/08/30), s/p 1L FOLFIRINOX*12 (80%) 2021/09/03-2022/02/24
    • Anemia
    • Type 2 diabetes mellitus
  • CC
    • Lower limbs edema for months and bilateral redness and tenderness for 5 days
  • Present illness
    • The is a 65-year-old female, with ADL-partially dependent. Past history of
      • Type 2 diabetes mellitus
      • Pancreatic head adenocarcinoma, pT2N1 with small intestine and CBD invasion, complicated with obstructive jaundice - s/p classical Whipple procedure with SMV-portal reconstruction on 20210629 - Recurrence with peritoneal carcinomatosis (2021/08/30), s/p 1L FOLFIRINOX x12 (80%) 2021/09/03-2022/02/24 at CGMH hospital follow up.
    • According to the patient’s sister and medical record, she complained lower limbs edema for months and bilateral redness and tenderness for 5 days, so she was brought to our ED for help on 2023/02/05. At ED, the lab data showed WBC 5720, Hb 6.1, PCT 0.55, CRP 1.2, Alb 2.1, normal liver and renal function. Initial antibiotic for suspect cellulitis over both leg and albumine supplement. She has few BW loss, but intake more (4 cans of nutritional supplements and powdered milk per day). She denied fever, conscious disturbance, dyspnea, dysuria or tarry stool in 1 month.
    • Under the impression of hypoalbuminemia with lower legs edema and anemia, so she was admitted on 2024/02/05.
  • Course of inpatient treatment
    • After admission, she received antibiotic as Augmentin for prevent infection.
    • Self paid of albumin for hypoalbuminemia.
    • LPRBC 2u for anemia correct and Lasix 10mg IVD after BT on 2/6.
    • We check stool ob for anemia survey.
    • (CGMH prescribed but not used yet) Novomix 10u bidac for sugar control during hospitalization.
    • Family denied ONC OPD for supportive care.
    • Under the stable condition, she can be discharged on 2024/2/7 and FM OPD follow up is arranged.
  • Discharge prescription
    • Curam (amoxicillin 500mg, clavulanic acid 125mg) 1# Q8H

700826143

240207

[lab data]

2024-01-03 BM chromosome analyz

• Chromosome Analysis：
  • Tissue Examined：Bone marrow
  • Staining Method：G-Banding
  • Colony number：NA
  • Bands level：350
  • Chromosome Counts：
    • 45-()、46-(19)、47-()、Other-(1) Total-(20)
  • Karyotype：46,XX[19]
• Interpretation：
  • Analysis of this bone marrow sample shows a female having 46,XX[19] karyotype. There was no significant clonal chromosomal abnormality detected. Additionally, one cell with 44,XX,-8,-19 was observed. No clinical significance can be ascribed to this single finding at the present time.
• Note: ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

[exam findings]

• 2024-02-06 CXR (supine)
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    
  • moderate enlarged cardiac silhoutte due to dilated cardiac chambers (LAD,RAD) and prominent cardiophrenic angle mediastinal fat pad /supine position
  • Crowding of vascular markings over Rt lower lung zone
  • Severe OA change at Lt glenohumeral joint
  • old fracture of Rt M/3 clavicle
• 2023-12-08 MR Cholangiography, MRCP
  • Indication: 20231206 US - pancreatic lesion 0.41 cm at the body.
  • Findings:
    • A cystic lesion 6 x 3 mm at the pancreatic body (Srs:103 Img:2) in MRCP is suspected but it is not identified on T2WI.
      • IPMN (side-branch type) is highly suspected.
      • Please correlate with contrast enhanced dynamic CT.
    • The liver shows marked hypointensity on both T1WI and T2WI that is c/w iron deposition (primary hemochromatosis). please correlate with clinical condition.
    • There are several renal cysts on both kidney (up to 1.2 cm).
  • IMP:
    • IPMN (side-branch type) is highly suspected. Please correlate with contrast enhanced dynamic CT.
    • Iron deposition (primary hemochromatosis) in the liver is suspected. please correlate with clinical condition.
• 2023-12-06 SONO - abdomen
  • Diagnosis:
    • Pancreatic cyst, body
    • Splenomegaly, borderline
    • Renal cyst, left kidney
    • Pleural effusion, right
  • Suggestion:
    • MRCP/MRI for pancreatic lesion
• 2023-12-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (154 - 74) / 154 = 51.95%
    • 2D (M-Simpson) = 52
  • Conclusion:
    • Mild global hypokinesia of LV with borderline LV systolic function.
    • Preserved RV systolic function.
    • Septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA and mildly dilated RA.
    • Mild to moderate MR; mild TR; mild PR; mild aortic valve sclerosis.
    • Dilated aortic root and proximal ascending aorta ( 36 mm) with mild calcification.
    • Minimal amount pericardial effusion ( < 50ml).
• 2023-12-05 Patho - bone marrow biopsy
  • PATHOLOGIC DIAGNOSIS
    • Bone marrow, biopsy — Compatible with myelodysplastic syndrome
    • Immunohistochemical stains:
      • MPO: positive for myeloid series
      • CD71: positive for erythroid series
      • CD61: positive for megakaryocytes
      • CD117: positive for blast
      • CD34: positive for blast
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of one strip of bone marrow tissue measuring 2.2 x 0.3 x 0.3 cm in size, fixed in B-5 solution. Grossly, it was tan in color and bony hard in consistence. All embedded for section after short decalcification.
  • MICROSCOPIC EXAMINATION
    • Microscopically, the sections show pictures as follows:
      • Hypercellularity for her age, 90%
      • M/E ratio about 2~3/1, hyperplasia of both myeloid and erythroid series
      • Megakaryocyte proliferation, 20% with nuclear atypia and interstitial distribution. No obviously myelofibrosis
      • No obvious increase of blast (3-5%)
    • According to all above histopathologic findings and past history, it is compatible with myelodysplastic syndrome. Please correlate with clinical and bone marrow smear findings for final diagnosis.
• 2022-07-22 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Gastric ulcer, Forrest classification type III, antrum, PW, s/p biopsy
    • Gastric erosion, antrum, AW/LC site
    • Duodenal ulcer, Forrest classification type III, bulb, AW
  • CLO test: Positive
  • Suggestion:
    • Pursue CLO test and biopsy result
    • PPI use
• 2022-07-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (154 - 48) / 154 = 68.83%
    • M-mode (Teichholz) = 68
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA, grade 2 LV diastolic dysfunction
    • Mild AR, TR and mild to moderate MR

[MedRec]

• 2024-01-23 SOAP Hemato-Oncology Gao WeiYao
  • A: a female having 46,XX[19] karyotype
  • Order
    • LPRBC 2U
  • Prescription
    • diphenhydramine 30mg ST IVD
    • NS 500mL IVD
    • Jadenu (deferasirox 360mg) 1# QDAC 7D
• 2023-12-26 SOAP Hemato-Oncology Gao WeiYao
  • Order
    • LPRBC 2U
  • Prescription
    • diphenhydramine 30mg ST IVD
    • NS 500mL IVD
    • Jadenu (deferasirox 360mg) 1# QDAC 7D
• 2023-12-19 SOAP Hemato-Oncology Gao WeiYao
  • O: 2023/12/05 PATHO - bone marrow biopsy
    • Compatible with myelodysplastic syndrome with no obvious increase of blast (3-5%)
  • A: Preliminary impression
    • D46.9 Myelodysplastic syndrome, unspecified
    • Transfusion-related hyperferritinemia
  • Prescription
    • Jadenu (deferasirox 360mg) 1# QDAC 7D
• 2023-12-02 ~ 2023-12-09 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Myelodysplastic syndrome, unspecified
    • Dizziness and giddiness
    • Anemia, unspecified
  • CC
    • general fatigue and weakness for days
  • Present illness
    • The is a 78-year-old female with the history of myelodysplastic syndrome with single linear dysplasia, ringed sideroblast (MDS-RS-SLD) which was diagnosed in 2022 at CGMH, APP s/p op for many years, bilateral TKR (total knee replacement) for many years at MacKay Hospital.
    • For MDS, she was under regular follow up at out hema OPD. Oral Danazol 1# QD was tried since 2023/10/20, no response to oral danazol and severe anemia was found on 2023/12/01 (Hb 4.4, Coomb test: negative). She was then referred to ER for blood transfusion and await admission for complete survey. Associated symptoms included dizziness for days, generalized chest discomfort, and general weakness.
    • At ER her conscious level was E4V5M6, vital sign: BT:35.9, PR:89, RR:18, BP:119/56mmHg. Physical examination showed conjunctiva pale, no abdominal pain, no acute bleeding sign, bilateral pitting edema 1-2+, and bilateral knee old OP scar. Lab data showed anemia (Hb 4.4 g/dL, after BT with LPRBC 4 units to 7.1 g/dL), high ferritin 2418.4 ng/mL. Chest x-ray showed cardiomegaly. Under the tentative diagnosis of myelodysplastic syndrome with severe anemia, she was admitted to our ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, blood transfusion was done with LPRBC 4u on 12/1, 2u on 12/4, 2u on 12/6, 2u on 12/8 due to anemia, Hb 4.4 -> 7.1 -> 6.1 -> 7.9 -> 7.7 g/dL.
    • We added Jadenu 1# QDAC for high ferritin.
    • She underwent bone marrow puncture on 2023/12/05, and the result showed compatible with myelodysplastic syndrome.
    • Heart echo was arranged due to cardiomegaly and old age, which showed LVEF (%) = 52, mild global hypokinesia of LV with borderline LV systolic function, preserved RV systolic function, septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA and mildly dilated RA, mild to moderate MR; mild TR; mild PR; mild aortic valve sclerosis, dilated aortic root and proximal ascending aorta (36mm) with mild calcification, minimal amount pericardial effusion (<50ml).
    • Due to abnormal liver function and RUQ mild tenderness, we followed lab datas and arranged abdominal echo. HBV, HCV were negative. Elevated GOT 50 -> 48 -> 47 U/L, GPT 53 -> 47 -> 48 U/L, total bilirubin 1.99 -> 2.25 mg/dL, direct bilirubin 0.98 mg/dL, GGT 301 U/L, ALK-P 165 U/L were found.
    • Abdominal echo revealed pancreatic cyst (body), borderline splenomegaly, left renal cyst, right pleural effusion. Lipase and amylase were normal.
    • MRCP was arranged and the report was still pending. During the admission, she had well appetite and no abdominal pain, no tarry stool.
    • Under stable condition, discharged on 12/9 and HEMA, GI OPD follow up was arranged.
  • Discharge prescription
    • Jadenu (deferasirox 360mg) 1# QDAC 11D
• 2023-12-01 SOAP Hemato-Oncology Li QiCheng
  • S: No response to oral danazol, Hb 4.4, Coomb test (-)
    • Plan: refer to ER for blood transfusion and await admission for complete survey
• 2023-11-17 SOAP Hemato-Oncology Li QiCheng
  • S: Hb 3.7, to arrange blood transfusion for 2 weeks
  • Order
    • LPRBC 4 unit
    • ferritin
    • direct Coombs’ test
    • indirect Coombs’ test
  • Prescription
    • NS 500mL IVD QD 2D
    • Danol (danazol 200mg) 1# QD 14D
• 2023-11-03 SOAP Hemato-Oncology Li QiCheng
  • S: 2023-11-03 Hb 4.9
  • Order
    • LPRBC 2 unit
  • Prescription
    • Benamine (diphenhydramine 30mg) ST IVD
    • NS 500mL IVD
    • Danol (danazol 200mg) 1# QD 14D
• 2023-10-20 SOAP Hemato-Oncology Li QiCheng
  • S:
    • 78 y female
      • 2022: Dx: MDS at CGMH, intermittent blood transfusion
      • 2023-10-11: Hb 4.6, s/p PRBC 2 units
      • 2023-10-20: No hepatosplenomegaly, try Danazol 1# QD
    • CC: dizzniess for days and need blood transfusion
      • last blood tranfusion was 3wks ago
      • generalized chest discomfort
    • no fever, no abdominal pain, no dysuria, no headachea, no vomiting, no diarrhea
    • Allergy: none
    • PHx: Myelodysplastic syndrome with single linear dysplasia, ringed sideroblast (MDS-RS-SLD) - f/u at CGMH
      • Gastric ulcer
  • A/P
    • Preliminary impression: D46.9 Myelodysplastic syndrome, unspecified
      • Dizziness, Chest tightness, MDS, Hb (8.6) 4.6 - BT 4U -> 6.7
      • GUs
    • Lab
      • 2023/10/11 12:27
        • WBC = 2.90 x10^3/uL;
        • HGB = 4.6 g/dL;
  • Prescription
    • Danol (danazol 200mg) 1# QD 14D
• 2022-07-27 SOAP Hemato-Oncology Wan XiangLin
  • S: Referred because of macrocytic anemia. constipation in recent 3 months, weight loss.
    • Vegeterian for more than 30 years
  • Preliminary impression
    • R06.00 Dyspnea, unspecified
    • Macrocytic anemia
• 2017-01-12 SOAP Cardiology Duan DeMin
  • S: no chest tightness after inderal use; Recheck BP: 142/71, 84bpm
  • Diagnosis
    • CHF [I50.9]
    • Chest pain, unspecified [R07.9]
    • GERD [K21.9]
    • HCVD [I11.9]
  • Prescription x3
    • Concor (bisoprolol 5mg) 1# QD
• 2017-01-05 SOAP Hemato-Oncology Wan XiangLin
  • S
    • Referred because of leukopenia, anemia.
    • Vegeterian for more than 10 years.
  • O
    • A: Bicytopenia.
    • P: anemia workups.
  • Diagnosis
    • Osteoarthrosis, localized,not specified whether primary or secondary, lower leg [M17.9]
    • Anemia, unspecified [D64.9]
    • IDA, unspecified [D50.9]

==========

2024-02-07

[NCCN guidelines on serum erythropoietin testing]

Revised international prognostic scoring system (IPSS-R) in myelodysplastic syndrome: score = 3.5 => risk grouop = intermediate

• Cytogenetics - Good — 1.0 (analysis of bone marrow sample shows a female having 46,XX[19] karyotype, no significant clonal chromosomal abnormality detected)
• Bone marrow blast >2 to <5 — 1.0
• HGB <8 — 1.5
• PLT >= 100 — 0
• ANC >= 0.8 — 0

The NCCN guidelines recommend evaluating serum erythropoietin (EPO) levels to determine the necessity of recombinant human (rHu) EPO therapy.

While luspatercept is approved for anemia associated with MDS, it is currently not available at this hospital.

701242135

240207

[MedRec]

• 2023-06-20 SOAP Hemato-Oncology Xia HeXiong
  • S: HBs Ag (+), Anti-HBc (+), AntiHBs (-), Anti-HCV (-)
  • P: Consider TNT: CCRT with 5-FU -> FOLFOX x 12-16 weeks (propose to be 8 cycles) -> evaluating OP
  • Prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-06-09 SOAP Radiation Oncology Wang YuNong
  • S: for neoadjuvant CCRT evaluation
  • Plan: He and his family will seek 2nd opinion at NTUH next W2. CT-simulation will be arragned on 2023/06/19. Plan to deliver 45 Gy/ 25 fx to the anus, rectum, lymphatic draiange area (including inguinal). Then boost the anal tumor and LAPs to 50.4~54 Gy/ 28~30 fx.
• 2023-06-08 SOAP Hemato-Oncology Xia HeXiong
  • S: Complicated anal fistula s/p op , chronic inflammation, Malignant change. patho: Anal canal, biopsy — Signet-ring cell carcinoma
  • A: RAS is done or not?
• 2023-05-28 ~ 2023-06-03 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Anorectal fibrosis with partial obstruction
    • Anal canal signet ring cell carcinoma, AJCC9th: cT2N1CM0, stage IIB     
    • Hypokalemia, K 2.5 mmol/L
    • Bilateral renal stones
  • CC
    • progressed abdominal distention for four days
  • Present illness
    • This 59-year-old male who has operation history of (1) Spinal angioma s/p surgery 4 years ago (2) 7 times fistulotomy history (3) Anal fistula s/p multiple fistulotomy and seton drainage enterostomy on 2021/08/23. (4) buttock and anal abscess, multiple anal fistulas and cutaneous fistulas; status post excision of all fistulas on 2021/09/02, status post closure of colostomy on 2023/03/15.
    • This time, he came to our ER due to progressing abdominal distention and constipation. The symptoms had exacerbated for 4 days and accompanied with nausea and vomitting, sever abdominal cramping, no defecation, poor appetite. However, no fever, jaudice, chest pain or tightness were reported.
    • At ER, vital signs were BP:160/103; HR:92bpm ; BT:37.2’C; RR:18; Con’s:E4V5M6, SpO2:95%. Lab showed CRP 7.5mg/dl without leukocytosis. Abdominal CT revealed fecal materials impaction in the course of colons and segmental asymmetrical wall thickening of the rectum. Complicated with gas-filled distended bowel loops of the abdomen. Under the impression of ileus, after initial managment at ER, the patient was admitted to our ward for further evaluation and manantment.
  • Course of inpatient treatment
    • After admission, NPO with fluid hydration and NG decompression were administered. EVAC Q6H and lactulose were prescribed for promoting bowel movement. However, there was no flatus yet. Thus, colostomy was suggested but the patient refused. He started defecating and flatus since 2023/05/29 morning.
    • Sigmoidscopy on 2023/05/30 and 2023/06/01 which had drainage of stool (>1000ml and >1500ml respectively) and large amount of air.
    • Rectal tube was inserted on 2023/06/01 for decompression. With improving abdominal distention, he was discharged on 2023/06/03 and would be followed up at CRS clinic.
  • Discharge prescription
    • Const-K (KCl 750mg 10mEq) 1# QD
    • Lactul (lactulose 666mg/mL) 10mL TID
    • MgO 250mg 2# BID

[radiotherapy]

• 2023-06-27 ~ 2023-08-04 - completed RT to the pelvis (including Rt buttock and bil. inguinal region): 45 Gy/ 25 fx. The anal tumor and LAPs: 50.4 Gy/ 28 fx.

[chemotherapy]

• 2024-02-05 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM (post oxalip) (FOLFOX)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2024-01-11 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM (post oxalip) (FOLFOX)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-12-22 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM D2 (post oxalip) (FOLFOX)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-11-28 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM D2 (post oxalip) (FOLFOX)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-11-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr + hydroxocobalamin 1mg IM D2 (post oxalip) (FOLFOX)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• ……….

• 2023-09-05 - oxaliplatin 85mg/m2 160mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr + hydroxocobalamin 1mg IM (post oxalip) (FOLFOX)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-07-25 - [fluorouracil 400mg/m2 750mg NS 50mL 10min + leucovorin 20mg/m2 40mg NS 100mL 10min] D1-4

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

• 2023-06-27 - [fluorouracil 400mg/m2 750mg NS 50mL 10min + leucovorin 20mg/m2 40mg NS 100mL 10min] D1-4,7

701251769

240207

[MedRec]

• 2021-10-29, -08-06, -05-14, -02-19 SOAP Cardiology Duan DeMin
  • S: come for BP control; mostly < 140/90mmHg with Concor and Exforge; formerly followed up at TMUH
  • Prescription x3
    • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
    • Concor (bisoprolol 5mg) 1# QD
• 2020-12-24 SOAP Chest Medicine Yang MeiZhen
  • S: bronchoscopy with electrocautery for RB10 endobronchial tumors with finally patent. Much purulent secretion runned out from RB10. give prophylactic anti for possible fever and transient bacteremia.
  • A/P: Bronchoscopy with/without electrocautery 2 months later.
  • Prescription
    • Transamin (tranexamic acid 250mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# TID
    • Curam (amoxicillin 500mg, clavulanic acid 125mg) 1# TID
    • Compesolon (prednisolone 5mg) 1# QD
• 2020-11-26 SOAP Chest Medicine Yang MeiZhen
  • S: bronchoscopy with electrocautery for RB10 endobronchial tumors, give prophylactic anti for possible fever.
  • Prescription
    • Transamin (tranexamic acid 250mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# TID
    • Curam (amoxicillin 500mg, clavulanic acid 125mg) 1# TID
    • Compesolon (prednisolone 5mg) 2# QD
    • Adrenalin (epinephrine 1mg) ST TOPI for bronchoscopy
• 2020-10-28 Hemato-Oncology Xia HeXiong
  • A/P:
    • Admission on 2020-10-28 for previous regimen of chemotherapy (2016-02-04 to 2019-01-12) with Docetaxel/Gemcitabine if data is adequate.
• 2020-10-21 Hemato-Oncology Xia HeXiong
  • A/P:
    • After discussion with Chest Expert Dr. Yang, the regimen will be shifted back docetaxel plus gemcitabine which is effective before.
    • Once the tumor over LLL is shrinked. Brochoscope will be arranged again.
  • Prescription
    • G-CSF (filgrastim 150ug) SC 3D
• 2020-10-13 SOAP Chest Medicine Yang MeiZhen
  • S: bronchoscopy for LLL endobronchial lesion enaluate and manage.
  • Prescription
    • Transamin (tranexamic acid 250mg) 1# BID
    • Curam (amoxicillin 500mg, clavulanic acid 125mg) 1# TID
    • Acetal (acetaminophen 500mg) 1# TID
• 2020-09-18 ~ 2020-09-19 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Malignant neoplasm of overlapping sites of corpus uteri
    • Essential (primary) hypertension
    • Idiopathic gout, unspecified site
  • CC
    • For further management of her disease
  • Present illness
    • The 57 y/o woman has past history of hypertension for 20+ years under medicine control. Cancer history of Endometrial stromal sarcoma, Stage I, high grade post surgcal intervention on 2015/04; Recurrently Ctage IV with lung and brain metastases on 2016/01. She start chemotherapy as doetaxel/gemcitabine from 2016-02-04 to 2019-01-12, best response: CR, but progression in brain, s/p craniotomy and s/p SBRT s/p IA, C1D1 on 2019-01-25, best response PD over brain (Brain MRI) 2019-04-26 vs 2019-01-14) and new lesion over LLL of lung (Chest CT 2019-04-25 vs 2019-01-14). Then the chemothrapy was shifted to temzolomide and irinotecan (TEMIRI: T: 150 mg/m2 on D1-5 and Irinotecan 100 mg/m2 on D1/D15 Q4W), C1D1 on 2019-05-16. Due to Gr 4 myelosuppression, the dose was adjusted to irinotecan 80 mg/m2 and temozolomide 140 mg/Day.
    • This time, she is admitted for further management with next dose of chemotherapy on 2020/09/18.
  • Course of inpatient treatment
    • After admission, she received C17D1 self paid of Temodol 140mg D1-D5 (Q1M) + Irinotecan (80mg/m2) (Q2W) on 2020/09/18. She can be toleranced chemotherapy during hospitalization. Under the stable condition, she can be discharged on 2020/09/19. OPD follow up is arranged on 2020/09/24 and re-admission for alone C17D15 Irinotecan on 2020/10/02.
  • Discharge prescription
    • Temodal (temozolomide 100mg) 1# QDAC 3D (for 9/20-9/22 use)
    • Temodal (temozolomide 20mg) 2# QDAC 3D (for 9/20-9/22 use)
    • Emend (aprepitant 125mg) 1# QD 2D (for 9/20-9/21 use)
    • Granocyte (lenograstim 250ug) SC 3D (for 9/24-9/26 use)
• 2020-09-08 SOAP Hemato-Oncology Xia HeXiong
  • S
    • NRS: 2
    • s/p TAH + BSO on 2015-03-19, Endometrial stromal sarcoma, Stage I, high grade; currently Ctage IV with lung and brain metastases
    • For follow up the disease condition
    • Dry couigh for days
  • O
    • s/p doetaxel/Gemcitabine from 2016-02-04 to 2019-01-12, best response: CR, but progression in brain, s/p craniotomy and s/p SBRT
    • s/p IA, C1D1 on 2019-01-25, best response PD over brain (Brain MRI) 2019-04-26 vs 01-14) and new lesion over LLL of lung (Chest CT 2019-04-25 vs 01-14)
    • CxR on 2020-09-08: Brochitis
    • Now temzolomide and irinotecan (TEMIRI: T: 150 mg/m2 on D1-5 and Irinotecan 100 mg/m2 on D1/D15 Q4W), C1D1 on 2019-05-16.
    • Due to Gr 4 myelosuppression, Irino 80 mg/m2, temozolomide 140 mg/Day
  • A/P
    • Check hemogram and biochemistry
    • May consider G-CSF if neutropenia
    • Admission for next dose of chemotherapy with TEMIRI if data is adequate

[consultation]

• 2024-02-05 Urology
  • Q
    • for Right adrenal mass, metastasis or original?
    • The 61-year-old woman has past history of hypertension for 20 more years under medicine control. Cancer history of Endometrial stromal sarcoma s/p TAH + BSO, Stage I, high grade s/p chemotherapy with Docetaxel/Gemcitabine (2016-02-04 to 2019-01-12), CR, with brain metastasis s/p craniotomy and s/p SBRT, with lung metastasis, cT0N0M1, Stage IV s/p chemotherapy with Docetaxel/Gemcitabine. This time, admission for suspect disease progression and for later line Chemotherapy.
    • We sincerely need your professional assistance!!
  • A
    • This 61-year-old female patient has history of endometrial sarcoma with brain and lung metastasis. Recent CT revealed a 4.5cm right adrenal mass which gradually enlarged from 1.5cm in 2022. The appearance of the mass suggest its metastatic origin. However, functional survey of adrenal tumor can still be arranged. Please treat her underlying malignancy as your expertise and arrange adrenal survey as follow:
      • Blood aldosterone, renin activity, ACTH, cortisol, and DHEA-S
      • Urine catecholamine and VMA
    • Thank you for your consultation !!!

[chemotherapy]

• 2023-12-21 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

  • dexamethasone 4mg + NS 250mL

• 2023-12-07 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 90mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-11-30 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

  • dexamethasone 4mg + NS 250mL

• 2023-10-18 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-10-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

  • dexamethasone 4mg + NS 250mL

• 2023-09-26 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-09-19 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

  • dexamethasone 4mg + NS 250mL

• 2023-09-05 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-08-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

  • dexamethasone 4mg + NS 250mL

• 2023-08-15 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 90mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-08-08 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

  • dexamethasone 4mg + NS 250mL

• 2023-07-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-06-27 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-06-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

  • dexamethasone 4mg + NS 250mL

• 2023-06-06 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-05-30 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

  • dexamethasone 4mg + NS 250mL

• 2023-05-16 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• ……….

• 2020-12-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2020-12-15 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2020-12-02 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2020-11-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 30mg/m2 50mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2020-10-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 30mg/m2 50mg D5W 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2020-10-07 - irinotecan 80mg/m2 125mg NS 500mL 1.5hr

  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 3mg + atropine 0.5mg SC + aprepitant 125mg PO + NS 250mL + NS 1000mL (Y-sited C/T 24hr)

• 2020-09-18 - irinotecan 80mg/m2 125mg NS 500mL 1.5hr + temozolomide 140mg PO D1-2

  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 3mg + atropine 0.5mg SC + aprepitant 125mg PO + NS 250mL + NS 1000mL (Y-sited C/T 24hr)

==========

700952699

240206

[MedRec]

• 2024-01-24 SOAP Gastroenterology Xu RongYuan
  • Diagnosis
    • Cirrhosis of liver without mention of alcohol [K74.69]
    • Pancytopenia [D61.818]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Anemia, unspecified [D64.9]
    • Esophageal varices without mention of bleeding [I85.00]
    • Hypoalbuminemia [E88.09]
    • Alcoholic fibrosis and sclerosis of liver [K70.2]
  • Prescription x3
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • Uretropic (furosemide 40mg) 1# BID
    • Pronolol (propranolol 10mg) 1# QD
    • Emetrol (domperidone 10mg) 1# BIDAC
    • Lactul Syrup (lactulose 666mg/mL) 10mL QD
    • BaoGAn (silymarin 150mg) 1# QD
    • Nexium (esomeprazole 40mg) 1# QDAC
• 2024-01-23 SOAP Rheumatology and Immunology Chen ZhengHong
  • A
    • Allergic urticaria & chronic dermaitits
    • Cirrhosis of liver
  • Prescription x3
    • Allegra (fexofenadine 60mg) 1# BID
    • Ichderm Cream (doxepin 50mg/gm) QID TOPI
• 2024-01-17 SOAP Metabolism and Endocrinology Guo XiWen
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
    • Goiter, specified as simple [E04.0]
    • Alcoholic fibrosis and sclerosis of liver [K70.2]
    • Obesity, unspecified [E66.9]
  • Prescription x3
    • Zulitor (pitavastatin 4mg) 1# QOD
    • Soliqua (insulin glargine 100unit/mL, lixesenatide 50ug/mL) 26unit QD SC
    • Kludone (gliclazide 60mg) 1# BID
• 2024-01-10 SOAP Neurology Liu ZhiYang
  • S: right wrist numb in recent days
  • Prescription x3
    • Neurontin (gabapentin 100mg) 1# PRNQD
    • TieShrShuPap (flurbiprofen 40mg/patch) 1# QD EXT
    • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# QD
    • Gingonin (ginkgo biloba 40mg) 1# QD
    • Acetal (acetaminophen 500mg) 0.5# PRNQD
• 2023-07-31 ~ 2023-08-04 POMR Gastroenterology Wang JiaQi
  • Discharge diagnosis
    • Chronic hepatic failure with coma
    • Unspecified cirrhosis of liver, CAUSE ?, CHILD B WITH ASCITES
    • Esophageal varices without bleeding
    • Type 2 diabetes mellitus without complications
    • anemias
  • CC
    • Conscious disturbance with abdomen fullness and left leg edema in recent 10 days.
  • Present illness
    • This 72 year-old female with underlying of 1. Type 2 DM, 2. liver cirrhosis, EV bleeding s/p ligation. This time, she suffered from fatigue and didn’t sleep well for 2 months. However, the symptoms of fatigue and weakness got worse since last month. She had walked hard and slept more than 18 hours/day.
    • According to her family, she suffered from conscious disturbance with abdomen fullness and left leg edema in recently 10 days. There was no fever, chillness or nausea/vomiting. She came to our ER for help on 2023/07/31. At ER, vital signs: BP:162/100mmHg, PR:67 bpm, BT:37’C, RR:18/min, Con’s:E3V5M6, SpO2: 96%. PE showed Abdomen: abdnominal bloating and tightness. Laboratory data revealed pancytopenia, elevated total bilirubin (1.65 mg/dL) and ammonia:82 umol/L. Paracentesis 250ml at ER. Denied TOCC history. Under the impression of hepatic encephalopathy, the patient was admitted to our GI ward for further evaluation and treatment on 2023/07/31.
  • Course of inpatient treatment
    • After admission, she received diuretic with lasix and spironolactone and lactulose for hepatic encephlopathy and liver cirrohosis with ascites treatment. The abdomen echo and panendoscopy were performed, which showed liver cirrhosis with severe ascites and splenomegaly, middle to lower esophagus esophageal varices and gastric varices. The abdomen CT revealed liver cirrhosis with portal hypertension. Follow-up laboratory data revealed improved ammonia level. We well explained the need and risk of esophageal varices ligation, but family is hesitated.
    • Under stable condition with clear consciousness, she was discharge on 2023/08/04, GI OPD follow up was arranged later.
  • Discharge prescription
    • BaoGan (silymarin 150mg) 1# QD
    • Lactul (lactulose 666mg/mL) 20mL BID
    • Nexium (esomeprazole 40mg) 1# QDAC
• 2017-09-01 SOAP Hemato-Oncology Gao WeiYao
  • Diagnosis
    • Pancytopenia [D61.818]
    • Anemia, unspecified [D64.9]
    • Cirrhosis of liver without mention of alcohol [K74.69]
    • Esophageal varices without mention of bleeding [I85.00]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Reflux esophagitis [K21.0]
    • Ulcer of esophagus [K22.10]
    • Ascites, moderate [R18.8]
    • Hypoalbuminemia [E88.09]
  • Prescription
    • Benamine (diphenhydramine 30mg) ST IVD
    • NS 500mL ST IVD
• 2017-01-04 SOAP Gastroenterology Xu RongYuan
  • Diagnosis
    • Cirrhosis of liver without mention of alcohol [K74.69]
    • Esophageal varices without mention of bleeding [I85.00]
    • Reflux esophagitis [K21.0]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Ulcer of esophagus [K22.10]
  • Prescription x3
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Mosad (mosapride citrate 5mg) 1# TID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • propranolol 10mg 1# QD

==========

2024-02-06

[optimizing basal insulin in hyperglycemia management]

Throughout this hospitalization, serum glucose levels in the TPR panel were consistently observed between 200mg/dL and 290mg/dL. It is recommended to increase the daily basal insulin dosage by 2 units to assess potential improvements in glucose management.

700142890

240205

[exam findings]

• 2024-02-02 CT - brain
  • Findings:
    • There are newly developed multiple poor enhancing masses in the liver and one poor enhancing mass in the spleen.
      • Metastases in the liver and spleen is highly suspected.
    • There are several soft tissue lesions in the mesentery and uterine fossa that are c/w local recurrent tumors.
    • There are several enlarged nodes in para-aortic space and para-cava space that are c/w metastatic nodes.
    • S/P colostomy at the sigmoid colon.
    • S/P double J catheter insertion, bilateral urinary tract.
      • However, mild bilateral hydroureteronephrosis are still noted.
  • Impression:
    • Multiple Metastases in the liver and spleen are highly suspected.
    • There are several soft tissue lesions in the mesentery and uterine fossa that are c/w local recurrent tumors.
    • There are several enlarged nodes in para-aortic space and para-cava space that are c/w metastatic nodes.
• 2024-02-02 CXR erect
  • S/p port-A placement with its tip at Superior vena cava
  • Increased pulmonary vasculature is found.
  • Osteopenia of the bony structure is noted.
• 2024-01-12 SONO - nephrology
  • Normal bilateral kidney size
  • Bilateral hydronephrosis, mild degree, s/p double J cathter placement
• 2024-01-01 CT - brain
  • Findings
    • Swelling of left parietal scalp.
    • No midline shift.
    • Lacunar infarcts at bil. basal ganglia.
    • No evidence of intracranial hemorrhage.
    • Intact bony structures.
    • Widening of cortical sulci and dilatation of ventricles.
  • IMP:
    • Swelling of left parietal scalp.
    • Brain atrophy and lacunar infarcts.
• 2023-12-31 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
  • Increased lung markings on both lower lungs are noted. Please correlate with clinical condition.
• 2023-12-12 PET scan
  • Glucose hypermetabolism in the periphery of some focal areas in the left pelvic cavity and midline lower pelvic cavity. Residual malignancy should be watched out. Please correlate with other clinical findings for further evaluation.
  • Multiple glucose hypermetabolic lesions in both lobes of the liver, suggesting multiple liver metastases.
  • Glucose hypermetabolism in some focal areas in the right paraaortic region. Metastatic lymph nodes may show this picture.
  • Glucose hypermetabolism in a foal area in the right anterior pelvic wall. The nature is to be determined (a metastatic lesion? inflammation/infection? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
• 2023-11-20 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Ovary, oophorectomy site unspecified, exploratory laparotomy with debulking tumor surgery (GYN)/ “Oopherectomy, side unspecified (F2023-519)” —- carcinosarcoma, see microscopic description. IHC stain: CK (+, on few minute foci of epithelium-like neoplastic cells), vimentin (diffuse strong + on neoplastic spindle cells and pleomorphic neplastic cells), SMA (-), CD34 (-), CD117 (-), NSE (-). Also present, benign mucinous cyst.
    • Sigmoid colon, exploratory laparotomy segmental resection of S-colon (end-colostomy) (S2023-13174A) — No residual tumor involvement. Two benign peri-clonic lymph nodes
    • Plevic tumor, excision (S2023-13174B) — Tumor invlovement.
    • pT2b, at least; pNX (if cM0); FIGO Stage: IIB, at least.
  • MACROSCOPIC EXAMINATION:
    • Procedure (select all that apply) exploratory laparotomy with debulking tumor surgery (GYN)/ “Oopherectomy, side unspecified(F2023-519)” + exploratory laparotomy segmental resection of S-colon (end-colostomy) (S2023-13174A) + pelvic tumor excision (S2023-13174B).
      • Pleurocentesis (pleural fluid)
    • Specimen size
      • Labled as “ovary site unspcified”: 1550 gms; 16 x 10 x 10 cm. Partially encapsulated.
    • Specimen Integrity
      • Specimen Integrity of unspcified Ovary (if applicable)
      • Specimen Integrity of Fallopian Tubes (if applicable)- not identified.
    • Tumor Site: (Note: Please select the primary tumor site only)
      • unspecified ovary (F2023-519FS)
      • pelvic tumor (S2023-23174B)
    • Ovarian Surface Involvement - Present
    • Fallopian Tube Surface Involvement (required only if applicable) - not applicable
    • Tumor Size : 16 x 10 x 10 cm. (Note: For bilateral tumors, please report maximum dimension for each primary tumor, specifying by laterality.)
      • Greatest dimension (centimeters): 16 cm
    • Additional dimensions (centimeters): 10 x 10 cm
    • Pelvic tumor (S2023-23174B): 2 pieces, 2.5 x 2.0 x 0.5 cm.
    • Sections are taken and labeled as: Tissue for frozen section: F2023-00519FSA1-3: ovarian tumor. Tissue for formalin fixation: F2023-519A1-5: ovarian tumor; A6: non-malignant ovary. S2023-23174A sigmoid colon; A1: bilateral cut ends; A2-4: sigmoid colon; A5-7: pericolonic tissue; B: “pelvic tumor”.
  • MICROSCOPIC EXAMINATION:
    • Histologic type: carcinosarcoma
    • Histologic grade: high grade
    • Contralateral ovary involvement: no tissue received
    • Tumor side ovarian surface involvement: present
    • Contralateral ovary surface involvement: no tissue received
    • Right tube involvement: no tissue received
      
    • Left tube involvement: no tissue received
    • In situ adenocarcinoma in right and/or left fallopian tube: no tissue received
    • Right adnexa soft tissue involvement: no tissue received
    • Left adnexa soft tissue involvement: no tissue received
    • Pelvic soft tissue involvement: present (sigmoid colon)
    • Uterine serosa involvement: non-applicable (if no uterus received)
    • Omentum involvement: not received
    • Uterine Cervix involvement: not received
    • Endometrium involvement: not received
    • Myometrium involvement: not received
    • Appendix involvement: not received
    • Largest Extrapelvic Peritoneal Focus (required only if applicable)
      • pelvic tumor (S2023-23174B): 2.5 x 2.0 x 0.5 cm
    • Regional Lymph Nodes: no tissue received
    • Other organs or specimens involvement: S2023-20163 Colorectum, recto-sigmoid junction, (clinically: huge pelvic mass), biopsy — carcinoma, poorly differentiated.
      • IHC stains: CK7 (+); CK20 (-): dis-favor colorectal or gastric primary adenocarcinoma, PAX-8 (-): dis-favor endometrial or ovarian adenocarcinoma; CD3 and CD20: no predomkinant sub-population, dis-favor lymphoma.
      • Additional IHC stains: CK7 (+), Napsin-A (-) and TTF-1 (-) (for pulmonary adenocarcinoma), GATA-3 (-) (for breast carcinoma), CD56 (-) (for neuroendocrine carcinoma), calretinin (-) (for mesothelioma), CK5/6 (-) and p40 (-) (for squamous cell carcinoma).
• 2023-11-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (63 - 25) / 63 = 60.32%
    • M-mode (Teichholz) = 60
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Mild MR and trivial TR
    • Borderline pulmonary hypertension
    • LV diastolic dysfunction. Gr 1
    • Preserved RV systolic function
    • Sinus tachycardia with HR 111 at the exam
• 2023-11-09 CT - abdomen
  • A large mass (14.5 x 14.5 x 16.9 cm) at lower abdomen with solid/ cystic parts and colon invasion. Another tumors (2.9cm, 4.3cm) at left pelvic cavity.
    • DDX: GYN tumor with colon invasion, colon cancer with uterus invasion.
  • Mild right hydronephrosis.
• 2023-11-01 Patho - colon biopsy
  • Colorectum, recto-sigmoid junction, (clinically: huge pelvic mass), biopsy — carcinoma, poorly differentiated.
  • IHC stains: CK7 (+); CK20 (-): dis-favor colorectal or gastric primary adenocarcinoma, PAX-8 (-): dis-favor endometrial or ovarian adenocarcinoma; CD3 and CD20: no predomkinant sub-population, dis-favor lymphoma.
    • An addendum report of additional IHC stains: Napsin-A and TTF-1 (for pulmonary adenocarcinoma), GATA-3 (for breast carcinoma), CD56 (for neuroendocrine carcinoma), calretinin (for mesothelioma) will be followed.
• 2023-10-31 Gynecologic ultrasonography
  • R/O Huge plevis mass: 170 x 129 mm (papillary: 95 x 75 mm) , no blood flow , Asites(-)
• 2023-10-31 SONO - abdomen
  • Findings
    • An at least 15.7 cm cystic lesion with an adjucent 8 cm heterechoic lesion at lower abdomen
  • Diagnosis:
    • Rule out abdominal cystic tumor with solid part, lower abdomen, rule out distended urinary bladder
• 2023-10-31 EGD
  • Reflux esophagitis LA Classification grade A (minimal)
  • Superficial gastritis
  • Gastric erosion, antrum
• 2023-10-30 MRI - L-spine
  • Presence of spondylolisthesis at L4/5, grade I.
  • There shows no evidence of significant spinal canal stenosis.
  • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression.
  • Abnormal multiple enlarged left paraaortic and iliac chain LAPs?
  • Abnormal distension of urinary bladder or a large ovarian cyst/CA? Suggest check low abdomen/pelvic CT.
• 2023-10-16 KUB
  • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.

[MedRec]

• 2023-11-19 ~ 2023-11-29 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Huge tumor lesion at low abdomen and pelvic involving rectosigmoid colon, ovary, urinary bladder and right hydronephrosis status post debulking tumor surgery and segmental resection of sigmoid colon (end-colostomy) on 2023/11/20.
    • diabetes mellitus
    • hyperlipidemia
    • Essential (primary) hypertension
  • CC
    • Abdominal distention with one palpable mass over lower abdomen area noted one month ago       
  • Present illness
    • This 69-year-old, G3P2AA1 woman had medical history of 1. Hypertension 2. DM 3. Dyslipidemia. She received hysterectomy 30 years ago due to huge myoma.
    • She had abdominal distention with one palpable mass over lower abdomen area noted one month ago. Body weight loss as 8 kg in the recent few months and decreased appetite was noted. She also mentioned frequent passage of little stool, blood streak in stool. Bilateral legs pitting edema 3-4+ was also noted. There was no fever, dyspnea, vaginal bleeding or other specific discomfort. Hence the patient visited GI OPD for further evaluation and management.
    • PES showed gastritis and GERD. Colonoscopy showed colon tumor, suspcious metastasis in rectosigmoid junction, biopsy was done and pathology showed carcinoma, poorly differentiated. She was then transferred to GYN OPD.
    • TVUS showed R/O Huge plevis mass, 170 x 129 mm (papillary: 95x75mm).
    • CT showed a large mass (14.5 x 14.5 x 16.9 cm) at lower abdomen with solid/ cystic parts and colon invasion. Another tumors (2.9cm, 4.3cm) at left pelvic cavity. DDX: GYN tumor with colon invasion, colon cancer with uterus invasion. Mild right hydronephrosis was also found.
    • After well explained and discussion with patient, she decided to accepted operation and admitted to our ward on 2023/11/19. On arrival, the vital signs were stable, Blood test showed Hgb level as 9.1 g/dL (ANEMIA), WBC level as 18290 and albumin level as 3.1 g/dL. We arranged preoperative evaluation and preparation. The CA125 level was 36.1, the CEA level was 4.23 and the CA153 level was 18.4.        
  • Course of inpatient treatment
    • After admission with ward routine and blood examination were done. Operation of DJ insertion, debulking tumor surgery, and segmental resection of sigmoid colon (end-colostomy) werer performed on 2023/11/20. NPO and IV fluids support. The wound healing well and no erythema change. The colonstomy was inatct and no infectino sign. Chewing cookies, toast, rice with gum was started at op day. No nausea and no vomiting, flatus passage thorough colostomy. On low residual diet was started at post-op day 1.
    • We treated her hypokalemia with intravenous KCl then taper to oral const K QID with spirolactone. Well bowel movement and stools passage with diet well tolerated. No fever and no complication. Removal of JP drain at post-op day 7 and 8. Removal of central venous catheter on post-op day 8. Discharged in general condition stable on 2023/11/29 and will follow up in our out-patient department next week.
  • Discharge prescription
    • Spiron (spironolactone 25mg) 1# QN
    • MgO 250mg 1# TID
    • Const-K (KCl 750mg/10mEq) 1# QID
    • Ceficin (cefixime 100mg) 2# BID
    • carvedilol 6.25mg 1# BID hold if HR < 60
    • Nincort Oral Gel (triamcinolone 1mg/gm) BID TOPI
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • OxyNorm (oxycodone 5mg) 1# PRNQ6H if pain couldn’t tolerate with tramacet.
• 2023-11-01 SOAP Gastroenterology Li ZhongXian
  • Prescription x3
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Uretropic (furosemide 40mg) 1# PRNQD
    • Through (sennoside 12mg) 1# HS

[surgical operation]

• 2023-10-20
  • Surgery
    • Exp. Lap with debulking tumor surgery (GYN) and segmental resection of S-colon (end-colostomy) on 2023-11-20     
  • Finding
    • Huge tumor lesion at low abdomen and pelvis with irregular ulcerative tumor massess involving whole pelvic wall, RS-colon, ovary, posterior urinary bladder and left common iliac vessels, causing tumor unresectable!
    • A big perforated hole(3cm in size was found at upper rectum after GYN Dr removal of the relatively cystic part of the huge tumor. Some liquid stool seepage from the hole was noted. Much normal saline irrigation and rectal wash was done.
    • The perforated hole can not be repaired due to a locally cancer invasion. Segmental resection of S-colon with end S-colostomy was done smoothly (Hartmann)
    • Two drains in pelvic floor and rectum.
• 2023-11-20
  • Surgery
    • Diagnosis: Pelvic mass, r/o malignancy
    • Operation: Oopherectomy, side unspecified   - Finding
    • Subumbilical midline vertical skin incision
    • Uterus: status post hysterectomy, invisible
    • Adnexa: a huge pelvic mass with solid part, about 25 X 15 cm in size, tense adhesion with the bladder, bowel and pelvic wall
    • CDS & pelvic wall: occupied with tumor cells
    • Ascites: scanty
    • Bilateral pelvic lymph nodes: not examined
    • Bowel: rectum rupture noted during surgery; status post colonostomy
    • Many residual tumors (+)
    • Estimated blood loss: 250 mL
    • Blood transfusion: nil
    • Complication: nil  

[chemotherapy]

• 2023-12-29 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 1000mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-02-05

[hyperglycemia and leukocytosis: a cortisol connection?]

Lab results:

• 2024-02-05 Cortisol 41.21 ug/dL
  
• 2024-02-05 Neutrophil 99.1 %
  
• 2024-02-05 WBC 49.03 x10^3/uL
  
• 2024-02-05 HGB 8.7 g/dL
  
• 2024-02-05 PLT 464 *10^3/uL
  
• 2024-02-05 ALT 46 U/L
  
• 2024-02-05 Bilirubin direct 0.47 mg/dL
  
• 2024-02-05 Alkaline phosphatase 1193 U/L
  
• 2024-02-05 CRP 37.7 mg/dL
  
• 2024-02-05 Procalcitonin (PCT) 2.15 ng/mL

Since 2024-02-04, hyperglycemia was noted in the TPR panel, accompanied by a right-shifted leukocytosis with a predominance of neutrophils, as confirmed by lab results on 2024-02-05. These findings could be secondary to hypercortisolism, recorded at 41 ug/dL, necessitating further investigation to determine the underlying cause, which could include adrenocortical carcinoma or Cushing’s syndrome. Evaluation of ACTH levels could provide more information to form insights.

2024-01-08

[hypokalemia]

The patient has had persistent hypokalemia since 2024-01-01. A single dose of 4 units of regular insulin was administered on 2023-12-31. No further insulin injections have been given since then. She has been receiving “0.298% KCl in 0.9% NaCl 500mL IVD BID” for a week. This delivers 40mEq of potassium daily, equivalent to 4 tablets of Const-K (750mg, 10mEq). Despite this, the serum potassium level remains low. Therefore, a gradual increase in the daily potassium supplementation may be necessary.

• 2024-01-08 K(Potassium) 2.1 mmol/L
• 2024-01-05 K(Potassium) 2.3 mmol/L
• 2024-01-04 K(Potassium) 2.1 mmol/L
• 2024-01-03 K(Potassium) 1.9 mmol/L
• 2024-01-02 K(Potassium) 2.4 mmol/L
• 2024-01-02 K(Potassium) 2.0 mmol/L
• 2024-01-02 K(Potassium) 1.8 mmol/L
• 2024-01-02 K(Potassium) 2.1 mmol/L
• 2024-01-01 K(Potassium) 2.1 mmol/L
• 2023-12-30 K(Potassium) 4.1 mmol/L

Low magnesium (1.7mg/dL on 2024-01-05) can independently cause the kidneys to waste potassium through the urine. This likely involves an increase in potassium channels that allow potassium to exit the body. Providing appropriate magnesium supplements could be helpful.

700540670

240205

[MedRec]

• 2018-10-04 ~ 2018-10-08 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • L03.116 - Cellulitis of left lower limb
    • C56.9- Ovarian cancer adenocarcinoma pT3bN1M0 stage IIIb
  • CC
    • Left thigh swelling, redness with pain
  • Present illness
    • The 64 year old woman past historyv had has (1) Thyroid tumor, multinodular goiter status post total thyroidectomy on 2011/12/12 (2) Hypothyroidism under medication (Thyroxine) control (3) DM (4) hyperlipidemia under medication (Vytorin) control (5) ovarian cancer adenocarcinoma pT3bN1M0 stage IIIb, status post debulking surgery (ATH + BSO + Cytoreduction surgery + infracolic omentectomy) on 2015/08/26.
    • She was diagnosed cellulitis of left thigh since from 2018/02/08. In infection outpatient department Dr Peng given Penicillin G 2.4MU/4mL/syringe IM (2018/04/25, 05/23, 06/20, 07/18, 08/15, 09/02). Pelvis CT showed status post operation, no evidence of tumor recurrence on 2018/06/06. we reviewed laboratory finded CRP (0.52mg/dL -> 0.13mg/dL -> 0.87mg/dL) on 2018/10/04.
    • This time, she was complained left thigh swelling, redness with pain (VAS 2/10) on 2018/10/04, she came to our Emergency room for help, she was denied fever and sweating, Laboratory showed CRP:0.87 mg/dL elevation, they given her Oxacillin 2g IVD Q6H then left thigh redness rapid improved. Now she was admitted for further evalaution and managment.
  • Course of inpatient treatment
    • After admission, she accept antibiotics treatment oxacillin 2gm IVD Q6H, during antibiotics treatment, she’s left thigh redness with pain improve. Under the stable condition, discharge the patient and OPD follow.
  • Discharge prescription
    • Diclocin (dicloxacillin 250mg) 2# Q6H
    • Allegra (fexofenadine 60mg) 1# BID
    • Through (sennosides 12mg) 1# HS

700371314

240202

[Lab data]

2023-10-05 BM Cytogenetics Lab Report

• Chromosome Analysis
  • Tissue Examined: Bone marrow
  • Staining Method: G-Banding
  • Colony number: NA
  • Bands level: 400
  • Chromosome Counts: 45-(5)、46-(15)、47-()、Other-() Total-(20)
  • Karyotype: 46,XY[15]
• Interpretation:
  • Analysis of this bone marrow sample shows a male having 46,XY[15] karyotype. There was no significant clonal chromosomal abnormality detected. However, from 20 cells analyzed, five cells with abnormal karyotypes [45,X,-Y; 45,XY,-7; 45,XY,-8; 45,XY,-13 and 45,XY,-18, respectively] were observed. No clinical significance can be ascribed to these non-clonal findings at the present time.
• Note
  • ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

2023-08-30 Anti-HBc Nonreactive
2023-08-30 Anti-HBc-Value 0.36 S/CO
2023-08-30 Anti-HBs 14.93 mIU/mL
2023-08-30 HBsAg Nonreactive
2023-08-30 HBsAg (Value) 0.39 S/CO
2023-08-30 Anti-HCV Nonreactive
2023-08-30 Anti-HCV Value 0.10 S/CO

[exam findings]

• 2023-12-26 CT - chest
  • Clinical diffuse large B-cell lymphoma.
  • Small right lower lung nodule, stastionary.
  • Post-op at lumbar spine.
• 2023-12-26 CT - neck
  • Negative result.
• 2023-12-25 SONO - neck (lymph node)
  • Prominent musular density in left neck. Suggest clinical correlation.
• 2023-11-13 Nasopharyngoscopy
  • crust over max opening, R otalgia, “mass over R acromion”
• 2023-09-11 Patho - bone marrow biopsy
  • Bone marrow, biopsy — No evidence of large B-cell lymphoma with bone marrow involvement
  • The sections show normocellular marrow (20%). M/E ratio = 4:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. IHC, scattered small CD3+ T-cells and CD20+ B-cells in interstitium without lymphoid aggregates.There is no evidence of large B-cell lymphoma with bone marrow involvement can be identified in the sections examined.
• 2023-09-07 MRI - larynx
  • Indication: Right maxillary Diffuse large B-cell lymphoma, Immunohistochemistry shows Bcl-2(+),Bcl-6(+), c-myc(weakly +, 10%) and MUM-1(+)
  • Findings
    • Severe mucosal thickening and air-fluid level in right maxillary sinus, indicating sinusitis.
    • A cyst-like lesion, about 35 mm x 30 mm x 7 mm, with air-fluid level inside and rim enhancement at right posterior cervical space, associating with diffuse faint enhancement in surrounding soft tissue. C/W abscess formation.
    • Multiple lymph nodes at both sides of the neck, with larger ones at right retropharyngeal region (20 mm) and left level II (15 mm).
    • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
    • No abnormality at parotid, submandibular and sublingual glands.
  • IMP:
    • Right maxillary sinusitis. Abscess formation at right posterior cervical space. Enlarged lymph nodes at right retropharyngeal region and left level II.
• 2023-09-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 27) / 108 = 75.00%
    • M-mode (Teichholz) = 75
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Concentric LVH; LV diastolic dysfunction, Gr 1
    • Mild MR and trivial TR
    • Preserved RV systolic function
• 2023-09-07 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 60 dB HL, LE 40 dB HL
    • R’t normal to severe SNHL
    • L’t normal to moderately severe SNHL
• 2023-08-30 CT - abdomen
  • History: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck s/p Neck LND
  • Prior CT identified hemangioma 1.58 cm in S5 of the liver is noted again, decreasing in size to 1.28 cm and blurring of the tumor border. Follow up is indicated.
• 2023-08-21 Patho - lymph node region resection
  • PATHOLOGIC DIAGNOSIS
    • Right paranasal sinuses, multiple sinusectomy — Chronic rhinosinusitis
    • Tumor, R’t maxillary sinus, excision — Diffuse large B-cell lymphoma
      
    • Nasopharynx, R’t, biopsy — Chronic inflammation
    • R’t neck level 3 LNs, dissection — Negative for malignancy (0/2)
    • R’t neck level IIa, IIb, Va and tumor, wide excision — Diffuse large B-cell lymphoma
      • Vessel, IJV, ditto — Free of tumor invasion
      • SCM Muscle, ditto — Free of tumor invasion
        
    • R’t neck level Ib LN, dissection — Fat only
    • R’t retropharyngeal lymph node, ditto — Nerve ganglia and one tiny lymph node
  • MACROSCOPIC DESCRIPTION
    • Operation procedure: neck dissection + multiple sinusectomy + wide excision + biopsy
    • Main location: (A) R’t neck and (B) R’t maxillary sinus
    • Specimen Size: (A) R’t neck level IIa, IIb, Va and tumor: 6.3 x 5.2 x 4.5 cm and SCM muscle 5.3 x 3.7 x 3.3 cm (B) R’t maxillary sinus: 2 x 1.5 x 0.7 cm
    • Tumor Site: (A) R’t neck and (B) R’t maxillary sinus
    • Tumor Size: (A) R’t neck: multiple, up to 4.7 cm and (B) R’t maxillary sinus: one piece, 2 x 1.5 x 0.7 cm
    • Right paranasal sinus: multiple small pieces, up to 1.3 x 0.7 x 0.6 cm
    • Nasopharynx: 2 small pieces, up to 0.4 x 0.3 x 0.2 cm
    • R’t retropharyngeal lymph node: 1.9 x 0.9 cm
    • Representative sections as A: R’t paranasal sinuses, B: R’t maxillary tumor, C: nasopharynx, D: R’t neck level III LNs, E1-E3: IJV, E4-E13: main tumor, E14-E18: SCM muscle, F: R’t neck level Ib LN and G: R’t retropharyngeal lymph node
  • MICROSCOPIC EXAMINATION
    • R’t neck level IIa, IIb, Va and tumor: diffuse large B-cell lymphoma shows diffusely large atypical lymphoid cells with prominent nucleoli. Immunohistochemistry shows CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), c-myc(weakly +, 10%), Ki-67(80-90%), CK(-) and MUM-1(+) for tumor, indicates a case of diffuse large B-cell lymphoma, non-germinal center B cell subtype. Besides, IJV and SCM muscle are free of tumor invasion as well as 18 reactive lymph nodes
    • Right paranasal sinuses: chronic rhinosinusitis and bone
    • Tumor at R’t maxillary sinus: diffuse large B-cell lymphoma
      
    • R’t nasopharynx: chronic inflammation
    • R’t neck level 3 LNs: negative for malignancy (0/2)
    • R’t neck level Ib LN: fat only
    • R’t retropharyngeal lymph node: nerve ganglia and one tiny benign lymph node at peripheral fat tissue
• 2023-08-08 PET
  • A prominent glucose hypermetabolic lesion in the right maxillary sinus. Primary malignancy in this region should be watched out. Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in a right retropharyngeal lymph node and in some right neck level II lymph nodes. Metastatic lymph nodes may show this picture.
  • Glucose hypermetabolism in the left pulmonary hilar lymph nodes. Inflammatory process is more likely. Howver, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Mild hypermetabolism in some mediastinal and right pulmonary hilar lymph nodes. Inflammation may show this picture.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiologcal FDG accumulation may show this picture.
• 2023-07-31 CT - neck
  • Multiple enlarged right posterior neck LAPs, up to 4.7 cm.
  • No obvious nasopharynx, hypopharynx or larynx mass.
  • Relative prominent right tonsil?
  • Suggest clinical correlation.
• 2022-05-02 CT - abdomen
  • History: 20220414 Sono abd: Moderate fatty liver with fat sparing area; Hepatic lesion, r/o hemangioma, S5/6; Renal stone, right
  • Findings
    • Abdominal CT with and without enhancement revealed:
    • Hypervascular hepatic tumor at S5 of liver about 1.58cm in largest dimension is found.
    • Two subpleural nodules are found at right lower lobe about 0.3cm and right middle lobe about 0.28cm in largest dimension is found.
  • Imp:
    • Hepatic hemangiomas.
    • Subpleural nodules at right lung. Suggest follow up.
• 2022-04-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 29) / 89 = 67.42%
    • M-mode (Teichholz) = 67.1
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Trivial TR
• 2021-12-03 Neck soft tissue
  • Osteoporosis. Loss of nature lordotic curve. Spondylosis, esp C4-5-6.

[MedRec]

• 2023-09-06 ~ 2023-09-28 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Right maxillary Diffuse large B-cell lymphoma, Immunohistochemistry shows Bcl-2(+), Bcl-6(+), c-myc(weakly +, 10%) and MUM-1(+) s/p chemotherapy with R-DA-EPOCH (Rituximab 375mg, D1, Etoposide 50mg/m2 + Doxorubicin 10mg/m2 + Vincristine 0.4mg/m2 D2~D5, Prednisone 60mg/m2 po D1~D5, Cyclophosphamide 750mg/m2 D6) from 2023/09/18~
    • Essential (primary) hypertension
    • Insomnia, unspecified
    • Herpes Zoster at the L3~L4
    • Constipation, unspecified
  • CC
    • For diffuse large B-cell lymphoma study and chemotherapy with R-DA-EPOCH (C1).
  • Present illness
    • This 64-year-old man patient suffered from hoarseness in 2022/09. He had been to our ENT OPD for check up, where vocal atrophy was told. Right neck palpable mass noted in 2023/07, he came to our ENT OPD foe help. At our Ent OPD, fiberscope revealed bulggin of right lateral pharyngeal wall, right tonsillar asymmetric hypertrophy with granular surface, biopsy was done; right neck level II a 4cm mass without tenderness.
    • The pathology revealed suspicious malignancy, we arrange a series of image survey. No chills with fever, night sweat and body weight loss was noted. Neck CT on 2023/07/31 which revealed multiple enlarged right posterior neck LAPs, up to 4.7 cm. Whole body PET scan on 2023/08/08 revealed right maxillary sinus of primary malignancy with right retropharyngeal lymph node and in some right neck level II lymph nodes metastatic.
    • Modified Radical neck dissection, right, type II, excision of maxillary sinus tumor, right, multiple sinusectomy, right, navigation-guided endoscopic sinus surgery, nasopharyngeal biopsy, right and sinoscopy on 2023/08/18 and right maxillary sinus excision patholoy showed Diffuse large B-cell lymphoma, Immunohistochemistry shows CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), c-myc(weakly +, 10%), Ki-67(80-90%), CK(-) and MUM-1(+) for tumor, indicates a case of diffuse large B-cell lymphoma, non-germinal center B cell subtype. Besides, IJV and SCM muscle are free of tumor invasion as well as 18 reactive lymph nodes.
    • Abdominal CT on 2023/08/30 showed prior CT identified hemangioma 1.58 cm in S5 of the liver is noted again, decreasing in size to 1.28 cm and blurring of the tumor border. Body weight loss 3kg(80 -> 77kg) for 1 month from 2023/08~2023/09.
    • Now, he was admitted to ward for diffuse large B-cell lymphoma study and prepare chemotherapy with R-DA-EPOCH (C1).
  • Course of inpatient treatment
    • After admitted, Port-A catheter insertion on 2023/09/06. Larynx MRI on 2023/09/07 showed right maxillary sinusitis. Abscess formation at right posterior cervical space, enlarged lymph nodes at right retropharyngeal region and left level II.
    • PTA on 2023/09/07 showed R’t normal to severe SNHL and L’t normal to moderately severe SNHL.
    • 2D echo on 2023/09/07 showed M-mode(Teichholz) = 75, 1. Adequate LV systolic function with normal resting wall motion 2. Concentric LVH; LV diastolic dysfunction, Gr 1 3. Mild MR and trivial TR 4. Preserved RV systolic function.
    • Check 24hrs CCr. on 2023/09/07 showed 103.5 mL/min.
    • Ultracet 0.5# po Q6H for pain control.
    • Allegra 1# po BID and Mycomb cream BID use for neck skin redness rash.
    • Bone marrow study on 2023/09/11 showed no evidence of large B-cell lymphoma with bone marrow involvement.
    • Chemotherapy with R-DA-EPOCH (Rituximab 375mg, D1, Etoposide 50mg/m2 + Doxorubicin 10mg/m2 + Vincristine 0.4mg/m2 D2~D5, Prednisone 60mg/m2 po D1~D5, Cyclophosphamide 750mg/m2 D6)(C1) from 2023/09/18~2023/09/23.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • Lenograstim 250mcg SC QD from D7 2023/09/24~2023/09/28, 2023/09/29, 2023/10/01.
    • Insomnia with Eurodin 0.5# po HS.
    • Herpes Zoster at the L3~L4 (rigth lower back skin redness rash 6cm–improving) with Valaciclovir 500mg 2# po TID from 2023/09/07~2023/09/18 and Acyclovir cream(self pay) TID TOPI use from 2023/09/07~2023/09/28.
    • Constipation with Sennoside 2# po HS, MgO 2# po Q6H and Bisadyl supp 1pill RECT PRNQD.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/09/28 and OPD followed up later.
  • Discharge prescription
    • Eurodin (estazolam 2mg) 0.5# HS
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# PRNQ6H
    • Bisadyl supp (bisacodyl 10mg) 1# PRNQD
    • Ulstop (famotidine 20mg) 1# BID
    • Through (sennoside 12mg) 2# HS
    • MgO 250mg 2# Q6H
    • Acetal (acetaminophen 500mg) 1# Q6H
    • Granocyte (lenograstim 250ug) SC on 2023-09-29 and 2023-10-01
• 2023-08-29 SOAP Hemato-Oncology Xia HeXiong
  • P
    • Regimen, R-DA-EPOCH
    • Admission for Chest/Abd/Pelvis CT and H&N MRI, BM study (A+B+C), Heart Echo, 24 hours CCr and Audiometry
    • Port-A insertion by CS Chief Hsieh
• 2023-08-18 ~ 2023-08-23 POMR Ear Nose Throat Su WanYu
  • Discharge diagnosis
    • Right neck mass status post right neck dissection on 2023-08-18.
    • Right maxillary sinus benign tumor status post navigation guide endoscopic sinus surgery on 2023-08-18.(8/24 patho: Diffuse large B-cell lymphoma)
    • Enlarged prostate without lower urinary tract symptoms
    • Localized enlarged lymph nodes
  • CC
    • Hoarseness over 6 months, right neck palpable mass noted for 3 weeks.
  • Present illness
    • This 64-year-old man denied of having chronic disease before. The patient suffered from hoarseness for over 6 months. He had been to our ENT OPD for check up, where vocal atrophy was told. Due to right neck palpable mass noted for 3 weeks, he came to our ENT OPD foe help. At our Ent OPD, fiberscope revealed bulggin of right lateral pharyngeal wall, right tonsillar asymmetric hypertrophy with granular surface, biopsy was done; right neck level II a 4cm mass without tenderness.
    • The pathology revealed suspicious malignancy, we arrange a series of image survey. The neck CT on 2023-07-31 which revealed multiple enlarged right posterior neck LAPs, up to 4.7 cm.
    • The whole body PET scan revealed: 1. A prominent glucose hypermetabolic lesion in the right maxillary sinus. Primary malignancy in this region should be watched out. 2. Glucose hypermetabolism in a right retropharyngeal lymph node and in some right neck level II lymph nodes. Metastatic lymph nodes may show this picture.
    • Under the impression of right nasal lesion, right neck mass and right oropharyngeal lesion suspect malignancy, surgery of right neck dissection, nasopharyngeal lesion biopsy and right tonsillectomy for tissue prof were suggested. After well explanation about the surgical details, he was admitted for the operation.
  • Course of inpatient treatment
    • After admission, pre-op evaluation was done. The patient underwent the operation of right neck dissection, right maxillary sinus tumor excision, right multiple sinusectomy and right nasopharyngeal biopsy. The whole procedure prformed smoothly, and the patient tolerated the whole procedure well. Post the operation, a hemo-vac drain tube was placed. Neck wound covered with steri-stip.
    • Prophylatic antibiotic with cephalexin 1# po q6h, pain control with Acetal 1# po q6h, anti-cough with Medicon-A 1# po tid. Under daily wound care and medication treatment, the hemo-vac drainage amount decrease day by day. The hemo-vac drainage tube was removed on post op day-5.
    • There was no wound infection or wound active bleeding noted.The surgical pathology was pending. Under relative stable condition, he was discharge today with OPD follow up.
  • Discharge prescription
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# QID
    • cephalexin 500mg 1# QID
    • Allegra (fexofenadine 60mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# QID
• 2022-04-28 SOAP Gastroenterology Li ZhongXian
  • Prescription x3
    • Dexilant (dexlansoprazole 60mg) 1# QD
• 2022-04-26 SOAP Cardiology Liu GuanLiang
  • Prescription x3
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 0.5# QD

[consultation]

• 2023-12-28 Orthopedics
  • Q
    • For mass behind right shoulder, nature??
    • This 64-year-old man patient suffered from hoarseness in 2022/09. He had been to our ENT OPD for check up, where vocal atrophy was told. Right neck palpable mass noted in 2023/07, he came to our ENT OPD foe help. At our Ent OPD, fiberscope revealed bulggin of right lateral pharyngeal wall, right tonsillar asymmetric hypertrophy with granular surface, biopsy was done; right neck level II a 4cm mass without tenderness.
    • The pathology revealed suspicious malignancy, we arrange a series of image survey. No chills with fever, night sweat and body weight loss was noted.
    • Neck CT on 2023/07/31 which revealed multiple enlarged right posterior neck LAPs, up to 4.7 cm. Whole body PET scan on 2023/08/08 revealed right maxillary sinus of primary malignancy with right retropharyngeal lymph node and in some right neck level II lymph nodes metastatic.
    • Modified Radical neck dissection, right, type II, excision of maxillary sinus tumor, right, multiple sinusectomy, right, navigation-guided endoscopic sinus surgery, nasopharyngeal biopsy, right and sinoscopy on 2023/08/18 and right maxillary sinus excision patholoy showed Diffuse large B-cell lymphoma, Immunohistochemistry shows CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), c-myc(weakly +, 10%), Ki-67(80-90%), CK(-) and MUM-1(+) for tumor, indicates a case of diffuse large B-cell lymphoma, non-germinal center B cell subtype. Besides, IJV and SCM muscle are free of tumor invasion as well as 18 reactive lymph nodes.
    • Abdominal CT on 2023/08/30 showed prior CT identified hemangioma 1.58 cm in S5 of the liver is noted again, decreasing in size to 1.28 cm and blurring of the tumor border. Body weight loss 3kg (80 -> 77kg) for 1 month from 2023/08~2023/09.
    • Port-A catheter insertion on 2023/09/06. Larynx MRI on 2023/09/07 showed right maxillary sinusitis. Abscess formation at right posterior cervical space, enlarged lymph nodes at right retropharyngeal region and left level II.
    • PTA on 2023/09/07 showed R’t normal to severe SNHL and L’t normal to moderately severe SNHL.
    • 2D echo on 2023/09/07 showed M-mode(Teichholz) = 75, 1. Adequate LV systolic function with normal resting wall motion 2. Concentric LVH; LV diastolic dysfunction, Gr 1 3. Mild MR and trivial TR 4. Preserved RV systolic function.
    • Check 24hrs CCr. on 2023/09/07 showed 103.5 mL/min.
    • Hold chemotherapy with Herpes Zoster at the L3~L4 (rigth lower back skin redness rash 6cm - improving) with Valaciclovir 500mg 2# po TID from 2023/09/07~2023/09/18 and Acyclovir cream (self pay) TID TOPI use from 2023/09/07~2023/09/28.
    • Bone marrow study on 2023/09/11 showed no evidence of large B-cell lymphoma with bone marrow involvement.
    • Chemotherapy with R-DA-EPOCH (Rituximab 375mg, D1, Etoposide 50mg/m2 + Doxorubicin 10mg/m2 + Vincristine 0.4mg/m2 D2~D5, Prednisone 60mg/m2 po D1~D5, Cyclophosphamide 750mg/m2 D6) (C1 from 2023/09/18~2023/09/23, C2 on 2023/11/1, C3 on 2023/11/23). Now, he was admitted for chemotherapy with R-DA-EPOCH (C4).
    • We sincerely need your professional assistance!!
  • A
    • Dx: Diffuse large B-cell lymphoma
    • PE:
      • right shoulder bony prominence over the right superior border of scapular, nontender (discovered soon after the surgery)
      • ROM: intact
      • No skin lesions
    • CXR: No bony lesion over the scapular or clavile
    • CT: no visible bony lesion, osteolytic lesion over the CT
    • Plan:
      • Arrange OPD f/u at ORTH OPD
      • Active survillance, may arrange imaging again if persisited symptoms or enlargement
      • Conservative treatment with symptomatic treatment

[surgical operation]

• 2023-08-18
  • Surgery
    • Modified Radical neck dissection, right, type II
    • Excision of maxillary sinus tumor, right
    • Multiple sinusectomy, right
    • Navigation-guided endoscopic sinus surgery
    • Nasopharyngeal biopsy, right
    • Sinoscopy
  • Finding
    • tumor over Right maxillary sinus
    • NP biopsy, right
    • huge neck mass with adheion to internal jugular vein and SCM muscle (unkown primary neck cancer? Occult metastasis from NPC? primary malignancy was from right maxillary sinus?)
    • Will check EBV and HPV status in the pathological specimen
• 2021-10-12
  • Surgery
    • Arthroscopic rotator cuff repair, acromioplasty + biceps tenodesis        
  • Finding
    • left rotator cuff tear, 3x2 cm, over supraspinatus tendon
    • type II acromion with subacromial spur
    • significant synovitis and bursitis        
    • biceps tendon subluxation with partial tear

[immunochemotherapy]

• 2024-02-01 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
• 2024-01-12 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
• 2023-12-22 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
• 2023-11-23 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
• 2023-11-01 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 50mg/m2 90mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
• 2023-09-18 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 50mg/m2 90mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2

Dose-adjusted R-EPOCH – (da)-R-EPOCH: Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma - 20231006 - https://www.uptodate.com/contents/image?imageKey=ONC%2F88411

• Cycle length: 21 days.
• Regimen
  • Rituximab
    • 375 mg/m2 IV
    • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. In the absence of an initial infusion reaction, for subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count ≥5000/microL.
    • Day 0 or 1
  • Etoposide
    • 50 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Doxorubicin
    • 10 mg/m2 per day IV
    • (together with etoposide)
  • Vincristine
    • 0.4 mg/m2 per day IV (dose not capped)
    • (together with etoposide)
  • Cyclophosphamide
    • 750 mg/m2 IV
    • Dilute with 250 mL NS or D5W and administer over 30 minutes.
    • Day 5
  • Prednisone
    • 60 mg/m2 orally twice daily
    • Administer first dose 30 minutes prior to chemotherapy on day 1.
    • Days 1 to 5
  • Granulocyte colony stimulating factor (G-CSF)
    • Start day 6
• Pretreatment considerations:
  • Hydration
    • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day) and void frequently to reduce risk of hemorrhagic cystitis.
  • Emesis risk
    • MODERATE.
  • Prophylaxis for infusion reactions
    • Premedicate with acetaminophen and diphenhydramine, with or without an H2 receptor blocker, 30 minutes prior to at least the first and second infusions of rituximab.
  • Vesicant/irritant properties
    • Doxorubicin and vincristine are vesicants; avoid extravasation. Etoposide is an irritant.
  • Infection prophylaxis
    • Primary prophylaxis with hematopoietic growth factors is an essential component of this regimen. Regular or pegylated G-CSF may be used according to center policy. In addition, due to the risk of developing Pneumocystis jiroveci pneumonia and other opportunistic infections, consider the use of antimicrobial prophylaxis.
  • Dose adjustment for baseline liver or renal dysfunction
    • Adjustment of initial cyclophosphamide, doxorubicin, etoposide, and vincristine doses may be needed for preexisting liver dysfunction. In addition, dose adjustment of etoposide and cyclophosphamide may be required for renal dysfunction.
  • Hepatitis screening
    • Patients should be screened for hepatitis B and C prior to starting rituximab, and, if positive, considered for antiviral prophylaxis.
  • Cardiac screening
    • Doxorubicin is associated with cardiomyopathy, the incidence of which is related to cumulative dose. Assess baseline LVEF prior to initiation of therapy. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation, those with recent myocardial infarction, severe myocardial dysfunction, severe arrhythmia, or previous therapy with high cumulative doses of doxorubicin or any other anthracyclines.
  • CNS prophylaxis
    • The need for CNS prophylaxis is determined based upon the aggressiveness of the tumor reflected in the histology, organ involvement, and presence or absence of high risk features.
  • HIV screening
    • Patients should be screened for HIV prior to starting therapy. Consider reducing the initial dose of cyclophosphamide to 187 mg/m2 if CD4 <100/microL at diagnosis.
  • Neurotoxicity
    • Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine.
• Monitoring parameters:
  • CBC with differential and platelet count twice weekly during treatment.
  • Assess basic metabolic panel (creatinine and electrolytes) and liver function prior to each subsequent treatment cycle.
  • Monitor cumulative doxorubicin dose. Reassess LVEF periodically during dose-adjusted EPOCH-R therapy, as clinically indicated.
  • Carriers of hepatitis B or C should be monitored for clinical and laboratory signs of active infection during and following completion of therapy. Rituximab should be discontinued if reactivation occurs.
• Suggested dose modifications for toxicity:
  • Myelosuppression
    • Each new cycle should be delayed until ANC is >1000/microL and platelet count is >100,000/microL. Doses of etoposide, doxorubicin, and cyclophosphamide are adjusted based upon the nadir ANC and platelet counts:
      • If nadir ANC ≥500/microL, increase doses by 20% over preceding cycle.
      • If ANC <500/microL on one or two measurements, doses remain the same as preceding cycle.
      • If ANC <500 on ≥3 measurements or platelets <25,000/microL on one measurement, doses reduced by 20% from preceding cycle. Doxorubicin and etoposide doses are not reduced below starting dose.
  • Neuropathy
    • Dose adjustment of vincristine may be necessary if the severity of neuropathy persists or worsens. No specific guidelines are available for dose adjustments.
  • Hepatic dysfunction
    • Dose adjustments of vincristine may be necessary in the setting of liver toxicity.

==========

2024-02-02

Lab results from 2024-01-29 and 2024-02-01, along with vital signs readings in the TPR panel during the current hospital admission, remained predominantly normal. Examination of the HIS5 and PharmaCloud databases disclosed no medication discrepancies.

2024-01-15

[etoposide dose increase back to standard recommended]

If no other issues or reasons for caution are identified, increasing the etoposide dose back to the standard level of 50mg/m2 (from the current 40mg/m2) is recommended.

2023-12-25

[etoposide back to standard? clear coast, time to increase dose]

Recent lab tests (2023-12-22) show no obviously abnormalities.

While the etoposide dose has been reduced since 2023-11-23 (40mg/m2 75mg instead of the standard 50mg/m2 90mg), no adverse reactions of grade 2 or higher have been documented in the latest progress notes (2023-12-06 and current admission). In the event that absence of other concerns or contraindications, it is recommended to increase the etoposide dose back to the standard level.

2023-11-02

The R-DA-EPOCH regimen was initiated on 2023-09-18 (cycle 1) and continued on 2023-11-01 (cycle 2). Lab values for LDH and B2 microglobulin were not particularly elevated at the time of diagnosis with DLBCL and have remained relatively stable, showing no significant changes after administration of one cycle of R-DA-EPOCH.

• 2023-10-27 B2-Microglobulin 2119 ng/mL
  

• 2023-08-31 B2-Microglobulin 1899 ng/mL

• 2023-10-26 LDH 179 U/L
  

• 2023-10-03 LDH 299 U/L
  

• 2023-09-06 LDH 200 U/L

During this hospitalization, the patient received the 2nd cycle of treatment. To date, there are no updated PET/CT imaging results following the initiation of therapy. The WBC DC in early Oct after the first cycle had shown single digit percentages of metamyelocytes, myelocytes, promyelocytes and atypical lymphocytes. However, in the most recent data from 2023-10-26, these numbers have dropped to zero.

WBC DC	2023-09-06	2023-09-18	2023-09-24	2023-09-26	2023-09-28	2023-10-03	2023-10-04	2023-10-09
Band	0.0	0.0	0.0	4.1	0.0	4.5	0.0	2.0
Neutrophil	73.5	54.5	57.2	92.9	80.4	53.9	66.7	59.4
Lymphocyte	16.7	34.6	38.3	2.0	15.7	22.5	18.2	24.7
Monocyte	8.1	7.7	1.0	1.0	1.9	6.7	10.1	9.9
Eosinophil	1.4	3.0	3.5	0.0	0.0	1.1	1.0	0.0
Basophil	0.3	0.2	0.0	0.0	1.0	0.0	0.0	0.0
Metamyelocyte	0.0	0.0	0.0	0.0	1.0	2.2	1.0	2.0
Myelocyte	0.0	0.0	0.0	0.0	0.0	4.5	3.0	2.0
Promyelocyte	0.0	0.0	0.0	0.0	0.0	2.3	0.0	0.0
Atypical Lymphocyte	0.0	0.0	0.0	0.0	0.0	2.3	0.0	0.0

No drug discrepancy is detected.

2023-10-06

No medication inconsistencies were identified in the review of both PharmaCloud and HIS5 records. Prophylactic G-CSF was prescribed after the patient’s first R-DA-EPOCH treatment on 2023-09-18, and only a brief period of leukopenia was observed.

700531243

240201

[exam findings] (not completed)

• 2024-01-15

  • LVEF = (LVEDV - LVESV) / LVEDV = (37 - 13) / 37 = 64.86%
    • LVEF (%) = 64
    • M-mode (Teichholz) = 64
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Mild AR; mild MR; moderate TR.
    • Sinus tachycardia during exam.

• 2024-01-10 MRA - brain

  • Indication: Just receive C/T and discharged on 2024-01-09
    • General weakness, dizziness, vomiting, and left hand weakness started from 2024-01-09
  • Findings
    • mild dilated intraventricular and extraventricular CSF spaces
    • foci with high SI on DWI and low SI on ADC in the bilateral frontal lobes, left temporal lobe and left cerebellar hemisphere
    • some white matter gliosis in the bilateral frontal lobes; old lacunar infarction in the right basal ganglion; mild bilateral periventricular leukoaraiosis.
  • IMP:
    • recent ischemic infarction in the bilateral frontal lobes, left temporal lobe and left cerebellar hemisphere without evidence of acute hemorrhagic transformation.

• 2024-01-10 CT - brain

  • Findings
    • mild dilated intraventricular and extraventricular CSF spaces
    • mild bilateral periventricular leukoaraiosis.
  • IMP
    • no acute intracranial hemorrhage

• 2024-01-03 Ascites tapping

  • Course: 18G needle was inserted at RLQ under echo guided insertion.
  • Findings: 1400ml of yellow ascited were aspirated.

• 2023-12-19 Ascites tapping

  • Course: 18G needle was inserted at RLQ under echo guided insertion.
  • Findings: 600ml of yellow ascites was aspirated.

• 2023-12-05 Ascites tapping

  • Course: 18G needle was inserted at RLQ under echo guided insertion.
  • Findings: 3000ml of yellow ascites were aspirated

• 2023-11-27 Body fluid cytology - asictes

  • 20 cc orange turbid ascites — Positive for malignancy

• 2023-11-27 Ascites tapping

  • Course: 18G needle was inserted at RLQ under echo guided insertion.
  • Findings: 3000 ml light orange color ascites was drained.

• ……….

• 2023-11-01 Patho - peritoneum biopsy

  • Peritoneum, biopsy — Consistent with metastatic ovarian serous adenocarcinoma
  • Specimen submitted in formalin consists of a piece of tan, irregular tissue measuring 1.5 x 1.5 x 0.6 cm. All for section in one cassette.
  • Sections show metastatic adenocarcinoma in fibrous tissue.
    • The immunohistochemical stain reveals PAX8(+). The result is consistent with metastatic ovarian serous adenocarcinoma.

• ……….

• 2023-09-14 Patho - ovary

  • Diagnosis:
    • Ovary, left, salpingo-oophorectomy —- high grade serous adenocarcinoma.
      • IHC stains: p53 (aberrant type), Napsin-A (-), WT-1 (focal +), ER (+, 5%, strong intensity), PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
    • Fallopian tube, left, salpingo-oophorectomy — free
    • if capsule intact during surgery pT1a pNx (if cM0), FIGO stage: IA, at least
    • if capsule ruptured during surgery pT1c1 pNx (if cM0), FIGO stage: IC1, at least
    • if capsule ruptured before surgery pT1c2 pNx (if cM0), FIGO stage: IC2, at least
  • Gross description:
    • Procedure - Left salpingo-oophorectomy: ovary: 11 x 9 x 2.3 cm opened. Tube: 5 x 0.3 x 0.3 cm intact.
    • Specimen Integrity-
      • Specimen Integrity of Right Ovary- no right ovary submitted.
      • Specimen Integrity of Left Ovary -Capsule opened. See comment.
      • Specimen Integrity of Right Fallopian Tube- no right fallopian tube submitted.
      • Specimen Integrity of Left Fallopian Tube- left tube intact
    • Tumor Site: Left ovary
    • Ovarian Surface Involvement- Absent
    • Fallopian Tube Surface Involvement - Absent
    • Tumor Size - Greatest dimension (centimeters): 11 cm
      • Additional dimensions (centimeters): 9 x 3 cm
    • Sections are taken and labeled as: A1: tube; A2: ovarian wall; A3-6: solid part of left ovarian tumor.
  • Microscopic Description:
    • Histologic Type: Serous carcinoma
    • Histologic Grade - High grade
    • Implants (required for advanced stage serous/seromucinous borderline tumors only) - Not applicable
    • Other Tissue/ Organ Involvement (select all that apply): Not applicable
    • Largest Extrapelvic Peritoneal Focus (required only if applicable) - no tissue submitted
    • Peritoneal/Ascitic Fluid - Not submitted
    • Regional Lymph Nodes: No lymph nodes submitted
    • Additional Pathologic Findings - None identified
    • Comment(s) - Please correlate with operation note.

• ……….

[MedRec]

• 2024-01-11 ~ 2024-01-17 POMR Neurology Xu BoRen
  • Discharge diagnosis
    • Multifocal cerebral infarcts involved cerebellum and bilateral cerebral hemisphere, TOAST:4. Specific etiology, suspect cancer type
    • Modified ranking scale 1
    • left ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV, status post Left salpingo-oophorectomy on 2023/09/13 + Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01, immunohistochemical stain reveals PAX8(+)
    • Postprocedural pelvic peritoneal adhesions
    • Reflux esophagitis LA Classification grade A
    • Urinary tract infection (U/C no grew)
  • CC
    • generalized weakness, vertigo, nausea and vomiting with left limbs clumsiness noted since yesterday.
  • Present illness
    • This 68 y/o woman has a history of
      • left ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV, status post Left salpingo-oophorectomy on 2023/09/13 + Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01, immunohistochemical stain reveals PAX8(+)
      • Postprocedural pelvic peritoneal adhesions
      • Reflux esophagitis LA Classification grade
      • Hypokalemia
      • Toxicoderma
      • Acute embolism and thrombosis of unspecified deep veins of right lower extremity under Eliquis 5 mg 1 tab BID.
      • massive ascites S/P abdominal tapping on 2023/11/27, 2023/12/5, 2023/12/19,
      • Cachexia.
    • She had received chemotherapy and was discharged on yesterday. However generalized weakness, vertigo, nausea and vomiting with left limbs clumsiness noted since yesterday. Hence she came to our for help 2024/01/10 afternoon.
    • Conscious remain clear, GCS E4V5M6, CNs: intact, MP: upper 5/4 lower 5/5, mild left dysmetria. NIHSS 000 000 1000 10000 (2).
    • Lab showed hyponatremia (Na 131), elevated D dimer 9414, CA-125 392.8 on 2023/12.
    • Brain CT showed no ICH.
    • Brain MRI showed multifocal cerebral infarcts involved cerebellum and bilateral cerebral hemisphere.
    • Thus she was admitted to our ward for further eveluation.
  • Course of inpatient treatment
    • After admisison, adequate hydration and continuted previous NOAC with Eliquis for DVT history.
    • Empirinic antibiotic with Flumarin day 7 for urinary tract infection, culture no grew.
    • PPI with Nexium for GERD, Hemoptysis since before, n’t progressive, high risk for ulcer.
    • Stroke risk factor survey showed No HTN, DM or Hyperlipidemia.
    • TCD/CCCD showed Increased PI in bilateral MCA, indicating distal stenosis.
    • Adequate total VA flow volume (280 ml/min).
    • 2D echo showed LVEF 64%, Mild AR; mild MR; moderate TR.
    • Sinus tachycardia during exam. Pending 24 hours holter.
    • We also maintenance rehab. program and well tolerance.
    • Only mild left hand clumsiness with weakness.
    • Regular schedule the chemotherapy also done during this admission on 2024/01/16.
    • Under the general condition stable, she is discharge on 2024/01/17 and will be followed up at OPD.
  • Discharge prescription
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Eliquis (apixaban 5mg) 1# BID
    • Eurodin (estazolam 2mg) 0.5# PRNHS if insomnia
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Through (sennoside 12mg) 2# HS
    • Uroprin (phenazopyridine 100mg) 1# TID
    • Durogesic (fentanyl 12ug/h, 2.1mg/patch) 1# Q3D EXT
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • diphenidol 25mg 1# TID
    • morphine 15mg 1# PRNQ6H if pain
• 2023-09-21, -06-15, -03-23, 2022-12-29, -10-06, -07-05, -04-12 SOAP Psychosomatic Medicine Li JiaFu
  • Diagnosis
    • Insomnia, unspecified [G47.00]
    • Anxiety disorder, unspecified [F41.9]
  • Prescription x3
    • Valdoxan (agomelatine 25mg) 1# QN
    • Rivotril (clonazepam 0.5mg) 1# QN
• 2023-09-13 ~ 2023-09-17 POMR Obstetrics and Gynecology Zen LunNa
  • Discharge diagnosis
    • Left ovarain tumor post Left salpingo-oophorectomy on 2023/09/13
    • Abdominal pain
  • CC
    • Lower abdominal pain since two months ago   - Present illness
    • This is a 68 y/o female paitent with the past histories of:
      • Anxiety disorder, unspecified
      • Insomnia, unspecified
      • Senile cataract s/p Intraocular lens on 2022/03/28 amd 2022/06/13
      • Age-related osteoporosis
      • Bilateral primary osteoarthritis of knee
      • Derangement of posterior horn of lateral meniscus due to old tear or injury, right knee
      • Benign neoplasm of liver
    • She has felt lower abdominal pain since the middle of July. She first seeked for help at TuCheng Hospital and she was informed there was a uterine cyst that caused the pain. Under conservative treatments, she was in relatively stable conditions. Hereafter, on 09/11 she seeked for second help at TuCheng hospital due to the intermittent abdominal pain and the CT was done and revealed as the followings:
      • Uterine mass lesion ~11 cm in diameter with compression forward and causing bladder compression
      • Mild R’t hydroureter, RUQ surgical clip retension
    • This time, she sufferred from acute lower abdominal pain this morning and she was sent to our ER for help. At that time PE performed and showed without nauseau, vomitting, diarrhea, constipation, and fever.
    • Additionally, GYN Dr. Tseng was consulted with the first impression: pelvic mass 126*93mm, r/o teratoma or endometrioma with torsion. Hence, the patient is now under urgent surgical interventions to control her pain.
    • Menstrual histories:
      • G2P2A0 (NSD*2)
      • menopause at age of 48 years old.
  • Course of inpatient treatment
    • The patient was admitted on 2023/09/13 from ER with the symptom acute lower abdominal pain. After the consultation with Dr. Saing, a pelvic mass with 126x93mm was observed under the sonography and left salpingo-oophorectomy was scheduled on the same day under the impression of teratoma or endometrioma with torsion.
    • She underwent left salpingo-oophorectomy on 2023/09/13 and her postoperative course was uneventful. Her appetite was fine and she can void well.
    • The patient complained of intermittent abdominal wound pain and constipation. The analgesic medications and stool softener were given accordingly.
    • The vital sign was stable after surgery. She is discharged on 2023/09/17 and she will have her OPD follow-up next week.
  • Discharge prescription
    • cephalexin 500mg 1# QID
    • Keto (ketorolac 10mg) 1# QID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Through (sennoside 12mg) 2# HS
    • Rivotril (clonazepam 0.5mg) 1# QN
    • Valdoxan (agomelatine 25mg) 1# QN

[consultation]

• 2024-01-12 Rehabilitation

  • A
    • Assessment
      • Recent ischemic infarction in the bilateral frontal lobes, left temporal lobe and left cerebellar hemisphere on 2024/01/10 with left hemiparesis
      • Left ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV, status post Left salpingo-oophorectomy on 2023/09/13 + Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01, immunohistochemical stain reveals PAX8(+)
    • Plan
      • Rehabilitation programs: arrange bedside PT and OT rehabilitation programs.
      • Goal: Ambulation without device smoothly indoor; BADL ID.
      • Suggest tracking the food and water intake for 2-3 days. If there are issues with inadequate food or water intake or frequent choking, please notify CR 羅元廷(69028). Swallowing therapy would be arranged to increase swallowing ability and NG tube insertion is recommended.
      • The patient was educated about oral hygiene and safe eating, including proper positioning (must be seated upright), consuming small amounts at a time and ensuring no wet voice before taking the next bite.

• 2024-01-10 Neurology

  • Q
    • General weakness, dizziness, vomiting , and left hand weakness started from 2024-01-09
  • A
    • O
      • Brain CT: no ICH
      • Brain MRI: multifocal cerebral infarcts involved cerebellum and bilateral cerebral hemisphere.
    • impression: multifocal cerebral infarcts, favor embolic stroke or Trousseau syndrome
    • suggestion:
      • give IV NS 40ml/hr, keep current medication including eliquis ( give eliquis 1# stat for evening dose)
      • give symptomatic treatment including promeran and cephadol
      • arrange neurology ward admission (Dr. Xu BoRen)
      • monitor vital signs/GCS/MP at least Q4H
      • tight control SBP < 220 or DBP < 120, tight control BS < 180

• 2023-11-10 Dermatology

  • Q
    • for skin rash & icthing (2023/11/08 C/T with Abraxance/Carboplatin)
    • This 68-year-old woman, a patient of ovary cancer with peritonal seeding and liver mets S/P C/T on 2023/11/08. intermittent skin rash, icthing over whole body for days. anti-histamin was given but did not improve. We need expertise to evaluate her condition thanks!
  • A
    • This patient suffered from generalized erytematous papules on trunk and 4 limbs for days
    • Imp: Toxicoderma
    • Suggestion:
      • Zaditen (ketotifen) 1 / Bid
      • Xyzal (levocetirizine) 1 / Hs
      • Mycomb (triacinolone, neomycin, nystatin) 2 tubes / bid

• 2023-11-02 Hemato-Oncology

  • A
    • This 68 year old woman is a case of newly diagnosis Ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV s/p Left salpingo-oophorectomy on 2023/09/13 and Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01. We are consulted for further treatment (neoadjuvant therapy).
    • Suggestion:
      • Consult GS for port A insertion if patient agree further treatment
      • Check HBsAg, Anti HBc, Anti HBs, Anti HCV before chemotherapy.
      • Consider commercial gene test for HRD, BRCA (self pay) for further study
      • Carboplatin + Paclitaxel +/- avastin is indicated for this patient
      • We had well explaint to patient and her husband this afternoon. Patient also said she and her children will discuss with Dr Gao tomorrow morning.

• 2023-10-26 Obstetrics and Gynecology

• 2023-09-13 Obstetrics and Gynecology

[surgical operation]

• 2023-09-13 - Op Method: Diagnosis: Left ovarian mass
  • Surgery: Left salpingo-oophorectomy
  • Finding:
    • Uterus: Avfl, normal size, grossly normal.
    • RAD: grossly normal.
    • LAD: one 1086 cm cystic lesion in the LOV with mucinous content, mild adhesion to left pelvic wall.
    • CDS: free of adhesion. No ascites.
    • Estimated blood loss: 50cc.
    • Blood transfusion: nil
    • Complication: nil

[chemotherapy]

• 2024-01-16 - nab-paclitaxel 100mg/m2 137mg 30min
  • dexamethasone 4mg + NS 250mL
• 2024-01-09 - nab-paclitaxel 100mg/m2 137mg 30min
  • dexamethasone 4mg + NS 250mL
• 2024-01-02 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + nab-paclitaxel 100mg/m2 140mg 30min + carboplatin AUC 5 550mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-20 - nab-paclitaxel 100mg/m2 150mg 30min
  • dexamethasone 4mg + NS 250mL
• 2023-12-13 - nab-paclitaxel 100mg/m2 150mg 30min
  • dexamethasone 4mg + NS 250mL
• 2023-12-06 - bevacizumab 15mg/kg 800mg NS 100mL 1.5hr + nab-paclitaxel 100mg/m2 150mg 30min + carboplatin AUC 5 750mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-22 - nab-paclitaxel 100mg/m2 150mg 30min
  • dexamethasone 4mg + NS 250mL
• 2023-11-15 - nab-paclitaxel 100mg/m2 150mg 30min
  • dexamethasone 4mg + NS 250mL
• 2023-11-08 - nab-paclitaxel 100mg/m2 150mg 30min
  • dexamethasone 4mg + NS 250mL
• 2023-11-07 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-02-01

[evaluating Avastin’s risks: cerebral infarcts and bleeding concerns]

Avastin (bevacizumab) has been linked to venous thromboembolism (grades 3/4: 5% to 11%; 2024-01-31 D-dimer 7060 ng/mL FEU) and hemorrhage (grades >=3: <=7%; including major hemorrhage). Given that this patient recently experienced multifocal cerebral infarcts affecting the cerebellum and bilateral cerebral hemispheres in early to mid-January 2024, it is crucial to exclude the possibility that these infarcts may have been induced by the medication prior to next administration.

Additionally, recent lab data indicated rising CA125 and CA199 levels, warranting close observation and subsequent follow-up.

• 2024-01-30 CA125 (NM) 719.6 U/ml
  

• 2024-01-02 CA125 392.8 U/mL
  

• 2023-12-13 CA125 159.2 U/mL

• 2024-01-30 CA199 (NM) 1468.90 U/ml
  

• 2023-12-13 CA199 333.96 U/mL
  

• 2023-11-27 CA199 161.03 U/mL

700941015

240131

[MedRec]

• 2024-01-30 SOAP Medical Emergency Li XuanQing
  • O
    • Abdomen: soft, RLQ tenderness, hyperactive bowel sounds
  • A
    • Preliminary impression: K35.80 Unspecified acute appendicitis
  • Prescription
    • Laston (ketorolac) 30mg ST IVP
    • Flumarin (flomoxef sodium) 1000mg ST IVD
    • Laston (ketorolac) 30mg ST IVD slow drip > 10 min
    • Despas (hyoscine-N-butylbromide) 20mg ST IVD slow drip > 10min
    • NS 500mL ST IVD
• 2023-10-27 SOAP Metabolism and Endocrinology Qiu QuanTai
  • S: T2DM since about 35 Y/O
  • Prescription x3
    • Jardiance (empagliflozin 10mg) 1# QD
    • Uformin (metformin 500mg) 2# BIDAC
    • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QDAC
    • Blopress (candesartan 8mg) 1# QD
• 2019-12-26 SOAP Metabolism and Endocrinology Zhang YaLi
  • Diagnosis
    • Type 2 diabetes mellitus without complications [E11.9]
    • Hyperlipidemia, unspecified [E78.5]
  • Prescription x3
    • Jardiance (empagliflozin 25mg) 1# QD
    • Crestor (rosuvastatin 10mg) 1# QD
    • Amepiride (glimepiride 2mg) 0.5# QDAC
    • Uformin (metformin 500mg) 1# BID

[surgical operation]

• 2024-01-30
  • Surgery
    • laparoscopic appendectomy        
  • Finding
    • diated appendix
    • pus ccumulation in appendix
    • rupture (-)
    • fecalith (-)
    • ascites (-)

==========

2024-01-31

[reconciliation]

No medication discrepancy identified in Stazolin (cefazolin) 1000mg Q8H IVD and metronidazole 500mg Q6H IVD after appendectomy.

701340072

240131

[exam findings]

• 2024-01-29 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
    • Modereate ascites is found.
    • Several low density lesions are found at both lobes of liver with marginal enhancement and loss of surface integrity at S5. Multiple metastatic tumor with probably previous tumor rupture is found.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • The portal vein and IVC are patent.
    • The stomach, colon and pancreas are intact.
  • Imp:
    • Multiple hepatic tumors with bone meta, the origin should be further investigated. HCC is less likely.
• 2024-01-29 KUB
  • Compression fracture of L1 vertebral body
  • marginal spurs of multiple vertebral bodies due to spondylosis.
  • increased air in nondistended loops of small bowel over RUQ, could be paralytic ileus

[MedRec]

• 2024-01-29 SOAP Medical Emergency Li XuanQing
  • S
    • Abdominal distension and pain 1 week
    • constipation in the first 2-3 days then few stools noticed
    • no fever, no chest pain, no back pain
    • no N/V, no diarrhea, no tarry stool, no dysuria
    • Past History: HBV carrier
    • Surgical history: denied abd OP
    • Drug allergy: NKDA
  • O
    • Vital signs: BP:134/80; HR:106; BT:35.7’C; RR:18;
    • Con’s:E4V5M6
    • SpO2:99%
    • Conscious: clear and oriented
    • HEENT: pink conjunc, anicteric sclera
    • BS: bil. symmetric expansion
    • Heart: RHB
    • Abdomen: distended, diffuse tenderness, no rebound tenderness, no muscle guarding
    • Ext: freely movable, no pitting edema
  • A/P
    • Preliminary impression: R10.9 Unspecified abdominal pain
    • 2024/01/29 09:04 WBC = 10.38 x10^3/uL;
    • 2024/01/29 09:16 Bilirubin total = 2.11 mg/dL;
    • 2024/01/29 09:16 CRP = 11.3 mg/dL;
    • 2024/01/29 09:16 Creatinine = 0.62 mg/dL;
    • 2024/01/29 09:16 ALT = 54 U/L;
    • 2024/01/29 10:43 Bilirubin direct = 1.11 mg/dL;
    • 2024/01/29 10:43 r-GT = 1054 U/L;
    • 2024/01/29 10:43 Alkaline phosphatase = 402 U/L;
    • 2024/01/29 10:43 AST = 56 U/L;
    • 2024/01/29 CT: ABD — whole abdomen, Pelvis (with and without contrast)
      • Imp: Multiple hepatic tumors with bone meta, the origin should be further investigated. HCC is less likely.
  • Prescription
    • TaiTa No.5 Inj (electrolyte solution) 1000mL ST IVD
    • Flumarin (flomoxef sodium) 1000mg ST & Q8H IVD
    • NS 1000mL ST IVD
    • Tramtor (tramadol) 100mg ST IVD
    • Imperan (metoclopramide) 10mg ST IVD

==========

2024-01-31

[reconciliation]

The patient presented to our emergency department with a week-long history of abdominal distension and pain. CT imaging revealed multiple hepatic tumors and bone mets, necessitating further investigation to determine the primary source. Lab tests highlighted abnormalities in liver function.

• 2024-01-29 Bilirubin direct 1.11 mg/dL
  
• 2024-01-29 r-GT 1054 U/L
  
• 2024-01-29 Alkaline phosphatase 402 U/L
  
• 2024-01-29 AST 56 U/L
  
• 2024-01-29 Bilirubin total 2.11 mg/dL
  
• 2024-01-29 CRP 11.3 mg/dL
  
• 2024-01-29 ALT 54 U/L

Ongoing management includes hydration, analgesics, electrolyte supplementation, diuretics, and gastrointestinal motility-enhancing agents. A review of the PharmaCloud database found no discrepancies in medication administration.

701505090

240130

[exam findings]

• 2024-01-18 CT - abdomen
  • History and indication: Rectal adenocarcinoma
  • With and without contrast CT of abdomen-pelvis revealed:
    • Mild regression of rectal cancer and liver metastases. Stable condition of LUL lesion.
    • Liver and renal cysts.
    • Gallbladder polyp (2.9mm).
  • IMP:
    • Mild regression of rectal cancer and liver metastases. Stable condition of LUL lesion.
• 2023-12-21 MRI - brain
  • No evidence of intracranial lesion.
• 2023-11-21 All-RAS + BRAF mutation
  • Cellblock No. S2023-23092
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-11-20 PET scan
  • Increased FDG uptake in a focal area from the R-S junction to rectal region, compatible with the primary rectal cancer.
    
  • Increased FDG uptake in both lobes of the liver, highly suspected rectal cancer with liver metastases.
    
  • Mildly increased FDG uptake in a small nodular lesion in the left upper lung, the nature is to be determined (favor inflammation process due to lower uptake of FDG).
  • Increased FDG uptake in several lymph nodes of bilateral neck regions, probably benign in nature, suggesting follow-up.
    
  • Increased FDG uptake in the left 7th rib, the nature is to be determined also (post-traumatic change, cancer with bone mets, or other nature ?), suggesting follow-up.
    
  • Rectal cancer, cTxNxM1a, stage IVA (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-11-20 Patho - colon biopsy (Y1)
  • Colorectum, low- middle rectum, 6 cm from anal verge, biopsy — Adenocarcinoma.
  • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands. An addendum report of the result of IHC stains of EGFR, PMS2, MSH6, MSH2, and MLH1 will be followed.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2023-11-17 Sigmoidoscopy
  • Diagnosis:
    • One ulcerative tumor mass was found at low-middle rectum (6cm AAV) with lumen narrowing and impending obstruction
  • Suggestion:
    • F/U pathology report
• 2023-11-15 CT - abdomen
  • CC: BW loss 13kg, altered bowel habit for 8 months, anal bleeding (+).
    • 20231114 CC: colorectal cancer Dx at the MaioLi HongDa Hospital.
    • 20231117 colonoscopy: One ulcerative tumor at low-middle rectum (6cm AAV) with lumen narrowing and scope cannot be passed through.
  • Findings:
    • There is circumferential mild asymmetrical wall thickening at the rectosigmoid junction (5 cm in size) and wall thickening at right lateral aspect of the rectum (2.3 cm in size).
      • Adenocarcinoma of the rectum (T3) is highly suspected.
      • Please correlate with colonoscopy and MRI.
    • There are seven enlarged nodes in the perirectal space and sigmoid mesocolon that may be metastatic nodes (N2b).
    • There are several lobulated poor enhancing masses on both hepatic lobes (up to 6.6 cm in S5/7/8) that are c/w liver metastases (M1a).
    • There is a small ground-glass opacity 6 mm at LUL of the lung (Srs:601 Img:30).
      • Primary lung cancer is suspected.
      • The differential diagnosis includes metastasis and intrapulmonary node.
    • There are several hepatic cysts in both lobes (up to 3.1 cm in S7).
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)

[MedRec]

• 2023-12-03 ~ 2023-12-07 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Rectal adenocarcinoma with impending obstruction and liver metastases, T3N2bM1a; stage: IVA
  • CC
    • For schedualed chemotherapy with FOLFIRI
  • Present illness
    • This is a 49 year-old female, with history of rectal adenocarcinoma with impending obstruction and liver metastases, T3N2bM1a; stage: IVA, left lung 0.6cm nodule., admitted for schedualed chemotherapy with FOLFIRI plus Erbutux.
    • Tracing back to her history, she suffered from body weight loss 13kg, bowel habit change for 8 months accompanied with anal bleeding without tarry stool. She visited MiaoLi HongDa Hospital for help and colorectal cancer was proven via colonoscopy by pathology, therefore, she was reffered to our GI OPD for survey.
    • Further abdominal CT revealed rectal cancer with liver metastases, and left lung nodule. Port-a insertion was done on 2023/11/30.
    • This time, she was admitted for Chemotherapy with FOLFIRI plus Erbitux C1.
  • Course of inpatient treatment
    • After admission, we prescribed C1 chemotherapy with 5-FU and Irinotecan
    • (this section should not be correct after reviewing the records) After she admitted, she received hydration. the stool softener drugs, Imperan for vomiting treatment. After treatment, the symptom of nausea, vomiting improved. He received C3 chemotherapy with cisplatin 40mg/m2 weekly on 2023/11/28. Then, he suffered from hematemesis once (64.2ml bloody) on 2023/11/29, and after radiotherapy, he suffered from hematemesis noted (174 ml blood clot) on 2023/11/30, so gave Transamine 500mg IVD, Transamine 500mg INHL, hold Bokey for bleeding control. Due to the tumor is bleeding, so continue radiotherapy. After treatment, the symptom of hematemesis improved, and hold C4 chemotherapy this moment. He can be discharged on 2023/12/05, the OPD follow-up will be arranged.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Vemlidy (tenofovir alafenamdie 25mg) 1# QD

[consultation]

• 2024-01-02 Dermatology
  • Q
    • for acne evaluation
    • This is a 49 year-old female, with history of rectal adenocarcinoma with impending obstruction and liver metastases, T3N2bM1a; stage: IVA, left lung 0.6cm nodule., admitted for schedualed chemotherapy with FOLFIRI plus Erbitux.
    • She complaints acne at face noted since targeted therapy with Erbitux, so we need your help for acne evaluation, thanks a lot!!
  • A
    • The patient had sufferred from anceiform eruption with fine pusutles formaiton over face with mild pruritus.
      
    • Under the impression of acne vulgaris favor target therapy related.
    • The following sugeetion:
      • allegra 1# bid po and Kolincin Gel 1 tube topical bid use over facial lesions.
      • If still progressive, consider add Doxycycline 1# bid po use for 5-7 days.

[immunochemotherapy]

• 2024-01-29 - cetuximab 400mg/m2 400mg 2hr + irinotecan 180mg/m2 255mg D5W 250mL 90min + leucovorin 400mg/m2 565mg NS 250mL 2hr + fluorouracil 2400mg/m2 3410mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.5mg SC
• 2024-01-15 - cetuximab 400mg/m2 400mg 2hr + oxaliplatin 85mg/m2 120mg D5W 250mL 4hr + leucovorin 400mg/m2 575mg NS 250mL 2hr + fluorouracil 2400mg/m2 3450mg NS 500mL 46hr (Erbitux + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2024-01-02 - cetuximab 400mg/m2 400mg 2hr + irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 575mg NS 250mL 2hr + fluorouracil 2400mg/m2 3470mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.5mg SC
• 2023-12-18 - cetuximab 400mg/m2 400mg 2hr + irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Erbitux + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.5mg SC
• 2023-12-04 - irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.5mg SC

701507492

240130

[lab data]

2024-01-22 HBV DNA PCR (Quantitative) 246 IU/mL

2024-01-20 HBeAg Nonreactive 2024-01-20 HBeAg Value 0.361 S/CO

2024-01-11 HBsAg (NM) Positive 2024-01-11 HBsAg Value (NM) 1660.000 2024-01-11 Anti-HCV (NM) Positive 2024-01-11 Anti-HCV Value (NM) 57.800 2024-01-11 Anti-HBc (NM) Positive 2024-01-11 Anti-HBc Value (NM) 0.007 2024-01-11 Anti-HBs (NM) Negative 2024-01-11 Anti-HBs value (NM) <2.000 mIU/mL

[exam findings]

• 2024-01-04 MRI - nasopharynx
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2024-01-04 SONO - abdomen
  • Indication: Cancer evaluation
  • Symptoms:
    • Liver
      • Coarse liver parenchyma with uneven surface.
    • Pancreas
      • Some parts of pancreas blocked by bowel gas, especially head and tail
    • Spleen
      • Splenomegaly
  • Diagnosis:
    • Liver cirrhosis
    • Status post cholecystectomy
    • Splenomegaly
  • Suggestion:
    • Check HBsAg, anti-HBc, anti-HCV, a-fetoprotein
    • Regular GI OPD follow up after discharge
• 2024-01-03 Tc-99m MDP bone scan
  • Faint hot spots in both rib cages, and increased activity in the right femoral shaft, U/3, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the lower L- spine, bilaterla shoulders, S-I joints, hips, and knees.
• 2023-12-25 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopharynx, left, biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
  • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern. Keratin formation is absent. Tumor necrosis and inflammatory exudate are present.
• 2023-12-22 CT - temporal bone HRCT (without contrast)
  • Indication: left otorrhea on and off for one year
  • Without-contrast high-resolution CT scan of temporal bones with 1-mm axial and coronal images reveals:
    • Soft tissue opacification in left mastoid air cells and right middle ear cavity, indicating mastoiditis and COM.
    • Diffuse soft tissue density associating bony destruction involving left nasopharynx, clivus, sphenoid sinuses, pterygopalatine fossa, inferior orbital fissure, foramen ovale and foramen lacerum. R/O advance NPC.
    • Tubular calcification along bilateral intracranial ICAs.
  • IMP:
    • Suspected advanced NPC. Suggest further evaluation.
    • Left COM and mastoiditis.
• 2023-12-22 Nasopharyngoscopy
  • Findings
    • left facial tender
    • HRCT showed left NP swelling
  • Diagnosis/Conclusion
    • Npscope: left NP swelling tumor, s/p biopsy
• 2023-12-11 Ear Nose Throat Hearing Test
  • Tymp:
    • RE type Ad; LE perforation?
  • ART:
    • RE ipsi absent, contra CNT.
    • LE ispi CNT, contra absent.
  • PTA:
    • Reliability FAIR
    • Average RE 45 dB HL; LE 85 dB HL.
    • RE normal to profound HL.(1k,4k Hz masking dilemma)
      
    • LE severe mixed type HL.

[MedRec]

• 2024-01-10 SOAP Oral and Maxillofacial Surgery He ChengHan
  • S
    • pre-RT dental extraction
  • O: the patient came for dental evaluation before RT of NPC.
    • O: Tooth 11,14,15,32: retained root, food deposition with local inflammation, poor prognosis
    • A: Tooth 11,14,15,32: retained root
    • P: Suggest extraction of tooth 11,14,15,31,32 and 41 before RT.
  • A
    • Nasopharyngeal squamous cell carcinoma, stage cT4N1M0, undifferentiated type.
  • Plan:
    • Explain the risk/benefit of the treatment to the patient
    • Sign informed consent.
    • Block anesthesia of anterior mandible.
    • Complicated extraction of tooth 31,32 and 41
    • Suture the gingiva with Vicryl 4-0.
    • Prescribe Acetal and Amoxicillin.
    • Teach the patient how to do home care and OPD follow-up.
    • Next visit for stitches removal.
  • Prescription
    • Acetal (acetaminophen 500mg) 1# PRNTID
    • Actein (acetylcysteine 200mg) 1# TID
    • amoxicillin 250mg 2# Q8H
• 2024-01-02 ~ 2024-01-05 POMR Ear Nose Throat Huang YunCheng
  • Discharge diagnosis
    • Nasopharyngeal squamous cell carcinoma, stage cT4N1M0, undifferentiated type.
  • CC
    • Intermittent left otorrhea for 1 year.
  • Present illness
    • This is a 68-year-old man with underlying hypertension, coronary artery disease and diabetes mellitus. he had noticed left otorrhea on and off for about one year. The patient visited local clinic, but the symptom didn’t subside despite medical treatment. The patient then visited our OPD where initial local finding showed right intact eardrum left tympanic membrane perforation with acute infection.
    • Antibiotic of Curam and Earflo were given with mild improvement.
    • Also, audiometry revealed left side mixed type hearing loss.
    • Microscope revealed left chronic otitis media with middle ear polyp.
    • Hence HRCT was arranged to evaluate the middle ear condition. However, the report showed not only left COM with mastoiditis but also diffuse soft tissue at left nasopharynx and density associating multiple bony subsite destruction.
    • Subsequent nasopharynoscope revealed left nasopharynx swelling tumor of which the biopsy report showed nasopharyngeal carcinoma.
    • Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, the patient was admitted for cancer work-up. 
  • Course of inpatient treatment
    • After admission, serial tests were arranged for tumor staging work up.
    • Nasopharynx MRI showed cT4N1MX.
    • Abdominal sonography showed no prominent metastasis.
    • Whole body bone scan showed faint hot spots in both rib cages, and increased activity in the right femoral shaft which suggested further follow-up.
    • OS, radio-oncologist, hematologist were consulted for evaluation.
    • Under relative stable condition, the patient was dishcarged with OPD follow up.

[consultation]

• 2024-01-05 Hemato-Oncology
  • Q: same content in the consultation to Radiation Oncology
  • A
    • Dear doctor: This 68 year old man is a case of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, stage cT4N1M0 (stage IVA). We are consulted for CCRT.
    • Please arrange port A insertion. And check HBsAg, Anti HBc, Anti HBs, Anti HCV. Thanks for your consultation.
    • Arrange our OPD after discharge.
• 2024-01-05 Radiation Oncology
  • Q
    • Dear doctor, this patient was a newly-diagnosed case of nasopharyngeal carcinoma.
    • He had undergone several study for tumor staging.
      • Bone scan survey report was currently pending. (Initial interpretation seemed to be fair.)
      • MRI showed cT4N1Mx disease with intra-cranial invasion.
      • Abdominal echo showed no evidence of liver metastasis.
    • For the above impression, we would like to ask your expertise to guide our CCRT treatment plan. Thx!!
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For radiotherapy due to nasopharyngeal carcinoma.
      • PI: According to the patient’s statement, he suffered fro diplopia, left facial focal numbness, occasional stuffy nose, or epistaxis, and hearing impairment for an uncertain period.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (-); HTN (+)
      • Previous RT Hx: (-)
    • O: ECOG: 0
      • PE: neck and bil SCF: neg; left lateral eye fixation; left facial focal numbness, left side hearing impairment.
        
      • NP scopy (2023-12-22): left NP swelling tumor , s/p biopsy
      • CT scan of temporal bone (2023-12-22): 1. Soft tissue opacification in left mastoid air cells and right middle ear cavity, indicating mastoiditis and COM. 2. Diffuse soft tissue density associating bony destruction involving left nasopharynx, clivus, sphenoid sinuses, pterygopalatine fossa, inferior orbital fissure, foramen ovale and foramen lacerum. R/O advance NPC. 3. Tubular calcification along bilateral intracranial ICAs. Imp: (1)Suspected advanced NPC. Suggest further evaluation. (2)Left COM and mastoiditis.
      • Pathology (S2023-25765, 2023-12-26): Nasopharynx, left, biopsy – Non-keratinizing squamous cell carcinoma, undifferentiated type.
      • CXR (2024-01-02): No cardiomegaly. No active lung lesion. Tortuosity of the aorta. Degenerative joint disease of T-spine with marginal osteophytes.
      • Bone scan (2024-01-03): Faint hot spots in both rib cages, and increased activity in the right femoral shaft, U/3, the nature is to be determined (post-traumatic change or other nature ?),
      • Abd sono (2024-01-04): Liver cirrhosis. Status post cholecystectomy. Splenomegaly.
      • MRI of nasopharynx (2024-01-04): T4 (intracranial, cranial nerves involvement; N1M0, stage IVA
    • A: Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, stage cT4N1M0 (stage IVA)
    • P: Radiotherapy is indicated for this patient with the following indicators: stage cT4N1M0 (stage IVA)
      • Goal: curative
      • Treatment target and volume: nasopharyngeal tumor, peripheral involved, and bilateral neck
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the nasopharyngeal tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the nasopharyngeal tumor and involved nodal lesions. The treatment modality and the possible effects of radiotherapy were well explained to the patient and his sister. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started after completion of pre-RT dental evaluation and management.
• 2024-01-04 Oral and Maxillofacial Surgery
  • Q
    • Dear doctor, this patient was a newly-diagnosed case of nasopharyngeal carcinoma, he was admitted for tumor staging and would receive examination schedule as following: Bone scan: 1/3 1200, Abd sono: 1/4 1030, MRI: 1/4 1240.
    • Since the patient would receive radiation therapy as primary treatment modality, we would like to sincerely ask for your expertise to evaluated the patient’s dental condition and perfomed tooth extraction if needed. Thx!!
  • A
    • Dear doctor, the patient came for dental evaluation before RT of NPC.
    • O: Tooth 11,14,15,32: retained root, food deposition with local inflammation, poor prognosis
    • A: Tooth 11,14,15,32: retained root
    • P: Suggest extraction of tooth 11,14,15,32 before RT.

[radiotherapy]

[chemotherapy]

==========

2024-01-30

[prophylactic nucleoside analogues prescribed for this HBV carrier, silymarin may also be considered.]

The presence of detectable HBV DNA PCR, positive HBsAg, and anti-HBc positivity in recent lab results warrants consideration of pre-emptive antiviral nucleoside analog therapy before commencing chemotherapy to mitigate the risk of HBV reactivation. Self-carried Vemlidy (tenofovir alafenamide) has been prescribed with no discrepancy identified.

Since elevated AST, ALT and direct bilirubin were also noted, the addition of BaoGan (silimarin) could be considered optionally if no contraindication exists.

701511954

240130

{donor}

[MedRec]

• 2024-01-29 ~ 2024-01-30 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Other blood donor, stem cells
  • CC
    • for Peripheral blood stem cell collection
  • Present illness
    • This is a 37-year-old female without any past medical history. She had been selcected for HSCT donor at almost one year ago.
    • This time, she was admitted for Peripheral blood stem cell, and DLI to the recipient.
  • Course of inpatient treatment
    • After being admitted, consult Anesthesia Department for A-line catheter inserting at left radial artery, Vitacal kept injection for prevention Hypocalcemia first. And she received the peripheral blood was circulated and collected the stem cells. After 16+6 liters of peripheral blood was circulated and collected the stem cells, adequate number of CD34+ cell were collected according to the recipient weight (Total CD34+ cell: 152.419*10^6). She was discharged at today with no specific condtion.
• 2024-01-16 SOAP Hemato-Oncology He JingLiang
  • S
    • BMT/HSCT donor for pre-donation evaluation.
    • Review the referring sheet and system review.
    • Past history: Nothing in particular.
    • Family history: No systemic disease in the family members.
    • Personal history: Smoking (no), alcohol consumption (no), betel nut chowing (no)
    • Allergy: no medicine allergy history.
    • Travel history: no recent travel history.
  • O
    • Skin: unremarkable.
    • HEENT: no deformity, no icteric sclera, no anemic conjunctiva, no visual or auditory deficit
    • Neck: soft and supple, no jugular vein engorgement
    • Chest: symmetrical, no deformity, clear breathing sound, bilaterally
    • Heart: regular heart beat, no murmur
    • Abdomen: soft and flat, no palpable liver and spleen, no inguinal LN enlargement
    • Back and spine: no deformity, no knocking pain at both CV angles
    • Extremity: free movable, no deformity, warm and pink in color
    • Digital examination: not done
  • Diagnosis
    • Bone marrow donor [Z52.3]

701513098

240130

{bone marrow donor}

[MedRec]

• 2024-01-30

• 2024-01-23 SOAP Hemato-Oncology He JingLiang

  • S
    • BMT/HSCT donor for pre-donation evaluation.
    • Review the referring sheet and system review.
    • Past history: Nothing in particular.
    • Family history: No systemic disease in the family members.
    • Personal history: Smoking (no), alcohol consumption (no), betel nut chowing (no)
    • Allergy: no medicine allergy history.
    • Travel history: no recent travel history.
  • O
    • Skin: unremarkable.
    • HEENT: no deformity, no icteric sclera, no anemic conjunctiva, no visual or auditory deficit
    • Neck: soft and supple, no jugular vein engorgement
    • Chest: symmetrical, no deformity, clear breathing sound, bilaterally
    • Heart: regular heart beat, no murmur
    • Abdomen: soft and flat, no palpable liver and spleen, no inguinal LN enlargement
    • Back and spine: no deformity, no knocking pain at both CV angles
    • Extremity: free movable, no deformity, warm and pink in color
    • Digital examination: not done
  • Plan
    • arrange admission
  • Diagnosis
    • Bone marrow donor [Z52.3]

700146860

240129

[exam findings] (not completed)

• 2023-12-14, -10-25, -04-06 EGD
  • Findings
    • Esophagus
      • Minimal mucosa break < 5mm was noted at EC junction.
    • Stomach
      • A huge ulcerative, fungating tumor with necrotic tissue and ozzing at distal stomach, almost occupied whole antrum, s/p hemostasis with Argon plasma coagulation.
      • Coffee ground content was noted at stomach.
  • Diagnosis:
    • Gastric adenocarcinoma, Borrmann type III, tumor bleeding, s/p hemostasis with APC.
    • Reflux esophagitis LA Classification grade A (minimal)
  • Suggestion:
    • PPI usage
• 2023-05-17 SONO - abdomen
  • Findings
    • Liver
      • Homogeneous echotexture of liver parenchyma. A 0.8 cm hyperechoic mass at rt ant seg.
      • A 0.45cm anechoic lesion was noted at S2.
    • Pancreas
      • Some parts of pancreas blocked by bowel gas, especially head and tail
    • Spleen
      • No splenomegaly
  • Diagnosis:
    • Liver cyst
    • Hepatic tumor R/O hemangioma
• 2022-11-21 PD-L1 IHC
  • Cellblock No. S2022-19870
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS >= 1 and < 10
    • Combined Positive Score (CPS): 5%
• 2022-11-21 PD-L1 (22C3)
  • Cellblock No. S2022-19870
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS >= 1 and < 10
    • Combined Positive Score (CPS): 5%
• 2022-11-21 PD-L1 (SP142)
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
  • Tumor type: adenocarcinoma
  • Tumor location: stomach
  • Testing assay: SP142 Assay (Ventana)
  • Testing platform: BenchMark ULTRA
  • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
  • Control slide result: [V]Pass, [ ]Fail
  • Adequate tumor cells present (>= 50 viable tumor cells): [V] Yes, [ ] No
  • Result:
    • Tumor cell (TC) staining assessment:
      • TC category: TC >= 5% and < 50%
      • Percentage of PD-L1 expressing tumor cells (%TC): 5%
    • Tumor-infiltrating immune cell (IC) staining assessment:
      • IC category: IC >= 1% and < 5%
      • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2022-11-11 Patho - stomach biopsy
  • Stomach, low body and antrum, biopsy — Adenocarcinoma
  • Microscopically, the sections show a picture of tubular adenocarcinoma of the gastric tissue characterized by tumor cells arranged in tubular, fused glandular or subtle cribriform pattern with enlarged and hyperchromatic nuclei infiltrating in ulcerative stroma.
• 2022-11-11 EGD
  • Indication: UGI bleeding
  • Findings
    • Esophagus
      • Mucosa break < 5mm was noted at EC junction.
    • Stomach
      • One large semi-annular ulcerative tumor with elevated and nodular margin was noted at low body and antrum. One hemoclip was in-place. One exposed vessel was noted on the ulcer base, s/p hemostasis with argon coagulation plasma, s/p biopsy*8.
  • Diagnosis:
    • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with APC and biopsy*7
    • Reflux esophagitis LA Classification grade A
  • Suggestion:
    • High dose PPI*3 days
• 2022-11-10 CT - abdomen
  • History and indication: suspect gastric cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of gastri antrum and lower gastric body with a big ulcer, adjacent fat stranding and regional LAP.
    • Liver and renal cysts (up to 1.4cm). Left liver hemangiomas (6mm, 7mm). Accessory spleen at LUQ.
    • Hyperplasia of left adrenal gland.
    • A nodule (2.5mm) at LUL.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P NG tube indwelling.
    • Degeneration and spondylosis of L-S spine.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N3a(N_value) M:M1(M_value) STAGE:IVB(Stage_value)
• 2022-11-10 SONO - abdomen
  • Findings
    • Liver
      • Homogeneous echotexture of liver parenchyma.
      • A 0.45cm anechoic lesion was noted at S2.
    • Kidney
      • A 1.91cm anechoic lesion was noted at right kidney.
      • A 0.86cm anechoic lesion was noted at left kidney.
    • Pancreas
      • Some parts of pancreas blocked by bowel gas, especially head and tail
  • Diagnosis:
    • Liver cyst, S2
    • Renal cyst, both kidney
• 2022-11-08 EGD
  • Diagnosis:
    • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3
    • Reflux esophagitis LA Classification grade A
    • Incomplete study
  • Suggestion:
    • High dose PPI*3 days
    • NG tube for decompression
    • Admission for UGI care and malinancy work-up

[MedRec]

• 2023-12-13 ~ 2023-12-18 POMR Gastroenterology Chen JiangHua

  • CC
    • tarry stool passage for days
  • Course of inpatient treatment
    • After admission, NPO with adequate IV fluid supplement, IV form PPI agent and IV transamin were administered.
    • Blood was transfused for the management of anemia.
    • Upper G-I panendoscopy was performed and revealed Gastric adenocarcinoma, Borrmann type III, tumor bleeding, s/p hemostasis with APC; Reflux esophagitis LA Classification grade A (minimal).
    • There was no more tarry stool passage after treatment, oral intake trying was administered. PPI agent and Transamin was shifted to oral form. Under stable condition, she was discharged on 2023/12/18 and GI OPD Follow-up would was arranged later.    
  • Discharge prescription
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Trand (tranexamic acid 250mg) 1# BID

• 2023-10-20 ~ 2023-10-26 POMR Gastroenterology Chen JiangHua

  • CC
    • tarry stool passage for days
  • Present illness
    • This time, she suffered from tarry stool passage for days. General malaise was noted. She denied chest tightness/pain, diarrhea/constipation, dysuria/frequency found. No TOCC history was noted. She was brought to our GI OPD for help. At GI OPD, the laboratory data showed anemia (Hb: 5.8 g/dL -> 6.4g/dL post LPRBC 2 Units), no leukocytosis. PE showed pale conjunctiva, no icteric sclera, soft abdomen, no leg pitting edema.
    • Under the impression of favor gastric cancer with bleeding. She was admitted to our GI ward for management and further survey.
  • Course of inpatient treatment
    • After admission, NPO with adequate IV fluid supplement, IV form PPI agent and IV transamin were administered.
    • Blood was transfused for the management of anemia.
    • Upper G-I panendoscopy was performed and revealed Reflux esophagitis LA Classification grade A (minimal); Gastric adenocarcinoma, Borrmann type III, tumor bleeding, s/p hemostasis with APC.
    • There was no more tarry stool passage after treatment, oral intake trying was administered. PPI agent and Transamin was shifted to oral form. Under stable condition, she was discharged on 2023/10/26 and GI OPD Follow-up would was arranged later.    
  • Discharge prescription
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Transamin (tranexamic acid 250mg) 1# BID

• 2023-05-15 ~ 2023-05-17 POMR Gastroenterology Chen JiangHua

  • Discharge diagnosis
    • Gastric adenocarcinoma T4aN3aM1, stage IVB
    • post bleeding Anemia
  • CC
    • Tarry stool passage 7 times since yesterday
  • Present illness
    • This is a 92-year-old male with underlying disease of:
      • Gastric adenocarcinoma T4aN3aM1,stage IVB, with bleeding, with Chinese herbal decoction management.
      • Chronic anemia
      • Old CVA
      • CKD stage III
      • HTN
      • DM
      • HLD
    • This time, he suffered from tarry stool passage 7 times since yesterday. He was brought to our GI OPD for help. He denied fever, URI sympyoms, chest tightness, epigastric pain, abdominal pain found.
    • At GI OPD, blood test showed mild anemia (Hb:10 g/dL). PE showed no icteric sclera, soft abdomen, no leg pitting edema. Under the impression of favor gastric cancer with bleeding. He was admitted to our GI ward for management and further survey.
  • Course of inpatient treatment
    • After admission, we gaved IV PPI for suspect UGIB control. LPRBC was transfusioned for anemia. Since there was no tarry or bloody stool passage, she started oral diet as toleravle. Under relative stable condition, she was discharged on 2024/05/17.  

• 2023-04-05 ~ 2023-04-08 POMR Gastroenterology Chen JiangHua

  • Discharge diagnosis
    • Malignant neoplasm of stomach with bleeding
    • Acute posthemorrhagic anemia
  • CC
    • tarry stool for 3 times for a day.
  • Present illness
    • This is a 92-year-old male with underlying disease of:
      • Gastric adenocarcinoma T4aN3aM1,stage IVB, with bleeding
      • Chronic anemia
      • Old CVA
      • CKD stage III
      • HTN
      • DM
      • HLD
    • He was admitted on 2022/11/08 for GIB. PES revealed:
      • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3
      • Reflux esophagitis LA Classification grade A
    • Abdomonal CT reported gastric carcinoma T4aN3aM1, stage:IVB. Further biopsy showed adenocarcinoma. The patient and his family preferred to palliative care.
    • Recurrent tarry stool and anemia was noticed after admission. This time, the patient was found tarry stool for 3 times since 2023/04/05 morning. Accompanied symptoms included productive cough with whitish sputum for 2 days and chronic bilateral legs pitting edema for 5-6 years. There was no fever, chillness, nausea, vomiting, abdominal pain, dyspena, orthopnea, PND or chocking history recently.Due to the above problem, he was sent to our ER.
    • At ER, his consciousness was E4V5M6, vital signs were BP:143/63; HR:78; BT:36.5’C; RR:20; SpO2:97%. PE showed chronic weak ill-looking, moderate anemia conjunctiva, pitting edema(+).
    • Lab data revealed severe normocytic anemia (Hb 6.2, 4/3 Hb: 8.1) and impaired renal function (Cr: 1.31).
    • CXR showed Ground glass opacity in RLL.
    • Pantoprazole was given.
    • Under the impression of UGI bleeding, he was admitted for further care and management.
  • Course of inpatient treatment
    • After admission, we gaved use PPI pump for UGIB control. Also, we arranged PES to survey the lesion. LPRBC was transfusioned for anemia.
    • As times went by, the patient regained fair spirit, Lab data follow up showed health status improved. Under stable status of health, we discharged the patient on 2023/04/08.

• 2022-12-21 SOAP Psychosomatic Medicine Chen YiQian

  • Diagnosis
    • Unspecified dementia, unspecified severity, with behavioral disturbance [F03.91]
  • Prescription x3
    • Risperdal (risperidone 1mg) 1# HS
    • Exelon Patch (rivastigmine 4.6mg/24h, 9mg/patch) 1# QD EXT
    • Anxiedin (lorazepam 0.5mg) 1# PRNHS

• 2022-11-08 ~ 2022-11-21 POMR Gastroenterology Chen JiangHua

  • Discharge diagnosis
    • Gastric adenocarcinoma T4aN3aM1, stage IVB
    • Gastric cancer with one exposed vessel bleeding status post hemostasis with submucosal epinephrine injection and hemoclips on 2022/11/08
    • Reflux esophagitis Los Angeles grade Classification grade A
    • Osteoarthritis of right knee with acute inflammation
    • Type 2 diabetes mellitus
    • Hypertension
    • Chronic kidney disease, stage 3
    • Chronic obstructive pulmonary disease
  • CC
    • tarry stool for a period of time (Family doesn’t know the exact duration)
  • Present illness
    • This 92-year-old female has histories of hypertension, diabetes mellitus, hyperlipidemia, coronary arteriosclerosis under plavix control, dementia, old CVA and COPD for years under regular medication control. She COVID-19 was confirmed on 2022/09/23.
    • This time, she suffered from tarry stool for a period of time (Family doesn’t know the exact duration). She visited ER for help.
    • At ER, vital sign BT 36.4C, HR 96/min, RR 18/min, BP 125/61 mmHg, SpO2 94% under room air, consciousness was clear (GCS:E4V5M6).
    • Blood test showed leukocytosis (11.11*10^3/uL), but no left shift, anemia (Hb:7.1 mg/dL), renal dysfunction (BUN/Cr:46/1.38mg/dl), no electrolyte imbalance.
    • EGD was performed and revealed
      • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3.
      • Reflux esophagitis LA Classification grade A.
    • Medical treatment with Hemoclot 500mg IVD, blood transfusion with LPRBC, pantoloc 80mg IVD and 200mg in NS 500ml IVD 21ml/hr.
    • There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastric pain.
    • Under impression of gastrointestinal bleeding with anemia,she was admitted to GI ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission to GI ward, NPO with adequate IV fluid supply, NG with decompression and high dose PPI for Gastrointestinal bleeding.
    • Anemia was corrected using blood trnasfusion with LPRBC.
    • EGD on 2022/11/08 was reported 1.Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3. 2.Reflux esophagitis LA Classification grade A.
    • The pathology was showed ulcer with intestinal metaplasia and atypical glands.
    • Abdominal sonography was reported 1.Liver cyst,S2. 2.Renal cyst, both kidney.
    • Abdomonal CT was reported gastric Carcinoma T4aN3aM1, STAGE:IVB.
    • Second look EFD was performed on 2022/11/11 for gastric biopsy.
    • The pathology was showed adenocarcinoma.
    • Family meeting on 2022/11/11 with her family talk about operation and palliative care, that her family need discuss.
    • Oncologist was consulted and who suggested 1. Well discussion with patient and family. 2. Please check HBV and HCV status. 3. Please check the biopsy with MMR (Mismatch Repair), Her2, PD-L1. 4. May consider NGS.
    • Family meeting with oncologist Dr. Xia on 2022/11/18 with her family talk about chemotheraphy, that her family need discuss.
    • Oral intake trying was administered since 2022/11/10 and there was no tarry stool nor coffee ground.
    • IV PPI shifted to oral form with Nexium.
    • Right knee swelling with local heat was found on 2022/11/15. Orthologist was consulted and who suggested 1. Conservative treatment with activity restriction and avoid excessive knee flexion. 2. May consider joint aspiration if progressive painful swelling noted, but carries risk of infection. But still complaint right knee swelling, we contact Orthologist and who suggested if worse may need right knee aspiration and steroid injection. The right knee swelling with local heat was improved.
    • Under the stable condition,she was discharge on 2022/11/21 and GI OPD was arranged leater.
  • Discharge prescription
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Bisacodyl supp 10mg 1# PRNQOD RECT if constipation
    • Ultibro Breezhaler (indacaterol 100mug, glycopyrronium 50ug) 1# QD INHL
    • Atanaal (nefedipine 5mg) 1# PRNQ6H if SBP > 170

• 2022-09-23 ~ 2022-09-27 POMR Integrative Medicine Chen HengXiang

• 2021-08-27 ~ 2021-08-28 POMR Nephrology Hong SiQun

• 2020-11-02 ~ 2020-11-10 POMR Ear Nose Throat Su WanYu

• 2019-06-05 SOAP Urology Xie ZhengXing

  • Diagnosis
    • Unspecified urinary incontinence [R32]
    • Neuromuscular dysfunction of bladder, unspecified [N31.9]
  • Prescription
    • Wecoli (bethanechol chloride 25mg) 1# BID

• 2017-08-14 SOAP Cardiology Zhang HengJia

  • Diagnosis
    • Cerebral artery occlusion, with cerebral infarction [I63.50]
    • Acute cystitis [N30.01]
    • Cardiac dysrhythmia, unspecified [I49.9]
    • Chest pain,unspecified [R07.9]
    • HCVD, unspecified, without CHF [I11.9]
  • Prescription x3
    • Norvasc (amlodipine besylate 5mg) 1# BID
    • Uretropic (furosemide 40mg) 0.5# QD
    • Plavix (clopidogrel 75mg) 1# QD
    • Olmetec (olmesartan medoxomil 20mg) 1# BID

• 2017-07-27 SOAP Chest Medicine Huang JunYao

  • Diagnosis
    • Chronic airway obstruction (COPD), NEC [J44.9]
    • GERD [K21.9]
    • Allergic rhinitis [J30.0]
    • bilateral lung nodules [R91.1]
  • Prescription x3
    • Pulmicort (budesonide 64ug/dose) 1 puff QD perNA
    • Ultibro (indacaterol 110ug, glycopyrronium 50ug) 1# QD INHL
    • Allegra (fexofenadine 60mg) 1# BID
    • Welizen (famotidine 20mg) 1# BID
    • Shitan (bromhexine 8mg) 1# BID
    • Fucou (dextromethorphan, cresolsufonate, lysozyme) 1# BID

• 2017-06-12 SOAP Metabolism and Endocrinology Yu LiJiao

  • Diagnosis
    • Right pons infarction on 2016/11/30 with left hemiparesis [I63.8]
    • Hypertension [I10]
    • Type 2 diabetes mellitus with hyperglycemia [E11.65]
    • Pure hypercholesterolemia [E78.0]
  • Prescription x3
    • Tulip (atorvastatin 20mg) 0.5# QD
    • Plavix (clopidogrel 75mg) 1# QD
    • Grumed (glimepiride 2mg) 0.5# QDAC
    • Trajenta (linagliptin 5mg) 1# QD
    • Uformin (metformin 500mg) 1# QD

[surgical operation]

• 2020-11-03 - Op Method:
  • Emergent incision and drainage of deep neck infection, right
  • Finding:
    • abscess over right submental deep neck
    • pus culture done
    • DM, HT, HCVD, angina, COPD, hyperlipidemia, senile = thus LA operation was advised by the superintendent

==========

2024-01-29

[addressing continuous high glucose readings]

During this hospital stay, 4 serum glucose measurements consistently showed values around 300 mg/dL despite the administration of regular insulin and oral antihyperglycemic agents. If hyperglycemia persists, consideration may be given to adding basal insulin to the regimen.

700185693

240129

[exam findings]

• 2023-11-29 Patho - soft tissue tumor, extensive resection
  • Diagnosis:
    • Ovary, left, laparoscopic debulking surgery — clear cell carcinoma, and endometrioma
    • Ovary, right, laparoscopic debulking surgery — negative for malignancy
    • Fallopian tube, bilateral, laparoscopic debulking surgery — negative for malignancy
    • Cervix, laparoscopic debulking surgery — severe dysplasia (CIN3) with glandular involvement
    • Myometrium, laparoscopic debulking surgery — adenomyosis
    • Endometrium, laparoscopic debulking surgery — negative for malignancy
    • Lymph node, left iliac, dissection — negative for malignancy
    • Lymph node, left obturator, dissection — negative for malignancy
    • Lymph node, right iliac, dissection — negative for malignancy
    • Lymph node, right obturator, dissection — negative for malignancy
    • Omentum, laparoscopic debulking surgery — negative for malignancy
    • AJCC 8th edition pathology stage: pTIc1N0(if cM0); FIGO stage: IC1
  • Gross description:
    • Procedure (select all that apply)
      • laparoscopic debulking surgery (total hysterectomy + bilateral salpingo-oophorectomy + BPLND + omentectomy) and laparoscopic fulguration of pelvic endometriosis
    • Specimen size:
      • Uterus: 8x 6x 6X 5 cm, 63-g
      • Ovary, left: 8x 8 cm
      • Ovary, right: 3x 2x 1 cm
      • Fallopian tube, right: 5 cm in length and 0.4 cm in diameter
      • Fallopian tube, left: 5 cm in length and 0.4 cm in diameter
      • Omentum: 10x 3x 1 cm
      • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
    • Specimen Integrity
      • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.
      • Specimen Integrity of Left Ovary (if applicable): Capsule ruptured
      • Specimen Integrity of Right Ovary (if applicable): Capsule intact
      • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
      • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
    • Tumor Site:
      • Note: Please select the primary tumor site only
      • Left ovary
    • Ovarian Surface Involvement (required only if applicable):
      • Absent
    • Fallopian Tube Surface Involvement (required only if applicable):
      • Absent
    • Tumor Size
      • Note: For bilateral tumors, please report maximum dimension for each primary tumor, specifying by laterality.
      • Greatest dimension (centimeters): 5 cm
      • Additional dimensions (centimeters): 3 x 2 cm
    • Sections are taken and labeled as: F2023-536FSA1-2 and A1-6:left ovarian tumor, F2023-527A5: left tube, A1-2:right adnexae, A3:cervix, A4-5:coprus, A6:omentum, A7:left iliac LN, A8:left obturator LN, A9: right iliac LN, A10:right obturator LN
  • Microscopic Description:
    • Histologic Type:
      • Clear cell carcinoma
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
      • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.)
      • WHO Grading System
      • Not applicable
    • Implants (required for advanced stage serous/seromucinous borderline tumors only)
      • Note: Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.
      • Not applicable
    • Other Tissue/ Organ Involvement (select all that apply):
      • Not identified
    • Largest Extrapelvic Peritoneal Focus (required only if applicable)
      • Not applicable
    • Peritoneal/Ascitic Fluid
      • Negative for malignancy
    • Regional Lymph Nodes:
      • Left iliac — negative for malignancy (0/3)
      • Left obturato — negative for malignancy (0/13)
      • Right iliac — negative for malignancy (0/3)
      • Right obturator — negative for malignancy (0/10)
    • Additional Pathologic Findings
      • Cervix: severe dysplasia (CIN3) with glandular involvement
      • Myometrium: adenomyosis
    • Immunohistocehncial stains — Napsin A (+), p16: negative( weak, < 5%), p53: wild type (weak to moderate, 50%).
• 2023-11-10 SONO - thyroid
  • Autoimmune thyroid disease
• 2023-10-11 CT - abdomen
  • Indication: p0, SEX (-). r/o chocolate cyst and adenomyosis
  • Findings:
    • There is a cystic mass in left adnexa with mild wall thickening and enhancing mural nodule, measuring 7.8 cm in size (the largest dimension).
      • Cystic adenocarcinoma of left ovary is highly suspected.
      • The differential diagnosis includes cystic adenoma.
  • Impression:
    • Cystic adenocarcinoma of left ovary 7.8 cm is highly suspected.
    • The differential diagnosis includes cystic adenoma.
• 2023-10-09 Gynecologic ultrasonography
  • IMP: R/O LT Ovarian cystic mass: 75mmx73mm, papillary: (37mmX27mm), no blood flow
• 2023-10-09 ENT Hearing Test
  • Tymp bil type A
  • ART RE contra 2000-4000 Hz and LE contra 500 ,4000 Hz absent
  • PTA:
    • Reliability FAIR
    • Average RE 11 dB HL; LE 16 dB HL
    • bil WNL except LE 4000 Hz absent
• 2023-08-07 ENT Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 8 dB HL, WNL
    • L’t : 16 dB HL, normal to mild SNHL
  • Tymp
    • R’t : Type As
    • L’t : Type A
  • ART
    • Bil contra absent.
• 2021-09-24 Neurosonograpy
  • Adequate total VA flow volume (154 ml/min).
  • Normal extracranial carotid, vertebral arterial flows.
• 2021-09-24 ENT Hearing Test
  • Tymp:
    • Bil type A
  • ART:
    • Bil WNL.
  • PTA
    • Reliability FAIR
    • Average RE 9 dB HL; LE 20 dB HL.
    • R’t WNL.
    • L’t normal to mild SNHL.
• 2021-09-24 OVEMP
  • cVEMP: Interaural Amplitude Asymmetry ratio : 11.17%, <35%, WNL.
  • oVEMP: Bil show no response.

[MedRec]

• 2024-01-26 SOAP Gastroenterology Xiao ZongXian
  • S: Bowel irritability after meal.
  • A: Possible chemotherapy-induced GI sx
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Dicetel (pinaverium bromide 100mg) 1# BID
    • Ulstop (famotidine 20mg) 1# BID
• 2024-01-16 SOAP Infectious Disease Yang QinHui
  • S: referred from Onco for URI
    • sorethroat, running nose, sneezing and ocugh for days
    • hx of ovary cancer under C/T
  • Prescription
    • Xyzal (levocetirizine 5mg) 1# QD
    • Actein Effervescent (acetylcisteine 600mg) 1# BID
    • ZCough (benzonatate 100mg) 1# TID
    • Acetal (acetaminophen 500mg) 1# PRNQ6H if fever BT > 38’C
• 2024-01-16 SOAP Cardiology Liu ZhiRen
  • S
    • Cystic adenocarcinoma of left ovary s/p first chemotherapy, palpitation off andon for 2 days just after C/T
    • improved now
    • Hx of MVP, COVID-19(+) 2023-03
    • occasionally cough
    • exertional dyspnea, mild, no chest pain
      
    • insmonia and anxiety
  • O
    • BP: 145/72; HR: 89;
    • 2024-01 ECG: Normal
    • 2023-12 CXR: Normal
    • 2023-11 Normal thyroid function
    • DM-
    • HTN-
    • asthma-
    • smoking-
    • NKA
    • RHB, no mur
    • BSclear
    • no leg edema
  • Prescription
    • Pronolol (propranolol 10mg) 1# PRNTID
• 2024-01-16 SOAP Psychosomatic Medicine Li JiaFu
  • Diagnosis
    • Unspecified Anxiety Disorder [F41.9]
    • Major Depressive Disorder, Single Episode, Moderate [F32.1]
  • Prescription
    • Lexapro (escitalopram 10mg) 0.5mg QN
    • Anxiedin (lorazepam 0.5mg) 1# QN
    • Alpraline (alprazolam 0.5mg) 1# PRNBID
    • Eurodin (estazolam 2mg) 1# PRNHS
• 2023-12-29 SOAP Gastroenterology Xiao ZongXian
  • S
    • For HBV prophylaxis
    • Dyspeisia recently
  • A: Resolved HBV - On prophylaxis of antiviral therapy for chemotherapy since 2023/12/29
  • Prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
• 2023-11-27 ~ 2023-12-03 POMR Obstetrics and Gynecology Chen GuoHu
  • Discharge diagnosis
    • Malignant neoplasm of left ovary
    • Left ovarian cancer, post laparoscopic debulking surgery (laparoscopic total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + omentectomy) and laparoscopic fulguration of pelvic endometriosis on 2023/11/28
    • Endometriosis of pelvic peritoneum
    • Pelvic peritoneal adhesions
  • CC
    • Progressive LY ENLARGINHG left ovarian cystic mass for six months.
  • Present illness
    • This is a 60 years old female, G0P0, sex(-), menopause at 52 years old, with A past history of breast cancer stage II status post left partial mastectomy with chemotherapy and radiation therapy 20+ years ago at Cardinal Tien Hospital, and hyperthyroidism 20+ years ago with regular follow-up without medication. She denied food or drug allergy, and denied hormone and illicit drug usage.
    • According to the patient, she had regular follow-up of breast cancer at Cardinal Tien Hospital, where sonography showed ovarian mass and the doctor suggested follow-up after 3 months. She then came to our OPD for consultation. She denied abdominal pain, increased vaginal discharged, urinary incontinence, dyuria, diarrhea or constipation. GYN Sonography on 2023/10/09 showed uterus size 49x26mm, endometrium thickness 5.5mm, but progression in size of the left ovarian cystic mass: 75x73mm, and papillary content 37x27mm without blood flow, and no ascites. Abdominal CT showed that cystic adenocarcinoma of left ovary 7.8 cm is highly suspected with the differential diagnosis including cystic adenoma. Tumor markers were within normal range (CA125 5.1 U/mL, CEA 1.42 ng/mL).
    • After discussing with the doctor, she asked for surgical intervention. The operation and complication had been fully explained to the patient and her family.
    • She was then admitted to the ward on 2023/11/27 for preparation of Laparoscopic Left salpingo-oophorectomy + frozen section or debulking depending on the frozen pathology report, and further management.
  • Course of inpatient treatment
    • The patient was admitted on 2023/11/27. She underwent laparoscopic Left salpingo-oophorectomy during the operation, and frozen section pathology of the left ovary showed malignant tumor. The debulking surgery (laparoscopic total hysterectomy and bilateral salpingo-oophorectomy + omentectomy + bilateral pelvic lymph node dissection) + laparoscopic fulguration of pelvic endometriosis + enterolysis were then done on 2023/11/28.
    • We gave her Cefazolin and Gentamycin IV form for 3 day and then shifted her antibiotics to Cephalexin oral form.
    • Post-operation wound was dry and clean without dehiscence, discharge, or oozing. Her lab data on 2023/11/28 also showed elevated WBC without fever. Her condition was stable without fever and special complaints since 3 days after the debulking surgery. After flatus, her eating, self voiding and defecation were all ok. The JP drain was removed on 2023/12/2 smoothly. Since all her general conditions were all improved and relatively stable, we arranged discharge on 2023/12/03 for her for further OPD follow up of her recovery status and surgical wound conditions.
  • Discharge presciption
    • Acetal (acetaminophen 500mg) 1# QID
    • Alpraline (alprazolam 0.5mg) 1# TID
    • cephalexin 500mg 1# QID
    • diphenidol 25mg 1# TID
    • Eurodin (estazolam 2mg) 1# PRNHS
    • MgO 250mg 1# QID
    • Through (sennoside 12mg) 2# HS
• 2021-11-22, -09-20 SOAP Metabolism and Endocrinology Guo XiWen
  • Diagnosis
    • Nontoxic goiter, unspecified [E04.9]
    • Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm [E05.00]
  • Prescription x3
    • Cardiolol (propranolol 10mg) 1# QD
    • methimazole 5mg 2# QD
• 2020-04-17 SOAP Metabolism and Endocrinology Zhang YaLi
  • Diagnosis
    • Nontoxic goiter, unspecified [E04.9]
  • Prescription x3
    • Polupi (propylthiouracil 50mg) 1# QW14
    • propranolol 10mg 1# PRNQD

[surgical operation]

• 2023-11-28
  • Op Method:
    • laparoscopic debulking surgery (total hysterectomy + bilateral salpingo-oophorectomy + BPLND + omentectomy) and laparoscopic fulguration of pelvic endometriosis
  • Finding:
    • Uterus: 7x6x5cm, normal-looking
    • LOV and tube
    • tumor rupture due to severe adhesion
    • LOV: 8x8cm cystic tumor with septums, mural part and chocolate fluid inside, suspected ovarian endometrioma
      • Frozen section pathology of left ovary: malignancy
      • left fallopian tube – grossly normal
    • ROV: 2x2cm, grossly normal
      • right fallopian tube – grossly normal
    • omentum, peritoneum, liver and bowels – seemed free of cancer invasion
    • CDS: no fluid but severe pelvic endometriosis (AFS score > 40) and pelvic adhesion were noted between post uterus, left adnexum, left pelvic wall, US ligament, sigmoid colon and rectum and s/p laparoscopic fulguration of pelvic endometriosis and lysis
    • After the surgery, optimal debulking was achieved
    • A 7 mm JP drain was placed in CDS

[chemotherapy]

• 2024-01-29 - paclitaxel 175mg/m2 257mg NS 250mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2024-01-08 - paclitaxel 175mg/m2 258mg NS 250mL 3hr + carboplatin AUC 5 825mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-01-29

[reconciliation]

Medications prescribed by specialists in family medicine and gastroenterology on 2024-01-26, and by cardiologists and psychosomatic medicine experts on 2024-01-16, are generally listed in the current active medication roster without issues noted.

700214839

240129

[exam findings]

• 2024-03-16 MRI - L-spine

  • Indication: left breast cancer with liver, bone matestasis, stage IV, s/p left partial mastectomy, axillary lymph node on 2018-01-31 s/p Epirubicin/Endoxan/Fluorouracil x4 (2018/02/22 ~ 04/27), tyrosine hydroxylas s/p Nolbaxol/Herceptin (2018/05/19-07/02). Recurrent multiple spine metastases in 2023-09. s/p C6 corpectomy, reconstruction with VDRS artificial bone, C5-7 plating on 2023/09/21, s/p radiotherapy (2023/10/06 - 11/15), liver, T-spine metastsis s/p radiotherapy with TPH (2023/12/04 ~).
  • Findings:
    • Multiple bone lesions in vertebral column, either enhancing (T8, T9 and T12), T1 and T2-hypointensity and non-enhancing (L1-5 and S1), or T2-hyperintensity (bilateral iliac bones). C/W Multiple bony metastases s/p radiochemotherapy.
    • No intramedullary lesion.
    • Bilateral pleural effusion, more prominent on right side.
  • IMP:
    • Multiple bony metastases involving vertebral column, s/p treatment.

• 2024-03-06 Nasopharyngoscopy

  • rt vocal palsy, minimal gap, LPR

• 2024-03-04 Tc-99m MDP bone scan with SPECT

  • Several new lesions of increased radioactivity in both rib cages, and some of previous old lesions in the sternum, spines, left S-I joint, left acetabulum, and right femoral trochanters become more evident, indicating metastatic bone disease in progression.
  • Suspected benign lesions at bilateral shoulders, right S-I joint, and knees.

• 2024-03-01 CT - chest

  • Diagnosis: Invasive carcinoma of no special type of the left breast, ER: (+, 75%); PR (+, 25%); Her2/neu: Positive (score＝3+), AJCC Pathologic Stage — pT2N1a(3/4)(cM0), stage IB, s/p partial mastectomy and axillary lymph nodes dissection, adjuvant chemotherapy, radiotherapy, Herceptin, and s/p endocrine therapy. Bone mets noted in Sep 2023. s/p spine C6 mets resection.
  • Chest CT with and without IV contrast ehnancement shows:
    • Mild atelectatic change at right lower lobe is found.
    • S/P mastectomy at left chest.
    • Mild right pleural effuison is found.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Very tiny nodules at right lower lobe is found. Lung meta is favored and the lesions regressed markedly.
    • Low density lesions are found at both lobes of liver. Liver meta is considered. In comparison with CT dated on 2023-11-20, the lesions decreased in size.
    • Low density change at pancreatic body is noted. Pancreas meta is considered.
  • Imp:
    • Left breast cancer s/p op. with lung, liver and bone meta. In much regression.

• 2024-03-01 SONO - breast

  • Diagnosis
    • Bil. fibroadenomas
    • s/p left breast operation
  • BI-RADS: 2. benign finding

• 2023-12-13 Nasopharyngoscopy

  • rt vocal palsy, LPR

• 2023-12-05 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (77 - 20) / 77 = 74.03%
    • M-mode (Teichholz) = 75

• 2023-11-20 CT - chest

  • Indication: Invasive carcinoma of the left breast s/p partial mastectomy and axillary lymph nodes dissection, adjuvant chemotherapy, radiotherapy and s/p endocrine
  • Findings comparison made with CT on 2023/10/06
    • Lungs: numerous randomly distributed pulmonary nodules of varying sizes due to metastases.
      • newly developed small Lt pleural effusion.
    • liver: multiple tumors of variable sizes in both lobes of liver due to metastases in progression as compared CT on 2023/10/06.
    • mediastinum: regression of meastatic lymphadenopathies in the visceral space and left anterior prevascular space, and both hila.
    • Thoracic aorta and central pulmonary arteries: normal caliber. Heart: normal size of cardiac chambers.
    • Visible abdominal-pelvic contents: mild dilatation of CHD and CBD that may be secondary to S/P cholecystectomy
    • Rt Lt bilateral renal cysts stone measuring up to cm (longest axial diameter)
    • a hepatic cyst multiple hepatic cysts measuring up to
    • Visualized bones: destructive lytic change in spine and manubrium of sternum
  • Impression:
    • Lt breast cancer s/p op. with lung, mediastinal and hilar LNs hepatic, and bones metastasis, in progression of hepatic metastassis and regression of mediastinal and hilars LNs metastases as compared with CT on 2023/10/06.

• 2023-11-17 Bronchodilator Test, BCT

  • There is mild restrictive lung defect.
  • The bronchodilator test is boderline.
  • Small airway disease was suspected.

• 2023-11-10 CXR erect

  • Multiple nodules of in both lungs due to metastases.
  • Enlargement of hila and superior mediastinal widening due to lymph node enlargement
  • Osteolytic metastasis spine

• 2023-10-06 CT - chest

  • Indication: Breast cancer with multiple bone mets
  • Chest CT without IV contrast ehnancement shows:
    • Tiny(< 1.0cm) nodules at bilateral lung fields are found. Lung meta is considered.
    • Some homogeneous soft tissue lymph nodes are found in the mediasitnum is found.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Necrotic tumors at both lobes of liver up to 5.0cm in largest dimension. Liver meta is considered.
    • The GB is well distended without soft tissue lesion
  • Imp:
    • Diffuse lung and liver meta. Mediastinal lymphadenopathy. Bone meta.

• 2023-09-27 Tc-99m MDP bone scan

  • Highly suspected multiple bone metastases in some C-, T- and L-spine, sternum, left sternoclavicular junction, left pelvic bones, left S-I joint, left acetabulum, and right femoral trochanters.
  • Suspected benign lesions in both rib cages, bilateral shoulders, right S-I joint, and knees.

• 2023-09-25 MRI - L-spine

  • Thoraco-lumbar spine MRI without and with IV Gd-DTPA administration shows:
  • Findings
    • Multiple bone destructions at thoraco-lumbar spine and bil. pelvic bones, especially at T12, L1, L3.
    • After IV contrast administration shows well or heterogenous enhancement of the masses or tumors.
  • IMP:
    • Multiple bone metastases/destructions at thoraco-lumbar spine and bil. pelvic bones, especially at T12, L1, L3.

• 2023-09-21 Patho - bone resection

  • C6 vertebrae and C56/C67 disc, C6 corpectomy — Metastatic invasive carcinoma, consistent with breast primary
  • The specimen submitted consists of multiple pieces of yellow gray bondy tissue, labeled C6 vertebrae and C56/C67 disc, measuring up to 0.5 x 0.4 x 0.3 cm and weighing 0.3 gm. All for section after decalcification.
  • The sections show a picture consistent with metastastic breast invasive carcinoma of no special type, composed of bony tissue and cartilaginous tissue with nests and cords of polygonal neoplastic cells in fibrous stroma. Extensive tumor necrosis is present.
  • IHC, the tumor cells show following features:
    • ER (Ab): Negative
    • PR (Ab): Negative
    • HER-2/Neu (Ab): Positive (score= 3+)
    • GATA3: Focally positive

• 2023-09-16 MRI - C-spine

  • Acute compression fracture of C6 vertebra. R/O pathologic fracture.
  • Enhancing lesions over C3, C6 and T1 vertebral bodies, favor metastases.
  • Retrolisthesis of C5 on C6, grade I.

• 2023-09-15 KUB + L-spine Lat

  • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
  • r/o Bone metastasis in left pubic bone.

• 2023-09-14 C-spine AP + Lat

  • Degenerative change of the cervical spine with narrowed intervertebral disc spaces,narrowed neuroforamina and spurs formation.

• 2023-02-17 Mammography

  • Impression:
    • Dense breast.
    • Post-op with breast tissue reduction in left breast. Benign calcifications in right breast.
  • BI-RADS: Category 2: benign findings.-annual screening.

• 2023-02-17 SONO - abdomen

  • Right liver calcification (0.47cm).
  • Bil. liver cysts (up to 1.55cm).
  • Left renal angiomyolipoma (0.44x0.46cm).

• 2023-02-17 SONO - breast

  • Diagnosis
    • Bil. fibroadenomas
    • s/p left breast operation
  • BI-RADS: 2. benign finding

• ….-..-..

• 2018-01-31 Surgical pathology Level VI

  • Clinical diagnosis: Malignant female breast neoplasm, NOS;
  • PATHOLOGIC DIAGNOSIS
    • Breast, left, partial mastectomy —- Invasive carcinoma of no special type, grade 2
    • Resection margins, ditto — Free of tumor invasion
    • Skin, ditto — Free of tumor invasion
    • Nipple, ditto — not received
    • Lymph node, level I — Positive for tumor metastasis (3/4) with extracapsular extension (1/3)
    • Lymph node, level II — No lymph node (0/0)
    • AJCC Pathologic Stage — pT2N1aMx, stage IB at least
  • MACROSCOPIC EXAMINATION
    • Breast: 7 x 6.5 x 4.2 cm
    • Skin: 7 x 1.4 cm
    • Nipple: not received
    • Tumor: 3.7 x 2.6 x 2.2 cm
    • Resection Margins: Free of tumor invasion, 1.4 cm to “down”, 2.1 cm to “up”, 2.3 cm to “in”, 2.5 cm to “out”, and 0.5 cm to base
    • Lymph node: axillary LN (level I and level II)
    • Representative sections: A1-A5: breast tumor and skin; B1-B3: level I; C: level II.
      • Reference: frozen: S2018-01971: FSA1-FSA2: down margin (1 piece, 3.5 x 2 x 0.5 cm); FSB: inner margin (1 piece, 2.5 x 2 x 0.5 cm)
  • MICROSCOPIC EXAMINATION (FOR INVASIVE CARCINOMA)
    • Histologic type: Invasive carcinoma of no special type
    • Size of invasive carcinoma: 3.7 x 2.6 x 2.2 cm
    • Histologic grade (Nottingham histologic score): Grade II (score 6)
      • 1. Tubule formation: score 2; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 2
    • Margins: Free of tumor invasion, 1.4 cm to “down”, 2.1 cm to “up”, 2.3 cm to “in”, 2.5 cm to “out”, and 0.5 cm to base
    • Nodal status: Positive for tumor metastasis (3/4) with extracapsular extension (1/3)
    • Treatment Effect: not applicable
    • Immunohistochemistry: refer to S2018-01044

• 2018-01-25 Tc-99m MDP bone scan

  • Increased activity in the lower C-spine and L3-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, bilateral S-I joints and hips, compatible with benign joint lesion.

• 2018-01-17 SONO - breast

  • Diagnosis
    • Highly suspicious of malignancy, with sonographic positive axillary LAP, multifocal, left 1/3 and 1.5/4 lesions.
  • BI-RADS:
    • 4B - intermediate suspicion of malignancy Biopsy Should Be Considered.

• 2018-01-17 Surgical pathology Level IV

  • Breast, left, core biopsy — Invasive carcinoma, NST (no special type). An addendum report of the result of ER, PR, Her2/neu, Ki-67, and p53 will be followed.
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration. An addendum report of the result of ER, PR, Her2/neu, Ki-67, and p53 will be followed.
  • IHC stain: ER: (+, 75%); PR (+, 25%); Her2/neu: Positive (score=3+), 95%; Ki-67: 40%; p53: 75%.

[MedRec]

• 2023-10-05 SOAP Hemato-Oncology Xia HeXiong
  • S
    • Treatment course:
      • s/p partial mastectomy and axillary lymph nodes dissection
      • Adjuvant chemotherapy (since 2018/02/22 AC follow by TH)
      • Adjuvant R/T (2018-09-18 ~ 2018-10-31: 5000cGy/25 fractions of the left breast to left SCF, and 6000cGy/30 fractions of the left breast tumor bed (scar) area.)
      • Adjuvant Herceptin (until 2019/05)
      • Adjuvant endocrine therapy (tamoxifen since 2018/09- (? or 2019-06-12) to 2023-06-14)
    • Recurrence over C3, C6 and T1 and L (MRI an Bone scan) vertebral bodies, favor
      • s/p C6 corpectomy to remove cervical spine metastasis
      • reconstruction with VDRS artificial bone+ C5-7 plating
      • R/T 30 Gy/ 10 fx to the multiple mets region, C-spine and sternoclavicular region
  • P
    • Arrange Chest/Abd/Pelvis CT in 2023-10
    • Breast sono Q1Y, next in 2024-01
    • Mammo Q1Y, net in 2024-03
    • Apply CDK4/6 + letrozole
• 2023-10-03 SOAP Radiation Oncology Wang YuNong
  • O
    • 2023/09/27 Tc-99m MDP whole body bone scan
      • Highly suspected multiple bone metastases in some C-, T- and L-spine, sternum, left sternoclavicular junction, left pelvic bones, left S-I joint, left acetabulum, and right femoral trochanters.
    • 2023/09/25 MRI: L-spine
      • Multiple bone destructions at thoraco-lumbar spine and bil. pelvic bones, especially at T12, L1, L3.
    • 2023/09/21 PATHO - bone resection
      • C6 vertebrae and C56/C67 disc, C6 corpectomy — Metastatic invasive carcinoma, consistent with breast primary
    • 2023/09/16 MRI: C-spine
      • Acute compression fracture of C6 vertebra. R/O pathologic fracture.
      • Enhancing lesions over C3, C6 and T1 vertebral bodies, favor metastases.
  • P:
    • CT-simulation for L-spine mets and pelvic and femoral mets will be done today.
    • Plan to deliver 30 Gy/ 10 fx to the multiple mets region. RT will start aorund 2023/10/09.
    • RT for the C-spine and sternoclavicular region will be arranged the the current Tx completes.
• 2023-09-15 ~ 2023-09-28 POMR Neurosurgery Hong LiWei
  • Discharge diagnosis
    • Acute compression fracture of cervical 6 vertebra, metastatic invasive carcinoma status post C6 corpectomy to remove cervical spine metastasis and reconstruction with VDRS artificial bone + C5-7 plating on 2023-09-20
    • Secondary malignant neoplasm of bone
    • Cervicalgia
    • Radiculopathy, cervical region
    • Malignant neoplasm of unspecified site of left female breast
  • CC
    • Neck soreness about 5 months, severe recurrent trapezius region pain brachialgia has been persistent for months, more sever of right side, associated with numbness in right hand a weeks.
  • Present illness
    • This 56 years old female patient had left breast cancer s/p left partial mastectomy + axillary lymph node dissection on 2018-01-31. Adjuvant chemotherapy with Epirubicin 90mg/m2 + Endoxan 600mg/m2 + Fluorouracil 500mg/m2 x4 course erery three weeks since since 2018/02/22 to 2018/04/27, then tyrosine hydroxylase (Nolbaxol 75mg/m2+ Herceptin 6mg/m2) since 2018/05/19-2018/07/02.
    • She was suffered from neck soreness about 5 months, severe recurrent trapezius region pain brachialgia has been persistent for months, more sever of right side, associated with numbness in right hand a weeks. Pain got worse at early morning and just awakened from sleep. She also complained itchy throat and frequent coughing, she visited to Orthopedics clinic first, but owing to ineffective conservative treatment and frequent recurrences. She visited our clinic, X-ray showed C5-6 vertebrae osteolytic picture, r/o metastasis. Then, she was admitted to neuro ward for further survey and treatment.
    • No trauma history
  • Course of inpatient treatment
    • Upon admission, C-spine MRI with contrast showed:
      • Acute compression fracture of C6 vertebra. R/O pathologic fracture;
      • Enhancing lesions over C3, C6 and T1 vertebral bodies, favor metastases.
      • Retrolisthesis of C5 on C6, grade I.
    • We also consulted Radiology and Oncology for further evaluation, who suggestion:
      • Please check CEA, CA-153, LDH, serum EP, albumin/globulin, ALK-P;
      • C-spine surgery biopsy for tissue proof.
    • After well explained to the patient about MRI findings. We informed that operation is a treatment option for cervical spine metastasis with cord compression and unstable spine. But the patient hesitated. Finally she decided operation.
    • Postoperative course was uneventful. Analgesic agents were used for wound pain control. One JP drain was inserted and record amount Q8H. Her neck and right shoulder pain got improved. C-spine X-rays showed good positions of implants.
    • She complained of right thigh sorness. L-spine MRI with contrast was performed on 2023/09/25 and revealed multiple bone metastases/destructions at thoraco-lumbar spine and bil. pelvic bones, especially at T12, L1, L3. JP drain was removed on 2023/09/25.
    • Dentistry was consulted for dental evaluation prior to Xgeva use.
    • The wounds were clean and dry. She was discharged and outpatient follow-up was mandatory. Sutures would be removed at outpatient.
  • Discharge prescription
    • Celebrex (celecoxib 200mg) 1# BID
    • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# TID
    • Through (sennoside 12mg) 2# HS
    • Sindine (povidone iodine aq soln) ASORDER EXT
• 2023-09-14 SOAP Neurosurgery Hong LiWei
  • S
    • neck pain, radiate to bil. shoulder pain (R>L) and right upper arm, for 1 month
    • s/p left partial mastectomy and axillary LN dissection on 2018/01/31, pT2N1aM0, stage IB, ER: (+, 75%); PR (+, 25%); Her2/neu: Positive (score=3+), 95%; Ki-67: 40%; p53: 75%
    • menopausal after chemotherapy
    • phx: breast ca.
  • O
    • E4V5M6
    • pupil: 3+/3+
    • MP R L
    • UE 5 5
    • LE 5 5
    • paresthesia
    • SLRT
    • patrick test
    • tineal test
    • x ray showed C56 vertebrae osteolytic picture, r/o metastasis
  • A
    • neck pain, radiate to bil. shoulder pain (R>L) and right upper arm, x ray showed C56 vertebrae osteolytic picture, r/o metastasisneed MRI c+-
    • 9/15 admission, arrange MRI C+- of C-spine
    • h/s hydration+acetylcysteine 1pc bid for renal protection

[consultation]

[surgical operation]

• 2023-09-21
  • Surgery
    • C6 corpectomy to remove cervical spine metastasis
    • reconstruction with VDRS artificial bone+ C5-7 plating
    • C-arm and microscope assisted
  • Finding
    • under c-arm localization
    • split platysma muscle
    • split to pre-vertebral space via medial side of carotid sheath
    • dissect bilateral longus coli muscle
    • set retraction screws on C5 and C7 body
    • do C56, C67 discectomy first
    • do C6 corpectomy to remove spinal metastasis, send pathology
    • insert VDRS artificial bone, length: 2.15cm
    • do C5-7 plating with screws fixation
    • plate: 4.2cm, screws: 1.4cm*4
    • well hemostasis
    • set vacuum ball*1
    • close wound layer by layer

[immunochemotherapy]

• 2024-05-25 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-05-03 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-04-09 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-03-15 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-02-17 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-27 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-30 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-04 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

Xgeva (denosumab 120mg)

• 2024-05-24 Xgeva (denosumab 120mg) SC ST IPD
• 2024-04-22 Xgeva (denosumab 120mg) SC Q1M OPD
• 2024-03-15 Xgeva (denosumab 120mg) SC ST IPD
• 2023-12-02 Xgeva (denosumab 120mg) SC ST IPD

==========

not posted yet

[Bard]

Missing the loading dose of Pertuzumab (840mg) and instead using a 420mg dose requires careful consideration, as its impact on treatment efficacy and potential risks depends on several factors:

1. Timing of missed dose:

Early in the treatment course: Missing the loading dose early on can significantly impact initial drug exposure and potentially weaken treatment efficacy. In this case, resuming with the recommended maintenance dose (420mg every 3 weeks) might not be sufficient to compensate. Later in the treatment course: If several loading doses have already been administered, the impact of missing one dose might be less significant, offering more leeway for resuming with the maintenance dose.

2. Reason for missing the dose:

Accidental: If the omission was accidental and unlikely to occur again, resuming with the maintenance dose may be acceptable after discussing it with your doctor.

[cGPT]

Missing the full loading dose of 840 mg and instead using a 420 mg dose could have implications for the effectiveness of the treatment, especially in the initial stages. Here are some potential considerations and impacts:

Reduced Initial Drug Levels:

The purpose of the loading dose is to quickly achieve effective drug levels in the body. Using only half of the intended loading dose may result in lower drug concentrations initially, which might reduce the effectiveness of the treatment during the early phase. Delayed Therapeutic Effect:

It might take longer to reach the therapeutic levels of pertuzumab in the bloodstream, potentially delaying the onset of the drug’s therapeutic effects. Adjustment of Subsequent Doses:

If the loading dose is missed or reduced, healthcare providers might need to adjust subsequent doses to achieve the desired drug levels. This could involve administering an additional dose or modifying the maintenance doses, though such adjustments should be based on clinical judgment and the specific circumstances of the treatment.

Clinical Decision and Monitoring:

In cases where the loading dose is not administered as recommended, it’s important for healthcare providers to closely monitor the patient’s response to treatment and adjust the dosing regimen as necessary. This might include more frequent assessments of tumor response and monitoring for side effects.

701494845

240129

[exam findings]

• 2023-12-07 CT - chest
  • Indication: Peripheral T-cell lymphoma, stage IV, CD3 (+, diffuse), CD20 (focal+ at background B cells), CK(-), CD4(+, diffuse), CD8(+), CD56(focal+, 1%), Ki-67 index: 50%, EBV (+)
  • Chest CT with and without IV contrast ehnancement shows:
    • Tiny nodule at url measuring 0.26cm in largest dimension. (Se202 IM37).
    • One ground glass nodule at right middle lobe measuring 0.2cm is also found. (Se202 Im99). Suggest follow up
    • Very small lymph nodes are found at paraaortic region. The findning in non-specific
  • Imp:
    • No evidence of lymphadenopathy in the study
    • Tiny lung nodules at right lung. Suggest regular follow up.
• 2023-09-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (88.6 - 21.9) / 88.6 = 75.28%
    • M-mode (Teichholz) = 63.1
    • 2D (M-Simpson) = 62.8
  • Conclusion:
    • Normal AV/MV, no AR, No MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, no TR, normal IVC size
• 2023-09-11 PET
  • Glucose hypermetabolism lesions in bilateral neck regions, SCF, left axilla, mediastinum, celiac lymph nodes, bilateral para-aortic space, and pelvis, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    
  • Glucose hypermetabolism lesions in the spleen and in skeleton including scapulae, left rib, pelvic bones, and femurs, highly suspected lymphoma with involvement of spleen and bone marrow.
    
  • Highly suspected lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-08-31 Patho - lymph node region resection
  • Lymph node, neck, left, excision — Malignant lymphoma — Peripheral T cell lymphoma, NOS (addendum)
  • Operation procedure: Excision; Topology: left neck; Specimen size and number: 1 piece, 5.2x 4.4x 3.6 cm in size
  • Immunohistochemical stain profiles: CD3 (+, diffuse), CD20 (focal+ at background B cells), CK(-), CD4(+, diffuse), CD8(+), CD56(focal+, 1%), Ki-67 index: 50%, EBV (+), ALK1(-), CD10(-), TdT(-), Granzyme B(-), CD15 ＆ CD30 ( focal+), EBER(+).
  • Special stain: Acid-fast stain: Negative for TB bacilli, PAS stain: negative for microorganism.
• 2023-08-26 CT - abdomen
  • History and indication: fever unknown and neck lymphma
  • Non-contrast CT of abdomen-pelvis revealed:
    • Hepato-splenomegaly. Enlarged LNs at retroperitoneum and bil. inguinal regions.
    • Some calcifications at pelvic cavity.
    • Collapse of gallbladder.
  • IMP:
    • Hepato-splenomegaly. Enlarged LNs at retroperitoneum and bil. inguinal regions.
• 2023-08-25 Nasopharyngoscopy
  • Findings: Smooth nasopharynx, oropharynx and hypopharynx; fair vocal cord movement.
  • Dx/Conclusion: No finding of mucosal lesion in the study.
• 2023-08-22 CT - neck
  • Diffuse multiple enlarged left neck LNs, mainly in the posterior cervical space.
  • Multiple LAPs also were noted in left supraclavicular space.
  • After IV contrast administration shows well or heterogenous enhancement of those LNs.
  • Suggest clinical correlation.

[MedRec]

• 2023-08-25 ~ 2023-09-18 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites, Lugano stage IV
    • Acute lymphadenitis of face, head and neck
    • Hepatomegaly with splenomegaly, not elsewhere classified
    • Nonspecific mesenteric lymphadenitis
    • Acute lymphadenitis of other sites
    • Unspecified adrenocortical insufficiency
  • CC
    • fever off and on for 6 months and left neck palpable lymph nodes for 4 months.
  • Present illness
    • The 23-year-old male patient has history of Covid-19 infection and influenza A infection. He has suffered from fever off and on for 6 months and left neck palpable lymph nodes for 4 months, since this April. He went to ShuangHe Hospital for with suspect malignancy by needle aspiration at ShuangHe Hospital on 2023-08-08. CT was scheduled on Aug 29, so he came to our Oncology OPD for help on 8/18 and Neck CT was done on Aug 22. CT report showed diffuse multiple enlarged left neck LNs, mainly in the posterior cervical space. Multiple LAPs also were noted in left supraclavicular space. After IV contrast administration shows well or heterogenous enhancement of those LNs.
    • He came to our ER yesterday due to fever again and skin rashes after contrast medium injection. At ER, fever noted with BT 39.7’C. Lab data showed normal white count WBC:8160, and elevated CRP level 17.5. Urinalysis showed no UTI and CxR film showed no pneumonia. Empirical antibiotic Augmentin was given for infection control at ER. Under the impression of Fever and left neck lymphadenopathy, cause unknown, he is admitted to our Infection ward for further evaluation and management on 2023-08-25.     
  • Course of inpatient treatment
    • After admission, patient received antibiotic with Cravit iv for infection control and cover possible atypical infection, fever off and on after admission under antibiotic treatment, check laboratory data with virus infection EMB, CMV, HIV all showed negative result, the abdominal CT scan showed Hepato-splenomegaly. Enlarged LNs at retroperitoneum and bil. inguinal regions and mass lestion over nack, the ENT was consulted and Impression of suspect lymphoma. the excisional biopsy for the patient was done on 8/30 and pending phathology.
    • The TB qauntiferon was check and report showed indeterminate, we will keept follow phathology report. Due to persisted fever the antibiotic Gentamicin was added since Aug 29 and check coartisol level showed 0.48 only, added Hydrocortisal 50mg Q8H and the Meta was consulted due to possbile medical effect, or possible related with stress caused adrenal insufficiency, and if the patient performs less adrenal insufficiency symptoms, suggested downgrade steroid dose gradually and check ACTH and corstisol level for evaluation.
    • No more fever and more stable condition, follow up laboratory data on Sep 05, with noraml WBC and CRP 1.7 mg/dL. Pending phathology report if negative finding, he can be discahrge in this week. However, the phathology report showed T- cell Lymphoma, so he was trasfer to Hematologist for continue care and treatment.    
    • After transferred to Hemalogy ward, we arranged heart echo, PET/CT scan, and bone marrow biopsy for the patient. Port-A insertion was arranged and done on 2023-09-11.
    • Lab data was then followed up, and as PET/CT reported Highly suspected lymphoma, c-stage IV (AJCC 8th ed.), the patient has started his chemotherapy on 9/12 with CHOEP.
    • After chemotherapy started, we followed up the patient’s blood data every day, and there was no more fever noted. We added Feburic, Promeran and Famotidine for symptom prevention, and the patient had no elevation of uric acid and LDH noted. The patient’s first session of chemotherapy was finished on 2023-09-15, and we followed up his lab data on renal function, electrolyte, uric acid and LDH every day.
    • There was no abnormal lab data noted in each follow up, and there was no discomfort or fever noted. Under stable condition, the patient was discharged on 2023-09-18, with OPD follow up arranged on 2023-09-22.
• 2023-08-18 SOAP Hemato-Oncology Gao WeiYao
  • S
    • He received needle aspiration over neck and lymphoma was suspected at ShuangHe Hospital.
    • Fever for 6 months and Neck tumor were noted since April, 2023.
    • Nonsmoker

[chemotherapy]

• 2024-01-26 - cyclophosphamide 750mg/m2 1430mg NS 500mL 30min D1 + doxorubicin 50mg/m2 95mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 190mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
• 2023-12-27 - cyclophosphamide 750mg/m2 1420mg NS 500mL 30min D1 + doxorubicin 50mg/m2 94mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 189mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
• 2023-12-09 - cyclophosphamide 750mg/m2 1410mg NS 500mL 30min D1 + doxorubicin 50mg/m2 94mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 188mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
• 2023-11-13 - cyclophosphamide 750mg/m2 1390mg NS 500mL 30min D1 + doxorubicin 50mg/m2 90mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 180mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
• 2023-10-23 - cyclophosphamide 750mg/m2 1350mg NS 500mL 30min D1 + doxorubicin 50mg/m2 90mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 180mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
• 2023-10-02 - cyclophosphamide 750mg/m2 1350mg NS 500mL 30min D1 + doxorubicin 50mg/m2 90mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 180mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
• 2023-09-12 - cyclophosphamide 750mg/m2 1330mg NS 500mL 30min D1 + doxorubicin 50mg/m2 88mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 177mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3

Initial treatment of peripheral T cell lymphoma - INDUCTION THERAPY - 2023-11-24 - https://www.uptodate.com/contents/initial-treatment-of-peripheral-t-cell-lymphoma

• Fit, younger patients
  • For medically fit, younger patients with CD30-negative PTCL, we suggest CHOEP rather than CHOP or more intensive regimens. Compared with CHOP, CHOEP is associated with better clinical outcomes and moderately increased toxicity; other intensive regimens are associated with similar outcomes but substantially greater toxicity.
  • CHOEP administration - Many experts limit use of CHOEP to medically fit patients <=60 or 65 years because of toxicity.
  • In CHOEP, intravenous etoposide 100 mg/m2 on days 1 through 3 of each 21-day cycle is added to the CHOP regimen. An alternate version of CHOEP administers intravenous etoposide 100 mg/m2 on day 1 of CHOP, followed by oral etoposide 200 mg/m2 on days 2 and 3 of each 21-day cycle. The higher oral dose of etoposide is necessary due to poor bioavailability with oral administration.
  • PET3 is performed after the first three cycles of CHOEP in order to decide whether to give three additional cycles of induction or treat for refractory PTCL (as described above for BV+CHP).
• Older or less-fit patients
  • For older or less medically fit individuals of any age with CD30-negative PTCL, we favor CHOP induction therapy to avoid the increased toxicity associated with CHOEP.
  • CHOP administration - CHOP is given every three weeks for three cycles, followed by PET3 to guide completion of six total cycles of CHOP (for patients with CR or PR) versus management for refractory disease.

==========

2024-01-29

[reconciliation]

Lab results on 2024-01-25 indicated normal liver and kidney function tests, with serum uric acid levels at 9.0 mg/dL, suggesting hyperuricemia. This condition is being managed with Feburic (febuxostat), and there are no discrepancies in medication.

700374777

240126

[exam findings] (not completed)

• 2023-05-10 PET
  • Increased FDG uptake in the middle third of esophagus, compatible with the primary esophageal cancer.
    
  • Increased FDG uptake in lymph nodes in bilateral upper mediastinum and in the left supraclavicular fossa, highly suspected cancer with regional lymph nodes metastases.
    
  • Increased FDG uptake in bilateral pulmonary hilar and right lower mediastinal lymph nodes, probably reactive nodes.
    
  • Increased FDG uptake at the left shoulder, probably benign in nature.
  • Increased FDG accumulation in bilateral kidneys and colon, physiological uptak of FDG is more likely.
  • Esophageal cancer, cTxN2M0, stage III at least (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-05-09 Patho - esophageal biopsy
  • Esophagus, 20 cm below incisor, biopsy — No significant pathologic change
  • Esophagus, 21-24 cm below incisor, biopsy — severe squamous dysplasia
  • Microscopically, section A shows bland squamous mucosal epithelium and no significant pathologic change. Section B shows severe squamous dysplasia with high grade nuclear atypia of the squamous cells and loss of polarity.
• 2023-05-09 MRI - brain
  • No evidence of brain metastasis.
• 2023-05-08 Miniprobe Endoscopic Ultrasound
  • Advanced esophageal SCC, middle esophagus, EUS staging T3Nx
  • Suspected esophageal dysplasia, 20 cm below incisors, s/p biopsy (A)
  • Suspected early esophageal SCC, 21-24 cm below incisors, uT1a, s/p biopsy (B)
  • Esophageal inlet patch, c/w heterotopic gastric mucosa
• 2023-05-08 SONO - abdomen
  • Renal stones, both
• 2023-05-05 ECG
  • Normal sinus rhythm
  • Minimal voltage criteria for LVH, may be normal variant
  • Borderline ECG
• 2023-05-05 CXR
  • Rt-sided convexity of the azygoesophageal recess interface, due to esophageal tumor
• 2023-04-28 CT - chest
  • Indication: 20230418 EGD: Esophageal mass like lesion, 25cm to 30cm below incisors, s/p biopsy, R/O malignancy; Stenosis at 30cm below
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lymphadenopathy at left lower neck and bilateral paratracheal is found.
      • Long segmental wall thickening at esophagus up to 6.7cm is found. Esophageal cancer is considered.
    • Visible abdomen:
      • Bilateral renal stones are found.
      • The spleen, liver, pancreas and adrenals are intact.
  • Imp: Esophageal cancer with mediastinal lymph nodes and left lower neck.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression ( Imaging stage ): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-04-27 Tc-99m MDP bone scan
  • Increased activity in the L3 spine. Severe degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Mildly increased activity in the lower T-spines, L4-5 spines and bilateral S-I joints. Degenerative change is more likely.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, left wrist, right knee, bilateral ankles and feet, compatible with benign joint lesions.
• 2023-04-19 Patho - esophageal biopsy (Y2)
  • Esophagus, 25 cm to 30 cm below incisor, biopsy — moderate differentiated squamous cell carcinoma
  • Microscopically, section shows moderate differentiated squamous cell carcinoma consisting of invasive irregular squamous epithelial tumor nests arranged in solid architecture. The tumor cells display nuclear pleomorphis, hyperchromasia, high N/C ratio and prominent nucleoli.
• 2023-04-18 Esophagogastroduodenoscopy, EGD
  • Esophageal mass-like lesion, 25cm to 30cm below incisors, s/p biopsy, R/O malignancy
  • Stenosis at 30cm below incisors

[chemotherapy]

• 2024-01-26 - docetaxel 75mg/m2 120mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-06-30 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 137mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1800mg NS 500mL 24hr D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-05-30 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 137mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1800mg NS 500mL 24hr D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-07-03

• According to the PharmaCloud database, our hospital was the sole provider for this patient’s healthcare needs. In addition to the hemato-oncology department, the patient had an appointment with our gastroenterologist on 2023-04-24 who prescribed a 28-day course of a PPI Pariet (rabeprazole) for his gastroesophageal reflux disease with esophagitis. This prescription is currently invalid and the symptoms are no longer listed on the active medical problem list. As a result, no problems were identified during the medication reconciliation process.

701507856

240126

[lab data]

2023-12-22 HBV-DNA-PCR Target Not Detected IU/mL
2023-12-21 Anti-HCV Nonreactive
2023-12-21 Anti-HCV Value 0.15 S/CO
2023-12-21 HBsAg Nonreactive
2023-12-21 HBsAg (Value) 0.49 S/CO
2023-12-21 Anti-HBs 267.16 mIU/mL
2023-12-21 Anti-HBc IgM Nonreactive
2023-12-21 Anti-HBc IgM Value 0.09 S/CO
2023-12-21 Anti-HBc Reactive
2023-12-21 Anti-HBc-Value 6.93 S/CO

[exam findings]

• 2024-01-22 CT - brain
  • Imp: Brain atrophy. Multiple bil. brain and right cerebellar metastases with hemorrhages.
• 2023-12-26, -12-21 CXR erect
  • A mass opacity projecting in left middle lung is noted that is c/w primary lung cancer after correlate with CT.
• 2023-12-25 ALK IHC (EGFR positive should be self-paid)
  • Cellblock No. S2023-24780
  • RESULT: Positive
• 2023-12-21 ECG
  • Sinus bradycardia
  • Nonspecific ST abnormality
• 2023-12-18 Peripheral Vascular Test - Artery, upper limbs
  • Findings
    • Atherosclerosis: Mild
    • Doppler: Decreased flow velocity at L’t Subclavian A., Axillary A., Brachial A., Radial A., Ulnar A.
  • Conclusions:
    • Decreased flow spectrum from left subclavian artery, consider severe left subclavian stenosis. Patent left axillary, brachial, antebrachial, raidal and ulnar artery.
    • Patent right upper limbs arteries.
• 2023-12-15 Tc-99m MDP bone scan
  • Increased activity in the middle C-spine, L2-3 spines and bilateral S-I joints. Degenerative change may show this picture.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • Some faint hot spots in the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, elbows, hips and knees, compatible with benign joint lesions.
• 2023-12-14 ROS1 IHC
  • Cellblock No.: S2023-24780
  • RESULTS: Negative
• 2023-12-14 PD-L1 IHC
  • Cellblock No.: S2023-24780
  • RESULTS：
    • Tumor cell (TC) staining assessment: TC: >= 5% and <10%
    • Percentage of PD-L1 expressing tumor cells (%TC): 5%
• 2023-12-14 PD-L1 (22C3)
  • Cellblock No.: S2023-24780
  • RESULTS：
    • Tumor Proportion Score (TPS) assessment: TPS <1%
    • Tumor Proportion Score (TPS): 0%
• 2023-12-14 EGFR
  • Cellblock No.: S2023-24780
  • No mutation was detected at exons 18,19, 20, 21 of EGFR gene in this specimen
• 2023-12-14 PET scan
  • A glucose hypermetabolic lesion in the upper lobe of the left lung near left pulmonary hilum. Primary lung malignancy may show this picture.
  • Glucose hypermetabolism in some left mediastinal lymph nodes. Metastatic lymph nodes should be watched out.
  • Multiple glucose hypermetabolic lesions in bilateral cerebral and cerebellar hemispheres, suggesting multiple cerebral and cerebellar metastases.
  • Glucose hypermetabolism in the stomach. Inflammation may show this picture. please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2023-12-11 Patho - brain biopsy
  • Brain tumor, frozen + biopsy — Metastatic pulmonary mucinous adenocarcinoma
  • The specimen submitted consists of some small pieces of sticky brain tumor tissue measuring 1.5 x 1.0 x 0.2 cm in aggregate, fixed in formalin. Grossly, they are gray in color and sticky mucus in consistency. All mbedded for section. Reference: frozen section, F2023-00562 some sticky mucoid tumor tissue, all embedded.
  • Microscopically, the section shows a picture of metastatic pulmonary adenocarcinoma characterized by atypical tumor cells arranged in papillary or tubular patterns with intracytoplasmic mucin.
  • Immunohistochemistry shows TTF-1(+), CK7(+), Napsin-A(+), PAX-8(-) and CK20(-) for tumor.
• 2023-12-11 Frozen Section
  • Brain tumor, frozen — Mucinous adenocarcinoma, metastatic
• 2023-12-09 CT - brain
  • Indication: brain meta, for navigator
  • With and without-contrast CT of brain shows:
    • Multiple mass lesions, up to 32mm, in bilateral cerebral and right cerebellar hemispheres. Enhancement after contrast administration.
    • Minimal midline shift to left, 4mm.
  • Impression
    • Multiple brain metastasis
• 2023-12-08 CT - chest
  • Indication: brain metastasis for tumor survey
  • Chest CT with and without IV contrast ehnancement shows:
    • One ground glass nodule at left upper lobe measuring 0.6cm in largest dimension is found. (Se202 Im24).
    • Soft tissue mass at left upper lobe measuring 2.73cm in largest dimension is found. The lesion attached to left hilar region
    • Some lymph nodes are found at bilateral paratracheal region.
    • Cystic change at left ovary up to 2.86cm is found.
  • Imp:
    • left upper lobe lung cancer with brain meta. and mediastinal lymphadenopathy.
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
• 2023-12-07 MRI - brain
  • Indication: Brain metastasis for survey
  • Without- and with-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
    • Numerous intra-axial tumors with heterogeneous enhancement and perifocal edema involving bilateral cerebral and cerebellar hemispheres, and pons, with the largest one about 33 mm at right anterior frontal lobe. Midline shift to left side for 8 mm also noted.
    • Mild degree of general enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
  • IMP:
    • Multiple brain metastases (with the largest one about 33 mm at right anterior frontal lobe causing mass effect).
• 2023-12-07 ECG
  • Prolonged QT
  • Nonspecific T wave abnormality
• 2023-12-06 CXR erect
  • A lobulated left parahilar lung tumor mass.

[MedRec]

• 2024-01-17 SOAP Hemato-Oncology He JingLiang
  • S: CDDP + Gemzar C1D8, ALK positive, apply Alectinib
  • O: Cancer multidisciplinary team meeting conclusion, Meeting date: 2023-12-26
    • RT to brain lesions
    • pending ALK, ROS1, PD-L1.
  • Prescription
    • Hepac Lock Flush (heparin sodium) ST IRRI
    • Norvasc (amlodipine 5mg) 1# QD
    • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC if nausea or vomiting
    • Through (sennoside 12mg) 2# HS
    • Ulstop (famotidine 20mg) 1# BID
    • Bokey (aspirin 100mg) 1# QD
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Crestor (rosuvastatin 10mg) 1# QD
• 2024-01-04 ProgressNote Gao ZhenYi
  • Problem #2: Left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy, cT3N2M1c, stage IVB
    • Assessment:
      • Chest CT:
        • LUL nodule, 0.6cm
        • Soft tissue mass at LUL 2.73cm
        • Some lymph nodes are found at bilateral paratracheal region.
    • Plan:
      • Carefully monitor vital signs and closely track the neurological status.
      • Administer Keppra at a dose of 500mg twice daily for anticonvulsant therapy.
      • Anti-brain swelling Mannitol 75ml QD then taper off
      • Prescribe an H2 blocker to prevent stress ulcers.
      • Administer pain relief as necessary (using Paran).
      • Administer dexamethasone 1 tablet twice daily, to alleviate brain swelling.
      • 8th RT on 1/3 for brain tumor for 3960cGy/12 fx for tumor control with hippocampal sparring. Much improved consciousness & verbal response. Impaired recent memory noted by her son.
      • Follow up lab data on 1/1 showed mild leukocytosis with WBC:12K, nuu:94%, CRP:0.1 and hypocalcemia with Ca:1.93.
      • Plan to start chemotherapy
• 2024-01-03 ProgressNote Zhang YouKang
  • Subjective
    • 8th RT fraction to metastatic brain tumors today.
    • Much improved consciousness & verbal response.
    • Impaired recent memory noted by her son.
    • Acceptable appetite and oral intake.
    • On wheel chair use.
  • Objective
    • RT dose: 2640cGy/8 fractions (6 MV photon) to metastatic brain tumors (sparring bilateral hippocampi), 2023/12/22 to 2024/01/03.
    • Date of evaluation, 2024/01/03: Radiation dermatitis, grade 0; N/V, grade 0; IICP, grade 1.
    • EGFR mutation: wild type; PD-L1: 5 % (IHC); 1% (22C3).
    • Radiotherapy Adverse Reactions (2024-01-03)
  • Problem #2: Left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy, cT3N2M1c, stage IVB
    • Assessment:
      • Lung cancer, LUL, mucinous adenocarcinoma, with multiple brain metastasis s/p stereotactic brain tumor biopsy on 2023/12/11; ECOG = 2.
      • RT response: partial response.
    • Plan:
      • Local RT (planning dose: 3960cGy/12 fx, sparring bilateral hippocampi); 4 more fx to finish.
  • Attending doctor comments
    • Keep dexamethasone 4mg 1# QD.
    • Walking slowly as rehabilitation.
• 2023-12-06 ~ 2024-01-11 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy, cT3N2M1, stage IVA
    • Brain metastasis status post stereotactic Brain tumor biopsy on 2023-12-11
    • Severe left subclavian artery stenosis
  • CC
    • intermmitent dizziness in recent one year, and worsened since this 2023 May.
  • Present illness
    • This is a 72-year-old female patient with no significant medical history. Over the past year, she has experienced intermittent episodes of dizziness, which worsened notably since May 2023. Additionally, she has reported disorientation, forgetfulness, and a tendency to become easily lost. Seeking medical attention, she initially visited Yonghe Cardinal Tien Hospital, where a brain CT scan revealed multiple intracranial lesions, raising suspicion of brain metastasis. Subsequently, she sought a second opinion at our neurosurgery clinic. During her outpatient visit, the patient presented with clear and responsive consciousness, with intact cranial nerve function, muscle strength, and deep tendon reflexes. Nevertheless, the brain CT scan again indicated the presence of multiple intracranial lesions, further heightening the suspicion of brain metastasis. Consequently, the patient was admitted to undergo additional evaluations, including brain MRI, chest and abdominal CT scans, and tumor marker testing.
  • Course of inpatient treatment
    • Upon admission, the anticonvulsant medication Keppra was prescribed. Elevated levels of tumor markers CEA and CA199 were detected, prompting preoperative examinations.
    • A lobulated left parahilar lung tumor mass was identified through a chest X-ray, and brain MRI revealed multiple brain metastases, with the largest one measuring about 33 mm, causing mass effect in the right anterior frontal lobe.
    • A whole-body CT scan indicated the presence of left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy.
    • A brain CT scan for navigation purposes was performed on 2023-12-09.
    • After thoroughly explaining the imaging findings to the patient and family, a brain biopsy was scheduled for 2023-12-11. The patient underwent a stereotactic brain tumor biopsy, which resulted in a frozen report indicating mucinous adenocarcinoma with metastatic properties. The post-operative course proceeded without complications, and analgesic agents were utilized to manage wound pain.
    • During the hospitalization, elevated blood pressure (systolic BP > 20 mmHg) was observed in both arms. The patient reported mild dizziness while ambulating after surgery, and a cardiovascular specialist was consulted. The assessment revealed a weak left radial pulse (1+) with no accompanying symptoms. Recommendations included:
      • Scheduling an upper extremity Duplex study.
      • Checking the lipid profile, including total cholesterol, LDL, HDL, and triglycerides, and prescribing rosuvastatin if LDL levels exceed 100.
      • Considering the addition of aspirin (100mg daily) if there are no contraindications.
    • A consultation with a hematologist-oncologist was also sought regarding the left upper lobe lung cancer, which involved brain metastasis and mediastinal lymphadenopathy, categorized as T3N2M1.
    • Further evaluation was requested, including:
      • Coordinating a bronchoscopy to obtain tissue proof of the left upper lobe lung cancer.
      • If the bronchoscopy results are inconclusive, considering a CT-guided biopsy.
      • Arranging a bone scan and PET/CT scan for a comprehensive assessment.
      • Pending the pathology results of the brain tumor, considering a colonoscopy if mucinous adenocarcinoma with an origin from the colon is identified.
      • As of the current status, the patient remains conscious with an E4V4M6 score. Head wounds are clean and dry, and continuous monitoring of the clinical condition is being conducted.
    • On 2023/12/20, Anticonvulsant Keppra was maintained.
    • Anti-swelling Mannitol was prescribed and tapper off.
    • Steroid prednisolone 2# TID was prescribed.
    • The final pathology reported metastatic pulmonary mucinous adenocarcinoma. EGFR. PD-L1, PD-L1 IHC and ROS1 IHC were conducted.
    • Oncology radiologist was consulted. RT to brain tumor for 3960cGy/12 fx for tumor control with hippocampal sparring if feasible.
    • CT simulation on 2023/12/20 13:30 will be arranged. RT will be initiated 2-3 days later.
    • Steroid dexamethasone 4mg oral BID was switched at least during brain RT.
    • Peripheral Vascular Test : Artery. upper limbs duplex was performed on 2023/12/20, which revealed 1. Decreased flow spectrum from left subclavian artery, consider severe left subclavian stenosis. Patent left axillary, brachial, antebrachial, raidal and ulnar artery; 2. Patent right upper limbs arteries.
    • We added aspirin 100mg qd for severe left subclavian stenosis.
    • We checked lipid profile and was within normal limit. As of the current status, she remains conscious with an E4V4M6 score. Head wound with stitches were clean and dry.
    • After trasnfered to Oncology ward, we consulted GS for port-A implantation for further chemotherapy.
    • Radiotherapy started on 2023/12/25 for brain metastasis. 12 times RT was done from 2023/12/22 to 2024/01/09 for metastatic brain tumors with hippocampal sparring. Much improved consciousness and verbal response were noted after RT.
    • Follow up lab data on 2024/01/01 showed mild leukocytosis with WBC 12K, nuu 94%, CRP 0.1 and hypocalcemia with Ca 1.93.
    • Follow up lab data on 2024/01/09 showed no leukocytosis and normal PCT. Chest xray showed no pneumonia patch.
    • We start chemothrapy of Gemcitabine 1000mg + cisplatin 35mg on 1/10. Vena, decan, and aloxi were given for vomitting prevent.
    • There were no nausea, vomitting, diarrhea after chemotherapy.
    • Under stable condition of no fever, no dyspnea, no nausea, no diarrhea, she was discharged and turned to OPD follow-up.
  • Discharge prescription
    • Norvasc (amlodipine 5mg) 1# QD
    • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC if nausea or vomiting
    • Through (sennoside 12mg) 2# HS
    • Keppra (levetiracetam 500mg) 1# BID
    • Ulstop (famotidine 20mg) 1# BID
    • Bokey (aspirin 100mg) 1# QD
    • Bisadyl supp (bisacodyl 10mg/pill) 2# PRNQD RECT
    • Acetal (acetaminophen 500mg) 1# PRNQID if pain
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Limeson (dexamethasone 4mg) 1# QD
    • Crestor (rosuvastatin 10mg) 1# QD
• 2023-12-06 SOAP Neurosurgery Xu XianDa
  • S
    • Female patient with recurring dizziness since the previous year.
    • Dizziness worsened significantly in May and reached a peak in November.
    • Symptoms include disorientation, forgetfulness, and a tendency to become lost.
    • No history of hypertension (H/T) or diabetes mellitus (DM).
    • Patient has a 30-year history of smoking one pack of cigarettes per day.
  • O
    • BP:148/73; HR:94;
    • Female patient with clear and responsive consciousness.
    • Normal cranial nerve function.
    • Muscle power (MP) rated at 5 in all limbs with no spasticity.
    • Brisk deep tendon reflexes (DTR) observed in limbs.
    • No signs of dysmetria in finger-nose-finger (FNF) testing.
    • Brain CT reveals multiple intracranial lesions.
    • Impression: Brain metastasis.
  • Plan:
    • Admit the patient for a comprehensive assessment, which will include brain MRI, chest and abdominal CT scans, as well as tumor marker testing.

[chemotherapy]

• 2024-01-17 - gemcitabine 800mg/m2 1000mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 350mL 3hr + NS 250mL 60min (after cisplatin) (Gemzar applied twice and omitted once)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2024-01-10 - gemcitabine 800mg/m2 1000mg NS 100mL 30min + NS 250mL 2hr (before cisplatin) + cisplatin 25mg/m2 35mg NS 350mL 3hr + NS 250mL 60min (after cisplatin) (Gemzar applied twice and omitted once)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-26

[alectinib administration via tube feeding]

The administration of Alecensa (alectinib) typically involves swallowing the capsule whole, as indicated in the Taiwan package insert, which advises against opening the capsule or dissolving its contents.

Despite this, there have been clinical cases where Alecensa was administered via tube feeding in patients with NSCLC, leading to positive outcomes. For instances:

• A Stage IV NSCLC patient reliant on ventilator support showed tumor shrinkage and improved respiratory status after receiving dissolved Alecensa through a nasogastric tube (NGT). [1]
• A patient with NSCLC and leptomeningeal carcinomatosis, experiencing drowsiness and difficulty swallowing, also benefited from NGT-administered Alecensa. [2]
• A Stage IV NSCLC patient with disease progression on crizotinib and tracheostomy for tumor-related airway obstruction responded well to Alecensa dissolved in an olive oil-based solution, administered via a percutaneous endoscopic gastrostomy (PEG) tube. [3]
• A Stage IV NSCLC patient showed improvement after Alecensa treatment but developed a Grade 3 maculopapular rash after three weeks. The medication was temporarily stopped for steroid treatment. Two weeks later, treatment resumed with Alecensa dissolved in olive oil, starting at 37.5 mg/day and gradually increasing to 300 mg BID. The patient’s rash did not recur, and no other significant adverse reactions were observed. After three weeks, the disease did not worsen. Once the patient’s appetite improved and weight increased, the PEG tube was removed, and they continued on Alecensa 300 mg BID. [4]

Pharmacologically, alectinib hydrochloride is a white to off-white powder containing insoluble particles, formulated into immediate-release capsules. Opening the capsules may lead to dispersion and inhalation of the contents, potentially altering the active ingredient’s concentration. Laboratory tests have shown that Alecensa capsules can dissolve in 40’C warm water within 10 minutes utilizing Simple Suspension Method (SSM), although the resulting suspension may appear cloudy, making it difficult to ascertain complete dissolution. This suspension remains stable for up to 6 hours at 25’C but may turn gel-like after 24 hours. [5]

A Phase I clinical trial assessed the relative bioavailability and pharmacokinetics of an oral suspension of Alecensa compared to its capsule formulation in healthy participants. The study found higher individual peak levels and overall systemic exposure to Alecensa and its metabolite M4 in the oral suspension group, both under fed and fasting conditions, compared to the capsule group. The bioavailability of Alecensa and M4 significantly increased post-administration in the oral suspension group, but there was no significant difference in the incidence or severity of treatment-emergent adverse events (TEAEs) between the two formulations. [6]

Ref: 1. Watanabe Y et al., Ann. Cancer Res. Ther. 2016; 24:47-51. https://www.jstage.jst.go.jp/article/acrt/24/2/24_47/_article 2. Kanai O et al., Clin. Case Rep. 2017; 26:927-930. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5458002/ 3. Bejarano MT et al., J Oncol Pharm Pract 2019;25:1722-1725. https://pubmed.ncbi.nlm.nih.gov/30124125/ 4. Anderson BE et al., J Oncol Pharm Pract 2020. https://journals.sagepub.com/doi/abs/10.1177/1078155220918644 5. Manufacturer inhouse data 6. Liu S et al., Clin Transl Sci 2023;16:1085-1096. https://pubmed.ncbi.nlm.nih.gov/36978270/

2024-01-25

[analyzing post-granocyte WBC recovery and left-shifted distribution]

Following the administration of Granocyte (lenograstim), the episode of leukopenia observed on 2024-01-22 resolved.

• 2024-01-25 Band 21.5 %
• 2024-01-25 Neutrophil 58.0 %
• 2024-01-25 Metamyelocyte 10.3 %
• 2024-01-25 WBC 12.91 x10^3/uL
• 2024-01-22 WBC 1.37 x10^3/uL **
• 2024-01-17 WBC 3.76 x10^3/uL
• 2024-01-09 WBC 8.74 x10^3/uL
• 2024-01-01 WBC 12.18 x10^3/uL

Subsequent lab results showed no further evidence of leukopenia and indicated a left-shifted distribution, consistent with ongoing G-CSF effect. The blood cell differential on 2024-01-25 revealed increased band cells, neutrophils, and metamyelocytes, alongside mild elevated WBC counts.

This left shift, often linked to rapid blood cell production in response to infections or inflammation, coincides with the CXR on 2024-01-22 showing patchy density in the left pulmonary hilar region. The current empirical use of Brosym (cefoperazone, sulbactam) aligns with these indications.

2024-01-23

[ALK rearrangement discovered: targeted therapy options]

For this patient, who tested positive for ALK on immunohistochemistry IHC on 2023-12-25, consideration might be given to using alectinib, brigatinib, or lorlatinib. If alectinib is the chosen medication, the recommended dosage is 600mg taken twice daily with food.

[hypokalemia - serial serum potassium monitoring and intervention]

The serial data of serum potassium levels indicate a continuing development of hypokalemia. Consequently, Const-K 10mEq TID has been recently initiated to address this condition.

• 2024-01-22 K(Potassium) 2.8 mmol/L
• 2024-01-17 K(Potassium) 3.3 mmol/L
• 2024-01-09 K(Potassium) 3.8 mmol/L
• 2024-01-01 K(Potassium) 4.2 mmol/L
• 2023-12-29 K(Potassium) 4.5 mmol/L

When increased sympathetic tone is thought to play a major role, the administration of a nonspecific beta blocker, such as propranolol, might be considered.

2024-01-05

[carboplatin, pemetrexed, pembrolizumab as NSCLC treatment]

For this patient, tests have not detected EGFR or ROS1 mutations, and the PD-L1 22C3 Tumor Proportion Score (TPS) is less than 1%, with Immunohistochemistry (IHC) Tumor Cells (TC) at 5%.

If the patient recovers to ECOG PS 0-1, a potential treatment regimen could include a combination of either carboplatin or cisplatin, along with pemetrexed and pembrolizumab.

700161986

240125

[exam findings]

[MedRec]

• 2024-01-24 SOAP Psychosomatic Medicine Li JiaFu
  • Diagnosis
    • Generalized anxiety disorder [F41.1]
    • Panic disorder [episodic paroxysmal anxiety] without agoraphobia [F41.0]
    • Malignant neoplasm of unspecified site of left female breast [C50.912]
  • Prescription x3
    • Anxiedin (lorazepam 0.5mg) 1# QN
    • Zoloft (sertraline 50mg) 1# QN
• 2024-01-08 SOAP Hemato-Oncology Gao WeiYao
  • Prescription
    • Femara (letrozole 2.5mg) 1# QD
• 2023-12-29 ~ 2024-01-01 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Infiltrating ductal carcinoma of the left breast, stage pT1N3(31/34)M0, ER(-), PR(+, 60%), Her-2/neu (-, 1+), s/p partial mastectomy and axillary lymph nodes dissection, with bone metastases
    • Mixed hyperlipidemia
    • Generalized anxiety disorder
  • CC
    • for Anti-estrogens with Q1M Faslodex (500mg, self pay) and follow up CT.            
  • Present illness
    • The 66-year-old woman has had infiltrating ductal carcinoma of the left breast, ER(-), PR(60%), Her-2/Neu(1+), s/p partial mastectomy and axillary lymph nodes dissection, pT1N3(31/34)M0 in 2005/12. However, recurrence progression with bony mets s/p RT to right low lateral chest wall area (30Gy/15fx) on 2017, under hormonal therapy with Letrozole and Hormonal therapy with Famera and self-paid of Faslodex (500mg) QM was given from 2018/06/07. Then she started kisqali CDK4/6 inhibitor 2 tab QD from 2019/07/22 (3 weeks plus rest 1 week). Follow up chest CT on 2021/9/18 which revealed no evidence of recurrent/residual tumor in the current study.
    • The bone-densitometry showed normal also noted on 2021/12/6. RT OPD follow up and who assassment the area can’t RT again and suggest to orthopedics for vertebroplasty, but patient refused for probable side effect. Xgeva was given Q4W since 2021/12/9. Anti-estrogens with Q1M Faslodex (500mg, self pay) from 2021/12/19~.
    • Bone scan was arranged on 2022/11/24 showed in comparison with the previous study on 2021/11/18, the bone lesion in the L3 spine is less evident. Mildly increased activity in some middle and lower T-spines. Degenerative change may show this picture.
    • Follwed CT was perfromed on 2023/07/18 revealed mild fibrosis at lower lobes of lungs, stable. no locoregional recurrent breast tumor based this exam.
    • Due to low back pain in progress, she sent to NS OPD for help. Spinal-MRI showed recent compression fractur at L3 and L4 vertebral bodies. Lumbar spondylosis with spinal canal stenosis and neuroforaminal narrowing, esp L3-4. Lumbar vertebra, L3 compression fracture status post L3 kyphoplasty on 2023/10/05.
    • This time, she denied vomit, bone pain or diarrhea, so she was admitted for follow up chest CT and Anti-estrogens with Q1M Faslodex (500mg, self pay) on 2023/12/29.
  • Course of inpatient treatment
    • After admission, she received Faslodex 500mg by self pay on 2023/12/30. Chest CT follow up on 2023/12/30 and report showed left adrenal nodule (1.0cm) and stable condition of bil. lung fibrosis. Under the stable condition, she can be discharged on 2024/01/01. OPD follow up is arranged.
  • Discharge prescription
    • Kisqali (ribociclib 200mg) 1# QD
    • BioThree (bacillus mesentericus, streptococcus faecalis, clostridium butyricum; 22mg) 1# TID
    • BioCal Chewable Tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# TID
• 2023-08-21 SOAP Hemato-Oncology Gao WeiYao
  • P: Refer to NS Lee for prior history of L compression fracture, but recent bone scan showed more prominent with back pain.
• 2018-02-07 SOAP Psychosomatic Medicine Chen YiQian
  • Diagnosis
    • Panic disorder [episodic paroxysmal anxiety] without agoraphobia [F41.0]
  • Prescription x3
    • Zoloft (sertraline 50mg) 1# HS
• 2018-01-15 SOAP Chest Medicine Su WenLin
  • Diagnosis
    • Asthma [J45.991]
    • Allergic rhinitis, unspecified [J30.9]
    • Malignant female breast neoplasm, NOS [C50.912]
    • Comnon migraine without mention of intractable migraine [G43.009]
    • Mixed hyperlipidemia [E78.2]
  • Prescription x3
    • Foster BID INHL
    • Xyzal (levocetirizine 5mg) 1# HS
• 2017-01-23 SOAP Hemato-Oncology Gao WeiYao
  • S
    • For follow up
    • History of infiltratig ductal carcinoma of Lt breast, Lt, T1N3Mx post operation (2025-12-xx) at TSGH followed by taxotere and pharmorubicin
    • HEAVILY LN METASTASES - S-node (2/2), level I (14/14), level II (3/3), level III (3/3), unlabelled lymphoid tissue (9/12), ER (-), PR (+), Her-2 (-)
  • O
    • She had nolvadex for 5 years and femara for almost 5 yrx and she requested to discontinue the femara today (20161226)
    • She was informed to have autonomic dysfunction (20160905) She claimed it was relieved by Rivotril 0.5 tab 0.5 mg/tab plus lepax10 mg hs (ativan 0.5 mg/tab).
    • Radiologist Dr Kuo suggest to repeat mammo and breast sono 3 months later based on April 21 suspected mammo findings by Dr Kuo. (20140516)
    • Questionable nodule over LLL (20140516)
    • s/P mastectomy
    • migraine relieved by sibelium (suzin)
    • Under femara treatment
  • Diagnosis
    • Malignant female breast neoplasm, NOS [C50.912]
    • Comnon migraine without mention of intractable migraine [G43.009]
    • Mixed hyperlipidemia [E78.2]

==========

2024-01-25

[stable vitals amidst possible treatment-related hematologic effects]

The patient, currently treated with fulvestrant, letrozole, and ribociclib for her infiltrating ductal carcinoma, exhibited largely normal lab values on 2024-01-25, except for leukopenia (2.1K/uL) and anemia (HGB 10g/dL). These conditions might be associated with her treatment, particularly ribociclib (anemia: 17% to 19%; leukopenia: 27% to 33%) and/or fulvestrant (anemia: 4% to 40%; lymphocytopenia: 35%).

Throughout this hospitalization, the patient’s vital signs have remained stable, and no discrepancies in medication have been identified.

700349893

240125

[exam findings]

• 2024-01-23 CXR erect
  • Increase bilateral lung markings.
  • Plerual calcification in right upper.
  • No cardiomegaly.
  • Tortuous thoracic aorta with intimal calcification.
  • Thoracic spondylosis and compression fractures.

[MedRec]

• 2024-01-25 Progress Note
  • Problem List
    • Problem #1: Thrombocythemia cause unknown
      • Assessment:
        • worsen for PLT higher
      • Plan:
        • bone marrow, BCRABL, Jak-c and chromosome is arranged
        • IVF hydration 1000ml qd
        • monitor PLT level
  • Problem #2: Urinary tract infection
    • Assessment:
      • no fever is stable condition
    • Plan:
      • antibiotic as Rocephine 2g qd
      • pending U/C
  • Attending physician ward round records and comments
    • Myeloproliferative disease should be ruled in.
• 2024-01-24 Vs Note on Admission Day Gao WeiYao
  • A 90-yr-old man with stroke history with ECOG 4 was sent to ER on account of poor intake for 3 days and malaise for 1+ weeks. Care-giver denied he has fever, chills, choking, diarrhea or falls. At ED, his vital sign showed BP:89/60mmHg, HR:109/bpm, BT:35.5’C, RR 20/bpm, conscious E3V2M5. Lab data showed WBC 28470/uL, PL 1649000/uL (his platelet count was 900,000 in Mar 2023), Reticulocyte 2.810, Lactate 2.5, Na 154, BUN/Cr 86/1.88.
• 2024-01-23 SOAP Medical Emergency Chen ZuYi
  • A/P
    • preliminary impression: other malaise
    • 2024/01/23 23:08 WBC = 28.47 x10^3/uL;
    • 2023/03/30 20:02 WBC = 14.50 x10^3/uL;
    • 2022/10/18 07:02 WBC = 17.70 x10^3/uL;
    • 2022/10/16 14:51 WBC = 17.47 x10^3/uL;
    • 2024/01/23 23:08 PLT = 1649 x10^3/uL;
    • 2023/03/30 20:02 PLT = 921 x10^3/uL;
    • 2022/10/18 07:02 PLT = 956 x10^3/uL;
    • 2022/10/16 14:51 PLT = 925 x10^3/uL;
• 2023-12-07 SOAP Orthopedics Huang ZhenWen
  • O
    • bilateral knee OA, knee flexion contracture.
    • creatine: 1.24
  • Prescription x3
    • Celebrex (celecoxib 200mg) 1# QD
• 2023-07-22 SOAP Orthopedics Zhu ChongHua
  • S
    • bilateral knee pain for days
    • surgical hx: left ITC fracture s/p ORIF
  • O
    • 2nd Prolia
  • A
    • left ITC fracture s/p ORIF
    • osteoporosis, T score: -4
    • bilateral OA knee
  • p:
    • prolia: 20221103, 20230722
    • Ca+ vit D supplemenet
  • Prescription x3
    • Mobic (meloxicam 15mg) ST IM
    • Celebrex (celecoxib 200mg) 1# QD
    • BioCal Chewable Tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# TID
    • Prolia (denosumab 60mg) ST SC
• 2017-03-22 SOAP Neurology Xiao ZhenLun
  • Diagnosis
    • Cerebral artery occlusion, with cerebral infarction [I63.9]
    • Essential hypertention, unspecified [I10]
    • Dyslipidemia; other and unspecified hyperlipidemia [E78.4]
    • Gout, unspecified [M10.9]
    • OA, localized, not specified whether primary or secondary, unspecified site [M19.90]
  • Prescription x3
    • Arcoxia (etoricoxib 60mg) 1# QD
    • Dulcolax (bisacodyl 5mg) 1# QN
    • Syntam (piracetam 1200mg) 1# BID
    • Rivotril (clonazepam 0.5mg) 1# BID
    • Through (sennosides 12mg) 2# HS
    • Robestar (rosuvastatin 10mg) 0.5# QD
    • Bokey (aspirin 100mg) 1# QD

==========

700654288

240125

[lab data]

2024-01-25 HBsAg Nonreactive
2024-01-25 HBsAg (Value) 0.44 S/CO
2024-01-25 Anti-HBc Nonreactive
2024-01-25 Anti-HBc-Value 0.17 S/CO
2024-01-25 Anti-HCV Nonreactive
2024-01-25 Anti-HCV Value 0.09 S/CO

[exam findings]

• 2024-01-25 Flow Volume Chart
  • Moderate restrictive ventilatory impairment
• 2024-01-24 CXR erect
  • Chest PA view shows: Normal heart size.
    • Placement of right subclavian port-A catheter.
    • Medial mass with bulging contour.
    • Left pleural effusion.
• 2024-01-24 Chest lateral Lt
  • Medial mass. Left pleural effusion, with blunted posterior costophrenic angle.

[MedRec]

• 2024-01-24 SOAP Medical Emergency Chen ZuYi
  • S
    • Transferred from XinDian Cardinal Tien Hospital by Dr Ou WeiRen. The patient unexpectedly found that her white blood cells were too high after giving birth late last year, and she was suspected of having lymphoma after examination.
    • 2023/12/20 at Cardinal Tien Hospital: Vaginal delivery in normal pregnancy.
    • 2023/12/25 at Cardinal Tien Hospital: CT of the chest without/with intravenous contrast.
      • FINDINGS:
        • Pleura: small bilateral pleural effusion.
        • Mediastinum: a huge heterogeneous mass in superior mediastinum, with internal hemorrhagic part, about 183mm in greatest dimension.
        • Heart/great vessel: cardiomegaly.
        • Pericardial effusion.
        • Other: splenomegaly.
      • Impression:
        • Suspect thymic tumor, suggest further evaluation.
        • Splenomegaly.
    • 2024/01/10 at Cardinal Tien Hospital:
      • CHEST MRI
        • MRI of the chest without and with contrast enhancement shows:
          • A 18.5129cm lobular heterogeneously enhanced mass in the anterior upper mediastinum. Some cystic component in the mass.
          • No definite nodules at bilateral hilar, supraclavicular area and upper abdominal cavity.
          • Presence of small amount of pericardial effusion and bilateral pleural effusion.
          • Splenomegaly.
        • Imp:
          • Anterior upper mediastinal mass, suspect thymoma or lymphoma pericardial effusion and bilateral pleural effusion
          • Splenomegaly
      • BRAIN MRI
        • MRI of the brain without and with contrast enhancement shows:
          • No abnormal signal intensity lesion in the brain parenchyma.
          • Normal size of the ventricles and cerebral sulci.
          • No mass effect. No abnormal contrast enhancement.
        • Imp:
          • No abnormal findings
  • A/P
    • Preliminary impression: C81.99 Hodgkin lymphoma, unspecified, extranodal and solid organ sites
    • Susp lymphoma, Rt, susp mediastinitis, WBC 30K, Hb 9.9, CRP 5.2, Loforan, OA ONC

==========

2024-01-25

[vaccine recommendations for hepatitis B susceptible individuals with cancer]

Lab results on 2024-01-25 show both HBsAg and anti-HBc as nonreactive. This could indicate either susceptibility to future hepatitis B infection (if anti-HBs is nonreactive) or immunity from hepatitis B vaccination (if anti-HBs is also nonreactive).

For susceptible individuals, it is recommended all unvaccinated patients with cancer aged 19 or older should receive the hepatitis B vaccine. (Ref: Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2024. MMWR Morb Mortal Wkly Rep. 2024 Jan 11;73(1):11-15. doi: 10.15585/mmwr.mm7301a3.) Additionally, coadministration of hepatitis B and hepatitis A vaccines is an option.

Inactivated vaccines are generally advised to be administered at least two weeks prior to starting chemotherapy or other immunosuppressive therapies to enhance the immune response. (Ref: Practical review of immunizations in adult patients with cancer. Hum Vaccin Immunother. 2015;11(11):2606-14. doi: 10.1080/21645515.2015.1062189.) A recombinant hepatitis B vaccine is available at this hospital.

700927977

240125

[MedRec]

• 2023-10-13 SOAP Cardiology Huang XuanLi
  • Prescription x3
    • Coralan (ivabradine 5mg) 1# BID
    • Entresto (sacubitril 97mg, valsartan 103mg; 200mg) 0.25# QD skip once if SBP < 100mmHg
    • Feburic (febuxostat 80mg) 0.5# QOD
    • Harnalidge (tamsulosin 0.4mg) 1# QDAC
    • Pentop (pentoxifylline 400mg) 1# QD
    • Through (sennoside 12mg) 2# HS
    • Budema (bumetanide 1mg) 0.5# QD
• 2017-01-04 SOAP Cardiology Huang XuanLi
  • Diagnosis
    • CHF; Congestive heart failure [I50.22]
    • Essential hypertention, unspecified [I10]
    • Femoral hernia unilateral or unspecified, recurrent without mention of obstruction or gangrene [K41.91]
    • Other insomnia [G47.09]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Neuralgia,neuritis, and radiculitis,unspecified [M79.2]
  • Prescription x3
    • Adalat Oros (nifedipine 30mg) 1# PRN
    • Urief (silodosin 4mg) 1# BID
    • Coxine (isosorbide-5-mononitrate 20mg) 0.5# HS
    • Busix (bumetanide 1mg) 1# QD
    • Concor (bisoprolol 5mg) 0.5# QD
• 2017-01-03 SOAP Neurosurgery Li DingZhou
  • Diagnosis
    • Spondylosis of unspecified site, with mention of myelopathy [M47.10]
    • Discitis, unspecified, lumbar region [M46.46]
    • Other spondylosis, cervical region [M47.892]
    • Unspecified systolic (congestive) heart failure [I50.20]
    • Spinal stenosis, site unspecified [M48.00]
    • Acute and subacute endocarditis, unspecified [I33.9]
    • Overflow incontinence [N39.490]
    • Cervical root disorders, not elsewhere classified [G54.2]
    • Close fracture of lumbar without mention of spinal cord injury [S32.000A]
    • Localized osteoporosis [Lequesne] [M81.6]
  • Prescription x3
    • Celebrex (celecoxib 200mg) 1# PRNQD
    • Neurontin (gabapentin 100mg) 1# QD
    • Aelocon (Vit B1 50mg, B2 5mg) 1# QD

[consultation]

==========

2024-01-25

[ongoing renal deterioration and bumetanide dosage considerations]

Recent test results indicate a mild increase in hs-Troponin I at 164.1 pg/mL, CKMB at 17.6 ng/mL, CK at 405 U/L, and ECG showing T wave depression in lateral leads, therefore a consultation with our cardiologist is just initialized.

This patient has experienced a gradual deterioration in kidney function in recent months. Consequently, all medication dosages on the active list have been adjusted to accommodate the patient’s current renal status.

• 2024-01-25 Cre 4.24 mg/dL
  
• 2024-01-25 BUN 57 mg/dL
  
• 2024-01-25 eGFR 14.36 ml/min/1.73m^2
  
• 2024-01-23 eGFR 16.14 ml/min/1.73m^2
  
• 2024-01-05 eGFR 21.73 ml/min/1.73m^2
  
• 2023-10-13 eGFR 27.16 ml/min/1.73m^2
  
• 2023-09-15 eGFR 37.38 ml/min/1.73m^2

Additionally, for the patient’s eGFR <30, increased doses of bumetanide may be necessary for an effective diuretic response (2024-01-24 input 1710 output 230 + loss).

Given the absence of serological hepatitis virus data in the patient’s history in HIS5, the elevated liver enzyme levels (AST at 170 U/L and ALT at 95 U/L on 2024-01-25) might be further investigated once the patient’s cardiological conditions have stabilized.

701512638

240125

[exam findingns]

2024-01-25 HBsAg Nonreactive
2024-01-25 HBsAg (Value) 0.42 S/CO
2024-01-25 Anti-HCV Nonreactive
2024-01-25 Anti-HCV Value 0.14 S/CO
2024-01-25 Anti-HBc Reactive
2024-01-25 Anti-HBc-Value 3.19 S/CO
2024-01-25 Anti-HBc IgM Nonreactive
2024-01-25 Anti-HBc IgM Value 0.08 S/CO
2024-01-25 Anti-HBs 184.65 mIU/mL

[MedRec]

• 2024-01-23 SOAP Hemato-Oncology Gao WeiYao
  • S
    • Hualian TzuChi Dr Hseu WL friend
    • Adenocarcinoma of stomach, diffuse type, Her-2 (-), pT4aN3aMb post total gastrectomy on 2024-01-02 (presenting with gastric outlet obstruction).
  • O
    • BP 125/76; BH 168 cm; BW 55 kg; BMI 19.5

==========

2024-01-25

[reactive anti-HBc and prophylactic antiviral strategy]

Lab results on 2024-01-25 indicated a reactive anti-HBc status. In light of this finding, it is advisable to consider prophylactic antiviral nucleoside analog therapy before commencing chemotherapy treatment.

700715400

240124

[lab data]

• 2022-02-18
  • All-RAS mutation not detected (wild type)
  • BRAF mutation not detected (wild type)
  • EGFR G719X mutation not detected
  • EGFR Exon19 deletion not detected
  • EGFR S768I not detected
  • EGFR T790M not detected
  • EGFR Exon20 insertion not detected
  • EGFR L858R not detected
  • EGFR L861Q not detected

[exam findings]

• 2023-11-24 CT - abdomen
  • History: S-colon cancer with liver metastasis S/P OP and C/T.
  • Findings: Comparison prior CT dated 2023/07/12 and MRI dated 2023/07/26.
    • Prior MRI identified seven metastases in left lobe liver are noted again, decreasing in size.
      • Liver metastases S/P C/T with partial response is highly suspected.
      • Follow up MRI 3 months later is indicated.
    • S/P LAR with autosuture retention over the sigmoid colon.
      • In addition, Prior CT identified a cystic lesion 1.9 cm in the right lateral aspect of the anastomosis area is noted again, decreasing in size to 1.7 cm.
    • S/P near total resection of S5/6/7.
      • S/P partial resection of S8 of the liver with biloma 4 cm.
      • S/P partial resection of left lateral aspect of S2-3 of the liver.
    • Prior CT identified some LNs at mediastinum, mesentery and retroperitoneum are noted again, decreasing in size.
    • A renal cyst 0.9 cm in left middle pole is noted.
    • There is no focal lesion in both lung and mediastinum.
    • S/P right lobectomy of the thyroid?
      • please correlate with clinical history.
  • Impression:
    • Liver metastases S/P C/T with partial response is highly suspected.
    • Follow up MRI 3 months later is indicated.
• 2023-08-07 PET
  • Increased FDG uptake in the S- and R-colon, probably feces accumulation.
    
  • At least six nodular lesions of increased FDG uptake in the right lobe of the liver, highly suspected colon cancer with liver metastases.
  • Increased FDG uptake in several celiac lymph nodes, highly suspected colon cancer with distant lymph nodes metastases.
    
  • Increased FDG uptake in the left rib cage, highly suspected bone metastases.
  • Sigmoid colon cancer s/p treatment with celiac lymph nodes, liver and left ribs metastases, ycTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-07-26 MRI - liver, spleen
  • History: S-colon cancer with liver metastasis S/P OP and C/T.
  • Findings:
    • There are seven newly developed masses on S2-3-4 of the liver, showing hypointensity on T1WI, mild hyperintensity on both T2WI and DWI, and poor enhancement in dynamic study. The largest one 1.7 cm in S4.
      • Seven metastases are noted.
    • S/P near total resection of S5/6/7.
    • S/P partial resection of S8 of the liver with biloma 4 cm.
    • S/P partial resection of left lateral aspect of S2-3 of the liver.
    • A renal cyst 0.9 cm in left middle pole is noted.
  • Impression:
    • Seven metastases on S2-3-4 of the liver are noted.
• 2023-07-12 CT - abdomen, pelvis
  • Findings:
    • There is an ill-defined poor enhancing lesion 1.9 cm in S6 of the liver that may be metastasis and flow artifact. Please correlate with sonography and MRI.
    • S/P LAR with autosuture retention over the sigmoid colon.
      • In addition, Prior CT identified a cystic lesion 1.9 cm in the right lateral aspect of the anastomosis area is noted again, stationary.
    • S/P near total resection of S5/6/7.
    • S/P partial resection of S8 of the liver with biloma 4 cm.
    • S/P partial resection of left lateral aspect of S2-3 of the liver.
    • Prior CT identified some LNs at mediastinum, mesentery and retroperitoneum are noted again, stationary.
    • A renal cyst 0.9 cm in left middle pole is noted.
    • S/P right lobectomy of the thyroid? please correlate with clinical history.
  • Impression:
    • There is an ill-defined poor enhancing lesion 1.9 cm in S6 of the liver that may be metastasis and flow artifact. Please correlate with sonography and MRI.
• 2023-04-19 CT - abdomen, pelvis
  • Findings:
    • S/P LAR with autosuture retention over the sigmoid colon.
      • In addition, Prior CT identified a cystic lesion 1.9 cm in the right lateral aspect of the anastomosis area is noted again, stationary.
    • S/P near total resection of S5/6/7.
    • S/P partial resection of S8 of the liver with biloma 4.6 cm.
    • S/P partial resection of left lateral aspect of S2-3 of the liver.
    • There is an ill-defined poor enhancing lesion 1.2 cm in the residual S2 of the liver. Follow up is indicated.
    • Prior CT identified some LNs at mediastinum, mesentery and retroperitoneum are noted again, stationary.
    • Hyperplasia of left adrenal gland.
    • A renal cyst 0.9 cm in left middle pole is noted.
    • S/P right lobectomy of the thyroid? please correlate with clinical history.
  • Impression:
    • S/P LAR with autosuture retention over the sigmoid colon. There is no evidence of tumor recurrence.
• 2023-01-17 CT - abdomen, pelvis
  • History and indication: S-colon cancer s/p c/T OP for liver and primary lesion
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon operation.
    • S/P liver operation with biloma formation (up to 4.6cm). Some hypodense lesions in liver.
    • Some LNs at mediastinum, mesentery and retroperitoneum.
    • Minimal ascites. Hyperplasia of left adrenal gland.
    • Tiny renal cysts.
    • Absence of right thyroid gland.
    • Atherosclerosis of aorta, iliac arteries.
    • Right minimal pleural effusion.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P colon operation.
    • S/P liver operation with biloma formation (up to 4.6cm).
    • Some LNs at mediastinum, mesentery and retroperitoneum.
• 2022-10-20 CT - abdomen, pelvis
  • History and indication: Sigmoid colon cancer with liver mets, s/p neoadjuvant C/T with P-FOLFIRI, s/p over sigmoid and liver, s/p adjuvant C/T with P-FOLFIRI
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon operation.
    • S/P liver operation with biloma formation (up to 6.1cm). Some hypodense lesions in liver.
    • Some LNs at mediastinum, mesentery and retroperitoneum.
    • Minimal ascites. Hyperplasia of left adrenal gland.
    • Collapse of gallbladder.
    • Atherosclerosis of aorta, iliac arteries.
    • Right minimal pleural effusion.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P colon operation.
    • S/P liver operation with biloma formation (up to 6.1cm). Some hypodense lesions in liver.
    • Some LNs at mediastinum, mesentery and retroperitoneum.
• 2022-08-16 Patho - liver partial resection
  • PATHOLOGIC DIAGNOSIS
    • Liver, S2, S2 resection — Metastatic colonic adenocarcinoma
    • Liver, S8 and S3, partial hepatectomy — Metastatic colonic adenocarcinoma
      
    • Liver, S6-7, S6-7 resection — Metastatic colonic adenocarcinoma
    • Tumor regression grade: Grade 3 (fibrosis > cancer cells)
  • MACROSCOPIC EXAMINATION
    • Procedures: S2 and S6-7 resection, and S8 and S3 partial hepatectomy
      
    • Specimen Size: 16 x 10 x 5.0 cm ＆ 190 gm (S2), 2.0 x 2.0 x 1.5 cm ＆ 10 gm (S3), 9.0 x 7.0 x 5.0 cm ＆ 110 gm S8), 20 x 11 x 6.0 cm and 420 gm (S6-7)
    • Tumor Focality: Multiple (number: 4)
      
    • Tumor Site: S2, S8, S3, and S6-7
      
    • Tumor Size: 6.0 x 5.0 x 5.0 cm (S2), 1.2 x 0.9 x 0.8 cm (S3), 6.5 x 5.5 x 5.0 cm (S8), and 11.5 x 7.9 x 6.5 cm (S6-7) respectively
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Not cirrhotic
      
    • Sections are taken and labeled as: A1-A4= S2 tumor, B= S3 tumor, C1-C4= S8 tumor, D1-D4= S6-7 tumor
  • MICROSCOPIC EXAMINATION
    • Diagnosis: Metastatic colonic adenoarcinoma
      
    • Histologic grade: Moderately differentiated
      
    • Tumor growth pattern: Infiltrative
      
    • Tumor pseudocapsule: Absent
      
    • Percentage of necrosis:10%; Percentage of fibrosis: 50%
    • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 0.1 cm (S2, S8, S6-7)
        
    • Vascular invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Tumor regression grade: Grade 3 (fibrosis > residual cancer cells)
    • Non-neoplastic liver parenchyma: Perivenular congestion, regeneration of hepatocytes, and mild lymphocytic portal inflammation, compatible with chemotherapy-associated liver injury
    • Fatty Change: Absent
• 2022-08-16 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Sigmoid colon, sigmoid colectomy — Adenocarcinoma, moderately differentiated
      
    • Resection margins, sigmoid colectomy – Free
      
    • Lymph nodes, mesocolic, sigmoid colectomy — Negative for malignancy (0/19)
      
    • Pathology stage: ypT3N0M1a; Stage IVA
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: Sigmoid colectomy
      
    • Specimen site: Sigmoid colon
      
    • Specimen size: 18.0 cm in length
      
    • Tumor size: 3.8 x 3.0 cm
      
    • Tumor location: 6.0 cm and 9.0 cm away from the two resection margins, respectively .
    • Depth of invasion grossly: Pericolic soft tissue
    • Mucosa elsewhere: Unremarkable
    • Representative parts are taken for section and labeled: A1= tumor + pelvic wall, A2-A4= tumor, A5-A8= regional LNs, B= anastomosis site, proximal, C= anastomosis site, distal.
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
      
    • Histology Grade: Moderately differentiated
      
    • Depth of invasion: Pericolic soft tissue
    • Angiolymphatic invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Tumor cell budding: Low
      
    • Margins
      • Proximal and distal anastomosis sites: Free
      • Circumferential (radial) margin: Uninvolved, 5 mm from the margin
      • Pelvic wall: Fibrous adhesion without cancer cells
    • Lymph node metastasis, mesocolic: Negative for malignancy (0/19) (No. Positive / No. Total)
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): ypT3 (Tumor invades pericolic tissue)
      • Regional Lymph Nodes (pN): ypN0 (No regional lymph node metastasis)
      • Distant Metastasis (pM): M1a (Metastasis to liver (see S2022-13475))
    • Type of polyp in which invasive carcinoma arose: Not identified
    • Additional pathologic findings: None identified
    • Treatment effect: Partial response; Residual cancer with evident tumor regression (partial response, score 2)
    • IHC(S2022-01236): EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2022-08-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 30) / 116 = 74.14%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis.
• 2022-07-29, -07-23 KUB
  • S/P sigmoid colon stenting.
• 2022-07-23 KUB
  • S/P sigmoid colon stenting with marked distension of the proximal colon. stenting obstruction is highly suspected.
• 2022-07-21 CT - abdomen, pelvis
  • Mild regression of S-colon cancer and liver metastases. S/P S-colon stenting. Dilatation of colon.
• 2022-05-05 CT - abdomen, pelvis
  • Much regression of S-colon cancer and liver metastases.
• 2022-01-22 CT
  • Findings
    • Huge heterogeneous soft tissue mass at both lobes of liver up to 12.5cm is found.
    • s/p sigmoid colon stent placement. The sigmoid colon wall is thick. Some lymph nodes (n = 4) is found.
  • Imp:
    • Sigmoid colon cancer s/p stent placement and liver mets.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T3N2M1
• 2022-01-20 Patho - colon biopsy
  • Colon, sigmoid, biopsy - Adenocarcinoma, moderately differentiated
  • IHC: EGFR(+), PMS2(focal +), MLH1(+), MSH2(+), and MSH6(+).
  • Section shows pieces of colonic tissue with tumor necrosis, tubulovillous glands and scant invasive irregular neoplastic glands.
• 2022-01-19 Colonoscopy
  • Colon cancer, sigmoid colon, with acute obstruction s/p self expandable metal stent placement and biopsy
  • Mixed hemorrhoid

[MedRec]

• 2024-01-02 ~ 2024-01-05 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • S-colon cancer with liver metastases, T3N2M1a, stage IVA s/p S-colon stenting on 2022/01/19 and chemotherapy with FOLFIRI from 2022/01/24~2022/07/13 (for 12 cycles), Vectibix (panitumumab) from 2022/03/23~2022/07/13 (for 8 cycles) s/p Sigmoid colectomy and open S6-7, S2 and S8 partial and S3 partial hepatectomy on 2022/08/15 s/p chemotherapy with FOLFIRI/Vectibix from 2022/09/13~2023/04/07, with liver metastasis, ypT3N2M1b, stabe IVB, s/p chemotherapy with FOLFIRI/Vectibix from 2023/08/29~
    • Chronic viral hepatitis B without delta-agent
    • Type 2 diabetes mellitus with hyperglycemia
    • Essential (primary) hypertension
    • Hyperlipidemia, unspecified
    • Dermatitis, due to Panitumumab related
  • CC
    • For palliative chemotherapy with FOLFIRI/Vectibix(self-paid)(C4D1).            
  • Present illness
    • This 60-year-old woman patient referred from Cardinal Tien Hospital due to abdominal discomfort 2022/01. According to patient and family statement, she had sufferred from of chronic constipation for 1 year and involuntary weight loss about 5kg in one month. She visited Cardinal Tien Hospital and low GI series was arranged. After examination, abdmonial fullness, watery diarrhea was noted, however laxatives had no effect. Due to persisted symptoms, she visited Cardinal Tien Hospital ER for help.
    • Abdominal CT on 2022/01/18 revealed dilated colon, a transition zone at sigmoid colon and multiple liver neoplasm, sigmoid cancer with multiple liver metastasis was highly suspected.
    • Sigmoidoscopy on 2022/01/19 showed colon cancer, sigmoid colon, with acute obstruction s/p self expandable metal stent placement and biopsy, mixed hemorrhoid. Sigmoid biopsy showed adenocarcinoma, moderately differentiated. Port-A catheter insertion on 2022/01/21. Chest CT on 2022/01/22 showed sigmoid colon cancer s/p stent placement and liver meta.
    • Palliative chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) was given on 2022/01/24~2022/07/13 for 12 cycles. Target therapy with Panitumumab (Vectibix) (6mg/kg) 400mg on 2022/03/23~2022/07/13 for 8 cycles. Abdominal CT on 2022/05/05 showed much regression of S-colon cancer and liver metastases.
    • Lower abdominal fullness with severe pain on 2022/07. Abdominal CT on 2022/07/21 showed mild regression of S-colon cancer and liver metastases, S/P S-colon stenting and dilatation of colon. KUB on 2022/07/21 showed ileus. Sigmoidoscopy on 2022/07/21 showed sigmoid colon cancer post SEMS with stent dysfunction (obstruction), s/p placement of a new metal stent, proctocolitis distal to the tumor, anal prolapse and incomplete study of colon.
    • 2D echo on 2022/08/09 showed M-mode(Teichholz) = 74, 1.Normal LV filling pressure. 2.Normal LV and RV systolic function. 3.Mild aortic valve sclerosis.
    • Sigmoid colectomy and open S6-7, S2 and S8 partial and S3 partial hepatectomy on 2022/08/15.
    • Sigmoid colon pathology showed adenocarcinoma, moderately differentiated without lymph node metastasis(0/19), ypT3N0M1a; Stage IVA.
    • Liver pathology showed metastatic colonic adenocarcinoma.
    • Post-OP chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, given 400mg) was given on 2022/09/13(C1D1), 2022/09/27(C1D15), 2022/10/11(C2D1), 2022/10/28(C2D15), 2022/11/08(C3D1), 2022/11/22(C3D15), 2022/12/06(C4D1), 2022/12/20(C4D15), 2023/01/03(C5D1), 2023/01/17(C5D15), 2023/02/08(C6D1), 2023/02/27(C6D15), 2023/03/17(C7D1).
    • Abdominal CT on 2022/10/22 showed S/P colon operation, S/P liver operation with biloma formation (up to 6.1cm). Some hypodense lesions in liver and some lymph nodes at mediastinum, mesentery and retroperitoneum. Follow-up, Abdominal CT on 2023/01/17 showed S/P colon operation, S/P liver operation with biloma formation (up to 4.6cm) and some lymph nodes at mediastinum, mesentery and retroperitoneum. Follow-up, Abdominal CT on 2023/04/22 showed S/P LAR with autosuture retention over the sigmoid colon, no evidence of tumor recurrence.
    • Follow-up, Abdominal CT on 2023/07/12 showed an ill-defined poor enhancing lesion 1.9 cm in S6 of the liver that may be metastasis and flow artifact. suggest correlate with sonography and MRI.
    • Abdominal MRI was done on 2023/07/26 showed seven metastases on S2-3-4 of the liver are noted.
    • Whole body PET scan on 2023/08/11 showed 1. Increased FDG uptake in the S- and R-colon, probably feces accumulation, 2. At least six nodular lesions of increased FDG uptake in the right lobe of the liver, highly suspected colon cancer with liver metastases, 3. Increased FDG uptake in several celiac lymph nodes, highly suspected colon cancer with distant lymph nodes metastases, 4. Increased FDG uptake in the left rib cage, highly suspected bone metastases, 5. Sigmoid colon cancer s/p treatment with celiac lymph nodes, liver and left ribs metastases, ycTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
    • Palliative chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, self pay, given 400mg) on 2023/08/29(C1D1), 2023/09/18(C1D15), 2023/10/09(C2D1), 2023/11/01(C2D15), 2023/11/21(C3D1), 2023/12/11(C3D15).
    • Follow up bdominal CT for survey on 2023/11/24 showed Liver metastases S/P C/T with partial response is highly suspected.
    • Now, she was admitted to ward for chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, self pay, given 400mg) on 2024/01/03(C4D1).
  • Course of inpatient treatment
    • After admitted, palliative chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, self pay, given 400mg) from 2024/01/03~2023/01/05(C4D1).
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting and Olanzpine 1# po HS for severe vomiting.
    • ULSTOP F.C 20mg/tab 1# PO BID for GERD.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for Anti HBc(+).
    • Type 2 diabetes mellitus with Diet control and check finger sugar and Meftormin 500mg 2# po BID, Canaglu 100mg 1# PO QD and Glitis 30mg 1# PO QD.
    • Hypertension with Irbesartan 300mg 0.5# PO QD, Zanidip F.C 10mg 1# PO QD and Concor 5mg 1# PO QD.
    • Hyperlipidemia with Crestor 10mg 1# PO QN.
    • Dermatitis, due to Panitumumab related, Allegra 60mg/tab 1# PO BID and Topsym cream 0.05%, 10gm/tube 1qs for skin rash and itchy.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/01/05 and OPD followed up later.
  • Discharge diagnosis
    • Allegra (fexofenadine 60mg) 1# BID
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Limeson (dexamethasone 4mg) 1# QD
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Ulstop (famotidine 20mg) 1# QD
    • Zyprexa Zydis (olanzapine 5mg) 1# HS
    • Topsym Cream (fluocinonide 0.05%) QD EXT

[surgical operation]

• 2022-08-15
  • Surgery: Sigmoid colectomy        
  • Finding: Sigmoid cancer with pelvic wall direct invasion
• 2022-08-15
  • Surgery: open S6-7, S2 and S8 partial and S3 partial hepatectomy
  • Finding: multiple liver tumor 0.5 to 7 cm bilat lobe

[consultation]

• 2022-07-21 colon and rectal surgery
  • Q
    • Lower abdomen pain VAS 10 for 2 days
    • Hx of sigmoid cancer with multiple liver metastasis
    • Deny abd op hx
  • A
    • S/O
      • S colon cancer with obstruction and multiple liver s/p stent by GI
      • low abdomen pain and no solid stool for 1~2 days
      • CT: favored solid stool stuck in stent
    • A/P:
      • suggested medical treatment + maybe st enema
      • T loop colostomy if no improving
• 2022-01-21 hematology and oncology
  • please check AntiHbc for chemotherapy HBV evaluation
  • if proven colon cancer, for advanced metastasis colon cancer, systemic therapy is indicated. Ex: FOLFOX+/-avastin or FOLFIRI+/-avastin, +ceftuximab if KRAS wide type, consider IO if dMMR/MSI-H
  • pending pathology result and we wound like to follow up this case
• 2022-01-19 colon and rectal surgery
  • This is a case of sigmoid cancer with obstruction, multiple liver metastasis. I’ve discussed with the patient and her families, palliative stent is indicated. After colonic stent, palliative chemotherapy and target therapy will be arranged.

[chemotherapy]

• 2024-01-23 - panitumumab 6mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL

• 2024-01-03 - panitumumab 6mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL

• 2023-12-11 - (FOLFIRI plus panitumumab)

• 2023-11-21 - (FOLFIRI plus panitumumab)

• 2023-10-31 - (FOLFIRI plus panitumumab)

• 2023-10-09 - (FOLFIRI plus panitumumab)

• 2023-09-18 - (FOLFIRI plus panitumumab)

• 2023-08-29 - (FOLFIRI plus panitumumab)

• 2023-04-07 - (FOLFIRI plus panitumumab)

• 2023-03-17 - (FOLFIRI plus panitumumab)

• 2023-02-27 - (FOLFIRI plus panitumumab)

• 2023-02-08 - (FOLFIRI plus panitumumab)

• 2023-01-17 - (FOLFIRI plus panitumumab)

• 2023-01-03 - (FOLFIRI plus panitumumab)

• 2022-12-20 - (FOLFIRI plus panitumumab)

• 2022-12-06 - (FOLFIRI plus panitumumab)

• 2022-11-22 - (FOLFIRI plus panitumumab)

• 2022-11-08 - (FOLFIRI plus panitumumab)

• 2022-10-25 - (FOLFIRI plus panitumumab)

• 2022-10-11 - (FOLFIRI plus panitumumab)

• 2022-09-27 - (FOLFIRI plus panitumumab)

• 2022-09-13 - (FOLFIRI plus panitumumab)

• 2022-07-13 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr (FOLFIRI plus panitumumab)

• 2022-06-29 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

• 2022-06-15 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

• 2022-06-01 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

• 2022-04-27 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

• 2022-04-13 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

• 2022-04-01 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

• 2022-03-23 - panitumumab 6mg/kg 90min

• 2022-03-18 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

• 2022-02-24 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

• 2022-02-11 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

• 2022-01-24 - irinotecan 120mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

==========

2024-01-24

[reconciliation]

The PharmaCloud database indicates that on 2024-01-22, the patient refilled prescriptions for Concor (bisoprolol), Zanidip (lercanidipine), Aprovel (irbesartan), and Xanax (alprazolam) at Cardinal Tien Hospital. These medications are currently being used, and no discrepancies in medication have been identified.

2023-11-01

[sharp rise and subsequent decline of CEA and CA199]

Both tumor markers, CEA and CA199, showed a sharp increase starting in 2023Q3 and have recently shown a decrease (although not yet in the normal range). Given that the primary treatment, P-FOLFIRI, has been used for over a year and a half without adjustments, the reasons for the decline in tumor markers may warrant further investigation.

• 2023-10-25 CEA 55.55 ng/mL

• 2023-09-06 CEA 484.09 ng/mL

• 2023-08-29 CEA 581.20 ng/mL

• 2023-07-17 CEA 172.08 ng/mL

• 2023-06-17 CEA 30.15 ng/mL

• 2023-05-25 CEA 7.86 ng/mL

• 2023-03-30 CEA 2.33 ng/mL

• 2023-03-09 CEA 2.64 ng/mL

• 2023-01-31 CEA 2.44 ng/mL

• 2023-01-17 CEA 2.46 ng/mL

• 2023-01-03 CEA 2.54 ng/mL

• 2023-10-25 CA199 52.99 U/mL

• 2023-09-06 CA199 183.01 U/mL

• 2023-08-29 CA199 268.44 U/mL

• 2023-07-17 CA199 76.81 U/mL

• 2023-06-17 CA199 16.80 U/mL

• 2023-05-25 CA199 8.73 U/mL

• 2023-03-30 CA199 5.91 U/mL

• 2023-03-09 CA199 6.00 U/mL

• 2023-01-31 CA199 6.64 U/mL

• 2023-01-17 CA199 6.84 U/mL

• 2023-01-03 CA199 7.19 U/mL

2023-08-30

The patient primarily receives medical care at Cardinal Tien Hospital. On 2023-08-28, refills were obtained for medications including metformin, pioglitazone, canagliflozin, bisoprolol, lercanidipine, irbesartan, rosuvastatin, and alprazolam. These drugs are mainly for the treatment of Type 2 Diabetes Mellitus and hypertension. As of now, these medications are accounted for in the active medication list and no discrepancies have been identified.

2022-07-22

• Irinotecan has been titrated up from an initial 2/3 recommended dose to its current recommended dose with normal liver function lab results as of 2022-07-21.
• It has been found that patients taking canagliflozin are more likely to develop genitourinary fungal infections (females: 11% to 12%; males: 4%), and those who do develop such infections are more likely to suffer recurrences. Additionally, pioglitazone has been associated with upper respiratory tract infections. Infection signs should be monitored as usual.

2022-04-01

• a patient diagnosed with sigmoid colon cancer s/p stent placement and liver mets transferred from Cardinal Tien Hospital on 2022-01-19 and start receiving FOLFIRI since 2021-01-24 (plus panitumumab since 2022-03-23).
• lab data reported on 2022-02-18 revealed that RAS and BRAF were both wild type and that no EGFR mutations were found. pathology results on 2022-01-20 indicated pMMR and EGFR(+). the patient is receiving appropriate treatment with no issues currently.

700852752

240124

[exam findings]

• 2023-12-25 CXR
  • multifocal areas of consolidation and ground-glass opacities
  • in both lungs, upper lung predominance
• 2023-11-28 SONO - abdomen
  • right neck tumor, r/o lymphadenitis
  • local cellulitis
• 2023-10-02 Patho - esophageal biopsy
  • Labeled as “middle esophagus”, biopsy — benign squamous mucosa.
  • PAS stain highlights abundant colonies of candida species.
• 2023-10-02 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • R/O Esophageal candidiasis, s/p biopsy
    • Superficial gastritis with erosions, s/p CLO
    • Gastric fundic gland polyps
    • Duodenitis
  • CLO test: Negative
  • Suggestion:
    • PPI therapy
    • Pursue CLO and pathology result
• 2023-09-08 CXR erect
  • Faint aveolar opacity over RIGHT MIDDLE LOBE is found.
  • Aonther opacity over left central lung is found.
• 2023-08-24 CT - chest
  • Impression
    • bilateral lung infection, most severe in RML with areas of necrosis and parapneumonic effusion.
    • extensive 3V-CAD. Calcified AV with stenosis and LVD.
• 2023-08-24 SONO - chest
  • Echo diagnosis: pleural effusion
  • Chest echography was performed first. The suitable intercostal space was selected and located. Catheter was inserted with negative pressure smoothly. Right side pleural effusion was drawn smoothly. Watch out BP after tapping.
  • Suggestion:
    • check BP and taking rest after tapping.
    • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
• 2023-08-18 SONO - chest
  • Echo diagnosis: right side minimal amount of pleural effusion, 450cc serosangious fluid was aspirated for analysis.
• 2023-06-21 Nasopharyngoscopy
  • Findings: smooth np, larynx and hp
  • Diagnosis: lt deep neck infection s/p IV ABX
• 2023-06-14 CT - neck
  • Indication: r/o deep neck infection
  • Without-contrast Ct scan of head and neck region with 3-mm axial, sagittal and coronal images reveals:
    • Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall.
    • Multiple lymph nodes at both side of the neck, more prominent on left side with the largest one about 18 mm at left level II.
    • Extensive severe beam-hardening artifacts over oral cavity.
  • IMP:
    • Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall, associating with enlarged lymph nodes at left neck.
    • D/D: tonsilitis, malignancy.
• 2023-06-12 Nasopharyngoscopy
  • Scope: smooth NPx, larynx, hypopharynx
  • adequate airway curently
  • left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating
• 2023-05-09 CT - brain
  • No brain lesion.
  • Intracranial ICAs atherosclerosis.
  • Age-appropriate cerebral atrophy.
• 2023-04-13 CT - abdomen
  • History and indication: Pancytopenia
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy.
    • Bil. minimal pleural effusions.
    • Tiny liver and renal cysts.
    • Mild hyperplasia of left adrenal gland.
    • Wall edema of gallbladder.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • S/P hysterectomy.
    • Bil. minimal pleural effusions.
• 2023-04-12 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with myelodysplastic syndrome with excess blasts-1
  • The sections show hypercellular marrow (70%). M/E ratio = 1:2 in CD71 and MPO stains. The erythoid precursors are marked increased, dispersed and scattered. The megakaryocytes are normal in number, and few micromegakaryocytes are present. Increased CD34+ and/or CD117+ immature cells, account for 5-10% of nucleated cells. No metastatic carcinoma can be identified in CK stain. The finding is compatible with myelodysplastic syndrome with excess blasts-1. Suggest further bone marrow smear evaluation and clinic correlation.
• 2023-04-11 EGD
  • Diagnosis:
    • Reflux esophagitis, Gr A
    • Superficial gastritis, antrum
  • CLO test: not done
  • Suggestion:
    • Medication and OPD f/u
    • Colon scope may be planned for GI bleeding and anemia survey
    • EGD was suggested annually for GERD f/u
• 2023-01-02 SONO - abdomen
  • Impression:
    • Fatty liver.
    • Right renal stone.

[MedRec]

• 2023-07-23 ~ 2023-08-02 POMR Hemato-Oncology Gao WeiYao
  • Present illness
    • This time, she has dizziness without SOB or dyspnea for 3 days. She was admitted for chemotherapy and blood transfusion on 2023/07/23.
  • Course of inpatient treatment
    • After admission, she received blood transfusion for anemia and thrombocytopenia correct. Chemo as C2 Dacogen since 7/24-7/28.
    • Fever was noted under neutropenic stage, antibiotic treatment for infection control, but no evidence of bacteremia. U/C mix growth without dysuria.
    • Under the stable condition, she can be discharged on 2023/08/02. OPD follow up is arranged.
  • Discharge prescription
    • Allegra (fexofenadine 60mg) 1# BID
    • Ceficin (cefixime 100mg) 2# Q12H
• 2023-06-24 ~ 2023-07-05 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Acute tonsillitis, unspecified
    • myelodysplastic syndrome with excess blasts-1
    • Oral mucositis (ulcerative), unspecified
    • Periapical abscess without sinus
  • CC
    • fever, sore throat and cough for 2~3 days
  • Present illness
    • She received target chemotherapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
    • Last hospitalization during 2023/06/11 to 2023/06/19 because of sore throat under the diagnosis of acute pharyngitis/tonsillitis, suspected deep neck infection, she received antibiotics treatment.
    • This time, she presented fever, sore throat and cough for 2~3 days. She visited to ENT for follow up with nasopharyngoscopy showed left deep neck infection.
    • Poor intake and generalized malaise developed, she visited to our ER. The laboratory disclosed pancytopenia and elevated CRP. CxR revealed clear bilateral costophrenic angles. Physical examination showed left tonsil, mild enlarged and redness and left upper neck swelling. Empirical antibiotics with Tapimycin was prescribed.
    • Under the tentative diagnosis of myelodysplastic syndrome with excess blasts-1 and left deep neck infection, she was admitted on 2023-06-24.
  • Course of inpatient treatment
    • After admission, tapimycin 4.5gm Q6H for tonsilitis.
    • Panadol was given for fever control.
    • On 2023/06/26, her fever subsided and sore throat was improved.
    • On 2023/06/27, we consult oral surgeon for further evaluation and 1. Oral ulcer of tooth 24 palatal side due to low immunity and 2. Apical abcess of tooth 26 noted.
    • Mycostatin 5cc QID + nincort were given.
    • Now, we keep complete IV tapimycin and will follow lab data later.
    • In addition, due to MDS with anemia and thrombocytopenia, we give blood transfusion for sdupportive care.
    • Under relative stable condition, she was discharge with OPD follow up.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • Mycostatin oral suspension (nystatin 0.1MU/mL) 5mL QID
    • Through (sennoside 12mg) 2# HS
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q12H
    • Bisadyl supp (bisacodyl 10mg/pill) 2# PRNHS RECT for constipation
    • Nincord Oral Gel (triamcinolone 1mg/gm) BID TOPI
    • Ceficin (cefixime 100mg) 2# Q12H
• 2023-06-11 ~ 2023-06-19 POMR Hemato-Oncology Gao WeiYao
  • CC
    • for planned target therapy schedule.
  • Present illness
    • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20. After the last chemotherapy, she complained sore throat, poor appetite, weakness, and weigh two kilograms less, no fever or chills, no cough or sputum, no dyspnea, no nausea or vomit, no diarrhea.
    • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.
  • Course of inpatient treatment
    • After admission, she complained sore throat. Comfflam was prescribed for her sore throat.
    • ENT was consulted. Acute pharyngitis/tonsillitis, deep neck infection can’t be ruled out. Neck CT was arranged on 06/14.
    • Infx was also consulted. tapimycin 4.5g Q6H was used for her acute pharyngitis/tonsillitis.
    • She had no fever. Neck CT (2023/06/14): Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall, associating with enlarged lymph nodes at left neck. D/D: tonsilitis, malignancy. Nasopharyngoscopy showed left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating.    
    • On 2023/06/15, her sore throat improved.
    • On 2023/06/19, skin rash on her left elbow improved.
    • Under stable condtion, she was discharged with Oncology and ENT OPD follow up.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# Q6H
    • Mycostatin oral suspension (nystatin 0.1MU/mL) 5mL QID
    • Through (sennoside 12mg) 2# HS
    • Bisadyl supp (bisacodyl 10mg/pill) 2# PRNHS RECT if no stool passage for 3 days
    • Ceficin (cefixime 100mg) 2# Q12H
    • Rivotril (clonazepam 0.5mg) 1# QD
    • Rivotril (clonazepam 0.5mg) 0.5# HS
    • Seroxat (paroxetine 20mg) 0.5# QD
    • Seroxat (paroxetine 20mg) 1# HS
• 2023-05-12 ~ 2023-05-20 POMR Hemato-Oncology Gao WeiYao
  • discharge diagnosis
    • myelodysplastic syndrome with excess blasts-1
    • Abnormal weight loss
  • CC
    • for first decitabine
  • Present illness
    • Under the impression of Compatible with myelodysplastic syndrome with excess blasts-1, so she was admitted for first decitabine on 2023/05/12.
  • Course of inpatient treatment
    • After admission, she received Target therapy as Decitibine 20mg/m2 IVD 1hr since 5/16-5/20.
    • Promeran 3.84mg/tab 1# tidac and monitor GI tract problem.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
• 2023-04-10 ~ 2023-04-13 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • myelodysplastic syndrome with excess blasts-1
  • CC
    • Tarry stool for 1 week
  • Present illness
    • This is a 73-year-old female with past history of
      • hyperlipidemia
      • gastric ulcer s/p treatment on 2018/12
      • right invasive ductal carcinoma, grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA, s/p partial mastectomy
      • uterine myoma s/p ATH.
    • This time, she suffered from tarry stool for 1 week.
    • She has suffered from chronic constipation for 6 months, 2-3 days of no stool passage would be followed by abdominal cramping pain and yellow-brownish diarrhea. The symptoms exacerabated since 2023/02, accompanied with decrease of appetite and general malaise. She went to Taipei city hospital HePing Branch for help on 2023/03 and colonoscopy was done and showed negative finding. According to the patient, diffuse abdominal pain especially at RLQ became more frequently since colonoscopy.
    • Last week she suffered from watery diarrhea for 3-6 times/day for 3 days. Thus, she went to a clinic for help. On 2023/04/09. she started to have watery tarry stool. There were 5 times of watery tarry stool passage in this 2 days. She also noticed body weight decrease for 4kg in 2 months. Thus, she went to the same clinic for help. Blood test was done and Hb 5.8mg/dL was found. Thus, she was refered to our hospital for help.
    • She went to Dr Gao’s OPD and was refered to ER for transfusion and arranged admission. At ER, vital signs was stable, with BP: 148/65mmHg, HR: 91bpm, BT: 36.6’C, RR:18bpm, Con’s:E4V5M6, SpO2:100%. Lab showed Hb 5.7mg/dL. 2 U of pRBC was tranfused and pantoprazole 40mg were first given. Afterwards, she was admitted to hemotology ward for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, 2U LPRBC was tranfused on 2023/04/11. EGD done on 2023/04/11 showed Reflux esophagitis, Gr A. Superficial gastritis, antrum. Therefore, we will try soft diet from 2023/04/12.
    • Due to CBC showed blast 13.9%., bone marrow biopsy (with chromosome) with peripheral smear was done on 2023/04/12. Peripheral smear showed hypercellular bone marrow with marked increase of erythroid lineage, and decreased M/E ratio. Furthermore, plasma cell markedly increased under microscopic high power field. Therefore, multiple myeloma lab profile was drawn, with results pending.
    • Due to blood-tinged stool noted on 2023/04/12 midnight, abdominal CT with contrast was done on 2023/04/13 which showed no structural lesion at small or large intestine.
    • Due to stable condition, the patient was discharged on 2023/04/13. Regular OPd f/u was arranged on 2023/04/18.
  • Discharge prescription
    • Nincort Oral Gel (triamcinolone 1mg/gm) BID TOPI
    • Through (sennoside 12mg) 1# PRNHS if no stool
    • Transamin (tranexamic acid 250mg) 1# PRNBID if bolldy stool

[consultation]

• 2024-01-19 Chest Medicine
  • Q
    • The 73 y/o woman has myelodysplastic syndrome with excess blasts-1. Due to frequency pneumonia over upper both lung, so we need your help for management. Thanks!
  • A
    • HX, PE, CXR review, pt is a case of myelodprofierative disorder, preleukemia stage with excess blasts-1, with frequency pneumonia
    • Suggest
      • sputum TB work up
      • check cryptococcus and aspergillus ag when next blood test
      • RX underlying condtion myelodprofierative disorder, preleukemia stage
      • best supportive carenutrtion, nutrition, I/O, electrolyte balance
      • add on amikin inhale
      • follow up lab, image and bacteria days later after work up and adjust antibiotics regimen
• 2023-11-09 Dermatology
  • Q
    • The 73 y/o woman has MDS under chemotherapy and blood transfusion. Her general skin rashes and itchy, so we need your help for management. Thanks!
  • A
    • Under the impression of blood tranfusion-related gernalized allergy reaciton. notice antibiotics ie Tapimycin association.
    • The following sugestion:
      • consider Vena 1 Amp and Deca 1 Amp Ivdrip before the following blood transfusion (prevention)
        • shift another type of antibiotic use as your experists.
          
      • adequent systemic medication use now.
      • If lesions progressive, consider elevate Vena dosage to 1 Amp Q8H use and regular sytemic steroid ie compresolone 2# QD to Bid po use.
      • Topysm cream (fluocinonide) 2 tube topical bid use over reddish lesions.
• 2023-09-01 Dermatology
  • Q
    • The 73 y/o woman has MDS with pancytopenia. This time, she has pneumonia over right lower lung. Due to oral candiads, we gave Flu-D for treatment, but skin rash is noted since 8/31 night. We hold it and gave antihistamin since 8/31 night, but in vain. We need your help for management. Thanks!
  • A
    • This patient suffered from generalized erytehamtous papules-plaques on trunk for days.
    • Imp: Subacute dermatitis
    • Suggestion:
      • dexamethasone *1 / Qd
      • Zaditen (ketotifen) 1 /Bid
      • Mycomb (nystatin, triamcinolone, neomycin, gramicidin) *10 tubes/bid
• 2023-08-24 Chest Medicine
  • Q
    • The 73 y/o woman has MDS under aggessive care. Due to fever and right lung pneumonia, so she was admitted. Her fever without control, chest CT was done this morning. We need your help for bilateral pneumonia management.
  • A
    • O
      • 20230823 CT of chest
        • RML lobar consolidation with air-bronchograms with areas of poor enhancement. dependent band subsegmental atelectasis at both lower lobe.
        • extensive consolidation with surrounding ground glass opacity over superior lingular and apicoposterior segment of LUL.
        • patchy consolidation and ground glass opacities at RUL.
        • airspace nodular opacities in LLL and LUL too.
      • Lab
        • 2023-08-22 WBC 1.28 x10^3/uL
          
        • 2023-08-22 HGB 9.3 g/dL
          
        • 2023-08-22 PLT 77 *10^3/uL
          
        • 2023-08-22 Neutrophil 1.3 %
          
        • 2023-08-22 Lymphocyte 80.3 %
          
        • 2023-08-22 Monocyte 0.6 %
          
      • 20230820 sputum culture: MNF.
    • Impression:
      • Lobar Pneumonia, RML.
      • Pneumonia, LUL (apicopost. segment), left lingula. RUL.
    • Suggestion:
      • AFB and TB/C of sputum: 3 sets in the morning (risk of pulmonary tuberculosis), possible TB PCR of sputum if positive
        • Suggest chest tapping again for culture, right side pleural effusion. (20230824 afternoon: safty completed)
      • Sputum culture, mycoplasma and chlamydia IgM of blood, Streptococcus pneumonia and legionella Ag in urine.
      • PJP PCR of sputum, CMV DNA (NHI）and IgM in blood, Cryptococcus Ag in blood, Aspergillus Ag in blood.
      • Empiric antibiotics first and guided by subsequent culture results.
• 2023-08-15 Infectious Disease
  • A
    • Consultation for Mepem antibiotic
      • 73-year-old MDS with leukemic transformation female patient suffers from neutropenic fever and right lung pneumonia.
      • White count only 1020, with ANC only 35.
      • Tapimycin is replaced by Mepem this afternoon.
    • Suggestion:
      • Continue Mepem for one week first
      • Add Targocid for possible MRSA coverage, Targocid 600mg iv q12h for 3 doses till 9AM, 2023/08/16, then 500mg iv qd since 2023/08/17.
      • Check blood and sputum culture report.
• 2023-06-27 Oral and Maxillofacial Surgery
  • Q
    • For gum pain
    • This 73 years old woman is a patient of myelodysplastic syndrome with excess blasts-1 s/p Target therapy as Decitibine 20mg/m2 IVD 1hr since 5/16-5/20, past history of
      • ptosis of eyelid,
      • hyperlipidemia,
      • gastric ulcer,
      • right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA)
      • uterine myoma s/p abdominal total hysterectom
    • this time was admitted to our ward for acute-tonsilitis.
    • Now her tonsilitis improved with no fever.
    • She complainted about pain in the upper left gums for about 6 days.
    • We need your expertise for evaluation of gum pain, thank you!
  • A
    • This is a 73-year-old woman with pain over her upper left gingiva for 6 days.
    • O:
      • A white patch with ulcerative surface over upper right gingiva near the palatal side of tooth 24, palpation pain was noted.
      • Mild swelling over her upper left posterior gingiva near the buccal side of tooth 26, percussion pain of tooth 26 was noted.
    • A:
      • Oral ulcer of tooth 24 palatal side due to low immunity
      • Apical abcess of tooth 26
    • P:
      • Physical exam
      • Keep observation of the oral ulcer, please contact us after her ANC raise to normal level.
• 2023-06-13 Infectious Disease
  • Q
    • For antiobiotics of acute pharyngitis/tonsillitis, ENT suggested consulting for ABX
    • This 73 years old woman is a patient of compatible with myelodysplastic syndrome with excess blasts-1, and past history of ptosis of eyelid, hyperlipidemia, gastric ulcer, right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA), and uterine myoma s/p abdominal total hysterectomy.
    • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
    • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.  
    • sore throat with dysphagia for since 5/16 after target therapy, left more severe
    • odynophagia+, fever-, WBC:2l, CRP:2.1
    • We consulted ENT for acute pharyngitis/tonsillitis, Abx was suggested.
    • We need your expertise for antiobiotics of acute pharyngitis/tonsillitis, thank you！
  • A
    • The patient’s conditin as your description.
    • Tapimycin 4.5g iv q8h is suggested for the acute pharyngitis/tonsillitis.
    • Please arrange neck CT to exclude deep neck infection.
    • Please collect adequte culture.
• 2023-06-12 Ear Nose Throat
  • Q
    • For evaluation of dysphagia after first dose of target therapy, cycle 1 Decitabine since 2023/05/16 to 05/20
    • This 73 years old woman is a patient of compatible with myelodysplastic syndrome with excess blasts-1, and past history of ptosis of eyelid, hyperlipidemia, gastric ulcer, right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA), and uterine myoma s/p abdominal total hysterectomy.
    • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
    • After last chemotherapy, she complained dysphagia, sore throat and cough. No fever.
    • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.  
    • We need your expertise for evaluation of dysphagia before second target therapy, thank you!
  • A
    • S:
      • sore throat with dysphagia for since 5/16 after target therapy, left more severe
      • odynophagia+, fever-, dyspnea-
      • Allergy: denied
    • O:
      • Oral cavity and oropharynx: left post. pharyngeal wall bulging
      • no uvula deviation
      • Scope: smooth NPx, larynx, hypopharynx
        • adequate airway curently
        • left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating
      • left upper neck tenderness
    • A: acute pharyngitis/tonsillitis, deep neck infection can’t be ruled out
    • Plan:
      • After discussing with Dr. Lan
        • Consult infection for IV antibiotic suggestion (stronger is favored)
        • suggest hold target/chemo therapy, infection control first
        • Pain control
        • self-paid Difflam spray and parmason for oral hygiene if the patient agreed
        • Instruct the patient to rinse her mouth after meals and avoid eating hot and spicy foods.
        • Monitor airway, well educated about airway issue
        • check infection profile
        • if s/s still progressed after antibiotic Tx, consider CT with/without contrast exam if no contraindication to rule out deep neck infection/mediastinitis
        • ENT OPD f/u
      • neck CT (without contrast CT): no obvious abscess formation, left pharyngeal wall swelling with enlarged LNs
      • leading Dx: infection with reactive LN
      • DDx: malignancy can’t be ruled out, lymphoma……..
      • please keep IV anti for 2 weeks
      • if s/s no improvement, suggest left tonsillectomy to rule out malignancy

[chemotherapy]

• 2023-11-02 - decitabine 20mg/m2 21mg NS 100mL 1hr D1-5
• 2023-07-24 - decitabine 20mg/m2 31mg NS 100mL 1hr D1-5
• 2023-05-16 - decitabine 20mg/m2 32mg NS 100mL 1hr D1-5

==========

2024-01-24

[addressing hemoptysis with inhaled tranexamic acid]

Today’s progress note indicated that the patient experienced a mild episode of coughing up blood last night. Should the hemoptysis persist, the use of inhaled tranexamic acid (500mg/5mL, up to five days) has been reported to effectively reduce the volume of hemoptysis, expedite its resolution, and potentially shorten the duration of hospitalization.

Ref: - Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018;154(6):1379. - Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series. Int J Emerg Med. 2020;13(1):45.

2023-07-05

• I visited the patient around 11:15 on 2023-07-05 carrying the decitabine medication usage information. The patient was lying in bed and her awake husband was sitting in the bench by the window.

• I first asked the patient’s husband how the patient’s recent condition was and whether the discomfort in the mouth had worsened or improved? The husband said that the patient is currently using the oral paste prescribed by the doctor, and the condition is manageable. He also asked if the infection was caused by the use of decitabine. I responded that since April, the patient’s white blood cell count has consistently remained around 2000 +- 500, and there was no significant fluctuation due to the administration of decitabine in mid-May. Although the effect of decitabine on white blood cells can’t be entirely ruled out, it does not seem to be the primary cause based on the observations.

701007202

240124

[exam findings]

2024-01-23 lab data showed both DGH and Toxin A/B positive.

==========

2024-01-24

[TDM scheduling for optimized vancomycin treatment in CDI]

Lab data from 2024-01-23 confirmed positivity for both DGH and Toxin A/B.

For patients with severe or fulminant C. difficile infection, an initial oral dose of vancomycin can be 10 mg/kg, administered four times daily for 10 days, with a maximum dose of 500 mg per administration. In critically ill patients, the addition of intravenous metronidazole may be considered.

This patient exhibits impaired renal function as evidenced with an eGFR of 21 mL/min/1.73m², an elevated serum creatinine (2.94 mg/dL) and blood urea nitrogen (BUN) (31 mg/dL) on 2024-01-24. While the vancomycin manufacturer’s labeling lacks specific dosage adjustments for this degree of renal impairment, the low systemic absorption of vancomycin suggests dose modification may not be necessary.

Oral vancomycin 500mg QID has just been prescribed from 2024-01-23 for a duration of seven days, adhering to standard usage. Therapeutic drug monitoring (TDM) is recommended to be scheduled on day 3, specifically on 2024-01-26, with a blood sample to be drawn within 30 min before the next dose.

Ref: Does oral vancomycin use necessitate therapeutic drug monitoring? Infection. 2020 Apr;48(2):173-182. doi: 10.1007/s15010-019-01374-7.

700752671

240123

[lab data]

2022-10-24 Anti-HBc Reactive
2022-10-24 Anti-HBc-Value 6.32 S/CO
2022-10-24 HBsAg Nonreactive
2022-10-24 HBsAg (Value) 0.35 S/CO
2022-10-24 Anti-HCV Nonreactive
2022-10-24 Anti-HCV Value 0.13 S/CO

[exam findings]

• 2023-10-24, -10-02 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Tortuosity of thoracic aorta
  • Borderline cardiomegaly
  • Spondylosis with scoliosis of the T-spine with convex to right side
• 2023-10-23 CT - abdomen
  • History and indication: duodenum cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Malignancy in GB and duodenum with adjacent structures invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with ascites.
    • Splenomegaly.
    • Tiny renal cysts.
    • Degeneration and spondylosis of L-S spine.
  • IMP:
    • Malignancy in GB and duodenum with adjacent structures invasion (stable). Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with ascites c/w tumor seeding. Splenomegaly.
• 2023-08-30 Joint soft tissue sonography
  • Findings: Hypoechoic disruption of the right supraspinatus tendon fibers extending from the bursal surface to the articular surface
  • Impression: Right supraspinatus tendon full-thickness tear
• 2023-08-02 Antegrade Venography
  • Venography via left port-A catheter administration revealed some blood clot around distal end of the catheter without occlusion. Patency of SVC.
• 2023-07-31 Abdomen - standing (diaphragm)
  • Spondylosis with scoliosis of the L-spine with convex to left side.
  • Ileus projecting at LMQ abdomen is suspected.
  • Pneumobilia on both hepatic lobes are noted.
• 2023-07-18 CT - abdomen
  • Clinical history: 81 y/o female patient with abdominal pain, suspect IAI.
  • With and without contrast enhancement CT of abdomen - whole:
    • Infiltrative soft tissue tumors in the GB, IHDs and along CHD region, hepatic hilar regions and around duodenum.
      
    • Dilatation of IHDs with pneumobilia, dilatation of P-duct.
    • Soft tissue tumors in the peritoneum and subphrenic region, could be due to carcinomatosis.
    • Mucosal enhancement at ascending colon.
    • Portal venous thrombosis.
    • Presence of ascites.
  • Impression:
    • Malignancy in GB, IHDs and CHD regions, hepatic hilar and around duodenum. Stationary.
    • Peritoneal tumors with ascites, r/o carcinomatosis.
    • More prominent mucosal enhancement at ascending colon. Suggest clinical correlation.
• 2023-07-16 KUB
  • Presence of scoliosis of the lumbar spine.
  • Presence of ileus.
• 2023-07-16 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
  • Left axis deviation
  • Abnormal ECG
• 2023-06-27 ECG
  • Sinus bradycardia
  • Left axis deviation
• 2023-05-19 Myocardial perfusion SPECT with persantin
  • Probably mild myocardial ischemia at the basal inferolateral wall.
  • Reverse redistribution of radioactivity to the apical lateral wall, either normal variant or myocardial ischemia may show this picture.
• 2023-05-02 Angegrade venography
  • Venography via left port-A catheter administration revealed some blood clot around distal end of the catheter without occlusion.
• 2023-04-20 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (72.1 - 21.0) / 72.1 = 70.87%
    • M-mode (Teichholz) = 70.6
  • Conclusion:
    • Dilated LA
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild MR, TR
• 2023-04-19 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
• 2023-04-17 CT - abdomen
  • History and indication: duodenum with S4 liver invasion, multiple metastatic nodes
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Malignancy in GB and duodenum with adjacent structures invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites.
    • Splenomegaly.
    • Enlargement of left thyroid gland.
    • Tiny renal cysts.
    • Partial atelectasis at LLL.
    • Degeneration and spondylosis of L-S spine.
  • IMP:
    • Malignancy in GB and duodenum with adjacent structures invasion (stable). Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites. Splenomegaly.
• 2023-03-02 SONO - abdomen
  • Liver tumor, S4, suspect metastasis
  • GB lesion, suspicious tumor, and cholecystopathy
  • Intra-IHD lesion, B8, unknown etology and IHD dilatation
  • CBD wall asymmetric thickness, suspicous infiltrative cause
  • Marked MPD dilatation
  • Splenomegaly
• 2023-01-12 CT - abdomen
  • History and indication: Adenocarcinoma of gallbladder cancer with S4 liver invasion
  • With and without-contrast CT of abdomen-pelvis revealed:
    • GB cancer (2.7cm) with liver invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites.
    • Splenomegaly.
    • Enlargement of left thyroid gland.
    • Tiny renal cysts.
    • S/P Port-A infusion catheter insertion. Degeneration and spondylosis of L-S spine.
  • IMP:
    • GB cancer (2.7cm) with liver invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites r/o tumor seeding.
• 2022-11-09 Patho - liver biopsy needle/wedge
  • Liver, EUS-FNB — Adenocarcinoma, moderately differentiated
  • The sections show a picture of adenocarcinoma, composed of nests of columnar neoplastic cells with glandular formation and mucin secretion, embedded in fibrous stroma.
  • IHC shows: CK7(+), CK20(-), and CDX2(+).
  • Comment: The histological pattern and immunophenotype are similar to duodenal biopsy specimen (S2022-9593). Adenocarcinoma of duodenum origin can not be completely excluded. Suggest clinic correlation.
• 2022-11-09 Patho - duodenum biopsy
  • Duodenum, 2nd portion PW, biopsy — Adenocarcinoma, moderately differentiated, upper GI type
  • The secvtions show a picture of adenocarcinoma, upper gastrointestinal type, composed of columnar neoplastic cells, arranged in glandular and papillary patterns with desmoplastic stromal reaction.
  • IHC, tumor cells reveal: CK7(+), CK20(-), and CDX2(+).
• 2022-11-08 EUS
  • Diagnosis：
    • GB tumor prob. cancer s/p EUSFNB (A)
    • Hepatic tumor Prob. GB cancer with liver involvement s/p FNB (B)
      
    • duodenal tumor s/p Bx (C)
    • Ascites, moderate
    • MPD dilatation
    • Lymphadenopathy
  • Suggestion:
    • pursue pathological result
• 2022-11-04 MRI - MR Chloangiography, MRCP
  • Findings:
    • There is an ill-defined, mild heterogeneous mass measuring 7.3 x 4 cm in the gallbladder fossa and S4 of the liver, showing hypointensity on T1WI and mild hyperintensity on both T2WI and DWI. During dynamic study, this tumor shows poor contrast enhancement in arterial phase, portal-venous phase and delayed phase images.
      • Gallbladder cancer is highly suspected.
      • The differential diagnosis include cholangiocarcinoma and poorly differentiated HCC.
    • There are enlarged nodes in gastrohepatic ligament, celiac trunk, hepatoduodenal ligament, aortocaval space, and para-aortic space that are c/w metastatic nodes.
    • There is ascites and soft tissue lesions in the parietal peritoneum in right perihepatic space and omentum that may be carcinomatosis? Please correlate with ascites cytology.
    • There is marked dilatation and pneumobilia on both lobes IHDS. please correlate with clinical history.
    • There is irregular liver contour, hypertrophy of S1, atrophy of S2-3, non-visualization of left portal vein.
      • Chronic cholangitis induce biliary cirrhosis is highly suspected.
    • There is spleen size prominence (long axis: 11 cm) and ascites that may be portal hypertension.
    • The pancreatic duct shows dilatation the may be IPMN, main duct type.
    • There are several renal cysts on both kidney and the largest one measuring 0.5 cm in size at left upper pole.
  • IMP:
    • Gallbladder cancer with S4 liver invasion is highly suspected.
      • The differential diagnosis include cholangiocarcinoma and poorly differentiated HCC at S4 liver with gallbladder invasion.
    • Multiple Metastatic nodes in gastrohepatic ligament, celiac trunk, hepatoduodenal ligament, aortocaval space, and para-aortic space.
    • Carcinomatosis is suspected. Please correlate with ascites cytology.
    • IHDs dilatation and pneumobilia.
    • Chronic cholangitis induce biliary cirrhosis is suspected.
    • IPMN of the pancreas is highly suspected.
• 2022-10-25 Patho - gall bladder (malignancy)
  • Labeled as “gallbladder”, core needle biopsy — high grade dysplasia. See description.
  • Section shows high grade dysplasia lined tissue with focal inner muscular layer and outer muscular layer.
  • IHC stains: CK 19 (+), Ki-67: 5%. Also present is one piece of benign liver tissue and benign bile canaliculi tissue.
• 2022-10-24 SONO - abdomen
  • Diagnosis:
    • Liver parenchymal disease
    • liver tumors: cause to be determined
    • dilatation of bilateral IHD, pneumobilia
    • GB sac could not be identified
    • dilatation of main pancreatic duct: body portion(some parts of pancreas obscured)
    • ascites: small amount
  • Suggestion:
    • 4 phase CT or dynamic MRI study

[MedRec]

• 2022-10-23 ~ 2022-10-26 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Upper abdominal pain, unspecified
    • Malignant neoplasm of gallbladder suspected S/P CT guide biopsy on 2022-10-25 and pathology report was pending .
  • CC
    • upper abdominal pain since Sep 2022
  • Present illness
    • This 81-year-old woman, a patient suspected gallbladder cancer by whole abdominal CT exam at CGMH hospital. She suffered form upper abdominal pain, distension, poor appetite and body weight loss (2-3kg) since Sep 2022 and she visited to CGMH for medical attention where abdominal CT showed decreased and heterogenous enhancement at biliary tract and mild dilated pancreatic duct, mild ascites noted, no GB stone nor CBD stone was found. She was referred to oncologist Dr. Kao’s OPD for second opinion.
    • Upon admission, she noted persisted intermittent epigastralgia and mild panic, no fever, no chillness, no bowel habit change, no jaundice. the laboratory data showed no significance, no abnormal liver chemistry, pending for tumor biomarker. Owing to above, she was aditted for further evaluation and management.
  • Course of inpatient treatment
    • After admission, image study with abdominal sono (2022/10/24) showed Liver parenchymal disease, liver tumors: cause to be determined, dilatation of bilateral IHD, pneumobilia, (GB sac could not be identified), dilatation of main pancreatic duct: body portion(some parts of pancreas obscured), ascites: small amount. Radiologist was consulted for CT guide biopsy evaluation.
    • CT guide biopsy was performed on 2022/10/25, smoothly without active bleeding or abdominal pain. The pathology report was pending. She was discharged on 2022/10/26 under stable condition and will follow-up at OPD.
• 2022-10-20 SOAP Hemato-Oncology Gao WeiYao
  • S
    • for 2nd opinion, referred by sister Lin
    • Being informed to have hepatobiliary tract neoplasm
    • Epigastric pain for one month but it resolved by itself and CT done at Linkou CGMH
    • History of biliary tract infection before
  • O
    • BP 145/85; HR 78
  • A
    • BH 152, BW 66.7

[consultation]

[chemotherapy]

• 2024-01-22 - oxaliplatin 85mg/m2 127mg D5W 250mL 6hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-27 - (FOLFOX)
• 2023-11-14 - (FOLFOX)
• 2023-10-02 - (FOLFOX)
• 2023-09-13 - (FOLFOX)
• 2023-08-30 - (FOLFOX)
• 2023-08-14 - (FOLFOX)
• 2023-06-27 - (FOLFOX)
• 2023-06-02 - (FOLFOX)
• 2023-05-02 - (FOLFOX)
• 2023-04-18 - (FOLFOX)
• 2023-03-29 - (FOLFOX)
• 2023-02-13 - (FOLFOX)
• 2023-01-30 - (FOLFOX)
• 2023-01-09 - (FOLFOX)
• 2022-12-26 - (FOLFOX)
• 2022-12-13 - (FOLFOX)
• 2022-12-01 - oxaliplatin 85mg/m2 137mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-11-17 - leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 48hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2024-01-23

[CEA marker trends and imaging updates]

The patient has been undergoing FOLFOX treatment since Dec 2022, for over a year, and has generally tolerated it well.

She is also receiving Baraclude (entecavir) for reactive Anti-HBc and Megejohn (megestrol acetate) for cachexia, with no discrepancies in medication identified.

The CEA marker showed a recent high in November 2023. There has been no updated imaging study since Oct 2023, which may warrant renewal.

701227488

240123

[MedRec]

• 2024-01-21 ~ 2024-01-22 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Other pancytopenia
    • Thrombocytopenia, unspecified
    • Anemia, unspecified
  • CC
    • shortness of breath for months
  • Present illness
    • This is a 89-year-old female with anemia for over ten years. She had family history of thalassemia. This time, she came to our HEMA OPD due to severe anemia, shortness of breath noted for months. She also complaint about low back pain for years. At OPD, blood test revealed pancytopenia, blood transfusion with LPRBC 2u was arranged. There was no fever, no chills, no chest pain, no nausea or vomiting, no tarry stool. The patient was admitted for clarifying the nature of severe anemia and pancytopenia.
  • Course of inpatient treatment
    • After admission, blood test was arranged which showed Hb 4.9 g/dL, blood transfusion with LPRBC 2u was ordered. She underwent bone marrow puncture and biopsy on 2024/01/22. Under stable condition, she discharged on 2024/01/22 and OPD follow up was arranged.
• 2024-01-18 SOAP Hemato-Oncology Gao WeiYao
  • S
    • Gyn Prof. Dr Hwang’s relative
    • History of anemia post transfusion 7 yrs ago
    • History of severe anemia as low as 3.9.
    • back pain, lower back nature?
    • family history of thalassemia
  • O
    • WBC = 1.94 x10^3/uL;
    • HGB = 4.2 g/dL;
    • MCV = 92.6 fL;
    • PLT = 47 x10^3/uL;
    • BP:116/47; HR:78/min;
  • A
    • BW 40
    • pancytopenia nature to be determined

701484337

240123

[exam findings]

• 2024-01-20 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Clinical sigmoid ccancer s/p treatment.
    • Small left renal stone without obstruction.
    • Right renal cyst, 1.1cm.
    • Stationary paraaortic lymph nodes.
    • Soft tissue tumor, 2cm in right pelvic cavity (lymph node or ovary?) stationary.
    • There are multiple liver tumors, up to 6.1cm in S4-8 liver, with peripheral nodular enhancement, r/o liver hemangiomas.
    • Dilatation of CBD.
    • Outpouching lesions in ascending colon, suggesting colon diverticula.
  • Impression:
    • Clinical sigmoid ccancer s/p treatment.
    • Stationary paraaortic lymph nodes.
    • Right pelvic cavity soft tissue, lymph node or ovary? stationary.
    • Multiple liver tumors, r/o hemangiomas.
    • Dilatation of CBD.
    • Ascending colon diverticula.
• 2023-12-19 CXR erect
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Tortuosity of thoracic aorta
  • Borderline cardiomegaly
• 2023-11-28 Gynecologic Ultrasonography
  • R/O Endometrial polyp
  • Uterine myoma
• 2023-10-27 CT - abdomen
  • Findings: Comparison: prior CT from NTUCC dated 2023/05/11.
    • There is no focal wall thickening at the rectum.
      • Please correlate with colonoscopy.
    • Prior CT identified one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space are noted again, stationary.
      • Please correlate with PET scan.
    • Prior CT identified ten hemangiomas on both hepatic lobes (the largest one 6 cm in S6/7) are noted again, stationary.
      • In addition, few cysts on both hepatic lobes are also noted.
    • S/P cholecystectomy.
      • There is mild dilatation of IHDs and CHD.
      • Please correlate with serum alk-p and bilirubin level.
    • A renal cyst 1.2 cm in right middle pole is noted.
  • Impression:
    • There is no focal wall thickening the rectum.
      • Please correlate with colonoscopy.
    • Prior CT identified one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space are noted again, stationary.
      • Please correlate with PET scan.
• 2023-07-10 All-RAS + BRAF mutation
  • Cellblock No. F2023-00289 A2
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-06-23 Patho - breast mastectomy with regional lymph nodes
  • PATHOLOGIC DIAGNOSIS
    • Breast tumor, left, BCT + frozen —- Solid papillary carcinoma with invasion
    • Resection margins, ditto — Free of tumor invasion
    • Lymph node, left axillary sentinel area, frozen (F2023-00289) — Free of tumor metastasis (0/4)
    • AJCC Pathologic Anatomic Stage — pT1cN0, if cM0, stage IA; Prognostic Stage — Stage IA
  • MACROSCOPIC EXAMINATION
    • Breast: 8.5 x 6 x 2.2 cm
    • Skin: 3.5 x 0.7 cm
    • Nipple: Not received
    • Tumor: 1.1 x 1.1 cm
    • Resection margins: Free, 0.2 cm away from closest 3 o’clock margin, 0.9 cm from base and at least 1.3 cm away from peripheral margins
    • Lymph node: left axillary sentinel LNs, sent for frozen section (F2023-00289)
    • Representative sections as F2023-00289 FSA: L’t axillary sentinel LNs, FSB: 3 o’clock margin and base, A1-A3: tumor and A4: skin
  • MICROSCOPIC EXAMINATION
    • Histologic type: solid papillary carcinoma with invasion
    • Size of invasive carcinoma: 1.1 x 1.1 cm
    • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
    • Margins: Free of tumor invasion
    • Nodal status: Free of tumor metastasis (0/4)
    • Treatment Effect: N/A
    • Lymphovascular space invasion: Not identified
    • Perienural invasion: Not identified
  • IMMUNOHISTOCHEMISTRY
    • F2023-00289A2: synaptophysin(+, diffuse), chromogranin-A(+, scatter) for tumor, CK5/6(-) and P63(-) for myoepithelial cell
    • Please refer to S2023-11754 for ER, PR, Her2/neu and Ki67 status
• 2023-06-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (84 - 34) / 84 = 59.52%
    • M-mode (Teichholz) = 59
  • Conclusion:
    • Mild septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis with mild AR; mild MR; mild TR; mild PR.
    • Mild aortic root calcification; mildly dilated proximal ascending aorta (32 mm).
• 2023-06-13 Patho - breast biopsy (no need margin)
  • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • IHC stains: ER (+, 100%, strong intensity), PR (+, 75%, strong intensity), Her2/neu: negative (score=0), Ki-67 (10 %), p63 (-), CK5/6 (-), E-cadherin (+).
• 2023-06-13 SONO - breast
  • Imp
    • Left breast tumor, r/o malignancy, suggest biopsy.
    • Left breast cyst.
      
  • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.
• 2023-06-13 Mammography
  • Impression: Hyperdense tumor, 1.47cm in UOQ of left breast (posterior third portion), suggest sonographic correlation.
    
  • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)
• 2023-06-07 MRI - pelvis
  • Findings:
    • There is soft tissue lesion in the left lateral wall of the upper rectum, measuring 1.2 cm in size, with submucosa involvement that is c/w adenocarcinoma (T2).
      • In addition, there are three enlarged node 0.4 cm in left perirectal space, 1.6 cm in right internal iliac chain, and 0.6 cm in left sigmoid mesocolon that are c/w regional metastatic node (N1b).
    • There is one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space. Non-regional metastatic node (M1a) is highly suspected.
      • Please correlate with PET scan.
    • There are ten hemangiomas on both hepatic lobes and the largest one measuring 6 cm in S6/7.
      • In addition, few cysts on both hepatic lobes are also noted.
    • S/P cholecystectomy.
    • A renal cyst measuring 1.2 cm in right middle pole is noted.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N1b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
• 2023-06-05 PET
  • A glucose hypermetabolic lesion at the R-S junction, compatible with the primary rectal cancer.
    
  • Increased FDG uptake in the left para-aortic lymph nodes, at the L2-3 spine level, metastatic lymph nodes should be considered.
  • Increased FDG uptake in the left breast, the other primary breast cancer should be considered, suggesting biopsy for investigation.
    
  • Increased FDG uptake at the upper pole of the right kidney, the nature is to be determined also (urine retention, tumor, or other nature ?). Please correlate with other clinical findings for further evaluation.
  • Low-dose CT showed focal or nodular lesions of faint FDG uptake in the liver and in the left upper lung, suggesting follow-up.

[MedRec]

• 2023-12-07 SOAP Urology Wu ShuYu
  • S: frequency for long, urgency, improving on Oxbu
  • O: ask for refill only
  • A: OAB (overactive bladder)
  • Prescription x3
    • Oxbu (oxybutynin 5mg) 1# QD
• 2023-10-19 Hemato-Oncology Xia HeXiong
  • S: Celebrex (celecoxib) and Solaxin (chlorzoxazone) prescribed on 2023-10-02 in NTUH BeiHu Branch, for soreness over body
• 2023-07-04 SOAP Hemato-Oncology Xia HeXiong
  • O
    • 2023/06/23 PATHO - breast mastectomy with regionl lymph nodes
      • Breast tumor, left, BCT + frozen —- Solid papillary carcinoma with invasion
      • Resection margins, ditto — Free of tumor invasion
      • Lymph node, left axillary sentinel area, frozen (F2023-00289) — Free of tumor metastasis (0/4)
      • AJCC Pathologic Anatomic Stage — pT1cN0, if cM0, stage IA; Prognostic Stage — Stage IA
      • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
      • Margins: Free of tumor invasion
      • F2023-00289A2: synaptophysin (+, diffuse), chromogranin-A (+, scatter) for tumor, CK5/6 (-) and P63 (-) for myoepithelial cell
      • Please refer to S2023-11754 for ER, PR, Her2/neu and Ki67 status
  • A/P
    • bevcizumab (bevacizumab will be given)
    • Admission for 1st cycle of FOLFOX
• 2023-06-19 ~ 2023-06-24 POMR General and Gastrointestinal Surgery Chen YenZhi
  • Discharge diagnosis
    • Invasive carcinoma of left of breast, no special type, cT1bN0M0, stage IA, status post left partial mastectomy and sentinel lymph node biopsy and right port-A implantation on 2023/03/21, ECOG:0, ER (+), PR(+), Her2(-), Ki-67(10 %)
    • Malignant neoplasm of sigmoid colon
    • Essential (primary) hypertension
  • CC
    • Left breast tumor was incidentally noted during sigmoid cnacer survey.
  • Present illness
    • This 74 years old female has history of 1) Hypertension under medicaiton control, 2) Sigmoid cancer cT2N1bM1a, stage IV.
    • According to her statement, sigmoid cancer was diagnosis on April, 2023 at NTUH. She went to our hospital for second opinion. However, left breast tumor was incidentally noted during sigmoid cnacer survey.
    • On 06/05 PET was performed which revealed primary rectal-sigmoid cancer with lymph node metastasis and suspecious primary breast cancer. She was referred to GS OPD for breast tumor survey.
    • On 06/13 mammography showed a hyperdense tumor, 1.47cm in UOQ of left breast. Breast sono revealed left 3o’clock/2.23cm, size 0.8x0.48cm irregular shape hypoechoic tumor, suspect malignancy, BI-RADS: Category 4c.
    • Therefore, arrange left breast sono-guide biopsy was done, pethology revealed invasive carcinoma, no special type, IHC stains: ER (+, 100%, strong intensity), PR(+, 75%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p63 (-), CK5/6 (-), Ecadherin (+). Physical examination showed no palpable mass at bilateral breast without tenderness, no nipple retraction and without disacharge nor bleeding, no palpable axillary lymph node.
    • Under impression of left breast cancer, she admitted for surgery management.
  • Course of inpatient treatment
    • After admitted, we arrange cardiopulmonary function test for preoperation survey. She received left breast partial mastectomy, sentinel lymph node biopsy and right port-A implantation was performed on 2023/06/21.
    • The post-operative course was relatively smooth without complication. During the hospitalization analgesic agent were administered and the wound management was performed. There were no nosocomial infection and other complications. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. The wound is clean and without hematoma. Under improved general condition, she was allowed to discharge today, take one JP drain to home and OPD follow up was arranged. 
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
• 2023-06-15 SOAP General and Gastrointestinal Surgery Chen YenZhi
  • S
    • left breast tumor was incidently noted
  • O
    • 2023/06/13 PATHO - breast biopsy (no need margin)
      • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains: ER (+, 100%, strong intensity), PR (+, 75%, strong intensity), Her2/neu: negative (score=0), Ki-67 (10 %), p63 (-), CK5/6 (-), E-cadherin (+).
  • A/P
    • left breast BCT and right chest port-A implantation
• 2023-06-13 SOAP Hemato-Oncology Xia HeXiong
  • S
    • Newly diagnosed sigmoid cancer
    • PH: HTN, lipoma, LC, ERCP
    • For further management of the disease
  • O
    • 2023/06/05 Whole body PET scan:
      • A glucose hypermetabolic lesion at the R-S junction, compatible with the primary rectal cancer.
        
      • Increased FDG uptake in the left para-aortic lymph nodes, at the L2-3 spine level, metastatic lymph nodes should be considered.
      • Increased FDG uptake in the left breast, the other primary breast cancer should be considered, suggesting biopsy for investigation.
        
      • Increased FDG uptake at the upper pole of the right kidney, the nature is to be determined also (urine retention, tumor, or other nature ?). Please correlate with other clinical findings for further evaluation.
      • Low-dose CT showed focal or nodular lesions of faint FDG uptake in the liver and in the left upper lung, suggesting follow-up.
        
    • 2023/05/11 CT (at NTUH) 0401180014
      • History of S-colon cancer – CEA = 1.73 ng/ml; CA19-9 = 16.8 U/ml (2023/05/8).
      • CT without and with contrast enhancement Indication: for evaluation Findings:
        • colon – the S-colon cancer should be correlated with clinical findings. – no regional LNs; – there is no evidence of paraaortic LAPs in abdomen; there is no evidence of LAPs in pelvic cavity and bilateral inguinal areas. – there is no ascites
        • liver – a large hemangioma 65.0mm at the S4a/8 area; – a large hemangioma 60.7mm at the S6 of right lobe of liver; – other multiple smaller hemangiomas are noted in both lobes of liver (arrow key images) – several small cysts in both lobes of liver; – hepatic veins and portal veins are patent
        • operative change of the GB; slightly dilated common bile duct
        • a duodenal diverticulum is noted at the second portion of duodenum
        • tiny cysts in the right kidney; there are no focal lesions in the spleen pancreas both adrenal and kidneys
        • no definite focal lesions in the pelvic cavity
        • atherosclerosis of the aorta;
        • spondylosis of the lumbar spine is noted; The alignment is intact.
        • A vertebral body hemangioma at the L2;
    • Impression
      • S-colon cancer cTxN0M0
      • multiple liver hemangiomas
    • 2023/06/07 MRI Pelvis
      • Findings
        • There is soft tissue lesion in the left lateral wall of the upper rectum, measuring 1.2 cm in size, with submucosa involvement that is c/w adenocarcinoma (T2).
          • In addition, there are three enlarged node 0.4 cm in left perirectal space, 1.6 cm in right internal iliac chain, and 0.6 cm in left sigmoid mesocolon that are c/w regional metastatic node (N1b).
      • There is one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space. Non-regional metastatic node (M1a) is highly suspected.
        • Please correlate with PET scan.
      • There are ten hemangiomas on both hepatic lobes and the largest one measuring 6 cm in S6/7.
        • In addition, few cysts on both hepatic lobes are also noted.
      • S/P cholecystectomy.
      • A renal cyst measuring 1.2 cm in right middle pole is noted.
      • T2N1bM1a, STAGE: IVA
  • P
    • Suggest admission for C/T with FOLFIRI with or without bevcizumab

[surgical operation]

• 2023-06-21
  • Surgery
    • left partial mastectomy and SLNB
    • port-A implantation
  • Finding
    • left 3/3 tumor
    • SLNB: negative of malignancy, 0/4
    • right chest port-A implantation via right cephalic vein with cut-down method and 7fr Kabi set fixed at 14cm

[chemotherapy]

• 2024-01-22 - bevacizumab 5mg/kg 260mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-12-29 - bevacizumab 5mg/kg 260mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-11-28 - bevacizumab 5mg/kg 260mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-10-27 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-09-27 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-09-08 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-08-23 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-08-04 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-07-21 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-07-07 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-01-23

[Vit B and CIPN: no clear recommendation, potential benefits remain]

B-Red (hydroxocobalamin) 1mg IM was administered on 2024-01-23 after chemotherapy to prevent oxaliplatin-induced neurotoxicity.

The year 2020 ASCO and joint ESMO/EONS/EANO guidelines concluded that clinicians should not offer vitamin B as a neuroprotectant agent to individuals receiving potentially neurotoxic chemotherapy.

Schloss et al. reported that vitamin B complex supplementation was statistically ineffective at preventing CIPN as compared to the placebo, although as indicated by the results of the Patient Neurotoxicity Questionnaire (PNQ), patients taking the vitamin B complex perceived a reduction in sensory peripheral neuropathy. Importantly, in cases of CIPN coexisting with vitamin B12 deficiency, patients did benefit from the oral supplementation of this medication. Lastly, Abe et al. reported that oral vitamin B12 supplementation did not help in the prevention of the CIPN onset. Their study did not include the control group and they compared the efficacy of B12 supplementation versus goshajinkigan—observed incidence of neuropathy was 88.9% and 39.3%, respectively.

Vitamin B complex supplementation cannot be recommended as the main way of CIPN prevention. Nevertheless, since such therapy does not impact the effectiveness of chemotherapy (with the exception of high doses of pyridoxine), and in some particular cases could potentially have an ameliorative effect, treatment with the vitamin B complex could be a safe and cheap solution.

Ref: Nutrients 2022, 14(3), 625; https://doi.org/10.3390/nu14030625

700857014

240122

[exam findings]

• 2024-01-17 SONO - abdomen
  • Mild GB wall thickening, possibly secondary to acute hepatitis
  • Minimal right perirenal fluid, focal
• 2024-01-15 Peripherally Inserted Central Catheter
  • Indication of PICC: plastic anemia with severe thrombocytopenia and anemia, for further chemotherapy
  • We perform PICC at cath room. Under the peripheral echo guiding, We successful pucnture left basilic vein. Under the fluroscopy revealed the wire in true lumin. Micro-sheath was advanced. PICC catheter tip advanced in high right atrial under the fluroscopy smoothly.
  • SvO2 was also check, it revealed 68 %.
    • Estimated Fick Cardiac index 2.28 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
    • Estimated Fick cardiac output 3.58 L/min. (nomral cardiac output range 5~6 L/min)
• 2024-01-02 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — marked hypocellularity.
  • Section shows piece(s) of bone marrow with 1% cellularity and M:E ratio of approximately 1:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are markedly reduced in number. There is no malignancy present.
  • IHC stains: CD117: <1%; CD34: <1 %; MPO: 50%, CD61: <1 %; CD71: 50 % (of the nucleated cells). Feature suggestive of severe aplastic anemia. Please correlate with clinical, hemogram, and other laboratoy findings.

[MedRec]

• 2024-01-12 SOAP Hemato-Oncology Gao WeiYao
  • A: Aplastic anemia with severe thrombocytopenia and anemia
• 2023-12-29 ~ 2024-01-02 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Severe Thrombocytopenia, unspecified
    • Severe anemia, unspecified
    • Other pancytopenia
  • CC
    • gum bleeding for three months
  • Present illness
    • This is a 58-year-old female with the past history of brain surgery 40 years ago due to intracranial hemorrhage caused by traffic accident.
    • This time, she visited our hema OPD due to purpura over extremiteis for years and gum bleeding for three months. Accompanied with mild dyspnea. There was no fever, no chills, no chest pain, no nausea or vomiting, no tarry stool. Blood test was arranged which revealed pancytopenia. She was then referred to ER for emergent blood transfusion and admission for further studies.
    • At our ER, her vital signs were BP 150/64; HR 114; BT 37’C; RR 18; Con’s:E4V5M6, SpO2 100%. Blood transfusion with LPRBC 4u was arranged. Chest x-ray revealed negative findings.
    • Under the impression of pancytopenia, she was admitted for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, blood transfusion with LPRBC 4u on 12/29, 2u on 12/30, LRP 2u on 12/29 were ordered. We followed up blood test which revealed Hb 4.3 -> 6.5 -> 8.5 g/dL, WBC 2920->1590->1670 uL, PLT 9000->106000->74000 uL. Bone marrow puncture and biopsy was arranged on 2024/01/02 which showed relative dry tapping, yellowish bone marrow biopst, suspect myelofibrosis.
    • She had no significant discomfort during her stay. Under under stable condition, she discharged on 2024-01-02 and OPD follow up was arranged.

[chemotherapy]

• 2024-01-16 Thymoglobuline (rabbit anti-human thymocyte immunoglobulin) 3.5mg/kg 194mg NS 500mL 12hr D1-5
  • [methylprednisolone 40mg + diphenhydramine 30mg + acetaminophen 1000mg PO + NS 250mL] D1-5

Triple IST (hATG, CsA, EPAG) — Triple immunosuppressive therapy (IST) for severe AA (SAA) comprises eltrombopag (EPAG; a bone marrow stimulating agent) plus two immunosuppressive agents (horse antithymocyte globulin [hATG] and cyclosporine [CsA]). As discussed above, triple IST is generally preferred over treatment with hATG plus CsA alone (no eltrombopag). Ref: 2024-01-22 https://www.uptodate.com/contents/treatment-of-aplastic-anemia-in-adults

==========

2024-01-22

[managing leukopenia and thrombocytopenia in aplastic anemia]

A 58-year-old female, newly diagnosed with aplastic anemia, began treatment with antithymocyte globulin at a dosage of 3.5mg/kg daily for five days starting on 2024-01-16. Additionally, ciclosporin at 300mg daily, divided into two doses (approximately 6mg/kg), was initiated on 2024-01-22. To manage severe leukopenia, G-CSF (filgrastim) has been administered since 2024-01-20. Due to observed thrombocytopenia episodes with platelet counts below 20K/uL, the concurrent initiation of eltrombopag with standard immunosuppressive therapy (antithymocyte globulin and cyclosporine) can also be considered.

Given the patient’s relatively young age, it might be advisable to assess eligibility and seek a match for allogeneic hematopoietic cell transplantation in advance.

700887256

240122

[MedRec]

• 2023-10-18 ~ 2023-10-22 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Pancreatic cancer under chemotherapy in VGHTPE, last chemotherapy with FOLFIRINOX on 2023/10/04
    • Agranulocytosis secondary to cancer chemotherapy
    • Fever, culture pending
    • Chronic ischemic heart disease, unspecified
    • Paroxysmal atrial fibrillation
    • Other hyperlipidemia
    • Hypomagnesemia
    • Hypokalemia
  • CC
    • He was found lying on the ground by his family members.
  • Present illness
    • The 77 year-old male with history of
      • Pancreatic cancer under chemotherapy in TPEVGH, last chemotherapy with FOLFIRINOX on 2023/10/04,
      • heart disease for least 10 years, CAD s/p stents,
      • spondylolisthesis s/p,
      • Retinal vascular occlusion left eye,
      • Prostatectomy for 10 years.
    • According to the statement of the family, he was found lying on the ground by his family members, so he was brought to our ER for help. Associated symptoms included poor appetite, weakness, fatigue and fever.
    • At ER he conscious level is E4V4M6, vital sign: BT: 38.5’C; PR: 61 time/min; RR: 18 time/min; BP: 124/59mmHg, physical examination showed not under distress, conjunctiva: pale, bilateral clear breathing sounds, no tenderness, no muscle guarding, no rebounding pain, no knocking pain. Denied TOCC history in recent three months.
    • Lab data showed leuokopenia, neutropenia, anemia were noted. CXR was showed no active lung lesion.
    • Follow Brain CT(-C) showed Brain atrophy. Under the tentative diagnosis of neutropenia fever due to cancer chemotherapy. So, he was admitted to our ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, last time chemotherapy with FOLFIRINOX on 2023/10/04 to 2023/10/06, neutropenia fever was noted, Granocyte 250mcg/vial 1vial SC QD from 2023/10/18~2023/10/20.
    • Empirical antibiotic with Tapimycin 4.5g/vial 4.5g IVD Q6H for infection control from 2023/10/17~2023/10/22.
    • Electrolyte imbalance and anemia were noted, after correction, get improved.
    • With the stable condition, he was discharged on 2023/10/22 and went to TPEVGH OPD followed up later.    

700972958

240122

[lab data]

2024-01-20 Anti-HCV Nonreactive
2024-01-20 Anti-HCV Value 0.16 S/CO
2024-01-20 HBsAg Nonreactive
2024-01-20 HBsAg (Value) 0.35 S/CO
2024-01-20 Anti-HBc Reactive
2024-01-20 Anti-HBc-Value 3.34 S/CO

==========

2024-01-22

[acute pancreatitis: supportive care on track, hepatic markers soar (ABD SONO reveals gallbladder sludge)]

This patient’s current primary medical concern is acute pancreatitis. Supportive therapy with fluid replacement and pain control (using normal saline and tramadol) is being effectively implemented.

Although vital signs, urine output, electrolytes, and serum glucose grossly remain within acceptable ranges, significant elevations were observed in hepatobiliary-related markers (AST, ALT, alkaline phosphatase, gamma-GT, and bilirubin) on 2024-01-20.

Abdominal sonography performed on 2024-01-22 revealed the presence of gallbladder sludge, which may represent a potential contributing factor requiring further management. Is this patient a candidate for cholecystectomy?

701157014

240122

[MedRec]

• 2023-10-14, -07-22, -04-29, -03-04, 2022-11-12 SOAP Orthopedics Liu JiYuan
  • Prescription x3 (2023-03-04 x2)
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
    • Celebrex (celecoxib 200mg) 1# QD
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# BID
• 2022-06-19 ~ 2022-06-24 POMR Orthopedics Liu JiYuan
  • Discharge diagnosis
    • Left femoral head avascular necrosis post Bipolar hemiarthroplasty on 2022/06/20
  • CC
    • Left hip pain for three months
  • Present illness
    • The 54 y/o male has hypertension under medication control. He has smoking and alcohol history. He received right bipolar hemiarthroplasty 3-4 ago. This time, he noticed left hip pain while climbing stairs and came to local clinic for treatment.
    • Due to failure to conservative treatment, he was referred to our OPD for evaluation. The PE showed limping gait and painful ROM. The xray showed left femoral AVN r/o septic arthritis. The bipolar hemiarthroplasty was suggested.
    • He was admitted for preoperative survey and further management.
  • Course of inpatient treatment
    • After admission, preoperative survey revealed no contraindication. The left bipolar arthroplasty was done on 2022/06/20 smoothly. The patient tolerated the procedure well. The postoperative care initiated and the Hb was rechecked on the second days which showed acceptable level. The wound showed mild oozing without loose stitch. The hemovac showed serous discharge and it was removed under low drain amount. The Foley was removed after the patient could walk with assistance to toilet. The patient was taught to place pillow between legs after operation. The rehabilitation started with stable clinical condition. Initially, The strengthening exercise of lower limb was taught and the patient could walk with walker for short distance. The general condition was improved after postoperative care and the wound was kept dry and clean. Due to stable condition, the patient was discharged on 2022/06/24 with some painkiller and the OPD follow-up was arranged one week later.   
  • Discharge prescription
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# BID
    • Sindine (povidone iodine aq soln) ASORDER EXT

[surgical operation]

• 2022-06-20 - Op Method: Left hip bipolar hemiarthroplasty         
  • Finding:
    • Left femoral head avascular necrosis
    • Prosthesis :
    • Brand : Stryker
    • Cup : 48mm
    • Head : 28mm, metal
    • Stem : #7         
  • Procedure:
    • Under spinal anesthesia, the patient was placed in right decubitus position with side post support in the back and the lower abdomen. Left hip and the whole left leg was disinfected and draped as usual.
    • Posterolateral approach with a curvilinear incision 12 cm in length centered over the greater trochanter was made. The wound was deepened. the fascia lata was split in the same direction along the wound. The short external rotators of the hip and the upper half of the gluteus maximus tendon were detached from their insertion to expose the joint capsule. One T capsulotomy was made and the hip was dislocated with internal rotation. The fractured femoral head was removed with a cork screw driver and the diameter of the head was measured. The remnant of the ligamentum teres was excised. The surface of the acetabulum was checked for smoothness.
    • The hip was flexed, adducted, and internally rotated again. The length of the neck was trimmed with one finger breath left. The femoral canal was prepared with reamer and rasp till appropriate size.
    • Then the femoral stem of desired size was inserted into the femoral canal. the femoral head and cup components of the prostheses were assembled and reduced into the joint cavity after profuse irrigation. The stability of the prostheses was checked.
    • Then the capsule was repaired. One #1/8 hemovac drain was placed. The gluteus maximus and the short external rotators were reattached. The fascia lata was repaired and the wound was closed in layers with compressive dressing to finish the procedure.         

701481589

240122

[lab data]

2023-05-30 Anti-HBc Reactive
2023-05-30 Anti-HBc-Value 3.37 S/CO
2023-05-30 Anti-HBs 80.54 mIU/mL

[exam findings]

• 2024-01-18 Nasopharyngoscopy
  • Scope: much crust at bi nasopharynx, removed; bi nasopharynx posterior wall and roof soft tissue necrosis and whitish change
  • Conclusion
    • NPC s/p CCRT
    • Post-irradiation nasopharyngeal necrosis
• 2023-12-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 21) / 88 = 76.14%
    • M-mode (Teichholz) = 75
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Trivial MR, TR
• 2023-12-04 MRI - nasopharynx
  • Findings comparison 2023/05/30 MRI
    • Remarkable tumor regression in the nasopharynx, skull base and intracranial parts. Still abnormal signal intensity of the skull base bones.
    • Total regression, No neck LAP.
    • Decreased pneumontization of the bilateral mastoid air cells indicating chronic mastoiditis.
    • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
  • IMP:
    • Remarkable tumor regression. Total regression, No neck LAP. Bilateral mastoiditis. Bil. CPS.
• 2023-11-16 Nasopharyngoscopy
  • Findings
    • much crust at bi nasopharynx (R>L) and right choana, removed; bi nasopharynx posterior wall and roof soft tissue necrosis and whitish change
  • Conclusion
    • NPC s/p CCRT
    • Post-irradiation nasopharyngeal necrosis
• 2023-10-19 Nasopharyngoscopy
  • Findings
    • much crust at bi posterior nasal cavity and bi nasopharynx (R>L), removed partially; residual crust at right nasopharynx
  • Conclusion
    • NPC s/p CCRT
    • suspect post-irradiation nasopharyngeal necrosis
• 2023-09-21 Nasopharyngoscopy
  • Findings
    • much crust at bi posterior nasal cavity and bi nasopharynx (R>L), removed partially; mucosa detail of the nasohparynx not clearly seen
  • Conclusion
    • NPC s/p CCRT
    • bi sinusitis, suggest nasal douch
• 2023-09-11 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 48 dB HL; LE 31 dB HL.
  • RE mild to severe mixed type HL.
  • LE normal to moderately severe HL.(0.5k,1k Hz masking dilemma)
• 2023-08-24 Nasopharyngoscopy
  • Findings
    • much crust at bi posterior nasal cavity and bi nasopharynx (R>L), removed partially; mucosa detail of the nasohparynx not clearly seen ; hypopharynx and larynx np; suspected right posterior nasal cavity synechiae
  • Conclusion
    • NPC s/p CCRT
• 2023-07-27 Nasopharyngoscopy
  • Findings
    • bi anterior nasal cavity erosions, crust/mucus coating on bi nasohparynx (right>left) and right middle meatus and bi choana, no gross tumor found
  • Conclusion
    • NPC with right nasal cavity invasion under CCRT
• 2023-06-29 Nasopharyngoscopy
  • Findings
    • mucus coating on bi nasohparynx and right middle meatus, pulsatile at right sphenoid ostium; tumor size decreased significantly
  • Conclusion
    • NPC with right nasal cavity invasion under CCRT
• 2023-06-01 PET
  • A large glucose hypermetabolic lesion involving the right posterior nasal cavity, right maxillary sinus, nasopharynx, skull base, sphenoid sinus and right medial temporal fossa of the brain, compatible with a primary malignant tumor.
  • Glucose hypermetabolism in some bilateral retropharyngeal lymph nodes and in some bilateral neck level II lymph nodes. Metastatic lymph nodes may show this picture.
• 2023-05-30 MRI - nasopharynx
  • Findings
    • Bilateral nasopharynx tumor, with nasal cavity invasion, invsion to the skull base bones and medial right temporal fossa and cavernous sinus.
      
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • Enlarged bilateral neck LNs, all above the level of cricoid cartilage.
  • IMP:
    • NPC with skull base and right intracranial extension T4N2M0 stage IVA
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:4(T_value) N:2(N_value) M:0(M_value) STAGE:IVA (Stage_value)
• 2023-05-24 Patho - nasopharyngeal/oropharyngeal biopsy (Y2)
  • Nasopharynx, right, biopsy — Squamous cell carcinoma, non-keratinizing and undifferentiated
    
  • The specimen submitted consists of 3 tissue fragments measuring up to 1 x 0.5 x 0.5 cm in size, fixed in formalin. Grossly, they are grayish and solid. All for section.
  • Microscopically, section shows undifferentiated, non-keratinizing squamous cell carcinoma composed of syncytial growth with oval or round vesicular nuclei and prominent nucleoli. There is inflammatory response with necrosis in the adjacent stroma.
    
  • IHC stain — EBER (+), CK (+), p16 (-)
• 2023-05-23 Nasopharyngoscopy
  • Findings
    • granular tumor with touch bleeding at bi nasopharynx posterior wall, right NP roof, right choana, bi septum posterior part, right inferior T posterior part and right middle meatus
    • biopsy from right nasopharynx done
  • Conclusion
    • right nasopharyngeal and right nasal tumor
• 2023-05-23 ENT Hearing Test
  • Tymp type C
  • ART bil absent
  • PTA:
    • Reliability FAIR
    • Average RE 60 dB HL; LE 25 dB HL
    • RE mild to profound MHL
    • LE normal to moderate SNHL
• 2023-05-19 CT - sinuses for navigator
  • Indication: right sinonasal tumor s/p biopsy. nasopharyngeal tumor
  • CT of sinus without/with contrast enhancement shows:
    • lobulated enhancing tumor centered at nasopharynx and posterior nasal cavity, maximal diameter about 4.5cm, with involvement of posterior ethmoid sinus, posterior and medial right maxillary sinus, right pterygopalatine fossa, sphenoid sinus, paired longus colli muscles, and possible also skull base bone involvement. Suspect nasopharyngeal carcinoma (NPC) or nasal cancer. Suggest tissue proof, and MRI evaluation for more accurate and complete staging.
    • enlarged lymph nodes at bilateral level II, probably lymphadenopathy.
    • right maxillary sinusitis change with increased effusion.
  • Impression:
    • Suspect NPC or nasal cancer. Suggest tissue proof, and MRI evaluation for more accurate and complete staging.
• 2023-05-19 Patho - paranasal biopsy
  • Nasal cavity, right, biopsy — Squamous cell carcinoma, non-keratinizing and poorly differentiated
  • Microscopically, section shows poorly differentiated squamous cell carcinoma characterized by diffuse sheets of non-keratinizing tumor with invsive growth pattern. The tumor shows nuclar hyperchromasia, pleomorphism, prominent nculeoli, high N/C ratio and mitotic activity.

[MedRec]

• 2023-07-27 SOAP Hemato-Oncology Xia HeXiong
  • P: Arrange weekly CDDP for CCRT “then followed by PF x 3”
• 2023-06-08 SOAP Hemato-Oncology Xia HeXiong
  • A: NPC with right nasal cavity invasion; cT4N2M0; stage:IVA
  • P:
    • prepare for CCRT
    • Port-A on 2023-06-13
    • Simulation on 2023-06-05
    • Arrange weekly CDDP for CCRT
• 2023-06-05 SOAP Radiation Oncology Chang YouKang
  • Diagnosis: Nasopharyngeal cancer, NK & undiffentiated carcinoma, cT4N2M0; stage IVA; ECOG = 1.
  • Plan: CCRT followed by adjuvant C/T or induction C/T followed by CCRT may be considered.
    • RT to NPX tumor and LAPs for 7140cGy/34 fx is suggested for locoregional control. Possible radiation toxicity (radiation mucositis, pharyngitis, esophagitis, dermatitis) is told to her.
    • CT simulation will be arranged on 2023-06-05, 09:30. Diet education & psychological support is given.
• 2023-05-29 POMR Ear Nose Throat Huang TongCun
  • Discharge diagnosis
    • Malignant neoplasm of nasopharynx, T4N2M0; stage:IVA
  • CC
    • Tinnitus and aural stuffiness (R>L) since 3 years ago, aggravated for half year
  • Present illness
    • This 62 year-old female patient denied any underlying disease. She suffered from tinnitus and aural stuffiness (R>L) since 3 years ago, aggravated and body weight loss 3kg for half year. Epistaxis off and on and intermittent nasal rhinorrhea for years was noted. Denied smoking, drinking and betel nut. She visited local clinic, but the symptom didn’t subside despite medical treatment. Therefore, the patient came to our ENT OPD for help. Physical exam showed polypoid mass at right nasal cavity upper part and right middle meatus with involvement of bilateral posterior septum and right choana. Bilateral nasopharynx posterior wall mass with smooth surface and mucus coating was also noted.
    • Biopsy of right nasal tumor was done on 2023/05/18 and pathology revealed squamous cell carcinoma, non-keratinizing and poorly differentiated.
    • Biopsy of right nasopharynx on 2023/5/23 also revealed Squamous cell carcinoma, non-keratinizing and undifferentiated.
    • Under the impression of nasopharyngenl carcinoma with nasal cavity involvement, admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, the patient was admitted for cancer work-up.           - Course of inpatient treatment
    • After admission, serial tests were arranged for tumor staging work up. Nasopharynx MRI showed nasopharynx carcinoma T4N2M0, stage:IVA. Abdominal sonography showed negative. PET was done on 2023/06/01 and the result was pending.
    • OS was consulted for pre-RT tooth evaluation. Radio-oncologist was consulted for radiation therapy. Under relative stable condition, the patient was dishcarged with OPD follow up
  • Discharge prescription
    • Allegra (fexofenadine 60mg) 1# BID

[consultation]

• 2023-05-30 Oral and Maxillofacial Surgery
  • Q
    • For tooth evaluation
    • This 62 year-old female patient denied any underlying disease. She suffered from tinnitus and aural stuffiness (R>L) since 3 years ago, aggravated for half year and epistaxis off and on. She went to our ENT OPD for help. In OPD, polypoid mass at right nasal cavity upper part and right middle meatus with involvement of bilateral posterior septum and right choana. Biopsy was done on 2023/05/18 and pathology revealed squamous cell carcinoma, non-keratinizing and poorly differentiated. Under the impression of nasopharyngenl Carcinoma. The patient was admitted for cancer work-up on 2023/05/29. After admitted, arragne MRI on 5/30; Abd sonography on 5/31; PET on 6/1. We will arrange CCRT for this patient. We need your help for tooth evaluation. Thank`s a lot
  • A
    • We are consulted for dental evaluation prior to CCRT.
    • panoramic film:
      • Prosthodontics: 27,36
      • no large decayed tooth or severe periodontitis of teeth
    • Plan:
      • intraoral physical eaxmination
      • take a panoramic film
      • teach her how to do home care (The patient’s current dental condition does not require extraction treatment.)
      • full mouth scaling and oral hygiene instruction

[radiotherapy]

• 2023-06-14 ~ 2023-08-01 - 7140cGy/34 fractions (6 MV photon) to NPX tumor and LAPs.

[chemotherapy]

• 2024-01-19 - cisplatin 60mg/m2 90mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL (Y-sited cisplatin D1) D1-4 (PF Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-12-18 - cisplatin 60mg/m2 90mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL (Y-sited cisplatin D1) D1-4 (PF Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-11 - cisplatin 60mg/m2 90mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL (Y-sited cisplatin D1) D1-4 (PF Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-28 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-21 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-14 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-07 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-30 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-23 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-16 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-01-22

[reconciliation]

Lab data from 2024-01-19 indicated generally normal levels across blood cell counts, electrolytes, and liver and kidney functions. Additionally, a review of the medication records revealed no discrepancies.

2023-10-30

[Achrimobacter xylosoxidans bacteremia]

For treating Achromobacter xylosoxidans infections in patients without cystic fibrosis:

• Ceftazidime 1-2 gm IV q8-12 h
• Imipenem-cilastatin 500 mg IV q6h or Meropenem 1-2 gm IV q8h or Doripenem 500 mg IV q8h (not for pneumonia)
• Ciprofloxacin 400 mg IV q12h

700206320

240119

[exam findings] (not completed)

• 2023-12-19 Patho - ureter biopsy
  • Labeled as “right renal pelvis tumor”, URS biopsy — carcinoma, high grade.
  • Specimen submitted in formalin consists of 3 piece(s) of tan, irregular tissue measuring 0.4 x 0.2 x 0.1 cm. All tissue for section(s) in one cassette(s).
  • Section shows pieces of high grade carcinoma.
  • IHC stains: CK7 (+), GATA-3 (equivocal), CD10 (-), CAIX (-), vientin (-), RCC (-). The tumor location and the IHC pattern are in favor of urothelial carcinoma.

[MedRec]

• 2023-12-19 ~ 2024-01-04 POMR Urology Cai YaoZhou
  • Discharge diagnosis
    • Right renal pelvis urothelial carcinoma, cT3N2M0, stage IV status post 1) Rightr ureterorenoscopic exam & double-J stenting on 2023-12-19; 2) Port-A insertion on 2023-12-25; 3) Immunotherapy with Nivolumab (#1) on 12/27, Chemotherapy with Carboplatin + Gemcitabine (#1 D1) on 12/27, Chemotherapy with Gemcitabine (D8) on 2024-01-03
    • Benign neoplasm of right kidney
    • Right hydronephrosis
  • CC
    • Presented with hematuria and right flank soreness for the past two weeks
  • Present illness
    • This 47-year-old female with no surgical or chronic medical history. Previously sought emergency care for urinary tract infection and migraines. On 2016-11-05, elevated Cr of 1.3 mg/dL was detected. Regular follow-ups have been conducted since then. Presented with hematuria and right flank soreness for the past two weeks. Sought consultation at the Nephrology Department, where lab data revealed elevated Cr of 2.9 mg/dL. Renal ultrasound showed right renal pelvic mass lesion and hydronephrosis, r/o urothelial carcinoma. Subsequently, referred to the Urology Department for further investigation.
    • Under the impression of right renal tumor, we advised the patient to receive right fURS exam biopsy. After well explaining, the patient agreed. This time, she was admitted for further evaluation and manageme.
  • Course of inpatient treatment
    • After admission, the surgery of 1) Rightr ureterorenoscopic exam & double-J stenting on 2023-12-19; 2) Port-A insertion was performed on 2023-12-25. Post operation, MRI revealed right renal pelvis urothelial carcinoma, cT3N2M0, stage IV. Pathrology showed carcinoma, high grade.
    • PET showed metastatic lymph node. She received Immunotherapy with Nivolumab (#1) on 12/27 and chemotherapy with Carboplatin + Gemcitabine (#1 D1) on 12/27.
    • After treatment, severe nausea and poor oral intake was noted. IVF support and symptom treatment. Stable condition she receive chemotherapy with Gemcitabine (D8) on 2024-01-03.
    • With fair urination, he was discharged today and would be followed up at urologic clinic for further treatment.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQID
    • Roumin (prochlorperazine maleate 5mg) 1# PRNQ12H
• 2021-02-26, 2020-11-20, -08-14, -05-22, -02-04, 2019-11-12, -08-13 SOAP Nephrology Hong SiQun
  • Prescription x3
    • Foliromin (ferrous sodium citrate 50mg) 1# QD
    • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QD
    • Compesolon (prednisolone 5mg) 2# QOD
    • Pentop (pentoxifylline 400mg) 1# QD
• 2019-05-21 SOAP Nephrology Hong SiQun
  • S
    • AIMHI study V1
  • O
    • Cr 1.6 -> 1.8 -> 1.8 -> 1.8 -> Cr 1.9, LDL 136
  • Diagnosis
    • Abnormal renal function test [R94.4]
    • Dyslipidemia [E78.4]
  • Prescription x3
    • Vytorin (ezetimibe 10mg, simvastatin 20mg) 1# HS
    • Compesolon (prednisolone 5mg) 2# QOD
    • Pentop (pentoxifylline 400mg) 1# QD
• 2019-01-11 SOAP Nephrology Hong SiQun
  • S
    • elevated CRE and came for F/U
    • add prednislone 2# qod and follow up
  • Diagnosis
    • Abnormal renal function test [R94.4]
  • Prescription x3
    • Compesolon (prednisolone 5mg) 2# QOD
    • Pentop (pentoxifylline 400mg) 1# QD
• 2018-09-21 SOAP Nephrology Hong SiQun
  • S
    • CKD for follow up
    • add trental and follow up
    • elevated CRE and came for F/U
    • acute on chronic CKD, cause?
  • O
    • arrange further study
    • consider renal biopsy if progression
  • Diagnosis
    • Abnormal renal function test [R94.4]
  • Prescription x3
    • Pentop (pentoxifylline 400mg) 1# QD
• 2018-08-23 SOAP Metabolism and Endocrinology Zen YiQian
  • S
    • PH: migraine, CKD
    • CC: frequently attacked recently, painkiller can’t improve, photophobia
  • O
    • E4V5M6
    • CNs: intact
    • MP: full
    • sensaiton: intact
    • FNF: no dysmetria
    • gait: steady
    • impression: migraine
    • plan: imigran and try suzin
    • 2017/12/26 BUN 26 mg/dL, CRE 1.6 mg/dL
    • 2018/05/04 BUN 25 mg/dL, CRE 1.6 mg/dL
    • 2018/05/04 CA 125 53.7 IU/mL
  • Diagnosis
    • Comnon migraine with intractable migraine, so stated [G43.019]
    • Chronic renal insufficiency [N18.9]
  • Prescription x3
    • Imigran (sumatriptan 50mg) 3# QW
• 2017-07-13 SOAP Metabolism and Endocrinology Zen YiQian
  • S
    • migrane attacked and lasted over 24 hrs
    • not subsided after panadol and NSAID tx
    • PH: eczema
  • O
    • palpule with severe itching and excoriation over back
    • 2016/11/23 GLU 136 mg/dL, CRE 1.3 mg/dL
  • Diagnosis
    • Eczema [L30.8]
    • Renal function impairment [N18.9]
    • Mixed hyperlipidemia [E78.2]
  • Prescription x3
    • Allegra (fexofenadine 60mg) 1# BID

[consultation]

[immunochemotherapy]

• 2024-01-19 - carboplatin 260mg NS 100mL 1hr + gemcitabine 1000mg/m2 1400mg NS 100mL 1hr
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
• 2024-01-03 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
  • diphenhydramine 30mg + NS 250mL
• 2023-12-27 - nivolumab 300mg NS 100mL 1hr + carboplatin 260mg NS 100mL 1hr + gemcitabine 1000mg/m2 1400mg NS 100mL 1hr
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
• 2023-12-20 mitomycin-C 30mg/m2 30mg BI 1hr

==========

2024-01-19

[transfusion in chemotherapy-induced anemia]

Given the patient’s renal impairment, a modified treatment regimen of nivolumab combined with gemcitabine and carboplatin was administered instead of the standard nivolumab, gemcitabine, and cisplatin therapy.

The patient’s hemoglobin levels have shown a consistent decline, indicating anemia:

• 2024-01-19 HGB 6.9 g/dL
• 2024-01-03 HGB 8.1 g/dL
• 2023-12-19 HGB 9.5 g/dL
• 2023-12-12 HGB 10.2 g/dL

Anemia is associated with gemcitabine (68%; grade 3: 7%; grade 4: 1%), carboplatin (21% to 90%), and nivolumab (26% to 41%; grades 3/4: <=3%). The downward trend in HGB might suggest insufficient red blood cell production to match the treatment schedule. A transfusion was performed on 2024-01-19, which is considered an appropriate action. If adverse reactions increase, modifying the administration interval or dose reduction could be further decided.

700959021

240119

{Triple cancer - endometrium ca, rectal ca, RCC}

[exam findings]

• 2024-01-18 SONO - chest
  • Symptom: dyspnea
  • Indication: r/o pleural effusion
  • Clinical diagnosis:
    • Triple cancer (endometrium, rectal ca, kidney RCC )
    • ESRD under maintenance H/D TIW
  • The patient was in sitting upright posture while th chest echography was performed using: 3.75-mHz convex probe.
  • Findings
    • Left-side of thorax:
      • moderate loculated effusion, septum and fibrin
    • Pleural thickening
      • LLL atelectasis
    • Right-side of thorax:
      • no effusion
      • no active lung lesion
    • Special Procedure
      • A 16# long catheter was inserted into left 5th ICS along mid-posterior scapular line. 750ml yellow fluid was drained and sent for routine, BCS, bacteria/TB/fungus cultures and cell block, TB-PCR.
  • Echo diagnosis
    • Pleural effusion, moderate, left, complicated
    • Atelectasis, LLL
• 2024-01-17 CT - neck
  • Indication: Left clavicle region swelling for 3 days, pain(+). History of endometrial cancer, colon cancer
  • Neck CT without/with contrast enhancement shows:
    • bilateral symmetric pharyngeal mucosa.
    • no definite enlarged cervical lymphadenopathy.
    • suspect left proximal humerus greater tubercle fracture.
    • no definite destructive bone lesion at bilateral clavicle or other visible bones.
    • left pleural effusion, status post pigtail insertion.
    • left perihilar lung collapse with calcification, occult lung lesion cannot be excluded. Suggest further evaluation.
  • Impression:
    • Suspect left proximal humerus greater tubercle fracture.
    • No destructive bone lesion.
    • Left pleural effusion.
    • Left perihilar lung collapse with calcification, occult lung lesion cannot be excluded. Suggest further evaluation.
• 2024-01-17 Clavicle LT
  • Left clavicle X-rays show: Left proximal humerus fracture, greater tubercle. Calcification near greater humeral tubercle, calcified tendinosis of distal supraspinatus tendon is suspected.
• 2024-01-10 Peropheral Vascular Test - AV fistula
  • Clinical diagnosis: AVF dysfunction
  • Report:
    • Access type: graft
    • Site: left upper arm
    • Clinical problem: left arm swelling
    • Age of vascular access:
    • Result:
      • Left brachio-graft axillary shunt, feeding volume 1489 ml/min, graft degeneration improved after POBA
      • There is no obvious hematoma over elbow area.
    • Suggestion: Clinical follow up
• 2024-01-09 Cardiac Catheterization
  • Past Medical History
    • The patient has a history of ESRD under H/D.
  • Indication
    • The patient was referred with left arm swelling. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
  • Approach
    • Percutaneous access was performed through the graft graft where a 6F sheath was inserted. Percutaneous access was performed through the graft graft where a 6F sheath was inserted.
  • Procedure
    • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 50cc. The patient was treated with Dormicum (dosage 2.5mg).
  • Finding Summary
    • Left Brachio graft axillary shunt, A to V puncture site with 50% stenosis(graft degeneratoin) GV junction with 55% stenosis with colalterals and left central vein with 90% stenosis.
  • Recommendation
    • PTA
  • Intervention Summary
    • Left Brachio graft axillary shunt, A and V puncture site degeneration, Pre-DS = 50%
      • MLD/RVD=3.5/7 mm → 5.6/7 mm, Post-DS = 20%.
      • Balloon: Bard Conquest. 7.0 X 40 mm. Pressure: 10 atmospheres.
    • Left Brachio graft axillary shunt, GV junction, Pre-DS = 55%
      • MLD/RVD=3.36/7.45 mm → 5.52/6.83 mm, Post-DS = 19%.
      • Balloon: Bard Conquest. 7.0 X 40 mm. Pressure: 20 atmospheres.
    • Left Brachio graft axillary shunt, left central vein, Pre-DS = 90%
      • MLD/RVD=1.2/12 mm → 4.48/10.22 mm, Post-DS = 62%.
      • Balloon: Boston Mustang. 10.0 X 40 mm. Pressure: 14 atmospheres.
      • Balloon2: Abbott Armada 35. 12.0 X 40 mm. Pressure: 10 atmospheres. but still suboptimal result,
  • In conclusion:
    • Left brachio graft-axillary shunt, A and V puncture site (graft) degeneration, GV junction and left central vein stenosis s/p POBA successful bur left central vein suboptimal result.
  • Recommendation:
    • close monitor venous pressure
• 2024-01-09 Peripheral Vascular Test - AV fistula
  • Clinical diagnosis: AVF dysfunction
  • Report:
    • Access type: graft
    • Site: left upper arm
    • Clinical problem: arm swelling
    • Age of vascular access:
    • Result: Left brachio-graft-axillary shunt, feeding volume 413 ml/min, AV junction 0.38 cm, near AV junction graft degeneration 0.15 cm, A puncture site 0.64 cm, V puncture site 0.42 cm, GV junction no obvious stenosis
  • Suggestion:
    • Because of arm swelling, and prior PTA history, arrange IVDSA and PTA PRN.
    • Suggestion: PTA
• 2024-01-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (174 - 128) / 174 = 26.44%
    • M-mode (Teichholz) = 26.4
    • 2D (M-Simpson) = 31.8
  • Conclusion:
    • Sclerosis of AV with severe AS, mild AR (AVA 0.86, Vmax 3.64)
    • Thickened and calcified MV, mild MR
    • Concentric LVH, dilated LV
    • Poor LV systolic function, global hypokinesia and apical akinesia
    • Mild PR, mild TR, normal IVC size
    • Dilated LA, pleural effusion noted
• 2024-01-07 CT - chest
  • Left pleural effusion with left lung collapse and clacifications.
  • Nodules (up to 5.6mm) at right lung.
  • Liver cirrhosis with a cyst (1.6cm).
  • Cardiomegaly.
• 2024-01-07 ECG
  • Sinus tachycardia with frequent Premature ventricular complexes in a pattern of bigeminy
  • Left ventricular hypertrophy with repolarization abnormality
• 2023-12-12 Parathyoid scan with SPECT
  • Two focal areas of mildly increased radiotracer uptake in the middle portion of the right thyroid bed and lower portion of the left thyroid bed respectively. The nature is to be determined (hyperplastic parathyroid glands or parathyroid adenomas? some kind of thyroid lesions?). Please correlate with clinical findings for further evaluation.
• 2023-09-05 CT - abdomen
  • S/P left nephrectomy.
  • Liver cirrhosis.
  • Left pleural effusion.
  • GB stones.
  • R/O liver cyst, 1.5cm in right lobe liver.
  • Coronary artery calcifications.
• 2023-07-06 CXR erect
  • S/P port-A implantation.
  • Enlargement of cardiac silhouette.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • A nodular opacity projecting in the right lower medial lung, retrocardiac area, is suspected. Please correlate with CT.
• 2022-12-08 ENT Hearing Test
  • Tymp RE type As, LE type A
  • ART bil absent
  • PTA:
    • Reliability FAIR
    • Average RE 18 dB HL, LE 23 dB HL
    • bil normal to mild SNHL
• 2022-11-11 CT - chest
  • Calcified coronary arteries is found.
  • Faint aveolar opacity over Right upper lobe, right lower lobe and left lower lobe
  • Bilateral pleural effusion.
  • Liver cirrhosis with splenomegaly
• 2022-10-20 EEG
  • Conclusion: Abnormal EEG.
  • The background activities were composed by alpha rhythm at 8-9 Hz, 20-60 uV in bilateral posterior head areas and beta rhythm at 13-15 Hz, 10-20 uV in bilateral anterior head areas. There were occasional diffuse slow waves at 4-6 Hz, 20-50 uV in bilateral hemispheres. No obvious photic driving response was noted. This EEG suggests mild diffuse cortical dysfunction. Advise clinical correlation.
• 2022-09-09 Patho - kidney partial/total resection
  • PATHOLOGIC DIAGNOSIS
    • Tumor, left kidney, laparoscopic radical nephrectomy — Clear cell renal cell carcinoma
    • Resection margin, ditto — Free of tumor invasion
    • Ureter, ditto — Free of tumor invasion
    • Perirenal fat, ditto — Free from tumor invasion
    • AJCC Pathologic staging — pT1a, if cN0 and cM0, stage I
  • Gross Description:
    • Procedure: laparoscopic radical nephrectomy
    • Laterality: Left
    • Specimen size: 19.2 x 12.3 x 3.8 cm, 468 gm in weight
      • kidney: 6.7 x 3.3 cm
      • ureter: 7.1 cm in length, 0.3 cm in diameter
    • Tumor size: 2.3 x 1.8 cm
    • Tumor site: hilar region
    • Tumor focalty: solitary
    • Tumor extent: The tumor is grossly confined in the kidney
    • Representatively embedded for sections as A1-A2: renal pelvis, A3-A7: tumor, A8: renal hilum, A9: perirenal fat and A10: ureter
  • Microscopic Description
    • Histological type: clear cell renal cell carcinoma
    • Histological grade: grade 2
    • Pathological staging: pT1a, if cN0 and cM0, stage I
    • Resection margins: Free
    • Lymphovascular invasion: Not identified
    • Tumor necrosis: absent
    • Additional pathologic findings: cystic change
    • Immunohistochemistry: CK7(-), vimentin(+), PAX8(+, focal), CD10(+, focal) and CA IX(+) for tumor
    • Non-tumor kidney: chronic pyelonephritis with thyroidization, diffuse global glomerulosclerosis, microcalcification and subintimal hyperplasia of arteries with microcalcification of arterial wall
• 2022-02-11 Patho - lung total/lobe/segmental
  • PATHOLOGIC DIAGNOSIS:
    • Lung, left, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
  • MACROSCOPIC EXAMINATION:
    • Specimen: Lung, size: 6.5 x 6.0 x 2.5 cm
    • Tumor Site: Periphery
    • Tumor Size: 2.8 x 2.6 x 1.8 cm
    • Gross tumor patterns: poorly defined,
    • Tissue for sections: A1: resection margin; A2: lung, non-tumor; A3-5: tumor.
      
  • Microscopic Description
    • Tumor Focality: Single tumor
      
    • Histologic Type (select all that apply): Adenocarcinoma; The immunohistochemical stains reveal CDX2(+) and TTF-1(-). The results are consistent with metastatic colonic tumor.
      
    • Histologic Grade: G2: Moderately differentiated
    • Spread Through Air Spaces (STAS):Present
    • Visceral Pleura Invasion: Not identified
    • Lymphovascular Invasion (select all that apply): present
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.3 cm;
      • Specify closest margin: resection margin
    • Treatment Effect: No known presurgical therapy
• 2019-03-20 SONO - nephrology
  • Interpretation:
    • Bilateral parenchymal renal disease with samll-sized kidney.
    • Right renal cyst.
    • Right moderate hydronephrosis.
    • Right peri-renal fluid acculumation.
• 2018-01-22 Surgical pathology Level VI
  • PATHOLOGIC DIAGNOSIS:
    • Lung, LLL, lobectomy —– Adenocarcinoma, moderately differentiated, consistent with metastatic colonic origin
      
    • Lymph node, lobar, lymphadenectomy —– Negative for malignancy (0/5)
    • Lymph node, area 5, lymphadenectomy —– Negative for malignancy (0/2)
    • Soft tissue, area 7, lymphadenectomy —– Negative for malignancy (0/0)
    • Lymph node, area 10, lymphadenectomy —– Negative for malignancy (0/1)
  • MACROSCOPIC EXAMINATION:
    • Topography: LLL
      
    • Procedure: lobectomy
      
    • Size of lung received: 14.8 x 8.0 x 4.5 cm
    • Weight of lung received: 120 gm
    • Tumor location: peripheral
      
    • Tumor size: 2.5 x 2.0 x 1.5 cm
    • Tumor description: gray, solid, and necrosis
      
    • Satellite tumor nodules: absent
      
    • Mainstem bronchus: not involved
      
    • Bronchial margin: free, 1.2 cm from margin
    • Visceral pleural margin: free, 0.9 cm
      
    • Pleura: smooth
      
    • Non-neoplastic lung: congestion
    • Lymph node: area 5, 7, and 10
    • Representative sections are taken and labeled as: A1: resection margin; A2: lymph node, lobar; A3: lung, non-tumor; A4-8: tumor; B: lymph node, area 5; C: lymph node, area 7; D: lymph node, area 10.
  • MICROSCOPIC EXAMINATION:
    • Histology type: adenocarcinoma; The immunohistochemical stains reveal CDX2(+) and TTF-1(-). The results are in favor of metastatic colonic adenocarcinoma.
      
    • Histology grade: moderately differentiated (G2).
      
    • Tumor necrosis: moderate (40%)
    • mitotic activity: marked (> 20/10hpf)
    • peritumor infiltrates: mild
    • in situ carcinoma: absent
      
    • angiolymphatic invasion: present
      
    • perineural invasion: absent
      
    • mainstem bronchus: no involvement
    • bronchial margin: free
      
    • visceral pleural involvement: The tumor does not invade the visceral pleura (P0).
      
    • Tumor cells in the subpleural lymphatics: no
    • non-neoplastic lung: congestion
      
    • Lymph node metastasis
      • group as specified
      • lobar: 0/5
      • area 5: 0/2
      • area 7: 0/0
      • area 10: 0/1
      • over all: 0/8
    • perinodal (extracapsular) tumor extension: absent

[MedRec]

• 2022-08-04 ~ 2022-08-06 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Malignant neoplasm of rectum
    • K-ras wild type, recurrent adenocarcinoma of rectum with lung metastasis, pT3N1bM1 pStage: IV
    • pathology (S2013-17848, 2013-11-19): Uterus, corpus, laparoscopic assisted vaginal hysterectomy (s/p RT) — endometrioid adenocarcinoma, Grade 2 — TNM: ypT1a, FIGO stage: ypIA.
    • Chronic kidney disease, unspecified
    • Type 2 diabetes mellitus without complications
  • CC
    • arrange chest CT exam for survey
  • Present illness
    • The 56-year-old woman has past history of old right brainstem hemorhagic stroke was noted on 2009, and then could not walk independently since 2016, hypertension for over 20 years, COPD for over 20 years without regular medications control currently, type II DM for around 10 years, and end-staged renal disease status post regular H/D since 2019/03 (QW135 currently).
    • She also had previous histories of endometrial cancer, adeno of rectal cancer stage IIIB on 2015/6, and left lower lung metastatic cancer (colonic related) status post surgical treatment (Please see the details at the past histories).
    • Left arteriovenous graft occlusion post Percutaneous Transluminal Angioplasty + thrombectomy on 2021/06/22. She was then referred back to our Chest surgery Dr. Xie’s OPD back for the further survey.
    • Further chest CT showed lobulated mass at left lower lobe, favored metastatic lesion related. After fully explanation and discussion to the patient and her families, she received video-assisted thoracic surgery (Left upper lobe tumor wedge resection) on 2022/02/10. Pathology showed Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor, CDX2(+) and TTF-1(-).
    • The chemotherapy regimen started as C1D1 HDFL on 2022/03/03 was complicated of related hepatic encephalopathy treated.
    • Under the impression of lung metastasis from colonic cancer, so she was admitted for reduced dose chemotherapy for recent history of HDFL related hepatic encephalopathy on 2022/03/29.
    • FOLFIRI was discontinued on 2022/03/31, because of the patient had improvement of numbness and weakness after the chemotherapy injection.
    • Sigmoidscopy was done, report showed internal hemorrhoid and no bleeding later.
    • The EEG on 2022/03/15 showed No obvious photic driving response was noted.
    • The tumor marker showed CEA:<0.3, CA-199:9.271.
    • She started took Xeloda 1# po bid since 2022-04-28 then shifted to 2# po bid since 2022-05-05.
    • Today, she was admitted arrange chest CT exam for Xeloda treatment response evaluation on 2022/08/04.
  • Course of inpatient treatment
    • After admission, Xleoda 2# po bid was given. The chest CT (2022-08-05) showed chest:s/p op. over left lower lobe with regional soft tissue is found. Suggest closely follow up. Small lymph nodes are found in the mediastinum. There is no evidence of mediastinal LAP. Patent airway is found. Left pleural effusion is found. Abdomen: Soft tissue mass with strong enhancement at left kidney up to 2.6cm is found. There is stone at dependent portion of GB. GB stone(s) are noted. Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis. The renal vein and INFERIOR VENA CAVA are patent.
    • QW 1.3.5 H/D was given. She was discharged on 2022-08-06 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • none
• 2017-06-13 SOAP Metabolism Guo XiWen
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
    • Obesity, unspecified [E66.9]
  • Prescription
    • Kludone (gliclazide 60mg) 1# QDAC
    • Victoza (liraglutide) 1.2mg QDAC SC
    • Blopress (candesartan 8mg) 1# QD
    • Glucobay (acarbose 100mg) 1# TIDAC
• 2017-02-07 SOAP Hemato-Oncology Gao WeiYao
  • Diagnosis
    • Malignant rectum neoplasm [C20]
    • Maliganat uterus neoplasm, corpus uteri, except isthmus [C54.1]
    • Arterial embolism and thrombosis of lower extremity [I74.3]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
• 2017-01-10 SOAP Neurology Su YuQin
  • Diagnosis
    • Unspecified late effect of cerebrovascular disease [I69.80]
    • Malignant rectum neoplasm [C20]
    • Arterial embolism and thrombosis of lower extremity [I74.3]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertention, unspecified [I10]
    • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
  • Prescription
    • Urinol (allopurinol 100mg) 1# QD
    • NovoNorm (repaglinide 1mg) 2# BID
    • Imolex (loperamide 2mg) 1# PRN
    • Grumed (glimepiride 2mg) 1.5# BID
    • Trajenta (linagliptin 5mg) 1# QD
    • Hyzaar (losartan 100mg, hydrochlorothiazide 12.5mg) 0.5# QD
    • Lipanthyl Supra (fenofibrate 160mg) 0.5# QD

==========

2024-01-19

[myocardial injury indicators: rising hs-Troponin I]

Lab results indicate low CK levels, normal CK-MB, and a consistent increase in hs-Troponin I, suggesting myocardial injury.

• 2024-01-17 CKMB 4.4 ng/mL
  
• 2024-01-17 CK 26 U/L
  
• 2024-01-17 hs-Troponin I 1095.8 pg/mL
  
• 2024-01-17 hs-Troponin I 983.3 pg/mL
  
• 2024-01-07 hs-Troponin I 589.8 pg/mL
  
• 2020-09-15 hs-Troponin I 69.6 pg/mL

The pattern of these biomarkers might point to several potential causes:

• Microinfarctions: These could occur without significant CK elevation due to their small scale.
• Unstable Angina: Persistent reduced blood flow may not trigger a pronounced CK rise but can still cause elevated hs-Troponin I levels.
• Myocarditis: This condition, marked by inflammation of the heart muscle, could elevate hs-Troponin I without substantially increasing CK.

Given these findings, consulting a cardiologist may be beneficial for further evaluation and management.

[optimizing midodrine dosage for this hemodialysis patient]

Midodrine, dosed at 7.5mg, commenced pre-hemodialysis treatment QW135 from 2024-01-18, aiming to prevent post-dialysis hypotension, with current blood pressure around 90/50 mmHg. The dosage, confirmed via telephone with the nurse practitioner, aligns with the patient’s customary regimen.

(the following text is wrong and not posted)

Midodrine, at a dose of 7.5mg, has been initiated for post-hemodialysis treatment as of 2024-01-18, with current blood pressure readings around 90/50 mmHg.

Midodrine’s effectiveness is attributed to its major metabolite, desglymidodrine, generated through the deglycination process. The peak plasma concentration of midodrine occurs about 30 minutes post-administration, with a half-life of approximately 25 minutes. Desglymidodrine reaches peak levels in the blood between 1 to 2 hours after midodrine administration and has a half-life of 3 to 4 hours.

For patients undergoing thrice-weekly intermittent hemodialysis, initiating midodrine at a low dose, such as 2.5 mg once or twice daily, is advisable. Dosage can be adjusted based on individual response and tolerability, with careful monitoring.

701505232

240119

[MedRec]

• 2024-01-10 SOAP Plastic and Reconstructive Surgery Zhang MengZong
  • S: Chronic ulcer with necrotizing fasciitis is found about 4 * 6 cm in size over the left medial ankle s/p Dermacell implantation for 30 days.
  • O: Chronic ulcer with necrotizing fasciitis is found over the left medial ankle s/p Dermacell implantation about 3 * 5 cm in size –> superficial debridement –> wound CD with Allevyn Ag q2d
• 2024-01-03 SOAP Plastic and Reconstructive Surgery Zhang MengZong
  • S: Chronic ulcer with necrotizing fasciitis is found about 4 * 6 cm in size over the left medial ankle s/p Dermacell implantation for 23 days.
  • O: Chronic ulcer with necrotizing fasciitis is found about 4 * 6 cm in size over the left medial ankle s/p Dermacell implantation –> removal of skin staples –> wound CD with Allevyn Ag q3d
• 2023-11-23 ~ 2023-12-27 POMR Rheumatology and Immunology Chen ZhengHong
  • Discharge diagnosis
    • Systemic lupus erythematosus
    • Chronic ulcer with necrotizing fasciitis over the left medial ankle; statsus post deep debridement + fasciectomy + negative pressure wound therapy on 2023/11/27, deep debridement + negative pressure wound therapy on 2023/12/04, deep debridement + Dermacell artificial dermis implantation + negative pressure wound therapy on 2023/12/11
    • Glomerular disease in systemic lupus erythematosus
    • Acute kidney failure
    • Antiphospholipid syndrome
    • Tiny duodenal ulcer, superior duodenal angle
    • Hypomagnesemia
    • Hemolytic anemia post spleenectomy
    • Hyperkalemia
    • Abnormality of albumin
    • Reflux esophagitis, grade A(minimal)
  • CC
    • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks
  • Present illness
    • This 41-year-old famale had histories of
      • Sytemic lupus erythematous with diffuse proliferatine lupus nephritis and membranous nephritis, ISN/RPS class IV+V,modified NIH AI:19& CI:4;2;with autoimmune hemolytic anema (post spleenectomy in 2018), with aPL psitive, seizure with lupus PRES,with lupus angitis, with suspect lupus pneumonitis, and plerual efffusion/ ascities status post.
      • Lupus nephritis,
      • Left medial ankle bulla, suspect lupus related —> calciphylaxis ulcer
      • Gall bladder stone with acute on chronic cholecystitis, refused surgery
    • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks.
    • She visited our OPD of plastic surgery. Physical examination showed chronic ulcer with necrosis is found about 4 * 6 cm in size over the left medial ankle,mild redness around wound, local heat, no discharge, VAS 5.
    • Surgical tangenital debridement were recommended. Then, she was admitted for surgical intervention.
  • Course of inpatient treatment
    • Belimumab (self-paid) course (Belimumab is an IgG1-lambda monoclonal antibody that prevents the survival of B lymphocytes by blocking the binding of soluble human B lymphocyte stimulator protein (BLyS) to receptors on B lymphocytes. This reduces the activity of B-cell mediated immunity and the autoimmune response.)
      • 1st Belimumab 640mg on 2023/09/13
      • 2nd Belimumab 640mg on 2023/09/27
      • 3rd Belimumab 640mg on 2023/10/13
      • 4th Belimumab 400mg on 2023/10/24
    • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks. She visited our OPD of plastic surgery. Physical examination showed chronic ulcer with necrosis is found about 4 * 6 cm in size over the left medial ankle, mild redness around wound, local heat, no discharge, VAS#5. Surgical tangenital debridement were recommended. Then, she was admitted for surgical intervention.
    • After admission, hyperkalemia (6.6) with metabolic acidosis, bicarbonate = 15 and hemolytic anemia were noted, We consulted Nephrology and DC Exforge, add Sodium bicarbonate 2# TID, NESP 20 ug IV st and QW3 for anemia, add Lasix, Kalimate, RI + Vitagen 50% for potassium control, follow up K showed improved potassium level: (5.8 -> 6.0 -> 5.1 -> 5.4 -> 4.7 -> 4.9 -> 4.8).
    • CVC was inserted on 2023/11/24 because of difficulty in placing peripheral intravenous catheters. We consulted Rheuma under the impression of SLE, lupus nephritis with uncontrolled lupus disease activiety and autoimmune hemolytic anemia.
    • Debridement for chronic ulcer with necrosis over the left medial ankle was performed on 2023/11/27. Due to uncontrolled lupus disease activity, she was transfered to Rheuma ward on 2023/11/27.
    • After transferral to rheumatology ward, we checked APS profile, SSA/SSB, anti-ICS, anti-BMZ, ESR, CRP, thyroid function & electrolytes which disclosed APS with Anti-Cardiolopin IgG 2023-11-28 51 GPL-U/mL, Anti-ENA SS-A(Ro) 224 EliA U/ml, and Anti-ENA SS-B(La) 24 EliA U/ml. We kept DMARDs treatment (CellCept250 mg/cap 4 cap BID, Plaquenil 200mg/tab 1 tab BID) and Prednisolone 1 tab BID for SLE with lupus nephritis control, Warfarin 1mg/tab 1 tab BID for APS control, Revatio 20mg/tab (Sildenafil) 1 tab TID for pulmonary hypertension control according to discharge summary of TMUH. We rechecked risk management plan before Belimumab infusion which disclosed Anti-HBc Reactive, Anti-HCV and HBsAg nonreactive.
    • Immunotherapy of Belimumab (self-paid) was administered on 2023/11/30. The 2023/11/28 cardiac echo revealed EF 75% with concentric LV hypertrophy with indeterminated LV filling pressure; mildly dilated LA, marked calcification of mitral papillary muscles with trivial MR; mild aortic valve with trivial AR, minimal amount pericardial effusion ( < 50ml), and sinus tachycardia.
    • Albumin 1 bot IVD x 3 days (11/28~30) was administered for hypoalbuminemia (Albumin 2.4 g/dL). The following thyroid function revealed Free-T4 1.10 ng/dL, TSH 1.754 uIU/mL.
    • For persistent nausea and intermittent vomiting since 2023/10, we arranged gastroscopy on 2023/11/29 - Reflux esophagitis LA Classification grade A (minimal), superficial gastritis, antrum, tiny duodenal ulcers, superior duodenal angle and PPI with Nexium was added for duodenal ulcers and GERD grade A.
    • We taper off Kalimate for hyperkalemia resolved and MgSO4 IVD stat + MgO 1# TID was added for hypomagnesemia (Mg 2023-11-29 1.1 mg/dL).
    • Deep debridement + negative pressure wound therapy (small size) was performed on 2023/12/04 and we kept wound care by negative pressure wound therapy.
    • We rechecked D-dimer, PT/APTT, lipid profile, Albumin which disclosed HGB 8.7 g/dL, D-dimer 4181.00 ng/mL, Albumin 2.7 g/dL, Cr 1.25 mg/dL, eGFR 50.20 ml/min. DVT of left foot was suspected and Clexane 60mg/0.6mL/syringe 60 mg SC QD was prescribed since 2023/12/09 and the follolwing D-dimer: 2284 ng/mL on 2023/12/11, D-dimer 1701.00 ng/mL on 2023/12/14. We consulted CV for pulmonary hypertension evaluation and recommendation for Revatio indication and suspect DVT who suggest to arrange venous duplex evaluation, check NTproBNP level, according to pulmonary hypertension history at TMUH, may keep revatio use, if still renal function and potassium, consider Angiotensin receptor blockade QD and carvedilol bid and spironolactone 1#QD for better BP control, and then discontinue clonidine under the impression of hypertensive heart disease, pulmonary hypertension? (may trace right heart catheterization and echocardiogram report at TMUH).
    • She received deep debridement + Dermacell artificial dermis implantation (4*4 cm) + negative pressure wound therapy (small size) on 2023/12/11 smoothly.
    • The following laboratory data revealed Cr 1.31 mg/dL, NT-proBNP 7291.8 pg/mL. We changed anti-hypertensive agents and monitored BP variation to protect renal function and adjusted to Carvedilol 25mg QD. 2023/12/15 Vein sonography showed no evidence of deep vein thrombosis at bilateral lower limbs, bilateral long saphneous vein engorgement at thigh level, left side more severe; with soft tissue edema at medial side of bilateral thighs. For foaming urine sometimes, we rechecked C3, C4, ESR, CRP, D-dimer, NT-proBNP and 24 hrs urine protein which disclosed low C3, mild improved creatinine, D-dimer and NT-proBNP.
    • She received immunotherapy of Belimumab (self-paid) 400 mg on 2023/12/26 smoothly. We tried to off VAC negative pressure and her Dermacell artificial dermis implantation attachment well, then was shiftted to self-paid Allevyn Ag covered. The whole therapeutic process was smooth & patient tolerated it well without severe side effect or complaints. With relatively stable condition, she was discharged on 2023/12/27 and AIR + PS OPD follow-up was arranged on 2024/01/03.
  • Discharge prescription
    • Atotin (atorvastatin 20mg) 1# QOD
    • Blopress (candesartan 8mg) 1# BID
    • CellCept (mycophenolate mofetil 250mg) 4# BID
    • Cofarin (warfarin 1mg) 1# BID
    • Compesolon (prednisolone 5mg) 1# BID
    • Eltroxin (levothyroxine 50ug) 1# QDAC
    • hydralazine 50mg 1# TID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
    • MgO 250mg 1# TID
    • Nexium (esomeprazole 40mg) 1# QDAC 2023/11/29 gastroscopy: GERD grade A
    • Plaquenil (Hydroxychloroquine 200mg) 1# BID
    • Revatio (sildenafil 20mg) 1# TID if SBP <90/50 mmHg hold
    • Rivotril (clonazepam 0.5mg) 1# BID
    • Spiron (spironolactone 25mg) 1# QD
    • Strocain (oxethazaine polymigel 5mg) 1# TIDAC for stomach ache
    • Syntrend (carvedilol 25mg) 1# BID
    • Zinga (zinc gluconatte 78mg) 1# QD
• 2023-11-17 SOAP Plastic and Reconstructive Surgery Zhang MengZong
  • P
    • Admission for debridement + NPWT (small), HBOT, IV antibiotic, Dopplar sonography
    • Consult Rheu, Nephro
• 2023-11-14 SOAP Plastic and Reconstructive Surgery Zhang MengZong
  • S
    • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks.
    • Hx. of SLE, Lupus nephritis, seizure attack
  • O
    • Height 160, Weight 47, BMI 18.4
    • Chronic ulcer with necrosis is found about 4 * 6 cm in size over the left medial ankle. –> superficial debridement (wound culture) –> wound CD with prontosan gel bid
  • P
    • education
    • HBOT is suggested.

==========

2024-01-19

[SLE management]

Based on the PharmaCloud database, this patient had multiple admissions to TMUH before seeking treatment at our hospital around late 2023. Given that immunosuppressive agents were used prior to her current treatment, vigilant monitoring for signs of infection is recommended. Typically, immunizations should precede immunosuppressive therapy.

Exposure to UV light can trigger or worsen systemic lupus erythematosus (SLE) symptoms, though this varies among patients. About one-third may react to sun exposure, another third with prolonged exposure, and the rest may not react at all. Most SLE patients are advised to avoid direct or reflected sunlight and UV light sources, using sunscreens with a minimum SPF of 55 that block both UV-A and UV-B rays.

A recent study in the Annals of the Rheumatic Diseases has confirmed the renal protective effects of sodium glucose cotransporter 2 (SGLT2) inhibitors in lupus nephritis, both in mouse models and patients, suggesting significant clinical benefits of this treatment approach. (Reference: Onuora S., “SGLT2 inhibitors protect podocytes in lupus nephritis”, Nat Rev Rheumatol, 2023 Oct, 19(10): 605, DOI: 10.1038/s41584-023-01024-1, PMID: 37666997).

701511827

240119

[lab data]

2024-01-18 Anti-HBc Nonreactive
2024-01-18 Anti-HBc-Value 0.42 S/CO
2024-01-18 HBsAg Nonreactive
2024-01-18 HBsAg (Value) 0.40 S/CO
2024-01-18 Anti-HCV Nonreactive
2024-01-18 Anti-HCV Value 0.15 S/CO

[MedRec]

• 2024-01-17 SOAP Medical Emergency Lin QinXiang
  • Preliminary Impression: N39.0 Urinary tract infection, site not specified
  • 20231222 33072AB_Abdomen C-/C+ N Imaging findings:
    • CT scan of the abdomen and pelvis without/with IV contrast enhancement shows:
    • suboptimal study due to some respiratory motion artifacts.
    • pericardial effusion(s) with calcifications of the tortuous aorta; bronchiectasis and bronchial wall thickening with ill-defined consolidation and air bronchogram at the left lingular, right middle and bil. lower lobes; moderate pleural effusion(s) on both sides; r/o funnel chest (pectus excavatum); presence of the interventricular septum sign, r/o anemia.
    • r/o parenchymal liver disease with hepatic cysts, both lobes.
    • gallbladder sludge, r/o cholecystitis, with pericholecystic fluid collection(s).
    • left renal cyst.
    • no evidence of focal lesion at the spleen, pancreas, bil. adrenals, and right kidney.
    • reflexed and enlarged uterus, r/o uterine fibroid(s), with simple fluid in the uterine cavity, and pelvic edema; enlargement and edema of the uterine cervi x with endocervical enhancement; s/p urinary catheterization in position with chronic cystitis.
    • s/p nasogastric (NG) intubation in position, r/o reflux esophagitis; r/o antral gastritis.
    • mild ascites with dirty mesenteric and omental fat; no evidence of enlarged lymphadenopathy.
    • mild degenerative scoliosis of the lumbar spine; chronic to old benign compression fracture(s) and wedge deformity or decrease in height of the T12 and L5 vertebrae with intravertebral vacuum phenomenon(a), suggestive of osteonecrosis, at the L5 level; varying-sized osteolytic lesions scattered at the bil. iliac bones.
    • extensive subcutaneous edema at the trunk.
    • Impression:
      • pericardial effusion(s);
      • bronchiectasis with secondary infections, left lingular, right middle and bil. lower lobes; bil. pleural effusion(s);
      • r/o funnel chest (pectus excavatum);
      • r/o anemia.
      • r/o parenchymal liver disease with hepatic cysts, both lobes.
      • GB sludge, r/o cholecystitis.
      • left ren al cyst.
      • reflexed and enlarged uterus, r/o uterine fibroid(s);
      • r/o pelvic inflammatory disease (PID) with possible cervicitis; chronic cystitis.
      • r/o reflux esophagitis;
      • r/o antral gastritis.
      • mild ascites, r/o peritonitis.
      • mild degenerative scoliosis, lumbar spine;
      • chronic to old benign compression fracture(s), T12 and L5 vertebrae, with osteonecrosis, L5 level;
      • r/o multiple bony metastases?, bil. iliac bones.
      • extensive subcutaneous edema, trunk.
• 2024-01-12 SOAP Psychosomatic Medicine Zen YuLun
  • S
    • C.C. & P.I.: The first time visit, the patient is abscent, her daughter come.
    • Background and current position: .
    • Hx of Suicide/Self-injury/Violence: .
    • Hx of Substance abuse: .
    • Hx of psychi/medical disease and treatment: .
    • Current medications: .
    • Family Hx: .
    • Premorbid personality: .
    • Key person and social support: .
  • O
    • Height:150 cm; Weight:38 kg; BMI: 16.9
    • [PPFE] Mental status examination:
      • Consciousness: clear
      • Appearance:
      • Attitude:
      • Affect:
      • Speech:
      • Behavior:
      • Thought:
      • Perception:
      • JOMAC:
  • A/P
    • • Establish therapeutic alliance
      • Confirm a diagnosis:
      • Psychoeducation on the disease course
      • Examinations
      • Pharmacotherapy
      • instill hope.

[consultation]

• 2024-01-17 Urology
  • Q
    • C.C. suspect papillary urothelial malignancy, poor intake since 2023 September, BW loss 59 -> 38 kg, dysuria and hypogastric pain for 2 months
    • Allergy: NKDA
    • PHx: major depression disorder
      • no cough, no dyspnea, no cold sweating
      • no fever, no chills
      • (+) hypogastric pain, no chest/back pain
      • no nausea, no vomiting, no diarrhea
      • no tarry stool
      • (+) dysuria
  • A
    • This 69-year-old female patient was transferred from the oncology ward at other hospital. We were consulted for suspected GU tract cancer.
    • PH:
      • Major depression
      • Chronic bed ridden status due to anorexia
    • Lab:
      • Urine
        • 2024-01-17 Color Yellow
          
        • 2024-01-17 App Turbid
          
        • 2024-01-17 SG 1.010
          
        • 2024-01-17 PH 5.5
          
        • 2024-01-17 Leucocyte Ester 3+
          
        • 2024-01-17 NIT 1+
          
        • 2024-01-17 Sediment-RBC 10-19 /HPF
          
        • 2024-01-17 Sediment-WBC ＞=100 /HPF
          
        • 2024-01-17 Bacteria 1+ /HPF
          
      • Blood
        • 2024-01-17 Creatinine 0.35 mg/dL
          
    • Image:
      • No image was available
      • The report of prior CT exam showed no evidence of bladder tumor, hydronephrosis or upper GU tract tumor
    • Impression:
      • Unknown cause of body weight loss
    • Suggestion:
      • There is no evidence of GU tract tumor currently.
      • Further examination can be arranged at OPD.
      • Suggest OPD follow up.

701343853

240118

[MedRec]

• 2024-01-17 DutyNote Li YuZhong
  • Problem List
    • Problem 1: gastric ulcer, Forrest classification III, prepyloric antrum, AW/LC, s/p CLO test and biopsy
  • Course of disease or treatment
    • This is a 72 year old female with underlying of HTN, CAD s/p PCI under bokey, uterine prolapse status post Robotic assisted sacrocolpopexy 2022/07/20
    • She complaint of general weakness, dizziness, nausea, vomiting and epigastric dullness on 2024/01/15 night. Tarry stool passage was seen on 2024/01/16 for 3 times. She was brought to our ER on 2024/01/16 morning. Vital sign was as following: BP:112/67; HR:109; BT:36.4’C; RR:18; Con’s:E4V5M6. Serum data reported normocytic anemia (Hb8.7 g/dL), mild leukocytosis and high BUN (55mg/dL). Blood transfusion 3 unit and PPI were given.
    • Under the impression of upper GI tract bleeding, EGD was done and reported: gastric ulcer, Forrest classification III, prepyloric antrum, AW/LC, s/p CLO test and biopsy.
    • Follow up serum data showed some recovery of anemia (9.4 g/dL). After her condition was relative stable, she was admitted to ward for further evaluation and management.
  • Treatment recommendations
    • Monitor vital sign
    • Recheck CBC, DC, renal function and electrolyte tomorrow
    • NPO with glucose one touch monitoring
    • Taita no5 500ml BID
    • Pantoprazole 40mg Q12H
    • Transamine 500mg Q12H
    • Hold bokey and xanthium
    • Keep other OPD medications
    • May try soft diet if serum data no abnormal tomorrow
• 2024-01-17 VsNoteOnAdmissionDay Li ZhongXian
  • Attending progress Note on admission
  • A:
    • Response to treatment: pending
    • GU with recent bleeding
  • P:
    • Diagnostic plan:
      • Check B/R, BUN/Cr, Na, K, ALP, GGT, GOT, GPT, TB, Amylase, lipase, CRP, Alb, LDH, UA, Free T4, TSH, HbA1c, HBsAg, Anti-HCV, IgM anti-HAV, AFP, Lactate, BNP, CRP, PCT, Urine/R, Stool/R, Stool/C, Blood/C, Urine/C, Sputum/C, iFOBT, EKG, CxR, KUB
      • Sono abdomen, colon scope and EGD may be planned
      • CT of abdomen/ liver, biliary tract and pancreas may be planned
    • Treatment plan:
      • NPO/Try water/diet
      • Empiric antibiotics with
      • PPI Tx + GI medication + Symptomatic treatment
      • Adequate volume resuscitation and Keep I/O & E balance
      • Keep Pt’s OPD medication
      • Consult GS/RAD specialist for
    • Education plan:
      • Explained the patient’s serious condition and all plans,infection related complications to the family and the patient
      • Avoid alcohol drinking, hepatoxicity agent, Nsaids, anticoagulants, spicy and fatty foods
• 2022-07-18 ~ 2022-07-23 POMR Urology Luo QiWen
  • Discharge diagnosis
    • Uterine prolapse status post Robotic assisted sacrocolpopexy 2022/07/20
    • Urge incontinence
    • Nocturia
  • CC
    • Urinary frequency (Q1H) for over six months
  • Present illness
    • This is a 71 year-old female with systemic underlying disease of Hypertension and history of angina s/p catheterization but without stenting, and were all under medications control with Norvasc, bokey, and theophylline. Her ADL is totally independent.
    • According to her statement and medical records, she suffered from severe urinary frequency (Q1H) and nocturia (4 times) for over six months. Besides, a protruding mass was also noted at her vigina, but spontaneously subscided. No pain, no abnormal discharge, no operation history, no incarceration nor other remarkable discomfort was told. She was referred from GI Dr. Chao to GU Dr. Yang’s OPD due to the clinical problem mentioned above. Urinalysis found no sign of urinary tract infection. However, uroflometry found urinary frequency. Thus, symptomatic treatment with detrusitol was prescibed and she can hold urine than before. Due to her clinical problem still persisted, surgical intervention was then suggested.
    • Under the impression of over active bladder with pelvic organ prolapse, she was admitted to our ward for robotic assisted uterine suspension and further care.
  • Course of inpatient treatment
    • After admission, she recieved Robotic assisted sacrocolpopexy on 2022/07/20. The operation went smooth without immediate complications. She had keep bed rest for two days. No fever, no wound oozing nor pus discharge, but gastric discomfort was noted. We had removed foley on 2022/07/22 and no urine retension was found. Now, her clinical condition is relatively stable and may discharge and follow up at OPD.
  • Discharge prescription
    • Through (sennoside 12mg) 2# HS
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • Cardizem Retard (diltiazem 90mg) 1# QD
    • Sindine (povidone iodine aq soln 10%) ASORDER EXT

[surgical operation]

• 2022-07-20 - Op Method: Robotic assisted sacrocolpopexy         
  • Finding:
    • pevic organ prolapse, stage III; cervix 2 cm outside of introitus
    • console time 3 hr 35 cm

==========

2024-01-18

Pre-meal blood glucose levels were recorded at 132, 157, and 108 mg/dL on 2024-01-16, 2024-01-17, and 2024-01-18, respectively, indicating consistently elevated values. It is recommended that the patient continues with follow-up monitoring.

Upon review of the HIS5 records, no discrepancies in medication were identified.

701358512

240117

[MedRec]

• 2023-12-22 ~ 2023-12-25 POMR Urology Cai YaoZhou
  • Discharge diagnosis
    • Left renal cell carcinoma, T3aN1M1, Stage IV
    • Anemia (Hb:6.6g/dl)
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
  • CC
    • Weakness, dizziness, poor appetite, and persistent nausea for several days.
  • Present illness
    • This is a 53-year-old woman with history of:
      • Hypertension
      • Type II DM
      • Left renal cell carcinoma, T3aN1M1, Stage IV
        • Axitinib + Pembrolizumab for 4 times, shift to Atezolizumab on 2021/07/15-2023/01/06 (19th) due to heart failure  
        • target tx with cabozantinib approved (2022/03/07-2023/11/26) and Afinitor (2023/10/23-11/21).
        • Immunotherapy with Nivolumab on 2023/02/10-2023/10/17, due to regioal lymphadenopathy and bilateral lung meta.
      • Sepsis, heart failure, left distal common femoral artery pseudoaneurysm in 2023/07.
    • She had been under the Cabozantinib and Nivolumab treatment.
      • CT on 2023/05/31 showed partial response to Nivo + cabo.
      • CT on 2023/10/18 revealed mild increased tumor size, disease progression.
    • Thus, shift to afinitor and cabozantinib had been made. After starting Afinitor treatment on 10/23, she experienced severe diarrhea and feelings of nausea and vomiting. Additionally, she had a noticeable weight loss. She was hospitalized twice to manage these symptoms and stopped taking Afinitor on 2023/11/21.
    • This time, She has suffered from weakness, dizziness, poor appetite, and persistent nausea for several days. Thus, she was admitted for further evaluation and management.
  • Course of inpatient treatment
    • After admission, she accepted blood transfusion therapy, due to anemia. During treatment, she still has weakness, dizziness, poor appetite, and mild nausea. After the blood transfusion, the hemoglobin level increased from 6.6 g/dL to 9.8 g/dL.
    • Because symptoms relieved after treatment, she was discharged today and would be followed up at urologic clinic.
• 2022-02-15 ~ 2022-02-19 POMR Urology Cai YaoZhou
  • Discharge diagnosis
    • Left renal cell carcinoma, cT3aN1M1, stage 4 status post immunotherapy with Atezozulimab (#8)
  • CC
    • Admission for immunotherapy with Atezozulimab (#8)
  • Present illness
    • This 51-year-old women had histories of
      • Hypertension and DM under medication control;
      • Left RCC, cT3aN1M1, stage 4 start Axitinib + Pembrolizumab for 4 times, shift Atezozumab since 2021/07/15 due to heart failure.
    • This time, she admission for immunotherapy with Atezozulimab (#8).
  • Course of inpatient treatment
    • At admission, 8th immonotherapy with Atezozulimab was gave. She was discharged with stable condition on 2022/02/19 and would be followed up at urologic clinic.

[immunochemotherapy]

• 2023-10-17 - nivolumab 200mg NS 100mL 1hr
  • diphenhydramine 30mg + NS 250mL
• 2023-09-28
• ……….
• 2022-02-15 - atezolizumab 1200mg NS 250mL 1hr
  • diphenhydramine 30mg + NS 250mL

---

• 2023-11-21 ~ 2024-01-17 going - sunitinib
• 2023-02-09 ~ 2023-11-26 - cabozantinib

==========

2024-01-17

[stage IV RCC on sunitinib: historical anemia, emergency event & HGB low]

This 53-year-old female patient with stage IV renal cell carcinoma (RCC) was started on sunitinib in late Nov 2023 after progression on cabozantinib. The patient had a history of anemia prior to starting sunitinib, with no hemoglobin (HGB) values within the normal range in 2023.

On 2024-01-16, the patient presented to the emergency department with suspected coffee-ground emesis. This was likely the primary cause of the recent anemia episode. However, sunitinib is known to be associated with an incidence of decreased HGB (26% to 79%; grades 3/4: 3% to 8%; grade 4: 2%) and hemorrhage (22% to 37%; grades 3/4: <=4%). Therefore, the historic low HGB value on 2024-01-16 cannot be definitively excluded as a side effect of sunitinib. The patient underwent a blood transfusion on the same day, which was a reasonable course of action. In addition, this patient also underwent multiple blood transfusions in 2023.

• 2024-01-16 HGB 6.3 g/dL
• 2023-12-25 HGB 9.8 g/dL
• 2023-12-22 HGB 6.6 g/dL
• 2023-11-23 HGB 8.9 g/dL
• 2023-11-21 HGB 9.7 g/dL
• 2023-11-03 HGB 9.1 g/dL
• 2023-10-16 HGB 8.7 g/dL
• 2023-09-28 HGB 8.1 g/dL
• 2023-09-05 HGB 9.5 g/dL
• 2023-08-18 HGB 9.9 g/dL
• 2023-07-25 HGB 10.7 g/dL
• 2023-07-24 HGB 10.5 g/dL
• 2023-07-21 HGB 9.8 g/dL
• 2023-07-20 HGB 7.9 g/dL
• 2023-07-18 HGB 9.2 g/dL
• 2023-06-25 HGB 10.0 g/dL
• 2023-06-07 HGB 10.3 g/dL
• 2023-05-21 HGB 10.6 g/dL
• 2023-05-02 HGB 11.0 g/dL
• 2023-04-14 HGB 10.4 g/dL
• 2023-03-29 HGB 11.2 g/dL
• 2023-03-10 HGB 10.4 g/dL
• 2023-02-23 HGB 9.8 g/dL
• 2023-02-10 HGB 8.5 g/dL
• 2023-01-05 HGB 10.1 g/dL

In the event of grade 3 or 4 hemorrhage, it is recommended to withhold sunitinib until resolution to <= grade 1 or baseline, then resume at a reduced dose or discontinue (depending on severity and persistence). Discontinue sunitinib if grade 3 or 4 hemorrhagic events do not resolve.

The standard dosage of sunitinib for advanced RCC is 50mg daily, but the patient is currently taking 12.5mg daily. This is a significant underdose, and there seems no room to further reduce the dose.

701393041

240116

[lab data]

2023-12-20 CMV viral load assay 1040 IU/mL

2023-12-19 STR DNA fingerprint FINISH %

2023-12-18 CMV viral load assay 396 IU/mL

2023-12-12 CMV IgM Nonreactive
2023-12-12 CMV IgM Value 0.10 Index

2023-12-11 CMV viral load assay 74 IU/mL

2023-12-08 Anti-HBc Reactive
2023-12-08 Anti-HBc-Value 3.10 S/CO

2023-12-06 CMV viral load assay <35 IU/mL

2023-11-18 STR DNA fingerprint FINISH %

2023-11-13 EB VCA IgG Positive Ratio
2023-11-13 EB VCA IgG Value 3.6 Ratio

2023-11-10 HBsAg (NM) Negative
2023-11-10 HBsAg Value (NM) 0.539
2023-11-10 Anti-HBs (NM) Positive
2023-11-10 Anti-HBs value (NM) 59.1 mIU/mL
2023-11-10 Anti-HCV (NM) Negative
2023-11-10 Anti-HCV Value (NM) 0.047
2023-11-10 Anti-HBc (NM) Positive
2023-11-10 Anti-HBc Value (NM) 0.008

2023-11-09 VZV IgG Positive Index
2023-11-09 VZV-G Value 5.9 Index

2023-11-09 Mycoplasma IgM Negative Index
2023-11-09 Mycoplasma IgM Value 0.1 Index

2023-11-08 RPR Nonreactive

2023-11-08 EB VCA IgM Negative Index
2023-11-08 EB VCA IgM Value 0.1 Index

2023-11-08 CMV IgG Reactive
2023-11-08 CMV IgG Value 92.1 AU/mL
2023-11-08 CMV IgM Nonreactive
2023-11-08 CMV IgM Value 0.27 Index

2023-11-08 HIV Ab-EIA Nonreactive
2023-11-08 Anti-HIV Value 0.05 S/CO

2023-11-08 Anti HTLV I/II Nonreactive
2023-11-08 Anti HTLV I/II Value 0.08 S/CO

2023-10-20 IgE 14.5 IU/mL
2023-10-19 IgG 1831 mg/dL
2023-10-19 IgM 51.0 mg/dL
2023-10-19 IgA 421 mg/dL

2023-07-20 Ferritin (NM) 1548.71 ng/ml
2023-06-23 Ferritin (NM) 1258.84 ng/ml

2023-06-23 HLA DQ-high 02:01
2023-06-23 HLA DQ-high 04:02

2023-04-10 HLA A-high 24:02
2023-04-10 HLA A-high 33:03
2023-04-10 HLA B-high 40:01
2023-04-10 HLA B-high 58:01
2023-04-10 HLA C-high 03:02
2023-04-10 HLA C-high 07:02

2023-04-10 HLA DR-high 03:01
2023-04-10 HLA DR-high 08:09

[exam findings]

• 2023-12-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 38) / 106 = 64.15%
    • M-mode (Teichholz) = 63
  • Conclusion
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA, LVH, grade 1 LV diastolic dysfunction
    • Mild AS, AR, and PR
• 2023-12-16, -12-14 Abdomen - Standing (Diaphragm)
  • Spondylosis of the L-spine is noted.
• 2023-12-14 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2023-07-14 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with myelodysplastic syndrome
  • The specimen submitted consists of two cores of gray-brown and hard bony tissue, measuring up to 2.7 x 0.3 x 0.3 cm. All for section after decalcification.
  • The sections show normocellular marrow (25%). M/E ratio = 2:1 in CD71 and MPO stains. The erythoid precursors are dispersed and scattered. The CD61+ megakaryocytes are moderately increased, and occasional micromegakaryocytes are present. Mild perivascular and paratrabecular fibrosis can be found. Slightly increased increased CD34+ and/or CD117+ immature cells, account for 3% of nucleated cells. The finding is compatible with myelodysplastic syndrome. Suggest further bone marrow smear evaluation and clinic correlation.
• 2023-01-04 SONO - Spleen
  • Homogeneous echogenicity of the spleen.
  • Soft tissue nodule, 2.06 in the lower pole of the spleen, accessary spleen? Suggest follow up study.
• 2022-06-20 SONO - Spleen
  • Homogeneous echogenicity of the spleen.
  • Mild splenomegaly (12.73 x 5.32 cm).
  • Soft tissue nodule, 1.7 x 1.51 cm in splenic hilar region, accessary spleen? Suggest follow up study.

[MedRec]

• 2023-11-05 ~ 2023-12-08 POMR Hemato-Oncology Gao WeiYao

  • Discharge diagnosis
    • Acute myeloblastic leukemia, post allo-PBSCT on 2023/11/17
    • Refractory anemia with excess of blasts
    • GVHD with mucositis and liver function
    • Anemia
    • Electrolyte imbalance
    • Hickman insertion
  • CC
    • for allo-PBSCT
  • Present illness
    • The 59 years old male was diagnosed of myelodysplastic syndrome (MDS) with Refractory Anemia with excess of blast (RAEB) since April 2022 at FuRen Univ Hosp. According to the patient, the initial presentation was dizziness. After diagnosing, he was then regularly taking Hydroxyurea 1# QOD since April 2022 at FuRen Univ Hosp.
    • He came to our hemato-oncologic clinic (Dr Zhang ShouYi) on 2022/06/18 and we have arranged JAK2 mutation test (2022/06/20) which was revealed undetectable.
    • We applied Azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/06/27. We suggest to check HLA high resolution for stem cell collection.
    • He was then started Azacitidine at our OPD since 2022/07/04 and regular follow up at our clinic. Azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/07/04-2023/9/18.
    • Family conference was done for allo-PBSCT on 2023/09/25.
    • This time, he sufferes from dry cough also noted at night. He denied fever, oral ulcer, sore-throat or anal pain. He was admitted for allo-PBSCT on 2023/11/05.
  • Course of inpatient treatment
    • After admission, he received hickmen insertion from CVS on 2023/11/09. During hospitalization, he received GCSF 150mcg qd for neutropenia.
    • ID/NST/OS were consulted for assessment.
    • Chemo are arranged as FluMel140-ATG since 2023/11/11-11/15 and ATG since 11/15-11/16.
    • Ciclosporin 1.5mg/kg q12h since 11/16.
    • Hydration and sent to BMT room on 11/16 night.
    • Allo-PBSCT on 11/17.
    • Chemo as MTX 15mg/m2 on 11/18 and 11/22.
    • GCSF 300mcg since 11/18.
    • Lasix 20mg bid for keep I/O balance.
    • MUD allogeneic PBSCT with donor blood type O and recepitent blood type A.
    • Day 0 in 2023/11/17 (CD34+/kg x 10^6 = 11.6/kg x 10^6).
    • Fortunately, his WBC up 960 in Day 10 on 11/27.
    • Blood transfusion during hospitalization.
    • Antibiotics as Cefepime and Targocid for fever control and add steroid for suspect engraftment symdrom.
    • Spiking fever was noted, so we shift Cefepime to Mepem treatment.
    • Follow up Cyslosporin level and adjust dose to 275mg daily.
    • GVHD with liver function impairement and lip mucositis grade II.
    • Hickman catheter was removed on 12/04 and wound healing well.
    • Under the stable condition, he can be discharged and take oral prednisolon 2# bid going back home. MBD on 2023/12/08. OPD follow up is arranged.       
  • Discharge prescription
    • MgO 250mg 1# TID
    • Rivotril (clonazepam 0.5mg) 1# PRNHS
    • Sandimmun Neoral (ciclosporin 100mg) 1# Q12H
    • Sandimmun Neoral (ciclosporin 25mg) 1# TID
    • Through (sennoside 12mg) 2# HS
    • Compesolon (prednisolone 5mg) 2# BID
    • Ulstop (famotidine 20mg) 1# BID

• 2023-08-19 ~ 2023-09-04 POMR Hemato-Oncology Gao WeiYao

• 2023-07-26 ~ 2023-08-01 POMR Hemato-Oncology Gao WeiYao

  • Discharge diagnosis
    • Refractory anemia with excess of blasts, unspecified
    • Acute myeloblastic leukemia, not having achieved remission
    • Anemia, unspecified
  • CC
    • mild gum bleeding
  • Present illness
    • The 59 years old male was diagnosed of myelodysplastic syndrome (MDS) with Refractory Anemia with excess of blast (RAEB) since April 2022 at FuRen Univ Hosp.
    • According to the patient, the initial presentation was dizziness. After diagnosing, he was then regularly taking Hydroxyurea 1# QOD since April 2022 at FuRen Univ Hosp.
    • He came to our hemato-oncologic clinic on 2022/06/18 and we have arranged JAK2 mutation test (2022/06/20) which was revealed undetectable.
    • We applied Azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/06/27. We suggest to check HLA high resolution for stem cell collection.
    • He was then started Azacitidine at our OPD since 2022/07/04 and regular follow up at our clinic.
    • According to the OPD medical record, therapy with Azacitidine was launched on C1 azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/07/04. C1b azacitidine x 2 on 2022/07/11, C2 azacitidine on 2022/08/01. C2b on 2022/08/08. C3 on 2022/08/29. C4 on 2022/09/05, C4b on 2022/09/26, C5 azacitidine 75mg/m2 SC D1~D7 Q4W x 7 on 2022/11/08, C6 on 2022/12/05, C7 on 2023/01/23, C8 on 2023/02/13, C9 2023/03/15, C10 2023/04/12, C11 2023/05/24 at our OPD.
    • He could tolerate with the therapy as well. This time, he has suffered from mild gum bleeding for days since 2023/07/23 as experienced before. Thus, he visited our OPD and revelaed leukopenia (WBC:1870, PLT:32K, MCV:95.2, Hb:6.8) was noted, then he was refered to ER for advanced evaluation. Under the impression of MDS with RAEB, he was admitted for further care.
  • Course of inpatient treatment
    • After admission, we have applied azacitidine 146mg SC D1~D7 x 7 since 2023/07/26 for him and explained about the stem cell collection for him. Family meeting was suggested in future. Patient could understand it as well. Under the stable condition, he was arranged discharge on 2023/08/01 and OPD follow up as planned.

• 2022-10-04 SOAP Dermatology Zhou WeiTing

  • S: dry skin over expose area.
  • O: xerotic dermaitits due to target therapy.
  • Prescription
    • Topsym Cream (fluocinonide 0.05%) QN EXT
    • Xyzal (levocetirizine 5mg) 1# QN
    • Sinpharderm Cream (urea) BID TOPI
    • Asthan (ketofifen 1mg) 1# QD

• 2022-09-01 SOAP Dermatology Zhou WeiTing

  • S: severe itchy papules and plaques erupition over trunk after medication
  • Prescription
    • Topsym Cream (fluocinonide 0.05%) BID EXT
    • Compesolon (prednisolone 5mg) 1# QD
    • Xyzal (levocetirizine 5mg) 1# QN
    • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# PRNTID
    • C.B. Ointment (chlorpheniramine, lidocaine, methyl salicylate, menthol, camphor) PRNBID TOPI

• 2022-06-20 SOAP Hemato-Oncology Zhang ShouYi

  • Order
    • LRP 1U
    • LPRBC 2U
  • Prescription
    • Transamin (tranexamic acid 250mg) 1# BID
    • Benamine (diphenhydramine 30mg) ST IVD
    • Decan (dexamethasone 4mg) ST IVD
    • NS 500mL ST IVD

• 2022-06-18 SOAP Hemato-Oncology Zhang ShouYi

  • S
    • 58 y/o male, a pt of myelofibrosis (?) or MDS wt RAEB (?), Dx in April 2022 at FuRen Univ Hosp, suffered from dizziness in April 2022.
    • Bone marrow biospy (4/29 22): Blast: 5.6%.
    • MDS wt excess blast & fibrosis.
    • Hb (3/29 22):7.1, MCV:89.4, MCHC:36.4, plt:61K, WBC:2610, blast:5%.
    • under Hydroxyurea 1# QOD since April 2022 by at FuRen Univ Hosp.
    • no exertional dyspnea, no easy fatigue, no easy dizziness, no lethargy, no palpitation
    • no tarry nor bloody stool passage
    • gum bleeding (+) epistaxis, no easy bruising.
    • no particular drugs in use (eg Aspirin or NASID or anonymous drugs)
    • came to our hemato-oncologic clinic on 6/18 22
    • R/I myelofibrosis
    • R/I MDS wt RAEB (?),
    • will do JAK2 mutation test (6/18 22).
    • will do abd sono (6/18 22).
    • will do CBC & DC, reticulocyte,
    • will do PT, APTT, fibrinogen.
    • s/p educate pt about preventing from trauma & avoiding NSAID (6/18 22).
    • RTC 1 wk later on 6/28 22 for JAK2 report.
      
  • Diagnosis
    • Anemia, unspecified [D64.9]
    • IDA, unspecified [D50.8]

[chemotherapy]

• 2023-11-28 - methotrexate 10mg/m2 19mg NS 50mL
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-23 - methotrexate 10mg/m2 18mg NS 50mL
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-20 - methotrexate 10mg/m2 19mg NS 50mL
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-18 - methotrexate 15mg/m2 28mg NS 50mL
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-11-11 - fludarabine 30mg/m2 50mg NS 250mL 1hr D1-5 + melphalan 70mg/m2 120mg NS 500mL 1hr D4-5
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-09-18 - azacitidine 75mg/m2 143mg SC D1-7
• 2023-07-26 - azacitidine 75mg/m2 146mg SC D1-7
• 2023-05-24 - azacitidine 75mg/m2 142mg SC D1-7
• 2023-04-12 - azacitidine 75mg/m2 145mg SC D1-7
• 2023-03-15 - azacitidine 75mg/m2 145mg SC D1-7
• 2023-02-13 - azacitidine 75mg/m2 130mg SC D1-7
• 2023-01-03 - azacitidine 75mg/m2 130mg SC D1-7
• 2022-12-05 - azacitidine 75mg/m2 130mg SC D1-7
• 2022-11-08 - azacitidine 75mg/m2 130mg SC D1-7
• 2022-09-26 - azacitidine 75mg/m2 130mg SC D1-7
• 2022-09-29 - azacitidine 75mg/m2 130mg SC D1-7
• 2022-08-01 - azacitidine 75mg/m2 130mg SC D1-7
• 2022-07-04 - azacitidine 75mg/m2 130mg SC D1-7

==========

2024-01-16

[Ciclosporin dose optimization]

Following the adjustment of the daily dose to 220mg, observed serum trough levels have shown a gradual decline. To maintain the desired concentration range of 200-300 ng/mL, an increase in the daily dose to 240mg is recommended.

• 2024-01-15 Cyclosporine-A 242.5 ng/mL
• 2024-01-12 Cyclosporine-A 295.5 ng/mL
• 2024-01-08 Cyclosporine-A 344.1 ng/mL

The administration of Grancicure (ganciclovir) 500mg Q12H IVD has effectively reduced the CMV viral load. Starting from 2024-01-17, Grancicure will be replaced with Valcyte (valganciclovir) 900mg QD PO.

• 2024-01-15 CMV viral load assay 786 IU/mL
  
• 2024-01-08 CMV viral load assay 64300 IU/mL
  
• 2023-12-30 CMV viral load assay 12200 IU/mL
  
• 2023-12-20 CMV viral load assay 1040 IU/mL
  
• 2023-12-18 CMV viral load assay 396 IU/mL
  
• 2023-12-11 CMV viral load assay 74 IU/mL
  
• 2023-12-06 CMV viral load assay <35 IU/mL

Also note that the patient’s WBC count and HGB level are gradually decreasing.

• 2024-01-15 WBC 2.30 x10^3/uL

• 2024-01-12 WBC 2.24 x10^3/uL

• 2024-01-08 WBC 3.89 x10^3/uL

• 2024-01-06 WBC 3.59 x10^3/uL

• 2024-01-04 WBC 4.30 x10^3/uL

• 2024-01-02 WBC 4.96 x10^3/uL

• 2024-01-15 HGB 7.3 g/dL

• 2024-01-12 HGB 8.6 g/dL

• 2024-01-08 HGB 9.3 g/dL

• 2024-01-06 HGB 9.3 g/dL

• 2024-01-04 HGB 7.4 g/dL

• 2024-01-02 HGB 10.2 g/dL

2024-01-03

[Sandimmun injection (Ciclosporin) TDM]

Following the recent ciclosporin trough level of 416.5 ng/mL on 2024-01-02, the Sandimmun injection dosage has been adjusted from 250mg to 220mg daily. To monitor the effectiveness of this adjustment, it is kindly requested a new blood sample four days after the adjustment, to be drawn prior to the scheduled administration, for another trough level test.

2023-12-26

[steady rise, time to tune down: ciclosporin level management - Sandimmun injection (Ciclosporin) TDM]

This patient has been taking ciclosporin 275mg QD since 2023-12-12. Lab results for ciclosporin trough levels on 2023-12-15, 2023-12-18, 2023-12-21, and 2023-12-25 showed values of 152, 222, 292, and 318 ng/mL, respectively. Based on this monotonic trend, if the current dose is continued, the trough level could exceed the recommended upper limit of 400 ng/mL by the end of 2023 or early 2024. Therefore, it is recommended to reduce the dose to 250mg QD and recheck the trough concentration 4 days after the change.

2023-09-25

The attending physician Dr. Gao held an interprofessional practice and patient family meeting in the ward conference room at 15:00 on 2023-09-25, to introduce the patient to the importance, possible risks, and prognosis of allogeneic peripheral blood stem cell transplantation in the treatment plan, and to answer questions from patients and their families. The patient did not ask the pharmacist any specific questions during the meeting. In a chat with the patient after the meeting, I emphasized the importance of controlling potential post-transplant infections.

700570266

240115

• diagnosis
  • 2022-08-15 discharge
    • Malignant neoplasm of cervix uteri, unspecified
    • cervical cancer (adenocarcinoma), stage IVa post CCRT, suspected cancer recurrence (C53.9)
    • urinary tract infection, urine culture: mixed growth 7000
    • constipation
• past history
  • Septoplasty, 20 years ago
  • Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion, start radiotherapy and chemotherpy since 2021/04
  • Large gallstone 2021/03
  • Left side moderate hydronephrosis and hydroureter 2021/03
  • C/S surgery (Cesarean Section), by patient personal choose  

[family history]

• Mother: Colon cancer
• Father: HCC
• Sister: Breast cancer   

[exam findings]

• 2023-12-07 CT - abdomen
  • History and indication: Cervical cancer s/p OP and C/T
  • Non-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. Some small LNs at mediastinum, retroperitoneum and bil. inguinal regions. Focal sclerotic change of L3.
    • S/P bilateral double J catheters insertion. Bil. renal cysts (up to 1.2cm). Tiny liver cysts.
    • Swelling of left lower extremity.
    • S/P Port-A infusion catheter insertion. S/P foley catheter indwelling.
    • A nodule (4.5mm) at RLL.
  • IMP:
    • S/P hysterectomy. A nodule (4.5mm) at RLL r/o metastases. Some small LNs at mediastinum, retroperitoneum and bil. inguinal regions. Focal sclerotic change of L3 r/o metastases.
• 2023-11-03 SONO - nephrology
  • Interpretation:
    • Bilateral chronic change with right small sized kidney.
    • Left mild hydronephrosis with D-J.
    • Bladder hyperechoic lesion, cause?
• 2023-09-22 All-RAS + BRAF
  • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
  • BRAF: There was no variant detect in the BRAF gene
• 2023-09-07 MRI - pelvis
  • Clinical history: 61 y/o female patient with Cervical cancer s/p OP and CCRT and C/T
  • Findings:
    • S/P hysterectomy. Irregular soft tissue tumor (2cm) between urinary bladder and vaginal stump, right, r/o recurrent tumor.
    • Enlarged lymph nodes in left inguinal region.
    • Diffuse swelling of left lower extremity.
    • S/P double J catheter insertion.
    • Non-enhancing nodule, 0.4cm in right lobe liver, r/o liver cyst.
    • There are lymph nodes in paraaortic and aortocaval regions.
  • Impression:
    • S/P hysterectomy. S/P double J catheter insertion, bilateral.
    • R/O recurrent tumor in posterior urinary bladder, between right posterior urinary bladder and vaginal stump region.
    • Left inguinal lymph nodes, paraaortic and aortocaval lymph nodes, r/o metastasis.
    • Diffuse swelling of left lower extremity.
• 2023-06-29 CT - abdomen
  • History and indication: Cervical cancer s/p OP and C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. Some small LNs at retroperitoneum and bil. inguinal regions.
    • S/P bilateral double J catheters insertion. Bil. renal cysts (up to 1.2cm). Tiny liver cysts.
  • IMP:
    • S/P hysterectomy. No evidence of tumor recurrence.
    • S/P bilateral double J catheters insertion.
• 2023-04-07 CT - abdomen
  • Findings
    • S/P hysterectomy
    • S/P double J catheter insertion, bilateral.
    • Prior CT identified a hepatic cyst 5 mm at S5/8 of the liver is noted again, stationary.
      • In addition, Left renal cyst, 1.2cm, also shows stationary.
  • Impression:
    • S/P hysterectomy.
    • There is no evidence of tumor recurrence.
• 2023-01-06 MRI - pelvis
  • Findings
    • S/P hysterectomy.
    • Segmental wall edema/thickening at rectosigmoid colon.
    • S/P double J catheter insertion, bilateral.
    • Non-enhancing nodule in left kidney, r/o left renal cyst (1.4cm).
  • Impression:
    • Clinical cervical cancer s/p hysterectomy.
    • Segmental wall edema/thickening at rectosigmoid colon. Suggest clinical correlation.
    • R/O left renal cyst.
• 2022-11-10 CT - abdomen
  • S/P hysterectomy. No evidence of tumor recurrence.
  • S/P bilateral double J catheters insertion.
• 2022-10-12 CXR
  • S/P Port-A infusion catheter insertion.
  • S/P bilateral double J catheters insertion.
  • Solitary pulmonary nodule at RLL.
  • Normal appearance of trachea and bil. main bronchus.
• 2022-10-04 SONO - breast
  • Diagnosis
    • Benign neoplasm of breast, infavor of benign fibrocystic disease (FCD), Uncertain breast tumor, in favor of benign fibroadenoma (FA)
  • Treatment
    • biopsy is not necessary
  • Suggestion and Plan
    • Regular OPD follow-up, Follow up breast sonography in next OPD visit
    • BI-RADS 3 - Probably Benign Finding (<2% malignant) Initial Short-Interval Follow-Up Suggested
• 2022-08-11 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • PTA
    • R’t : 30 dB HL, normal to mild SNHL
    • L’t : 33 dB HL, normal to severe SNHL.
• 2022-07-13 Patho - uterus with or without SO non-neoplastic/prolapse
  • Cervix uteri cancer checklist:
  • pathologic diagnosis
    • Tumor, uterine cervix, laparoscopic total hysterectomy — Adenocarcinoma
    • Endometrium, uterus, ditto — Free of tumor
    • Myometrium, uterus, ditto — Tumor invasion, leiomyoma
    • Lymph nodes, dissection — Not received
    • AJCC pathological stage (post CCRT) — ypT2a1, if cN0 and cM0, stage IIA1 / FIGO stage IIA1
      
  • microscopic examination
    • Tumor location:
      • Cervix
        
      • Vagina involvement: N/A
      • Corpus involvement: involved and one leiomyoma measured 3 cm
    • Tumor size: 2.5 x 2.0 cm
    • Tumor type: Adenocarcinoma
    • Histologic grade: moderately differentiated
    • Depth of invasion: about 0.6 cm, ＞1/2 cervical wall
    • Parametrial involvement: N/A
    • Parametrial cut end: N/A
    • Vaginal cut end: N/A
    • Lymphovascular invasion: NOT identified
    • Perineural invasion: Present
    • Lymph nodes: NOT received
  • IHC
    • P16(-), CEA(+), ER(-), PR(-), vimentin(-), P53(focal +, wild type), compatible with endocervical origin
• 2022-05-31 Patho - cervix biopsy, endocervix curretage/biopsy
  • Uterus, cervix, biopsy (S2022-8981) — adenocarcinoma, well differentiated.
    • IHC stains: p16 (-), vimentin (-), p53 (diffuse +), Napsin-A (-), PAX-8 (+).
  • Uterus, endocervix, ECC (S2022-8982) — adenocarcinoma, well differentiated.
    • IHC stains: p16 (-), vimentin (-), p53 (diffuse +), Napsin-A (-), PAX-8 (equivocal).
• 2022-05-18 MRI - pelvis
  • Findings
    • Soft tissue tumor(2.5cm) in cerivcal region, suspected cervical malignancy.
    • Relative thickening posterior wall of urinary bladder.
    • Soft tissue tumor, 3cm in posterior wall of uterine body, suspected uterine myoma.
    • Presence of gallbladder stones.
      
  • Impression
    • Cervical tumor, suspected malignancy.
    • Suspected uterine myoma.
    • Relative thickening posterior wall of urinary bladder.
    • GB stones.
• 2022-02-24 Gynecologic ultrasonography
  • suspect degeneration myoma
  • adenomyosis
• 2022-02-18 CT - abdomen
  • Findings
    • There is mild enhancing lesion 1.5 cm in left side uterine cervix area. Please correlate with physical examination or hysteroscope.
    • There is no enlarged node in left common iliac chain.
    • Soft tissue tumor 2.6 cm in posterior aspect of uterine body myometrium is noted that may be myoma.
    • S/P double J catheter insertion, bilateral.
    • Left renal cyst, 1.2cm.
  • Impression
    • Mild enhancing lesion 1.5 cm in left side uterine cervix araa. Please correlate with physical examination or hysteroscope.
• 2021-12-06 Gynecologic ultrasonography
  • EM: 7.5mm with fluid
  • Uterine myoma
• 2021-11-24 MRI - pelvis
  • Cervical cancer s/p RT.
  • Relative thickening posterior wall of urinary bladder with adhesion with anterior uterine cervix. Residual tumor? Suggest cystoscopy follow up.
  • Suspected uterine myoma.
  • GB stones.
• 2021-08-17 CT - abdomen, pelvis
  • Cervical cancer with lymph node in left common iliac region s/p, regression as compare with old CT study.
  • S/P double J catheter insertion, bilateral.
  • Suspected uterine myoma.
  • Left renal cyst.
• 2021-05-02 Gynecologic ultrasonography
  • Uterine myoma
  • Clinical: cervical cancer VIIA under CCRT with massive vaginal bleeding
• 2021-04-19 Pure Tone Audiometry, PTA
  • PTA: Reliability FAIR
  • Average RE 31 dB HL // LE 31 dB HL
  • RE normal to mild SNHL
  • LE normal to moderately severe SNHL
• 2021-03-31 Pathology (Cardinal Tien Hospital)
  • Uterus, exocervix, biopsy — Adenocarcinoma.
• 2021-03-30 Patho - endocervix curretage/biopsy
  • Uterus, endocervix, ECC — severe glandular dysplasia
    
  • Immunohistochemical stain reveals CK(-), VIMENTIN (-), p16(-) and CEA(+).
• 2021-03-30 Patho - cervix biopsy
  • Cervix, biopsy— adenocarcinoma
    
  • Immunohistochemical stain reveals CK(+), p16(-), CEA(+), vimentin(-). CK20(-), GATA3(-)
• 2021-03-23 CT (Cardinal Tien Hospital)
  • Findings
    • A 7 x 3.5cm mass in the uterine cavity and extension to the cervix and, to the posterior urinary bladder wall.
    • A 3.5cm cyst at the left adnexa. No definite iliac or paraaortic lymphadenopathy.
    • No abdominal fluid collection.
  • Imp:
    • Uterine tumor involving endometrial cavity and cervix with posterior, urinary bladder wall extension, suspect endometrial ca or cervical ca.
    • Small hepatic cysts in the right lobe, Left ovarian cyst, stage cT4N1M0.
• 2021-03-22 IntraVenous Pyelography, IVP (Cardinal Tien Hospital)
  • suspect left bladder tumor with left side obstructive uropathy.
• 2021-03-20 SONO - abdomen (Cardinal Tien Hospital)
  • Moderate fatty liver and fat infiltration the pancreas
  • Large gallstone
  • Left side moderate hydronephrosis and hydroureter

[consultation]

• 2023-11-15 Rehabilitation
  • Q: for Lymphedema of left lower limb
  • A: The patient had undergone lymphedema treatment at Dr. Qiu JiaYi’s outpatient clinic. Please schedule a follow-up appointment with Dr. Qiu after discharge.
• 2023-11-06 Dermatology
  • Q
    • for multiple lesion of left femoral biopsy
  • A
    • This patient suffered from multiple nodules on abd area for months.
    • Imp: R/O Malignat, skin meta
    • Suggestion: Arrange skin biopsy
• 2023-11-03 Nephrology
  • Q
    • for BUN/Cr elevated, decrease of urine output step by step
    • This 61-year-old woman patient is a case of Cervical cancer (adenocarcinoma), cT4N0M0, stage IVa post concurrent chemoradiotherapy with tumor recurrence s/p chemotherapy with Avastin(15mg/kg)/Taxol(175mg/m2)/Carboplatin(AUC:5) from 2022/08/12~2023/02/04(6 cycles), recurrence s/p chemotherapy with Taxol(175mg/m2)/Topotecan(0.75mg/m2) from 2023/09/28~ admitted for palliative chemotherapy.
    • We sincerely need your professional assistance!!
  • A
    • 61-year-old woman
    • Dx: Cervical cancer (adenocarcinoma), cT4N0M0, stage IVa post concurrent chemoradiotherapy with tumor recurrence s/p chemotherapy with Avastin(15mg/kg)/Taxol(175mg/m2)/Carboplatin(AUC:5) from 2022/08/12~2023/02/04(6 cycles), recurrence s/p chemotherapy with Taxol(175mg/m2)/Topotecan(0.75mg/m2) from 2023/09/28~ admitted for palliative chemotherapy.
    • O
      • BW 81-82.4
      • Urine output: ~580+loss
      • BUN: 23-24-39-43-53
      • CRE: 1.52 -> 2.30 -> 3.61 -> 5.26 within 1 mo
      • U-CRE: 112.09, U/O 350 cc(09/27)
      • Na/K: 138/3.5
      • HCO3: 32.4
      • Hgb: 8.1-8.6
      • Urinalysis -> NIL
      • Renal echo/Abd CT: bil. DBJ insertion
      • Pelvis MRI 09/07: R/O recurrent tumor in posterior urinary bladder, between right posterior urinary bladder and vaginal stump region.
      • Bil. DBJ in situ, inerted in 2023-07
      • Unable to obtain renal image
      • Medication history:
        • Diuretics: lasix #1 BID 40 mg/day + Budema #1 TID , aldactone -> U/O 580 + loss
        • DM: NIL
        • HTN:
        • Abx: Rocephin
        • Fluid: For drug
        • Other: Ketosteril, pentop
      • Accompanied by husband
      • Consciousness: E4V5M6, depressed
      • Bilateral lower limbs severe edema
      • Vital signs: 144/91 HR 102, SpO2 95% under N/C 2L
    • Impression AKI on CKD, progression in one month
    • Recommendation:
      • Please arrange renal echo first to r/o obstructive uropathy, consult GU for DBJ revision if hydronephrosis/hydroureter
      • Consider dialysis for fluid extraction if necessary by Dr. Wang but patien hesitated
      • Keep current medication use and correct infection status, keep recording I/O, avoid any nephrotoxic medications
      • f/u hemograms, electrolyte, BUN/CRE, blood gas routinely
      • Please feel free to contact us if any inquiries.
• 2021-05-02 Obstetrics and Gynecology
  • Q
    • S: Abnormal viginal bleeding since yesterday
      • No TOCC
      • She just discharged from OBGYN ward 2 days ago due to 2nd course C/T of cervical cancer.
  • A
    • S
      • P1NSD1, 25 years ago. Adenocarcinoma of the uterine cervix, FIGO stage IVA under CCRT.
      • Denied TOCC
      • She just discharged from hematology ward 2 days ago due to 2nd course C/T of cervical cancer.
        • Family history: (mother: colon cancer, elder sister: breast cancer)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM(-); HTN(-)
    • O
      • Endocervical adenocarcinoma; S/P radiotherapy due to cervical cancer.
      • PI: The patietn suffered from urinary frequence and post menopausal bleeding (uncertain duration).
        • GU cystoscopy – suspected meta adenocarcinoma in Cardinal Tien hospital. cervical biopsy as done in Cardinal Tien hospital, cervical cancer.
      • Previous RT Hx: (-)
      • Lab data: Hb=8.9 g/dL; CRP=1.7
      • Vaginal bleeding was noted in our ER.
      • Echo:
        • Uterus: 11.9x8.36 cm, EM: 1.3 cm with blood clot.
        • Uterine myoma 2.4x3.0 cm
    • A: Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion.
    • P: CCRT is indicated for this patient with the following indicators: FIGO stage IVA.
      • Plan:
        • Blood transfusion for anemia
        • Transamin and Ergometrine for hemostasis
        • OPD follow up
• 2021-04-20 Obstetrics and Gynecology
  • Q
    • For vaginal bleeding
    • This 58 y/o woman was Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion.
    • She was admitted for per-chemotherapy examination and CCRT with weekly CDDP on 2021/04/15.
    • Vaginal bleeding was noted last night, we need your help for further mamagement, thanks a lot.
  • A
    • Blood clot was noted in vagina. No active bleeding right now.
    • Bosmin gauze was inserted for compression.
    • Conservative treatment, CCRT and Transamin IV were suggested.

[radiotherapy]

• 2021-04-20 ~ 2021-06-17
  • 4500cGy/25 fractions (15MV photon) of the pelvic
  • 5400cGy/30 fractions (15MV photon) of the cervical tumor
  • 7020cGy/39 fractions (15MV photon) of the cervical tumor bed.

[immunochemotherapy]

• 2023-12-12 - paclitaxel 80mg/m2 120mg NS 400mL 3hr + topotecan 0.75mg/m2 1.2mg NS 40mL 30min D1-3 (He JingLiang)

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-11-20 - bevacizumab 15mg/kg 900mg NS 100mL 90min + paclitaxel 80mg/m2 120mg NS 500mL 3hr + topotecan 0.75mg/m2 1.2mg NS 40mL 30min D1-3 (Xia HeXiong)

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2023-09-28 - topotecan 0.75mg/m2 1.4mg NS 40mL 30min D1-3 (Xia HeXiong)

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2023-02-03 - bevacizumab 15mg/kg 900mg NS 100mL 90min + paclitaxel 175mg/m2 295mg NS 500mL 3hr + carboplatin AUC 5 350mg NS 250mL 2hr (Xia HeXiong)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL

• 2022-12-01 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

• 2022-11-10 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

• 2022-10-21 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

• 2022-09-01 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

• 2022-08-12 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

• 2021-06-10 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

• 2021-05-28 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

• 2021-05-21 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

• 2021-05-13 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

• 2021-05-07 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

• 2021-04-28 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

• 2021-04-20 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

==========

2024-01-15

[levofloxacin dose adjust needed! eGFR 12 recommend 500mg QOD per Sanford Guide]

The Cravit (levofloxacin) dosage for this patient with an eGFR of 12.03 (2024-01-15) requires adjustment based on the Sanford Guide recommendations. While the current regimen uses 750mg QOD, the recommended regimen for this eGFR range is 750mg once followed by 500mg Q48H. Therefore, it is recommended to reduce the dose to 500mg QOD to align with the Sanford Guide for optimal safety and efficacy.

2024-01-03

Imaging and Disease Status: MRI (2023-09-07) and CT (2023-12-07) both indicate disease progression, aligning with the rising CEA levels over the past year.

• 2024-01-03 CEA 69.11 ng/mL
• 2023-10-11 CEA 69.94 ng/mL
• 2023-09-20 CEA 51.92 ng/mL
• 2023-08-30 CEA 48.75 ng/mL
• 2023-08-01 CEA 39.69 ng/mL
• 2023-07-05 CEA 24.40 ng/mL
• 2023-06-07 CEA 25.70 ng/mL
• 2023-05-10 CEA 13.94 ng/mL
• 2023-04-12 CEA 7.26 ng/mL
• 2022-11-22 CEA 2.85 ng/mL
• 2022-11-02 CEA 4.12 ng/mL
• 2022-10-19 CEA 2.82 ng/mL
• 2022-10-04 CEA 2.11 ng/mL

Renal Function: Deteriorated in late Oct to early Nov 2023, with partial improvement but still not meet normal levels. Latest eGFR value was below 30 mL/min/1.73m2.

• 2024-01-02 Creatinine 1.84 mg/dL (eGFR 29)
• 2023-12-19 Creatinine 1.37 mg/dL
• 2023-12-15 Creatinine 1.51 mg/dL
• 2023-12-07 Creatinine 2.52 mg/dL
• 2023-11-29 Creatinine 1.65 mg/dL
• 2023-11-22 Creatinine 1.86 mg/dL
• 2023-11-17 Creatinine 2.34 mg/dL
• 2023-11-15 Creatinine 2.54 mg/dL
• 2023-11-13 Creatinine 2.23 mg/dL
• 2023-11-07 Creatinine 2.29 mg/dL
• 2023-11-02 Creatinine 5.26 mg/dL

Medication Recommendations:

• Continue Pentop (pentoxifylline) 400mg QD, as it’s already at the recommended maximum daily dose.
• Consider reducing Promeran (metoclopramide) tab from TIDAC to BIDAC.
• Closely monitor potassium levels due to ongoing potassium supplementation to avoid over-supplementation.

2023-11-16

[renal function follow-up]

On 2023-11-02, the patient’s serum creatinine reached a recent peak of 5.29 mg/dL and has since stabilized around the 2.2 - 2.5 mg/dL range. The patient, 61F, 62.9 kg, has a calcuated CrCl of 23 mL/min.

The current prescription of Tapimycin (piperacillin and tazobactam) at a dosage of 2.25g IVD Q6H is appropriate.

• 2023-11-15 Creatinine 2.54 mg/dL
• 2023-11-13 Creatinine 2.23 mg/dL
• 2023-11-07 Creatinine 2.29 mg/dL
• 2023-11-02 Creatinine 5.26 mg/dL (recent peak)
• 2023-10-30 Creatinine 3.61 mg/dL
• 2023-10-18 Creatinine 2.30 mg/dL
• 2023-10-11 Creatinine 1.52 mg/dL
• 2023-10-02 Creatinine 0.99 mg/dL

[rapid weight loss]

The patient experienced a rapid weight loss of over 20 kg within two weeks, dropping from 83.2 kg on 2023-11-01 to 62.9 kg by 2023-11-15.

Currently, the patient is being treated with furosemide and bumetanide, both of which are potent diuretics. Excessive use of these medications can result in significant diuresis, leading to water and electrolyte depletion. Consequently, close medical monitoring is essential, and the dosage and administration schedule should be tailored to the specific needs of the patient.

2023-10-31

[renal function]

2023-10-30 BUN 43 mg/dL, eGFR 13.62 mL/min/1.73m2, Cre 3.61 mg/dL -> CrCl 21 mL/min (Cockcroft-Gault).

For patients with a CrCl of 20 to 39 mL/minute, the recommended dose of topotecan is reduced to 0.75 mg/m2 - this was the dose administered on 2023-09-28.

While the manufacturer’s labeling does not provide dosage adjustments for CrCl <20 mL/minute, it can be inferred that the dosage restrictions for this range would be even more stringent. Given the patient’s consistent decline in renal function over time, it is crucial to exercise caution when using this medication and to closely monitor for any adverse reactions.

[rapid weight gain]

According to the HIS5 records, the patient’s body weight was 67.5kg on 2023-09-20 and increased to 83kg by 2023-10-30. This significant weight gain could suggest the presence of edema or potential heart failure. Further evaluation is recommended.

2022-12-02

• There is no LVEF test result available in HIS5 currently. Since bevacizumab has been determined to be an agent that may either cause reversible direct myocardial toxicity or exacerbate underlying myocardial dysfunction (magnitude: moderate/major) (AHA [Page 2016]), It is recommended that a 2D cardiac sonography be ordered.
• Other than a slightly elevated SBP, the vital signs are stable. Readings from the lab on 2022-12-01 were generally normal.

2022-11-11

• Exforge (amlodipine 5mg + valsartan 160mg) QD has been prescribed by our cardiologist on 2022-10-01 for 28 days as a treatment for the patient’s primary hypertension.
• Since the patient’s blood pressure remains elevated during this hospitalization, Exforge might be considered for reinstatement to replace current Diovan (valsartan).

2022-10-24

• In the last 3 weeks, the serum creatinine level has increased (1.24 2022-10-19 <- 1.18 2022-10-04 <- 0.80 2022-09-26). Please monitor the renal function if it continues to decline.

2022-09-21

• The patient’s SBP appeared to be between 146 and 197 when she arrived on the ward. The use of Sevikar (amlodipine + olmesartan) 1# QD or Exforge (amlodipine + valsartan) 1# QD might be considered to replace current Norvasc if hypertension (SBP > 150mmHg) for consecutive days is observed.

700823818

240115

[exam findings]

• 2023-11-29 CT - abdomen
  • History: Adenocarcinoma of the pancreas with liver and left adrenal gland metastases, pT3N1M1, stage IV.
  • Findings: Comparison: prior CT dated 2023/07/14.
    • Prior CT identified lobulated cystic lesion 7 cm in the pancreatic body and tail is noted again, increasing in size to 10 cm.
      • It is c/w progressive disease.
    • Prior CT identified several metastases on both hepatic lobes are noted again, marked increasing in size and number that is c/w multiple liver metastases with progressive disease.
    • There are two newly developed soft tissue masses in the cranial and right lateral aspect of the upper described cystic pancreatic mass that are c/w metastatic nodes.
    • There is a soft tissue nodule 8 mm at RLL of the lung.
      • Follow up is indicated.
    • Ascites in the pelvis is highly suspected. Please correlate with sonography.
    • The entire colon shows mild distension and fecal material that is c/w chronic constipation.
    • Partial atelectasis in RML of the lung is suspected.
      • Please correlate with chest CT.
  • Impression:
    • Mucinous cystic adenocarcinoma of the pancreas with multiple liver metastases shows progressive disease. please correlate with clinical condition.
• 2023-10-03 Uroflowmetry
  • Q max : poor
  • flow pattern : obstructive
• 2023-09-26 Bladder sonography
  • PVR: 164 ml
• 2023-09-04 KUB
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
  • Fecal material store in the colon.

[MedRec]

• 2023-10-31 SOAP Rheumatology and Immunology Chen JunXiong
  • S: told has RA under ShuangHe Hosp. plaquenil
  • Prescription x3
    • Plaquenil (hydroxychloroquine 200mg) 1# QDCC 28D
• 2023-08-25 ~ 2023-09-14 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Adenocarcinoma of panceras with liver and left adrenal gland metastases, pT3N1M1, stage IV
    • Oxacillin Resistant Staphylococcus aureus urinary tract infection
    • Cachexia
    • Hypokalemia
    • Hypertension
    • Constipation
    • Port-a insertion on 2023/09/07
  • CC
    • for pain control and future treatment
  • Present illness
    • The 74 y/o woman has adeno of panceras with liver and left adrenal gland metastases, pT3N1M1, stage 4 under Gemicitabin on 2023/06/10 and 2023/06/21 at TSGH. Port-a was removed due to infection.
    • Due to abdominal pain, she has Fentanyl 75mcg + Noxycodone 1# prnq6h + Painkyl 1 patch prnq4h.
    • Her BW loss 6kg in 3 months and poor intake bother her.
    • Under the impression of adenocarcinoma of panceras with liver and left adrenal gland metastases, pT3N1M1, stable 4 with cachexia, so she was admitted on 2023/08/25.
  • Course of inpatient treatment
    • After admission, we taper nacrotic for con’s confuse and severe weakness.
    • Foley catheter insertion for ICP > 500ml.
    • PPN supplement by selfpay for cachexia and poor intale.
    • Antibiotic as Rocephin for UTI treatment.
    • We gave Promeran, Through, Lactulose and Dulcolax for severe constipation.
    • IVF with NAKO NO.5 500 mL qd supplement.
    • Adjust narcotic with Fentanyl 62.5mcg + morphine 1# prnq4h.
    • Fortunately, her performance improvement and ADL well during hospitalization.
    • Her antibiotic shifted to Avelox for ORSA UTI on 2023/08/30. Foley was removed on 2023/09/01.
    • Sudden onset, fever without chills on 2023/08/31, check lab data showed PCT 0.05, but no bacteremia.
    • GS was consulted for port-a insertion on 2023/09/07.
    • C1D1 Gemzar + Abraxane on 2023/09/12.
    • She can be tolerance without side effect, MBD is arranged on 2023/09/14.
  • Discharge prescription
    • morphine 15mg 1# PRNQ4H 7D if pain
    • Alpraline (alprazolam 0.5mg) 1# HS 7D
    • Baraclude (entecavir 0.5mg) 1# QDAC 7D
    • Lactul (lactulose 666mg/mL) 20mL TID 7D
    • Neurontin (gabapentin 100mg) 1# TID 7D
    • Oxbu ER (oxybutynin 5mg) 1# QD 7D
    • Norvasc (amlodipine 5mg) 1# QD 7D
    • Through (sennoside 12mg) 2# HS 7D
    • Wecoli (bethanechol 25mg) 1# TIDAC 7D
    • bisacodyl supp 10mg/pill2# QOD RECT 7D
    • Durogesic (fentanyl 12ug/h 2.1mg/patch) 1# Q3D EXT 7D
    • fentanyl Transdermal Patch 50ug/h 5mg/patch 1# Q3D EXT 7D
    • Const-K ER (potassium chloride 750mg/10mEq/tab) 1# BID 3D
• 2023-08-24 SOAP Hemato-Oncology Gao WeiYao
  • S: She was diagnosed to have pancreatic adenocarcinoma with liver metastase in May 2023 and diagnosed at TSGH. She experienced sepsis after 1 dose of chemotherapy. Port-A was removed.
  • A: BW 34 (originally 50 kg; admission 38.8 kg in May 2023), Under fentanyl

[chemotherapy]

• 2024-01-12 - irinotecan liposome 70mg/m2 87mg D5W 250mL 1.5hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3515mg NS 500mL 46hr (Onivyde + 5-FU. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-12-29 - irinotecan liposome 70mg/m2 84mg D5W 250mL 1.5hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3300mg NS 500mL 46hr (Onivyde + 5-FU. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-11-14 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-10-31 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-10-17 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-10-03 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-09-19 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 153mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-09-12 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 153mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Liposomal Irinotecan drug information - 2024-01-15 - https://www.uptodate.com/contents/liposomal-irinotecan-drug-information

• Dosing - Adult - Pancreatic adenocarcinoma, metastatic:
  • IV: 70 mg/m2 once every 2 weeks (in combination with fluorouracil and leucovorin); continue until disease progression or unacceptable toxicity (Wang-Gillam 2016).
    • Note: Reduce initial starting dose to 50 mg/m2 in patients known to be homozygous for the UGT1A1*28 allele; the dose may be increased to 70 mg/m2 as tolerated in subsequent cycles.

Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer - 2023-12-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F89668

• Cycle length: 4 weeks.

• Regimen

  • Nabpaclitaxel
    • 125 mg/m2 IV
    • Administer undiluted over 30 minutes.
    • Days 1, 8, and 15
  • Gemcitabine
    • 1000 mg/m2 IV
    • Dilute in 250 mL NS (concentration no greater than 40 mg/mL) and administer over 30 to 60 minutes, after nabpaclitaxel.
    • Days 1, 8, and 15

• Pretreatment considerations:

  • Emesis risk
    • MODERATE.
  • Vesicant/irritant properties
    • Nabpaclitaxel can cause significant tissue damage; avoid extravasation.
  • Prophylaxis for infusion reactions
    • Premedication to prevent hypersensitivity reactions is generally not needed. Premedication may be needed in patients who have had a prior hypersensitivity reaction to nabpaclitaxel.
  • Infection prophylaxis
    • The incidence of febrile neutropenia with this regimen is 3%. Primary prophylaxis with G-CSF is not indicated.
  • Dose adjustment for baseline liver or renal dysfunction
    • A lower starting dose for gemcitabine and nabpaclitaxel may be needed for patients with liver impairment. Do not administer nabpaclitaxel to patients with pancreatic cancer and moderate to severe liver impairment (AST <10 times the ULN and total bilirubin >1.5 times the ULN OR AST >10 times the ULN OR bilirubin >5 times the ULN).

• Monitoring parameters:

  • CBC with differential and platelets weekly during treatment.
  • Assess comprehensive metabolic panel prior to each cycle or when clinically indicated during treatment.
  • Monitor for infusion reactions.
  • Monitor for extravasation.
  • Sensory neuropathy occurs frequently with nabpaclitaxel; assess for changes in neurologic function prior to each treatment cycle.
  • Monitor for signs and symptoms of pneumonitis.

• Suggested dose modifications for toxicity:

  • Myelotoxicity
    • Do not administer nabpaclitaxel and gemcitabine on day 1 of each new cycle unless ANC is >1500/microL and platelet count is >100,000/microL. For patients who develop neutropenic fever OR ANC <500/microL for >7 days or delay of next cycle by >7 days or thrombocytopenia, withhold treatment until counts recover to an ANC of at least 1500/microL and platelet count of at least 100,000/microL on day 1, or to an ANC of at least 500/microL and platelet count of at least 50,000/microL on days 8 or 15 of the cycle. Upon resumption of therapy, reduce both drugs by 20 to 25% upon the first occurrence, an additional 20 to 25% on the second recurrence, and discontinue treatment for a third occurrence.
  • Sepsis
    • Sepsis has occurred in patients with or without neutropenia (risk factors are biliary obstruction or presence of a biliary stent). Initiate broad-spectrum antibiotics in the presence of fever, even if not neutropenic. Interrupt nabpaclitaxel and gemcitabine until sepsis resolves and, if neutropenic, until neutrophils are at least 1500/microL, then resume at lower doses.
  • Thrombotic microangiopathy
    • Thrombotic microangiopathy (TMA; also sometimes called thrombotic thrombocytopenic purpura [TTP] or hemolytic uremic syndrome [HUS]) has been associated with gemcitabine in individuals who have received a large or small cumulative dose. Consider the possibility of TMA if the patient develops Coombs-negative hemolysis, thrombocytopenia, renal failure, and/or neurologic findings. Management consists of drug discontinuation and supportive care, without plasma exchange, as long as there is high confidence in a drug-induced etiology rather than TTP.
  • Peripheral neuropathy
    • For days 1,8, and 15: withhold nabpaclitaxel for grade 3 or 4 neuropathy. Resume nabpaclitaxel at 20 to 25 percent reduced doses when peripheral neuropathy improves to grade ≤2 or completely resolves. Upon resumption of therapy, reduce nabpaclitaxel by 20 to 25% for the first occurrence of grade 3 or 4 peripheral neuropathy, and an additional 20 to 25% for the second occurrence. Discontinue treatment for a third occurrence. For grade 2 peripheral neuropathy, decrease nabpaclitaxel dose by 20 to 25%.
  • Hepatotoxicity
    • Gemcitabine is commonly associated with a transient rise in serum transaminases, but these are seldom of clinical significance. There is insufficient information from clinical studies to allow clear gemcitabine dose recommendations in these patients.
    • Reduced starting doses of nabpaclitaxel are recommended for individuals with pre-existing moderate to severe hepatic impairment; the need for further dose adjustments in subsequent courses based upon ongoing hepatotoxicity should be based on individual tolerance and clinician judgment.
    • One protocol recommends the following: on days 1, 8, and 15, for serum bilirubin elevations ≥grade 2, withhold both drugs until toxicity resolves to grade ≤1; resume treatment at the same dose as before. If not resolved, discontinue therapy.
  • Pulmonary toxicity
    • A variety of manifestations of pulmonary toxicity have been reported with gemcitabine. Pneumonitis has occurred with the use of nabpaclitaxel in combination with gemcitabine. Permanently discontinue treatment with both agents.
  • Other toxicity
    • On days 1, 8, and 15: for grade 3 cutaneous toxicity, hold both drugs until recovered to <= grade 2, and reduce nabpaclitaxel dose by 20 to 25% and gemcitabine dose by 20%. For grade 3 mucositis or diarrhea, withhold therapy until it improves to ≤grade 1, then resume with reduction of nabpaclitaxel dose by 20 to 25% and gemcitabine dose by 20%.

Treatment protocols for pancreatic cancer - 2023-12-25 - https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer

• Adjuvant setting
  • Adjuvant gemcitabine - https://www.uptodate.com/contents/image?imageKey=ONC%2F81436
  • Adjuvant gemcitabine plus capecitabine - https://www.uptodate.com/contents/image?imageKey=ONC%2F109104
  • Modified FOLFIRINOX - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
• Locally advanced/metastatic disease
  • Gemcitabine monotherapy - https://www.uptodate.com/contents/image?imageKey=ONC%2F60330
  • Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) - see above
  • Gemcitabine plus capecitabine - https://www.uptodate.com/contents/image?imageKey=ONC%2F103038
  • Gemcitabine plus cisplatin - https://www.uptodate.com/contents/image?imageKey=ONC%2F89633
  • FOLFIRINOX (fluorouracil plus leucovorin, irinotecan, and oxaliplatin) - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
  • Modified FOLFIRINOX - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
  • Modified FOLFOX6 (fluorouracil plus leucovorin and oxaliplatin) - https://www.uptodate.com/contents/image?imageKey=ONC%2F50132
  • Liposomal irinotecan and 5-FU for metastatic pancreatic cancer - https://www.uptodate.com/contents/image?imageKey=ONC%2F109026
  • Pembrolizumab monotherapy for microsatellite-unstable (mismatch repair-deficient) advanced cancer - https://www.uptodate.com/contents/image?imageKey=ONC%2F127101

==========

2024-01-15

[reconciliation]

This patient was admitted for her second dose of the liposomal irinotecan + leucovorin + fluorouracil regimen on 2024-01-14. She tolerated the treatment.

Her hypokalemia, which was low at 2.5 mmol/L on 2024-01-12, improved to 3.6 mmol/L by 2024-01-15. No medication discrepancies were identified.

2023-12-25

[revise nab-paclitaxel sequence to ensure treatment efficacy]

Concerns have arisen regarding a deviation from the established administration sequence for the gemcitabine plus nab-paclitaxel regimen. The protocol explicitly mandates administering nab-paclitaxel first, followed by gemcitabine. However, recent administrations reversed this sequence, potentially compromising treatment efficacy. To ensure optimal outcomes, it is recommended to revert to the original protocol’s sequence.

Ref: Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med. 2013 Oct 31;369(18):1691-703. doi: 10.1056/NEJMoa1304369. Epub 2013 Oct 16. PMID: 24131140; PMCID: PMC4631139.

[disease progress: comfort first, intensive chemo might not fly]

A recent CT scan on 2023-11-29 unfortunately indicated disease progression.

There is an article reporting a comparative effectiveness cohort study, FOLFIRINOX was associated with improved survival of approximately 2 months compared with gemcitabine plus nab-paclitaxel and was also associated with fewer posttreatment complications. A randomized clinical trial comparing these first-line treatments is warranted to test the survival and posttreatment hospitalization (or complications) benefit of FOLFIRINOX compared with gemcitabine plus nab-paclitaxel. Ref: Comparison of FOLFIRINOX vs Gemcitabine Plus Nab-Paclitaxel as First-Line Chemotherapy for Metastatic Pancreatic Ductal Adenocarcinoma. JAMA Netw Open. 2022 Jun 1;5(6):e2216199. doi: 10.1001/jamanetworkopen.2022.16199. PMID: 35675073; PMCID: PMC9178436.

Given the patient’s currently compromised performance status (ECOG PS 4 as of 2023-12-25 progress note), intensive chemotherapy might not be the most suitable option. Therefore, best supportive care or a less intensive regimen like mFOLFOX6 might be more appropriate at this time.

2023-08-30

According to PharmaCloud, this patient has only received medical treatment at TSGH in the last three months. However, the last date of treatment was on 2023-06-21, and there are currently no active prescriptions from TSGH. Therefore, no medication reconciliation issues have been found.

701361664

240115

[exam findings]

• 2024-01-02 EGD
  • Diagnosis:
    • Esophageal varices, F1-2CbLi. RCS(+) White nipple sign(-), s/p EVLx4 with super 7.
    • Reflux esophagitis LA Classification grade A (minimal)
    • Portal hypertensive gastropathy
    • Gastric ulcers, antrum and angle
    • Gastric varix, cardia
    • Duodenal shallow ulcers, bulb and SDA
  • CLO test: not done
  • Suggestion:
    • Cold and liquid diet for 1-2 days
    • Monitor the signs of GI bleeding
• 2023-12-29 CT - abdomen
  • Findings: Comparison prior CT dated 2023/10/20.
    • Prior CT identified wall thickening at the gastric antrum is noted again, mild increasing size. Please correlate with gastroscopy.
      
    • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
    • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
    • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
      • There is splenomegaly (the greatest cranial-caudal dimension: 17.7 cm).
    • Left renal cyst, 0.9cm
    • There is mild ascites in the pelvis.
  • Impression:
    • Prior CT identified wall thickening at the gastric antrum is noted again, mild increasing size. Please correlate with gastroscopy.
      
    • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
• 2023-12-29 ECG
  • Normal sinus rhythm
  • Incomplete right bundle branch block
  • Borderline ECG
• 2023-10-20 CT - abdomen
  • Findings: Comparison prior CT dated 2023/09/04.
    • Prior CT identified wall thickening at the gastric antrum is noted again, stable in size. Please correlate with gastroscopy.
      
    • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
    • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
    • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
      • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
    • Left renal cyst, 0.9cm
• 2023-09-04 CT - abdomen
  • Findings
    • Stable condition of gastric cancer, LNs and liver metastases.
    • Liver cirrhosis with portal vein and splenomegaly. Mild small bowel ileus.
    • Left renal cyst (8mm). Minimal ascites.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Stable condition of gastric cancer, LNs and liver metastases.
    • Liver cirrhosis with portal vein and splenomegaly. Mild small bowel ileus.
• 2023-06-05 CT - abdomen
  • Indication: Gastric cancer with liver mets
  • Abdominal CT with and without enhancement revealed:
    • Lobulated low density lesion at S5/6/7/8 of liver measuring 9.8cm in largest dimension is found. Liver meta is considered. In comparison with CT dated on 2023-02-24, the lesion progressed slightly.
    • Chains of lymphadenopathy at gastrohepatic ligment and perigastric region is found. In enlargement.
    • The GB is well distended without soft tissue lesion
    • Wall thikening at gastric antrum is found. Compatible with gastric cancer.
    • Splenomegaly is found.
    • The GB is well distended without soft tissue lesion
  • Imp:
    • Gastric cancer with regional lymphadenopathy and liver meta. In progression.
• 2023-06-01 All-RAS + BRAF mutation
  • Cellblock No. S2023-03168
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-04 EGD
  • Diagnosis:
    • Gastric cancer, Borrmann type III, antrum, AW
    • Reflux esophagitis LA grade A
    • Esophageal varices, F1CbLi. RCS(-)
    • Superficial gastritis
    • Duodenal ulcer, Forrest type IIc, bulb and pylorus
    • Deformed antrum
  • CLO test: not done
  • Suggestion:
    • Oral PPI use
    • If bleeding continued, suggest ER visit.
• 2023-02-24 CT - abdomen
  • History: gastric cancer.
  • Indication: for clinical trail
  • Findings: Comparison prior CT dated 2023/01/13.
    • Prior CT identified wall thickening at the gastric antrum is noted again, mild increasing in size. Please correlate with gastroscopy.
      
    • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size.
    • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, increasing in size.
    • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
      • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
    • Left renal cyst, 0.9cm
  • Impression:
    • Metastases on both hepatic lobes and metastatic lymph nodes in the gastrohepatic ligament and hepatoduodenal ligament show increasing in size that is c/w progressive disease. please correlate with clinical condition.
• 2023-01-13 CT - abdomen
  • Findings: Comparison: prior CT dated 2022/12/09.
    • Prior CT identified wall thickening at the gastric antrum is noted again, stationary. Please correlate with gastroscopy.
      
    • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size.
    • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
    • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
      • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
    • Left renal cyst, 0.9cm
  • Impression:
    • Liver metastases on both lobes show increasing in size, please correlate with clinical condition.
• 2022-12-09 CT - abdomen
  • Findings: Comparison: prior CT dated 2022/10/28.
    • Prior CT identified wall thickening at the gastric antrum is noted again, stationary. Please correlate with gastroscopy.
      
    • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
    • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
    • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size. There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
    • Left renal cyst, 0.7cm
  • Impression:
    • Gastric cancer with lymph nodes and liver metastases (mild increasing in size), and portal venous thrombosis S/P C/T show stable disease. Follow up is indicated.
• 2022-10-28 CT - abdomen
  • Findings: Comparison: prior CT dated 2022/09/14.
    • Prior CT identified wall thickening at the gastric antrum is noted again, stationary. Please correlate with gastroscopy.
      
    • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
    • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
      • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
    • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
    • Left renal cyst, 0.7cm
  • Impression:
    • Gastric cancer with lymph nodes and liver metastases(mild increasing in size), and portal venous thrombosis S/P C/T show stable disease. Follow up is indicated.
• 2022-09-14, -08-03, -06-22 CT - abdomen
  • Gastric cancer with lymph nodes and liver metastases, and portal venous thrombosis S/P C/T show stable disease.
  • Follow up is indicated.
• 2022-05-20 CT - abdomen
  • Findings:
    • Prior CT identified wall thickening at the gastric antrum is noted again, stationary that is c/w gastric cancer.
    • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, mild decreasing in size.
    • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, marked decreasing in size.
      • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
    • Prior CT identified several metastases on both hepatic lobes are noted again, decreasing in size.
    • Left renal cyst, 0.7cm
    • Minimal ascites in the lower pelvis is suspected.
  • Impression:
    • Gastric cancer with lymph nodes and liver metastases, and portal venous tumor thrombosis S/P C/T show partial response.
• 2022-03-18 CT - abdomen
  • Findings:
    • Prior CT identified wall thickening at the gastric antrum is noted again, stationary that is c/w gastric cancer.
    • Prior CT identified multiple metastatic nodes nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stationary.
    • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, increasing in size.
      • There is splenomegaly and the greatest cranial-caudal dimension measuring about 14.8 cm in length.
    • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size. However, the tumor margin is hard to define. Please correlate with MRI.
    • Left renal cyst, 0.7cm
    • Minimal ascites in the lower pelvis is suspected.
  • Impression:
    • Gastric cancer with lymph nodes and liver metastases, and portal venous tumor thrombosis. cT3N2M1. cstage:IVb.
• 2022-03-16 MRI - brain
  • No intracranial metastasis.
• 2022-03-11 Tc-99m MDP bone scan
  • Increased activity in the lower C-spines and L5 spine. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • A hot spot in the posterolateral aspect of left rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, hips and right knee, compatible with benign joint lesions.
• 2022-03-01 CT - abdomen gastric filling with water
  • Clinical history: 42 y/o male patient with gastric cancer was suspected.
  • With and without contrast enhancement CT of abdomen - whole:
    • Thickening wall at the gastric antrum, r/o gastric malignancy.
    • There are multiple enlarged perigastric lymph nodes, could be due to lymph nodes metastasis.
    • Presence of thrombosis at main portal vein.
    • Left renal cyst, 0.7cm.
    • There are multifocal poor enhancing lesions in both lobes of liver, R/O liver metastasis.
    • Presence of some ascites in the pelvic cavity.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • Impression:
    • R/O gastric malignancy with lymph nodes metastasis, portal venous invasion/thrombosis.
    • Suspicious liver metastasis. if proven metastasis, cstage T3N2M1. IVb.
• 2022-02-25 Patho - stomach biopsy (Y1)
  • Stomach, antrum, AW side, biopsy — moderately differentiated adenocarcinoma
  • Microscopically, it shows moderately differentiated adenocarcinoma composed of a proliferation of irregular neoplastic glands and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei, pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • Immunohistochemical study reveals CK(+), CD56(-), SOX10(-), S100(-) and Ki-67 50%.
  • IHC stain — Her2/neu: negative (0/1+)

[chemotherapy] (not completed)

• 2023-12-26 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-11-29 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-11-14 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-10-31 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-10-17 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-09-26 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-09-12 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-08-22 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-08-08 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-07-25 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-11 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-20 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-31 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
• 2023-05-10 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
• 2023-04-20 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
• 2023-03-29 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
• 2023-03-09 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
• 2023-02-22 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
• 2023-02-01 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
• 2023-01-04 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
• 2022-12-14 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
• 2022-11-23 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
• 2022-11-02 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
• 2022-10-12 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
• 2022-09-21 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
• 2022-08-31 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
• 2022-08-10 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
• 2022-08-03 - oxaliplatin 130mg/m2 239mg D5W 500mL 2hr + capecitabine 500mg PO 2# QD 3# QN D1-14
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
• 2022-07-27 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
• 2022-06-29 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + oxaliplatin 130mg/m2 239mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
• 2022-06-02 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + oxaliplatin 130mg/m2 236mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
• 2022-04-28 - oxaliplatin 130mg/m2 230mg D5W 500mL 2hr + capecitabine 500mg PO 2# QD 3# QN D1-14
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
• 2022-04-22 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
• 2022-03-31 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + oxaliplatin 130mg/m2 230mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14

==========

701492350

240115

[exam findings]

• 2023-09-01 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 25) / 80 = 68.75%
    • M-mode (Teichholz) = 68
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Mild MR, TR
• 2023-08-14 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, left sternoclavicular junction, bilateral shoulders, S-I joints, hips, and knees.
• 2023-08-14 CT - chest
  • Indication: right breast cancer, diagnosed at Feng Rong Hospital, CNB: invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67<5%
  • Findings:
    • Lungs:a subleural bulla or lung cyst at RML 16mm.
      • a reticular opacity over RLL may represents atelectasis or r/o fibrosis. normal appearance of Lt lung.
    • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
    • Chest wall and visible lower neck: a Rt axillary enlarged LN (25mm in longest axial dimension). two enhancing nodules at UOQ of Rt breast measuring up to 14mm.
    • Mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries. small and large bowels grossly unremarkable.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • Rt breast cancer T1c or T2 N1
• 2023-07-31 Patho - lymphnode biopsy
  • Lymph node, right axilla, core needle biopsy — Metastatic carcinoma, consistent with breast origin
  • Section shows cores of lymphoid tissue with metasatic irregular neoplastic glands. The immunohistochemical stain of GATA3 is positive.
    
  • IMMUNOHISTOCHEMICAL STUDY
    • 1. ER (Ab): Positive (>90%, strong)
    • 2. PR (Ab): Positive (10%, moderate)
    • 3. Her-2/neu (Ab): Equivocal (2+)
    • 4. Ki-67: 15%
• 2023-07-31 Her-2/neu - DISH
  • HER-2 (by in situ hybridization) — Negative (NOT amplified)
  • METHOD AND DETAILS:
    • Number of observers: 1
    • Number of invasive tumor cells counted: 20
    • Average number of HER2 signals per cell: 2.9
    • Average number of CEP17 signals per cell: 2.6
    • HER2/CEP17 ratio: 1.12
    • Heterogeneous signals: Absent
    • Origin slide and block number: S2023-15086
    • Specimen: Formalin-fixed paraffin embedded tissue
    • Adequacy of sample for evaluation: Yes
    • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
  • APPENDIX:
    • ASCO/CAP scoring criteria (2018):
      • Group 1 = HER2/CEP17 ratio >=2.0; >=4.0 HER2 signals/cell
      • Group 2 = HER2/CEP17 ratio >=2.0; <4.0 HER2 signals/cell
      • Group 3 = HER2/CEP17 ratio <2.0; >=6.0 HER2 signals/cell
      • Group 4 = HER2/CEP17 ratio <2.0; >=4.0 and <6.0 HER2 signals/cell
      • Group 5 = HER2/CEP17 ratio <2.0; <4.0 HER2 signals/cell
    • Negative:
      • Group 5
      • Group 2 and concurrent IHC 0-1+ or 2+
      • Group 3 and concurrent IHC 0-1+
      • Group 4 and concurrent IHC 0-1+ or 2+
    • Positive:
      • Group 2 and concurrent IHC 3+
      • Group 3 and concurrent IHC 2+ or 3+
      • Group 4 and concurrent IHC 3+
      • Group 1

[MedRec]

• 2023-09-01 ~ 2023-09-07 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Right breast invasive ductal carcinoma, ER(+), PR(+), HER-2(-), T1N1M0, stage IIA s/p chemotherapy with EC by T from 2023/09/06~
  • CC
    • For prepare chemotherapy.
  • Present illness
    • This 60-year-old woman patient suffered from right breast tumor in 2022/05. Sono by myself: two hypoechoi lesions over right 10’ region, 1.41x0.76x1.08 and 0.79x0.60x0.72 respectively, LAP(+) over right axilla. MMG at LMD showed heterogenous dense breast tissue with a small hyperdense lobular mass at right UOQ retroglandular area. Right breast cancer, diagnosed at Feng Rong Hospital. CNB at Feng Rong Hospital showed invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67: <5%, refer for further management.
    • Right axilla lymph node core needle biopsy on 2023/07/31 pathology showed metastatic carcinoma, consistent with breast origin, ER: Positive(> 90%, strong), PR: Positive(10%, moderate), Her-2/neu: Equivocal(2+), Ki-67: 15%. Chest CT on 2023/08/14 showed right breast cancer T1c or T2 N1. Whole body bone scan on 2023/08/14 showed no strong evidence of bone metastasis. Colonoscopy on 2023/08/22 showed colon polyp and mixed hemorrhoid. Breast sona on 2023/09/01 showed right 10 o’clock / 4 cm, size: 1.44 x 0.90 x 1.42cm, right 10 o’clock / 3 cm, size: 0.72 x 0.71 x 0.81cm, highly suspicious of malignancy, with sonographic positive axillary LAP. Now, she was admitted to ward for prepare chemotherapy with EC * 4 followed by docetaxel * 4 followed by OP.
  • Course of inpatient treatment
    • After admitted, 2D echo on 2023/09/01 showed M-mode (Teichholz) = 68, 1. Preserved LV and RV systolic function with normal wall motion; 2. Normal chamber size; 3. Mild MR, TR. Consult GS for Port-A catheter insertion on 2023/09/05.
    • Chemotherapy with EC by T(Epirubicin 90mg/m2, Cyclophamide 600mg/m2)(C1) on 2023/09/06.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/07 and OPD followed up later.     
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2023-08-22 SOAP Hemato-Oncology Xia HeXiong
  • O
    • 2023/07/31 Her-2/neu - DISH
      • HER-2 (by in situ hybridization) — Negative (NOT amplified)
  • P
    • EC * 4 followed by docetaxel * 4 followed by OP
    • Admission for Port-A (if not done), Heart echo and then C/T
• 2023-08-19 SOAP General and Gastrointestinal Surgery Chen YenZhi
  • O
    • 20230819 CT: no liver metastasis, no bone metastasis
    • bone scan: no bone metastasis
  • A/P
    • right breast cancer, multifocal, luminal A, cT1N1, stage 2
    • suggest: neoadjuvant chemotehrapy with following operation
    • arrange port-A implantation on 9/7
    • refer to oncologist for neoadjuvant chemotherapy
• 2023-08-08 SOAP General and Gastrointestinal Surgery Chen YenZhi
  • S:
    • right breast cacner, diagnosied at Feng Rong Hospital, refer for further management
  • O:
    • no palpable breast tumor, no large movable LAP over right axilla
    • CNB at Feng Rong Hospital: invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67<5%
    • MMG at LMD: heterogenous dense breast tissue with a small hyperdense lobular mass at right UOQ retroglandular area
    • sono by myself: two hypoechoi lesions over right 10’ region, 1.41x0.76x1.08 and 0.79x0.60x0.72 respectively, LAP(+) over right axilla
    • 2023/07/31 PATHO-lymphnode biopsy
      • Lymph node, right axilla, core needle biopsy — Metastatic carcinoma, consistent with breast origin
      • 1. ER (Ab): Positive (> 90%, strong)
      • 2. PR (Ab): Positive (10%, moderate)
      • 3. Her-2/neu (Ab): Equivocal (2+), FISH (-)
      • 4. Ki-67: 15%
    • no neurological sign
    • no bone pain
  • A
    • right breast cancer, multifocal, luminal A, cT1N1
• 2023-07-29 SOAP General and Gastrointestinal Surgery Chen YenZhi
  • S:
    • right breast cacner, diagnosied at Feng Rong Hospital, refer for further management
  • O:
    • no palpable breast tumor, no large movable LAP over right axilla
    • CNB at Feng Rong Hospital: invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67<5%
    • MMG at LMD: heterogenous dense breast tissue with a small hyperdense lobular mass at right UOQ retroglandular area
    • sono by myself: two hypoechoi lesions over right 10’ region, 1.41x0.76x1.08 and 0.79x0.60x0.72 respectively, LAP(+) over right axilla

[chemotherapy]

• 2024-01-13 - docetaxel 60mg/m2 90mg NS 250mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-12-22 - docetaxel 60mg/m2 90mg NS 250mL 1hr
  • dexamethasone 4mg PO + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-24 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-30 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-27 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-06 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-01-15

Lab results on 2024-01-12 were grossly normal with no evidence of a contraindication to docetaxel administration.

701174678

240112

[exam findings]

• 2023-10-31 ECG portable 7 days
  • Findings
    • Baseline was persistent AFIB with SVR
      • MAX HR: 82 bpm
      • Avg HR: 54 bpm
      • MIN HR: 32 bpm
    • Ventricular Ectopy: 359
    • 1 episode of short-run VT (7 beats, 109bpm)
    • 1 episode of long pause, max 2.00 sec, related to AFIB SVR
    • 1 test events at begining, ECG showed persistent AFIB
  • Conclusion
    • Baseline was persistent AFIB with SVR
    • Rare isolated VPC
    • 1 episode of short-run VT (7 beats, 109bpm)
    • 1 episode of long pause, max 2.00 sec (related to AFIB SVR)
• 2023-10-24 MRA - brain
  • Focal old ischemic cortical infarct over right medial occipital lobe.
  • Mild periventricular small vessel disease. NO acute ischemic infarct.
  • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
  • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
  • Short segmental severe stenosis of left distal ICA (ophthalmic segment) with post-stenotic dilatation.
  • Paranasal sinusitis.
• 2023-10-24 CXR
  • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
  • patchy opacity at medial RUL
• 2023-10-23 ECG portable 24hr
  • Baseline was incessant AFIB with SVR (Average HR: 57bpm, range between: 51-70 bpm)
  • A few isolated VPCs / VPC couplets
  • 1 episode of non-sustained VT (5 beats, 120 bpm)
  • No long pause
• 2023-10-20 ECG
  • Atrial fibrillation
  • Abnormal ECG
• 2023-09-25 Neurosonography
  • Moderate atheromatous lesion in R CCA bifurcation with ulcerated plaqaue; mild to moderate atheromatous lesions in R ICA; L middle CCA and L CCA bifurcation; mild atheromatous lesions in R subclavian artery; irregular bradycardia with heart rate between 31 and 53 BPM.
  • Elevated flow velocities in bilateral MCAs (PS/ED: R = 207/49, L = 295/59 cm/s), suggesting bialteral MCA stenosis.
  • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows. 4) Normal bilateral ophthalmic arterial flows.
  • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
• 2023-09-11 C-spine AP + Lat
  • mild anterior and posterior spur formation at the lower C-spine.
  • mild decreased disc space in the C6/7 disc.
• 2023-06-16 MRI - prostate
  • Clinical history: 75 y/o male patient with 112/05/02, high PSA 41.5, he prefer TRUS-P biopsy after discussion (2023/05/11)
    • 2023/05/11, DRE: no hard nodule, TRUS-P biopsy 12 cores, educate further care, 2023/05/18, pathology showed
      • Histologic Type: Prostatic acinar adenocarcinoma
      • Histologic Grade: Gleason score = 7 (4 + 3).
    • arrange MRI and bone scan for staging
  • Imaging Report Form for Prostate Carcinoma
    • Impression (Imaging stage): T:T3b(T_value) N:N0(N_value) M:Mo(M_value) STAGE: IIIB (Stage_value)
  • Impression
    • Prostate cancer (in body, base and apex, mainly in left lobe with abutting left seminal vesicle base), r/o seminal vesicle involvement. cstage T3bN0M0.
• 2023-05-24 Tc-99m MDP bone scan
  • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, mandible, some C-, T- and L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, and knees.
• 2023-05-11 Patho - prostate needle biopsy
  • PATHOLOGIC DIAGNOSIS
    • Prostate, right, needle biopsy — Prostatic acinar adenocarcinoma (Gleason score 7 = 4 + 3) involving 5 of 6 strips of prostatic tissue by the number of involved strips or 70 % by the involved volume of the specimen. The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
    • Prostate, left, needle biopsy — Prostatic acinar adenocarcinoma (Gleason score 7 = 4 + 3) involving 6 of 6 strips of prostatic tissue by the number of involved strips or 80 % by the involved volume of the specimen. The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Prostatic acinar adenocarcinoma
    • Histologic Grade: Gleason score = 7 (= 4 + 3 ).
• 2023-05-02 Low dose CT, LDCT - chest
  • Mild subpleural fibrosis both lower and upper lobes.
  • extensive 3V-CAD, suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries
• 2023-05-02 ECG 8C
  • Atrial fibrillation with slow ventricular response with premature ventricular or aberrantly conducted complexes
  • Incomplete left bundle branch block
• 2023-05-02 SONO - abdomen
  • GB polyp, tiny
  • Pancreas not shown
• 2022-11-30 EGD
  • Reflux esophagitis LA Classification grade A-
  • R/o intestinal metaplasia, antrum to body
  • Superficial gastritis
  • Post clipping, LC of low body
• 2022-10-03 Patho - colorectal polyp
  • Diagnosis
    • Intestine, large, rectum, polypectomy — tubular adenoma
    • Intestine, large, transverse colon, polypectomy — tubular adenoma
    • Intestine, large, ascending colon, 100 cm from anal verge, polypectomy — tubular adenoma
• 2022-08-12 SONO - nephrology
  • Chronic parenchymal renal disease
• 2022-07-18 CT - chest
  • Findings
    • Lungs:
      • with areas of patchy expiratory air-trapping in both lower lobes and posterior both upper lobes.
      • patchy ground glass opacities with septal thickening in bilateral lungs RUL most prominent..
    • Mediastinum and hila: the trachea and main bronchi are normallly identified without endobronchial lesion.
    • Vessels: moderate calcified plaques of the LAD, and LCX, and right coronary arteries.
    • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: dilated LA and RA, and LVH.
    • Pleura: trace effusion.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: a tiny calcification over pancreatic tail.
      • Atherosclerotic change of the abdominal aorta.
    • Visualized bones: multiple marginal spurs of vertebrae.
  • Impression:
    • interstitial lung process or infection.
    • obstructive small airways disease.
    • moderate 3V-CAD.
• 2022-07-13 CXR erect
  • hazy areas of increased opacity (ground-glass opacities) over and Lt perihilar midlung zone
  • reticular opacities over RUL
  • mild enlarged cardiac silhoutte
  • Costophrenic angles are preserved
• 2022-05-31 Myocardial perfusion SPECT with persantin
  • Probably mild to moderate myocardial ischemia with possible a portion of severe ischemia at the inferolateral wall and posterior wall and mild myocardial ischemia at the anteroseptal wall.
• 2022-05-30 ECG portable 24hr
  • Baseline was sinus bradycardiawith 1st degree AVB (average HR: 44-59 bpm)
  • Occasional junctional esacape beats noted (13:20)
  • Paroxysmal AFIB noted
  • A few isolated VPCs
  • Frequent isolated APCs / APC couplets (burden 2%)
  • 22 episodes of long pause, max 2.304 sec, related to blocked APC +/- junctional escape beats
• 2022-05-25 Neurosonography
  • Mild to moderate atheromatous lesions in bilateral distal CCAs and bilateral CCA bifurcations; mild atheromatous lesions in bilateral middle CCA and R ICA.
  • Normal extracranial carotid and vertebral arterial flows.
• 2022-05-24 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 19) / 104 = 70.49%
    • LVEF (%) = 82
    • M-mode (Teichholz) = 82
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 3 (restrictive pattern).
    • Normal RV systolic function.
    • Mild to moderate MR; moderate to severe TR; mild PR; mild aortic valve sclerosis (NCC).
    • Possible severe pulmonary hypertension, estimated PASP 78 mmHg.
• 2022-04-18 ECG
  • Sinus rhythm with 1st degree A-V block with Premature atrial complexes
• 2022-01-14 SONO - nephrology
  • Chronic parenchymal renal disease
• 2021-03-26 EGD
  • Diagnosis:
    • Extensive intestinal metaplasia, antrum to body
    • Atrophic gastritis, antrum, s/p CLO test
    • Gastric polyp, 0-Is, LC of lower body, favor adenomatous or inflammatory polyp, s/p cold-snaring polypectomy(A), s/p hemoclipping
    • Gastric ulcer, H2, LC of lower body, s/p biopsy(B)
    • duodenal ulcer scar, GC of bulb
  • CLO test: Positive
  • Suggestion:
    • Please monitor bleeding and pursue pathology report, CLO test results.
    • Consider EGD FU for extensive IM change
• 2021-01-08 EGD
  • Diagnosis
    • Hypertrophic fold, body, s/p biopsy (A)
    • Gastric polyp, prob. adenoma, angularis, s/p biopsy (B)
    • Atrophic gastritis, body
    • Reflux esophagitis LA Classification grade A
    • gastritis, antrum s/p CLO test negative
• 2020-12-25 SONO - abdomen
  • Suspected liver hemangioma, right
  • Pancreas not shown
• 2019-07-22 MRA - brain
  • Mild general brain atrophy.
  • Mild intracranial arteriosclerosis.
• 2019-06-27 Color Transcranial Sonography
  • Moderate to severe atherosclerosis in Rt ICA (with diameter stenosis of 33.1%), Rt CCA (with diameter stenosis of 38.8%), Rt Bifurcation (with diameter stenosis of 50.3%), Rt Subclavian Artery, & Lt CCA (with diameter stenosis of 52.7%), Lt Bifurcation (with diameter stenosis of 51%).
  • Normal RI in bilateral ICA.
  • Elevated PI in Rt ACA, Rt MCA, Rt PCA, & Lt ACA, Lt MCA, indicating distal stenosis.
  • Increased PSV in bilateral MCA, suggesting focal stenosis.
  • Adequate total VA flow volume (199 ml/min), indicating absence of Vertebrobasilar insufficiency.
  • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
  • Advise clinical correlation.
• 2019-04-09 Transrectal Ultrasound of Prostate, TRUS-P
  • CC: nocturia, right inguinal mass, weak stream.
  • Prostate 　　- Size of prostate: 4.71(T)cm x1.99(L)cm x4.46(AP)cm=21.8cc 　　- Size of adenoma: 2.87(T)cm x1.37(L)cm x2.55(AP)cm=5.2cc 　　- Calculi: No 　　- Cyst:(Max) No 　　- Intravesical growth: No
  • Seminal vesicles 　　- Size: L’t 1.95x0.685cm 　　- Cyst: No
    • Abscess: No 　　 - Tumor: No
      　　- Size: R’t 1.36x0.698cm
    • Cyst: No 　　 - Abscess: No
    • Tumor:No
  • Diagnosis 　　- Benign prostatic hyperplasia

[medication]

• 2023-10-21 - CELIG - Eligard (leuprorelin acetate 22.5mg) Q3M SC
• 2023-07-27 - CELIG - Eligard (leuprorelin acetate 22.5mg) Q3M SC

700268312

240110

[exam findings]

• 2023-12-29 Nasopharyngoscopy
  • Findings
    • Nose: no tumor lesion, bil meatus purulency
    • Nasopharynx: smooth purulent PND
    • Oropharynx: no tumor lesion
    • Larynx: no tumor lesion, bilateral vocal movement: symmetric
    • Hypopharynx: no tumor lesion
  • Diagnosis/conclusion
    • sinusitis
• 2023-12-21 CT - abdomen
  • History and indication: Adenocarcinoma of ascending colon cT4bN2M0 IIIC
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A-colon cancer s/p operation.
    • Colonic diverticula.
    • Liver cysts (up to 6.7cm).
    • S/P right THR.
    • Atherosclerosis of aorta, iliac and visceral arteries.
    • Increased density at bilateral basal lungs.
  • IMP:
    • A-colon cancer s/p operation. No evidence of tumor recurrence.
• 2023-10-23 All-RAS + BRAF mutation
  • Cellblock No. S2023-18526 A5
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 12 GGT>TGT, p.G12C)
    • BRAF: Detected (BRAF codon 600 GTG>GAG, p.V600E)
• 2023-09-15 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, ascending colon, right hemicolectomy —- Adenocarcinoma, poorly differentiated
      
    • Small intestine, terminal ileum, right hemicolectomy —- Negative for malignancy
    • Omentum, right hemicolectomy —- Adenocarcinoma, metastatic
    • Resection margins: free
    • Lymph node, mesocolic, dissection —- Metastatic adenocarcinoma (1/22)
    • Lymph node, IMA / SMA, dissection —- Not received
    • AJCC 8th edition Pathology stage: pStage IVA, pT3N1aM1a or pStage IVC, pT3N1aM1c, Please discussion the tumor stage in tumor board.
  • Gross Description:
    • Operation procedure: right hemicolectomy;
    • Specimen site: ascending colon
      
    • Specimen size: Colon: 9.3 cm in length; Terminal ileum: 4.0 cm in length; Omentum: 6.2 x 5.3 x 2.3 cm with a metastatic tumor, measuring 3.5 x 3.0 x 2.3 cm; Appendix: not found
    • Tumor size: 8.0 x 4.5 x 1.7 cm
    • Tumor location: 5.5 cm and 5.0 cm away from the two resection margins, respectively.
    • Depth of invasion grossly: mesocolic soft tissue
    • Mucosa elsewhere: Several diverticula are found in ascending colon.
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as: A1: proximal resection margin; A2: distal resection margin; A3: ileocecal valve; A4: diverticula; A5-9: tumor; A10: colon; A11-13: lymph node, mesocolic; A14: metastatic tumor in omentum.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G3: Poorly differentiated
    • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: very close, <0.1 cm
    • Lymphovascular Invasion: Present
    • Perineural Invasion: Present
    • Tumor Budding: Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 1/22
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply) :not applicable
      • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
      • Regional Lymph Nodes (pN): pN1a: One regional lymph node is positive
      • Distant Metastasis (pM):
        • pM1a: Metastasis to one site or organ is identified without peritoneal metastasis or
        • pM1c: Metastasis to the peritoneal surface is identified alone or with other site or organ metastases
    • Additional Pathologic Findings (select all that apply): Diverticula are found.
• 2023-09-12 Flow Volume Loop Chart
  • Mild restrictive ventilatory impairment
• 2023-09-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (61 - 18) / 61 = 70.49%
    • 2D (M-Simpson) = 70
  • Conclusion:
    • Indeterminated LV filling pressure and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis with trivial AR; mild MR; mild PR.
    • Mild aortic root calcification with small protruding atheroma (3.4 mm of thickness).
• 2023-08-29 CT - abdomen
  • With and without contrast enhancement CT of abdomen - whole:
    • Segmental wall thickening at ascending colon with abutting to adjacent liver and regional peritoneal mass. R/O asending colon malignancy.
    • Liver cysts, up to 6.6cm in right lobe.
    • Unremarkable change of the spleen, pancreas and both kidneys.
    • Enlarged lymph nodes in pericolnic region.
    • No ascites.
    • Outpouching lesions in sigmoid colon, suggesting sigmoid colon diverticula.
    • Post-op at right hip.
    • T11 compression fracture.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIc__(Stage_value)
  • Impression:
    • Ascending colon cancer with regional lymph nodes, cstage T4bN2bM0.
    • Sigmoid colon diverticula.
    • Liver cysts.
• 2023-08-28 Patho - colon biopsy
  • Colon, ascending, 67-70 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    
  • Specimen submitted in formalin consists of 5 pieces of tan, irregular tissue measuring up to 0.3 x 0.1 x 0.1 cm. All for section in one cassette.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands and extravasated mucin.
  • The immunohistochemical stains reveal EGFR(+), PMS2(-), MLH1(-), MSH2(+), and MSH6(+).
• 2023-08-28 EGD
  • Reflux esophagitis LA Classification grade A (minimal)
  • Duodenal ulcer scar, bulb
• 2023-08-24 MRA - brain
  • Short segmental severe stenosis of left distal VA. Suggest PTA and stenting.
  • Short segmental moderate stenosis of left distal ICA (cavernous segment).
  • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
  • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
• 2023-08-18 Neurosonology
  • moderate atheroma on right carotid bifurcation and left CCA, ICA with diameter reduction of 33-47%, severe atheroma on left carotid bifurcation with diameter reduction of 64%,
  • higher peak systolic velocities (166/23 cm/s) on left carotid bifurcation, (185/37 cm/s) on left ICA, may suggest focal severe stenosis (50-69%)
  • antegrade of bil. ophthalmic a. flows

[MedRec]

• 2023-09-12 ~ 2023-09-19 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Adenocarcinoma of ascending colon, cT4bN2bM0, IIIC status post single-incision laparoscopic right hemicolectomy on 2023/09/14, pT3N1aM1a(1/22), G3, LVI(+), PNI(+), CRM(-), stage IVa (metastastic tumor on omentum), stage IVa
  • CC
    • tarry stool for around one month
  • Present illness
    • This is a 82 y/o female with underlying disease of anemia, syncope episode and insomnia. This time she was admitted due to tarry stool for around one month.
    • According to the patient statement, she suffered from tarry stool for around one month with iFOB positive and HGB = 8.2 g/dL. She denied nausea/vomiting, fever, abdominal pain, constipation, diarrhea, dyspnea or dysuria. Due to above symptoms, she went to our GI OPD on 8/22.
    • Upper GI endoscopy showed Reflux esophagitis LA Classification grade A (minimal) and Duodenal ulcer scar, bulb.
    • And colonoscopy showed suspected ascending colon cancer. Pathology showed adenocarcinoma.
    • Abdominal CT on 8/29 showed 1. Ascending colon cancer with regional lymph nodes, cstage T4bN2bM0, IIIc. 2. Sigmoid colon diverticula. 3. Liver cysts.
    • Under impression of Adenocarcinoma of A-colon, she was admitted for further evaluation and surgical intervention.
  • Course of inpatient treatment
    • This 82 years old female patient was a case of Adenocarcinoma of A-colon. She underwent single-incision laparoscopic right hemicolectomy on 2023/09/14. The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable. She started semi liquid diet on 9/17 and JP drain was removed on 9/19. She was discharged on 112/9/19 and will follow up in our out-patient department next week.
  • Discharge prescription
    • MgO 250mg 2# BID
    • Through (sennoside 12mg) 1# HS

[surgical operation]

• 2023-09-14
  • Surgery
    • Laparoscopic right hemicolectomy (Glove port use)      
  • Finding
    • A locally advanced 5-6cm tumor is located at proximal A-colon with suspected a 2cm tumor deposit (seeding) on nearly omentum    
    • Right hemicolectomy was achieved smoothly. Blood loss was about 30ml.    
    • Anastomosis was performed using endo-GIA for both ends and side-to-side sutures with 4/0 PDS+ seromuscular retention    
    • A drain in Morrison’s pouch    

[chemotherapy]

• 2024-01-09 - irinotecan 180mg/m2 195mg D5W 250mL 90min + leucovorin 400mg/m2 435mg NS 250mL 2hr + fluorouracil 2800mg/m2 3050mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU 80%; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-12-19 - irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU 80%; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-12-01 - irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 425mg NS 250mL 2hr + fluorouracil 2800mg/m2 2000mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU <70%; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-11-10 - irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 425mg NS 250mL 2hr + fluorouracil 2800mg/m2 2000mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU <70%; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-10-23 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 425mg NS 250mL 2hr + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU 80%; Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

==========

2024-01-10

[reconciliation]

The patient received repeat prescriptions for Rivotril (clonazepam) and Mirtapine (mirtazapine) at NTUH on 2023-11-13, followed by refills on 2023-12-07 and 2024-01-01. However, these medications are currently not listed as active in her medication record. Here are some possible explanations:

• The patient may no longer require these medications. To confirm this, it would be helpful to review the reason for their initial prescription and any recent clinical assessments.
• There may be an error in the medication record. Please double-check the patient’s active medication list and compare it to available PharmaCloud records.
• The patient may not be taking the medications as prescribed. This could be due to various reasons, such as side effects, lack of perceived benefit, or forgetting to take them.

Therefore, it is recommended to understand the reason for the non-use of the prescribed medications will help determine the most appropriate course of action.

2023-12-04

Currently, PharmaCloud access is unavailable.

Following the initiation of a dose-reduced FOLFIRI regimen, with the 3rd session starting on 2023-12-01, the patient has not experienced vomiting or nausea and reports good sleep and appetite.

No discrepancies in medication have been identified in the HIS5 records.

700274792

240110

[MedRec]

• 2024-01-05 SOAP Hemato-Oncology Gao WeiYao
  • A: CML
    • 2024/01/05 BCR/abl Philadelphia chromosome (qualitative) - Presence of mutation
  • Diagnosis
    • C92.10 - Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
    • D47.1 - Chronic myeloproliferative disease
    • D72.829 - Elevated white blood cell count, unspecified
  • Prescription
    • Tasigna (nilotinib 150mg) 2# Q12H 14D

[chemotherapy]

Comparison of tyrosine kinase inhibitors used for chronic myeloid leukemia - 2024-01-10 - https://www.uptodate.com/contents/image?imageKey=HEME%2F89930

Agent	Dosing frequency and timing in relation to food	Dose adjustments for baseline kidney/liver dysfunction	Major toxicities	Other
Imatinib	Daily (or twice daily) with food	Yes (kidney, liver)	Bone marrow suppression; fluid retention/edema; gastrointestinal effects; heart failure; hepatotoxicity.	Longest record of safety data
Nilotinib	Twice daily without food	Yes (liver)	Bone marrow suppression; cardiovascular events; electrolyte imbalance; hepatotoxicity. Black box warning: QT prolongation (screening required).	_
Dasatinib	Daily with or without food	No	Bone marrow suppression; pleural/pericardial effusions; pulmonary arterial hypertension; QT prolongation; aspirin-like effect.	_
Bosutinib	Daily with food	Yes (kidney, liver)	Bone marrow suppression; fluid retention/edema; gastrointestinal effects.	_
Ponatinib	Daily with or without food	Yes (liver)	Bone marrow suppression; fluid retention/edema; gastrointestinal effects; heart failure; hypertension; pancreatitis; aspirin-like effect; arterial thrombosis. Black box warning: cardiovascular events; hepatic toxicity.	Active against BCR::ABL1 T315I mutation; limited long-term safety data
Asciminib	Daily or twice daily without food	No	Upper respiratory tract infections; musculoskeletal pain; fatigue; nausea; rash; and diarrhea. Hypertriglyceridemia; cytopenias; elevated creatine kinase; hepatotoxicity; pancreatitis.	Active against BCR::ABL1 T315I mutation; limited long-term safety data

==========

2024-01-10

[nilotinib]

This patient is newly diagnosed with CML.

Lab data: 2024/01/05 - BCR/abl Philadelphia chromosome (qualitative) - Presence of mutation.

• 2024-01-10 WBC 41.60 x10^3/uL
• 2024-01-05 WBC 72.21 x10^3/uL
• 2023-12-25 WBC 73.26 x10^3/uL
• 2023-12-08 WBC 94.03 x10^3/uL

Absence of blasts in recent WBC DC makes the diagnosis of advanced CML (accelerated phase or blast phase) highly improbable. Chronic phase CML is therefore the most likely diagnosis.

BCR-ABL1 tyrosine kinase inhibitors (TKIs) are the first-line therapy for all CML phases, except for specific contraindications like pregnancy.

Initial CML treatment typically employs either imatinib or a second-generation TKI (dasatinib, nilotinib, bosutinib). Other TKIs (ponatinib, asciminib) are reserved for refractory patients or those with specific mutations (e.g., T315I). Notably, nilotinib is currently the patient’s TKI of choice.

Nilotinib is known to prolong the QT interval. Monitoring for and correcting hypokalemia, hypomagnesemia, and pre-existing QTc prolongation are crucial before and during nilotinib treatment. Regular ECGs (baseline, 7 days after initiation, periodic) are essential to track QTc, especially after dose adjustments.

Sudden deaths have been reported with nilotinib. Contraindications include hypokalemia, hypomagnesemia, and long QT syndrome. Concomitant medications that prolong the QT interval or strongly inhibit CYP3A4 should be avoided. Nilotinib intake should be separated from food by at least 2 hours (before) and 1 hour (after).

[reconciliation]

This patient’s primary hospital is New Taipei City Hospital according to PharmaCloud database. On 2024-01-09, refills were prescribed for several medications: Gaslan, Periscon (mosapride), Vesicare (solifenacin), Harnalidge (tamsulosin), Eurodin (estazolam), Meptin-Mini (procaterol hydrochloride hemilydrate), Colin Soln (chlorpheniramine maleate), and Allevo (levocetirizine dihydrochloride).

However, these refilled medications are not currently listed as active in the patient’s record. Please verify with the patient whether he still require these medications and, if clinically necessary, ask him or his family member to bring them to the hospital.

Note that Tasigna (nilotinib 150mg) 2# Q12H prescribed on 2024-01-05 in the outpatient clinic is currently being used without any identified issues.

701337994

240110

[exam findings]

• 2023-12-12 CT - chest
  • Adenocarcinoma of lung (ROS: mutation) with LNs mets & disease progression
  • Comparison was made with CT dated on 2023/08/25
    • Lungs: no interval change in size of LUL spiculated tumor (2.1 cm srs/img302/51), associated interlobular septal thickening, and with regression of radiation pneumonitis in upper and midlung zonesas compared with CT on 2023/08/25
    • Mediastinum and hila: stationary of metastaic LAP at Lt hilum
    • Pleura: minimal Lt-sided effusion..
    • segmental OPLL at T2-T4 levels.
  • Impression:
    • LUL cancer with hilar LAP, post treatment, stationary with regression of radiation penumonitis as compared with CT on 2023/08/25
• 2023-08-25 CT - chest
  • Malignant neoplasm of upper lobe, left bronchus or lung
    • MRA: Brain (2023-07-19): multiple brain met.
    • RT (2023-7-27 ~ 2023-8-10) Completion of radiotherapy on 2023-8-10.
  • Comparison was made with previous CT dated on 2023/5/6
    • Lungs: no interval change size of LUL spiculated tumor (2 cm srs/img202/28), associated interlobular septal thickening, and with extensisve radiation pneumonitis in upper and midlung zones as compared with CT on 2023/05/06
    • Mediastinum and hila: stationary of metastaic LAP at Lt hilum
    • Pleura: minimal Lt-sided effusion..
  • Impression:
    • LUL cancer stationary with radiation penumonitis as compared with CT on 2023/05/06
• 2023-07-19 MRA - brain
  • Findings
    • mild dilated intraventricular and extraventricular CSF spaces
    • punctate white matter gliosis in the supratentorial brain; nodular lesions in the left posterior frontal lobe, left superior parietal lobe, left occipital lobe and left pons. r/o metastasis. PLeaes correlate with contrast-enhanced study.
  • IMP:
    • r/o brain metastasis. Please correlate with contrast-enhanced study.
• 2023-05-06 CT - chest
  • Progression of left lung lesions.
  • Stable of right lung lesions.
• 2023-01-30 CT - chest
  • Progression from adenocarcinoma of lung with left supraclavicular lymph node metastases post Iressa (since 2011 to 2022), stage T4N3M0, stage III on MK 2009/10/01 Poar LIUMR c6D1 on MK 2010/02/09AFU6, local recurrent
  • Comparison was made with previous CT dated on 2022/8/18
    • Lungs: interval significant decreased LUL spiculated tumor (3.9 cm srs/img302/25) and decreased numbe and size of small nodules in both lungs as compared with CT on 2022/08/18.
    • Mediastinum and hila: signficant regresion of metastaic LAP as compared with previous CT son 2022/0/18
    • Pleura: trace Lt-sided effusion.
  • Impression:
    • LUL cancer T4N3M1a, signficant in regression as compared with previous CT study on 2022/08/18
• 2022-11-03 Tc-99m MDP bone scan
  • Some hot spots in the skull and right rib cage and increased activity in the distal portion of left humeral shaft. The nature is to be determined (post-traumatic change? bone metastases? other nature?). Please correlate with other clinical findings and follow up bone scan for further evaluation.
  • Mildly increased activity in some T- and L-spines and sacrum. Degenerative change is more likely.
  • Increased activity in bilateral shoulers, hips, knees and feet. Benign joint lesions may show this picture.
• 2022-08-18 CT - chest
  • Indication: follow up progessive Rt lung adenocaricnoma with ALK-positive under TKI. Evaluate tumor response to TKI
  • Chest CT with and without IV contrast ehnancement shows:
    • Huge soft tissue mass at left upper lobe with regional consolidation is found. The left upper lobe bronchus is partially obstructed by the mass. Lung cancer is considered. In comparison with CT dated on 2022-02-22, the lesion enlarged with broader extension.
    • Lymphadenopathy at mediastinum is found.
    • Left mild pleural effusion is found.
    • Minimal pericardial effusion is also found.
    • Mild pericardial effusion is found.
  • Imp:
    • Left upper lobe lung cancer with mediastinal lymphadenopathy and consolidation over left upper lobe, in progression.
• 2022-05-16 PD-L1 (SP142)
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana) S2022-6896
    • Tumor type: adenocarcinoma
    • Tumor location: lung
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark XT
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: Pass,
    • Adequate tumor cells present (>=50 viable tumor cells): Yes
  • Result:
    • Tumor cell (TC) staining assessment: TC category: TC < 1%
    • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
  • Note:
    • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
    • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2022-04-21 Patho - lung transbronchial biopsy
  • Lung, ? side, CT-guide biopsy — adenocarcinoma, moderately differentiated
  • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
• 2022-02-22 CT - chest
  • History of adenocarcinoma of lung with Lt supraclavicular LN metastases post Iressa
    • Initial stage T4N3M0, stage III on MK 2009/10/01
    • Poar LIUMR X6D1 on MK follow up ca of lung status under Iressa
  • Comparison made with previous CT dated on 2021/11/19
    • Lungs:
      • the LUL spiculated tumor with pleural tails is 2.84 cm in longest axial dimension (srs/img10/22).
      • small nodule in anterior LUL (srs/img10/23 and a tiny centrilobular nodule in LLL (srs/img10/73)
    • Mediastinum and hila: heterogeneous enhancing left hilar lymphadenopathy (24 mm) and several small LNs in both sides of visceral space, increase in size as compared with previous CT study on 2021/11/19.
  • Impression:
    • LUL cancer T4N3, seems slightlt in progression as compared with previous CT study on 2021/11/19.
• 2021-11-19 CT - chest
  • History of lung Ca under Iressa TKI treatment, evaluate tumor status
  • Chest CT with and without IV contrast ehnancement shows:
    • Spicualted mass at left upper lobe up to 2.61cm in largest dimension is found.
    • Enlarged lymph nodes are found at left hilar region. Non-specific lymph nodes are found at paratracheal region is found.
  • Imp:
    • Left upper lobe lung mass with left hilar lymphadenopathy, T2N1-2Mx.

[consultation]

• 2023-09-19 Ear Nose Throat
  • Q
    • The 67 years old woman has adenocarcinoma of lung cancer with brain mets. Due to vertigo frequency in 1+ months, so we need your help for management. Thanks!
  • A
    • Hx of adenocarcinoma of lung cancer with brain mets
    • Vertigo (unsteadiness, exacerbated when sitting up and standing up, lasted for hours) for a month.
      • Ear drum: bil intact
      • EAC: clean
      • FNF: ok
      • HINTS: normal VOR, no nstagmus, normal test of skew
    • Imp: Vertigo, nature?
    • Plan:
      • May try Diphenidol (patient mentioned s/s improved under Diphenidol, and she claimed she had drugs)
      • ENT OPD f/u for inner ear battery test

[radiotherapy]

[chemotherapy]

• 2024-01-09 - vinorelbine 20mg 1# PO + carboplatin AUC 5 400mg NS 250mL (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-13 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-14 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-17 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-21 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-07-06 - docetaxel 75mg/m2 110mg NS 150mL 1hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-06-16 - docetaxel 75mg/m2 110mg NS 150mL 1hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-05-26 - docetaxel 75mg/m2 110mg NS 150mL 1hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-21 - pemetrexed 500mg/m2 745mg NS 100mL 10min + carboplatin AUC 5 365mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-23 - pemetrexed 500mg/m2 727mg NS 100mL 10min + carboplatin AUC 5 280mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-24 - pemetrexed 500mg/m2 727mg NS 100mL 10min + carboplatin AUC 5 280mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-31 - pemetrexed 500mg/m2 727mg NS 100mL 10min + carboplatin AUC 5 275mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-05 - pemetrexed 500mg/m2 730mg NS 100mL 10min + [NS 500mL 2hr + diphenhydramine 30mg + NS 250mL] (before CDDP) + cisplatin 75mg/m2 110mg NS 350mL + NS 500mL 2hr (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-13 - pemetrexed 500mg/m2 730mg NS 100mL 10min + NS 500mL 2hr (before CDDP) + cisplatin 75mg/m2 110mg NS 350mL + NS 500mL 2hr (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-22 - pemetrexed 500mg/m2 730mg NS 100mL 10min + NS 500mL 2hr (before CDDP) + cisplatin 75mg/m2 110mg NS 350mL + NS 500mL 2hr (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Vinorelbine - 2024-01-10 - https://www.uptodate.com/contents/vinorelbine-drug-information

• Dosing - Adult
  • Non–small cell lung cancer:
    • Metastatic (single-agent therapy): IV: 30 mg/m2 once a week.
    • Locally advanced or metastatic (in combination with cisplatin): IV: 25 mg/m2 on days 1, 8, 15, and 22 of a 28-day cycle or 30 mg/m2 once a week.
    • Advanced disease (off-label dosing): IV: 25 to 30 mg/m2 days 1, 8, and 15 every 28 days (in combination with gemcitabine) for 6 cycles or until disease progression or unacceptable toxicity.
  • Small cell lung cancer, refractory (off-label use):
    • IV: 25 or 30 mg/m2 every 7 days until disease progression or unacceptable toxicity.

==========

not posted

dosage not correct?

701342169

240110

[lab data]

2023-05-23 Anti-HBc Reactive
2023-05-23 Anti-HBc-Value 9.12 S/CO
2023-05-23 Anti-HCV Nonreactive
2023-05-23 Anti-HCV Value 0.16 S/CO
2023-05-23 HBsAg Reactive
2023-05-23 HBsAg (Value) 3336.74 S/CO
2023-05-23 Anti-HBs 0.53 mIU/mL

[exam findings]

• 2023-12-25 CT - abdomen
  • S/P colon operation.
  • Grade 4 fatty liver. A hypodense lesion (1.6cm) at left hepatic lobe. S/P right liver operation..
• 2023-09-07 CT - abdomen
  • S/P colon operation.
  • Grade 4 fatty liver. A hypodense lesion (1.6cm) at left hepatic lobe r/o metastases. S/P right liver operation.
• 2023-06-16 PET scan
  • Increased FDG uptake in the left anterior upper abdominal cavity. The nature is to be determined (post-operative infecton/inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • Two glucose hypermetabolic lesions in the segment 8/4 and segment 7 of the liver respectively. Liver metastases may show this picture.
  • A small and mild glucose hypermetabolic lesion in the segment 8 of the liver. An early liver metastasis can not be ruled out.
    
  • A focal area of decreased FDG uptake in the segment 5 of the liver, compatible with post-operative change.
  • Mild glucose hypermetabolism in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammatory process is more likely.
• 2023-05-06 ECG
  • Sinus tachycardia with frequent Premature ventricular complexes
  • Possible Inferior infarct , age undetermined
  • Abnormal ECG
• 2023-05-06 CT - abdomen
  • S/P colon operation. Fat stranding at upper abdomen. Some fluid collection at upper abdomen and abdominal wound.
  • Left pleural effusion. Partial atelectasis at bil. basal lungs.
  • Grade 4 fatty liver. A hypodense lesion (2.8cm) at right hepatic lobe, metastases ?

[MedRec]

• 2023-05-06 ~ 2023-05-23 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Transverse colon cancer with liver metastasis status post right hemicolectomy and hepatectomy at S5 on 2023/03/22 (Taichung ChengChing Hospital), pT3N1bM1a stage IVa, complicating with deep wound infection and intra-abdomen abscess status post limited laparotomy with debridement and drainage of intra-abdomen abscess on 2023/05/06
    • Coronary artery disease with stent
    • Type 2 diabetes mellitus without complications
    • Hypertensive heart disease
    • Hyperlipidemia
  • CC
    • surgical wound swelling and arrythemia and fever was noted
  • Present illness
    • This is 69-year-old female patient had past history of colon cancer stage III with liver metastasis. She received colon cancer on 2023/03/23 at Taichung ChengChing Hospital.
    • This time, she suffered from surgical wound swelling and arrythemia and fever was noted. She was brough to our emergency room for help. PE no muscle guarding or peritoneal signs. Arrange abdominal CT revealed 1. S/P colon operation. Fat stranding at upper abdomen. Some fluid collection at upper abdomen and abdominal wound. 2. Left pleural effusion. Partial atelectasis at bil. basal lungs. 3. Grade 4 fatty liver. A hypodense lesion (2.8cm) at right hepatic lobe, metastases ? CRS. was consultion, after well explain for surgery is indication, she received surgery of limited laparotomy with drainage of deep wound and intra-abdomen abscess on 2023-05-06, post operative she was admitted to SICU for intensive care.
  • Course of inpatient treatment
    • She received surgery of limited laparotomy with drainage of deep wound and intra-abdomen abscess on 2023/05/06. After operation, she was transferred to SICU for intensive care.   
    • At SICU, antibiotics with Vancomycin and Doripenem administered. Extubated of endotracheal tube smoothly after pass weaning parameter on 5/8. We started try clear liquid diet since 5/9. After gemeral condition being stabilized, she will be transferred to ordinary ward for further care on 5/10.
    • After transferred to ward, we have kept wound wet dressing with normal saline and emperical antibiotics with vancomycin+ doripenem. The wound culture found Proteus spp. infection., which is only resistance to first generation antibiotics. We have also followed up laboratory data, and has also showed improvement. Her vital sign was relatively stable and conscious, appetite were also good. We have shifted emperical antibiotics to cefoxitin on 2023/05/13. Laboratory was followed up on 05/15, and has showed improvement. Furthermore, surgical wound was dressing with green guard gel due to no more pus like discharge nor bad oder. Now, her clinical condition is relatively stable, and she may discharge and keep follow up at OPD.
  • Discharge prescription
    • Ceficin (cefixime 100mg) 2# Q12H 7D

[consultation]

• 2023-05-22 Hemato-Oncology
  • A
    • This 69 year old woman is a case of T-colon cancer with liver metastasis, s/p right hemicolectomy + liver S5 segment resection on 2023/03/22, pT3N1bM1a, stage IVA, RAS wide type, no BRAf mutation, proficient mismatch repair.
    • She had underline disease of CAD s/p stent. She was admiited due to deep wound infection with necrotizing fasciitis s/p limited laparotomy with drainage of deep wound and intra-abdomen abscess on 2023/05/06 - Wound culture with Proteus species.
    • We are consulted for further palliative chemotherapy after infection control.
    • Palliative chemotherapy + target therapy is indicated (FOLFIRI+Avastin). We will discuss with patient.
    • Please check HbsAg, Anti HBc,Anti HBs, Anti HCV, CEA, CA199, LDH. Arrange our OPD after discharge.
• 2023-05-08 Infectious Disease
  • Q
    • Peritonitis with intra-abdomen and deep wound infection s/p emergent debridement and drain on 5/6
    • r/o septic shock
  • A
    • Agree with your current antibiotcs us of finibax and vancomycin.
    • Please adjust antibiotic according to culture results and clinical conditions.

[surgical operation]

• 2023-05-06
  • Surgery
    • Limited laparotomy with drainage of deep wound and intra-abdomen abscess
  • Finding
    • After limited laparotomy, much pus was drained from a deep and poor healing wound, and underlying bowel like organ can be seen. however, severe adhesions over intraabdominal cavity was found and thorough exploration is difficult and impossible.
    • Debridement of the deep wound and much normal saline irrigation was done.
    • Wound was left open for wet dressing.

[immunochemotherapy]

• 2024-01-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 325mg D5W 250mL 90min + leucovorin 400mg/m2 725mg NS 250mL 2hr + fluorouracil 2800mg/m2 5050mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-12-14 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-11-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-11-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 319mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4970mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-10-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 319mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4970mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-09-25 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 315mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4930mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-09-04 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 315mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4925mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-08-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4930mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-07-28 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 4840mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-07-10 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr (FOLFIRI Q2W. Gao WeiYao)

==========

2024-01-10

[labs confirm HBV: Vemlidy maintained, medication compliance assured]

Lab results (2023-05-23) showed HBsAg and anti-HBc reactive and Vemlidy (tenofovir alafenamide) is currently in use, no medication discrepany found.

700043422

240109

[exam findings]

• 2023-09-01 All-RAS + BRAF gene mutation analysis
  • Cell Block No. S2023-12334
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 12 GGT>GTT, p.G12V)
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-08-27 ECG
  • Normal sinus rhythm
  • Low voltage QRS
  • Prolonged QT
  • Abnormal ECG
• 2023-08-26 CT - abdomen
  • Non-contrast CT of abdomen-pelvis revealed:
    • S/P ileostomy with incisional hernia. Progression of A-colon cancer (10.3x11.6x15.4cm) with right lateral abdominal wall and psoas muscle invasion.
    • Small stones in left kidney.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • GGO at right basal lung.
  • IMP:
    • S/P ileostomy with incisional hernia.
    • Progression of A-colon cancer (10.3x11.6x15.4cm) with right lateral abdominal wall and psoas muscle invasion.
    • Some lymph nodes at RLQ.
    • GGO at right basal lung.
• 2023-08-26 CT - brain
  • Non-contrast brain CT revealed:
    • Widening of cortical sulci and dilatation of ventricles.
  • IMP:
    • Brain atrophy.
• 2023-06-26 ECG
  • Sinus rhythm with occasional atrial-paced complexes and Fusion complexes
  • Low voltage QRS
  • Prolonged QT
• 2023-06-21 Patho - colon biopsy
  • Colorectum, ascending colon, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2023-06-16 CT - abdomen
  • CC: general weakness, poor appetite,
  • PHx: COPD, HTN, DM, colon cancer diagnosed by Cardinal Tien Hospital
  • Findings:
    • There is a well-defined heterogeneous enhancing mass in the ascending colon, measuring 15 cm (the largest dimension), and direct invasion right psoas muscle and duodenum 2nd-3rd junction that is c/w adenocarcinoma of the ascending colon (T4b).
      • The differential diagnosis includes adenocarcinoma associated with tumor necrosis and abscess formation.
      • please correlate with clinical condition.
      • In addition, there are four enlarged nodes in the right side mesocolon that are c/w metastatic nodes (N2a).
    • S/P ileostomy at right upper pelvis.
    • Hyperplasia of left adrenal gland is noted.
  • Imaging Report Form for Colorectal Carcinoma
• 2023-06-16 ECG
  • Sinus tachycardia
  • Low voltage QRS
  • Borderline ECG
• 2023-06-16 CXR
  • Tortous aorta with calcification is noted.
  • S/p port-A placement with its tip at Superior vena cava.

[MedRec]

• 2023-06-16 ~ 2023-06-20 POMR Colorectal Surgery Lv ZongRu
  • Discharge diagnosis
    • Advance ascending colon cancer with psoas muscle invasion post loop ileostomy, cT4bN2aM0, stage IIIC. ECOG:1.
    • Hypertension
    • Diabetes mellitus
    • Hyperlipidemia
    • Chronic obstructive pulmonary disease
  • CC
    • complaint of no hospital bed for chemotherapy in Cardinal Tien Hospital
  • Present illness
    • This is a 58 year-old men had history of
      • hypertension with medicin control over 10 years;
      • diabetes mellitus with medicin control over 10 years;
      • hyperlipidemia with medicin control over 10 years;
      • Chronic Obstructive Pulmonary Disease with medicin control for many years;
      • Gastroesophageal reflux disease with medicine control for many years.
      • Diangosised of Malignant tumor in ascending colon with right psoas muscle invasion on 2023/05 by Cardinal Tien Hopital.
      • port-A insertion on 2023/05/15 at Cardinal Tien Hospital.
      • ileostomy post operation on 2023/05/15 at Cardinal Tien Hospital.
    • He denied any TOCC histories in recent 3 months.
    • According the patient statement, discharge on 2023/05/18 at Cardinal Tien Hospital. Due to he had watery diarrhea off and on for about month,and intermittent right back pain over 1 years. Poor intake about 1 month and body weight loss over 20 kg. During hospitalization, diangosised of Malignant tumor in ascending colon with right psoas muscle invasion. Port-A insertion and ileostomy post operation on 2023/05/15 at Cardinal Tien Hospital.
    • PET 2023/05/23 showed 1). Malignant tumor in ascending colon with right psoas muscle, invasion; cT4bN0M0, c-stage IIC., 2). Bilateral pleural effusion., 3). Post colostomy in RUQ.
    • Brain MRI showed no organic brain lesion and no evidence of metastasis on 2013/05/27.
    • Due to the complaint of no hospital bed for chemotherapy in Cardinal Tien Hospital, the patient visited our emergency room for his disease.
    • At emergency room, Abdominal CT showed There is a well-defined heterogeneous enhancing mass in the ascending colon, measuring 15 cm (the largest dimension), and direct invasion right psoas muscle and duodenum 2nd-3rd junction that is c/w adenocarcinoma of the ascending colon (T4b). In addition, there are four enlarged nodes in the right side mesocolon that are c/w metastatic nodes (N2a). no distant metastasis. Laboratory data showed WBC: 12.80 x10^3/uL, CRP: 12.5 mg/dL.
    • After consultation to proctologist and initial management, the patient was admitted to our ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, highly suspect ascending colon cancer with local advanced invasion. Paliative chemotherapy + radiotherapy first, but insufficient information of pathology report in other hospital. Thus, colonscopy biopsy was performed on 2023/06/20. Under the stable condition, he was discharged today and the final report will be follow up in OPD.
  • Discharge prescription
    • Curam (amoxicillin 875mg, clavuanic acid 125mg) 1# Q12H
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQID
• 2023-08-27 Colorectal Surgery
  • Q
    • Family members said that when the patient wanted to get up to change his stoma, he collapsed and fell to the ground, not sure where he hit.
    • denied fever, tarry stool, chocking recently.
    • Hx
      • Advance ascending colon cancer with psoas muscle invasion post loop ileostomy, cT4bN2aM0, stage IIIC. ECOG:1.
      • Hypertension
      • Diabetes mellitus
      • Hyperlipidemia
      • Chronic obstructive pulmonary disease
  • A
    • This is a Advance ascending colon cancer with psoas muscle invasion post loop ileostomy, cT4bN2aM0, stage IIIC. ECOG:1. with conscious change this morning
    • GCS: E3M5V2
    • A/P: admission for antibioitc drugs treatment
    • please check BZD drug overdose problem
    • thanks for your consultation

[immunochemotherapy]

• 2024-01-08 - bevacizumab 5mg/kg 150mg NS 100mL 60min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3875mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
• 2023-12-25 - bevacizumab 5mg/kg 150mg NS 100mL 60min + irinotecan 180mg/m2 198mg D5W 250mL 90min + leucovorin 400mg/m2 440mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
• 2023-12-11 - bevacizumab 5mg/kg 150mg NS 71mL 60min + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 524mg NS 250mL 2hr + fluorouracil 2800mg/m2 3670mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
• 2023-11-27 - bevacizumab 5mg/kg 100mg NS 71mL 60min + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 524mg NS 250mL 2hr + fluorouracil 2800mg/m2 3670mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. doce reduced) (Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
• 2023-11-14 - bevacizumab 5mg/kg 100mg NS 71mL 60min + irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 422mg NS 250mL 2hr + fluorouracil 2800mg/m2 2960mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
• 2023-10-31 - bevacizumab 5mg/kg 100mg NS 71mL 60min + irinotecan 180mg/m2 257mg D5W 250mL 90min + leucovorin 400mg/m2 572mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. doce reduced) (Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
• 2023-10-16 - irinotecan 180mg/m2 276mg D5W 250mL 90min + leucovorin 400mg/m2 615mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 1000mL 46hr (FOLFIRI Q2W. doce reduced) (Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
• 2023-10-02 - irinotecan 180mg/m2 294mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 1000mL 46hr (FOLFIRI Q2W. doce increased) (Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
• 2023-09-18 - irinotecan 180mg/m2 268mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4172mg NS 1000mL 46hr (FOLFIRI Q2W) (Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
• 2023-08-14 - oxaliplatin 85mg/m2 112mg D5W 250mL 2hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 1000mL 46hr (FOLFOX Q2W) (Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-02 - (FOLFOX Q2W) (Lv ZongRu)
• 2023-07-17 - (FOLFOX Q2W) (Lv ZongRu)
• 2023-07-03 - (FOLFOX Q2W) (Lv ZongRu)

==========

2024-01-09

[anemia]

Compared to the previous session on 2023-12-25, the dosage of Irinotecan and fluorouracil administered during this session on 2024-01-08 was increased.

The patient’s HGB level remains low at 7.8g/dL as of 2024-01-08. Available lab data indicates persistent anemia since at least June 2023, with no recovery to normal levels. If the anemia becomes symptomatic, RBC transfusion may be necessary.

The patient has already received several blood transfusions throughout the previous months, specifically on 2023-08-30, 2023-11-13, and 2023-12-11.

2023-12-27

[anemia]

Hemoglobin has been around 7 to 8 g/dL for the past two months. The FOLFIRI dose has been reduced during this hospitalization. If anemia is symptomatic, please perform RBC product transfusion as clinically indicated.

• 2023-12-25 HGB 7.3 g/dL
• 2023-12-11 HGB 7.1 g/dL
• 2023-11-27 HGB 8.3 g/dL
• 2023-11-13 HGB 7.2 g/dL
• 2023-10-30 HGB 8.9 g/dL

2023-12-13

[anemia]

In the pharmacist note dated 2023-11-16, the following assessment was made: Considering the already reduced dose of the FOLFIRI regimen, further alleviation of anemia severity might necessitate lengthening the treatment intervals, potentially impacting the expected therapeutic effectiveness. In the recent two administrations (irinotecan on 2023-11-27 and 2023-12-11: 235mg; 5-FU on 2023-11-27 and 2023-12-11: 3670mg), both irinotecan and 5-FU doses were increased compared to the previous administration (irinotecan on 2023-11-14: 190mg; 5-FU on 2023-12-11: 2690mg), while maintaining a biweekly interval. Recent data may indicate that the rate of hemoglobin supplementation is not keeping pace with the anemia caused by the treatment. Consequently, in subsequent therapy sessions, blood transfusions may become a necessary adjunct to the treatment regimen.

• 2023-12-11 HGB 7.1 g/dL BT
• 2023-11-27 HGB 8.3 g/dL
• 2023-11-13 HGB 7.2 g/dL BT
• 2023-10-30 HGB 8.9 g/dL
• 2023-10-16 HGB 10.6 g/dL

2023-11-16

[anemia]

Laboratory data indicated episodes of anemia. Blood transfusions were appropriately administered to the patient on 2023-08-30 and 2023-11-13.

• 2023-11-13 HGB 7.2 g/dL BT
• 2023-10-30 HGB 8.9 g/dL
• 2023-10-16 HGB 10.6 g/dL
• 2023-10-02 HGB 10.1 g/dL
• 2023-09-18 HGB 10.1 g/dL
• 2023-09-04 HGB 9.7 g/dL
• 2023-08-30 HGB 8.1 g/dL BT
• 2023-08-27 HGB 9.5 g/dL
• 2023-08-26 HGB 10.6 g/dL
• 2023-08-14 HGB 9.3 g/dL
• 2023-08-01 HGB 10.5 g/dL
• 2023-07-17 HGB 8.8 g/dL
• 2023-07-03 HGB 9.4 g/dL
• 2023-06-19 HGB 8.8 g/dL
• 2023-06-16 HGB 9.3 g/dL
• 2021-09-03 HGB 13.7 g/dL

The patient is currently being treated with Avastin and a reduced dose of the FOLFIRI regimen. Bevacizumab is less commonly associated with anemia. Given that the dose of the FOLFIRI regimen has already been reduced, further mitigation of the severity of anemia might require extending the treatment intervals, which could potentially affect the anticipated therapeutic efficacy.

700359263

240109

==========

2024-01-09

Lab results:

• 2024-01-08 NT-proBNP > 35000.0 pg/mL
  

• 2024-01-08 CKMB 5.5 ng/mL
  

• 2024-01-08 hs-Troponin I 62.9 pg/mL
  

• 2024-01-08 CK 86 U/L

• 2024-01-08 ECG

  • Sinus rhythm with 1st degree A-V block
  • Non-specific intra-ventricular conduction block
  • T wave abnormality, consider inferolateral ischemia

• 2024-01-08 CXR

  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    
  • moderate enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad /supine position
  • Rt and Lt subpulmonary effusion
  • Linear band subsegmental atelectasis at lung bases
  • marginal spurs of multiple vertebral bodies

Potential causes:

• Heart failure remains a likely cause, strongly supported by the significantly elevated NT-proBNP and the enlarged cardiac silhouette on CXR.
• Myocardial infarction (heart attack) is still a possibility, given the elevated hs-Troponin I and T wave abnormality on ECG. Further investigations like a repeat ECG and echocardiography would be crucial to confirm or rule out this diagnosis.
• Acute coronary syndrome (ACS) is also a possibility due to the potential for ischemia suggested by the ECG findings.
• Other potential contributing factors:
  • Atherosclerosis, as evidenced by the calcified changes in the aorta on CXR.
  • Possible pulmonary congestion or effusions, as indicated by the subpulmonary effusions on CXR.

It might be beneficial to consult a cardiologist.

700817160

240109

[lab data]

2023-12-04 FKLC 135.0 mg/L
2023-12-04 FLLC 178.0 mg/L

2023-11-28 Protein, total 5.9 g/dL
2023-11-28 Albumin 35.2 %
2023-11-28 Alpha-1 2.3 %
2023-11-28 Alpha-2 14.6 %
2023-11-28 Beta 21.9 %
2023-11-28 Gamma 26.0 %
2023-11-28 M-peak Positive
2023-11-28 A/G Ratio 0.50

[MedRec]

• 2023-12-09 ~ 2023-12-12 POMR Nephrology Lin DingYun
  • Discharge diagnosis
    • Nephrotic syndrome with other morphologic changes
    • Type 2 diabetes mellitus with diabetic chronic kidney disease
    • Essential (primary) hypertension
    • Idiopathic gout, unspecified site
    • Pure hypercholesterolemia
    • Anemia, unspecified
    • Cyst of kidney, acquired
  • CC
    • Lower limbs edema for 2 months
  • Present illness
    • This is a 65 years old male with underlying disease of type 2 DM, hypertension, gouty arthritis, CKD stage 4, was admitted for lower limbs edema for 2 months.
    • The patient was in his usual health status, until the end of Sep 2023, when he was infected with COVID-19 infection. He noted that lower limbs edema developed gradually thereafter. His general appetite and spirit also became worsen. He denied use of NSAIDs recently. There was no fever, chills, dyspnea, decreasing urine output.
    • He visted the nephrologist OPD on 2023-10-28, and low serum albumin was noted, 2.9 to 2.1 mg/dL. Urine protein was also increased, UACR 1.98 to UPCR 9.3. Renal function was relative stable, around 2.67~3.3mg/dL.
    • Relevant studies for proteinuria showed presence of M-protein on protein EP and IFE, suspected to be IgG + Kappa. Under the impression of nephrotic syndrome with unclear cause, he was admitted for kidney biopsy.
  • Course of inpatient treatment
    • After admission, we have checked the CBC, coaggulation and bleeding time, and we also adjusted anti-hypertensive agents for blood pressure control.
    • Due to anemia (HB 8.5g/dL), blood transfustion with LPRBC 2U was done on 12/09 and 12/10.
    • Desmopressin was given for preventing bleeding before kidney biopsy on 12/11.
    • The patient stood well during the whole procedure, and follow-up renal echo showed minimal hematoma and stable hemogram level.
    • Due to stable condition, he was discharge on 2023/12/12.
  • Discharge prescription
    • Budema (bumetanide 1mg) 1# QD
    • Feburic (febuxostat 80mg) 0.5# QD
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
    • colchicine 0.5mg 0.5# QD
    • Foliromin (ferrous sodium citrate 50mg) 1# BID

700867511

240109

[exam findings]

• 2024-01-07 ECG
  • Normal sinus rhythm
  • Septal infarct, age undetermined
• 2023-12-08 ECG
  • Normal sinus rhythm
  • Anterolateral infarct, age undetermined
  • Abnormal ECG
• 2023-11-22 Peipheral Vascular Test - AV fistula
  • Result: Adequate size of RIJV
• 2023-11-17 PET scan
  • Glucose hypermetabolism in multipe bones as mentioned above, suggesting multiple bone metastases.
  • Glucose hypermetabolism in some left supraclavicular lymph nodes, bilateral pulmonary lymph nodes and multiple bilateral mediastinal lymph nodes. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
    
  • Mild glucose hypermetabolism in the lower portion of the esophagus. Inflammation is more likely. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2023-11-10 Tc-99m MDP bone scan
  • The scintigraphic findings suggest multiple bone metastases.
• 2023-10-26 T-spine AP + Lat.
  • Post percutaneous vertebroplasty of the visible lumbar or thoracic spine at T8.
• 2023-10-16 Patho - bone fragment/pathologic fracture
  • T8 vertabrae, biopsy — Metastatic adenocarcinoma and see description
  • The specimen submitted consists of three strips of brown-gray bony tissue, labeled T8 vertebrae, measuring up to 1.2 x 0.2 x 0.2 cm. All for section.
  • The sections show a picture of metastatic adenocarcinoma, composed of nests and cords of columnar to cuboidal neoplastic cells, arragned in glandular and cribrifrom patterns with muicin secretion.
  • IHC shows: CK7(+), CK20(-), CDX2(-), TTF1(-) and PSA(-). Suggest check respiratory tract and pancreaticobiliary tract.
• 2023-10-14 ECG
  • Anteroseptal infarct, age undetermined
• 2023-10-14 CXR
  • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture at T8, mets or multiple myeloma?
• 2023-09-15 Nasopharyngoscopy
  • Findings: smooth nasopharynx, oropharynx, hypopharynx
  • Diagnosis: multiple bone metastasis
• 2023-09-01 MRI - T-spine
  • Diffuse bony metastases involving vertebral column, including T1-4, T6-9, T11-12, L1-3, L5 and S2 vertebral body.
• 2023-08-24 CT - abdomen
  • R/O vascular thrombosis of bil. lower lungs.
  • Enlargement of prostate.
• 2023-08-24 T spine AP + Lat
  • T8 compression fracture
  • General osteoporosis
  • Concave vertebrae of T-L spine
• 2023-08-16 CT - chest
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T0(T_value) N:N0(N_value) M:M1c(M_value) STAGE:IVB(Stage_value)
  • Findings
    • Lungs:
      • extensive, bilateral, upper lobes predominant, centrilobular emphysema, in the lungs.
      • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
      • areas of septal thickening at S6 and S10 of LLL and central bronchial
      • wall thickening at both lower lobes.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels: mild coronary arterial calcification
    • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal size of cardiac chambers.
    • Pleura: no effusion
    • Visible abdominal contents: no abnormal density in visible portion of the the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
    • Visualized bones: lytic or blastic change with compression fracture of T8 vertebral body.
  • Impression:
    • extensive emphysema with lower lobes bronchitis, LLL interstitial infiltration r/o edema, and pathological compression fracture of T18.
    • no obvious solid lung tumor.
• 2023-05-31 Bronchodilator Test
  • severe obstructive impairment after bronchodilator; non-significant bronchodilator response; compatible with GOLD stage III.
• 2022-11-03 CXR erect
  • Increased lung volume and areas of hyperlucency/decreased vascular markings due to emphysematous change
• 2022-11-03 Bronchodilator Test
  • moderate obstructive impairment; non-significant bronchodilator response; compatible with GOLD stage II
• 2022-10-24 Myocardial perfusion SPECT with persantin
  • Probably mild myocardial ischemia at the apex, middle to basal inferior wall, and inferoseptal wall (LAD and RCA territories) of LV.
  • Mild dilatation of LV is noted on post-stress images.
• 2022-08-11 ECG
  • Anteroseptal infarct, age undetermined
• 2022-05-19 Bronchodilator Test
  • compatible with GOLD stage II
• 2022-05-04 Bruce ECG
  • Findings
    • The patient exercised according to the BRUCE for 07:05 min:s, achieving a work level of max METS: 8.6.
    • The resting heart rate of 91 bpm rose to a maximal heart rate of 144 bpm.
    • This value represents 92 % of the maximal, age-predicted heart rate.
    • The resting blood pressure of 113/76 mmHg, rose to a maximum blood pressure of 208/95 mmHg.
    • The exercise test was stopped due to Target heart rate [85-99% MHR], Dyspnea, Fatigue.
  • Conclusion
    • Probably negative for myocardial ischemia (baseline Q wave at V1-3)
• 2022-04-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (67 - 27) / 67 = 59.70%
    • M-mode (Teichholz) = 58
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy; LV diastolic dsyfunction, Gr 1
    • Trivial MR and trivial TR
    • Preserved RV systolic function

[MedRec]

• 2023-12-08 ~ 2023-12-12 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Adenocarcinoma of lung cancer with multiple bone metastasis, stage IV
    • Chronic obstructive pulmonary disease
    • Anterolateral infarct
    • Chronic ischemic heart disease
    • Essential (primary) hypertension
    • Mixed hyperlipidemia
  • CC
    • for chemotherapy and pain control
  • Present illness
    • The 67 y/o man has BPH, COPD (smoking 1.5 PPD for 50 years and Lung function: severe obstructive impairment after bronchodilator; non-significant bronchodilator response; compatible with GOLD stage III on 2023/05/31), HTN, Hyperlipidemia and CAD under ASA and Coxine since 2022/11-2023/12/7.
    • Due to he has dyspnea on exercise, the chest CT was done from CM OPD on 2023/08/16, report showed extensive emphysema with lower lobes bronchitis, LLL interstitial infiltration r/o edema, and pathological compression fracture of T18. no obvious solid lung tumor.
    • He was refered to ONC OPD for T8 pathologic fracture, so he did the MM survey and the T-spine MRI was done on 2023/09/01, report showed diffuse bony metastases involving vertebral column, including T1-4, T6-9, T11-12, L1-3, L5 and S2 vertebral body.
    • ENT OPD for suspect unknown primary and multiple bone mets survey, but no evidence of NPC.
    • The EGD also was done for primary unknown on 2023/09/26, report showed Reflux esophagitis LA Classification grade A(minimal), Gastric erosions, antrum, s/p biopsy(B) and Gastric shallow ulcers, bulb, s/p biopsy(A), but all of pathology showed not cancer.
    • On 2023/10/16, the bone pathology showed metastatic adenocarcinoma, IHC shows: CK7(+), CK20(-), CDX2(-), TTF1(-) and PSA(-).
    • The bone scan and self paid of PET were showed multiple bone metastases on 2023/11.
    • ONC OPD gave pain killers as Fentanyl 12 mcg, Ultracet 1# q6h and Cataflam 75mg qd, but in vain.
    • Under the impression of metastatic adenocarcinoma, primary origin suspect lung, so he was admitted for chemotherapy and pain control on 2023/12/08.
  • Course of inpatient treatment
  • After admission, he received pain control with Durogesic 12mcg/h, 2.1mg/patch 2 patch q3d. B12 IM and MultiVit on 2023/12/11. First chemo as Alimta + Cisplatin on 2023/12/12. Under the stable condition, he can be discharged on 2023/12/12. OPD follow up is arranged.
  • Discharge prescription
    • Limeson (dexamethasone 4mg) 1# BID
    • Cough Mixture (platycodon ) 8mL PRNQ8H
    • Neurontin (gabapentin 100mg) 1# TID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
    • Ulstop (famotidine 20mg) 1# BID
    • Durogesic (fentanyl 12ug/h, 2.1mg/patch) 2# Q3D EXT
• 2023-11-15 SAOP Chest Medicine Wu ZhiWei
  • A/P
    • Plan:
      • refer to ortho/oncology fot spine T8 pathologic fracture (adenoCA with unknown origin)
      • quit smoking
    • smoking: 2 PPD x 50 years, current
    • PHx: COPD s/p anoro [chest Dr. Huang & Wu]; CAD under aspirin
  • Prescription x3
    • Anoro Ellipta (umeclidinium 55ug/dose, vilanterol 22ug/dose; 30 doses/bot) 1# QD INHL

[chemotherapy]

• 2024-01-02 - pemetrexed 500mg/m2 726mg NS 100mL 10min + cisplatin 75mg/m2 100mg NS 350mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-12-12 - pemetrexed 500mg/m2 726mg NS 100mL 10min + cisplatin 75mg/m2 100mg NS 350mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-09

[reconciliation]

A repeat prescription for Anoro Ellipta for the patient’s COPD, issued on 2023-11-15 by our pulmonologist, has been added to the active medication list.

[reduced CEA growth after pemetrexed-cisplatin initiation]

The patient’s CEA level doubled within a month, from 2023-11-14 to 2023-12-15. Notably, this rapid increase seems to have slowed down in the following 21 days (2023-12-15 to 2024-01-05), with only a 12% increase observed. The initiation of pemetrexed + cisplatin therapy on 2023-12-12 may be contributing to this slowdown.

• 2024-01-05 CEA (NM) 383.080 ng/ml
• 2023-12-15 CEA (NM) 341.960 ng/ml
• 2023-11-14 CEA (NM) 176.550 ng/ml
• 2023-09-15 CEA 49.34 ng/mL
• 2023-08-23 CEA 20.17 ng/mL

700289323

240108

[MedRec]

==========

2024-01-08

[reconciliation]

The medications prescribed by both your cardiologist and psychosomatic medicine specialist on 2023-10-19 are currently in use without any discrepancies. These repeat prescriptions will expire soon. Please remind the patient to consider scheduling follow-up appointments with both specialists before the prescriptions expire, if clinically necessary.

701111632

240108

[MedRec]

• 2024-01-04 ~ 2024-01-08 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Invasive carcinoma (NST, no special type) of the left breast, stage pT2N1a (2/21)(cM0); pStage: IIB, ER (+, 90 %), PR (+, 70 %), HER-2/Neu (-, score=1+); HER2 Dual ISH: (-, non-amplified), s/p MRM and axillary lymph nodes dissection, chemotherapy, radiotherapy, and status during endocrine therapy, with multiple bone metastases, stage IV
    • Right lower lung pneumonia, sputum culture: Mixed normal flora Growth:4+
    • Hypokalemia
    • Oral candidas
  • CC
    • for fever without comtrol for 10 days
  • Present illness
    • This 54 year-old woman has invasive carcinoma (NST, no special type) of the left breast, stage pT2N1a (2/21)(cM0); pStage: IIB, ER (+, 90 %), PR (+, 70 %), HER-2/Neu (-, score=1+); HER2 Dual ISH: (-, non-amplified), s/p MRM and axillary lymph nodes dissection on 2016-08-04, Chemotherapy was started on 2016-09-02 and completed on 2017-03-27.
    • Nolvadex since 2017-04-14. Completion of radiotherapy on 2017-06-16.
    • Regular followed up and abdominal echo showed Hepatic tumor, rule out metastatic tumor on 2021/01/19.
    • Followed up ABD CT showed the largest one measuring 1.5 x 0.7 cm at S2, are noted again, stable in size and feature and a hemangioma 0.7 cm in the spleen is suspected on 2021/01/29.
    • Bone scan also was done on 2021/03/16, image showed in comparison with the previous study on 2016/07/21, the lesions in the sternum and lower T-spine are new. Bone metastases should be considerd.
    • 2021/04/20 E2 <15.0 pg/mL, FSH 31.14 mIU/mL. Whole body PET scan on 2021/04/13 showed glucose hypermetabolism in the sternum and T11 spine, compatible with bone metastases.
    • Under the impression of Invasive carcinoma (NST, no special type) of the left breast, stage pT2N1a (2/21)(cM0); pStage: IIB, ER (+, 90 %), PR (+, 70 %), HER-2/Neu (-, score=1+); HER2 Dual ISH: (-, non-amplified), s/p MRM and axillary lymph nodes dissection, chemotherapy, radiotherapy, and status during endocrine therapy, with newly identified recurrence with multiple bone metastases, stage IV, /p RT and Kisqualis permitted in May 2021. but declined in April 2023, /p Aromasin since 2023/11.
    • Follow up chest CT on 2023/08/19 showed left upper lobe tiny nodule, right middle lobe ground glass nodule stationary and bone meta is found.
    • Follow up bone scan on 2023/10/9 showed increased tracer uptake in the sternum and T11 spine come to more evident, indicating metastatic bone disease in progression.
    • She was diagnosed with influenza B on 2023/12/25 and took antiviral drugs at my own expense. But, she still have a fever up to 39.1C at LMD and Tamiflu for 5 days productive cough (yellowish sputum) with sore throat for 7 days, so she was brought to our ED for help on 2024/01/03.
    • CXR showed pneumonia over RLL. Lab data showed WBC 3400/uL, CRP 3.6mg/dL, ALT 71U/L and AST 79U/L, normal renal function.
    • Initial antibiotic as Cravit for infection control. Under the impression of RLL pneumonia, so she was admitted on 2024/01/04.
  • Course of inpatient treatment
    • After admission, she received Cravit for pneumonia control. Throat swab was done for oral candidas and we gave Nystatin treatment. After treatment, her cough with sputum decrease and no fever, so she can be discharged and take oral antibiotic going back home on 2024/01/08. OPD follow up is arranged.
  • Discharge prescription
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Z-cough (benzonatate 100mg) 1# TID
    • Cravit (levofloxacin 500mg) 1.5# QDAC

700179585

240105

[History]

• Left iavasive ductal carcinoma of breast (2023/09/21): Femara and Palbociclib
• Infiltrating tubulolobular carcinoma (2006): chemotherapy, radiotherapy (21 times) and tamoxifen

[exam findings]

• 2023-12-30 CXR supine
  • S/P PICC catheter insertion via right forearm.
  • Pleura effusion of right and left costal-phrenic angle
  • S/P pigtail catheter implantation at bilateral CP angle.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2023-12-29 SONO - chest
  • Right massive pleural effusion post pig-tail insertion.
• 2023-12-22 MRI - brain
  • No evidence of brain metastasis. Cerebral white matter T2-hyperintensities, stationary as compared with scan MRIs.
• 2023-12-20 SONO - chest
  • Pleural effusion, moderate, left
  • Pleural effusion, moderate, oragnized, right
  • Atelectasis, LLL, RLL
  • Pleural thickening, diffuse
• 2023-12-15 Tc-99m MDP bone scan
  • Increased activity in the middle and lower T-spines, L3-5 spines and bilateral S-I joints. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2023-12-14 CXR
  • S/P PICC catheter insertion via right forearm.
  • Pleura effusion of right and left costal-phrenic angle
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
• 2023-12-14 Cardiac Catheter
  • SvO2 was also check, it revealed 76 %.
  • Estimated Fick Cardiac index 2.44 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
  • Estimated Fick cardiac output 3.88 L/min. (nomral cardiac output range 5~6 L/min)
• 2023-12-14 SONO - chest
  • Pleural effusion, moderate and organized, right
  • Pleural effusion, moderate, left
  • Atelectasis, RML, RLL and LLL
  • Lung nodule, left
  • Pleural thickening, bilateral
• 2023-12-12 CXR erect
  • Rt greater than Lt, large volume of bilateral pleural effusions
  • Regression of Rt pleural effusion s/p thoracocentesis
  • Consolidation and volume reduce over lower lung zones dependent lung parenchyma.
• 2023-12-12 CT - chest
  • without contrast enhancement, coronal and sagittal reconstructed images shows:
    • large volume of bilateral pleural effusions.
    • lungs: partial posterior atelectasis of both lower lobes.
      • mild interstitial and alveolar lung edema at nondependent LUL, RML, and RUL r/o lymphangitic infiltration.
    • Mediastinum and hila: no enlarged LN or mass.
    • Thoracic aorta: normal caliber,
    • Central pulmonary arteries: normal caliber.
    • Heart: normal size of cardiac chambers.
    • Chest wall and visible lower neck: absence of Rt breast,
      • skin thickening over left breast, anterior chest wall.
    • Visible abdominal-pelvic contents: Rt renal stone measuring 0.4cm.
    • Visualized bones: small blastic change in multiple vertebrae, may be bony metastasis
• 2023-12-12 ECG
  • Sinus tachycardia
  • Cannot rule out Inferior infarct, age undetermined
  • Possible Anterior infarct, age undetermined
• 2023-12-12 CXR erect
  • Rt greater than Lt, moderate bilateral pleural effusions
  • Consolidation and volume reduce over lower lung zones dependent lung parenchyma.
  • elongated and tortuosity of thoracic aorta
• 2023-12-12 SONO - chest
  • Right thorax: large amount, septated pleural effusion s/p drainage twice; total 250cc yellowish fluid was drained.

[chemotherapy]

• 2024-01-04 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min (Gemzar weekly)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-12-21 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min (Gemzar weekly)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-12-15 - gemcitabine 800mg/m2 1200mg NS 250mL 30min (Gemzar weekly)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

700712591

240105

[lab data]

2023-12-05 EBV DNA quantative PCR <35 IU/mL
2023-12-04 HCV RNA-PCR quantative Target Not Detected IU/mL

2023-11-28 HBsAg Nonreactive
2023-11-28 HBsAg (Value) 0.35 S/CO
2023-11-28 Anti-HCV Reactive
2023-11-28 Anti-HCV Value 14.16 S/CO
2023-11-28 Anti-HBc Nonreactive
2023-11-28 Anti-HBc-Value 0.21 S/CO
2023-11-28 Anti-HBs 1.51 mIU/mL

[exam findings]

• 2024-01-03 Pap Smear
  • Moderate dysplasia (CIN2)
• 2024-01-03 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 39 dB HL; LE 38 dB HL.
  • RE normal to moderate mixed type HL.
  • LE normal to moderately severe mixed type HL.
• 2023-11-30 PET scan
  • Glucose hypermetabolism involving the nasopharynx, more prominent at the right side. Primary nasopharyngeal malignancy may show this picture.
  • Glucose hypermetabolism in a left retropharyngeal lymph node. Metastatic lymph node may show this picture.
  • Mild Glucose hypermetabolism in some bilateral neck level II and right neck evel Ib lymph nodes. The nature is to be determined (inflammation? metastatic lymph nodes of low FDG uptake?). Please correlate with other imaging modalities for further evaluation.
  • Glucose hypermetabolism in some focal areas in the maxilla and mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG uptake may show this picture.
• 2023-11-29 MRI - nasopharynx
  • Indication: NPC
  • Neck MRI without/with Gadolinium-based contrast enhancement shows:
    • abnormal thickening of bilateral nasopharyngeal mucosa, especially on right side, compatible with nasopharyngeal carcinoma (NPC). There is no involvement to parapharngeal space, nor pterygoid and prevertebral muscles. T1 disease is favored.
    • enlarged lymph nodes at bilateral retropharyngeal spaces, bilateral level Ib and II, compatible with N2 disease.
  • Impression:
    • NPC, T1N2.
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:T1(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
• 2023-11-17 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopahrynx, right, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
  • IHC stain: CK (+).
• 2023-11-17 Nasopharyngoscopy
  • Findings
    • Some clear mucus content at nasopharynx, right nasopharyngeal Rosenmullar fossa
    • smooth oropharynx, hypopharynx and patent airway.
  • Dx, Conclusion
    • Postnasal dripping.
    • right nasopharyngeal lesion, r/o cyst or tumor

[MedRec]

• 2023-11-28 ~ 2023-11-30 POMR Ear Nose Throat Huang TongCun
  • Discharge diagnosis
    • Malignant neoplasm of nasopharynx, cT1N2M0, stage III
  • CC
    • Lumping throat, dry cough, easy choking for 2 months
  • Present illness
    • This 72-year-old woman was a HCV carrier for more than 10 years. Lumping throat, dry cough, and easy choking were noted for 2 months and worsened recently. Hoarseness was noted too. She denied alcohol drinking, smoking and betel nut chewing. Neigher body weight loss nor poor appetite were noted. She went to our ENT OPD for help. Physical exam showed right nasopharyngeal smooth bulging tumor at Rosenmuller fossa and no neck mass. Fiberscopic exam showed smooth oropharynx and hypopharynx.
    • Biopsy of the tumor was done, and the pathology report revealed non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B). Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, the patient was admitted for cancer work-up.        
  • Course of inpatient treatment
    • After admission, serial tests were arranged for tumor staging work up.
    • Nasopharyngeal MRI showed nasopharyngeal carcinoma T1N2M0, stage:III.
    • Abdominal sonography showed gall stones and GB slugde.
    • PET was done and the result was pending.
    • GI man was consulted for HCV, and check a-Fetoprotein and HCV RNA PCR quantative was suggested.
    • Under relative stable condition, the patient was dishcarged with OS/ Dental/ ENT OPD follow up.     

[radiotherapy]

• 2023-12-07 SOAP Radiation Oncology Huang JingMin
  • S: For CCRT due to nasopharyngeal carcinoma.
    • PI: Incidental finding nasopharyngeal tumor at TuCheng Hospital. nasopharyngeal carcinoma was proved at our hospital. Due to old age, CCRT then C/T was suggested by medical oncologist.
    • Family history: (mother: nasopharyngeal carcinoma)
    • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
    • Personal Hx: DM (-); HTN (-)
    • Previous RT Hx: (-)
  • A:
    • Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B) of the nasopharynx, stage cT1N2M0.
  • P: CCRT then adjuvant chemotherapy is indicated for this patient with the following indicators: NPC, stage cT1N2M0. The medical oncologist opinion: Due to old age, suggest CCRT then C/T.
    • Goal: curative
    • Treatment target and volume: nasopharyngeal tumor to bilateral neck
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 5000cGy/25 fractions of the nasopharyngeal to bilateral neck, and 7000cGy/35 fractions of the nasopharyngeal tumor to involed neck nodal lesions.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2023-12-13.
    • According to the patient and her family statement, the pre-RT dental evaluation: no dental extraction.
• 2023-11-30 SOAP Oral and Maxillofacial Surgery He ChengHan
  • S
    • Ask for oral examination
    • pre-CCRT dental evaluation
  • O
    • Panoramic findings:
      • Missing: 16,17,24_27,3537,46,47
      • Impaction: nil
      • Crown and Bridge: 13,14,42X31-32,43X45
      • Caries: nil
      • retained root:23
      • Periodontal condition: chronic periodontitis
    • multiple questionable teeth were present
  • A/P
    • Take panoramic film for evaluation
    • Explain the findings and treatment plan to the patient (multiple teeth might be extracted for prevention).
    • patient understands but chose to receive CCRT first.

[chemotherapy]

• 2024-01-05 - cisplatin 40mg/m2 64mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited with cisplatin) (CCRT. Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

700039857

240104

[exam findings]

• 2023-11-03 MRI - nasopharynx
  • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T: 1(T_value) N: 0(N_value) M: 0(M_value) STAGE: I(Stage_value)
• 2023-10-30 Patho - larynx biopsy
  • Labeled as “Arytenoid and aryepiglottic fold uneven mucosal surface, left”, LMS biopsy — squamous cell carcinoma in situ (CIS)
  • Section shows squamous cell carcinoma in situ (CIS).
• 2023-10-27 Bronchodilator Test
  • poor done, difficult interpretation
  • Mild restrictive ventilatory impairment
  • with response to bronchodilator, AHR or learning effect?
• 2023-10-26 Miniprobe Endoscopic Ultrasound
  • Diagnosis：
    • Esophageal cancer, cT3NxMx, upper to lower esophagus
    • Rule out left dysplastic arytenoid cartilage mucosal lesion
    • Gastric mucosal lesions, rule out gastric cancer, upper body, GC, s/p biopsy
    • Superficial gastritis and atrophic gastritis
  • Suggestion:
    • Consider to consult ENT for left arytenoid cartilage mucosal lesion biopsy
    • Pursue the pathology report
• 2023-10-25 Tc-99m MDP bone scan
  • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change, bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, S-I joints, and hips.
• 2023-10-24 PET
  • Glucose hypermetabolism in the middle portion of the esophagus, compatible with primary esophageal malignancy.
  • Mild glucose hypermetabolism in three adjacent lymph nodes. Metastatic lymph nodes of low FDG uptake can not be ruled out. Please correlate with other imaging modalities for further evaluation.
  • Glucose hypermetabolism in a right supraclavicular lymph node. A metastatic lymph node may show this picture.
  • Glucose hypermetabolism in the region about the left posterior aspect of the cricoid cartilage. The nature is to be determined. Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumultion in both kidneys. Physiological FDG accumulation may show this picture.
• 2023-10-23 MRI - brain
  • Old lacunes in bilateral basal ganglia. Cerebral small vessel disease. General brain atrophy. Venous angioma in left cerebellum.
• 2023-10-21 CT - chest
  • Indication: Esophageal cancer survey
  • Chest CT with and without IV contrast ehnancement shows:
    • Wall thickening at middle third esophagus measuring 5.5cm in largest dimension. Regional lymph nodes (n＝4) is found.
    • Some reticulation at right lower lobe is found. Previous aspiration is considered.
    • Bilateral renal cysts are found. Polycystic disease is considered.
  • Imp:
    • Compatible with esophageal cancer with regional lymph nodes. No evidence of distant meta.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-10-16 Patho - stomach biopsy
  • Esophagus, 30 cm to 33 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
  • Section shows pieces of squamous mucosa with infiltration of nests of neoplastic squamous cells.
• 2023-10-16 EGD
  • Diagnosis:
    • Esophageal polypoid lesion, 30cm to 33cm below incisors, s/p biopsy (B)
    • Gastric mucosal lesion, upper body, GC, s/p biopsy (A)
    • Mucosal lesion, left arytenoid cartilage.
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis and atrophic gastritis
  • Suggestion:
    • ENT OPD for mucosal lesion, left arytenoid cartilage.
    • Pursue pathology report
• 2023-10-16 SONO - abdomen
  • R/o polycystic kidney disease

[MedRec]

• 2023-12-15 SOAP Radiation Oncology Wang YuNong
  • S
    • Diagnosis:
      • Esophageal ca, cT3N2M0
      • Hypopharygneal ca, cT1N0M0.
    • However, the Rt SCF LAP could be counted as from hypopharynx, and the staging won’t be the same.
    • CC: can’t swallow saliva.
  • O
    • Since 2023-12-08 RT to the hypophayrnx and bil. neck: 12 Gy/ 6 fx. The esophagus and adjacent lymphatic drainage area: 10.8 Gy/ 6 fx.
    • Chest CT showed esophageal cancer, middle third, cT2N2M0
    • 2023-10-26) EUS showed:
      • Esophageal cancer, cT3NxMx, upper to lower esophagus
      • Rule out left dysplastic arytenoid cartilage mucosal lesion
      • Gastric mucosal lesions, rule out gastric cancer, upper body, GC, s/p biopsy
  • Plan:
    • RT to the hypopharynx and bil. neck: 50 Gy/ 25 fx.
    • The hypopharyngeal tumor and Rt SCF LAPs: 70 Gy/ 35 fx.
    • The esophagus and adjacent lymphatic drainage area: 45 Gy/ 25 fx.
    • The esophageal tumor: 50.4 Gy/ 28 fx.
• 2018-01-12 SOAP Orthopedics Lin KunHui
  • diagnosis
    • Synovitis and tenosynovitis, unspecified [M65.9]
    • Olecranon bursitis [M70.22]

[consultation]

• 2023-11-02 Oral and Maxillofacial Surgery
  • Q
    • for perpare CCRT evaluation
    • This 68 year old man is a case of Squamous cell carcinoma of esophageal cancer, middle third, moderately differentiated, cT2N2M0, stage IIIB &　hypophargenal cancer (SCC). We need expertise to evaluate his condition thanks!
  • A
    • This is a 68-year-old male patient recently diagnosed with esophageal cancer and laryngeal cancer and is scheduled for concurrent chemoradiotherapy, and we were consulted for pre-CCRT dental evaluation.
    • O:
      • Full mouth multiple residual roots and severe periodontitis was noted.
      • Poor oral hygiene was noted.
      • Multiple caries was revealed by radiographic examination.
    • P:
      • Explained the findings and treatment plan to the patient and his family.
      • Suggest extraction of tooth 16, 24, 26, 34, 42, 43
      • Patient wanted to consider.
• 2023-10-26 Radiation Oncology
  • Q
    • This 68-year-old man, had past history of hypertension and a smoker.
    • He had suffered from dysphagia for solid material with sorethorat for 1~2 months, associated with body weight loss 13~14 kg in 2-3 month.
    • He came to GI OPD and done PES and biopsy showed esophageal cancer, SCC.
    • This time, he admission for esophageal cacner staging.
    • Chest CT show esophageal cancer, middle third, cT2N2M0
    • Arrange on port A and jejunostomy on 10/30.
    • We would like to consult for CCRT further treatment. Thank you.
    • Sincerely request your help to evaluate and manage this patient.
  • A
    • 2023-10-26 EUS showed:
      • Esophageal cancer, cT3NxMx, upper to lower esophagus
      • Rule out left dysplastic arytenoid cartilage mucosal lesion
      • Gastric mucosal lesions, rule out gastric cancer, upper body, GC, s/p biopsy
    • In consideration of the possiblity of hypopharyngeal ca. and gastric ca., I will follow up the biopsy result (Lt hypopharynx and stomach) next Monday (10/30) and discuss the treatment plan with medical oncologist Dr. Hsia accordingly. Thank you very much.
• 2023-10-26 Hemato-Oncology
  • Q
    • This 68 year old man is a case of Squamous cell carcinoma of esophageal cancer, middle third, moderately differentiated, cT2N2M0, stage IIIB. He will received port A insertion and jejunostomy on 2023/10/30. We are consulted for CCRT.
    • Please check HBsAg, Anti HBc, Anti HBs, Anti HCV before chemotherapy.
    • We will disucss with patient about CCRT with PF. Thanks for your consultation.

[surgical operation]

• 2023-10-30
  • Surgery: Laryngomicrosurgery    
  • Finding: Left arytenoid and AE fold uneven mucosal surface
• 2023-10-30
  • Surgery: Feeding jejunostomy + port-A insertion.
  • Finding
    • 8.0 Fr. Polysite, left cephalic vein, cut-down method.
    • 18 Fr. silicon Foley catheter as jejunostomy tube.

[chemotherapy]

• 2023-12-18 - NS 500mL 2hr (before CDDP) + cisplatin 75mg/m2 110mg NS 500mL 4hr + NS 500mL 2hr (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-04

The patient is properly hydrated and Cefim (cefepime) has been dose adjusted for the patient’s renal function. G-CSF (filgrastim) is used for neutropenia. No medication discrepancies are found.

2023-12-19

The entirety of the oral medications listed on the active medication list are compatible with enteral feeding administration.

2023-11-06

All of the oral drugs on the list of active medications can be fed by tube.

700175387

240104

[exam findings]

• 2024-01-01, 2023-12-11 KUB

  • Scoliosis of the L-spine with convex to right side.
  • Wedge deformity at right lateral aspect of L2 vertebral body is noted.

• 2023-12-12 MRI - brain

  • Old lacuna infarcts over right putamen and inferior capsule.
  • One lobulated mass lesion (40.8mm) over left carotid space, encasement of ICA and ECA. R/O neurogenic tumor or enlarged nodes or metastatic lesion. Suggest check enhanced study.

• 2023-10-20 Patho - bone exostosis

  • Labeled as “L4 spine”, CT guided biopsy — diffuse large B cell lymphoma, non-germinal center type.
  • Section shows tissue diffusely infiltrated by diffuse large B cell lymphoma, non-germinal center type.
  • IHC stais: CD3 (focal +), CD20 (-), CD20 repeat stain: (-), CD79a (diffuse +), PAX5 (diffuse +), bcl-2 (+), bcl-6 (+) MUM-1 (+, > 30%), C-myc (-), Ki-67 (90%), CD23 (-), cyclin-D1: (-).

• 2023-10-18 Nerve Conduction Velocity, NCV

  • Findings
    • Prolonged distal latenies in bilateral medial and ulnar CMAPs. Decreased amplitudesin all sampling CMAPs. Slowed CNVs in right medial, bilatal ulnar, peroneal and tibial CMAPs.
    • Proloned distallatencies and slowed NCVs in bilateral medial, ulnr and sural sNAPs.
    • Prolonged f-wave latencies followed all sampling nerve stimulations.
    • Absence of H-refelx peaks followed bilatral tibial nerve stimulations.
  • Conclusions
    • This abnormal NCV study suggested mix-type sensorimotor polyneuropathy superiposed polyradiculopathy.

• 2023-10-17 PET

  • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm and extralymphatic organ involvement as mentioned above (stage IV).
  • In comparison with the previous study on 2022/09/16, the previous FDG avid lesions in the lower mediastinum and upper abdomen are less evident or disappeared. However, more new FDG avild lesions are noted.

• 2023-10-16 CT - chest

  • Indication: Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • Findings:
    • Lungs: dependent band subsegmental consolidation or atelectasis at Rt lower lobe.
    • Chest wall and lower neck: extensive lymphadenopathies in left neck from the level of the nasopharynx to the supraclavicular fossa. enlarged LNs at Rt supraclavicular fossa.
    • Mediastinum and hila: no enlarged LN or mass.
      • mild coronary arterial calcification
    • Thoracic aorta: normal caliber, mild atherosclerotic change of Heart: normal size of cardiac chambers.
    • Pleura: no effusion but Rt posterior pleural thickeing.
    • Visible abdominal-pelvic contents: large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles.
      • a 13mm low attenuation in the spleen.
      • mild soft tissue lesion in para-aortic and para-cava spaces stationary
      • unremarkable of the liver, GB, both adrenal glands, pancreas, and both kidneys.
      • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • Diffuse large B-cell lymphoma, in both sites of diaphgram with extranodal and solid organ sites.

• 2023-10-14 MRI - L-spine

  • Indication: Diffuse large B cell lymphoma, non- GCB, stage III, S/P chemotherapy with R-CHOP
  • Thoraco-lumbar spine MRI without and with IV Gd-DTPA administration shows:
    • Abnormal abundant soft tissue in right low parasinal and psoas muscle regions.
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • Dilated right ureter, likely due to tumor obstruction.
    • A small focal right L4 body leison.
    • Thick and well enhanced nerve roots in low lumbar spine due to tumor infiltration?
    • Correlation with previous imaging study for comparison is suggested.

• 2023-10-13 L-spine AP + Lat. (including sacrum)

  • Scoliosis of the L-spine with convex to right side.
  • Wedge deformity at right lateral aspect of L2 vertebral body is noted. Please correlate with clinical symptom and history.

• 2023-10-12 MRI - brain

  • Imaging finding:
    • Old lacuna infarcts over right putamen and internal capsule.
    • The size of the cerebral ventricles is normal.
    • There is no space occupying lesion in the brain or midline shift of the brain supratentorially or infratentorially.
    • The intracranial vessels are normally signal-void.
    • The paranasal sinuses and mastoid air cells are aerated.
    • The globes, optic nerve and extraoccular muscles are sketchyily intact in the non-FatSat images.
    • 3D TOF MR angiography of circle of Willis reveals no aneurysm or vascular malformation. The intracranial vessels in the territories of anterior, middle and posterior cerebral arteries and vertebro-basilar arteries are of normal in calibres and flows. No focal stenosis is identified.
  • Impression:
    • Old lacuna infarcts over right putamen and internal capsule.

• 2023-10-12 CT - brain

  • Mild cortical brain atrophy. Old right putamen-corona radiata infarct. Abnormal abundant soft tissue mass? in left skull base, anterior lateral C1 region, nature?
  • With abnormal soft tissue in left anterior lateral skull base/C1 region, nature?

• 2023-10-06 Nasopharyngoscopy

  • B cell lymphoma
  • left neck mass, progressive recent weeks

• 2023-10-06 SONO - ENT head and neck soft tissue

  • Clinical Impression/Intent: LEFT NECK MASS LEVEL II
  • Sonographic Impression: LEFT NECK LEVEL II MULTIPLE LAP, ROUND NO CENTRAL HILUM, R/O MALIGNANCY

• YYYY-MM-DD many omitted …

• 2022-09-30 KUB

  • Stool impaction at the abdominal cavity is noted.
  • Phlebolith at pelvic cavity is also found.

• 2022-09-19 CXR

  • Blunted bilateral CP angle is found.

• 2022-09-16 Whole body PET scan

  • The FDG PET findings are compatible with lymphoma involving the huge confluent soft tissue masses in the retroperitoneal space, stomach, multiple focal areas in the abdominal and pelvic cavities and some focal areas in the mediastinum. Please correlate with other clinical findings for further evaluation.

• 2022-09-09 CT - abdomen

  • Findings:
    • There is huge confluent soft tissue masses in retroperitoneal space with total encasement of celiac trunk, superior mesenteric artery, abdominal aorta, and bilateral renal artery. The largest cranial-caudal dimension of this mass measuring 19 cm in size.
      • In addition, There are multiple enlarged nodes in the omentum, mesentery, gastrohepatic ligament, para-aortic space, bilateral common iliac chain.
      • Malignant lymphoma is highly suspected.
    • There is mild ascites in the pelvis.
    • There are minimal pleura effusion in bilateral posterior basal CP angle.
  • Impression:
    • Malignant lymphoma is highly suspected.
      • CT-guided biopsy is indicated.

• 2022-09-08 Patho - stomach biopsy

  • Stomach, AW of low body, biopsy — Diffuse large B cell lymphoma, non- GCB
    
  • Histology type: B-cell neoplasms — Diffuse large B-cell lymphoma (any subtype)
  • Immunohistochemical stain profiles: Ki-67 index: 90%, CK(-), CD20(+), CD3(-, immunoreactive at background T cells), CD10(focal +), MUM-1(+), Bcl-2(+), CD23(-), CD5(focal+), C-myc (-, < 30%), cyclin D1(-).

• 2022-09-08 Esophagogastroduodenoscopy, EGD

  • Highly suspected gastric cancer, Borrmann type III, AW of low body, s/p biopsy
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis, s/p CLO test
  • Pseudodiverticula and deformed bulb

• 2022-09-08 SONO - abdomen

  • Finding: A huge retroperitoneal lesion measured at least 13 cm was noted.
  • Diagnosis: Retroperitoneal tumor, huge

• 2022-09-02 ECG

  • Sinus tachycardia
  • Possible Left atrial enlargement
  • Nonspecific T wave abnormality
  • Abnormal ECG

• 2021-10-12, 2020-11-02 SONO - neurology

  • Mild atheromatous lesions in R subclavian artery.
  • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • Poor temporal windows for transcranial insonation.

• 2019-12-02 Carotid phonoangiograph, CPA

  • Sonographic diagnosis:
    • Mild atheromatous lesions in R distal CCA.
    • Normal extracranial carotid, vertebral, and L intracranial basal cerebral arterial flows.
    • Poor R temporal windows for transcranial insonation.

[MedRec]

• 2017-03-22 SOAP Neurology Xiao ZhenLun
  • Diagnosis
    • Cerebral artery occlusion, with cerebral infarction [I63.511]
    • Essential hypertention, unspecified [I10]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
  • Prescription x3
    • Romicon-A (dextromethorphan, cresolsulfonate, lysozyme) 1# TID
    • Allegra (fexofenadine 60mg) 1# BID
    • Mefno (mephenoxalone 200mg) 1# BID
    • Tonec (aceclofenac 100mg) 1# BID
    • Pentop (pentoxifylline 400mg) 1# BID
    • Robestar (rosuvastatin 10mg) 1# QD
    • Uformin (metformin 500mg) 0.5# BIDCC
    • Bokey (aspirin 100mg) 1# QD

[consultation]

• 2023-12-14 Rehabilitation
  • A
    • P
      • Rehabilitation programs: arrange bedside PT and OT rehabilitation programs.
      • Goal: recondition; maintain ROM; improve endurance and muscle strength.
• 2023-12-12 Radiation Oncology
  • Q
    • for radiotherapy evaluation
    • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non-GCB , stage III s/p R-CHOP and regular follow-up at our OPD.
    • The patient complaints edema at left eye, and Diplopia noted for 2 days, follow-up brain MRI (2023/12/12) revealed 1. Old lacuna infarcts over right putamen and inferior capsule. 2. One lobulated mass lesion (40.8mm) over left carotid space, encasement of ICA and ECA. R/O neurogenic tumor or enlarged nodes or metastatic lesion. Suggest check enhanced study, so we need your help for radiotherapy evaluation, thanks a lot!!
  • A
    • Diagnosis: Diffuse large B cell lymphoma, non-GCB, origin from stomach, stage III s/p 7th R-CHOP on 2023/04/28 with relapse and involvement of right low paraspinal and psoas muscle & nerve roots in low lumbar spine, r stage IV; ECOG 3.
    • Plan: R/T to left retro-pharyngeal tumor for 2500cGy/10 fx is suggested for symptom control & neurological sequela. CT simulation is arranged on Dec 13 15:30 and possible RT toxicity is told. Diet education.
• 2023-10-26 Rehabilitation
  • A
    • Due to deconditioning, we were consulted for bedside PT rehabilitation programs
    • Premorbid status
      • Walk ID / BADL ID
    • Physical examination
      • 2023/10/26 20:05 T/P/R: 36.2’C / 119bpm / 18bpm BP:154/79mmHg
      • Body weight: 42.5
        • Consciousness: E4V5M6
        • Cognition: grossly intact
        • Sphincter: urinary and stool incontinence with diaper
        • Muscle power:
          • RUE/RLE 2/2
          • LUE/LLE 4/3
        • Functional status: roll ID; sit up under modA with poor to fair balance
        • BADL: light hygiene modA / heavy hygiene: maxA
    • Assessment
      • Diffuse large B cell lymphoma, non- GCB, involving multiple lymph node regions on both sides of the diaphragm and extralymphatic organ involvement as right psoas muscle, lower lumbar spines, sacrum and possible adjacent nerve roots (stage IV), status post chemotherapy with R-CHOP
      • Old lacuna infarcts over right putamen and internal capsule about 7 years ago with mild left hemiparesis
      • Mix-type sensorimotor polyneuropathy superiposed polyradiculopathy
    • Plan
      • Rehabilitation programs: arrange bedside PT rehabilitation programs.
      • Goal: recondition; maintain ROM; improve endurance and muscle strength.
• 2023-10-18 Radiation Oncology
  • Q
    • for radiotherapy evaluation
    • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non-GCB, stage III s/p R-CHOP and regular follow-up at our OPD.
    • The patient complaints bilateral lower limbs numbness, and right side weakness, T-L spine MRI revealed A small focal right L4 body leison, neck-chest CT: large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles, marginal spurs of multiple vertebrae due to spondylosis, so we need your help for radiotherapy evaluation, thanks a lot!!
  • A
    • Subjective:
      • History: This is a 64 years-old female who has the history of diffuse large B cell lymphoma, non- GCB , stage III s/p 7th R-CHOP on 2023/4/28 and regular follow-up at our OPD. The patient complaints bilateral lower limbs numbness, and right side weakness. Her T-L spine MRI on 10/14 revealed abnormal abundant soft tissue in right low parasinal and psoas muscle regions; dilated right ureter, likely due to tumor obstruction; a small focal right L4 body lesion; thick and well enhanced nerve roots in low lumbar spine due to tumor infiltration. Neck-chest CT showed large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles, marginal spurs of multiple vertebrae due to spondylosis. PET scan showed increased FDG uptake in the right psoas muscle (SUVmax early: 14.12, delay: 17.59), in the lower lumbar spines, sacrum and possible adjacent nerve roots (SUVmax early: 13.30, delay: 18.71); but no FDG uptake over C spines.
        • Previous RT: denied.
        • Other disease: Old CVA at right cerebral artery; hypertension; type II DM; hyperlipidemia with medication control.
        • Family history: denied.
          • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
          • Married. Caregiver: her husband (survivor of buccal cancer s/p OP, R/T ＞ 10 years ago). Job: housewife. Mild or no economic stress at least.
          • Language: Mandarin. Taiwanese.
          • Religion: Buddhism.
    • Objective:
      • General Condition-ECOG: 3.
      • PE, 2023/10/18: Multiple LAPs over bilateral necks and SCFs. Rt upper and lower limb muscle power: only 2/5.
      • Pathology, 2022/9/08, Stomach, AW of low body, biopsy— Diffuse large B cell lymphoma, non- GCB.
      • Images:
        • Brain MRI, 2023/10/12: Old lacuna infarcts over right putamen and internal capsule.
        • T-L spine MRI, 2023/10/14 revealed abnormal abundant soft tissue in right low parasinal and psoas muscle regions; dilated right ureter, likely due to tumor obstruction; a small focal right L4 body lesion; thick and well enhanced nerve roots in low lumbar spine due to tumor infiltration.
        • CT, 2023/10/16: Chest wall and lower neck: extensive lymphadenopathies in left neck from the level of the nasopharynx to the supraclavicular fossa. Enlarged LNs at Rt supraclavicular fossa. Pleura: no effusion but Rt posterior pleural thickening. Large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles. A 13mm low attenuation in the spleen. Mild soft tissue lesion in para-aortic and para-cava spaces, stationary. Imp: Diffuse large B-cell lymphoma, in both sites of diaphragm with extranodal and solid organ sites.
        • PET scan, 2023/10/17: There was increased FDG uptake in the left neck and left supraclavicular lymph nodes (SUVmax early: 23.30, delay: 31.55), right lower neck and right supraclavicular lymph nodes (SUVmax early: 16.33, delay: 24.67), bilateral axillary lymph nodes (SUVmax early: 17.01, delay: 26.20), some mediastinal lymph nodes (SUVmax early: 13.49, delay: 23.66), multiple right abdominal and pelvic lymph nodes (SUVmax early: 19.24, delay: 25.43), right inguinal lymph nodes (SUVmax early: 11.61, delay: 16.12) and possible lymph nodes in bilateral thighs (SUVmax early: 19.01, delay: 31.93).
          • Besides, there was increased FDG uptake in the right psoas muscle (SUVmax early: 14.12, delay: 17.59), in the lower lumbar spines, sacrum and possible adjacent nerve roots (SUVmax early: 13.30, delay: 18.71). IMP: The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm and extralymphatic organ involvement as mentioned above (stage IV). In comparison with the previous study on 2022/09/16, the previous FDG avid lesions in the lower mediastinum and upper abdomen are less evident or disappeared.
        • Shoulder X-ray, 2023/10/13: No significant abnormality is seen in this study.
    • Diagnosis: Diffuse large B cell lymphoma, non- GCB, origin from stomach, stage III s/p 7th R-CHOP on 2023/04/28 with relapse and involvement of right low parasinal and psoas muscle & nerve roots in low lumbar spine, r stage IV; ECOG 3.
    • Plan: C spine MRI may be considered to R/O tumor involvement of C spinal cord and nerve root or intramedullary lesion. R/T to L spines, nerve roots and psoas muscle for 2500cGy/10 fx is suggested for symptom control & neurological sequela. CT simulation is arranged on Oct 19 08:30 and possible RT toxicity is told. Diet education and psychological support.
• 2023-10-17 Neurology
  • Q
    • for bilateral lower limbs numbness, and right side weakness.
    • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non-GCB , stage III s/p R-CHOP and regular follow-up at our OPD.
    • The patient complaints bilateral lower limbs numbness, and right side weakness, T-L spine MRI revealed A small focal right L4 body leison, neck-chest CT: large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles, marginal spurs of multiple vertebrae due to spondylosis, so we need your help for evaluation, thanks a lot!!
  • A
    • This 64 y/o female p’t is a case of olf right hemisphere infarction, HTN, DM, and hyperlipidemia with regular F/U at our OPD. He is also a caw of B-cell lymphoma with regular F/U at Hema OPD.
    • Since 2023/08/24, easy chocking and bulatral leg numbness was noted. She visited our ER on 8/29 and I arranged brain CT for excluded recurrent stroke in left hemisphere but no no newly lesion was noted.
    • This time, she admitted at Hema ward. Due to right leg weakness became worse, brain MRI and L-spine MRI was performed. So, we were consulted for further evaluation .
      • E4V5M6
      • Pupil: 3+/3+
      • EOM: Full
      • dysarthria:-
      • Dysphagia:+/- (no obvious chnage when compared to 8/29)
      • sensory:Bilateral leg numbness (smilar to 8/29)
      • MP:Rl: 2, RU:４Left limbs: all 4
      • DTR: bilateral knee:+, left ankle:+, right ankle: -
    • Imp:
      • right lumbosacral radiculopathy, highly suscepted tumor related
      • old Left henmisphere infarction
      • B-cell lymphoma
      • DM
      • HTN
      • Hyperlipidemia
    • Suggestion:
      • We agreed your treatment plan for tumor biopsy
      • may consider arrange lower limb NCV study (motor, sensory, F-wave, H-reflex), but this study only for pre-treatment baseline data collection.
      • Due to complainted right leg radiation pain, may increase neurontin to 2# tid, may titrate to 3# tid if necessary
      • Consider tramacet 1# prnHS
      • F/U consultation prn.
• 2023-10-16 Radiation Oncology
  • Q
    • for biopsy at L4
    • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non- GCB , stage III s/p R-CHOP and regular follow-up at our OPD.
    • The T-L spine MRI revealed A small focal right L4 body leison, so we need your help for biopsy, thanks a lot!!
  • A
    • According to the clinical condition and imaging findings, biopsy is indicated.
• 2022-10-24 Infectious Disease
  • Q
    • This time, PortA blood culture yeild Candida albicans. Blood cultrure yield yeast-like, Pending culture result. WBC:18.26 *10^3/uL . we need your help, thank you a lot!
  • A
    • Consultatiaon for anti-fungal Mycamine
      • There was MRSA and Enterococcus bacteremia on 2022-10-14, followed by Candida albicans candidemia on 2022-10-20.
      • Peripheral blood and Port-A blood culture all shows Candida albicans isolate.
      • Use of Candin drug acceptable.
      • Since there is no GNB isolate, further use of Mepem can be stopped.
      • For MRSA bacteremia, Targocid can be shifted to oral Avelox or Cipro as sequential therapy to complete 3-week treatment course.
    • Suggestion:
      • DC Mepem and fluconazole
      • Add oral Avelox or Cipro
      • Add Mycamine 100mg iv qd for one week first
      • Repeat Port-A and peripheral blood culture 3 days later, to see if there is sterile blood.
• 2022-10-15 Infectious Disease
  • A
    • Consultation for Mepem antibiotic
      • Covid-19 related right lung pneumonia and post-chemotherapy neutropic fever with severe sepsis case.
      • Now Mepem and Targocid use.
      • Preliminary blood culture shows GPC isolate.
    • Suggestion:
      • Continue Mepem and Targocid for 3 days first.
      • Check blood and sputum culture report for further antibiotic adjustment.

[immunochemotherapy]

• 2024-01-04 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 2000mg NS 500mL 2hr D5 (R-ESHAP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
• 2023-12-11 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 2000mg NS 500mL 2hr D5 (R-ESHAP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
• 2023-11-16 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 2000mg NS 500mL 2hr D5 (R-ESHAP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
• 2023-10-24 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 1500mg NS 500mL 2hr D5 (R-ESHAP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
• 2023-04-28 - rituximab 375mg/m2 550mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
  • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
• 2023-04-07 - rituximab 375mg/m2 550mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
  • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
• 2023-02-24 - rituximab 375mg/m2 540mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
  • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
• 2023-02-01 - rituximab 375mg/m2 540mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
  • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
• 2023-01-17 - rituximab 375mg/m2 540mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
  • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
• 2022-12-22 - (R-CHOP Q3W)
• 2022-12-01 - (R-CHOP Q3W)
• 2022-10-03 - (R-CHOP Q3W)

R-ESHAP (rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) - from 2023-11-17 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-patients-who-are-medically-fit

• Administration - R-ESHAP refers to
  • rituximab 375 mg/m2 on day 1,
  • etoposide 40 mg/m2/day as a one-hour infusion on days 1 to 4,
  • methylprednisolone 250 to 500 mg/day as a 15-minute infusion on days 1 to 5,
  • cisplatin 25 mg/m2/day as a continuous infusion from day 1 to 4, and
  • cytarabine 2 g/m2 as a two-hour infusion on day 5,
  • every three or four weeks.
• Adverse effects
  • Hematologic toxicity is universal, with significant rates of neutropenic fever (30 percent) if growth factors are not used.
  • Other AEs (eg, nausea, vomiting, diarrhea, nephrotoxicity, electrolyte disturbances) are generally mild.
• Outcomes
  • A retrospective study of 163 patients reported that R-ESHAP for relapsed DLBCL was associated with a 75 to 86 percent ORR and 41 to 50 percent CR, while for primary refractory DLBCL, ORR was 33 percent and CR was 8 percent.

==========

2024-01-04

The latest lab results, drawn on 2024-01-03, show that the patient’s neutropenia has resolved.

• 2024-01-04 WBC 11.05 x10^3/uL
• 2023-12-27 WBC 11.88 x10^3/uL
• 2023-12-25 WBC 0.33 x10^3/uL ***
• 2023-12-18 WBC 1.21 x10^3/uL **
• 2023-12-07 WBC 28.29 x10^3/uL

The sputum aerobic culture, drawn on 2023-12-22, grew S. aureus (MRSA). The patient was started on Targocid (teicoplanin) on 2023-12-12 and continued on this medication until 2024-01-02. Avelox (moxifloxacin) was started on 2023-12-27 and is still being used.

Both CRP and PCT levels on 2024-01-04 were undetectable. Given this, kindly reassess whether the patient still exhibits any potential signs of infection.

2023-11-17

Leukopenia was observed in early Nov, approximately 1 to 2 weeks after the patient first started the R-ESHAP regimen on 2023-10-24. The WBC reading has since returned to almost normal, and no further treatment is currently required.

• 2023-11-16 WBC 3.29 x10^3/uL
• 2023-11-08 WBC 1.28 x10^3/uL ** Granocyte (lenograstim 250ug administered)
• 2023-11-02 WBC 1.83 x10^3/uL **
• 2023-10-30 WBC 4.47 x10^3/uL
• 2023-10-22 WBC 5.52 x10^3/uL
• 2023-10-19 WBC 6.69 x10^3/uL

2022-10-14

• Tube feeding is possible with all oral medications included in the active prescription.

• The CNS depressant estazolam might enhance the CNS depressant effect of tramadol, so please monitor any adverse effects as always.

2022-10-03

• In the case of this patient, who has recently been diagnosed with DLBCL, RCHOP might be an option for treatment.
• Under prescribed medications, blood pressure and blood sugar levels were in acceptable ranges.
• Serum electrolyte imbalances (lab data 2022-10-03) are treated with corresponding supplements currently.
• Hypoalbuminemia (2.6 g/dL 2022-10-03), could it be due to albumin loss in the urine in the nephrotic syndrome? due to decreased hepatic albumin synthesis?
• There is no issue with the active prescription.

700532258

240104

[exam findings]

• 2023-12-26 CXR erect
  • Solitary pulmonary nodule at RUL.
• 2023-12-26 SONO - abdomen
  • Two hepatic cyst measuring 1 cm and 0.8 cm at S3.
  • Multiple gallstones (< 1 cm) are noted.
• 2023-10-11 CT - chest
  • Indication: breast cancer with lung metastasis
  • With and without contrast enhancement CT of chest shows:
    • s/p mastectomy.
    • Mild regression of left axillary lymph nodes.
    • Small nodules in both lung fields, mild in regression.
    • Hyperdense gallstones.
  • Impression
    • Brease CA, s/p operation
    • Lung and left axillary lymph node metastasis, mild in regression
• 2023-10-05 SONO - abdomen
  • Sonography of hepatobiliary system revealed:
    • Left liver cysts (0.66x0.95cm, 0.73x0.91cm).
    • Gallbladder stones (up to 0.86cm).
  • IMP:
    • Left liver cysts (0.66x0.95cm, 0.73x0.91cm). Gallbladder stones (up to 0.86cm).
• 2023-04-10 CT - chest
  • Indication: left breast cancer s/p MRM with lung and LN mets
  • Findings: comparison was made with previous CT dated on 2022/07/07
    • Lungs:
      • multiple nodules as miliary and small nodular patterns in bilateral lungs consistent with lung metastases, seem stationary as compared with CT on 2022/07/07
    • Mediastinum and hila no enlarged LN or mass.
      • old tiny calcified LNs in both hila.
    • Chest wall and lower neck: stastionary of small left axillary LAP as compared with CT on 2022/7/7. s/p Lt MRM.
    • Visible abdominal contents: tiny gall bladder stones.
    • Visualized bones: marginal spurs of vertebrae and no lytic or blastic change.
  • Impression:
    • left breast ca s/p MRM with stationary of lung metastass as compared with CT on 2022/07/07
• 2022-12-27 SONO - abdomen
  • Two hepatic cyst measuring 1 cm and 0.8 cm at S3.
  • Multiple gallstones (< 1 cm) are noted.
• 2022-11-03 CT - abdomen
  • S/P left MRM.
  • Left liver cysts (up to 7.6mm).
  • Hyperplasia of left adrenal gland.
  • Gallbladder stones (2-4mm).
• 2022-10-04 SONO - abdomen
  • Two hepatic cyst measuring 1 cm and 0.8 cm at S3.
  • Multiple gallstones (< 1 cm) are noted.
• 2022-07-07 CT - chest
  • Hx
    • Lt breast ca biopsied at Far Eastern Hospital.
    • Lt breast ca s/p MRM at our hospital on 2013-03-29
    • Adjuvant C/T (FEC) since 2013-04-15
  • Chest CT with and without IV contrast ehnancement shows:
    • Mild atelectatic change at bilateral basal lungs is found.
    • Non-specific lymph nodes are found at left axillary region. In comparison with CT dated on 202-01-20, the lesion is stationary.
    • One calcified dot at right upper lobe up to 0.43cm in largest dimension.
    • There is stone at dependent portion of GB. GB stone(s) are noted.
  • Imp:
    • S/P mastectomy at left side.
    • Non-specific lymph nodes at left axillary region. Stable.
    • Right upper lobe calcified dot. Old granulation is favored.
• 2022-01-20 CT - chest
  • Hx
    • Lt breast ca biopsied at Far Eastern Hospital.
    • Lt breast ca s/p MRM at our hospital on 2013-03-29
    • Adjuvant C/T (FEC) since 2013-04-15
    • AI since 2013-08-26 and extension therapy or E/T 5 yrs
  • Chest CT with and without IV contrast ehnancement shows:
    • Calcified dot at right upper lobe up to 0.3cm in largest dimension is found. (Se9 IM22).
    • Several tiny nodular lesions scattered at both lungs are found. LUng meta is considered. In comparison with CT dated on 2021-08-03, the lesions are stationary.
    • S/P mastectomy at left side.
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • Degenerative change of the bony structure with marginal osteophyte formation is identified.
    • The GB is well distended without soft tissue lesion
  • Imp:
    • S/P mastectomy at left side.
    • Diffuse lung meta. Stationary.
• 2021-09-23 Tc-99m MDP bone scan
  • In comparison with the previous study on 2020/9/29, the lesions in the lower C-spine, lower T-spine and L4-5 spines are either stationary or a little less evident. Degenerative change may show this picture.
  • The previous faint hot spots in bilateral rib cage and the lesion in the distal portion of the sternal body are less evident, possibly more benign in nature.
  • Increased activity in the maxilla and mandible. Dental prolbem may show this picture.
  • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
• 2021-08-03 CT - chest
  • Impression: left breast ca s/p MRM with stationary of lung and left axillary LN metastass as compared with CT on 2021/02/16
• 2021-02-16 CT - chest
  • Impression: left breast ca s/p MRM with stationary of lung metastases and regression of left axillary LN metastass as compared with CT on 2020/09/08.
• 2020-09-29 Tc-99m MDP bone scan
  • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Increased activity in the maxilla and mandible. Dental prolbem may show this picture.
  • Some faint hot spots in bilateral rib cage and mildly increased activity in the distal portion of the sternal body. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.

[MedRec]

• 2023-11-13 SOAP Neurology
  • S
    • 2023/11/13: neurological condition stable
    • 2023/08/21: more cramp, try requip bid
    • 2023/05/29: more cramp, add trental –> improved
    • 2022/12/07: keep plavix qw1357 prevention (self-pay)
    • 2022/09/19: clinical stable, keep current dose, 3m
    • 2022/06/27: clinical stable, 3m
    • 2022/03/30: f/u carotid sono: mild P, right SCA, bil BIF, little progression, f/u carotid sono every year, keep low dose plavix prevention
    • 2022/01/05: less cramp with current dose, 3m
    • 2021/10/13: vital signs stable, 3m
    • 2021/07/19: clinical stable, taper plavix, 3m
    • 2021/04/26: clinical stable, 3m
    • 2021/02/01: less cramp, keep current dose, 3m
    • 2020/12/07: easy cramp, less effect with rivotril, try rivotril +requip, 2m
    • 2020/10/14: NCV: WNL, electrolyte: WNL, easy cramp at night, increase rivotril dose
    • 2020/09/07: left leg soreness and weakness, 1 month, check NCs and ABI
    • 2020/06/15: clinical stable, 3m
    • 2020/03/23: f/u carotid sono: mild P, left BIF, improved, keep current dose, 3m
    • 2020/02/24: no discomfort with plavix, f/u carotid sono for medication adjustment
    • 2020/02/17: gemfibrozil was added at LMD, severe HA with pletaal, try plavix(self-pay)
    • 2020/02/03: epigastric pain with licodin, try pletaal, TG 250, diet control, f/u
    • 2019/11/04: stable, 3m
    • 2019/09/16: less pain but numbness, increase licodin dose
    • 2019/07/22: WBC 4200, Cr 0.7, stable with current dose
    • 2019/06/24: stable with current dose, f/u CBC and renal function
    • 2019/06/17: little effect, no sleepy, increase dose, carotid sono: mod P, RSCA, mild P, bil BIF, epigastric pain with ASA, try licodin
    • 2019/06/03: more fullness and tingling discomfort over bil feet, less effect with neurontin this time, try lyrica; neck stiffness and pain and limited motion, try celebrex PRN
    • 2019/05/06: HA with cerenin, less tingling pain and numbness, consider to taper neurontin next time
    • 2019/04/08: no discomfort with cerenin, keep current dose, increase neurontin dose
    • 2019/03/25: HA with trental, try cerenin, check electrolyte & vit B12, Hb
    • 2019/02/25: s/s recurred, related to weather change, re-add rivotril, trental & neurontin
    • 2018/07/02: improved, more cramp recently, increase rivotril dose, 2m
    • 2018/06/04: no response to neurontin 2# bid, try cymbalta
    • 2018/05/07: sometimes more pain and sleepy, DC TCa, increase neurontin
    • 2018/03/12: sometimes more tingling discomfort, increase neurontin
    • 2018/01/15: sometimes more tingling discomfort, related to weather change
    • 2017/12/18: still numbness, no severe pain, try neurontin
    • 2017/11/20: blood exam: WNL, less tingling pain, still numbness, increase trental, keep TCA
    • 2017/11/06: still bil feet numbness, try TCA, check metabolic condition
    • 2017/10/9: HA with TCA, clinical improved with rivotril & trental, increase dose
    • 2017/09/25: NCV: right C4 radiculopathy and left L45 radiculopathy; less cramp and tingling pain still numbness, try TCA
      • bil feet numbness and tingling pain, easy cramp, years, more severe after op
    • Hx
      • Lt breast ca biopsied at Far Eastern Hospital.
      • Lt breast ca s/p MRM at our hospital on 2013-03-29
      • Adjuvant C/T (FEC) since 2013-04-15
      • AI since 2013-08-26 and extension therapy
  • Diagnosis
    • Cerebral atherosclerosis [I67.2]
    • Polyneuropathy [G62.9]
    • Cramp [R25.2]
  • Prescription x3
    • Lyrica (pregabalin 75mg) 1# Q12H
    • Rivotril (clonazepam 0.5mg) 1# HS
    • Pentop (pentoxifylline 400mg) 0.5# HS
    • Mirapex (pramipexole 0.375mg) 1# HS

[chemotherapy]

• 2024-01-03 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-12-06 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-11-10 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-10-11 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-09-14 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-08-17 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-07-19 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-06-21 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-05-25 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-04-26 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-03-30 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-03-01 - fulvestrant 500mg IM - Zhang YaoRen
• 2023-02-01 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-12-28 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-11-30 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-11-02 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-10-05 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-09-07 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-08-10 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-07-13 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-06-15 - fulvestrant 500mg IM - Zhang YaoRen OPD
• 2022-05-18 - fulvestrant 500mg IM - Zhang YaoRen OPD
• 2022-04-20 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-03-23 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-02-23 - fulvestrant 500mg IM - Zhang YaoRen
• 2022-01-26 - fulvestrant 500mg IM - Zhang YaoRen
• 2021-12-29 - fulvestrant 500mg IM - Zhang YaoRen
• 2021-12-01 - fulvestrant 500mg IM - Zhang YaoRen
• 2021-11-03 - fulvestrant 500mg IM - Zhang YaoRen
• 2021-10-06 - fulvestrant 500mg IM - Zhang YaoRen
• 2021-09-08 - fulvestrant 500mg IM - Zhang YaoRen
• 2021-08-11 - fulvestrant 500mg IM - Zhang YaoRen
• 2021-06-16 - fulvestrant 500mg IM - Zhang YaoRen OPD
• 2021-05-19 - fulvestrant 500mg IM - Zhang YaoRen OPD
• 2021-04-21 - fulvestrant 500mg IM - Zhang YaoRen
• 2021-03-24 - fulvestrant 500mg IM - Zhang YaoRen
• 2021-02-24 - fulvestrant 500mg IM - Zhang YaoRen
• 2021-01-27 - fulvestrant 500mg IM - Zhang YaoRen
• 2020-12-30 - fulvestrant 500mg IM - Zhang YaoRen
• 2020-12-02 - fulvestrant 500mg IM - Zhang YaoRen
• 2020-10-07 - fulvestrant 500mg IM - Zhang YaoRen

Ibrance (palbociclib 125mg -> 100mg since 2024) 1# QDCC - 2022-09-07 ~ 2024-01-24 ongoing (21 days of 28 days) Kisqali (ribociclib 200mg) 3# QD - 2020-10-07 ~ 2022-08-03 (21 days of 28 days)

Femara (letrozole 2.5mg) 1# QD - 2017-02-20 ~ 2018-10-01 (repeat prescription)

==========

2024-01-04

[neutropenia]

The patient’s WBC count has been gradually declining for a long time. In late 2023, the count dropped to less than 2K/uL, which is considered grade 3 neutropenia.

• 2023-12-26 WBC 1.83 x10^3/uL ** Neutrophil 45.5% => ANC 833/uL, grade 3
• 2023-10-05 WBC 2.92 x10^3/uL *
• 2023-07-05 WBC 2.16 x10^3/uL *
• 2023-04-10 WBC 2.91 x10^3/uL *
• 2023-03-01 WBC 2.32 x10^3/uL *
• 2022-12-27 WBC 2.75 10^3/uL
• 2022-11-30 WBC 2.55 10^3/uL
• 2022-11-02 WBC 2.14 10^3/uL
• 2022-10-30 WBC 2.89 10^3/uL
• 2022-10-05 WBC 2.47 10^3/uL
• 2022-09-19 WBC 2.22 10^3/uL
• 2022-09-07 WBC 3.36 *10^3/uL
• 2022-07-07 WBC 2.61 10^3/uL
• 2022-04-12 WBC 2.47 10^3/uL
• 2022-01-20 WBC 2.61 10^3/uL
• 2021-11-03 WBC 3.79 *10^3/uL
• 2021-09-07 WBC 3.15 *10^3/uL
• 2021-06-16 WBC 2.77 10^3/uL
• 2021-05-19 WBC 2.15 10^3/uL
• 2021-04-21 WBC 3.62 *10^3/uL
• 2021-02-16 WBC 3.49 *10^3/uL
• 2020-12-30 WBC 3.12 *10^3/uL
• 2020-12-02 WBC 3.73 *10^3/uL
• 2020-11-04 WBC 3.03 *10^3/uL
• 2020-10-21 WBC 3.12 *10^3/uL
• 2020-10-05 WBC 5.40 *10^3/uL
• 2020-08-31 WBC 5.06 *10^3/uL

The patient is currently taking fulvestrant and palbociclib as the main treatment medications. Fulvestrant was started on 2020-10-07, and palbociclib was started on 2020-09-07, to replace ribociclib.

The incidence of neutropenia for fulvestrant is 2%, with 1% grade 3 and <1% grade 4. The incidence of neutropenia for palbociclib is 80-83%, with 55-56% grade 3 and 10-11% grade 4. Therefore, neutropenia is more likely to be attributed to palbociclib.

It is recommended considering a palbociclib dose reduction in future cycles if recovery from grade 3 neutropenia is prolonged (>1 week) or if grade 3 neutropenia recurs on day 1 of subsequent cycles.

There is no evidence of prolonged neutropenia yet, but the dose of palbociclib has been reduced from 125mg daily to 100mg daily since 2024. This is a conservative approach.

700524385

240102

[MedRec]

• 2023-12-12 SOAP NeuroSurgery Xi XianDa
  • Prescription x3
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Siliverzine (silver sulfadiazine 10mg/g) QD EXT for head wound
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
    • Nexium (esomeprazole 40mg) 1# QDAC stool OB 3+
• 2023-11-07 SOAP Nephrology Wu ZheXiong
  • Diagnosis
    • HCVD, unspecified, without CHF [I11.9].
    • Mixed hyperlipidemia [E78.2].
    • Coronary atherosclerosis of native coronary artery [I25.10].
    • With unspecified pathological lesion in kidney [N05.9].
  • Prescription x3
    • Pentop (pentoxifylline 400mg) 0.5# BID
    • Euricon (benzbromarone 50mg) 0.5# QD
• 2023-10-31 ~ 2023-11-04 POMR NeuroSurgery Xu XianDa
  • Discharge diagnosis
    • Cervical spinal stenosis and compression of cervical cord with myelopathy at C3-4-5-6-7.
    • Retention of urine
    • Fracture of right 4th, 5th, 7th, 9th, 10th ribs, and left 4th, 5th, 8th, 9th, 10th ribs.
    • Poor healing wound of scalp with tissue necrosis and defect.
    • Anemia post blood transfusions
    • Atherosclerotic heart disease of native coronary artery without angina pectoris
    • Rheumatic aortic stenosis
    • Hypertensive heart disease without heart failure
    • Mixed hyperlipidemia
    • Chronic kidney disease, stage 3 (moderate)
  • CC
    • Less urine output for one day.
  • Present illness
    • This 90-year-old female patient had several underlying health conditions, including:
      • Hypertensive heart disease
      • Atherosclerotic heart disease of the native coronary artery without angina pectoris
      • Chronic kidney disease, stage 3 (moderate)
    • According to medical records and her daughter’s account, she suffered a head injury from a fall down the stairs on 2023-10-18. Subsequently, she was admitted due to COVID-19 virus infection from 2023-10-18 to 2023-10-25. However, on 2023-10-31, decreased urine output was observed, prompting her visit to our emergency room for assistance. A Foley catheter was inserted for urine retention. The patient displayed weakness in motor function, with the right-side extremities graded as 1, the left upper limb as grade 3, and the left lower limb as grade 2.
    • A cervical spine MRI revealed severe spinal stenosis at the C3-4-5-6-7 levels, along with compression of the cervical cord leading to myelopathy. After consultation with a Neurosurgeon, she was admitted for further management.
    • No cervical surgery
    • No cancer histroy
  • Course of inpatient treatment
    • Following admission, a neck collar was applied for protective purposes. The patient experienced severe pain when changing positions. A bilateral rib X-ray revealed injuries to the right 4th, 5th, 7th, 9th, and 10th ribs, as well as the left 4th, 5th, 8th, 9th, and 10th ribs. Consultation with Thoracic Surgery specialists confirmed the absence of hemopneumothorax. To manage the pain, analgesics were prescribed, and the use of a ThoraxBelt for stabilizing the chest wall was recommended.
    • Anemia was also identified, with a hemoglobin level of 7.5 mg/dL, leading to a prescription for a blood transfusion. Once the patient’s neurological condition had improved to an acceptable level, she was discharged home with plans for outpatient follow-up care.
  • Discharge prescription
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Siliverzine (silver sulfadiazine 10mg/g) QD EXT for head wound
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
    • Nexium (esomeprazole 40mg) 1# QDAC stool OB 3+
    • Sindine (povidone iodine Aq Soln) ASORDER EXT for wound dressing change
• 2023-10-11 SOAP Cardiology Zhang HengJia
  • Prescription x3
    • Concor (bisoprolol 5mg) 0.5# QD
    • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
    • Doxaben (doxazosin 4mg) 1# QN
    • Crestor (rosuvastatin 10mg) 1# QD

==========

2024-01-02

Upon comparing the refilled repeat prescription with patient records in PharmaCloud and HIS5, all medications were successfully integrated into the active medication list without any discrepancies.

701496796

240102

[exam findings]

• 2023-12-19 Bronchodilator Test
  • mild to moderate restrictive ventilatory impairment with partial bronchodilator ressposne
• 2023-12-14 CT - chest
  • Indication: esophageal cancer, clinical stage II, status post operation in 2022/12 and due to N(+), s/p CCRT (25 fx) in 2023/02. PET on 2023/9/25 showed cervical esophagus recurrence. s/p cervical esophgeal tumor palliative RT in Oct 2023.
  • Chest CT with and without IV contrast ehnancement shows:
    • S/p port-A placement with its tip at Superior vena cava.
    • s/p esophagectomy and gastric tube reconstruction
    • Diffuse soft tissue change at superior mediastinum is found. In comparison with CT dated on 2023-09-13, the lesion is slightly progressed.
    • s/p jejunalstomy.
    • The GB is well distended without soft tissue lesion
    • The liver, spleen, pancreas, both kidneys and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
  • Imp:
    • s/p esophagectomy and gastric tube reconstruction
    • Mediastinal lymphadenopathy s/p C/T, in slightly progression.
• 2023-11-22 Tc-99m MDP bone scan
  • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, knees, and feet.
• 2023-11-10 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • s/p gastric tube reconstruction at chest region.
    • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening
    • s/p jejunostomy.
    • Normal heart size. Mild pericardial effusion is found.
    • Elevation of right hemidiaphragm is found.
  • Imp:
    • s/p gastric tube reconstruction at chest region.
    • Gallstones.
    • No evidence of free air is noted at the subphrenic region.
• 2023-11-10 KUB
  • Scoliotic alignment of the lumbar spine is found.
  • The psoas shadow is clear.
  • s/p drainage tube placement.
  • Increased intestinal gas is found.
• 2023-09-26 PET
  • A glucose hypermetabolic lesion in the retrotracheal and prevertebral space, extending from the level of the cricoid carlage to the upper mediastinun at the level of aortic arch, compatible with recurrent esophageal maliangncy. Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in a left paratracheal lymph node, in a lymph node in the right paravertebral region at the level of T4 spine and in three right precarinal lymph nodes. Metastatic lymph nodes may show this picture.
• 2023-09-25 Patho - stomach/small bowel polyp
  • Soft tissue, jejunostomy outlet, left upper, excisison — Granulation tissue
• 2023-09-22 Standing KUB
  • S/P feeding jejunostomy at left upper abdomen.
• 2023-09-18, -09-11 CXR
  • surgical clips over left apical hemithorax
  • Rt superior mediastinal widening with thickening of paratracheal stripes and Rt shift of trachea s/p reconstructed esophagus, may be recurrent tumor
• 2023-09-11 Nasopharyngoscopy
  • Bilateral vocal cord paralysis.
• 2023-09-07 ECG
  • Sinus tachycardia
  • Incomplete right bundle branch block
  • Possible Right ventricular hypertrophy
• 2023-09-07 CXR
  • Rt-sided convexity of the azygoesophageal recess interface

[MedRec]

• 2023-10-20 SOAP Radiation Oncology Wang YuNong
  • Diagnosis: esophageal cancer, clinical stage II, status post operation in 2022/12 and due to N(+), s/p CCRT (25 fx) in 2023/02 and dysphagia post esophageal balloon dilatation procedure 5 times between 2023/07 to 2023/08 at NTUH, Jejunostomy at NTUH in 2023-07and s/p 5 times of esophageal dilatation procedures but failed. PET on 2023/9/25 showed cervical esopahgus recurrence.
  • S: less blood in saliva, r/o esophageal tumor oozing. no melena this week. numbness over the chin.
  • O: 2023/9/28~ RT to the cervical esophagus and adjacent lymphatic drainage area: 28 Gy/ 14 fx.
  • Plan to deliver 20 Gy/ 10 fx to the esophgeal tumor below the superior border of the manubrium. The above esophageal tumor and lymphatic drainage area: at least 50 Gy/ 25 fx.
• 2023-09-07 ~ 2023-10-17 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Eesophageal cancer, squamous cell carcioima, cT2N1M0, stage II, s/p single-port minimally ivasive tri-incision esophagectomy and reconstruction with gastric tube via posterior mediastinum on 2022/12/02 at NTUH s/p CCRT in 2023/02 s/p balloon dilatation on 2023/07/05, 2023/08/11, 2023/08/15, 2023/08/23, post Jejunostomy in 2023/07/21, recurrent esophageal cancer at neck and upper mediastinum lymph node metastases, s/p left Port-A implantation on 2023/09/18,
    • Eesophageal cancer, squamous cell carcioima, s/p radiotherapy 30 Gy/ 15 fractions for the esophageal tumor from 2023/09/28~ and Concurrent chemotherapy with Q2W PF(CDDP 50mg/m2, 5FU 2000mg/m2 IVF 48hrs) on 2023/10/06(C1D1)
    • Insomnia, unspecified
    • Constipation, unspecified
    • Chronic viral hepatitis B without delta-agent
    • Fever, unspecified
    • Anemia due to antineoplastic chemotherapy
  • CC
    • Difficult swallowing of fluid since 2023-07.
  • Present illness
    • A 55-year-old man had underlying diseases of esophageal cancer status post operation in 2022/12 and post CCRT in 2023/02 at NTUH, and dysphagia post esophageal balloon dilatation procedure 5 times between 2023/07 to 2023/08 at NTUH, Jejunostomy at NTUH in 2023-07, and hepatitis B infection under Baraclude and insomnia.
    • According to his statement, esophageal cancer stage II was diagnosed in 2022-11 and he received esophagestomy with gastric tube recontruction at NTUH in 2022-12. Due to lymph nodes metastasis, he received CCRT in 2023-02 at NTUH. Then he was admitted to NTUH due to pancreatitis in 2023-06. He started to feel difficult swallowing of fluid in 2023-07, and admitted to NTUH for Jejunostomy and esophageal dilatation procedure. After 5 times of esophageal dilatation procedure, he still couldn’t drink water and re-contruction of esophageal was suggested but he wanted to try dilatation procedure again, thus he came to this hospital chest surgery department on 2023-09-05. After well discussed with the doctor about the successful rate, benifit and complication, he decided to undergo endoscopic esophageal dilatation. At ward he couldn’t take anything by mouth and hoarseness was noticed since yesterday.
  • Course of inpatient treatment
    • After admitted, Follow-up suspected GI bleeding condition with Panzolec 1pc iv Q12H from 2023/09/19~2023/09/25.
    • Esophageal obstruction status post endoscopic inspection on 2023-09-11 and image showed recurrence of esophageal cancer on 2023-09-13.
    • Chest CT on 2023/09/13 showed recurrent esophageal cancer at neck and upper mediastinum with metastatic mediastinal LAP s/p esophagectomy and gastric tube reonstruction.
    • Port-A catheter insertion on 2023/09/18.
    • Ultracet 1# po Q6H and Tramadol 100mg iv PRNQ6H for pain control.
    • Sodicon 1# po QID, Shitan 1# po TID and NS 3ml I/H QID for cough with sputum.
    • Whole body PET on 2023/09/26 showed esophageal cancer with left paratracheal, right paravertebral lymph node and upper mediastinun lymph node metastatic.
    • Radiotherapy 30 Gy/ 15 fractions for the esophageal tumor from 2023/09/28~.
    • Concurrent chemotherapy with PF(CDDP 50mg/m2, 5FU 2000mg/m2 IVF 48hrs)(C1D1) on 2023/10/06~2023/10/09 -> 2023/10/08 Hold chemotherapy for fever, R/O spesis.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • NS 500ml Q8H IVF hydration.
    • Double lower teeth shake with consult Dentistry on 2023/10/02 IMP: #27, 313235, 414245: suggest ext at os.
    • Consult OS on 2023/10/03 IMP:Tooth #27, #31, #32, #35, #41, #42, #45 chronic periodontitis A:1.Tooth 35 45 extracted under local anestheia 2.We will arrange stitches removal on 2023/10/10.
    • Cough Mixture 5ml po QID for cough. Allegra 1# po BID for runny nose.
    • Comfflam spray (self pay) 1 puff MOSP PRNQ4H for sore throat.
    • Insomnia with Mirtapine 1# po HS, Zolon F.C 1# po HS and Xanax 1# po HS.
    • Constipation with MgO 2# po Q6H -> DC for diarrhea and Sennoside 2# po HS -> DC for diarrhea.
    • Chronic viral hepatitis B without delta-agent (Anti-HBc(+)) with Baraclude 0.5mg 1# po QDAC.
    • Fever with Antibiotic therapy with Rocephin 2000mg iv QD from 2023/09/23~2023/10/05 and Antibiotic with Tapimycin 4.5gm iv Q6H from 2023/10/08~2023/10/16 and Panadol 1# po PRNQ6H for BT >38^C.
    • Anemia(Hb:9.1 -> 8.5 -> 9.7g/dL) with BT P-RBC 2u on 2023/09/26, 2023/10/02. Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, he was discharged on 2023/10/17 and OPD followed up later.
  • Discharge prescription
    • Allegra (fexofenadine 60mg) 1# BID
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Lysozyme (lysozyme 90mg) 1# TID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Sodicon (dextromethorphan 15mg) 1# QID
    • Zolon (zopiclone 7.5mg) 1# HS
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Cough Mixture (platycodon) 5mL QID
    • Mirtapine (mirtazapine 30mg) 1# HS
    • Shitan (bromhexine 8mg) 1# TID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
• 2023-09-05 SOAP Thoracic Surgery Xie MinXiao
  • S
    • Esophageal ca. s/p op + adjuvant CCRT.
    • complicated with eso. stricture.
  • P
    • arrange admission 9/7
    • 9/8 endoscopic eso. dilatation.

[chemotherapy]

• 2023-12-26 - docetaxel 75mg/m2 114mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-11-03 - cisplatin 50mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 30mL 10min (after CDDP) D2 + fluorouracil 2000mg/m2 3100mg NS 500mL 48hr D2 (PF CCRT Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
• 2023-10-06 - cisplatin 50mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 30mL 10min (after CDDP) D2 + fluorouracil 2000mg/m2 3100mg NS 500mL 48hr D2 (PF CCRT Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2024-01-02

[tube feeding]

All medications currently listed on the active drug list for oral administration are suitable for enteral tube feeding.

[reconciliation]

The PhamaCloud database did not contain any records of the patient’s medical history from other healthcare facilities. No medication discrepancies were identified.

2023-12-22

[tube feeding]

All medications currently listed for oral administration on the active medication list are suitable for enteral feeding via tube.

2023-11-06

The patient has been a long-term patient at NTUH before seeking treatment at our institution. Currently, there are no valid repeat prescriptions issued by NTUH. No discrepancies with medication reconciliation have been identified.

701510054

240102

[exam findings]

• 2023-12-29 SONO - abdomen
  • Diagnosis:
    • Liver tumor, left
    • Left pleural effusion, moderate
    • Suspected GB polyp
  • Suggestion:
    • Please correlate with other image
    • Check AFP, CA-199, CEA, HBV, HCV
      
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2023-12-25 CT - brain
  • Brain atrophy.

[MedRec]

• 2023-12-30 MultiTeam - Multidisciplinary Team Recommendations - Palliative Care
  • Consultation Date: 2023-12-29
  • Response Content:
    • During the visit, the patient was conscious and reported no pain or difficulty breathing, feeling more fatigued.
    • The palliative care team established a relationship and explained the concept of shared palliative care.
    • The patient was somewhat guarded but nodded in agreement to shared care.
    • The patient’s ex-husband, who was caring for her, mentioned that the patient verbally expressed not wanting resuscitation but had not yet completed the advance directive for palliative care.
    • The patient’s father and younger brother lean towards not resuscitating, letting the patient pass naturally and comfortably.
    • Diagnosed with breast cancer at the end of last year at another hospital, the first phase of chemotherapy (May and June 2023) was very effective, with the tumor disappearing. Radiation therapy was recommended, but the patient did not proceed.
    • The tumor grew again around August-September with a wound, and subsequent chemotherapy was ineffective, leading to the current large wound.
    • The patient is still struggling to accept the disease’s progression.
    • The ex-husband left with the shared care consent form to be signed by the family later. Follow-up is planned.
  • Conclusion and Recommendations: Shared palliative care and follow-up on the advance directive for palliative care.
  • Responder: Chen Hui
  • Response Date: 2023-12-29 18:35
  • Doctor’s Response: 12/30 02:16 Response by Zhang JiaYu: Noted
• 2023-12-28 MultiTeam - Multidisciplinary Team Recommendations - Psycho-Oncology
  • Consultation Date: 2023-12-26
  • Reason for Consultation: Stress events due to illness: Psychological stress response due to physical illness or deciding on treatment options, Emotional distress: Anxiety, fear, depression, anger; shyness, shock, and other emotional categories.
  • Conclusion:
    • S
      • Visit on 12/27, accompanied by the ex-husband.
      • The patient reported severe mouth pain, painful to talk and swallow, unsure of the next steps or what to ask.
      • The ex-husband mentioned they are applying for medical records from TPEVGH, using spray powder for mouth sores, and glutamine for temporary relief, expecting slow recovery.
      • The patient was unprepared and needed time to think, sleeping a lot these past two days, and will see how it goes in the next few days.
    • O
      • Breast cancer diagnosed in 11/12, radiation therapy in November, last chemotherapy on 12/19, wound on the left breast, self-dressing; lost consciousness at home for 5 minutes on 12/25 and recovered, fever started three days ago, admitted on 12/26, inpatient doctor referred for psychosomatic stress response.
    • I
      • Care for the family’s care expectations.
    • AP
      • The ex-husband and patient appeared worried but did not express it explicitly, still hoping to discuss palliative treatment plans, should consider overall treatment tolerance, enhance prognosis awareness and preparedness, and timing for shared palliative care. Counseling psychologist Huang XiaoFang
  • Responder: Huang XiaoFang
  • Response Date: 2023-12-27 17:53
  • Doctor’s Response: 12/28 08:06 Response by Zhang JiaYu: Noted
• 2023-12-27 ProgressNote
  • Problem #1: Left breast cancer
    • Assessment:
      • under chemotherpy at TPEVGH
      • R/T done in 2023/11
      • Hb 5.1 -> 6.4 -> 8.1 g/dL, WBC 240 -> 130 uL, PLT 58000 -> 86000 -> 52000 uL
      • CRP 26.4 mg/dL
      • blood transfusion with LPRBC 2u on 12/25, 2u on 12/26, LRP 1u on 12/25
      • 12/25 CXR: Left pleural effusion
      • stool OB 3+
    • Plan:
      • keep OPD medications:
        • Xeloda 2# Q12H,
        • Cartil 1# Q8H,
        • Jardiance 1# QD,
        • Eltroxin 1# QDAC,
        • Zcough 1# TID,
        • Trand 1# BID -> shift to IV form,
        • Tramacet PRN for pain,
        • Megest 5ml QD
      • fungus infection told at TPEVGH:
        • keep FLU-D 2# QD,
        • Avelox 1# QDAC,
        • Nystatin 1# TID
      • wound care (consult wound nurse)
      • check finger sugar QDAC, HS
      • fluid supplement with normal saline BID
      • empirical antibiotic with Cefim 2mg Q8H since 12/26
      • Filgrastim (G-CSF) 300 mcg QD
      • Loperamide PRN for diarrhea
      • Hemoclot 500mg Q12H
• 2023-12-26 MultiTeam - Multidisciplinary Team Recommendations - Wound Care
  • Consultation Date: 2023-12-26
  • Reason for Consultation: Malignant fungating ulcer wound care, Other: Cancer wound
  • Response Content:
    • The left breast has a malignant fungating tumor wound, with 100% yellow necrotic tissue in the wound bed, moderate exudate (yellow-green in color), and a strong foul odor (++).
    • The wound was cleaned with saline solution using cotton swabs, and some necrotic tissue was locally debrided.
    • It is recommended to apply Aq-BI + N/S 1:1 wet dressing BID.
    • The skin under the left armpit and the inner side of the upper arm is damaged due to friction, showing red granulation tissue. After cleaning, a foam silver ion dressing was applied (to be changed during the visit on 12/29).
  • Responder: Chen ShuRong
  • Response Date: 2023-12-26 16:09
  • Doctor’s Response: 12/26 16:33 Response by Zhang JiaYu: Noted, will proceed as recommended.

==========

2024-01-02

[tube feeding]

This hospital offers Const-K 750mg, the only oral potassium supplement available. Each extended-release tablet delivers 10 mEq of potassium, equivalent to about 4.5 medium bananas. While a single banana can provide some potassium (2.2 mEq per inch, 0.9 mEq per cm), Const-K offers a concentrated and stable dose for easier dietary supplementation. For easier swallowing, the tablet can be crushed into fine particles and mixed with water.

700784315

231228

[exam findings]

• 2023-12-18, -12-14, -12-11, -12-07, -12-05, -11-30, -11-28, -11-27 CXR
  • Normal heart size and contour.
  • Increased bilateral parahilar peribronchial /interstitial and low lungs infiltration.
• 2023-11-29 Patho - brain biopsy
  • Brain, right FT lobe, stereotactice biopsy — astrocytic glioma, IDH wild type, in favor of high grade
  • Microscopically, sections shows astrocytic glioma characterized by hypercellular astrocytic neoplasm with hyperchromatic, elongated nuclei and irregular nuclear membranes. It shows microvascular proliferation with multilayered, small caliber vessels with glomeruloid appearance. Mitotic activity is not frequent and no geographic-like necrosis is identified in current specimen. A small piece of non-tumor choroid plexus tissue is also noted.
  • Immunohistochemical stains reveals IDH-1 (-), GFAP (+), CK (+ at glial filaments), p53: wild-type (scanty, weak, <1%), EMA (-), SOX10 (focal+), LCA (-).
• 2023-11-24 CT - chest
  • chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and axial slab MIP images shows:
    • lungs: a small thin-walled cyst at RUL.
      • mild centrilobular nodules at RML..
      • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine. normal appearance of left lung.
    • Mediastinum and hila: no enlarged LN or mass.
      • moderate coronary arterial calcification
    • Thoracic aorta: dilated ascending aorta (4cm). extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Visible abdominal-pelvic contents: a 5mm Lt hepatic cyst.
      • enlarged prostate with tiny calcifications indenting the bladder base.
      • questionable wall thickening the urinary bladder.
      • mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
      • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • no lung tumor. no abnormal mass in abdomen.
    • BPH
    • Mild RML bronchiolitis.
• 2023-11-23 MRI - brain
  • Past History: Azihemier disease.
  • Surgical history: s/p cata
  • Pre- and post-contrast multiplanar cerebral MRI (including axial and coronal T1W, axial and sagittal T2W, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) and cerebral TOF MRA reveal:
    • A well-defined extra-axial enhancing tumor, about 39 mm at the largest dimension, with diffusion restriction at midline of anterior frontal base.
    • An intra-axial well-enhancing tumor, about 24 mm at the largest dimension, with central necrosis and diffusion restriction in tumor bulk involving right mesial temporal lobe, associating with extensive perifocal white matter edema and diffuse infiltrative parenchymal enhancement and irregular thick enhancement along cistern spaces (including interhemispheric fissure, right hippocampal sulcus, right Sylvian fissure, basal cistern and walls of bilateral frontal horns).
    • Elevation of bilateral A1 segments due to mass effect from frontal base tumor. Otherwise, no remarkable finding at major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
  • IMP:
    • Tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement.
    • D/D: meningioma or/and lymphoma, metastases.
• 2023-11-23 CT - brain
  • Imp: Brain atrophy. A large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma.

[consultation]

• 2023-12-11 Infectious Disease
  • Q
    • This is a 79-year-old male patient with medical history of Alzheimer’s disease. This time, he had drolling, slurred speech, impaired response and muscle weakness at left extremities were noticed for 2 days. He was then brought to our emergent department for evaluation.
    • Brain CT showed a large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma.
    • Neuro-surgeon was consulted and further survey was done.
    • Brain MRI revealed tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement, r/o meningioma,lymphoma or metastases.
    • After he received brain tumor biopsy on 11/18.
    • The frozen section revealed No evidence of lymphoma or metastasis, pending pathology data.
    • During SICU, under keppra and Hemotastic use.
    • The GCS around E3VTM6, try weaning ventilator and extubation on 11/29.
    • The respiratory pattern smooth, under the general condition became stable, he was transferred to NS ward on 11/30.
    • During ward, solwly taper mannitol.
    • Rehabiliation therapy were undertaken.
    • Brain biopsy report show astrocytic glioma, consultation radiation oncology suggest radiotherapy to brain tumor for 5000cGy/20 fx for tumor control with concurrent temozolamide if feasible.
    • We give applying Temodal for NHI.
    • Suputum culture showed pseudomonas aeruginosa, we shift antibiotic to Ciprofloxacin.
    • Current problem:
      • Fever was noted on 12/17, and brosym was give for pneumonia.
      • Suputum culture showed pseudomonas aeruginosa, we shift antibiotic to Ciprofloxacin since 12/8.
    • We need your expertise for further management. Thank you for your reply.
  • A
    • Serial CxR films has shown marked pneumonia regression and patient has received antibiotic more than 2 weeks.
      • Sputum culture grew P.aeruginosa.
      • IV Cipro can be shifted to oral Ciproxin.
    • Suggestion:
      • Continue inhaled Colimycin for one more week
      • DC IV ciprofloxacin
      • Add oral ciprofloxacin as sequential therapy.
• 2023-12-04 Radiation Oncology
  • Q
    • This is a 79-year-old male patient with medical history of
      • Alzheimer’s disease
      • Bilateral cataract, status post operation
    • According to his sons’ statement, he was ADL/iADL partially dependent within his usual status. Conversation was intact but mild delayed. However, drolling, slurred speech, impaired response and muscle weakness at left extremities were noticed for 2 days. He was then brought to our emergent department for evaluation.
    • Brain CT showed a large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma. Neuro-surgeon was consulted and further survey was done.
    • Brain MRI revealed tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement, r/o meningioma,lymphoma or metastases. Tumor markers was collected and the result was pending. As a result, admission for close monitoring and possible intervention was suggested and accpeted after explanation of pros and cons.
    • Chest CT revealed no lung tumor. no abnormal mass in abdomen. BPH. Mild RML bronchiolitis. Tumor marker was arranged.
    • He received brain tumor biopsy on 11/18. The pathology reported astrocytic glioma, IDH wild type, in favor of high grade. Thus we need your expertise for further CCRT. Temodal applying in advance. Thanks very much!
  • A
    • Subjective:
      • History: This is a 79-year-old male patient was ADL/iADL partially dependent within his usual status. Conversation was intact but mild delayed. However, saliva drooling, slurred speech, impaired response and muscle weakness at left extremities were noted for 2 days. He was brought to our emergent department for evaluation. Brain CT showed a large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma. Brain MRI revealed tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement, r/o meningioma, lymphoma or metastases. Chest CT revealed no lung tumor; no abnormal mass in abdomen; BPH; mild RML bronchiolitis. He received brain tumor biopsy on 11/18. The pathology reported astrocytic glioma, IDH wild type, in favor of high grade.
        • Previous RT: denied.
          
        • Other disease: Alzheimer’s disease noted since 2023/01 (CDR?); bilateral cataract, status post operation.
        • Family history: denied.
          • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
          • Married. Caregiver: special nurse (his wife, 3 sons). Job: retired cloth merchant. No or mild economic stress at least.
          • Language: Mandarin. Taiwanese.
      • Objective:
        • General Condition-ECOG: 3.
        • PE, 2023/12/05: no SCF LNs; muscle weakness at left extremities. NG feeding.
        • Pathology, 2023/12/04: Brain, right FT lobe, stereotactic biopsy—astrocytic glioma, microvascular proliferation, few mitosis & no necrosis; IDH wild type, in favor of high grade. IHC: IDH-1(-), GFAP(+), CK(+at glial filaments), p53: wild-type (scanty, weak, ＜ 1%), EMA(-), SOX10(focal+), LCA (- ).
        • Images:
          • Brain MRI, 2023/11/23: A well-defined extra-axial enhancing tumor, about 39 mm at the largest dimension, with diffusion restriction at midline of anterior frontal base. An intra-axial well-enhancing tumor, about 24 mm at the largest dimension, with central necrosis and diffusion restriction in tumor bulk involving right mesial temporal lobe, associating with extensive perifocal white matter edema and diffuse infiltrative parenchymal enhancement and irregular thick enhancement along cistern spaces (including interhemispheric fissure, right hippocampal sulcus, right Sylvian fissure, basal cistern and walls of bilateral frontal horns).
          • Chest CT, 2023/11/24: no lung tumor; no abnormal mass in abdomen; BPH; Mild RML bronchiolitis.
          • Tumor marker, 2023/11/24: SCC, CEA, PSA (negative); aFP 21.0, CA199 106.53.
      • Diagnosis: Astrocytic glioma, IDH wild type, in favor of high grade, involving anterior frontal base, right mesial temporal lobe, cistern spaces (including interhemispheric fissure, right hippocampal sulcus, right Sylvian fissure, basal cistern and walls of bilateral frontal horns), s/p stereotactic brain tumor biopsy on 2023/11/18; ECOG =3.
        
      • Plan:
        • I suggest RT to brain tumor for 5000cGy/20 fx for tumor control with concurrent temozolamide if feasible.
        • I informed him & his family possible radiation toxicity (radiation dermatitis & IICP). I will arranged CT simulation on 2023-12-07 09:30. RT will be initiated 2-3 days later.
• 2023-11-23 Neurosurgery
  • A
    • A case of 79 y/o male, Alzheimer disease under treatment at TSGH.
    • BWL for > 6 months. Progressive left side weakness for days.
    • A brain CT showed A large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma.
    • A brain MRI showed Tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement. D/D: meningioma or/and lymphoma, metastases.
    • P: check tumor markers; Chest CT for staging; Brain stereotactic biopsy if needed.

[radiotherapy]

[chemotherapy]

• 2023-12-13 ~ undergoing - temozolomide 100mg QW12345 (1 hr before CCRT)

==========

2023-12-28

[body weight loss]

According to the weight records revealed by the TPR panel, the patient’s weight was 48kg on 2023-11-23, 37.6kg on 2023-12-13, and 37.2kg on 2023-12-27. CCRT with temozolomide QW12345 began on 2023-12-13. It can be found that the patient’s weight loss mainly occurred before temozolomide initialization. Therefore, temozolomide is less likely to be the main cause of the patient’s weight loss.

It is worth noting that the incidence of anorexia with temozolomide is 27%, nausea (49% to 53%; grades >= 3: 1% to 10%), vomiting (29% to 42%; grades >= 3: 2% to 6%), and lymphocytopenia (grades 3/4: 55%). The patient is currently receiving tube feeding. It is important to monitor the patient’s nutritional intake, observe for nausea and vomiting, and monitor CBC and WBC counts.

[lymphopenia]

The patient’s lymphocyte percentage in WBC DC consistently falls below the normal range of 20% to 45% across all available data points, both pre- and post-CCRT. This persistent lymphopenia might suggest a potential impairment in the patient’s capacity for orchestrated and specific immune responses, which could impact their ability to fight the cancer.

• 2023-12-28 Lymphocyte 5.7 %
• 2023-12-25 Lymphocyte 9.5 %
• 2023-12-18 Lymphocyte 10.0 %
• 2023-12-14 Lymphocyte 5.9 %
• 2023-12-11 Lymphocyte 7.7 %
• 2023-12-07 Lymphocyte 8.7 %
• 2023-12-05 Lymphocyte 10.7 %
• 2023-11-30 Lymphocyte 1.9 %
• 2023-11-28 Lymphocyte 4.8 %
• 2023-11-27 Lymphocyte 9.6 %
• 2023-11-23 Lymphocyte 12.4 %

701233507

231227

[MedRec]

• 2023-12-26 Multi-team consultation - Psycho-oncology
  • Consultation date: 2023-12-25
  • Consultation reason: Others: Cancer in-hospital patient simplified health scale >=10 points
  • Conclusion:
    • S
      • On 2023-12-25, the patient’s wife said that she filled in the score for him because she was right next to him and knew his mood best.
      • The patient said that when he first started chemotherapy, the numbness would slowly go away after 3-4 days, but it didn’t go away after that. He would feel pain when he touched something cold, and his feet would also hurt. He couldn’t walk for long distances.
      • “If this is how it’s going to be for the rest of my life, then what’s the point of living?” The patient’s wife said that she was afraid that he would be disabled.
      • The patient said that if he wanted to create a work of art, the ability to control the fine details was very important. Even a small difference could make a big difference. Now, he didn’t even know if he was tying his shoelaces too tightly.
      • The patient’s wife said that she would discuss with the doctor whether the last two rounds of chemotherapy could omit the drug that caused numbness in the hands and feet. The patient said that he had to complete the treatment plan. He would go to see a Chinese medicine doctor after that to see if it would help. If the case manager had any methods, that would be great.
    • O
      • The patient was diagnosed with colon cancer (stage II) in 2012/06. He is undergoing post-operative chemotherapy. He was admitted to the hospital on 2023-12-25 for his 11th round of chemotherapy. His BSRS score was 15 (severe), and his suicidal ideation score was 1 (mild).
    • I
      • Care for the impact of side effects on life. Affirm the patient’s positive attitude towards recovery.
    • AP
      • The patient is actively cooperating with the treatment plan, but is concerned about the impact of the side effect (numbness in the hands and feet) on his life and work. This part is transferred to the case manager for educational care.
  • Responder: Huang Xiaofang
  • Response date: 2023-12-25 17:56
  • Doctor’s response: 2023-12-26 08:06 Lu Zongru Response: Acknowledged
• 2023-06-05 ~ 2023-06-10 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Sigmoid tumor post tattooed status post 3 dimensions single-incision laparoscopic (SILS) sigmoidectomy on 2023/06/07
  • CC
    • bright red blood on toilet paper since last year and epigastric dull discomfort in recent weeks.
  • Present illness
    • This 59 years old man patient has the history of
      • Calculus of gallbladder for 20-30 years
      • Hyperlipidemia without medication
      • Superficial gastritis without medication
      • Mitral valve prolapse
      • Appendicitis s/p traditional open appendectomy for 30+ years at JingMei Hospital
      • Puckering of macula, right eye, status post 25G pars plana vitrectomy and epiretinal membrane peeling on 2022/08/17.
    • He suffered from bright red blood on toilet paper since last year and epigastric dull discomfort in recent weeks.
    • He came to GI OPD for help and colonoscopy revealed
      • One sessile polyp was noted in the transverse colon Size 0.8 cm. (90 cm from anal verge)
      • One large polypoid tumor lesion was noted in the sigmoid colon Size 3.0 cm. (20 cm from anal verge).
    • Upper gastrointestinal endoscopy showed superficial gastritis.
    • Abdominal CT revealed focal wall thickening of S-colon.
    • Therefore he was referred ro CRS OPD for further evaluation. After fully explained of the condition, the surgical intervention was indicated and the patient understood and agreed.
    • This time, he is admitted to our ward for preoperative preparation and surgical treatment.
  • Course of inpatient treatment
    • After admission with ward routine and pre-op study were done. After well explain the risk of surgery including heart, lung complications and risk of leakage.
    • Operation of 3D SILS sigmoid colectomy under general anesthesia were performed on 2023-06-07.
    • NPO and adequate IV fluid supplement. His wound pain is acceptable by Dynastat.
    • Early activity is encouraged. Chewing cookies, toast, rice with gum was started at op day.
    • The wound healing well and no erythema change. He had flatus passage and abdominal wound pain subsided. So he started to take oral diet well and no abdominal discomfort after meal. He had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. His abdominal wound pain had got much better.
    • In stable condition, he was discharged on 2023-06-10 and will receive OPD follow up next week.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H

[chemotherapy]

• 2023-12-25 - leucovorin 400mg/m2 720mg NS 250mL 2hr + fluorouracil 2800mg/m2 5045mg NS 1000mL 46hr (Lv ZongRu)
  • betamethasone 4mg + metoclopramide 10mg + NS 250mL
• 2023-11-27 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4900mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-07 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4900mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-19 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4933mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-02 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4914mg NS 1000mL 46hr (FOLFOX Q2W. Lv ZongRu)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-14 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 715mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-28 - oxaliplatin 85mg/m2 148mg D5W 250mL 2hr + leucovorin 400mg/m2 698mg NS 250mL 2hr + fluorouracil 2800mg/m2 4891mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-14 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4920mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-01 - oxaliplatin 85mg/m2 148mg D5W 250mL 2hr + leucovorin 400mg/m2 698mg NS 250mL 2hr + fluorouracil 2800mg/m2 4891mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-07-17 - oxaliplatin 85mg/m2 148mg D5W 250mL 2hr + leucovorin 400mg/m2 698mg NS 250mL 2hr + fluorouracil 2800mg/m2 4891mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-07-03 - oxaliplatin 85mg/m2 147mg D5W 250mL 2hr + leucovorin 400mg/m2 694mg NS 250mL 2hr + fluorouracil 2800mg/m2 4858mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-12-27

[chemotherapy-induced peripheral neuropathy]

Due to concerns about the developed peripheral neuropathy, oxaliplatin was not included in the FOLFOX protocol administered during this hospital stay.

Recent guidelines support the use of duloxetine for managing chemotherapy-induced peripheral neuropathy (CIPN). Both the 2020 ASCO guideline and the joint ESMO/EONS/EANO guideline recommend duloxetine as a treatment option for neuropathic pain in this setting. (Reference: Loprinzi CL, et al. J Clin Oncol 2020; 38:3325)

For adult patients with CIPN, duloxetine is typically started at 30mg orally once daily for the first week, then increased to 60mg once daily thereafter. This dosing recommendation is based on a large, randomized clinical trial by Smith et al. (Reference: Smith EM, et al. JAMA 2013;309(13):1359-67)

There is Cymbalta (duloxetine 30mg capsules) readily available within our stock to be prescribed.

700147427

231226

[exam findings]

• 2023-12-25 CT - brain
  • Indication: dyspnea with much sputum for 2 days
  • Past history: hx of NSTEMI, duodenal ulcer, gastric ulcer s/p op, HTN
  • Without contrast helical Head CT - 4mm thickness in each slice from the axial and saggital projections showed
    • moderate dilated intraventricular and extraventricular CSF spaces
    • moderate bilateral periventricular leukoaraiosis; old lacunar infarction in the bilateral basal ganglia
      
    • unremarkable change in the skull base
  • IMP:
    • no acute intracranial hemorrhage
• 2023-12-24 CXR (erect)
  • cardiomegaly
  • Lung markings: focal increased desity in the left upper and left retrocardiac lung fields.
  • blunting left costophrenic angle

[MedRec]

• 2023-12-07 SOAP Cardiology Zhou XingHui
  • Prescription x3
    • Norvasc (amlodipine 5mg) 1# QD
    • Plavix (clopidogrel 75mg) 1# QOD
    • Eurodin (estazolam 2mg) 1# HS
• 2020-04-09 SOAP Cardiology Zhou XingHui
  • Prescription x3
    • Concor (bisoprolol 1.25mg) 1# QD
    • Plavix (clopidogrel 75mg) 1# QD

==========

2023-12-26

Based on the findings of the upright CXR performed on 2023-12-24, which showed cardiomegaly, focal consolidation in the left upper and retrocardiac lung fields, and blunted left costophrenic angle, empirical Sintrix (ceftriaxone) was initiated while culture results are pending.

The patient’s persistent hypertension (170/75 mmHg since admission) could suggest exploring a target systolic blood pressure (SPB) of 150 mmHg. Amlodipine 5mg QD and hydralazine 50mg PRNBID have been prescribed for blood pressure control.

701114210

231225

[MedRec]

• 2023-10-24 SOAP Metabolism and Endocrinology Hu YaHui
  • Diagnosis
    • Corticoadrenal insufficiency [E89.6]
    • Malignant neoplasm of rectum [C20]
    • Goiter, unspecified [E04.9]
    • Malignant adrenal gland neoplasm [C74.02]
    • Anemia [D64.9]
  • Prescription x3
    • Crestor (rosuvastatin 10mg) 1# QD
    • Decone (dexamethasone 0.5mg) 1# QD
    • Florinef (fludrocortisone 0.1mg) 1# QD
    • Lipanthyl Supra (fenofibrate 160mg) 1# QD
    • MgO 250mg 1# BID
    • Ezetrol (ezetimibe 10mg) 1# QD
    • cortisone acetate 25mg 2# PRNBID if headache or fever
• 2023-07-25 SOAP Metabolism and Endocrinology Hu YaHui
  • Diagnosis
    • Corticoadrenal insufficiency [E89.6]
    • Malignant neoplasm of rectum [C20]
    • Goiter, unspecified [E04.9]
    • Malignant adrenal gland neoplasm [C74.02]
    • Anemia [D64.9]
  • Prescription x3
    • Docone (dexamethasone 0.5mg) 1# QD
    • Florinef (fludrocortisone 0.1mg) 1# QD
    • Crestor (rosuvastatin 10mg) 1# QD
    • Lipanthyl Supra (fenofibrate 160mg) 1# QD
    • cortisone acetate 25mg 2# PRNBID if headache or fever
• 2023-06-21 ~ 2023-06-29 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • K-RAS wild type Rectum cancer, pT3N0M0 post neoadjuvant with concurrent chemoradiotherapy, status post low anterior resection in 2018-08 WITH recurrence post palliative chemotherapy. Multiple LNs, lung and liver metastases in 2023-04.
    • Secondary malignant neoplasm of right adrenal gland
    • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • CC
    • for further management
  • Present illness
    • This 68-year-old male, a pt of rectal adeno CA, cT3N0M0 s/p neoadjuvant CCRT, s/p LAR in Aug 2018 by Dr Xiao GuangHong, s/p post-Op adjuvant Xeloda & R adrenal mets s/p bil adrenectomy in 2020-01 by Dr Cai YaoZhou, s/p post-Op palliative C/T with FOLFIRI / Avastin from April to July 2020 by Dr Liu JunHuang & recurrenec at para-aortic LN mets in 2021-01.
    • KRAS: wild type., s/p 2nd line palliative C/T wt CapeOx x 12 from Feb to Nov 2021 wt Dz in progress at new hepatic tumor, s/p 3rd line palliative C/T wt FOLFIRI / Erbitux IV Q2W x 12 since 12/7 21.
    • L adrenal tumor with rapid increase in size after surgery, Adrenal gland, R, lap.
    • Adrenalectomy (2/21 20) proved mets adenoCA, favoring colorectal origin. Adrenal MRI (1/20 20) showed mets in right adrenal gland is highly suspected. Right adrenaltumor enlargment suspect adrenal mets, suggest LPS adrenalecotmy. Lt adrenalectomyin 06/2019 & Rt adrenalectomy on 2020/02/21.
    • A left para-aortic glucose-hypermetabolic soft tissue lesion, metastasis in a leftpara-aortic lymph node was noted.He was referred to our clinic on 5/25 20 for continuous C/T by Dr Liu JunHuang. #5 chemotherapy with Avastin / FOLFIRI IV Q2W x 8 on 6/8 20, #6 on 6/22 20. #7 on7/6 20. #8 on 7/20 20 (finished).
    • Follow-up abd CT (7/15 20) showed s/p LAR with autosuture retention at the rectum.No evidence of tumor recurrence. CEA: 1.4 (7/15 20), CEA: 1.0 (12/28 20).FCXR & abd sono (9/28 20): negative. Abd CT (1/228 20) revealed rectal CA s/p Op. A LN (1.8cm) at paraaortic region r/o tumor mets. Newly developed para-aortic LNs;biopsy (1/12 21) proved adenocarcinoma. IHC stain: CK20(+), c/w lcolorectal recurrence.
    • We explain to pt about the indication & risk / benefit of 2nd line palliative C/T wt mFOLFOX IV Q2W x 12.
    • Follow-up abd CT (12/28 20) showed rectal CA s/p Op. A LN (1.8cm) at paraaortic region r/o tumor mets.newly developed para-aortic LNs; biopsy (1/12 21) proved adenocarcinoma. IHC stain: CK20(+), c/w colorectal recurrence.
    • 2nd line palliative C/T wt mFOLFOX IV Q2W x 1 on 2/1 21. (DC it due to SE & pt declined it). Due to SE, may shift to CapeOx.will shift to CAPEOX ( Capecitabine 1000mg/m2 PO BID D1~14 Q3W + Oxaliplatin 130mg/m2 ) IV Q3W .
    • 2nd line palliative C/T wt CapeOx ( Capecitabine 700mg/m2 ( 2# ) PO BID D1~14 Q3W + Oxaliplatin 60mg/m2 IV Q3W ) x 6 on 2/23 21, #2 CapeOx ( Capecitabine 1000mg/m2 (3#) + Oxaliplatin 70mg/m2 IV Q3W x 6 on 3/16 21, #3 on 4/6 21, #4 on 4/27 21. #5 on 5/18 21. #6 on 6/30 21. #7 ( Oxalip 100mg/m2 ) on 7/13 21. #8 ( Oxalip 110mg/m2 ) on 8/3 21. #9 ( Oxalip 120mg/m2 ) on 8/24 21. #10 on 9/14 21. #11 ( Oxalip 130mg/m2 ) on 10/5 21. #12 on 11/2 21. ( portable ).Abd CT (5/4 21) (8/4 21) showed s/p R hemicolectomy, post-op at rectum with left paraaortic recurrence, stationary.
    • Abd CT (11/16 21) revealed s/p RAR. L perirenal space metastatic lymphadenopathy, stable. New hepatic tumor at dome. r/o meta.#1A 3rd line palliative C/T wt FOLFIRI / Erbitux IV Q2W x 12 on 12/7 21.Erbitux 400mg/m2 (give 600mg) IVF 2 hr then 250mg/m2 ( give 400mg ) IVF 1 hr QW x8, plus FOLFIRI as 3rd line palliative C/T.
    • RTC 1 wk later on 5/10 22 for #3 4th palliative C/T wt FOLFIRINOX / Erbitux IV Q2W x 12 (the last biochemotherapy on 2022/7/5).
    • Followed CT of abdominal on 2023/5/16 revealed S/P colon operation. Multiple LNs, lung and liver metastases. He was admitted for further management
  • Course of inpatient treatment
    • After admission,CT guide biopsy was administered on 2023/6/23 revealed Metastatic adenocarcinoma, consistent with colorectal primary.
    • Chemotherapy with C1D1 FOLFIRI (dose adjusted to 20% off) was administered on 2023/6/26-28 after fully explaination.
    • Adequate hydration. selfpaid of Emend and PRN Dexamethasone for chemotherapy related emesis.
    • With the relatively stable condition, he was discharged on 2023/06/29 and will OPD follow up later
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H as painkiller
    • loperamide 2mg 1# PRNQ6H if diarrhea
    • Limeson (dexamethasone 4mg) 1# PRNBID as antiemetic
• 2019-08-07 SOAP Metabolism and Endocrinology Hu YaHui
  • Diagnosis
    • Corticoadrenal insufficiency [E89.6]
    • Malignant neoplasm of rectum [C20]
    • Goiter, unspecified [E04.9]
    • Malignant adrenal gland neoplasm [C74.02]
    • Anemia [D64.9]
  • Prescription x3
    • cortisone acetate 25mg 2# PRNBID
    • Compesolon (prednisolone 5mg) 0.5# BID
• 2018-03-29 SOAP Colorectal Surgery Xiao GuangHong
  • S: A case of newly diagnosed rectal cancer at 8cm from AV

[chemotherapy]

• 2023-12-05 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-11-21 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-11-07 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-10-24 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-10-03 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-09-19 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2860mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-08-17 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2860mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-07-12 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2h4 + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI Q2W. Iri, Lv and Fu 20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-06-26 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2h4 + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI Q2W. Iri, Lv and Fu 20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2022-07-05 - (FOLFOXIRI)

• 2022-06-21 - (FOLFOXIRI)

• 2022-06-07 - (FOLFOXIRI)

• 2022-05-24 - (FOLFOXIRI)

• 2022-05-10 - (FOLFOXIRI)

• 2022-04-12 - (FOLFOXIRI)

• 2022-03-22 - (FOLFOXIRI)

• 2022-03-08 - (cetuximab + FOLFOXIRI)

• 2022-02-22 - (cetuximab + FOLFOXIRI)

• 2022-02-08 - (cetuximab + FOLFOXIRI)

• 2022-01-18 - (cetuximab + FOLFOXIRI)

• 2022-04-04 - (cetuximab + FOLFOXIRI)

• 2021-12-07 - (cetuximab + FOLFOXIRI)

• 2021-11-02 - (Oxa)

• 2021-10-05 - (Oxa)

• 2021-09-14 - (Oxa)

• 2021-08-24 - (Oxa)

• 2021-08-03 - (Oxa)

• 2021-07-13 - (Oxa)

• 2021-06-09 - (Oxa)

• 2021-05-18 - (Oxa)

• 2021-04-27 - (Oxa)

• 2021-04-06 - (Oxa)

• 2021-03-16 - (Oxa)

• 2021-02-23 - (Oxa)

• 2021-02-01 - (FOLFOX)

• 2020-07-20 - (Avastin + FOLFIRI)

• 2020-07-06 - (Avastin + FOLFIRI)

• 2020-06-22 - (Avastin + FOLFIRI)

• 2020-06-08 - (Avastin + FOLFIRI)

• 2020-05-25 - (Avastin + FOLFIRI)

• 2020-05-06 - (Avastin + FOLFIRI)

• 2020-04-15 - (Avastin + FOLFIRI)

• 2020-04-01 - (Avastin + FOLFIRI)

• 2020-03-20 - (Avastin + FOLFIRI)

==========

2023-12-25

[reconciliation]

It is noted that not all of the drugs prescribed on 2023-10-24 by our endocrinologistare currently reflected on the active medication list. To prevent any potential misunderstandings and to ensure timely access to necessary medications, it might be beneficial to double-check and update the list if needed.

2023-08-18

Our endocrinologist issued a repeat prescription for Docone (dexamethasone), Florinef (fludrocortisone), Crestor (rosuvastatin), and Lipanthyl Supra (fenofibrate), all of which are currently in use, with no medication reconciliation problems found.

700039896

231222

[chemotherapy]

• 2023-12-20 - bortezomib 1.3mg/m2 2mg SC (VTd QW)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-12-21 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

• Cycle length: 28 days.

• Regimen

  • Bortezomib
    • 1.3 mg/m2 SC
    • Given as a single SC injection.
    • Days 1, 8, 15, and 22
  • Thalidomide
    • 100 mg for first 14 days then 200 mg per day thereafter by mouth
    • Take with water on an empty stomach at least one hour after the evening meal.
    • Daily, days 1 through 21
  • Dexamethasone (“low dose”)
    • 40 mg by mouth
    • Take with food (after meals or with food or milk) in the morning.
    • Days 1, 8, 15, and 22

• Pretreatment considerations:

  • Emesis risk
    • MINIMAL TO LOW.
  • Prophylaxis for infusion reactions
    • Routine premedication is not indicated. If a hypersensitivity reaction (not including local reactions) occurs with bortezomib or thalidomide, then neither drug should be readministered.
  • Antithrombotic prophylaxis
    • Routine antithrombotic prophylaxis is warranted. Thromboembolism (grade 3 and 4) was reported in 3% of patients in a clinical trial receiving VTd despite antithrombotic prophylaxis. In addition, reported risk of thromboembolism (grade 3 and 4) was 5% in the Td arm of this study.
  • Infection prophylaxis
    • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VTd. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on Mondays, Wednesdays, and Fridays during treatment. Primary prophylaxis with G-CSF is not indicated.
  • Vesicant/irritant properties
    • Bortezomib is an irritant.
  • Dose adjustment for baseline liver or renal dysfunction
    • Bortezomib: No dosage adjustment for bortezomib secondary to renal insufficiency is necessary. For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the upper limit of normal) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
    • Thalidomide: Dosage adjustment of thalidomide is not required for either preexisting renal or hepatic dysfunction.
  • Pregnancy warning
    • Thalidomide can result in severe, life-threatening human birth defects. Pregnancy testing is required within 24 hours prior to initiation of thalidomide therapy.

• Monitoring parameters:

  • Assess CBC with differential, electrolytes, renal function, liver function, and M protein prior to starting each cycle. A CBC should also be performed prior to the dose of bortezomib on days 1, 8, 15, and 22.
  • Monitor for signs of neuropathy. Many clinicians provide a prophylactic bowel regimen for patients taking thalidomide.
  • Monitor for hypotension during therapy; adjustment of antihypertensives and/or administration of IV hydration may be needed.
  • Monitor for signs of rash, infection, or thrombotic event periodically.

• Suggested dose modifications for toxicity:

  • Neuropathy
    • Dose adjustment guidelines for bortezomib in patients who develop peripheral neuropathy or neuropathic pain are available.
    • Thalidomide should be discontinued or dose reduced if a patient develops paresthesias accompanied by pain, motor deficit, or interference with activities of daily living.
  • Rash
    • Thalidomide has been associated with rashes including SJS and TEN. If a rash develops, thalidomide should be discontinued and the rash further evaluated. Thalidomide should not be administered again if the rash is exfoliative, purpuric, or bullous, or if SJS or TEN is suspected.
  • Thrombotic microangiopathy
    • Rarely, bortezomib has been associated with TMA, which can present with Coombs-negative hemolysis, thrombocytopenia, renal failure, and/or neurologic findings.[3] If TMA is suspected, stop bortezomib and evaluate.
  • Other nonhematologic toxicity
    • For grade 3 or 4 nonhematologic toxicity other than neuropathy, bortezomib should be held. Once symptoms have resolved to grade 1 or baseline, bortezomib may be reinitiated with one dose level reduction (from 1.3 mg/m2 to 1 mg/m2, or from 1 mg/m2 to 0.7 mg/m2).

==========

2023-12-22

[hyperuricemia]

Hyperuricemia was detected on 2023-12-22 with a serum uric acid level of 11.7 mg/dL. Two potential treatment options for this elevated uric acid level might be considered:

• Fasturtec (rasburicase 1.5mg/mL/vial is available): This is a medication that directly breaks down uric acid in the blood, offering a rapid and effective way to lower its levels. It may be an appropriate choice for patients with severe hyperuricemia or those who require a quick reduction in uric acid levels.
• Urinary alkalinization: This approach aims to make the urine more alkaline, which can help uric acid dissolve and be excreted more easily through the kidneys. This can be achieved through various medications, including acetazolamide and sodium bicarbonate. However, the specific choice and effectiveness of these medications for controlling hyperuricemia remain an area of ongoing research and debate.

2023-12-21

[anemia]

The patient’s HGB level has been consistently below normal since admission. The lowest level was observed on 2023-12-21. Bortezomib was administered on 2023-12-20 and is associated with anemia in 12-23% of patients (grades 3-6). It is possible that bortezomib exacerbated the existing anemia.

• 2023-12-21 HGB 7.2 g/dL *
• 2023-12-18 HGB 9.2 g/dL
• 2023-12-14 HGB 9.6 g/dL
• 2023-12-11 HGB 8.1 g/dL
• 2023-12-09 HGB 8.4 g/dL
• 2023-12-09 HGB 8.5 g/dL
• 2023-12-07 HGB 8.0 g/dL
• 2023-12-05 HGB 8.7 g/dL
• 2023-12-04 HGB 7.7 g/dL
• 2023-12-02 HGB 9.7 g/dL
• 2023-12-01 HGB 9.7 g/dL
• 2023-11-27 HGB 9.8 g/dL

The patient should receive red blood cell transfusions as clinically indicated.

[VTd regimen administration schedule]

VTd regimen is supposed to be administered as following:

• Bortezomib
  • 1.3 mg/m2 SC
  • Given as a single SC injection.
  • Days 1, 8, 15, and 22
• Thalidomide
  • 100 mg for first 14 days then 200 mg per day thereafter by mouth
  • Take with water on an empty stomach at least one hour after the evening meal.
  • Daily, days 1 through 21
• Dexamethasone
  • 40 mg by mouth
  • Take with food (after meals or with food or milk) in the morning.
  • Days 1, 8, 15, and 22

Bortezomib and dexamethasone were administered on 2023-12-20 (C1D1). However, thalidomide 100 mg daily was started ahead of schedule on 2023-12-14. To align with the administration cycle (28 days) and discontinue thalidomide on C1D22, it should be stopped on 2024-01-10.

[CMV viral load detected]

As of 2023-12-18, the CMV viral load was measured at 190 IU/mL. Depending on the clinical context and your concerns about this level, valganciclovir 900mg BID could be a potential treatment option.

700971109

231222

[exam findings]

• 2023-11-14 CT - chest
  • Indication: Diffuse large B-cell lymphoma, NOS, non-germinal center B-cell subtype, CD3(-), CD20(+), BCL2(+), CD10(-), BCL6(+), MUM1(+) and MYC(-). Bone marrow involvement. Lugano stage IV, IPI 4.
  • Without & with contrast enhancement, coronal and sagittal reconstructed images shows: comparison made with CT on 2023/07/04
    • Lungs: patchy ground-glass opacities and septal thickening at nondependent LUL and medial RUL.
      • subpleural reticulation at both lower lungs, associated scattered patchy ground-glass opacities.
      • residual enlarged LN at left anterior perivascular space of the mediastinum.
      • resolution of lymphadenopathy at bilateral lower neck involving bilateral thoracic inlet, bilateral axillary, splenic hilum, paraaortic and left inguinal region as well as at left anterior chest wall.
    • Visible abdomen:
      • hyperplasia of left adrenal gland, stable.
      • interval significant decrease in size of low density at right lobe liver measuring 1cm and Lt renal tumor based on this F/U exam.
      • extensive coronary arterial calcification
    • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: dilated LA, s/p MVR.
    • Pleura: no effusion
  • Impression:
    • resolution of the diffuse B-cell lymphoma in both sides of diaphgram and in extra-nodular locations, as compared with previous CT on 2023/07/04. post treatment related change in lungs.
• 2023-07-26 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — lymphoma involvement
  • Section shows piece(s) of bone marrow with one nodule of lymphoma involvement.
• 2023-07-25 CXR (erect)
  • S/P median sternotomy with metalic wires fixation. Please correlate with clinical history.
  • S/P mitral valve replacement.
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
• 2023-07-24 PET scan
  • Glucose hypermetabolism lesions in bilateral neck regions, SCF, ICF, axillae, mediastinum, abdomen, pelvis, left upper thigh and left inguinal regions, and spleen, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
  • Glucose hypermetabolism lesions in the right lobe of the liver, and in C2 spine, right rib cage, bilateral pelvic bones and femurs, highly suspected lymphoma with involvement of liver, bones and/or bone marrow.
    
  • B-cell lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-07-11 Patho - lymph node region resection
  • Lymph node, inguinal, left, excision — Diffuse large B-cell lymphoma, NOS, non-germinal center B-cell subtype
    
  • Immunophenotyping: CD3(-), CD20(+), BCL2(+), CD10(-), BCL6(+), MUM1(+) and MYC(-)
• 2023-07-04 CT - chest
  • Generalized enlarged lymph nodesHe was informed to have abnormal LN enlargement over Rt axillary and Rt lower neck and Lt inguinal region
  • Chest CT with and without IV contrast ehnancement shows:
    • Lymphadenopathy at bilateral lower neck involving bilateral thoracic inlet, bilateral axillary, mediastinum, splenic hilum, paraaortic and left inguinal region.
    • One enlarged soft tisuse at left anterior chest wall, r/o meta.
    • s/p sternotomy with metalic wire fixation of the sternum.
    • s/p thymectomy.
    • Enlarged left adrenal gland is found.
    • Low density at right lobe liver is found with target appearance measuring 2.3cm in largest dimension. Liver meta is considered.
    • Soft tissue mass at left renal cortex measuring 3.58cm in largest dimension. r/o renal meta
  • Imp:
    • Extensive lymphadenopathy from lower neck to mediastinum and abdominal cavity as well as left inguinal region.
    • Liver, left adrenal and left renal soft tissue mass, meta is favored.
    • r/o thymoma with recurrence
• 2023-06-05 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 37) / 93 = 60.22%
    • M-mode (Teichholz) = 59
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, septal hypertrophy
    • Trivial MR, mild AR and mild TR
    • Preserved RV systolic function

[MedRec]

• 2023-08-18 SOAP Cardiology Xie JianAn
  • Prescription x3
    • Caduet (amlodipine 5mg, atorvastatin 20mg) 1# QD
    • Plavix (clopidogrel 75mg) 1# QD
    • carvedilol 6.25mg 0.5# QD (hold if HR < 60)

[immunochemotherapy]

• 2023-12-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
• 2023-11-14 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
• 2023-10-19 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
• 2023-09-19 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
• 2023-08-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
• 2023-07-26 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 47mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2

==========

2023-12-22

Serum uric acid levels sometimes exceed the normal range, and Feburic (febuxostat) has been prescribed for treatment. No medication discrepancies have been identified.

2023-10-06

[reconciliation]

The patient’s PharmaCloud records are not currently available. However, after reviewing HIS5, no medication discrepancies were found.

[leukopenia]

Leukopenia was noted in early Oct, approximately 2 weeks after his last R-CHOP treatment (3rd dose) on 2023-09-19. On 2023-10-04, the patient was started on G-CSF (filgrastim) 300mg SC QD. A slight improvement in WBC count was observed on 2023-10-06. There is no problem with the treatment.

2023-10-06 WBC 0.85 x10^3/uL
2023-10-04 WBC 0.65 x10^3/uL
2023-09-26 WBC 3.37 x10^3/uL
2023-09-18 WBC 4.63 x10^3/uL

2023-09-19

• On 2023-08-18, our cardiologist provided a repeat prescription for Caduet (amlodipine, atorvastatin), Plavix (clopidogrel), and carvedilol, each with a 3x28-day supply. These medications are currently being taken as prescribed without any reconciliation issues detected.

700021401

231219

[lab data]

• 2023-11-26 Aerobic Culture - Wound/Pus
  • Proteus mirabilis Growth:3+
    • Doripenem(S), Amilkacin(S =2), Flomoxef(S =2), Gentamicin(S =1), Imipenem(S), Ceftriaxone(S =1), Ampicillin(R >=32), Cefazolin(other)(R 8), Cefoperazone/Sulbactam(S =8), Ciprofloxacin(S =0.25), Amoxicillin/Clavulanic Acid(R), Cefazolin(Urine)(S 8), Piperacillin/tazobactam(S =4), Levofloxacin(S =0.12)
  • Escherichia coli Growth:3+
    • Gentamicin(S =1), Flomoxef(S =2), Cefazolin(Urine)(R >=64), Ceftriaxone(R >=64), Ciprofloxacin(S =0.25), Levofloxacin(S =0.12), Cefazolin(other)(R >=64), Piperacillin/tazobactam(S =4), Ampicillin(R >=32), Doripenem(S =0.12), Imipenem(S =0.25), Cefoperazone/Sulbactam(S 16), Amilkacin(S =2), Amoxicillin/Clavulanic Acid(R)
  • VREfm(E.faecium) Growth:3+
    • Teicoplanin(R >=32), Vancomycin(R >=32), Gentamicin High Level Resistance(S SYN-S), Penicillin(R >=64), Linezolid(S), Erythromycin(R >=8)
• 2023-11-25 Blood Culture - Whole Blood - Gram Strain: GNB
  • Pseudomonas aeruginosa
    • Piperacillin/tazobactam(S 8), Amilkacin(S =2), Cefepime(S =1), Levofloxacin(S 1), Ceftazidime(S 4), Imipenem(S 1), Ciprofloxacin(S =0.25), Colistin(S =0.5), Gentamicin(S =1)
• 2023-11-25 Blood Culture - Whole Blood - Gram Strain: GNB
  • Pseudomonas aeruginosa
• 2023-10-10 Aerobic Culture - Wound/Pus
  • Escherichia coli Growth:3+
    • Flomoxef(S =2), Ciprofloxacin(S =0.25), Cefoperazone/Sulbactam(S 16), Amoxicillin/Clavulanic Acid(R), Doripenem(S =0.12), Cefazolin(Urine)(R >=64), Gentamicin(S =1), Cefazolin(other)(R >=64), Piperacillin/tazobactam(S 8), Ceftriaxone(R >=64), Ampicillin(R >=32), Levofloxacin(S =0.12), Imipenem(S =0.25), Amilkacin(S =2)
• 2023-10-10 Anaerobic Culture - Wound/Pus
  • Bacteroides fragilis Growth:2+
    • Clindamycin(S), Tetracycline(R), Metrenidazole(S), Ampicillin/Sulbactam(I), Penicillin(R), Cefoperazone(R)
• 2023-10-03 Aerobic Culture - Sputum
  • Mixed normal flora Growth:4+
  • Staphylococcus aureus Growth:4+
    • Rifampin(S =0.5), Vancomycin(S 1), Erythromycin(R >=8), Linezolid(S 2), Trimethoprim/Sulfamethoxazole(S =10), moxifloxacin(S =0.25), Daptomycin(S 0.25), Fusidic Acid(S =0.5), Penicillin(R >=0.5), Teicoplanin(S =0.5), Tetracycline(R >=16), Tigecycline(S =0.12), Oxacillin MIC(S), Clindamycin(S =0.25)

[exam findings]

• 2023-12-06 ENT Hearing Test
  • Reliabilty Poor
  • PTA
    • R’t : 55 dB HL, moderate to severe mixed type HL
    • L’t : 63 dB HL, moderateto profound mixed type HL
  • Tymp
    • Bil Type C
  • ART
    • Bil absent.
• 2023-12-05 ECG
  • Atrial fibrillation with premature ventricular or aberrantly conducted complexes
  • Right bundle branch block
  • T wave abnormality, consider inferolateral ischemia
• 2023-12-05 CXR
  • S/P Port-A infusion catheter insertion.
  • Patch density at RUL.
  • Atherosclerosis of the aorta.
• 2023-11-25 CXR
  • S/P port-A implantation.
  • Patchy consolidation projecting at right upper lung is noted. Please correlate with clinical condition to rule out Bronchopneumonia.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2023-11-07 Patho - brain biopsy
  • PATHOLOGIC DIAGNOSIS
    • Left hippocampus tumor, frozen + stereotactic biopsy — Diffuse large B-cell lymphoma
      
  • MACROSCOPIC DESCRIPTION
    • Operation procedure: stereotactic biopsy
    • Topology: left hippocampus
    • Specimen size and number: multiple fragments, up to 0.4 x 0.2 x 0.1 cm
    • All embedded for section [Reference: frozen, F2023-00496 one tiny piece measured 0.2 x 0.1 x 0.1 cm]
  • MICROSCOPIC EXAMINATION
    • Histology type: diffuse large B-cell lymphoma shows large atypical lymphoid cells with nucleoli, frequent mitoses and starry-sky feature
    • Immunohistochemistry: CK(-), GFAP(-), CD3(-), CD20(+), Bcl-2(+), CD10(-), Bcl-6(+), C-MYC(+, 30%), MUM-1(+) and Ki-67(>90%) for tumor cells. Clinical correlation is advised.
• 2023-11-07 CXR
  • Supine chest film shows:
    • Presence of borderline cardiomegaly by cardiac/thoracic ratio.
    • Presence of calcification of the intima at the aortic knob.
    • No obvious lung patchy density or nodule.
• 2023-11-07 Frozen Section
  • Left hippocampus tumor, frozen — Atypical lymphoid hyperplasia. Please pending for followed IHC for final diagnosis.
• 2023-11-06 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2023-11-06 ECG
  • Atrial fibrillation
  • Right bundle branch block
  • Abnormal ECG
• 2023-11-02 CT - brain for navigator
  • Clinical information: R/O secondary CNS lymphoma
  • Cranial CT scans from the vertex to the mid-maxillary level were performed with i.v. contrast injection.
  • Impression:
    • One lobulated enhancing lesion (3.5cm in size) over left medial temporal lobe.
    • The size of the lateral and third ventricles appears normal.
    • Prominent peritumoral edema.
• 2023-10-31 MRA - brain
  • Clinical information: R/O secondary CNS lymphoma
  • Findings:
    • Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis. Suggest clinical correlation.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • MR angiography of the brain shows normal intracranial vessel including circle of willis.
• 2023-10-31 EEG
  • The back ground activity were composed by alpha rhythm with 8-12 Hz, 20-50 uv in bilateral occipito-temporal area.
  • There were diffuse beta waves with 15-25 Hz, 1-5 uV in bilateral hemisphere.
  • No epileptiform discharge was noted. Intermittent muscle artifact may interference with interpretation.
  • The above findings may suggest normal EEG study. Advice clinical correlation
• 2023-09-29 CT - abdomen
  • History and indication: Two weeks ago, the patient had chemotherapy. Now he feel unwell all over his body, and his bowel movements are not smooth.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Some small LNs at retroperitoneum and right axillary region.
    • Splenomegaly.
    • Renal cysts (up to 2.4cm).
    • Mild enlargement of prostate.
    • Hyperplasia of right adrenal gland.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • Focal GGO at bilateral lungs.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Some small LNs at retroperitoneum and right axillary region.
    • Splenomegaly.
• 2023-09-08 PET
  • In comparison with the previous study on 2023/03/10, the previous FDG avid lesions in multiple lymph nodes on both sides of the diaphragm and in the right lung, liver, spleen and multiple bones/bone marrow disappeared.
  • Increased FDG uptake in some focal areas in bilateral lungs and in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation/infection may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Increased FDG uptake in a focal area in the left aspect of the maxilla. Dental problem is more likely.
  • Increased FDG uptake in a focal area in the left lobe of the liver, in a focal area in the region about the spinal cord of T12 level and in the region about the lower portion of the rectum. The nature is to be determined (inflammation/infection? other nature?). Please also correlate with other clinical findings for further evaluation.
• 2023-09-07 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right upper lung and left middle lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2023-08-25 CT - abdomen
  • History and indication: reccurent DLBCL involving right lung, liver, spleen and multiple bone marrow, Lugano stage IV
  • Findings:
    • There are several newly developed patchy ground-glass opacities with air-bronchogram at both lungs. Bronchopneumonia is highly suspected.
      
    • Prior CT identified some LNs (up to 1.2cm) at para-aortic space and para-cava space are noted again, decreasing in size to 0.6 cm.
    • Prior CT identified enlarged node at right axillary region is noted again, stationary.
    • Prior CT identified some low attenuations in the spleen are noted again, stationary that may be old infarction.
    • Renal cysts (up to 2.4cm).
    • Hyperplasia of right adrenal gland.
    • There is mild bilateral Pleura effusion and pericardial effusion.
    • There is a poor enhancing lesion 7 mm in S4 of the liver that may be cyst. Please correlate with sonography.
  • Impression:
    • There are several newly developed patchy ground-glass opacities with air-bronchogram at both lungs. Bronchopneumonia is highly suspected. please correlate with clinical condition.
• 2023-08-16 SONO - abdomen
  • Diagnosis:
    • cholecystopathy, unknown etiology
    • GB polyp
    • Renal cyst, left
    • pancreatic neck cystic lesion, suspicious, IPMN
    • splenomegaly, mild
    • Pleural effusion, left
    • Enteropathy, uknown etiology.
  • Suggestion:
    • correlate with other image
• 2023-08-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 29) / 78 = 62.82%
    • LVEF(%) = 63
    • M-mode(Teichholz) = 63
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; atrial fibrillation (elevated average E/e’).
    • Normal RV systolic function.
    • Aortic valve sclerosis with no AS and AR; mild MR; mild to moderate TR.
    • Minimal pericardial effusion without tamponade and constriction sign.
• 2023-08-02 24hr portable ECG
  • Atrial fibrillation thoughout the holter recording period
  • HR:47-165 bpm, AVE:85 bpm
  • Intraventricular conduction delay
  • Longest R-R interval 2.01 secs at 04:40
• 2023-05-25 CT - abdomen
  • History and indication: reccurent DLBCL involving right lung,liver,spleen and multiple bone marrow, Lugano stage IV
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Some LNs (up to 1.2cm) at retroperitoneum and right axillary region.
    • Some low attenuations in spleen.
    • Renal cysts (up to 2.4cm).
    • Hyperplasia of right adrenal gland.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Some LNs (up to 1.2cm) at retroperitoneum and right axillary region.
    • Some low attenuations in spleen.
• 2023-03-13 Peropheral Vascular Test - AV fistula
  • Result: adequate size of RIJV
• 2023-03-10 PET
  • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm and involving right lung, liver, spleen and multiple bones/bone marrow as mentioned above (stage IV).
  • In comparison wih the previous study on 2022/05/05, more new FDG avid lesions are noted, suggesting lymphoma in progression.
• 2023-01-31 Spirometry
  • DLCO 48 -> 66 -> 73%
  • TLC: 88%
• 2022-11-08 CXR
  • RRt paratracheal stripe thickening
  • reticular opacities and hazy areas of increased opacities over both lungs scatteredly
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • mild enlarged cardiac silhoutte
• 2022-11-02 Spirometry
  • TLC: 82%.
  • DLCO 66% improved
  • FEV1/FVC<75%.
• 2022-08-16 Spirometry
  • TLC: 68%.
  • DLCO 48%.
• 2022-05-05 PET
  • The FDG PET findings are compatible with recurrent lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above and involving the bone marrow of left femoral shaft (stage IV).
  • Glucose hypermetabolism in a a focal area in the left humeral shaft. The nature is to be determined (lymphoma? other nature?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in multiple focal areas in bilateral lung fields. Inflammation is more likely.
• 2022-04-26 CT - chest
  • History of relapsed lymphoma over neck and mediastinum post autoPBSCT
  • Comparison made with previous CT dated on 2022/01/11
    • Lungs:
      • extensive centrilobular micronodular and branching opacities associated scattered lobular areas of ground-glass opacity
      • focal minimal paraspinal fibrosis in RLL, related to osteophytes of spine.
      • a subpleural paraseptal emphysema at medial right apical lung region.
    • Pleura:
      • minimal bilateral pleural effusions.
      • small pericardial effuion.
    • Mild atherosclerotic change of the aortic arch and descending thoracic aorta. mild coronary arterial calcification.
    • An irregular soft-tissue lesion at Rt axilla (19 mm in longest axial dimension), stationary in size as compared with CT on 2022/1/11
    • Neck, mediastinum and hila: multiple enlarged LNs in visceral space of the mediastinum.
    • Visible abdomen and pelvis:
      • unremarkable of the liver, Rt kidney, spleen, adrenal glands, and pancreas. Several left renal cysts up to 25 mm.no enlarged LNs. mild enlarged prostate.
  • Impression:
    • post treatment change in Rt axillary region, stationary.
    • lung infection, infectious bronchiolitis.
    • new neoplastic LAP in the mediastinum.
• 2022-02-15 SONO - chest
  • Echo diagnosis:
    • pleural effusion, trivial amounts located over left CP angle.
    • Favor arrhythmia, heart failure related pleural effusion and history of pneumonia before.
• 2022-02-14 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2022-01-18 ECG
  • Sinus rhythm with Premature atrial complexes
  • Possible Left atrial enlargement
  • Right bundle branch block

[MedRec]

• 2023-10-02 ~ 2023-12-19 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Recurrent Diffuse large B-cell lymphoma involving right lung, liver, spleen and multiple bones/bone marrow, Lugano stage IV, status post autoPBSCT on 2021/11/03, 11/04. Recurrent brain metastsis on 2023/11/07 S/P Left navigation assisted biopsy for temporal hippocampus lesion
    • neutropenia with Sepsis blood culture: GNB -> Pseudomonas aeruginosa
    • Aspiration pneumonia progression sputum culture; Staphylococcus aureus Growth:4+ on 2023/10/03 and the CXR film revealed LUL cavitation, despite broad spectrum antibiotic, S/P receiving high-flow nasal cannula
    • nystagmus due to brain metastasis and brainstem compression
    • anal perianal abscess S/P fistulotomy + debridement + drainage on 2023/11/29 pus culture: Escherichia coli Growth:3+
    • Hypomagnesemia
    • Anemia due to Myelosuppression
    • Thrombocytopenia due to Myelosuppression
    • Hypokalemia
    • memory loss due to brain metastasis related
  • CC
    • fever without chills and dyspnea for 4 days
  • Present illness
    • This 71-year-old man was relatively well until June 2019. He first noticed a mass lesion at right side axillary when June 2019. He went to the ZhengXing Hospital for workups and splenic lesion was demonstrated as well. The axillary LN biopsy confirmed the diagnosis of diffuse large B cell lymphoma.
    • The PET examination also disclosed dissimentated involvement of the disease, including multiple LNs, spleen, skull, spine and bone marrow, Lugano stage IV. The Bone marrow biopsy from the iliac bone (2019-08-22) also had bone marrow involvement of lymphoma with IHC characteristics of the following: CD3 (-), CD20 (+). bcl-2 (+), bcl-6 (equivocal, -/+), CD10 (-).
    • After the above staging workups, he had chemotherapy with R-DA-EPOPCH regimens for 6 cycles (from 2019/08/23 to 2020/01/03) without special events for his diffuse large B cell lymphoma with bone marrow involvement, Lugano stage IV with R-DA-EPOPCH with recurrence, he was admitted to hematology ward (from 2021/04/18 to 05/03) for restaging workups.
    • Bone marrow biopsy was done on 2021/04/19, and the pathology report no lymphoma involvement in the bone marrow. The left side neck LN’s pathology confirmed the DLBCL in nature.
    • Chemotherapy with R-DHAP (C1) on 2021/4/29 to 2021/5/2 but he tolerated it poorly.
    • He received C1 Pola-BR (Polatuzumab 1.8mg/kg on D1, Mabthera 375mg/m2 on 2021/5/28 D1, self paid of Bendamustine 90mg/m2 on D2-D3) on 2021/5/28-30.
    • C2 P-BR on 6/28-30 and received autologus stem cell transplantation on 2022/10/29-11/3.
    • PET was performed on 2023/3/10 revealed lymphoma involving multiple lymph nodes on both sides of the diaphragm and involving right lung, liver, spleen and multiple bones/bone marrow as mentioned above (stage IV).
    • Under the impression of Recurrent Diffuse large B-cell lymphoma involving right lung, liver, spleen and multiple bones/bone marrow, Lugano stage IV, status post autoPBSCT on 2021/11/3, 11/4, PS 1, post C1 selfpaid of P-BR on 2023/03/15 - 03/16.
    • C2 selfpaid of P-BR on 2023/4/25-4/26. C3 selfpaid of P-BR on 2023/05/24-25. Neulasta was given after the chemotherapy. C4 P-BR on 2023/07/17 - 07/18, C5 P-BR on 2023/09/15 - 09/16.
    • Follow-up abdominal CT (2023/08/25) showed there are several newly developed patchy ground-glass opacities with air-bronchogram at both lungs. Bronchopneumonia is highly suspected.
    • PET scan (2023/09/08) revealed lesions in multiple lymph nodes on both sides of the diaphragm and in the right lung, liver, spleen and multiple bones/bone marrow disappeared. Increased FDG uptake in some focal areas in bilateral lungs and in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation/infection may show this picture.
    • This time, general malasie for 2-3 days and mild dyspnea were noted on 09/29 23 and visited to ER for aid and antibiotic with Cefim was given then shifted to Ceficin 2# po q12h x 3 days for take home. Fever (37.1 degree C) without chills and mild cough without sputum and dyspnea were also developed on 9/30 23 and came to our infection OPD for aid and laboratory shwoed leukopenia (WBC = 1.46 x10^3/uL) and Lenograstim 250mcg sc x 2 days was given. The Laboratory shwoed WBC = 0.46 x10^3/uL, seg:6.2% ANC: 28.5, Monocyte = 47.5 %, Creatinine = 1.36 mg/dL.
    • Under the impression of neutropenia fever. He was admitted for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, hydration, antibiotic with Cefim/Targocid/G-CSF 300mg sc were given for neutropenia fever. The White blood cells rise slowly was noted. Blood transfusion with LPRBC 2U & LRP 2PH was given on 10/5 23 for anemia & thrombocytopenia.
    • Sudden onset of dysuria & bladder distension and residual urine volume about 400cc by ICP were noted and we consulted uro for difficulty intubating and advisted to I have successfully inserted a 22Fr three-way Foley catheter. Please keep the catheter in place for at least one week and prescribe Harnalidge to increase the success rate of catheter removal.
    • Intravenous KCL/Const-K and MgSo4 were administered for hypokalemia & hypomagnesemia. He complained of tenderness perianal and anal canal about 6o’clock region, no fluctuation, no pus discharge for days and rectal surgical Dr was consulted for evaluation and advisted to empyric antibiotic drugs treatment/Biomycin onitment for topic use/if s/s got worse then call us again for I&D.
    • Blood transfusion with LRP 2PH was given on 10/9 23 and anal absecss I & D was done and collected pus culture.
    • Blood transfusion with LPRBC 2U 10/11 & LRP 2PH was given on 10/13 & 10/16 23 for anemia & thrombocytopenia. The pus culture Aerobic/Anaerobic yeilded Escherichia coli Growth:3+/Bacteroides fragilis Growth:2+ and antibiotic shifted to Tapimycin 4.5mg ivd q6h since 10/17 23 by infection Dr suggested. Sudden onest of hematuria & blood colt obstruction via foley cather was developed on 10/17 23 at 3:00 AM and foley irrgation with normal saline 2000cc qd and Transamin 1# po bid were given and contact uro Dr for evaluation again.
    • Blood transfusion with LPRBC 2U 10/16 & LRP 2PH was given on 10/23 23 for anemia & thrombocytopenia. Tapimycin 4.5mg ivd q6h qas given since 10/17 23 for anal infection.
    • Blood transfusion with LRP 2PH was given on 10/26 23 & LPRBC 2U on 10/28 23 for anemia & thrombocytopenia. Tapimycin 4.5mg ivd q6h qas given since 10/17 to 10/30 23 for anal infection. He complained of memory loss in recent 3 days and we consulted neuro for further evaluation.
    • Blood transfusion with LRP 2PH was given on 10/31, 11/3, 11/5 23 for thrombocytopenia. CT Brain for Navigator (11/2 23) showed one lobulated enhancing lesion (3.5cm in size) over left medial temporal lobe. The size of the lateral and third ventricles appears normal. Prominent peritumoral edema.  We consulted neurosurgery for biopsy evaluation and will arrange biopsy on 11/7 23. Intravenous Dexa 4mg ivd q6h + Mannitol 100ml IVD q8h were added for peritumoral edema & IICP sign. Keppra 500mg ivd q12h was added. Anti-fungus infection was suspected by brain MRA exam and anti-fungus drugs was added by Dr 李啟誠 suggested.
    • Brain MRA (10/31 23) showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis. Suggest clinical correlation. 2. Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation. 3. MR angiography of the brain shows normal intracranial vessel including circle of willis.
    • Brain biopsy was done on 11/7 23 and he was transferred to SICU for further treatment on 11/7 23.
    • G-CSF 300mg sc was given for neutropenia. Blood transfusion with LRP 2PH was given on 10/31, 11/3, 11/5 23 for thrombocytopenia.
    • Left hippocampus tumor, frozen + stereotactic biopsy (11/10 23) proved Diffuse large B-cell lymphoma, Immunohistochemistry: CK(-), GFAP(-), CD3(-), CD20(+), Bcl-2(+), CD10(-), Bcl-6(+), C-MYC(+, 30%), MUM-1(+) and Ki-67(＞90%) for tumor cells.  
    • Keppra shifted to oral form since 11/14 23. We consulted radiologist for radiotherapy evaluation and advisted to preliminary planning dose: 2340cGy/13 fractions of the whole brain, and 3600cGy/20 fractions of the metastatic brain tumor. Radiotherapy started since 11/14 23 and Dexa 4mg ivd was added.
    • Right face reddish, swelling and pain was noted cellulitis was suspected and septic work-up was performed and antibiotic with Augmentin was given since 11/14 23. He complained of severe anal pain and pus yellowish dischage in recent days and constact rectal surgical again for evaluation and suggested to Fistulotomy or fistulectomy,compliitated subcutaneous on next week. Ultracet 1# po q6h was added for pain control.
    • Fistulotomy or fistulectomy,compliitated subcutaneous on 11/27 23. Owing to abnormal liver function was noted and Ultracet change to prn used. Sudden onest of fever with chills was developed on 11/25 23 night and septic work-up was performed and G-CSF 300mcg sc qd + antibiotic with Cefim 2mg ivd q8h were administered for neutropenia fever with sepsis. The blood culture (port-A & peripheral )showed GNB. Sudden onest of fall down (the patient walked out of the bathroom and fell forward without knowing how it happened) was found on 11/26 23 and without any discomfort or trauma wound. He complained of his jaw had been always clenched for days and neuro was consulted for evaluation.
    • G-CSF 300mcg sc qd + antibiotic with Cefim 2mg ivd q8h were administered for neutropenia fever with sepsis. The blood culture (port-A & peripheral )showed Pseudomonas aeruginosa. Consulted Neuro for evaluation and advisted to arranged EEG. Anal culture revealed E coli & VRE to sensitive anti treatment. blood transfusion with LRP 2PH was given on 12/3 23. Repeat blood culture x 2 on 11/30 23.
    • Blood transfusion with LRP 2PH was given on 12/7 23. Repeat blood culture x 2 showed negative. Romiplate 250mcg was given on 12/8 23.
    • Hold Radiotherapy on 12/11 23 due to poor condition. G-CSF 300mcg sc qd .Blood transfusion with LRP 2PH & LPRBC 2U were given on 12/12-12/14 23. Sudden onest of fever with chills and dyspnea were noted on 12/11 23 and CXR showed ARDS, bilateral pneumonia and pulmonary edema and septic work-up was performed and antibiotic with antibiotic with Bestnem 500mg ivd q6h since 12/11, Targocid 600mg ivd qd since 12/12, Mycamine 100mg ivd qd since 12/11 for R/O fungus infection hydration/ Albumin 50mg (self-paid)+ Lasix 1amp ivd q12h on 12/12-12/14 23 & Sevatrim 10mg in N/S 250ml IVD q8h and Norepinephrine 8mg + D5W 250ml were given and O2 therapy with HFNC total flow:60L, O2 flow:40L/74%/Medason 40mg ivd q8h were added for sepsis with septic shock , ARDS, pulmonary edema and bilateral pneumonia. Intravenous KCL 10cc in N/S 250ml IVF 2hrs was given for hypokalemia. Follow-up CXR showed pulmonary edema improving and bilateral pneumonia remain.
    • There is pneumonia progression and the lastest yeterday CXR film revealed LUL cavitation, despite broad spectrum antibiotic, including Tienam, Targocid, iv Baktar, and Mycamine combination therapy.Suspect seizure with hand tremor noted yesterday, which may be related to Tienam use.Since there is cavitation and high PCT level one week ago, that PJP possibility is not hight.Patient is receiving high-flow nasal cannula now, that intubation indicated for him.But patient refused intubation and DNR consent already been signed. antibiotic shifted to DC Tienam, Targocid, Mycamine and PJP/Add Mepem, Zyvox, and Cresemba. Follow up serum Aspergillus antigen titer again by infection De suggested.
    • Owing to nystagmus was happened on 12/16 afternoon and Keppar shifted to IV from 750mg q12h for symptom relief. Neurologist revisits patient again on 12/18 23 and explained his poor condition to his family and suggested add Morphine 3mg ivd prnq6h for symptom relief.
    • Consciousness coma & dyspnea were noted and EKG monitor showed asystole, no respiratory movement, pupil size dilated and he was expired at 04:24 AM on 11/19 23.
    • skin: right upper lip black scab & left 2nd hand reddsih scab, Pseudomonas aeruginosa infection related by infection Dr said, if wound pus will collect pus culture and wating blood culture report.
    • The patient reported shortness of breath but refused intubation. The patient’s wife was informed of the current condition and that not intubating would lead to respiratory failure. The patient and the wife expressed they could understand clearly. Infection specialist Dr. Peng MingYe visited the patient and explained the current condition and medication treatment to the family. Oxygen can be changed to high flow used. The patient still refused to put in a nasogastric tube.
• 2023-09-18 SOAP Cardiology Ye GuanHong
  • Prescription x3
    • Urief (silodosin 8mg) 1# HS
    • spironolactone 25mg 0.5# QD
    • Multaq (dronedarone 400mg) 1# BID
    • Lixiana (edoxaban 30mg) 1# QD
    • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QN
    • Wecoli (bethanechol 25mg) 1# BID
    • Nirandil (nicorandil 5mg) 1# BID

[consultation]

• 2023-11-10 Radiation Oncology
  • Q
    • For radiotherapy evaluation
    • This 71 year old man is a retired Oral and Maxillofacial Surgery Chief of the Tri-Service General Hospital (underline CAD, HTN and PAf), a case of Diffuse large B cell lymphoma, diagnosis on 2019-08, Lugano stage IV with R-DA-EPOPCH with recurrence s/p Pola-BR and then autologoud stem cell transplantation on 2022-11-03, disease recurrent on 2023-03, s/p Pola-BR with image complete remission (2023-09 PET).
    • This time, he was admiited due to neutropenia fever after chemotherapy. During this time, he suffered from memory loss in recent 3 days. Brain MRA showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis.
    • The Left hippocampus tumor, frozen + stereotactic biopsy (11/9 23) proved diffuse large B-cell lymphoma, Immunohistochemistry: CK(-), GFAP(-), CD3(-), CD20(+), Bcl-2(+), CD10(-), Bcl-6(+), C-MYC(+, 30%), MUM-1(+) and Ki-67(>90%) for tumor cells.
    • We need your expertise for further evaluation thanks!
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For radiotherapy due to brain metastasis with memory loss.
      • PI: The patient suffered from memory loss for about 2 weeks. MRI of brain (2023-10-31) showed focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
    • O: ECOG: 1
      • PE: poor memory function.
      • PET (2019-8-16): 1. The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, spleen and multiple bones or bone marrow as mentioned above. Please correlate with other clinical findings for further evaluation. 2. A mild glucose hypermetabolic lesion in the upper lobe of right lung. The nature is to be determined (lymphoma? inflammatory process? other nature?).
      • Pathology (S2019-14043, 108-8-26): Bone marrow, iliac, clinical history of diffuse large B cell lymphoma dignosed inJune 2019, biopsy — Lymphoma involvement, B cell type, IHC stains: CD3 (-), CD20 (+). bcl-2 (+), bcl-6 (equivocal, -/+), CD10 (-). The pattern is compatible with large B cell lymphoma.
      • CT scan of lung (2019-11-27): normal appearance of lungs based on this follow up CT study. Rt axillary tumor lesion.
      • CT scan of lung (2020-3-17): Minimal nonspecific inflammation in RLL, paravertebral region. Rt axillary mass lesion, in regression.
      • PET (2020-3-25): 1. Almost all glucose-hypermetabolic lesions disappear including multiple lymph node regions on both sides of the diaphragm, spleen, and skeleton compared with the previous study on 2019-08-16, indicating lymphoma with good response to current therapy. 2. Glucose hypermetabolism involving vocal cord and post. wall of pharynx, probably inflammation process. 3. Glucose hypermetabolism in the myocardium of the right ventricle, suggesting pulmonary dysfunction.
      • Pathology (s2020-05124, 2020-4-28): Bone marrow, iliac, history of lymphoma in 2019, biopsy — Negative for malignancy. IHC stains: LCA (15% of the nucleated cells). CD and CD20 no monoclonality. Bcl-2 (-), bcl-6 (-).
        
      • CT scan of lung (2020-6-16): Minimal nonspecific inflammation or fibrosis in RLL related to aging, paravertebral region. Rt axillary mass lesion, stationary based on CT exam.
      • RT (2020-7-3 ~ 2020-7-31): 3600cGy/20 fractions of the right axillary area.
      • CT: Lung/Mediastinum/Pleura (2020-9-17): Right axillary lesion. Mildly decreased in size. Splenic lesion, r/o hemangioma. Suggest MRI, if necessary. Enlarged prostate, please correlate with PSA.
      • PET (2023-9-8): 1. In comparison with the previous study on 2023/03/10, the previous FDG avid lesions in multiple lymph nodes on both sides of the diaphragm and in the right lung, liver, spleen and multiple bones/bone marrow disappeared. 2. Increased FDG uptake in some focal areas in bilateral lungs and in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation/infection may show this picture. 3. Increased FDG uptake in a focal area in the left aspect of the maxilla. Dental problem is more likely. 4. Increased FDG uptake in a focal area in the left lobe of the liver, in a focal area in the region about the spinal cord of T12 level and in the region about the lower portion of the rectum. The nature is to be determined (inflammation/infection? other nature?).
      • MRI of brain (2023-10-31): 1. Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis. Suggest clinical correlation. 2. Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation. 3. MR angiography of the brain shows normal intracranial vessel including circle of willis.
      • Pathology (S2023-22180, 2023-11-9): Left hippocampus tumor, frozen + stereotactic biopsy — Diffuse large B-cell lymphoma
        
    • A: Large B cell lymphoma, stage IV, s/p chemotherapy, with residual tumor over right axillary area, s/p radiotherapy, with recurrence s/p autologous stem cell transplantation, with brain metastasis.
    • P: Radiotherapy is indicated for this patient with the following indicators: brain metastasis
      • Goal: palliation
      • Treatment target and volume: brain
      • Technique: 2D and VMAT/IGRT
      • Preliminary planning dose: 2340cGy/13 fractions of the whole brain, and 3600cGy/20 fractions of the metastatic brain tumor
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, the treatment planning of radiotherapy will be started at 1330, 2023-11-13.
• 2023-11-01 Neurosurgery
  • Q
    • For tissue biopsy?
    • This 71 year old man, retired Oral and Maxillofacial Surgery Chief of the Tri-Service General Hospital (underline CAD, HTN and PAf), is a case of Diffuse large B cell lymphoma, diagnosis on 2019-08, Lugano stage IV with R-DA-EPOPCH with recurrence s/p Pola-BR and then autologoud stem cell transplantation on 2022-11-3, disease recurrent on 2023-3, s/p Pola-BR with image complete remission (2023-09 PET). This time, he was admiited due to neutropenia fever after chemotherapy. During this time, he suffered from memory loss in recent 3 days.
    • Brain MRA showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis.
    • We need your expertise for further evaluation (tissue biopsy?). Thanks a lot.
  • A
    • A case of 71 y/o male, Diffuse large B cell lymphoma s/p C/T. Fever?
      • Memory impairment noted for days; NS is consulted for left temporal intraaxial lesion. Biopsy evalaution.
      • A brain MRI showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size).
    • P: please arrange brain CT with contrast for NAVIGATION; Brain biopsy will be performed after well explanation of surgical benefits and risks to him.
• 2023-10-30 Neurology
  • Q
    • for memory loss in recent 3 days
    • The 71 y/o man has DLBCL s/p auto-PBSCT. This time, he was admitted for neutropenia fever stage. He complained of memory loss in recent 3 days. We need expertise to his condition thanks!
  • A
    • O
      • CN: intact
      • MP: full
      • Gait: intact
    • Suggestion:
      • Arrange EEG
      • Arrange brain MRA with contrast in case of secondary CNS lymphoma
      • Check free T4, TSH, vit B12, folic acide, homocysteine, and RPR
    • I will F/U this case
      • Thanks for consultation
      • Feel free to contact me if you have any problem
• 2023-10-03 Urology
  • Q
    • for dysuria and feeling like he can’t finish urinating
    • The 71 y/o man has DLBCL /p auto-PBSCT. This time, he was admitted for with neutropenia fever stage. Due to anal pain progression noted for days. We need expertise to his condition thanks!
  • A
    • I have successfully inserted a 22Fr three-way Foley catheter.
    • Please keep the catheter in place for at least one week and prescribe Harnalidge to increase the success rate of catheter removal.
    • Arrange Dr. Hsu’s OPD’s follow up after discharge. Thank you for your consultation!
• 2023-10-03 Colorectal Surgery
  • Q
    • for anal pain progression
    • The 71 y/o man has DLBCL /p auto-PBSCT. This time, he was admitted for with neutropenia fever stage. Due to anal pain progression noted for days. We need expertise to his condition thanks!
  • A
    • This is a 71-yr old man with anal pain for days
      • hx: DLBCL /p auto-PBSCT
      • DRE: tenderness perianal and anal canal about 6o’clock region, no fluctuation, no pus discharge
    • A: anal pain, R/I perianal abscess, R/I DLBCL induce anal pain
    • P: empyric antibiotic drugs treatment
      • Biomycin onitment for topic use
      • if s/s got worse then call us again for I&D
      • we will also closely follow up this case
  • A 2023-10-09 17:50:49
    • CC: much anal pain was told
    • PE: fluctuation was found
    • A/P: perianal abscess
      • I&D with epineprhine gaunze wet dressing was done
      • explaint the possilbe of anal fistula
  • A 2023-11-11 08:18:16
    • CC: bloody discharge was told 2 days ago
    • PE: one 0.2cm pin hole over 6 o’clock region with clear fluild discharge when compression
    • A: R/I anal fistula over 6 o’clock region
    • P: wound cd and biomycin local treatment
• 2023-08-21 Colorectal Surgery
  • Q
    • The 71 y/o man has DLBCL /p auto-PBSCT. This time, he was admitted for sepsis with neutropenia stage. Due to anal pain, so we need your help for management. Thanks!
  • A
    • This is a 71-yr old man with anal pain for 2 days
      • hx: DLBCL /p auto-PBSCT
      • DRE: tenderness perianal and anal canal about 6 o’clock region,no fluctuation, no pus discharge, mild tenderness over 12 o’clock region
    • A: anal pain, R/I perianal abscess, R/I DLBCL induce anal pain
    • P: empyric antibiotic drugs treatment add alcos anal onitment topic treatment
      • if s/s got worse then call us again for I&D
• YYYY-MM-DD xxxxxxxxxx
• YYYY-MM-DD xxxxxxxxxx
• YYYY-MM-DD xxxxxxxxxx

[surgical operation]

• 2023-11-29 - Op Method: fistulotomy + debridement + drainage
  • Finding:
    • one anal fistula over 6o’clock region (extra-sphincter type)
  • Procedure:
    • Under IVG anesthesia ,the outer and internal opening was wide opening and curretage and irrigation with large amount of H2O.
    • The internal opening was closed with 3-0 vicryl and outer opening was layed opened.
    • Check bleeding and pack the wound with gaunze.
• 2023-11-07   - Op Method: Left navigation assisted biopsy for temporal hippocampus lesion
  • Finding:
    • Four pieces of soft yellowish brain tissue obtained by stereotactic biopsy from left temporal lobe.
  • FROZEN SECTION REPORT
    • Left hippocampus tumor, frozen — Atypical lymphoid hyperplasia. Please pending for followed IHC for final diagnosis
  • Procedure:
    • Under ETGA, Mayfield clamp was appied and Metronic NAVIGATION was set for target plans. After proper disinfection and draping, A 3 cm-long scalp incision was made in left temporofrontal region. A burr hole was made and the dura was tented to the pericranium. The dura was incised in the cruciate fashion. The side-cutting type biopsy needle was inserted. The obtained specimens were sent to pathology for diagnosis. Frozen section, cultures and permient section were harvested. Hemostasis with bipolar coagulation and FLOSEL. The wound was closed in layers. 

[chemoimmunotherapy]

• 2023-09-15 - polatuzumab vedotin 1.8mg/kg 90mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 142mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
• 2023-07-17 - polatuzumab vedotin 1.8mg/kg 105mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
• 2023-05-24 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
• 2023-04-25 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
• 2023-03-15 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
• 2021-10-27 - busulfan 3.2mg/kg 210mg NS 300mL 3hr D1-3 + etoposide 400mg/m2 690mg NS 250mL 6hr D3-4 + cyclophosphamide 50mg/kg 3300mg NS 500mL 4hr D5-6
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + palonosetron 250ug D1-3 + granisetron D4-6 + NS 250mL D1-2
• 2021-09-03 - etoposide 500mg/m2 400mg NS 1000mL 4hr D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-3
• 2021-06-28 - polatuzumab vedotin 1.8mg/kg 113mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 6hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D2-3 + NS 250mL D1-3 + acetaminophen 500mg PO D1
• 2021-05-28 - polatuzumab vedotin 1.8mg/kg 113mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 6hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D2-3 + NS 250mL D1-3 + acetaminophen 500mg PO D1
• 2021-04-29 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cisplatin 100mg/m2 170mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3400mg Q12H D2-3 + dexamethasone 20mg BID PO D1-5
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + acetaminophen 500mg PO D1 + palonosetron 250ug D2-4 + NS D1-3
• 2020-01-30 - rituximab 375mg/m2 600mg NS 500mL 6hr D1 + [etoposide 50mg/m2 84mg doxorubicin 10mg/m2 16mg vincristine 0.4mg/m2 0.5mg NS 1000mL] 24hr D1-4 + prednisolone 60mg/m2 50mg PO BID D1-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D5 (R-DA-EPOCH Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO
• 2020-01-03 - rituximab 375mg/m2 600mg NS 500mL 6hr D1 + [etoposide 50mg/m2 84mg doxorubicin 10mg/m2 16mg vincristine 0.4mg/m2 0.5mg NS 1000mL] 24hr D2-5 + prednisolone 60mg/m2 50mg PO BID D1-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D6 (R-DA-EPOCH Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO

Romiplate (romiplostim 250ug) ST SC

• 2023-11-17 IPD
• 2023-10-31 IPD
• 2023-10-24 IPD
• 2023-09-07 OPD
• 2023-08-31 OPD
• 2023-08-26 IPD
• 2023-08-08 OPD
• 2023-07-27 OPD
• 2023-07-20 OPD

==========

2023-11-23

[atrial fibrillation]

Multaq (dronedarone) and Lixiana (edoxaban) were prescribed for the patient’s atrial fibrillation (AF) in a repeat prescription issued by our cardiologist on 2023-09-18. These medications are not currently being used. Please confirm whether there is a contraindicated condition or if the medications are no longer necessary.

2023-07-17

Our cardiologist prescribed Urief (silodosin), spironolactone, Multaq (dronedarone), Lixiana (edoxaban), Atozet (ezetimibe, atorvastatin), Wecoli (bethanechol), and Nirandil (nicorandil) on 2023-06-28, and these drugs are correctly included in the active formulary, so no reconciliation issues were found.

700843887

231219

[exam findings]

• 2023-11-02 SONO - abdomen
  • Diagnosis:
    • Propable liver cyst, left
    • Suspected fatty infiltration of pancreas
    • S/p cholecystectomy
    • Suboptimal examination of liver,especially the subcostal view due to poor echo window (disruption of the transmission of US waves by bowel gas and patient’s body habitus)
  • Suggestion:
    • OPD f/u
    • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
• 2023-10-27 Patho - lymphnode biopsy
  • Neck mass, right, sono-guide biopsy — Squamous cell carcinoma
  • Microscopically, the section shows a picture of squamous cell carcinoma with moderate differentiation characterized by solid tumor nests infiltrating in desmoplastic stroma.
• 2023-10-13 MRI - nasopharynx
  • Findings
    • a nodular lesion in the right thyroid gland
    • a heterogeneous enhancing nodular lesion, about 29.7mm, in the right upper neck, just anterior to the right SCM with tumor attachment to it. THe other heterogeneous enhancing nodular, about 9.8mm in the right carptod spaces.
    • unremarkable change in the nasopharynx, oropharynx and hypopharynx.
    • post-OP change in the right oral cavity.
  • IMP:
    • heterogeneous enhancing nodules in the right neck.
• 2023-04-10 Patho - oral cancer (wide excision without lymph node)
  • Diagnosis:
    • Oral mucosa, right floor of mouth, wide excision —- Squamous cell carcinoma, moderately differentiated, AJCC 8th edition: pStage IVA, pT4aNx (if cM0)
    • Mandible, right side, marginal mandibulectomy —- Squamous cell carcinoma, by direct invasion
    • Mandible, right side, alveolar bone, large, marginal mandibulectomy —- Squamous cell carcinoma, by direct invasion
    • Mandible, right side, alveolar bone, small, marginal mandibulectomy —- Squamous cell carcinoma, by direct invasion
  • Microscopic examination
    • Histologic Type: Squamous cell carcinoma,
      
    • Histologic Grade: G2: Moderately differentiated,
      
    • Microscopic Tumor Extension: (specify) bone (main specimen), alveolar bone large, and alveolar bone small.
    • Lymph-Vascular Invasion: present
      
    • Perineural Invasion: not identified
      
    • Neck Lymph Nodes: not recived
      
    • F2023-00154:
      • Sections of specimens A, B, C, and D show fibrous tissue without malignancy.
      • Section os specimen E ulcerated tissue with granulation tissue and acute and chronic inflammation. No malignancy is seen.
• 2023-04-06 MRI - nasopharynx
  • Findings:
    • The current study was compared to the prior one obtained on 2022/09/09.
    • Known a case of right buccal cancer and right mouth floor cancer S/P operation. Newly-developed enhancing lesion (1.7cm) over right mouth floor. May be recurrent tumor. Suggest tissue proof.
    • Normal appearance of both mastoid air-cells.
    • Mild paranasal sinusitis.
• 2023-03-29 Patho - gingival/oral mucosa biopsy
  • Labeled as “right lower gingiva”, biopsy — squamous cell carcinoma.
  • Section shows squamous cell carcinoma.
  • IHC stain: p16 (-).
• 2022-09-09 MRI - nasopharynx
  • Findings
    • post-OP change at the right buccogingical region
    • a heterogeneous enhancing lesion, abour 23mm, in the left lower buccogingival mucosa.
    • no neck LAP
  • IMP:
    • r/o a tumor in the left lower buccogingical mucosa.
• 2021-08-23 MRI - nasopharynx
  • Findings
    • Post-operation change with flap reconstruction at right part of oral tongue and cheek.
    • Post-operation change with right neck for lymph node dissection.
    • Post resection of right submandibular gland.
  • IMP:
    • Post OP for right oral CA with neck LNs dissection. No local recurrence. No neck LAP.
• 2020-10-26 CT - brain
  • Indication: R/O hydrocephalus
  • Without-contrast CT of brain shows:
    • Prominent sulci, fissures, and cisterns. Dilatation of the ventricles.
    • s/p right F-T craniotomy.
    • Atherosclerosis of intracranial ICAs, cavernous portion, and vertebral arteries.
  • IMP:
    • Brain atrophy, ventriculomegaly, and intracranial atherosclerotic disease
• 2020-10-22 MRI - nasopharynx
  • Findings
    • Post-operation change with flap reconstruction at right part of oral tongue and cheek.
    • Post-operation change with right neck for lymph node dissection.
    • General brain atrophy.
    • Partial opacification of bilateral ethmoid sinuses and mucosal thickening in bilateral maxillary sinuses.
      
    • Scoliosis of C-spine.
  • IMP:
    • C/W oral cancer s/p operation, without evidence of recurrence.
• 2020-05-12 Patho - soft tissue tumor, extensive resection
  • PATHOLOGIC DIAGNOSIS
    • Right mouth floor and mandibular gingiva, wide excision — mderaterly differentiated squamous cell carcinoma
      
    • Sulingual gland, right, wide excision — involved by tumor
      
    • Margin, right mouth floor and mandibular gingiva, wide excision — free (1 mm away from anterior margin)
      
    • Tissue, labeled “Sublingual gland”, wide excision — no evidence of tumor
      
    • Pathology stage: pT2NX
      
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure(s): wide excision
      
    • Specimen Type:
      • Main location: Right mouth floor and mandibular gingiva
        
      • Other part(s) included: right sulingual gland
        
      • Lymph node dissection: no
        
    • Specimen Integrity: intact
      
    • Specimen Size: Greatest dimensions: A, main tumor: 3.5 x 2.8 x 2.2 cm; B:sublingual gland: 1.3x 0.8x 0.7 cm
      
    • Tumor Site: Right mouth floor
      
    • Tumor Focality : single focus
      
    • Tumor Size: Greatest dimension: 2 cm
    • Depth of Invasion (for pT1 to pT3 tumors only): 10 mm of DOI
      
    • Mucosal Surface : ulcerated
      
    • Gross Tumor Extension : extenstion to sublingual gland
      
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Squamous cell carcinoma
      
    • Histologic Grade: G2: Moderately differentiated
      
    • Microscopic Tumor Extension: extenstion to sublingual gland
      
    • Margins: Margins free, Distance from closest margin: 0.1 cm away from anterior margin
      
    • Lymph-Vascular Invasion: present
      
    • Perineural Invasion: not identified
      
    • Neck Lymph Nodes: Not included
      • Ipsilateral: N/A
        
      • Number examined: N/A
        
      • Number involved: N/A
        
      • Contralateral: N/A
        
      • Number examined: N/A
        
      • Number involved: N/A
        
      • Size (greatest dimension) of the largest metastatic deposit: N/A
        
      • Extranodal extension (not identified / present / indeterminate): N/A
• 2020-04-30 MRI - nasopharynx
  • Imaging Report Form for Oral Cavity Carcinoma
    • Impression (Imaging stage) : T:2(T_value) N:0(N_value) M:x(M_value) STAGE:II(Stage_value)
• 2020-04-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 42) / 120 = 65.00%
    • M-mode (Teichholz) = 64
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, possible LV diastolic dysfunction, Gr II
    • Trivial MR and trivial TR
    • Preserved RV systolic function
• 2018-06-22 Surgical pathology Level IV
  • PATHOLOGIC DIAGNOSIS
    • Lower gingiva, right, wide excision — Squamous cell carcinoma
    • Pathology stage: rT1Nx(cMx), stage I at least
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure: Wide excision
      
    • Specimen Type:
      • Main location: Right lower gingiva
      • Lymph node dissection: No
        
    • Specimen Integrity: Intact
      
    • Specimen Size: 3.0 x 2.4 x 1.2 cm
    • Tumor Site: Lower gingiva, Laterality : Right
      
    • Tumor Focality: Single focus
      
    • Tumor Size: Greatest dimension: 1.5 cm
      
    • Additional dimensions (if available): 1.1 cm
      
    • Depth of Invasion (for pT1 to pT3 tumors only): 2 mm
      
    • Mucosal Surface : Ulcerated
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Squamous cell carcinoma
      
    • Histologic Grade: G2 (Moderately differentiated)
      
    • Microscopic Tumor Extension: To subepitheliall connective tissue
    • Margins: Free, Distance from closest margin: 0.3 cm (deep margin)
      
    • Lymph-Vascular Invasion: Not identified
      
    • Perineural Invasion: Not identified
      
    • Neck Lymph Nodes: Not submitted
    • IHC for p16: Negative (Reference: path 2018-09723)
• 2018-06-21 Tc-99m MDP bone scan
  • Mildly increased activity in the middle and lower T-spines. Degenerative change may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesion.
• 2018-06-20 MRI - nasopharynx
  • Indication: SCC of right lower gingiva
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration showed:
    • Post fat-containing flap reconstruction surgery at right anterior buccal region with heterogeneous enhancement in the right lower buccogingival region. .
    • Post LNs dissection, right.
    • No evident abnormal enlarged lymph node in the visible neck.
    • unremarkable change in the skull base.
  • Impression:
    • Post-OP of right buccal CA with suspicious recurrent right buccogingival tumor.
• 2018-06-11 Surgical pathlogy Level IV
  • RIGHT LOWER GINGIVA, biopsy — Squamous cell carcinoma.
  • IHC stain: p16 (-).

[immunochemotherapy]

• 2023-12-13 - cetuximab 250mg/m2 400mg 1hr + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
  • ………………. diphenhydramine 30mg
• 2023-12-04 - cetuximab 250mg/m2 400mg 1hr + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
  • ………………. diphenhydramine 30mg + metoclopramide 10mg
• 2023-11-27 - cetuximab 250mg/m2 400mg 1hr + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-11-16 - cetuximab 250mg/m2 450mg 1hr - He ChengHan
  • ………………. diphenhydramine 30mg
• 2023-11-07 - cetuximab 400mg/m2 700mg 30mg + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-10-31 - …………………………. carboplatin AUC 2 150mg NS 500mL 3hr - He ChengHan
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-09-16 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carboplatin, 5FU, LV) - Xu BoZhi
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-09-08 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carboplatin, 5FU, LV) - Xu BoZhi
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-08-27 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carboplatin, 5FU, LV) - Xu BoZhi
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-08-04 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carpoplatin, 5FU, LV) - Xu BoZhi
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-07-23 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-07-06 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-06-15 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-06-08 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
  • ………………. diphenhydramine 30mg + granisetron 1mg

==========

2023-12-19

[mucositis]

Combining the suggestions from both the MASCC/ISOO 2020 guidelines and the JCO Oncology Practice, here’s a pointwise summary of the recommendations:

Preventive Measures

• Benzydamine mouthwash for head and neck cancer patients undergoing moderate-dose radiotherapy (MASCC/ISOO).
• Photobiomodulation therapy with low-level laser for prevention in adult patients undergoing hematopoietic stem cell transplantation (MASCC/ISOO).
• Oral cryotherapy for preventing mucositis in patients receiving high-dose melphalan during autologous HSCT (MASCC/ISOO).

General Management

• Recognize the risk of infections and increased mortality associated with mucositis (JCO).
• Consider the financial implications of mucositis management (JCO).

Pain Management and Symptom Relief

• Avoid alcohol and tobacco use until symptom resolution (JCO).
• Use 2% morphine mouthwash swish and spit for head and neck cancer patients (JCO).
• Dexamethasone mouthwash for mTOR inhibitor-induced mucositis; in severe cases, high-dose systemic steroids (JCO).
• 2% viscous lidocaine swish and spit (JCO).
• Doxepin-containing mouthwashes and systemic opiates (JCO).
• Transdermal formulations of morphine or fentanyl for long-lasting background pain control (JCO).

Hospital Admission Considerations

• Severe cases with intractable pain, dehydration, inability to tolerate oral intake, end-organ damage, neutropenia or neutropenic fever, systemic infection (JCO).
• Patient-controlled analgesia with morphine for severe pain (JCO).

Diet and Oral Care

• Bland rinses (normal saline or salt and soda) for mild to moderate cases (JCO).
• Diet modification to manage symptoms (JCO).

Use of Specific Agents

• Avoiding sucralfate and glutamine for certain patient groups (MASCC/ISOO).

Ref:

• Management of Cancer Therapy - Associated Oral Mucositis. JCO Oncology Practice. 2020;16(3):103-109. doi:10.1200/JOP.19.00652

• MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020;126(19):4423-4431. doi:10.1002/cncr.33100

700898653

231218

[lab data]

2023-08-04 HBV DNA-PCR (quantative) Target Not Detected IU/mL
2023-08-04 Anti-HCV (NM) Negative
2023-08-04 Anti-HCV Value (NM) 0.044
2023-08-04 Anti-HBc (NM) Negative
2023-08-04 Anti-HBc Value (NM) 1.110
2023-08-04 Anti-HBs (NM) Positive
2023-08-04 Anti-HBs Value (NM) 45.800 mIU/mL
2023-08-04 HBsAg (NM) Negative
2023-08-04 HBsAg Value (NM) 0.362
2023-08-04 HBsAg Nonreactive
2023-08-04 HBsAg (Value) 0.27 S/CO
2023-08-04 Anti-HBs 45.52 mIU/mL
2023-08-04 Anti-HBc Nonreactive
2023-08-04 Anti-HBc Value 0.48 S/CO
2023-08-04 Anti-HCV Nonreactive
2023-08-04 Anti-HCV Value 0.22 S/CO

[exam findings]

• 2023-12-14 2D transthoracic echocardiography
  • Clinical diagnosis: ARDS s/p V-V ECMO
  • LVEF = (LVEDV - LVESV) / LVEDV = (52 - 23) / 52 = 55.77%
    • M-mode (Teichholz) = 55
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Mild to moderate MR, moderate AR, trivial TR
    • Mild pulmonary hypertension
    • Possible LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
• 2023-12-13 CT - chest
  • Indication: SOB, Bil. pneumonia, ARDS S/P ETTI decrease SpO2 down to 70% since 4 days ago
  • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 1.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest without contrast enhancement, coronal and sagittal reconstructed images shows:
    • dependent moderate bilateral pleural effusions and large volume of right pneumothorax.
    • lungs: diffuse consolidation in both lower lobes and diffuse ground glass opacity with interlobular septal thickening at both upper lobes and RML.
    • Mediastinum and hila: extensive coronary arterial calcification
    • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal size of cardiac chambers. minimal pericardial effusion.
    • Visible abdominal contents: Rt renal cyst measuring 1.9cm.
  • Impression:
    • moderate bilateral pleural effusions and large volume of right pneumothorax and ARDS and/or diffuse pneumonia d/d AIP
• 2023-12-13 SONO - chest
  • Echo diagnosis: Right side pneumohydrothorax. Although small volume, 14 Fr. pig-tail catheter was still needed to insert under echo-guidance since the patient was a victim of ARDS on ECMO treatment. Due to emergent, picture was not captured.
• 2023-08-04 CXR (erect)
  • S/P Port-A infusion catheter insertion.
  • Presence of scoliosis of the lumbar spine.
  • Ground glass opacity in RLL.
• 2023-08-01 PD-L1 (22C3)
  • Block No. S2023-14496 A4
  • RESULTS：
    • Combined Positive Score(CPS) assessment: CPS<1
    • Combined Positive Score(CPS): 0
• 2023-07-21 Patho - breast mastectomy with regional lymph nodes
  • Diagnosis
    • Breast, right, simple mastectomy —- Invasive carcinoma of no special type
    • Resection margin: free
      
    • Lymph node, right axilla, sentinel, lymphadenecomy —- Negative for malignancy (0/6)
    • Soft tissue, right axilla, excision —- Negative for malignancy (0/0)
    • AJCC 8 th edition, Pathology stage: Anatomic stage: pStage IIA, pT2N0(sn)(if cM0); Prognostic stage: IIA
  • Gross Description
    • Breast: Size: S2023-14496: 18.5 x 15.5 x 3.0 cm
    • Skin: Size: S2023-14496: 17.3 x 6.0 cm.
      
    • Nipple: S2023-14496: Not retracted
    • Tumor: Size: S2023-14496: 2.2 x 2.0 x 1.1 cm.
    • Resection Margin: S2023-14496: Free, 0.5 cm from the deep margin
      
    • Lymph node: F2023-00329: sentinel; S2023-14496: axilla soft tissue
    • Sections are taken and labeled as:
      • F2023-00329: All lymph nodes are dissected and labeled as: FsA1: a bisected sentinel lymph node; FsA2: lymph node, sentinel, for frozen examination.
      • S2023-14496: Representative sections are taken and labeled as: A1: nipple; A2: skin; A3: breast; A4-8: tumor; B: right axillary soft tissue.
        
  • Microscopic Description
    • For Invasive Carcinoma
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma (mm): 22 x 20 x 11 mm
      • Histologic grade (Nottingham histologic score): grade II (score 6)
        • Tubule formation: score 3
        • Nuclear pleomorphism: score 2
        • Mitotic count: score 1
      • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: Absent
        • Chest wall invasion deeper than pectoralis muscle: Absent
    • For Ductal Carcinoma In Situ
      • Tumor size (mm): 12 x 18 mm (mixed with invasive carcinoma)
      • Nuclear grade: 2
      • Architectural pattern: Non-comedo (cribriform)
      • Tumor necrosis: Present
    • Margins: Negative, Closest margin (5 mm from deep margin)
    • Nodal status: Negative, sentinel
      • No. examined: sentinel: 6; axilla soft tissue: 0
      • No. macrometastases (>2 mm): sentinel: 0; axilla soft tissue: 0
      • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): sentinel: 0; axilla soft tissue: 0
      • No. isolated tumor cells (<=0.2 mm and <=200 cells): sentinel: 0; axilla soft tissue: 0
    • Treatment Effect: patient not received
    • Lymphovascular invasion: present
    • Perineural invasion: present
    • Immunohistochemical Study: S2023-13126
    • Tumor infiltrating lymphocytes (TILs): < 10%
• 2023-07-20 SONO - abdomen
  • Diagnosis:
    • Fatty liver, mild
    • Liver lesions, left. Suspected focal fat-spared area or true liver lesion (?)
    • Suspected right renal cyst
    • Pancreas not shown
    • Suboptimal examination of liver, especially the subcostal view due to poor echo window
  • Suggestion:
    • OPD f/u
    • Because of poor echo window, please follow sono abd 3-6 months later or correlate with other image
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2023-07-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (68 - 21) / 68 = 69.12%
    • M-mode (Teichholz) = 67
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy; impaired LV relexation
    • Trivial MR, trivial AR and mild TR
    • Preserved RV systolic function
• 2023-07-10 Tc-99m MDP bone scan
  • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, mandible, some C-, T- and L-spine, bilateral shoulders, and knees.
• 2023-07-03 Her-2/neu DISH
  • RESULT OF HER2 IN SITU HYBRIDIZATION:
    • HER-2 (by in situ hybridization) — Negative (NOT amplified)
  • METHOD AND DETAILS:
    • Number of observers: 1
    • Number of invasive tumor cells counted: 20
    • Average number of HER2 signals per cell: 2.55
    • Average number of CEP17 signals per cell: 2.15
    • HER2/CEP17 ratio: 1.19
    • Heterogeneous signals: Absent
    • Origin slide and block number: S2023-13126
    • Specimen: Formalin-fixed paraffin embedded tissue
    • Adequacy of sample for evaluation: Yes
    • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
  • APPENDIX:
    • ASCO/CAP scoring criteria (2018):
      • Group 1 = HER2/CEP17 ratio >=2.0; >=4.0 HER2 signals/cell
      • Group 2 = HER2/CEP17 ratio >=2.0; <4.0 HER2 signals/cell
      • Group 3 = HER2/CEP17 ratio <2.0; >=6.0 HER2 signals/cell
      • Group 4 = HER2/CEP17 ratio <2.0; >=4.0 and <6.0 HER2 signals/cell
      • Group 5 = HER2/CEP17 ratio <2.0; <4.0 HER2 signals/cell
    • Negative:
      • Group 5
      • Group 2 and concurrent IHC 0-1+ or 2+
      • Group 3 and concurrent IHC 0-1+
      • Group 4 and concurrent IHC 0-1+ or 2+
    • Positive:
      • Group 2 and concurrent IHC 3+
      • Group 3 and concurrent IHC 2+ or 3+
      • Group 4 and concurrent IHC 3+
      • Group 1
• 2023-07-03 Patho - breast biopsy (no need margin)
  • DIAGNOSIS:
    • Breast, right, core biopsy — Invasive carcinoma of no special type
      
  • GROSS DESCRIPTION:
    • The specimen submitted consisted of three strips of tan irregular tissue measuring up to 0.8 x 0.1 x 0.1 cm. All for section in one cassette.
  • MICROSCOPIC DESCRIPTION:
    • Section shows cores of breast tissue with irregular neoplastic glands infiltration. The immunohistochemical stain of E-cadherin is positive.
      
  • IMMUNOHISTOCHEMICAL STUDY
    • ER (Ab): Negative (Internal control: positive)
    • PR (Ab): Negative (Internal control: positive)
    • Her-2/neu (Ab): Equivocal (2+)
    • Ki-67: 10%

[MedRec]

• 2023-10-27 ~ 2023-10-28 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Right breast invasive carcinoma. pT2N0M0, stage IIA. Triple negative. ECOG:0
    • Encounter for antineoplastic chemotherapy
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
  • CC
    • for chemotherapy
  • Present illness
    • Breast sono showed a lesion, Right 9/1.7 cm , size: 1.4x1.38 cm, r/o malignancy suggest biopsy. Core needle biopsy revealed invasive carcinoma, ER(-), PR(-), Her2/neu(2+) but FISH negative, Ki-67 10%. CA-153 22.384 U/ml, CEA 1.670 ng/ml.
    • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. Surgery of right breast simple mastectomy + SLNB on 2023/07/21. pT2N0M0, stage IIA.
    • Adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 4 cycles. Add keytruda since 2023/08/25 by family reguest.
    • Under the impression of right breast invasive carcinoma, she was admitted for 5th adjuvant chemotherapy with weekly Taxol 80mg/m2 + Keytruda 200mg Q3W.
  • Course of inpatient treatment
    • After admission, 5th adjuvant chemotherapy with weekly Taxol 80mg/m2 + Keytruda 200mg Q3W were given. No discomfort after chemotherapy.
    • Under the stable condition, she was discharged today, arrange next admission three weeks later.
  • Discharge prescription
    • Limeson (dexamethasone 4mg) 1# BID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2023-08-03 ~ 2023-08-05 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Right breast cancer status post port A insertion on 2023/08/04. pT2N0M0, stage IIA. Triple negative, ECOG:0
    • Encounter for antineoplastic chemotherapy
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
  • CC
    • for chemotherapy
  • Present illness
    • This 78-year-old female patient has past history of hypertension over 30 years with regular medicine control. Type II diabetes mellitus for 5 years with regular medicine control. She went to United States on 2023/05.
    • She noted a palpable mass at right breast over 6 months. She came to our OPD for help. Breast sono showed a lesion, Right 9/1.7 cm , size: 1.4x1.38 cm, r/o malignancy suggest biopsy. Core needle biopsy revealed invasive carcinoma, ER(-), PR(-), Her2/neu(2+) but FISH negative, Ki-67 10%. CA-153 22.384 U/ml, CEA 1.670 ng/ml.
    • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. Surgery of right breast simple mastectomy + SLNB on 2023/07/21. pT2N0M0, stage IIA.
    • Adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 4 cycles.
    • Under the impression of right breast invasive carcinoma, she was admitted for surgery of port A insertion. Adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 on 2023-08-05.
  • Course of inpatient treatment
    • After admission, port A insertion was performed on 2023/08/04. 1st adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 were given. The wound is clean and dry. No discomfort after chemotherapy.
    • Under the stable condition, she was discharged today, wound will be follow up on 8/9. And arrange next admission three weeks later.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Emend (aprepitant 125mg) 1# QD 2D for 8/6 and 8/7
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 3D for 8/8, 8/9, 8/10
    • loperamide 2mg 2# PRNQ6H if diarrhea > 2 per day
• 2023-07-20 ~ 2023-07-22 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Right breast invasive carcinoma status post simple mastectomy + sentinel lymph node biopsy on 2023/07/21. cT2N0M0, stage IIA. Triple negative. ECOG 0
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
  • CC
    • noted a palpable mass at right breast over 6 months.
  • Present illness
    • This 79-year-old female patient has past history of hypertension over 30 years with regular medicine control. TypeII diabetes mellitus for 5 years with regular medicine control. She wnet to United States on 2023/05.
    • She noted a palpable mass at right breast over 6 months. She came to our OPD for help. Breast sono showed a lesion, Right 9/1.7 cm , size: 1.4x1.38 cm, r/o malignancy suggest biopsy. Core needle biopsy revealed invasive carcinoma, ER(-), PR(-), Her2/neu(2+) but FISH negative, Ki-67 10%. CA-153 22.384 U/ml, CEA 1.670 ng/ml.
    • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis.
    • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
    • PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 2x2 cm without discharge. The nipple was dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulitis change.
    • Under the impression of right breast invasive carcinoma, she was admitted for surgery of simple mastectomy + SLNB.    
  • Course of inpatient treatment
    • After admission, right breast simple mastectomy + SLNB was performed on 2023/07/21. The wound is clean and dry. Under the stable condition, she was discharged today, wound will be follow up in OPD.
  • Discharge prescripton
    • Acetal (acetaminophen 500mg) 1# QD

[surgical operation]

• 2023-12-13
  • Surgery
    • VV ECMO
  • Finding
    • 15Fr A cannula at right IJV, fixed 15cm.
    • 19Fr V cannula at right CFV, fixed 45cm.
• 2023-08-04
  • Surgery
    • Port-A insertion, L’t after L’t cephalic vein exploration        
  • Finding
    • We explore and identify the L’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.  
• 2023-07-21
  • Surgery
    • Simple mastectomy and sentinel lymph node biopsy        
  • Finding
    • a 2.5 x 2 x 1.5 cm slight firm mass in rt breast
    • SLN 0/6 

[immunochemotherapy]

• 2023-12-04 - paclitaxel 80mg/m2 115mg D5W 250mL 90min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-11-27 - paclitaxel 80mg/m2 117mg D5W 250mL 90min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-11-20 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 80mg/m2 117mg D5W 250mL 90min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-11-13 - paclitaxel 80mg/m2 117mg D5W 250mL 90min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-11-06 - paclitaxel 80mg/m2 117mg D5W 250mL 90min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-10-27 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 80mg/m2 117mg D5W 250mL 90min
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-10-06 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 880mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-09-15 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 875mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-08-25 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 875mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-08-04 - cyclophosphamide 600mg/m2 898mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

[acute respiratory distress syndrome, ARDS]

Treatment course

• 2023-08-04: AC(lipo) initiated Q3W for 4 cycles after the patient recovered from mastectomy on 2023-07-21.
• 2023-10-27 onward: weekly paclitaxel.
• 2023-08-25, 2023-09-15, 2023-10-06, 2023-10-27, 2023-11-17: pembrolizumab 200mg administered Q3W as per patient’s family request (noted in discharge document).

ARDS and pembrolizumab considerations

• Recent: ARDS developed.
• Pembrolizumab association: Pneumonitis is a known risk associated with anti-PD-1 monoclonal antibodies like pembrolizumab, with documented cases of grade 3, 4, and fatal severity. The incidence is higher compared to anti-PD-L1 agents. Recurrence is possible after symptom resolution, regardless of re-challenge with immune checkpoint inhibitors. Chronic courses can also occur. The mechanism is non-dose-related and immunologic, with a median onset of approximately 3 months. Treatment-naive patients are at higher risk.

Current status and recommendation

• Patient currently on VV-ECMO.
• Recommendation: Due to ARDS and pembrolizumab’s association with pneumonitis, further re-challenge with pembrolizumab is not advisable.

Ref:

• Management of pulmonary toxicity associated with immune checkpoint inhibitors - https://err.ersjournals.com/content/errev/28/154/190012.full.pdf
• Pulmonary Toxicities Associated With the Use of Immune Checkpoint Inhibitors: An Update From the Immuno-Oncology Subgroup of the Neutropenia, Infection & Myelosuppression Study Group of the Multinational Association for Supportive Care in Cancer - https://www.frontiersin.org/articles/10.3389/fphar.2021.743582/full

700938533

231218

[exam findings]

• 2023-12-14 20:46 ECG
  • Sinus tachycardia
  • Left axis deviation
• 2023-12-14 CXR
  • Tortuosity of the aorta with atherosclerotic change.
  • Increased lung markings over both lungs.
  • R/O right pleural effusion.
  • Degenerative joint disease of T-spine with marginal osteophytes.
  • S/P port-A catheter insertion.
• 2023-12-14 18:08 ECG
  • Sinus tachycardia
  • Right superior axis deviation
• 2023-12-11 MRI - brain
  • Findings
    • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • The interhemispheric fissure is centered on the midline.
    • Sella and pituitary are normal. The parasellar structures are unremarkable.
    • Favor bilateral cerebral and cerebellar metastases in leptomeninges, cortex and subcortical region, also a deep lesion in right basal ganglia.
      
    • Patchy or nodular abnormal enhancement after contrast administration of those lesions were found.
  • Imp:
    • Mild cortical brain atrophy. Bilateral cerebral and cerebellar metastases.
• 2023-11-07 Patho - stomach biopsy (Y1)
  • Labeled as “upper abdominal tumor”, CT guided biopsy — adenocarcinoma. IHC stains: CK19 (+), CA19-9 (-), CK7 (-), CK20 (-), CDX-2 (-). An addendum report of the result of IHC stain of TTF-1 will be followed.
  • Section shows adenocarcinoma in papillary and cribriform patterns.
  • IHC stains: CK19 (+), CA19-9 (-), CK7 (-), CK20 (-), CDX-2 (-).
  • Additional IHC stains: amylase-A (-), TTF-1 (-).
• 2023-11-07 Patho - colon biopsy
  • Colorectum, ascending colon. Cold snaring polypectomy (A) — Hyperplastic polyp
  • Colorectum, transverse colon. Cold snaring polypectomy (B) — Tubular adenoma with low grade dysplasia
  • Colorectum, descending colon. Cold snaring polypectomy (C) — Hyperplastic polyp
  • Colorectum, rectum. Polypectomy (D) — Tubulovillous adenoma with low grade dysplasia.
• 2023-11-07 Patho - stomach biopsy
  • Stomach, antrum, biopsy — Chronic gastritis, H pylori NOT present
• 2023-11-06 EGD
  • Reflux esophagitis, lower esophagus, LA classification, grade A
  • Superfical gastritis, antrum
  • Gastric ulcer, multiple, antrum, s/p biopsy
• 2023-11-06 Colonoscopy
  • Findings
    • The scope had been inserted up to cecum.
    • A 0.6 cm IIa polyp was noted at ascending colon. Cold snaring polypectomy was done (A).
    • A 0.6 cm IIa polyp was noted at transverse colon. Cold snaring polypectomy was done (B).
    • A 0.6 cm IIa polyp was noted at descending colon. Cold snaring polypectomy was done (C).
    • Active oozing from wound was noted. Clip was applied on wound with hemostasis.
    • An about 2 cm Ip polyp was noted at rectum. Polypectomy was done after submucosal injection (D).
    • Active oozing from wound was noted. Clips were applied on wound with hemostasis.
    • Several smaller polyps less then 0.5 cm were noted from transverse colon to sigmoid colon.
    • Several diverticulum were noted at ascending colon.
    • Internal hemorrhoid was noted
  • Diagnosis:
    • Colon polyp, ascending colon, s/p polypectomy
    • Colon polyp, tranverse colon, s/p polypectomy
    • Colon polyp, descending colon, s/p polypectomy + cliping
    • Colon polyp, rectum, s/p polypectomy + cliping
    • Colon diverticulum, ascending colon
    • Multiple small colon polyp, trasnverse colon to sigmod colon
    • Internal hemorrhoid
• 2023-11-04 CT - abdomen
  • History and indication: Abdominal pain and nudules
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A large mass (10.8cm) at upper abdomen with duodenum, stomach, celiac trunk, common hepatic artery, splenic artery, SMA, SMV, splenic vein and portal vein invasion. Indistinct contour of pancreatic body and tail. Enlarged LNs around the tumor. Some soft tissues in peritoneal cavity.
    • Liver cirrhosi with portal hypertension, GV, collateral circulation, ascites and splenomegaly.
    • Atherosclerosis of aorta.
  • IMP:
    • A large mass (10.8cm) at upper abdomen with duodenum, stomach, celiac trunk, common hepatic artery, splenic artery, SMA, SMV, splenic vein and portal vein invasion r/o pancreatic tumor.
    • Enlarged LNs around the tumor. Some soft tissues in peritoneal cavity r/o tumor seeding.
    • Liver cirrhosi with portal hypertension, GV, collateral circulation, ascites and splenomegaly.
• 2023-11-04 SONO - abdomen
  • Findings
    • Bile duct: Hard to access CBD because of cavenous transformation of main portal vein
    • Portal vein: Cavenous transformation of protal vein at hilar area
    • Pancreas: Part of head and part of tail masked. The relationship of tumor and pancreas is hard to access
    • Spleen: Measured 6.8 x 4.7 cm
    • Ascites: Massive
    • A huge, more than 11 cm heteroechoic, multi-nodular tumor was noted upper abdomen with celiac trunk involve.
  • Diagnosis:
    • Upper abdominal tumor, huge, with celiac trunk involve
    • Cavenous transformation of main portal vein
    • Splenomegaly, mild
    • Ascites, massive
  • Suggestion:
    • arrange admission for work up

[MedRec]

• 2023-11-17 SOAP Radiation Oncology Wang YuNong
  • Plan: Palliative CCRT is indicated.
    • CT-simulation will be arranged on 2023/11/20.
    • Plan to deliver 45 Gy/ 25 fx to the gross tumor and LAPs with partial simultaneous boost.
    • RT will start around 11/23.
• 2023-11-15 SOAP Hemato-Oncology He JingLiang
  • S: abdominal adenocarcinoma, but CA199 WNL
    • apply major illness, refer to GS for port-A
    • C/T with FOLFOX
• 2023-11-04 ~ 2023-11-09 POMR Gastroenterology Su WeiZhi
  • Discharge diagnosis
    • Pancreatic tumor, rule out pancreatic cancer, status post biopsy
    • Alcoholic cirrhosis of liver
  • CC
    • abdominal distension and weight loss (12kg in 2 months)
  • Present illness
    • This 50-year-old man without medical history was refferred to to our GI OPD on 2023-11-05 from LMD. His chief complaint was abdominal distension and weight loss (12kg in 2 months). Accompanied symptoms included mild abdmonial pain sometimes, dyspepsia, soft stool passage for months. There were no no fever, no chills, no nausea, no vomitting, no chest tightness, no dysuria. Alcoholic abuse was told.
    • Echo 2023/11/04: upper abdomianl huge tumor with celiac trunk involve. Ascites was told by LMD. Lab data showed no leukocytosis of WBC:7.77K, HB:9.1, TBI:1.88, r-GT:24, ALP:111.
    • Physical examination showed abdominal distension with lower abdominal tenderness.
    • Under the impression of abdmonial pain and ascites, r/o upper abdomianl huge tumor, he was admitted for further evlauaiton and managemnt.
  • Course of inpatient treatment
    • After admission, we kept monitoring his vital sign and prescribed medication for hypertension.
    • KUB showed stool retention in bowl.
    • ABD Liver CT with contrast on 11/4 showed (1) a large mass (10.8cm) at upper abdomen with duodenum, stomach, celiac trunk, common hepatic artery, splenic artery, SMA, SMV, splenic vein and portal vein invasion r/o pancreatic tumor. (2) enlarged LNs around the tumor. (3) some soft tissues in peritoneal cavity r/o tumor seeding. (4) liver cirrhosis with portal hypertension, GV, collateral circulation, ascites and splenomegaly.
    • Adequate iv hydration with nako.5 500ml QD for NPO.
    • We arranged anesthetic EGD and colonscopy on 11/6. EGD showed Reflux esophagitis, LA classification, antrum gastric ulcer, multiple, antrum, s/p biopsy. Colonscopy revealed multiple small colon polyp, trasnverse colon to sigmod colon, s/p polypectomy + cliping, and internal hemorrhoid. Nexium QD was given since 2023-11-07.
    • CT guided biopsy was arranged on 2023-11-07, pending pathology report. Follow-up lab data on 2023-11-08 showd mildanemia with HB:8.3. LPRBC 2U was given.
    • Under stable condition, he was discharged and turned to OPD folloed-up.
  • Discharge prescription
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Acetal (acetaminophen 500mg) 1# PRNQ8H if pain

[chemotherapy]

• 2023-11-30 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 30min (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-21 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 30min (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-12-18

On 2023-12-18, the patient exhibited pancytopenia, including severe grade 3 anemia. Blood product transfusion was administered the same day.

• 2023-12-18 WBC 2.95 x10^3/uL
  
• 2023-12-18 HGB 6.7 g/dL
  
• 2023-12-18 PLT 98 *10^3/uL

Low levels of serum sodium, potassium, calcium, magnesium, and albumin were also detected. Taita No.5 electrolyte solution, KCl, and MgSO4 were prescribed.

• 2023-12-18 Na (Sodium) 130 mmol/L
  
• 2023-12-18 K (Potassium) 3.0 mmol/L
  
• 2023-12-18 Albumin (BCG) 3.1 g/dL
  
• 2023-12-18 Ca (Calcium) 1.91 mmol/L
  
• 2023-12-18 Mg (Magnesium) 1.6 mg/dL

A positive stool occult blood test (1+) was identified on 2023-12-17. The patient is currently receiving Panzolec (pantoprazole) and Hemoclot (tranexamic acid).

Medication reconciliation found no discrepancies.

701500949

231218

[lab data]

2023-11-02 Ferritin 667.6 ng/mL
2023-10-26 FLT3-D835 (bone marrow) Undetectable
2023-10-25 MPO stain Positive (3+)
2023-10-25 ANAE stain Negtive
2023-10-25 CAE stain Positive
2023-10-18 NPM1 (qualitative)(BM) Undetectable
2023-10-18 FLT3/ITD (bone marrow) Undetectable
2023-10-18 JAK2-single site (BM) Undetectable
2023-10-18 BCR/abl (BM) PhiladChr (qual) Undetectable
2023-10-16 Von willebrand factor 100.8 %
2023-10-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-10-12 TSH (NM) 2.348 uIU/ml
2023-10-12 T3 (NM) 95.975 ng/dl
2023-10-12 Free T4 (NM) 1.190 ng/dl

2023-10-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-10-12 HBsAg Nonreactive
2023-10-12 HBsAg (Value) 0.41 S/CO
2023-10-12 Anti-HBc Reactive
2023-10-12 Anti-HBc-Value 4.57 S/CO
2023-10-12 Anti-HCV Nonreactive
2023-10-12 Anti-HCV Value 0.10 S/CO

[exam findings]

• 2023-11-18 CXR (supine)
  • S/P PICC catheter insertion via left forearm.
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2023-11-15, -10-13 CXR (erect)
  • S/P PICC catheter insertion via left forearm.
  • Borderline cardiomegaly
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2023-10-16 SONO - abdomen
  • mild fatty liver (incomplete exam of liver)
  • gallbladder polyps
  • fatty infiltration of pancreas
  • bilateral renal cysts
• 2023-10-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (131 - 43) / 131 = 67.18%
    • M-mode (Teichholz) = 66
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Mitral valve prolapse, posterior mitral leaflet with moderate MR
    • Concentric LVH; impaired LV relexation
    • Mild AR (aortic regurgitation), trivial TR (tricuspid regurgitation) and trivial PR (pulmonary regurgitation)
    • Preserved RV systolic function
• 2023-10-13 Peripherally Inserted Central Catheters, PICC
  • Indication of PICC: leukemia
  • Under the echo guiding, we successful puncture left basilic vein. PICC catheter was advanced to SVC smoothly, total into 35 cm.
  • SVO2 65%, estimated Fick Cardiac index 2.86L/min/m2 (normal range cardiac index 2.5~4 L/min/m2)
• 2023-10-12 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Acute myeloid leukemia
  • Specimen submitted in formalin consists of a piece of tan, rod shape bone marrow tissue measuring 2.5 cm in length. All for section in one cassette after decalcification.
  • Sections show 80-90% cellularity. Blasts account for about 40-50% of all nucelated cells.
  • The immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3(-), and PAX5(-). The results are consistent with acute myeloid leukemia. Please correlate with the clinical presentation and lab studies.

[MedRec]

• 2023-11-12 ~ 2023-11-23 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Acute myeloblastic leukemia, not having achieved remission; Blast:41%, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3(-), and PAX5(-) S/P chemotherapy with 7 + 3 (Cytarabine + Idarubicin) on 10/13-10/20 23
    • Essential (primary) hypertension
    • Chronic viral hepatitis B without delta-agent
    • Urinary tract infection, urine culture growth Enterococcus faecalis
  • CC
    • for C2 chemotherapy with 5 + 2 (Cytarabine + Idarubicin).
  • Present illness
    • This 72-year-old, had history of hypertension for 3 years under oral medication treatment at LMD.
    • He suffered form spontaneous ecchymosis over bilateral hands & bilateral thight and gum bleeding for 1-2 months and body weight loss about (70 -> 65kg within 1 month and poor appetite were also noted. The patient did not take painkillers or chinese herbal medicines. He visited to LMD for aid and ecchymosis & gum bleeding progression was developed in recent one week and transferred to our ER on 10/11 23.
    • At arrival to ER, the laboratory showed WBC:30610, Hb:9.8, PLT:11K, LDH:1038, Seg:18, Metamyelocyte:4.0%, Myelocyte:10%, promyelocyte:3%, Blast:41% on 2023/10/9. Under the impression of Leukocytosis rule out acute myeloblastic leukemia, not having achieved remission Blast:41%.
    • The bone marrow was done on 10/12 23 and pathology (10/17 23) proved acute myeloid leukemia, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3 (-), and PAX5(-). The BCR/abl/NPM1/FLT3/ITD/JAK2 showed Undetectable. Blood transfusion with LPRBC 2U was given on 10/23 23. The FLT3-D835/NPM1/FLT3/ITD/JAK2 - single site/MPO/ANAE/CAE/(AML+ALL/Myeloid/AML/21-30/BcR/abL Philadelphia chromosome/bone marrow cell chromosomes (self-paid) were checked. PICC was inserted on 10/13 23.
    • Chemotehrapy with 7 + 3 (Cytarabine + Idarubicin) was administered on 10/13-10/20 23, smoothly without obvious side effect.
    • Vemlidy 1# po qd was added due to anti-Hbc positive.
    • We arranged abdominal sono & heart echo for perpare chemotherapy evaluation and which showed mild fatty liver (incomplete exam of liver) gallbladder polyps and LVEF 66%, adequate LV systolic function with normal resting wall motion, mitral valve prolapse, posterior mitral leaflet with moderate MR , concentric LVH; impaired LV relexation, mild AR, trivial TR and trivial PR.
    • Chemotehrapy with 7 + 3 (Cytarabine + Idarubicin) was administered, C1 on 10/13-10/20 23.
    • This time, he is admitted for C2 chemotherapy with 5+2 (Cytarabine + Idarubicin).
  • Course of inpatient treatment
    • After admission, blood transfusion with LPRBC for anemia, hydration, chemotehrapy with 5+2 (Cytarabine + Idarubicin) was administered on 11/13-11/17 23,
    • Vemlidy 1# po qd was added due to anti-Hbc positive.
    • After chemotherapy, he suffered from fever noted, so gave Cefim for infection control, followed-up PICC culture growth Staphylococcus epidermidis, and remove PICC catheter, blood culture not growth, urine culture growth Enterococcus faecalis.
    • Followed-up the lab of CBC/DC showed neutropenia (WBC: 1830/uL, Neutrophil: 49%, ANC: 896.7), so gave protective isolation.
    • Re checked the lab of CBC/DC showed WBC: 1510/uL, Neutrophil: 52.1%, ANC: 789.
    • After treatment. he denide having a fever, vomiting, diarrhea, or any uncomfortable. He can be discharged on 2023/11/23, take oral antibiotic with Ceficin back home, the OPD follow-up will be arranged.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • Smecta (dioctahedral smectite 3mg) 1# PRNTIDAC
    • Urosin (atenolol 100mg) 0.5# QD
    • Mosapin (mosapride citrate 5mg) 1# TID
    • Ulstop (famotidine 20mg) 1# BID
    • Ceficin (cefixime 100mg) 2# Q12H
• 2023-11-01 SOAP Hemato-Oncology He JingLiang
  • O: 2023-11-01 Plt 6K
  • P: 2023-11-01 BT Plt 2u
• 2023-10-11 ~ 2023-10-28 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Acute myeloblastic leukemia, not having achieved remission Blast:41%, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3(-), and PAX5(-) S/P chemotherapy with 7 + 3 (Cytarabine + Idarubicin) on 10/13-10/20 23
    • Essential (primary) hypertension
    • Chronic viral hepatitis B without delta-agent
  • CC
    • spontaneous ecchymosis over bilateral hands & bilateral thight for 1-2 months
  • Present illness
    • This 72-year-old, had history of hypertension for 3 years under oral medication treatment at LMD. He suffered form spontaneous ecchymosis over bilateral hands & bilateral thight and gum bleeding for 1-2 months and body weight loss about (70 -> 65kg) within 1 month and poor appetite were also noted. The patient did not take painkillers or chinese herbal medicines.
    • He visited to LMD for aid and ecchymosis & gum bleeding progression was developed in recent one week and transferred to our ER on 10/11 23.
    • At arrival to ER, the laboratory showed WBC:30610, Hb:Hb:9.8, PL:11K, LDH:1038, Seg:18, Metamyelocyte:4.0%, Myelocyte:10%, promyelocyte:3%, Blast:41% on 2023/10/9.
    • Under the impression of Leukocytosis rule out acute myeloblastic leukemia, not having achieved remission Blast:41%. He was admitted for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, hydration and bone marrow was done on 10/12 23 and pathology was pending. The FLT3-D835/NPM1/FLT3/ITD/JAK2-single site/MPO/ANAE/CAE/(AML+ALL/Myeloid/AML/21-30/BcR/abL Philadelphia chromosome/bone marrow cell chromosomes (self-paid) were checked.
    • PICC was inserted on 10/13 23. Chemotehrapy with 7 + 3 (Cytarabine + Idarubicin) was administered on 10/13-10/20 23, smoothly without obvious side effect.
    • Vemlidy 1# po qd was added due to anti-Hbc positive.
    • We arranged abdominal sono & heart echo for perpare chemotherapy evaluation and which showed mild fatty liver (incomplete exam of liver) gallbladder polyps and LVEF:66%, adequate LV systolic function with normal resting wall motion, mitral valve prolapse, posterior mitral leaflet with moderate MR , concentric LVH; impaired LV relexation, mild AR, trivial TR and trivial PR.
    • The WBC idex from 30610 -> 25680 -> 3490 and blast:41%–>40.9%–>2.9 were noted post C/T treatment.
    • Bone marrow, iliac, biopsy (10/17 23) proved acute myeloid leukemia, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3 (-), and PAX5(-). The BCR/abl/NPM1/FLT3/ITD/JAK2 showed Undetectable.
    • Blood transfusion with LPRBC 2U was given on 10/23 23. Followed-up the lab of CBC/DC showed neutropenia (WBC: 1010/uL, Band: 1.2%, Neutrophil: 9.9%, ANC: 112.11). No more fever was noted and good appetite. He was discharged on 10/28 23 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • MgO 250mg 2# TID
    • Through (sennoside 12mg) 1# HS
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-10-11 - SOAP Medical Emergency Lin QingXiang
  • S: Triage Revised As Needed System: 3
    • The patient’s white blood cell count was high on an outpatient blood test, and they were suspected of having leukemia and transferred in.
  • O:
    • BP: 191/86; HR: 112; BT: :36.2’C; RR: 18;
    • SpO2: 97%
    • GCS: E4V5M6 alert, and oriented.
    • General-looking: acute ill looking
    • HEENT: supple neck, no injected throat, no pale conjunctiva, no icteric sclera
    • Heart: no murmur, regular heart beat
    • Chest: bilateral clear breathing sounds. symmetrical
    • Abdomen: flat and soft, normal bowel sound, no tenderness
    • Extremitis: warm, freely movable, no pitting edema
    • Neurologic: well muscle power of four limbs, stable gait. isocoric pupil with light reflex
  • A
    • preliminary impression: R23.3 Spontaneous ecchymoses
    • Limb Ecchymosis, Oral bleeding, suspect leukemia, WBC 31k, Hb 9.8, Plt 11k -> LRP 2U, OA Hema (GBard: outpatient hematology)
    • HTN
    • Lab
      • 2023/10/09 20:53 ALT = 27 U/L;
      • 2023/10/09 20:53 Creatinine = 0.95 mg/dL;
      • 2023/10/09 20:53 CRP = 0.3 mg/dL;
      • WBC = 30.61 x10^3/uL; HGB = 9.8 g/dL;
      • PLT = 11 x10^3/uL;
• 2023-10-09 - SOAP Family Medicine Ye JiaZe
  • S
    • Multiple ecchymosis red papules non itchy over ext, off and on for days
      • tarry stool -
      • bloody stool -
        
      • recent URI -
      • body weight loss (BWL) -
      • referred from LMD
    • 2023-10-09 2040 voice chat consultation
    • Occupation: noodle/pasta, retired
    • Current med: atenolol, losartan, red yeast rice
  • O
    • BP: 186/93 mmHg; HR: 123 pulse/min; Weight: 65.6 kg
    • Lab
      • 2023/10/09 D-dimer = 704.00 ng/mL(FEU);
      • 2023/10/09 INR = 1.06;
      • 2023/10/09 CBC
        • WBC = 30.61 x10^3/uL;
        • HGB = 9.8 g/dL;
        • PLT = 11 x10^3/uL;
        • Blast = 41.0 %;
    • hard & soft palate ecchymosis
    • general skin red papules
  • P
    • hema OPD F/U
    • ER if condition deteriorated

[chemotherapy]

• 2023-12-15 - idarubicin 10mg/m2 15mg NS 100mL 30min D1-2 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-5 ((2+5) idarabicin/cytarabine Q4W)
  • dexamethasone 4mg + palonosetron 250ug D1,3 + NS 250mL D1,3
• 2023-11-13 - idarubicin 10mg/m2 15mg NS 100mL 30min D1-2 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-5 ((2+5) idarabicin/cytarabine Q4W)
  • dexamethasone 4mg + palonosetron 250ug D1,3 + NS 250mL D1,3
• 2023-10-13 - idarubicin 10mg/m2 15mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-7 ((3+7) idarabicin/cytarabine Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug D1,4 + NS 250mL D1,4

Acute myeloid leukemia: Induction therapy in medically-fit adults - 2023-10-16 - https://www.uptodate.com/contents/acute-myeloid-leukemia-induction-therapy-in-medically-fit-adults

• AML without mutated FLT3 - For newly diagnosed AML without mutated FLT3, we recommend treatment with a seven-day continuous infusion of cytarabine plus an anthracycline for three days (so-called “7+3 therapy”), based on the favorable balance of outcomes and toxicity.
  • Administration – The regimen that is most often used is:
    • Cytarabine - 100 to 200 mg/m2/day by continuous intravenous (IV) infusion for days 1 to 7
    • Anthracycline
      • Daunorubicin - 60 to 90 mg/m2 IV on days 1 to 3 or
      • Idarubicin - 12 mg/m2 IV on days 1 to 3
• AML with mutated FLT3 - For patients with FLT3-mutated AML, we recommend addition of either midostaurin (for any FLT3 mutation) or quizartinib (for FLT3 with internal tandem repeats [ITD]) to intensive induction chemotherapy
  • Administration
    • Midostaurin
      • Administered orally 50 mg twice daily on days 8 through 21. Cytarabine and an anthracycline are administered, as described above. (See ‘AML without mutated FLT3’ above.)
      • Strong CYP3A4 activators and inhibitors may alter exposure to midostaurin and its active metabolites; alternatives to agents that strongly affect CYP3A4 should be considered [17].
    • Quizartinib
      • Administered 35.4 mg orally once daily on days 8 to 21 of 7+3 therapy.
      • A boxed warning for quizartinib notes QT prolongation, torsades de pointes, and cardiac arrest. The QT interval should be assessed prior to initiating quizartinib and periodically during treatment. Hypokalemia and hypomagnesemia should be corrected. Treatment should not be initiated if the QT interval (corrected by Fridericia’s formula [QTcF]) is >450 ms. The dose of quizartinib should be reduced when used concomitantly with strong CYP3A inhibitors.
    • The US Food and Drug Administration (FDA) and the European Medicines Agency approved midostaurin in combination with chemotherapy for newly diagnosed AML with mutated FLT3 in adults. The US FDA approved quizartinib in combination with 7+3 induction therapy for AML that is positive for FLT3-ITD, but not for other FLT3 mutations; quizartinib is available only through a Risk Evaluation and Mitigation Strategy (REMS) in the US.

==========

(not posted yet)

2023-11-01 WBC 2.15 x10^3/uL
2023-10-28 WBC 1.40 x10^3/uL
2023-10-27 WBC 1.01 x10^3/uL
2023-10-25 WBC 0.96 x10^3/uL
2023-10-23 WBC 0.87 x10^3/uL
2023-10-21 WBC 1.07 x10^3/uL
2023-10-19 WBC 1.82 x10^3/uL
2023-10-16 WBC 3.49 x10^3/uL
2023-10-12 WBC 25.68 x10^3/uL
2023-10-09 WBC 30.61 x10^3/uL

2023-11-01 HGB 7.7 g/dL
2023-10-28 HGB 8.0 g/dL
2023-10-27 HGB 8.1 g/dL
2023-10-25 HGB 8.7 g/dL
2023-10-23 HGB 7.6 g/dL
2023-10-21 HGB 8.1 g/dL
2023-10-19 HGB 7.7 g/dL
2023-10-16 HGB 8.9 g/dL
2023-10-12 HGB 10.3 g/dL
2023-10-09 HGB 9.8 g/dL

2023-11-01 PLT 6 10^3/uL
2023-10-28 PLT 40 10^3/uL
2023-10-27 PLT 56 10^3/uL
2023-10-25 PLT 91 10^3/uL
2023-10-23 PLT 17 10^3/uL
2023-10-21 PLT 32 10^3/uL
2023-10-19 PLT 9 10^3/uL
2023-10-16 PLT 48 10^3/uL
2023-10-12 PLT 148 10^3/uL
2023-10-09 PLT 11 10^3/uL

preparing blood on 2023-11-29, -11-12, -10-28, -10-23, -10-19, -10-11

2023-12-18

[anemia]

Pre-existing anemia was identified in this patient prior to the initiation of the standard 7+3 regimen on 2023-10-13. Following completion of three cycles (one 7+3 and two 5+2), it is anticipated to possibly lead to pancytopenia within three weeks. Therefore, RBC transfusions should be provided as needed to manage the patient’s anemia.

2023-10-25

[WBC nadir 870/uL on 2023-10-23, no blast found after 2023-10-16]

In AML patients undergoing the 7+3 induction chemotherapy regimen, a nadir leukocyte level, specifically below 200/uL, was linked to a higher probability of achieving complete remission (CR). This indicates that patients who experience a more significant decrease in their leukocyte levels during chemotherapy tend to have a more favorable prognosis in terms of reaching CR. Ref: Association of leukocyte nadir with complete remission in Indonesian acute myeloid leukemia patients undergoing 7+3 remission induction chemotherapy. F1000Res. 2022 May 5;11:495. doi: 10.12688/f1000research.110320.2. PMID: 35721596; PMCID: PMC9194516.

The patient started the standard 7+3 regimen on 2023-10-13 and recent lab data suggest that the nadir was reached on 2023-10-23 with a WBC of 960/uL. Based on the aforementioned study, this correlates with a reduced chance of achieving CR.

• 2023-10-25 WBC 0.96 x10^3/uL
  
• 2023-10-23 WBC 0.87 x10^3/uL *
• 2023-10-21 WBC 1.07 x10^3/uL
  
• 2023-10-19 WBC 1.82 x10^3/uL
  
• 2023-10-16 WBC 3.49 x10^3/uL
  
• 2023-10-12 WBC 25.68 x10^3/uL
  
• 2023-10-09 WBC 30.61 x10^3/uL

However, looking at the percentage of blasts in the WBC differential count, no blasts were detected after 2023-10-16. This indicates at least a short-term effect of the treatment.

• 2023-10-16 Blast 2.9 %
  
• 2023-10-12 Blast 40.9 %
  
• 2023-10-09 Blast 41.0 %

2023-10-20

[pancytopenia]

The onset of pancytopenia is an expected consequence following the initiation of the standard 7+3 chemotherapy regimen on 2023-10-13. In response to this, the patient received a transfusion of 2 units of leukocyte-poor red blood cells (LPRBC) and 2 units of leukocyte-reduced platelets (LRP) on 2023-10-19, a standard procedure in such cases. This intervention proceeded without any complications.

• 2023-10-19 WBC 1.82 x10^3/uL
  

• 2023-10-16 WBC 3.49 x10^3/uL
  

• 2023-10-12 WBC 25.68 x10^3/uL

• 2023-10-19 HGB 7.7 g/dL
  

• 2023-10-16 HGB 8.9 g/dL
  

• 2023-10-12 HGB 10.3 g/dL

• 2023-10-19 PLT 9 *10^3/uL
  

• 2023-10-16 PLT 48 *10^3/uL
  

• 2023-10-12 PLT 148 *10^3/uL

2023-10-18

[von Willebrand factor (VWF)]

The von Willebrand factor (VWF) test results showed normal on 2023-10-16, it means that the amount of VWF in the blood is within the normal range. However, this does not necessarily mean that the person does not have von Willebrand disease (VWD).

There are several types of VWD, and some people with VWD may have normal VWF levels. For example, people with type 2N VWD have normal levels of VWF antigen and VWF activity, but the VWF molecules are not functioning properly.

Other possible reasons for normal VWF levels in a person with VWD include:

• The person has a mild form of VWD. (unknown)
• The person is taking a medication that is increasing VWF levels. (less likely, this patient is not taking desmopressin, tranexamic acid or aminocaproic acid)
• The person has recently had a blood transfusion. (probably, blood transfusion done at MER on 2023-10-11)
• The person is pregnant or breastfeeding. (not applicable)

If a person with normal VWF levels has a history of bleeding or a family history of VWD, they may still need further testing to rule out VWD. This may include tests such as the ristocetin cofactor (RCo) assay and the VWF multimer analysis.

2023-10-16

[leukopenia]

There is no identified history of AML and/or MDS from PharmaCloud or HIS5 records, suggesting this is a newly diagnosed de novo AML in this patient.

The patient was started on the standard 7+3 cytarabine/idarubicin chemotherapy regimen on 2023-10-13. The patient’s white blood cell count (WBC) was high on 2023-10-09, but quickly decreased to 3.49K/uL on 2023-10-16. While a WBC of 3.49K/uL is considered mild leukocytopenia, a decrease in all three types of blood cells (pancytopenia) is expected within the first three weeks after starting the 7+3 regimen.

• 2023-10-16 WBC 3.49 x10^3/uL
• 2023-10-12 WBC 25.68 x10^3/uL
• 2023-10-09 WBC 30.61 x10^3/uL

[hypertension]

Per the records, the patient visited the family medicine department on 2023-10-09 and has a history of hypertension, managed with atenolol, losartan, and red yeast rice. Although no antihypertensive medications are currently listed as active, the latest blood pressure reading of 130/63 mmHg (taken on 10/16 at 08:39) does not indicate significant hypertension. Therefore, there’s no immediate necessity to reintroduce antihypertensive agents. However, it’s advisable to continue monitoring blood pressure to determine if there’s a need to resume these medications.

[risk stratification]

If AML is strongly suspected, genetic analysis is recommended for risk stratification and to determine the presence of actionable mutations (such as FLT3), which may warrant the consideration of additional treatments like midostaurin or potentially quizartinib.

[antiviral prophylaxis]

• Lab
  • 2023-10-12 Anti-HBc Reactive
    
  • 2023-10-12 Anti-HBc-Value 4.57 S/CO

The American Society of Clinical Oncology and the Infectious Disease Society of America recommend that severely neutropenic patients undergoing intensive chemotherapy receive prophylactic antibacterial and antifungal therapy and that patients who are seropositive for hepatitis B core antibody or herpes simplex virus with leukemia receive antiviral prophylaxis. Ref: Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical Practice Guideline Update. J Clin Oncol. 2018 Oct 20;36(30):3043-3054. doi: 10.1200/JCO.18.00374. Epub 2018 Sep 4. PMID: 30179565.

Vemlidy (tenofovir alafenamide) is currently used to reduce the risk of reactivation of HBV infection. However, laboratory results for herpes simplex virus are not yet available.

[prophylaxis of bacterial infection in neutropenia]

Severe and prolonged cytopenias are a common occurrence with intensive remission induction therapy, as the patient is likely to develop pancytopenia within three weeks of receiving the standard 7+3 regimen. Transfusions of red blood cells and platelets should be given as needed. However, the routine use of granulocyte colony-stimulating factor (G-CSF; filgrastim) and other myeloid growth factors is not usually recommended.

High-risk patients of chemotherapy-induced neutropenia are those who are expected to be neutropenic (ANC < 500 cells/uL) for > 7 days.

Guidelines from the American Society of Clinical Oncology (ASCO) and Infectious Diseases Society of America (IDSA) recommend consideration of fluoroquinolone prophylaxis in patients at high risk for profound prolonged neutropenia (anticipated ANC <= 100 cells/uL for > 7 days)

Consensus-based National Comprehensive Cancer Network (NCCN) guidelines suggest strong consideration of fluoroquinolone prophylaxis for high-risk patients: those undergoing allogeneic HCT, neutropenic patients receiving induction chemotherapy for acute leukemia, and any patient in whom the duration of anticipated neutropenia is > 10 days.

Ciprofloxacin and levofloxacin have been studied most extensively. Ciprofloxacin has greater in vitro activity than levofloxacin against P. aeruginosa, but levofloxacin has greater in vitro activity against gram-positive bacteria (eg, alpha-hemolytic streptococci) and is given only once daily compared with twice daily for ciprofloxacin.

[prophylaxis of invasive fungal infection in neutropenia]

Continuing from the previous pharmacist’s note:

• Prophylaxis against Candida infections:
  • For patients with acute leukemia undergoing initial-induction or salvage-induction chemotherapy who are expected to develop severe oral and/or gastrointestinal mucositis, fluconazole (400 mg orally once daily) is recommended.
  • Alternative agents include itraconazole, voriconazole, posaconazole, micafungin, caspofungin, and anidulafungin.
• Prophylaxis against invasive mold infections and Candida spp:
  • For selected patients who are expected to experience prolonged severe neutropenia (ANC < 500 cells/uL for > 7 days) due to intensive chemotherapy for AML or advanced MDS, it is suggested that prophylaxis with posaconazole or voriconazole rather than targeted anti-Candida prophylaxis with fluconazole.
  • An alternative for patients who cannot receive voriconazole or posaconazole is isavuconazole.
• Dosing of posaconazole and voriconazole:
  • Posaconazole delayed-release tablets:
    • Loading dose: 300 mg (three 100 mg tablets) every 12 hours on the first day
    • Maintenance dose: 300 mg (three 100 mg tablets) daily starting on the second day
  • Posaconazole oral suspension: 200 mg three times daily
  • Voriconazole: 200 mg orally twice daily

[chemotherapy dose to remain the same for patient with normal lab results]

For patients receive standard 7+3 regimen, it is recommended to assess for comorbidities that may affect the ability to tolerate intensive therapy.

• Heart disease
  • Special attention to cardiac function is required because of the large volumes of intravenous (IV) fluids administered during remission induction therapy and the routine use of anthracyclines.
• Liver disease
  • Liver disease may affect the dose and schedule of anthracycline administration.
• Kidney disease
  • Renal insufficiency might affect the schedule and dose of cytarabine and influence management of tumor lysis syndrome.

The patient’s liver and kidney function tests on 2023-10-16 were normal. His 2D transthoracic echocardiography on the same day showed an M-mode Teichholz measurement of 66, adequate left ventricular systolic function, and normal resting wall motion. There is no evidence of tumor lysis syndrome (no serum phosphate was tested). Therefore, there is no need to adjust the patient’s current standard 7+3 chemotherapy dose.

• 2023-10-16 AST 14 U/L
  

• 2023-10-16 ALT 21 U/L
  

• 2023-10-16 BUN 18 mg/dL
  

• 2023-10-16 Creatinine 0.70 mg/dL
  

• 2023-10-16 eGFR 117.82 ml/min/1.73m^2
  

• 2023-10-16 Bilirubin total 0.60 mg/dL
  

• 2023-10-16 Bilirubin direct 0.08 mg/dL
  

• 2023-10-16 DBI/TBI 13.33 %

• 2023-10-16 K(Potassium) 3.6 mmol/L
  

• 2023-10-16 Uric Acid 6.3 mg/dL
  

• 2023-10-16 Ca (Calcium) 2.08 mmol/L

[nadir response assessment]

A bone marrow biopsy is done at the lowest point of the patient’s blood counts (hematologic nadir), which is usually between days 14 and 22 of treatment. However, for patients who are not receiving midostaurin (a drug used to treat AML), the nadir assessment does not have to be done on day 22.

Further treatment decisions are based on the results of the bone marrow biopsy:

• Hypoplasia: If the biopsy shows that the bone marrow is hypoplastic (meaning that there are fewer than 20% blood cells) and that the blasts (cancer cells) have been cleared (meaning that there are fewer than 5% blasts remaining), the patient’s blood counts will be monitored and they will receive supportive care until their blood counts recover.
• Persistent blasts: If the biopsy shows that the bone marrow is not hypoplastic and/or that there are 5% or more blasts remaining, the patient should start a second cycle of induction therapy without delay, if they are able to tolerate it.

If the results of the bone marrow biopsy are unclear, another bone marrow biopsy should be done 5 to 7 days later.

700726873

231215

[MedRec]

• 2023-11-14, -07-18 SOAP Metabolism and Endocrinology Zhang JiaHui
  • Diagnosis
    • Inflammatory spondylopathies in disease classified elsewhere [M49.80]
    • Chondromalacia of patella [M22.40]
    • Contusion of knee [S80.00XA]
    • Unspecified monoarthritis, lower leg [M13.161]
    • Contracture of joint, other specified sites [M24.50]
    • Chondromalacia of patella [M22.40]
    • Unspecified internal derangement of knee [M23.90]
    • Degeneration of lumbar or lumbosacral intervertebral disc [M51.36]
    • Unspecified monoarthritis, lower leg [M13.161]
    • Contracture of joint,other specified sites [M24.50]
    • Psychoneurosis with fibromyalgia [F48.9]
    • Herpes zoster [B02.9]
  • Prescription x3
    • cortisone acetate 25mg 2# QD
    • cortisone acetate 25mg 0.5# QN
    • Tulip (atovastatin 20mg) 0.5# QD

700199573

231214

[exam findings]

• 2023-09-13 CT - abdomen
  • Findings:
    • There is long segmental dilatation of the small intestine and the transition zone in the right upper pelvis mesentery.
      • Adhesion band induce mechanical small bowel obstruction is suspected.
    • Prior CT identified several enlarged nodes in aortocaval space are noted again, stationary.
      • Non-regional metastatic lymph nodes (M1b) are highly suspected.
      • Please correlate with PET scan.
    • S/P hysterectomy
    • There is ascites.
    • S/P nasogastric tube insertion
  • Impression:
    • Adhesion band induce mechanical small bowel obstruction is suspected.
    • Non-regional metastatic lymph nodes (M1b) in aortocaval space are highly suspected. Please correlate with PET scan.
• 2023-08-29 Patho - soft tissue tumor, extensive resection
  • PATHOLOGIC DIAGNOSIS
    • Ovarian mass, left, frozen + debulking surgery — High-grade serous carcinoma
      • Fallopian tube, left, ditto — Tumor invasion microscopically
    • Endometrium, uterus, debulking surgery — Free of tumor invasion
    • Myometrium, uterus, ditto — Free of tumor invasion
    • Cervix, uterus, ditto — Free of tumor invasion
    • Ovary, right, ditto — Tumor invasion microscopically
      • Fallopian tube, right, ditto — Tumor invasion
    • Omentum ttissue, omentectomy — Tumor invasion microscopically
    • Peritoneal tumors, excision — Tumor invasion
    • Lymph node, L’t iliac, dissection — Free of tumor metastasis (0/6)
    • Lymph node, L’t obturator, ditto — Free of tumor metastasis (0/5)
    • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/8)
    • Lymph node, R’t obturator, ditto — Free of tumor metastasis (0/13)
    • Lymph node, L’t paraaortic, ditto — Tumor metastasis (3/3) with extracapsular extension (1/3)
    • Lymph node, R’t paraaortic, ditto — Tumor metastasis (4/5) with extracapsular extension (2/4)
    • AJCC Pathologic staging: pT3cN1b, if cM0; stage IIIC
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: frozen + debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + bilateral paraaortic LN dissection + peritoneal tumor excision)
    • Specimen type: uterus, peritoneal tumors, omentum and lymph nodes
    • Specimen size:
      • L’t ovary (frozen): opened, solid and cystic mass measured 19.7 x 19.3 x 5.2 cm with necrosis and serous fluid
      • L’t fallopian tube (frozen): normal appearance, 5 cm in length, up to 0.5 cm in diameter
      • R’t ovary (frozen): normal appearance, 2 x 1.7 x 0.7 cm
      • R’t fallopian tube (frozen): solid mass at fimbrial area measured 6.5 x 6.2 x 3.5 cm
      • Uterus: 7.8 x 3.9 x 3.3 cm and 66 gm, no tumor seeding
      • Omentum: 28 x 12 x 0.5 cm, normal appearance
      • Peritoneal tumors: five tumors, up to 3.6 x 2.8 x 1.3 cm
    • Tumor site: left ovary
    • Tumor size: 19.7 x 19.3 x 5.2 cm
      
    • Tumor appearance: solid and cystic mass
    • Specimen integrity: intact
    • Lymph nodes: pelvic lymph nodes + bilateral paraaortic LNs
    • Representative sections as A1: bilateral parametria, A2-A3: cervix, A4: endometrium+ myometrium, B1-B2: peritoneal tumors, C: omentum, D: L’t iliac LNs, E: L’t obturator LNs, F: R’t iliac LNs, G: R’t obturator LNs, H: L’t paraaortic LNs and I: R’t paraaortic LNs [Reference: frozen section: F2023-00383 FSA1-A2: L’t ovarian tumor, A1: fallopian tube and A2-A8: ovarian mass, FSB: R’t tubal mass, B1-B2: R’t tubal tumor, B3: ovary and B4-B5: R’t fallopian tube]
  • MICROSCOPIC EXAMINATION
    • Histologic type: serous carcinoma
    • Histologic grade: high grade
    • Tumor side ovarian surface involvement: present
    • Contralateral ovary involvement: tumor invasion microscopically
    • Right tube involvement: present
    • Left tube involvement: tumor invasion microscopically
    • In situ adenocarcinoma in right ＆/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: present
    • Left adnexa soft tissue involvement: present
    • Pelvic soft tissue involvement: present
    • Bilateral parametria: tumor invasion
    • Uterine serosa involvement: absent
    • Omentum involvement: tumor invasion microscopically
    • Uterine Cervix involvement: absent
    • Endometrium involvement: absent
    • Myometrium involvement: absent
    • Lymph nodes metastasis: tumor metastasis (7/40) with extracapsular extension (3/7) in total number
    • Immunohistochemistry: WT-1(+), PAX-8(+), P53(aberrant expression), ER(+, scatter) and vimentin(-)
    • Ascites cytology: positive
    • Perineural invasion: present
    • Lymphovascular space invasion: present
• 2023-08-29 Body fluid cytology - ascites
  • DIAGNOSIS: Adenocarcinoma
    
  • MACROSCOPIC DESCRIPTION: 40cc, orange, turbid
  • MICROSCOPIC DESCRIPTION: Smears show dense clusters of atypical tumor cells with nuclear hyperchromasia and irregular contour.
• 2023-08-29 Frozen Section
  • L’t ovary tumor, FSA1-FSA2 — Adenocarcinoma
  • R’t ovary tumor, FSB — Adenocarcinoma
• 2023-07-11 CT - abdomen
  • With and without contrast enhancement CT of abdomen - whole:
    • There are large cystic tumors (up to 18cm)in bilateral adnexa, r/o bilateral ovarian malignancy.
    • There are peritoneal tumors, r/o peritoneal carcinomatosis.
    • Diffuse enlarged lymph nodes in aortocaval region.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T3c(T_value) N:N1b(N_value) M:M0(M_value) STAGE:IIIA__(Stage_value)
  • Impression:
    • Bilateral ovarian tumors with peritoneal tumors, aortocaval lymph nodes, r/o ovarian malignancy with carcinomatosis and lymph nodes metastasis.
    • If proven ovarian malignancy, cstage T3cN1M0.
• 2023-07-10 Gynecologic ultrasonography
  • Imp: R/O Bilateral Ovarian mass

[MedRec]

• 2023-08-27 ~ 2023-09-25 POMR Obstetrics and Gynecology Chen GuoHu
  • Discharge diagnosis
    • Left ovarian cancer (High-grade serous carcinoma) AJCC Pathologic staging: pT3cN1bcM0; stage IIIC status post debulking surgery on 2023/08/29
    • Female pelvic peritoneal adhesions (postinfective)
    • Acute posthemorrhagic anemia
    • Ileus, unspecified
    • Left ovarian mass, frozen + debulking surgery —> High-grade serous carcinom, AJCC Pathologic staging: pT3cN1bcM0; stage IIIC
  • CC
    • Abdominal mass noted for 1 month.
  • Present illness
    • This is a 49 years old unmarried female, G1P0AA1, without ANY underlying disease. She had found a palpable mass at her abdomen since 2023/07. Accompanied with mild decreased appetite. She denied marked abdominal fullness, dysuria, bowel behavior change or abnormal vaginal bleeding. Her menstrual cycle was as follows: duration/interval 2days/28days.
    • Due to the palpable mass, she went to LMD for help and the echogram revealed suspected adnexa mass. Therefore, she was transferred to our hospital for further evaluation.
    • The GYN echogram on 2023/07/10 revealed uterus 6027mm with EM 5.8mm and a fundal myoma 4X4cm, right adnexa mass 5130mm, left adnexa mass 154*101mm, bilateral hydronephrosis and asites.
    • The abdominal CT checked on 2023/07/11 revealed large cystic tumors (up to 18X16cm) in bilateral adnexa, peritoneal tumors and diffuse enlarged lymph nodes in aortocaval region, suspected bilateral ovarian malignancy, cstage T3cN1M0.
    • The tumor marker examination revealed CA125 level was 633.1U/mL, CA199 level was 3.67U/mL, and CEA level was 1.35ng/mL. Under the impression of huge pelvic cystic tumor with solid parts, suspected bilateral ovarian malignancy with carcinomatosis, she was admitted for further cancer survey, work-up (GI panendoscopy) and further treatment.
  • Course of inpatient treatment
    • The female was admitted on 2023/08/27 because of ovarian cancer, stage IIIc, and she underwent debulking and enterolysis on 2023/08/29. After flatus, her eating, defecation and self voiding were okay. However, nausea and vomit occurred since 2023/09/07 after eating for almost one week.
    • KUB revealed ileus, and she started to NPO with IV fluid. Her ileus improved on 9/15, 9/17, 9/19 and 9/25 plain abdomen; bowel sound was also improved day by day. We kept observation, and started to let her undergo water and juice intake since 2023/09/16 am. She could tolerated well when trying porridge and fulldiet. Her urination and ambulation were also okay.
    • An episode of fever was noted on 9/19, which subsided later, and the blood culture yieleded GPC. We gave augmentin to her, and there were no more fever with normal CRP. Since all of her condition were improved, she may be discharged on 2023/09/25 with OPD follow up.
  • Discharge prescription
    • naproxen 250mg 1# TID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • MgO 250mg 2# QID

[surgical operation]

• 2023-08-29
  • Surgery: debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + para-aortic LN dissection + pelvic tumor excision) + enterolysis
  • Finding
    • left ovary and tube (unruptured during surgery, removed intact and then cut open outside the body)
      • LOV – 17x15cm tumor with mixed solid mass and multicystic parts with some brown fluid (>1000 c.c) inside, suspected LOV cancer
      • Frozen report – high grade (serous?) adenocarcinoma
      • left tube – np
    • right ovary and tube (unruptured during surgery, removed intact and then cut open outside the body)
      • ROV – 2x2cm, grossly no tumor invasion
      • right tube – enlarged 6x6cm tumor with solid mass, suspected cancer invasion,
      • Frozen report – high grade (serous?) adenocarcinoma
    • uterus: seemed free of cancer invasion
    • peritoneal tumors 3~4#, 1~2cm over low pelvis (CDS site between cervix and rectum), cancer invasion likely
    • omentum – seemed free of cancer invasion
    • left iliac LNs
    • left obturator LNs
    • right iliac LNs
    • right obturator LNs
    • left para-aortic LNs – enlarged mass 1~2cm, cancer metastasis?
    • right para-aortic LNs – enlarged mass 2~3cm, cancer metastasis?
    • liver, bwoels and other peritoneum – seemed free of cancer invasion
    • After the operation, optimal debulking surgery was achieved.
    • Residue tumor: 3~4 small tumors < 1cm , over low pelvis (CDS site between cervix and rectum)
    • A 7mm JP drain was placed in CDS

[chemotherapy]

• 2023-12-14 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 425mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-11-16 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-10-21 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-12-14

According to the eGFR laboratory data since Nov, the patient’s renal function has decreased in the past two weeks. The dose of carboplatin has been adjusted accordingly (2023-12-14 425mg <- 2023-11-16 580mg), while the dose of paclitaxel does not require adjustment due to the change in renal function.

• 2023-12-13 eGFR 72.29 ml/min/1.73m^2
  
• 2023-11-29 eGFR 124.35 ml/min/1.73m^2
  
• 2023-11-15 eGFR 119.82 ml/min/1.73m^2
  
• 2023-11-01 eGFR 122.29 ml/min/1.73m^2

Furthermore, no adjustments are needed for the drugs listed on the active medication list other than those used in chemotherapy, based on the renal function test results from 2023-12-13.

700734229

231214

[lab data]

2023-12-13 Influenza A Ag Negative
2023-12-13 Influenza B Ag Negative

2023-12-04 Rubella IgM Negative Index
2023-12-04 Rubella IgM Value 0.05
2023-12-04 Measles virus IgM Ab Negative Ratio
2023-12-04 MeaslesIgM Value 0.1 Ratio
2023-12-04 Mumps Virus IgG Positive AU/mL
2023-12-04 Mumps Virus IgGValue >300.0 AU/mL
2023-12-04 Mumps Virus IgM Negative Index
2023-12-04 Mumps IgM Value <0.5 Index

2023-11-27 Anti-HBs 13.70 mIU/mL

2023-11-27 Anti-HCV Nonreactive
2023-11-27 Anti-HCV Value 0.12 S/CO

2023-11-27 HBsAg Nonreactive
2023-11-27 HBsAg (Value) 0.37 S/CO

2023-11-27 Anti-HAV IgM Nonreactive
2023-11-27 Anti-HAV IgM Value 0.20 S/CO
2023-11-27 Anti-HAV IgG Reactive
2023-11-27 Anti-HAV IgG Value 9.77 S/CO

[MedRec]

• 2023-11-22 ~ 2023-12-04 POMR Qiu ShengKang
  • Discharge diagnosis
    • Sepsis, suspect EBV infection
    • Fever, suspect EBV infection
    • Mixed hyperlipidemia
    • single vessel coronary artery disease status post percutaneous coronary intervention with drug eluting stenting toleft anterior descending artery on 2022/11/23
    • Chronic ischemia heart diseasae
    • Hypertensive heart disease
    • Unspecified abdominal pain
  • CC
    • fever and chills for 4 days.
  • Present illness
    • This is a 65-year-old male ex-smoker (2ppd 20+ years and quit 20+ years) with the past history of Hypertension, mixed Hyperlipidemia for years, Chronic ischemic heart disease by CT scan at 2020/06 showed mod calcification (score 192) with 20-50% stenosis of LAD and LCX and erosive esophagitis LA Classification grade A, Superficial gastritis, gastric ulcers, multiple, antrum, duodenal ulcers by PES on 2021/10/21 under regular medication control at our OPD.
    • He sufferes from fever and chills for 4 days. He came to our ER for help on 11/21. He came back from Thaiand on 11/19. At ER, vital sign showed BP:143/83; PR:113; BT:39.5’C; RR:18; Con’s:E4V5M6, SPO2:93%. Lab data showed WBC:8420, CRP:4, Cr:1.19. Influenza A and B Ag showed negative. Urine analysis showed negative. CxR showed no infiltration. Abdomen CT with and without showed fatty liver, grade 5 and gallstones.
    • Empirical antibiotic with Cefoxitin was givne for infection control.
    • Under the impression of fever cause unknown, he is admitted to our ward for treatment on 2023-11-22.
  • Course of inpatient treatment
    • After admission, empirical antibiotic with Cefoxitin was shifted to Mepem and Doxymycin were given for fever flarep since 11/24. Urine culture showed Group B streptococci. Pending culture. we consulted Meta Qiu QuanTai for TG>2000 on 11/23. We checked Myocardial perfusion SPECT with persantin and no obvious finding. We kept follow up lab data. Cardiac and abdominal echo were done and no obvious abnormality. For the diffused rash over skin, we consulted dermatology and they suggested Sinpharderm and Mycomb used. Spike fever and chills persisted during admission. Series of studies for fever of unknown origin were taken.
    • Fever subsided after above. Lab data finally showed Epstein-Barr virus infection. His WBC and CRP decreased. We shifted tagocid + mepem to cefoxitin. He complaint of palpable mass in his anus and above his anus so we consulted CRS. The mass was ligated.
    • His vital sign was stable today so he was discharged and referred for OPD foolow up.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNTID
• 2022-11-22 ~ 2022-11-25 POMR Cardiology Ke YuLin
  • Discharge diagnosis
    • Angina pectoris
    • single vessel coronary artery disease status post percutaneous coronary intervention with drug eluting stenting toleft anterior descending artery on 2022/11/23
    • Hypertensive heart disease
    • Mixed hyperlipidemia
    • Erosive esophagitis, Los Angeles Classification grade A, Superficial gastritis, gastric ulcers, multiple, antrum, duodenal ulcers by Panendoscopy on 2021/10/21
  • CC
    • episode of short of breath with moving a Sofa from 1st floor to 4th floors about three months ago and still exertional dyspnea with chest discomfort while walking up to 2nd floor and exacerbated in recent two weeks
  • Present illness
    • This is a 64-year-old male ex-smoker (2ppd 20+ years and quit 20+ years) with the past history of Hypertension, mixed Hyperlipidemia for years, Chronic ischemic heart disease by CT scan at 2020/06 showed mod calcification (score 192) with 20-50% stenosis of LAD and LCX and erosive esophagitis LA Classification grade A, Superficial gastritis, gastric ulcers, multiple, antrum, duodenal ulcers by PES on 2021/10/21 under regular medication control at our OPD.
    • This time, he was admitted via our OPD because of episode of short of breath with moving a Sofa from 1st floor to 4th floors about three months ago and still exertional dyspnea with chest discomfort while walking up to 2nd floor and exacerbated in recent two weeks. The symptoms without associated with cold sweating or radiation pain to back, without dizziness, palpitation or acid regurgitation. It may be relieved after rest without try NTG, the duration was several minutes. So he came to our CV OPD for further help.
    • At CV OPD, heart CTA was arrange on 2022/11/11 and revealed Calcification of the coronary arteries (LAD＝60, LCX＝14, RCA＝8, Left main trunk＝82, total calcium score＝219, uisng AJ-130 method); Left anterior descending coronary artery: 50% stenosis at S6. (Se402 IM78); Left circumflex coronary artery: >75% stenosis at S11. (Se402 IM87) and Right coronary artery: 50% stenosis at S1. (Se402 Im113)
    • Cardiac catheterization was indicated and suggested. After well explanation the risk and the procedures to the patient and family, he was admitted to ward for further evaluation and management.
  • Course of inpatient treatment
    • During admission, cardiac catheterization was arranged on 11/23 after well explained the risks and the procedures to the patient and family. N/S hydration was given to reduce the incidence of contrast induced renal injury.
    • Coronary angiography was done via right radial artery smoothly which revealed single vessel coronary artery disease status post percutaneous coronary intervention with drug eluting stenting to left anterior descending artery.
    • The patient denied any chest discomfortable but chronic exertional dyspnea persistent after PCI.
    • After intervention, we go on aspirin 1# qd and added plavix 1# qd use. The right wrist cath wound healed well. Neither ecchymosis nor hematoma developed. Follow up cardiac markers and EKG after PCI were unremarkable. His urine output remained adequate after PCI and follow up renal function is improving.
    • We also arrange echocardiography on 2022-11-24 for dyspnea evaluation andrevealed
      • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function(78%)
      • Mild aortic valve sclerosis with trivial AR; mild MR.
      • Mildly dilated proximal ascending aorta (35 mm), mild aortic root calcification.
    • Under stable hemodynamics, he was discharged on 11/25 and OPD followed up was arranged.
  • Discharge prescription
    • Bokey (aspirin 100mg) 1# QD
    • Concor (bisoprolol 5mg) 1# QD
    • Linicor (niacin 500mg, lovastatin 20mg) 1# HS
    • Lipanthyl Supra (fenofibrate 160mg) 1# QD
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Norvasc (amlodipine 5mg) 1# QD
    • Olmetec (olmesartan medoxomil 20mg) 1# QD
    • Plavix (clopidogrel 75mg) 1# QD
• 2017-01-04 Gastroenterology Xu RongYuan
  • Diagnosis
    • Mixed hyperlipidemia [E78.2]
    • Chronic hepatits, unspecified [K73.9]
  • Prescription x3
    • Olbetam (acipimox 250mg) 1# BID
    • Lipanthyl Supra (fenofibrate 160mg) 1# QD

700783400

231214

[exam findings]

• 2023-11-24 CTA - chest
  • Without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Chest
      • Moderate Rt pleural effusion with dependent volume loss of RLL and patchy opacities at LLL as well as a nodular lesion lingula of the lungs.
      • Mediastinum and hila: no enlarged LN or mass.
      • Thoracic aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber and well opacification.
      • Heart: normal size of cardiac chambers. conventric LVH?
      • Pleura: unremarkable, no effusion or thickening or nodule.
      • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal-pelvic contents:
      • a large soft-tissue tumor in the lower part of Rt kidney (at 92mm in longest dimension) and a huge soft-tissue tumor at Rt posterior perirenal/pararenal space (15cm in longest dimension).
      • with several LAP at para-aortic region.
      • several small renal cysts and atrophic pancreatc tail.
      • unremarkable of the liver, GB, spleen, Lt adrenal gland,
      • bile ducts: No dilatation.
      • Mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
      • marginal spurs of multiple vertebrae due to spondylosis.
      • compression fracture of L2 vertebral body
  • Impression:
    • large Rt renal cancer and largest malignant tumor in Rt posterior perirenal/pararenal space with several metastatic LAP at para-aortic region.
    • Lt lung metastasis or infection?

[MedRec]

• 2023-12-13 ~ 2023-12-14 POMR Family Medicine Ye JiaZe

  • Discharge diagnosis
    • B-cell lymphoma without treatment, diagnosed at Taipei Veterans General Hospital in 2017.
    • Hyperkalemia
    • Right pleural effusion
    • Chronic kidney disease, stage 3 (moderate)
  • CC
    • decline of consciousness level and dyspnea on 2023/12/13 morning.
    • vomiting once after NG tube feeding
  • Present illness
    • The 83-year-old man had past history of
      • Hypertension
      • Type II diabetes mellitus
      • Arrythmia
      • Urolithiasis status post DJ insertion
      • Low grade B-cell lymphoma on 2017/11
    • According to his son, the patient had B-cell lymphoma without treatment in 2017, diagnosed at TPEVGH. He was admitted to our Oncology ward on 2023/11/24 for disturbance. Laboratory data revealed hypercalcemia. Chest CTA (2023/11/24) showed large Rt renal cancer and largest malignant tumor in Rt posterior perirenal/pararenal space, with several metastatic LAP at para-aortic region. Lt lung metastasis or infection? Renal biopsy was suggested to the family, they refused schedule and preferred supportive care.
    • This time, he had decline of consciousness level and dyspnea on this morning. Vomiting once after NG tube feeding was also note. There was no cough, abdominal pain, nor tarry stool. Desaturation with SpO2: 75% by EMT. He was sent to our ER for help. At ER, his GCS was E2V1M1. TPR: 37.9, 130, 26. BP: 102/54mmHg. PE showed bilateral breathing sounds rhonchi. Abdomen flat and soft. Laboratory data showed anemia, HGB 8.3g/dL, elevation for Lactic Acid 7.3 mmol/L, hs-Troponin I 216.5 pg/ml, CRP=11.8 mg/dL. U/A showed pyuria. CXR disclosed Right pleural effusion and ground glass opacity in right lung and LLL. Pending B/C and S/C. Due to poor prognosis, the family asked for palliative care. FM was consulted for hospice care. The patient was admitted to our hospice ward on 2023/12/13.
  • Course of inpatient treatment
    • After admission, vital signs were unstable. Morphine was given as 3mg SC Q6H, other sedatives were given PRN as neccessary according to his symptoms. His condition had downhilled fast which low blood pressure was noticed during the night. He had expired on 2023.12.14 04:54. We had informed the family and mental support was done to the family.

• 2023-11-24 ~ 2023-12-08 POMR Hemato-Oncology Gao WeiYao

• 2023-11-24 VS Note on Admission Day

  • Summary
    • The 83 y/o man has HTN, DM, ARRYTHMIA, UROLITHIASISS/P DJ INSERTION.
    • He was admitted through ER with the chief complaint of concious disturbance for 6 days. A series of studies at ER supported that a large Rt renal cancer and largest malignant tumor in Rt posterior perirenal/pararenal space. with several metastatic LAP at para-aortic region. Lt lung metastasis and HYPERCALCEMIA and hypernatremia were noted.
  • Plan to do:
    • On critical condtition
    • Correct hypercalcemia, hyperuricemia, hypernatremia and blood sugar.
    • Tissue proof of Rt renal tumor (lymphoma or kidney ca ??) with regional and distant metastases.

• 2021-11-06 ~ 2021-11-19 POMR Urology

  • Discharge diagnosis
    • Left ureteral stone status post left ureterorenoscopic lithotripsy with double J stenting on 2021/11/17
    • Left hydronephrosis status post left percutaneous nephrostomy on 2021/11/10
    • Urinary tract infection with E-coli
    • Infectious gastroenteritis and colitis, unspecified
    • Type 2 diabetes mellitus with hyperglycemia
    • Hypertensive heart disease without heart failure
  • CC
    • Tenesmus and chills for 1 day
  • Present illness
    • This is a 81-year-old male with underlying parkinsonism, type II diabetes mellitus with insulin control for years, BPH, Hypothyroidism under medication control, arrhythmia under Eliquis and hypertension for years. This time, he had tenesmus and chills last night, and symptoms relieved after defecated soft stool twice.
    • He had tenesmus and chills last night, and symptoms relieved after defecated soft stool twice. He came to our ER for help. At ER, PE found pale conjunctiva. Lab data showed WBC 17550, Hb 10.8, CRP 8.83, Cre 1.54, Pyuria (WBC >100, OB 3+, Bact 3+), Stool OB 2+.
    • KUB revealed Compression fracture of L2, Radiopaque spot(s) at left renal region r/o renal stone(s), Stool retention in the bowel.
    • Under the impression of UTI, he came to our ward to do further management and examination.
  • Course of inpatient treatment
    • After admission, the surgery of left percutaneous nephrostomy on 2021/11/10. Antibiotic with Tapimycin (11/11~) due to his fever not improved. After antibiotic treatment, his fever much improved.
    • The surgery of left ureterorenoscopic lithotripsy with double J stenting on 2021/11/17. With clinical improvement and stable condition, she was discharged and would be followed up.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
    • Urief (silodosin 8mg) 1# QN
    • Ceficin (cefixime 100mg) 1# BID

==========

2023-11-27

[enhancing patient care through shared medical records from Far Eastern Memorial Hospital]

Per the PharmaCloud database, the patient was diagnosed with “Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma)” at Far Eastern Memorial Hospital, with his last visit on 2023-08-24. The patient should be requested to provide the examination results and treatment details from that hospital to enable our medica team a more comprehensive consideration of the current situation.

[optimizing calcitonin Use for hypercalcemia management]

The patient, who has hypoalbuminemia, shows a corrected calcium level of 3.1 mmol/L (12.4 mg/dL) and is currently receiving Miacalcic (calcitonin) at 100 IU SC Q6H.

• 2023-11-27 Ca (Calcium) 2.91 mmol/L
  

• 2023-11-26 Ca (Calcium) 3.03 mmol/L
  

• 2023-11-24 Ca (Calcium) 3.08 mmol/L

• 2023-11-27 Albumin (BCG) 3.0 g/dL
  

• 2023-11-24 Albumin (BCG) 3.2 g/dL

For severe hypercalcemia, the maintenance dose of calcitonin can be up to 8 units/kg Q6H to Q12H, starting with an initial dose of 4 units/kg Q12H. Since the current administration of 100 IU Q6H is below the recommended dosage, this may extend the duration of therapy. It’s advisable to limit calcitonin therapy to a period of 24 to 48 hours to avoid tachyphylaxis.

Given that the serum calcium level has not exceeded 3.5 mmol/L (14 mg/dL) and is trending downwards, the combined use of calcitonin with bisphosphonates for a long-term effect may not be essential.

[basal insulin initiation for consistent hyperglycemia]

All recorded blood glucose levels in the TPR panel fall between 230 and 380 mg/dL during this hospitalization, frequently exceeding 300 mg/dL, despite the current use of Insulin Actrapid, NovoRapid, and Trajenta. Therefore, it is advisable to introduce basal insulin (a long-acting type) starting with a daily dose of 2 units, with evaluations every other day to determine if further adjustments are necessary.

[replacing D5W with NS in hyperglycemic hydration plan]

Given the patient’s obvious hyperglycemia, it is advisable to switch from D5W to NS for hydration purposes.

[evaluating causes of hypercalcemia: beyond hyperthyroidism]

The lab results showed no elevation in TSH, Free-T4, or T3, suggesting that hyperthyroidism is an unlikely cause of the hypercalcemia. Could osteolytic bone metastases and local cytokines be contributing factors?

• 2023-11-27 TSH 1.012 uIU/mL
  
• 2023-11-27 Free-T4 1.08 ng/dL
  
• 2023-11-27 T3 0.31 ng/mL

700701383

231213

[MedRec]

• 2023-12-05 Cardiac Surgery Xu ZhanYang
  • Discharge diagnosis
    • Adenocarcinoma of the gastric antrum; status post subtotal gastrectomy on 2023-11-02; status post Port-A catheter implantation through the right internal jugular vein on 2023-12-06
    • Prostate cancer; status post radical prostatectomy and pelvic lymph node dissection on 2019-06-26
    • Hypertension
    • Type 2 diabetes mellitus
    • Asthma
    • Hepatitis B carrier
  • CC
    • Expected hospitalization for Therapeutic catheter implantation - Port-A catheter implantation surgery.
  • Present illness
    • This is a 62-year-old male patient with a history of hypertension, type 2 diabetes, and asthma for several years. He is also a carrier of Hepatitis B. His surgical history includes:
      • C5-6-7 herniated intervertebral disc (HIVD) and stenosis; status post discectomy and spinal fusion on 2013-07-30
      • Anal fistula and hemorrhoids; status post fistulotomy and hemorrhoidectomy on 2015-07-08
      • Benign prostatic hyperplasia; status post transurethral resection of the prostate on 2019-04-17
      • Prostate cancer; status post radical prostatectomy and pelvic lymph node dissection on 2019-06-26
      • Prostate cancer and phimosis; status post bilateral orchiectomy on 2019-12-25.
    • He was diagnosed with adenocarcinoma of the gastric antrum in 2023 and underwent subtotal gastrectomy on 2023-11-02 at National Yang Ming Chiao Tung University Hospital.
    • Further chemotherapy is needed. The patient was then referred to the cardiovascular surgery department for Port-A catheter implantation. The surgery is scheduled for 2023-12-06, and the patient was admitted on 2023-12-05 for elective Port-A catheter implantation.
  • Course of inpatient treatment
    • After admission, the patient underwent Port-A catheter implantation through the right internal jugular vein on 2023-12-06. Following the surgery, wound management skills education was performed. The patient was discharged home on 2023-12-06.
  • Discharge prescription
    • Sindine Aq Soln (povidone iodine 10%) QD EXT
    • Acetal (acetaminophen 500mg) 1# QID
    • Lactul (lactulose 666mg/mL) 10mL PRNTID
• 2023-11-23 SOAP Hemato-Oncology Gao WeiYao
  • A:
    • Metchronous double cancer (prostate first and gastric ca later 2023)
      • The term metachronous is used in oncology to refer to two (or more) independent primary malignancies, when the second (or third, etc.) malignancy arose more than six months after the diagnosis of the first malignancy. These may be in the same, or in different, organs.
      • The term synchronous is used in oncology to refer to two (or more) independent primary malignancies, when the second (or third, etc.) malignancy arose within six months of the diagnosis of the first malignancy. These may be in the same, or in different, organs.
    • Adenocarcinoma of gasric antrum , pT3N3aMx, stage IIIb post subtotal gastrectomy on 2023-11-02 at YiLan YanMing Hospital.
• 2019-11-11 SOAP Urology LinJiaDa
  • O: Cancer Multidisciplinary Team Meeting Conclusion, Date: 2019-10-07
    • Start androgen deprivation therapy (ADT) on 2023-10-01. Monitor for efficacy for a period of time.
    • If the prostate-specific antigen (PSA) level does not decrease by at least 50% after 6 months, chemotherapy should be considered.
    • Germline mutation testing should be considered.
• 2019-04-16 ~ 2019-04-19 POMR Urology Lin JiaDa
  • Discharge diagnosis
    • N40.1 Benign prostatic hyperplasia status post transurethral resection of the prostate on 2019/04/17
    • R97.2 Elevated prostate specific antigen status post Transrectal ultrasound guided (TRUS) biopsy on 2019/04/17
  • CC
    • urinary frequency, weak stream and nocturia 4-6 times/night.
  • Present illness
    • This 58-year-old man has histories of 1) C5-6-7 HIVD was diagnosed at CGMH 4-5 years ago; 2) Hemorrhoid s/p operation 13 years ago at CGMH; 3) Anal fistula post fistulotomy on 2015/07/08; 4) BPH under medication treatment for 2+ years.
    • He has LUTS such as urinary frequency, weak stream and nocturia 4-6 times/night. He received follow-up at urologic clinic periodically for BPH treatment. He complained symptoms more severe in this month and visited our urologic clinic ask surgery.
    • PSA：7.619 ng/mL. Transrectal echo revealed benign prostatic hyperplasia (36.8 cc). Though some alpha-blockers were prescribed, but no significant effect was noted.
    • Under the impression of benign prostatic hyperplasia and elevated prostate specific antigen (PSA), we advised the patient to receive laser TURP and TRUSP biopsy. After well explaining, the patient agreed.
    • This time, he was admitted for further evaluation and management.
  • Course of inpatient treatment
    • After admission, the surgery of transurethral resection of the prostate and transrectal ultrasound guided (TRUS) biopsy was performed on 2019/04/17.
    • Postoperative course was uneventful and continued N/S bladder irrigation.
    • Removed Foley done smoothly on 4/19 with fair urination, he was discharged today and would be followed up at urologic clinic.
  • Discharge prescription
    • Atanaal (nifedipine 5mg) 2# PRNQ6H
    • MgO 250mg 1# QID
    • Lactam (acetaminophen 500mg) 1# QID
    • cephalexin 500mg 1# QID

[surgical operation]

[chemotherapy]

• 2023-12-13 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 720mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-12-13

The PharmaCloud records show that this patient recently refilled his prescription for metformin and Sevikar (amlodipine, olmesartan) on 2023-12-03 for a 28-day supply. These drugs have been included in the active medication list.

Zytiga (abiraterone) has been in use since early 2021 and continues to be part of the patient’s treatment regimen. Androcur (cyproterone) was administered from 2019-10 to 2020-01, with two doses of Leuplin (leuprorelin) given on 2019-10-01 and 2019-10-31 prior to the initiation of Zytiga.

It is advisable that patients receiving abiraterone should also receive a gonadotropin-releasing hormone (GnRH) analog concurrently (or have had a bilateral orchiectomy).

700796645

231213

[exam findings]

• 2023-03-28 Patho - uterus (with or without SO) neoplastic
  • PATHOLOGIC DIAGNOSIS
    • Uterus, endometrium, total hysterectomy — Carcinosarcoma with heterologous element
    • Ovaries and fallopian tubes, bilateral, BSO — No remarkable change
    • Lymph nodes, pelvic and para-aortic, bilateral, BPLND+PALND— Negative for malignancy (0/51)
    • AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II
  • MACROSCOPIC EXAMINATION
    • Procedure: total hysterectomy + BSO + omentectomy + BPLND + bilateral para-aortic LN dissection
    • Specimen Size: 20.5 x 12.0 x 8.0 cm(uterus), 3.0 x 2.0 x 2.0 cm (Lt ovary), 4.5 x 1.0 cm (Lt tube), 3.0 x 2.0 x 2.0 cm (Rt ovary), 4.5 x 1.0 cm (Rt tube), and 24 x 12 x 2.0 cm (omentum)
    • Specimen Integrity: Intact
    • Tumor Site: Endometrium
    • Tumor Size: 19.5 x 10.5 cm
    • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para=aortic, and right para-aortic. Representative parts are taken for section and labeled as: A1-A2= left iliac LNs, B= left obturator LNs,C1-C2= right iliac LNs, D1-D3= right obturator LNs, E= left para-aortic LNs, F= right para-aortic LNs, G1-G2= left ovary and fallopian tube, G3-G4= right ovary and fallopian tube, G5-G13= uterine corpus, G14-G15= cerivx, H1-H2= omentum.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Carcinosarcoma with heterologous (chondrosarcomatous) component
    • Histologic Grade: High-grade
    • Depth of tumor invasion: Tumor invading > 1/2 of the myometrium
    • Uterine Serosal Involvement: Not identified
    • Cervical Stromal Involvement: Present
    • Other Tissue/Organ Involvement: Not identified
    • Peritoneal/Ascitic Fluid: Negative
    • Margins: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin: 0.1 cm from parametrium
    • Lymphvascular Invasion: Present
    • Regional Lymph Nodes: All lymph nodes negative for tumor cells (0/51)
      • number of lymph node examined: 16 (left iliac), 4 (left obturator), 7 (right iliac), 13 (right obturator), 5 (left para-aortic), 6 (right para-aortic)
      • number with metastases > 2 mm: 0
      • number with metastases > 0.2 mm and up to 2 mm or less: 0
      • number with isolated tumor cells (<= 0.2mm): 0
    • Pathologic Stage
      • Primary Tumor: pT2 (tumor invading the stroma of the cervix)
      • Regional Lymph Nodes: pN0 (no regional lymph node metastasis
      • Distant Metastasis: cM0
    • FIGO Stage: Stage II
    • AdditionalPathologic Findings
      • Cervix: Chronic cervicitis with Nabothian cyst
      • Myometrium: Leiomyoma
      • Ovary, right: No remarkable change
      • Ovary, left: No remarkable change
      • Fallopian tubes, blateral: No remarkable change
      • Omentum: Free of carcinoma
• 2023-03-24 CT - chest
  • Minimal interstitial change at Right lower lobe and left lower lobe
  • Calcified coronary arteries is found.
  • Right upper lobe tiny nodule. 0.2cm, meta is less likely but follow up is suggested.
• 2023-03-20 MRI - pelvis
  • Clinical history: 68 y/o male patient with Vagina, excisional biopsy — Carcinosarcoma.
  • With and without contrast enhancement MRI: Pelvis
    • Diffuse soft tissue tumors(up to 10cm) in the uterine cacvity, involving more than half of myometrium, focal soft tissue in the uterine cervical region.
    • Focal soft tissue tumor in border of left uterine surface, r/o adnexal or parametrium invasion.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE: IIIB_(Stage_value)
• 2023-03-17 Gynecologic ultrasonography
  • Findings
    • Uterus Position : AVF
      • Size: 104 x 88 mm
    • Endometrium:
      • Thickness: 71.8 mm
    • Adnexae:
    • CUL-DE-SAC: with fluid
      
    • Other: Bilateral adnexae free
  • IMP: R/O EM:71.8mm (RI:0.51), or Uterus mass?
• 2023-03-10 Patho - vaginal biopsy
  • Vagina, excisional biopsy — Carcinosarcoma
  • The sections show a picture of carcinosarcoma, composed of both malignant epithelial and mesenchymal components. The epithelial component arranged in glandular and solid patterns. The sarcomatous components composed of fascicles of spindle-shaped neoplastic cells with focal hyalinized stroma and focal chondroid differentiation. Surface ulcer, moderate inflammatory cells infiltrate, and granulation tissue are present. The surgical margin is involved by tumor.
  • IHC: CK (+ for epithelial component), Vimentin (+ for both epithelial and mesencymal components), PAX8 (+), ER (-), PR (+) and Napsin A (-).

[consultation]

• 2023-05-18 Radiation Oncology
  • Q
    • The patient is an 68-year-old female with a history of 1. hypothyroidism s/p medical control, 2. hyperlipidemia s/p medical control, 3. Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy), stage pT2N0cM0; stage II; FIGO stage II.
      
    • This time, she suffered from fever with chillness since 2023/05/03, last chemotherapy on 2023/05/02, until symptoms worsen, so she was brought to our ER for help. Associated symptoms included poor appetite, frequent urination, fever with chillness. Denied painful urination, cough or URI symptoms and abdominal pain. At ER he conscious level is E4V5M6, vital sign BP:121/69; PR:112; BT:38; RR:18. Physical examination showed abdominal OP scar clear, breathing sound clear. Lab data showed Sediment-WBC >=100 /HPF; Bacteria = 3+ /HPF; Creatinine = 2.51 mg/dL; CRP = 36.8 mg/dL; WBC = 13.14 x10^3/uL. Under the tentative diagnosis of Urinary tract infection. So, she was admitted to our ward for further evaluation and management.
    • For radiotherapy, we need your further evaluation and management.
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: Recovery from urinary tract infection.
      • PI: Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy) on 2023-03-27, stage AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II.
      • Chemotherapy: since 2023-05-02
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM(-); HTN(-)
      • Allergy(-)
    • O:
      • ECOG: 0
      • PE: neck and bil SCF: neg; abdomen: surgical scars.
      • CXR (2023-03-03): No active lung lesion. No cardiomegaly. Thoracic spondylosis.
      • MRI of pelvis (2023-03-20): Diffuse soft tissue tumor in the uterine cavity, with focal soft tissuse tumor in left uterine border, r/o parametrial/adnexal invasion. Clinical biopsy vaginal carcinosarcoma, cstage T3bN0M0.
      • Operation (2023-03-27): Staging surgery (Total hysterectomy + bilateral salpingo - oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy)
      • Ascites (2023-01154, 2023-03-29): neg.
      • Pathology (S2023-05755, 2023-03-30): 1. Uterus, endometrium, total hysterectomy — Carcinosarcoma with heterologous element. 2. Ovaries and fallopian tubes, bilateral, BSO — No remarkable change. 3. Lymph nodes, pelvic and para-aortic, bilateral, BPLND + PALND — Negative for malignancy (0/51). 4. AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II. Lymphvascular Invasion: Present.
      • RT (2023-04-28 ~): at 900cGy/5 fractions (10MV photon) of the pelvic area.
    • A: Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo - oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy), stage AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II.
    • P: The patient interrupted radiotherapy after 2023-05-05 due to urinary tract infection. Because she already recovery from that, radiotherapy can be continued.
• 2023-05-12 Neurology
  • Q
    • The patient is a 68-year-old female with a history of 1. hypothyroidism s/p medical control, 2. hyperlipidemia s/p medical control, 3. Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy), stage pT2N0cM0; stage II; FIGO stage II.
    • She presented with chronic migraine for many years, under treatment (ponstan) at LMD, but renal function has worsened. For chronic migraine, we need your further evaluation and management.
  • A
    • If renal function is poor, consider using the following (all are PRN, used only when having a headache):
      • acetaminophen
      • ultracet/tramadol
      • ergotamine/caffeine: limited to one a day, not recommended for those with cardiovascular disease
      • imigran: limited to 50mg a day, no more than twice a week, at most 8 tablets a month
    • You can use (choose one from 1, 2) in combination with (choose one from 3, 4)
    • The patient has used inderol 10mg qd as a prophylactic for migraines in the past (June 2019 neurology clinic), and the effect was good, it can be tried again.

[chemotherapy]

• 2023-12-13 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO
• 2023-11-17 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO
• 2023-10-03 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO
• 2023-09-01 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-2
• 2023-08-11 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-2
• 2023-07-17 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-2
• 2023-06-20 - carboplatin AUC 2 150mg D5W 2hr (weekly CDDP changed to carboplatin, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-06-13 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-06 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-30 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-22 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-02 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-09-04

The leukopenia observed on 2023-08-24 (WBC 1.5K/uL) was likely a result of the paclitaxel and carboplatin administered on 2023-08-11. Following a 3-day course of G-CSF from 2023-08-24 to 2023-08-26, no further instances of leukopenia have been observed.

A new cycle of the treatment regimen was initiated on 2023-09-01, and prophylactic G-CSF is scheduled for 2023-09-06, 2023-09-07, and 2023-09-08.

2023-08-31 WBC 3.20 x10^3/uL
2023-08-24 WBC 1.50 x10^3/uL
2023-08-08 WBC 5.12 x10^3/uL
2023-07-25 WBC 3.29 x10^3/uL
2023-07-17 WBC 5.76 x10^3/uL
2023-07-12 WBC 4.41 x10^3/uL
2023-07-03 WBC 1.64 x10^3/uL
2023-06-28 WBC 1.69 x10^3/uL
2023-06-19 WBC 2.08 x10^3/uL
2023-06-12 WBC 2.72 x10^3/uL
2023-06-05 WBC 4.78 x10^3/uL
2023-05-30 WBC 3.99 x10^3/uL
2023-05-22 WBC 4.35 x10^3/uL
2023-05-15 WBC 4.67 x10^3/uL
2023-05-12 WBC 4.78 x10^3/uL
2023-05-09 WBC 8.17 x10^3/uL
2023-05-09 WBC 13.14 x10^3/uL
2023-04-19 WBC 5.07 x10^3/uL
2023-04-03 WBC 5.23 x10^3/uL
2023-03-28 WBC 13.97 x10^3/uL
2023-03-23 WBC 7.35 x10^3/uL
2023-03-03 WBC 5.22 x10^3/uL

2023-09-01

The Eltroxin (levothyroxine) prescribed by our endocrinologist on 2023-08-01 is currently listed in the active medications without any reconciliation discrepancies identified.

2023-08-11

Our endocrinologist wrote a repeat prescription for Eltroxin (levothyroxine) on 2023-08-01 and the drug is included in the formulary with no reconciliation issue identified.

2023-07-18

[reconciliation]

The patient was seen by our urologist on 2023-07-12 who prescribed Cero (cefaclor 250mg) 2# TID and Celebrex (celecoxib 200mg) 1# QD for a period of 7 days to treat suspected UTI infection or catheter-related discomfort. These medications are not currently on the active medication list, so it’s advisable to confirm resolution of these symptoms.

701260169

231213

[exam findings]

• 2023-04-14 Patho - breast mastectomy with regional lymph nodes
  • PATHOLOGIC DIAGNOSIS
    • Breast tumor, right, simple mastectomy —- Solid papillary carcinoma with invasion
    • Resection margins, ditto — Free of tumor invasion
    • Lymph node, right axillary sentinel area, frozen (F2023-00167) — Free of tumor metastasis (0/2)
    • AJCC Pathologic Anatomic Stage — pT2N0, if cM0, stage IIA; Prognostic Stage — Stage IA
  • MACROSCOPIC EXAMINATION
    • Breast: 19.9 x 18.2 x 3.4 cm
    • Skin: 17.2 x 4.4 cm
    • Nipple: 1.6 x 1.3 cm
    • Tumor: 2.7 x 1.9 cm
    • Resection margins: Free, 0.7 cm away from closest base, at least 2.8 cm away from peripheral margins
    • Lymph node: right axillary sentinel LNs, sent for frozen section (F2023-00167)
    • Representative sections as A1: four peripheral margins, A2: base, A3-A7: tumor, A8: skin + nipple [Reference: frozen F2023-00167 FSA1-A2: right axillary sentinel LNs}
  • MICROSCOPIC EXAMINATION
    • Histologic type: solid papillary carcinoma with invasion and focal ductal carcinoma in situ, intermediate grade
    • Size of invasive carcinoma: 2.7 x 1.9 cm
    • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
    • Margins: Free of tumor invasion
    • Nodal status: Free of tumor metastasis (0/2)
    • Treatment Effect: N/A
    • Lymphovascular space invasion: not identified
    • Perienural invasion: not identified
  • IMMUNOHISTOCHEMISTRY
    • Synaptophysin(+, diffuse), chromogranin-A(+, diffuse) for tumor and P63(+, rim pattern) for DCIS
    • Please refer to S2023-05519 for ER, PR, Her2/neu and Ki67 status
• 2023-03-24 Patho - breast biopsy (no margin)
  • Breast, right, core needle biopsy — Invasive carcinoma of no special type
  • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism and increased N/C ratio.
  • Immunohistochemical study demonstrates ER: positive (strong, 99%), PR: positive (strong, 99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative.

[MedRec]

• 2023-05-10 SOAP General and Gastroenterological Surgery Zhang YaoRen
  • O: Conclusion of the Multidisciplinary Cancer Team Meeting - Meeting Date: 2023-04-28
    • FEC x6 followed by AI for 5 years.
• 2023-05-01 ~ 2023-05-03 POMR General and Gastroenterological Surgery Zhang YaoRen
  • Discharge diagnosis
    • Malignant neoplasm of unspecified site of right female breast
    • Right breast invasive carcinoma status post port A insertion on 2023/05/02. pT2N0M0, stage IIA. ECOG:0.
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
  • Present illness
    • Under surgery of right breast simple mastectomy + SLNB on 2023/04/14.
    • Pathology: solid papillary carcinoma with invasion,size 2.7 cm,Gr 2, pT2N0M0, stage IIA.
    • Adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles were suggest.
    • Under the impression of right breast invasive carcinoma, she was admitted for surgery of port A insertion. Arrange 1st adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 on 2023-05-03.
• 2023-04-13 ~ 2023-04-15 POMR General and Gastroenterological Surgery
  • Discharge diagnosis
    • Right breast invasive carcinoma status post simple mastectomy + sentinel lymph node biopsy  on 2023/04/14. cT2N0M0, stage IIA. ECOG:0.
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
  • CC
    • noted a palpable mass at right breast and stabbing pain over 2 months.
  • Present illness
    • This 40-year-old female patient has past history of hypertension and Type 2 diabetes mellitus over 3 years with regular medicine control. She denied cancer history. She denied any TOCC histories in recent 3 months.
    • She noted a palpable mass at right breast and stabbing pain over 2 months. She came to our OPD for help. Breast sono showed right breast heteregeneous tumor, 10’ region, suggest biopsy. Right breast 9’ region and left 12’ region angulated tumors, suggest close follow up. Core needle biopsy revealed invasive carcinoma, ER: positive (strong,99%), PR: positive (strong,99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative. CA-153：10.123 U/ml, CEA：2.247 ng/ml. PET and abdomen echo showed no obvious lesion for metastasis. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss. PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 4x4 cm without discharge. left breast P scar. The nipple was dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
    • Under the impression of right breast invasive carcinoma, she was admitted for surgery of simple mastectomy + SLNB.  
  • Course of inpatient treatment
    • After admission, right breast simple mastectomy + SLNB was performed on 2023/04/14. The wound is clean and dry. Under the stable condition, she was discharged today, wound will be follow up in OPD.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
• 2023-04-10 SOAP General and Gastroenterological Surgery
  • O
    • 2023/03/31 PET scan
      • A glucose hypermetabolic lesion in the right breast, compatible with primary breast malignancy.
      • Mild glucose hypermetabolism in two small right axillary lymph nodes, in a small left axillary lymph node and in the right pulmonary hilar region. Inflammatory process is more likely.
      • Glucose hypermetabolism in a focal area in the body of the pancreas.
      • Increased FDG accumulation in both kidneys and colon.
    • Lab
      • 2023/03/31 Anti-HCV (NM) = Negative;
      • 2023/03/31 Anti-HCV Value (NM) = 0.032;
      • 2023/03/31 Anti-HBc (NM) = Negative;
      • 2023/03/31 Anti-HBc Value (NM) = 2.410;
      • 2023/03/31 Anti-HBs (NM) = Positive;
      • 2023/03/31 Anti-HBs value (NM) = 480.000 mIU/mL;
• 2023-03-29 SOAP General and Gastroenterological Surgery
  • S: Rt breast ca proved by CNB on 2023-03-24
  • O
    • 2023/03/24 PATHO - breast biopsy (no need margin)
      • Breast, right, core needle biopsy — Invasive carcinoma of no special type
      • ER: positive (strong,99%), PR: positive (strong, 99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative.
• 2023-03-22 SOAP General and Gastroenterological Surgery
  • S: breast lump
  • O
    • premenopausal
    • menarche 13 y/o
    • G0P0
    • FH of breast ca (-)
    • Hormone (-)
    • A 4 cm elastic firm mass in rt breast
• 2021-05-14 SOAP Metabolism and Endocrinology
  • Prescription x3
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QDAC
    • Ankomin (metformin 500mg) 1# BIDAC
    • Zulitor (pitavastatin 4mg) 1# QNAC
    • Amepiride (glmepiride 2mg) 0.5# QDAC
    • Galvus Met (vidagliptin 50mg, metformin 500mg) 1# BIDAC
• 2021-01-22 SOAP Metabolism and Endocrinology
  • Prescription x3
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
    • Ankomin (metformin 500mg) 2# BIDCC
    • Zulitor (pitavastatin 4mg) 1# QN
• 2020-12-12 SOAP Metabolism and Endocrinology
  • A/P
    • Complete metabolic profiles
    • Diet control
    • Prescribe metformin 500 TID
    • SMBG QDAC at home
    • RTC 2 W later
  • Prescription
    • Ankomin (metformin 500mg) 1# TIDCC

[surgical operation]

• 2023-04-14
  • Surgery: Simple mastectomy and sentinel lymph node biopsy        
  • Finding:
    • a 3x2x2 cm slight firm mass in rt breast
    • SLN 0/1  

[chemotherapy]

• 2023-09-27 - docetaxel 75mg/m2 138mg NS 250mL 1hr (D Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-09-07 - docetaxel 75mg/m2 138mg NS 250mL 1hr (D Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-08-17 - docetaxel 75mg/m2 138mg NS 250mL 1hr (D Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-07-28 - docetaxel 75mg/m2 140mg NS 250mL 1hr (D Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-07-06 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-06-15 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-05-25 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1088mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-05-03 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1083mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-12-13

[leukopenia, diarrhea]

Review of lab data from HIS5 reveals that the last documented episode of leukopenia occurred on 2023-10-04, exceeding two months ago. Serial WBC counts demonstrate a period of low values approximately one week after docetaxel administration. However, recent data is insufficient to confirm or rule out the current presence of leukopenia.

• 2023-10-04 WBC 1.52 x10^3/uL <- leukopenia
• 2023-09-27 WBC 6.85 x10^3/uL <- docetaxel
• 2023-09-13 WBC 3.17 x10^3/uL
• 2023-09-07 WBC 6.27 x10^3/uL <- docetaxel
• 2023-08-23 WBC 2.94 x10^3/uL
• 2023-08-17 WBC 7.32 x10^3/uL <- docetaxel

This patient is currently taking Nolvadex (tamoxifen citrate 10mg/tablet) 1# BID, a medication that is generally not linked to leukopenia.

Moreover, the lab results indicate increased levels of myelocytes and metamyelocytes. It might be important to investigate further to determine if these findings have clinical significance.

No significant episodes of diarrhea were found documented in the recent medical history.

2023-08-21

[leukopenia]

The patient underwent 4 rounds of liposome doxorubicin and cyclophosphamide treatment on 2023-05-03, 2023-05-25, 2023-06-15, and 2023-07-06 without any signs of leukopenia.

However, a week following the initial dose of docetaxel on 2023-08-04, leukopenia was detected. Consequently, Granocyte (lenograstim 250ug) was administered the same day.

• 2023-08-17 WBC 7.32 x10^3/uL <- docetaxel
• 2023-08-06 WBC 3.47 x10^3/uL
• 2023-08-04 WBC 1.12 x10^3/uL <- leukopenia
  
• 2023-07-28 WBC 4.20 x10^3/uL <- docetaxel
• 2023-07-06 WBC 4.19 x10^3/uL
• 2023-06-15 WBC 4.65 x10^3/uL
• 2023-05-25 WBC 7.70 x10^3/uL
• 2023-05-10 WBC 7.11 x10^3/uL
• 2023-04-13 WBC 5.66 x10^3/uL

Docetaxel is associated with a high incidence of leukopenia. (UpToDate: 84% to 99%; grades 3/4: 49%; grade 4: 32% to 44%)

The patient received a second dose of docetaxel on 2023-08-17. Prophylactic G-CSF is scheduled for 2023-08-22 and 2023-08-23. Currently, there’s no indication of newly emerging leukopenia.

700136759

231208

[exam findings]

• 2023-11-30 CT - neck
  • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
  • Coronal reformation was performed. The slice thickness is 5 mm.
  • Findings:
    • No identifiable source of infection is seen in the neck.
    • The oral cavity shows no evidence of focal lesion.
    • The mouth floor and submandibular regions are normal. No focal lesion is identified.
    • The salivary and submandibular gland remain intact.
    • No neck lymphadenopathy is visualized.
    • The thyroid appears normal in size and enhancement.
    • Fibrocalcified change over right apical lung, may be old TB.
• 2023-12-04, -11-27, -11-22 CXR
  • Linear infiltration projecting at both lung is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
  • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • Scoliosis of the T-spine with convex to right side.
  • Enlargement of cardiac silhouette.
  • Old fracture of left 7th rib.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-11-23 CT - chest
  • Indication: multiple myeloma, R/O ITP pneumonia over bilateral lungs
  • Chest CT with and without IV contrast ehnancement shows:
    • Diffuse interstitial change at bilateral lung fields with sparing of the peripheral lungs and combined with mild right pleural effusion is found. Pneumonia is considered. Viral or bacterial infection are possible. PCP or CMV infection is less likely.
    • Fibrocalcified lesions are noted at right upper lobe and lu ill-defined opacity is found.
    • Permeative change of the bony structure is found. Multiple myelooma is compatible
  • Imp:
    • Diffuse interstitial change at bilateral lung fields with sparing of the peripheral lungs and combined with mild right pleural effusion is found. Pneumonia is considered.
• 2023-11-20, -11-17 CXR
  • Linear and patchy infiltration projecting at both lung is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
  • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • Scoliosis of the T-spine with convex to right side.
  • Enlargement of cardiac silhouette.
  • Old fracture of left 7th rib.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-11-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (127 - 29.7) / 127 = 76.61%
    • M-mode (Teichholz) = 73.1
    • 2D (M-Simpson) = 67.8
  • Conclusion:
    • Normal AV with mild AR
    • Normal MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, dilated IVC size
• 2023-11-07 Patho - bone marrow biopsy
  • PATHOLOGIC DIAGNOSIS
    • Bone marrow, biopsy — Plasma cell myeloma
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consists of a piece of gray-brown and hard bony tissue, measuring 1.0 x 0.3 x 0.3 cm. All for section after decalcification.
  • MICROSCOPIC EXAMINATION
    • The sections show hypercellular marrow (50%). The marrow space is largely replaced by a population of small to medium-sized immature and mature CD138+ plasma cells, constitue 90% of marrow cells. The plasma cells also shows lambda light chain restriction and negative for kappa light chain .
• 2023-11-07 Skull AP + Lat.
  • Multiple nodular defects in the skull are suspected. Please correlate with brain CT.
• 2023-11-07 Long Bones series
  • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
• 2023-11-06 Patho - bone marrow biopsy
  • Bone marrow, post iliac creast, biopsy — plasma cell myeloma
  • The specimen submitted consists of 1 bone marrow tissue fragment measuring 3.4x 0.2x 0.2 cm in size, fixed in formalin. Grossly, it is brownish and elastic to hard.
  • Microscopically, it shows hypercellularity (about 60%) and marked proliferation of plasma cells (>=70% of bone marrow cellularity). Some mature eryhtroid cells and megakaryocytes are present. No blast is identified.
  • Immunohisotchemical stain reveals CD34(-), CD117(-), CD138 (diffuse +), MPO(+), CD71(focal+), CD61(focal +), Kappa chain(-), lambda chain(+, restriction).
• 2023-10-20 KUB + L-spine Lat.
  • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
  • S/P posterior longitudinal transpedicular screws and rods fixation with paraspinal bone grafting or disc cage implantation L3-5.
• 2023-10-13 Patho - interveterbral disc
  • Bone and joint, vertebra, L3-4-5 TPS-RF revision and L3-4 TLIF — Confirmed
  • Specimen submitted in formalin consists of multiple pieces of tan, irregular tissue with the largest piece measuring 1 x 0.5 x 0.3 cm. All tissue for section in one cassette after decalcification.
  • Section shows pieces of bone, degenerated ligament, and cartilage.
• 2023-10-06 MRI - L-spine
  • Without-contrast multiplanar spine MRI revealed:
    • post-OP change from L4 to L5.
    • high SI chnage on STIR in the sacral multifidus muscles. Moderate to severe atrophic change in the bilateral lower L-spine multifidus muscles, more on the left side was noted.
    • unremarkable change in the visible cord.
    • decreased SI on T2WI in the L2/3, L4/5 and L5/S1 disc spaces; high SI change on T2WI in the L3/4 disc; focal high SI change on T2WI in the posterior aspects of the L5/S1 and L4/5 discs. Herniated disc in the L3/4 disc caused moderate bilateral L3-4 lateral recess stenosis and moderate anterior indentation on the L3-4 thecal sac.
    • hyperemic endplate change in the lower L3 vertebral body and upper S1 vertebral body. Focal high SI change on STIR in the bilateral iliac bones was noted.
      
    • degenreative change at the L-spine facet joints.
  • IMP
    • moderate bilateral L4-5 lateral recess stenosis;
    • high SI change on bone marrow of the bilateral iliac bones. Please correlate with contrast-enhanced study.
    • r/o discitis in the L3/4 disc.
• 2023-09-25 Exercise Electrocardiogram, Treadmill exercise test (TET)
  • Findings
    • The patient exercised according to the CORNELL for 11:40 min:s, achieving a work level of max METS: 8.3.
    • The resting heart rate of 70 bpm rose to a maximal heart rate of 146 bpm.
    • This value represents 100 % of the maximal, age-predicted heart rate.
    • The resting blood pressure of 143/77 mmHg, rose to a maximum blood pressure of 146/72 mmHg.
    • The exercise test was stopped due to Target heart rate maximal, Arrhythmias, Fatigue.
  • Conclusion
  • Positive for myocardial ischemia
  • PVCs that develop with exercise
• 2023-09-25 Bronchodilator Test
  • Normal ventilatory function
  • Not significant bronchodilator reversibility
• 2023-04-06 ECG - 8C high level
  • Sinus bradycardia with 1st degree A-V block
  • ICRBBB in V2
• 2023-04-06 Bone densitometry - Hip
  • Hip BMD performed by DXA revealed: Hip, BMD is 0.726 gms/cm2, about 1.8 SD below the peak bone mass (77%) and 0.0 SD at the mean of age-matched people (100%).
  • IMP: osteopenia
• 2023-04-06 CT - chest
  • Low dose spiral CT of the chest without contrast enhancement for screening of lung tumor showed:
    • Lungs: Fibrotic change at bilateral apical lungs is found. Pleural based nodule at left upper lobe measuring 0.53cm in largest dimension.
  • IMP: Fibrotic change at bilateral apical lungs. Pleural based nodule at left upper lobe.

[MedRec]

• 2023-10-30 SOAP Cardiology Zhang HengJia
  • S: stable CAD, PAC, PVC, Anxiety possible old TB, has no UAP and DOE is not getting worse, Home BP: WNL, BS: no crackles, no rales, no wheezes, HS: no s3, s4, no sys m, no leg edema, s/p spine op, uneventful
  • A/P: regular exercise and diet control, F/U blood biochemistry, keep current Rx; F/U in 1 m, then she will go back to California
  • Prescription
    • Concor (bisoprolol 5mg) 0.5# QD
    • Bokey (aspirin 100mg) 1# QD
    • Crestor (rosuvastatin 10mg) 0.5# QD
• 2023-10-11 ~ 2023-10-16 POMR Neurosurgery Li DingZou
  • Discharge diagnosis
    • L3-4 stenosis and spondylolsihtesis, compatable with adjacent syndrome status post L3-4-5 Transpedicular screw fixation revision and L3-4 Transforaminal Lumbar Interbody Fusion on 2023/10/12
    • Postlaminectomy syndrome
    • Cardiac arrhythmia
    • Hyperlipidemia
  • CC
    • Low back and right buttock pain with right knee pain in reccent two months.
  • Present illness
    • This 75-year-old female patient who hyperlipidemia and cardiac arrhythmia umder medicinal control. She complained of low back and right buttock pain with right knee pain in reccent two months. It would be worsened by arising, forward bending or prolonged sitting/standing, and relieved by bed rest. There was intermittent claudication. She visited our neurosurgery clinic for help. L-spine x-ray showed status post L4-5 trans-pedicular screw-rod fixation. Lumbar spine MRI showed L3-4 stenosis and spondylolsihtesis, compatable with adjacent syndrome. We had fully inform to patient and her family about the condition, treatment plan, surgical procedure and risks. She was admitted for revision diskectomy.
    • No trauma history
    • No cancer history        
  • Course of inpatient treatment
    • Post-operative course was uneventful. Analgesic agents was used for wound pain control. Her discomfort was relieved a lot. The wound was clear and dry. She was discharged home and outpatient follow-up was mandatory.
  • Discharge prescription
    • MgO 250mg 1# TID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# QID
    • Celebrex (celecoxib 200mg) 1# BID
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
    • Lyrica (pregabalin 75mg) 1# BID
    • Toricam (piroxicam 10mg/gm) ASORDER TOPI
• 2023-10-06 ~ 2023-10-07 POMR Neurosurgery Li DingZou
  • Discharge diagnosis
    • L3-4 spondylolsihtesis, spinals stenosis and compatable with adjacent syndrome.
    • Postlaminectomy syndrome, not elsewhere classified
    • Mixed hyperlipidemia
    • Cardiac arrhythmia, unspecified
    • Anxiety disorder, unspecified
    • Insomnia, unspecified
  • CC
    • low back pain with right knee pain in reccent two months
  • Present illness
    • This 75-year-old female patient who hyperlipidemia and cardiac arrhythmia umder medicinal control. She complained of low back pain with right knee pain in reccent two months. It would be worsened by arising, forward bending or prolonged sitting/standing, and relieved by bed rest. There was intermittent claudication.
    • She visited our neurosurgery clinic. L-spine x-ray showed status post L4-5 trans-pedicular screw-rod fixation. Lumbat spine MRI on schedule.
    • She had serve painful this night. She came to our ER for help. Tramadol IVD st for pain control.
    • Lumbar spine MRI showed L3-4 stenosis/ spondylolsihtesis, compatable with adjacent syndrome. Revision surgery considerated.
    • Previous NSAID was ineffective. She was admitted for pain control.
    • No trauma history
    • No cancer history        
  • Course of inpatient treatment
    • After admission. pain control was given.
    • A MRI at ER showed L3-4 stenosis/spondylolsihtesis, compatable with adjacent syndrome.
    • Explained the image finding to her and her daughter. Revision surgery considerated. Hold Aspirin since today. The surgery is scheduled for next Wednesday. She was arrange discharge today. Re-admission on next Tuesday.
• 2023-10-06 SOAP Ophthalmology Xu WeiCheng
  • S: 2013-07 glaucoma under xalatan, no discomfort
  • Prescription x3
    • Xalatan (latanoprost 50ug/mL) 1 drop HS OU
    • Ementin (emedastine 2.5mg/5mL) 1 drop BID OU
• 2023-10-06 SOAP Neurosurgery Li DingZou
  • S: LBP and right knee radiated pain for 2 weeks; ineffective to pain killer; relief by rest;
  • Prescription
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# PRNTID
    • Neurontin (gabapentin 100mg) 1# PRNTID
• 2023-10-02 SOAP Cardiology Zhang HengJia
  • A: newly Dx of CAD, with mild TET ischemic changes, PFT is WNL
  • P: GDMT with ASA, BB and statin, regular exercise and diet control, F/U in one m
  • Prescription
    • Concor (bisoprolol 5mg) 0.5# QD
    • Bokey (aspirin 100mg) 1# QD
    • Crestor (rosuvastatin 10mg) 0.5# QD
    • Nitrostat (nitroglycerin 0.6mg) 1# ASORDER SL for angina
• 2023-09-06 SOAP Cardiology Zhang HengJia
  • S: a case of PAC, arrhythmia and DOE referred after health wellness checkup, by TC V Yang Lee Hwua; no UAP, DOE is not getting worse, home BP WNL, BS: no rales, no wheezes, HS: No s3, s4, no systolic murmur, no leg edema, Lab exam: anemia
  • A: Cardiac dysrhythmia, PAVC, PVC, Anxiety possible old TB, Insomnia,
  • P: TET for DOE and chest pain, and PFT for possible restrictive lung, also advise hema clinic W/U for anemia

[consultation]

• 2023-11-13 Infectious Disease
  • Q
    • for pnrumonia over both lungs
    • This 75-year-old woman, a patient of myltiple myeloma IgG type was diagnosed in Nov 2023.
    • This time, fever with chills and dyspnea were noted and antibiotic with Cefim + Targocid was given and CXR (11/12 23) showed bilateral pnrumonia.
    • We need expertise to evaluate her condition thanks!
  • A
    • 75-year-old multiple myeloma female patient has low grade fever for 6 days during hospitalization, followed by diffuse alveolar infiltrations over both lungs on this morning chest X-ray film, especially right lung.
    • Acute pulmonary edema is the first impression, that IV diuretic recommended first.
    • Pulmonary edema may be related to frequent transfusion and underlying impaired heart function.
    • For possible superimposed pneumonia, patient is receiving Targocid, Mepem and oral Baktar now.
  • Suggestion:
    • Continue the present antibiotic regimen
    • Arrange echocardiography and give diuretic.
    • Follow up CxR 2 days later.
    • Check sputum culture report, PJP-PCR.
• 2023-10-07 NeuroSurgery
  • Q
    • CC: pain over lower back and right thigh to knee with right leg paralysis and numbness for 2 weeks
      • paralysis, numbness, severe pain over right knee and thigh, cannot walk freely
      • bending down can alleviate the symptoms
    • PHx:
      • lumbar laminectomy L4-5 in TSGH 20 years ago
      • arrthymia
    • lumbar spine X ray and knee X ray already done in clinic –> came here for MRI
  • A
    • A case of 75 y/o female, arrythmia under aspirin tx; s/p L4-5 TPS-RF 20 yrs ago.
    • LBP with right knee pain for weeks.
    • A MRI at ER showed L3-4 stenosis/spondylolsihtesis, compatable with adjacent syndrome.
    • P: pain control; Revision surgery considerated;

[immunochemotherapy]

• 2023-12-07 - Velcade (bortezomib) 1.3mg/m2 1.9mg ST SC (VTd C1D15)
• 2023-11-30 - Velcade (bortezomib) 1.3mg/m2 1.9mg ST SC (VTd C1D8)
• 2023-11-23 - Velcade (bortezomib) 1.3mg/m2 1.9mg ST SC (VTd C1D1)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-12-01 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

• Cycle length: 28 days.

• Regimen

  • Bortezomib
    • 1.3 mg/m2 SC
    • Given as a single SC injection.
    • Days 1, 8, 15, and 22
  • Thalidomide
    • 100 mg for first 14 days then 200 mg per day thereafter by mouth.
    • Take with water on an empty stomach at least one hour after the evening meal.
    • Daily, days 1 through 21
  • Dexamethasone (“low dose”)
    • 40 mg by mouth
    • Take with food (after meals or with food or milk) in the morning.
    • Days 1, 8, 15, and 22

• Pretreatment considerations:

  • Emesis risk
    • MINIMAL TO LOW.
  • Prophylaxis for infusion reactions
    • Routine premedication is not indicated. If a hypersensitivity reaction (not including local reactions) occurs with bortezomib or thalidomide, then neither drug should be readministered.
  • Antithrombotic prophylaxis
    • Routine antithrombotic prophylaxis is warranted. Thromboembolism (grade 3 and 4) was reported in 3% of patients in a clinical trial receiving VTd despite antithrombotic prophylaxis. In addition, reported risk of thromboembolism (grade 3 and 4) was 5% in the Td arm of this study.
  • Infection prophylaxis
    • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VTd. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on Mondays, Wednesdays, and Fridays during treatment. Primary prophylaxis with G-CSF is not indicated.
  • Vesicant/irritant properties
    • Bortezomib is an irritant.
  • Dose adjustment for baseline liver or renal dysfunction
    • Bortezomib: No dosage adjustment for bortezomib secondary to renal insufficiency is necessary. For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the upper limit of normal) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
    • Thalidomide: Dosage adjustment of thalidomide is not required for either preexisting renal or hepatic dysfunction.
  • Pregnancy warning
    • Thalidomide can result in severe, life-threatening human birth defects. Pregnancy testing is required within 24 hours prior to initiation of thalidomide therapy.

Bortezomib - 2023-11-24 - https://www.uptodate.com/contents/bortezomib-drug-information

• Multiple myeloma, first-line therapy: Note: Bortezomib regimens also containing melphalan should be avoided in patients who are potential candidates for hematopoietic cell transplantation.
  • VMP regimen: IV, SUBQ: 1.3 mg/m2 on days 1, 4, 8, 11, 22, 25, 29, and 32 of a 42-day treatment cycle for 4 cycles, followed by 1.3 mg/m2 on days 1, 8, 22, and 29 of a 42-day treatment cycle for 5 cycles (in combination with melphalan and prednisone). Retreatment may be considered for patients who had previously responded to bortezomib (either as monotherapy or in combination) and who have relapsed at least 6 months after completing prior bortezomib therapy; initiate at the last tolerated dose.
  • First- line therapy, other dosing/combinations: Note: Refer to protocol for dosage adjustment details.
    • VRd (or RVd) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for 8 cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for up to 8 induction cycles, followed by 1.3 mg/m2 on days 1, 8, 15, and 22 of a 42-day treatment cycle (as a single agent) for 4 maintenance cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for 3 cycles, followed by conditioning/transplant, followed (after hematologic recovery in patients without progression) by 1.3 mg/m2 (or last tolerated dose from cycle 3) on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for 2 cycles.
    • VRd (or RVd) regimen: SUBQ: 1.3 mg/m2 on days 1, 8, 15, and 22 of a 35-day treatment cycle (in combination with lenalidomide and dexamethasone) for 9 induction cycles, followed by 1.3 mg/m2 (or last tolerated dose from cycle 9) on days 1 and 15 of a 28-day treatment cycle (in combination with lenalidomide) for 6 consolidation cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day treatment cycle (in combination with lenalidomide and dexamethasone) for 6 induction cycles (with mobilization after the third induction cycle), followed by conditioning/transplant, followed by 2 additional consolidation cycles 3 months after transplant.
    • VTd regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for 3 induction cycles (in combination with thalidomide and dexamethasone), followed by tandem transplant, followed by (3 months after second transplant) 1.3 mg/m2 on days 1, 8, 15, and 22 every 35 days for 2 consolidation cycles (in combination with thalidomide and dexamethasone).
    • VTd regimen: SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with thalidomide and dexamethasone) for 4 induction cycles, followed by conditioning/transplant.
    • CyBorD (or VCd) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for up to 8 induction cycles (in combination with cyclophosphamide and dexamethasone), followed by 1.3 mg/m2 on days 1, 8, 15, and 22 of a 42-day treatment cycle (as a single agent) for 4 maintenance cycles or 1.5 mg/m2 on days 1, 8, 15, and 22 of a 28-day treatment cycle for 4 cycles (may continue beyond 4 cycles) in combination with cyclophosphamide and dexamethasone.
    • PAD regimen: IV: Induction: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day treatment cycle for 3 cycles (in combination with doxorubicin and dexamethasone), followed by conditioning/transplantation, and then maintenance bortezomib 1.3 mg/m2 once every 2 weeks for 2 years.
    • Daratumumab-containing regimens: SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day cycle (in combination with daratumumab, lenalidomide, and dexamethasone; DVRd regimen) for 4 induction cycles and 2 post-transplant consolidation cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day cycle (in combination with daratumumab, thalidomide, and dexamethasone; DVTd regimen) for up to 4 pretransplant induction cycles and 2 posttransplant consolidation cycles or 1.3 mg/m2 two times a week during weeks 1, 2, 4, and 5 of the first 6-week cycle (cycle 1; 8 doses/cycle), followed by 1.3 mg/m2 once a week during weeks 1, 2, 4, and 5 for eight 6-week cycles (cycles 2 to 9; 4 doses/cycle) in combination with daratumumab, melphalan, and prednisone; after cycle 9, daratumumab is continued as a single agent.
    • VD regimen: IV: Induction: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with dexamethasone) for 4 cycles, followed by autologous cell transplantation.
    • Patients ≥65 years of age: IV: 1.3 mg/m2 on days 1, 8, 15, and 22 of a 35-day treatment cycle for 9 cycles, in combination with either melphalan and prednisone or melphalan, prednisone, and thalidomide.
  • Maintenance therapy in transplant-eligible patients (following induction and transplant; in patients intolerant to or unable to receive maintenance therapy with lenalidomide): IV: 1.3 mg/m2 once every 2 weeks for 2 years. For high-risk patients, maintenance therapy with a proteosome inhibitor ± lenalidomide may be considered.
• Multiple myeloma, relapsed/refractory:
  • Single-agent therapy: IV, SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle. Therapy extending beyond 8 cycles may be administered by the standard schedule or may be given once weekly for 4 weeks (days 1, 8, 15, and 22), followed by a 13-day rest (days 23 through 35). Retreatment may be considered for patients who had previously responded to bortezomib (either as monotherapy or in combination) and who have relapsed at least 6 months after completing prior bortezomib therapy; initiate at the last tolerated dose. Administer twice weekly for 2 weeks on days 1, 4, 8, and 11 of a 21-day treatment cycle (either as a single agent or in combination with dexamethasone) for a maximum of 8 cycles.
  • Relapsed or refractory disease, other dosing/combinations: Note: Refer to protocol for dosage adjustment details.
    • VRd (or RVd) regimen: IV: 1 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for up to 8 cycles (in combination with lenalidomide and dexamethasone), followed by maintenance therapy (if response or stable disease) of 1 mg/m2 (or the dose tolerated in cycle 8) on days 1 and 8 of a 21-day treatment cycle (± lenalidomide and/or dexamethasone) until disease progression or unacceptable toxicity.
    • DVd regimen: SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 every 21 days (in combination with daratumumab and dexamethasone) for up to 8 cycles.
    • VPd regimen: IV, SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for 8 cycles, followed by 1.3 mg/m2 on days 1 and 8 of a 21-day treatment cycle until disease progression or unacceptable toxicity (in combination with pomalidomide and dexamethasone).
    • SVd regimen: SUBQ: 1.3 mg/m2 on days 1, 8, 15, and 22 every 35 days (in combination with selinexor and dexamethasone) until disease progression or unacceptable toxicity.
    • Bortezomib/Doxorubicin (liposomal) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for at least 8 cycles or until disease progression or unacceptable toxicity (in combination with liposomal doxorubicin).
    • CyBorD (or VCD) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for up to 8 cycles, followed by 1.3 mg/m2 on days 1, 8, 15, and 22 of a 35-day treatment cycle for up to 3 cycles (in combination with cyclophosphamide and dexamethasone).
    • Bendamustine/Bortezomib/Dexamethasone regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day treatment cycle for 4 cycles (if no response) or for up to a maximum of 8 cycles (in combination with bendamustine and dexamethasone).

==========

2023-12-08

[thrombocytopenia]

The C1D15 dose of Velcade (bortezomib) in the VTd regimen was administered on 2023-12-07. As mentioned in the pharmacist’s note from 2023-12-04, the severe thrombocytopenia observed may not be entirely due to the VTd regimen.

• 2023-12-07 PLT 49 *10^3/uL
  
• 2023-12-04 PLT 16 *10^3/uL
  
• 2023-12-01 PLT 33 *10^3/uL

Severe thrombocytopenia, with platelet counts falling below 30K to 50K/uL, significantly increases the risk of bleeding and often necessitates treatment. However, the relationship between platelet count and bleeding risk can vary depending on the underlying condition and may be unpredictable. Therefore, platelet product transfusion may be required in this situation.

2023-12-04

[thrombocytopenia]

Severe thrombocytopenia emerged in mid and late Nov, necessitating multiple blood transfusions.

• 2023-12-04 PLT 16 *10^3/uL BT (scheduled on 2023-12-05)
• 2023-12-01 PLT 33 *10^3/uL
• 2023-11-30 PLT 44 *10^3/uL
• 2023-11-29 PLT 12 *10^3/uL
• 2023-11-28 PLT 12 *10^3/uL
• 2023-11-27 PLT 11 *10^3/uL
• 2023-11-26 PLT 2 *10^3/uL
• 2023-11-25 PLT 1 *10^3/uL BT
• 2023-11-24 PLT 1 *10^3/uL
• 2023-11-23 PLT 2 *10^3/uL
• 2023-11-22 PLT 2 *10^3/uL
• 2023-11-21 PLT 4 *10^3/uL
• 2023-11-20 PLT 1 *10^3/uL
• 2023-11-19 PLT 1 *10^3/uL BT
• 2023-11-18 PLT 3 *10^3/uL
• 2023-11-17 PLT 1 *10^3/uL
• 2023-11-15 PLT 2 *10^3/uL
• 2023-11-13 PLT 6 *10^3/uL BT
• 2023-11-11 PLT 7 *10^3/uL
• 2023-11-09 PLT 28 *10^3/uL BT
• 2023-11-08 PLT 6 *10^3/uL
• 2023-11-07 PLT 71 *10^3/uL
• 2023-11-06 PLT 44 *10^3/uL
• 2023-11-05 PLT 27 *10^3/uL
• 2023-11-04 PLT 3 *10^3/uL BT
• 2023-10-16 PLT 79 *10^3/uL
• 2023-10-14 PLT 93 *10^3/uL BT (2023-10-12)
• 2023-10-06 PLT 176 *10^3/uL BT
• 2023-07-12 PLT 172 *10^3/uL
• 2023-04-06 PLT 180 *10^3/uL

The initial session of the VTd regimen was given on 2023-11-23. Notably, the thrombocytopenia episode was present even prior to this treatment. Anemia and thrombocytopenia are frequent complications in multiple myeloma (MM) patients (Ref: Patients With Multiple Myeloma Have a Disbalanced Whole Blood Thrombin Generation Profile. Front Cardiovasc Med. 2022 Jun 27;9:919495. doi: 10.3389/fcvm.2022.919495. PMID: 35833182; PMCID: PMC9271700). The thrombocytopenia should not be solely attributed to the use of bortezomib.

2023-12-01

[antiviral prophylaxis key to reducing HZ]

Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. It is recommended that antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VTd. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on QW135 during treatment. Primary prophylaxis with G-CSF is not indicated.

700193556

231208

[diagnosis] - 2023-04-18 admission note

• Malignant neoplasm of retroperitoneum
• Retroperitoneum extraskeletal Ewing sarcoma, s/p tumor resection 2022/11/18, pT2N0M0, Stage IIIA
• Chronic viral hepatitis B without delta-agent
• Hypertension
• Anxiety disorder, unspecified
• Generalized anxiety disorder
• Dysthymic disorder

[past history] - 2023-04-18 admission note

• Hypertension,under medication control
• s/p LM on 2018-07
• Dysthymic disorder,under medication control
• s/p hernia operation
• s/p uterine myoma operation
• TAE, open radical nephrectomy,partial intestine resection were performed on 2022/11/17, 11/18

            

[allergy]

Demerol 50 mg/1 mL/amp (Meperidine):anaphylactic shock

[family history]

Father:DM No cancer, CVA, CAD history in her family

[exam findings]

• 2023-10-30 Gynecologic ultrasonography
  • R/O Uterine myoma
• 2023-10-26 KUB
  • Spondylosis with scoliosis of the L-spine with convex to right side
• 2023-10-26 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
• 2023-10-05 CT - abdomen
  • History and indication: Retroperitoneum Ewing sarcoma s/p OP and C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P left nephrectomy. S/P Port-A infusion catheter insertion.
    • A patchy density (2.2cm) at RLL.
    • Colonic diverticula.
    • Grade 4 fatty liver with liver cysts (up to 2.2cm).
    • Tiny renal cysts.
    • Gallbladder stones (up to 1.3cm).
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • S/P left nephrectomy. No evidence of tumor recurrence.
• 2023-07-31 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 26) / 88 = 70.45%
    • M-mode (Teichholz) = 70.5
  • Conclusion:
    • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Trivial pulmonary regurgitation; mildly dilated pulmonary trunk (27 mm).
• 2023-07-10 CT - abdomen
  • Indication: Retroperitoneum extraskeletal Ewing sarcoma
  • Abdominal CT with and without enhancement revealed:
    • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening
    • s/p colon. op.
    • Hepatic cysts at S2 of liver up to 2.0cm in largest dimension is found.
    • s/p left nephrectomy.
  • Imp:
    • s/p left nephrectomy.
    • s/p colon. op.
    • NO evidence of recurrent/residual tumor in the study.
• 2023-04-12 MRA - abdomen
  • History
    • 20221107 CT: A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis. R/O liposarcoma
    • 20221121 PATHO - Kidney total resection
      • Retroperitoneum, tumor excision — Compatible with extraskeletal Ewing sarcoma/primitive neuroectodermal tumor (PNET)
      • Kidney, left, radical nephrectomy — Focal infarction and free of tumor involvement
        
      • Pathologic stage: pT2N0G2; Stage IIIA if cM0
      • refer to oncology and RT
        
  • Findings:
    • S/P left nephrectomy.
    • There are several hepatic cysts in both lobes and the largest one 1.8 cm in size at S3.
    • Two gallstones (up to 1.3 cm) are noted.
    • Tiny renal cysts on right kidney.
    • There is no focal abnormality in the biliary system, pancreas, spleen.
      
    • There is no evidence of ascites or lymphadenopathy.
      
    • The abdominal aorta and IVC are grossly unremarkable.
      
  • IMP:
    • S/P left nephrectomy.
    • There is no evidence of tumor recurrence.
• 2023-03-15 SONO - nephrology
  • Chronic change with right small sized kidney.
  • Abscent of left kidney.
• 2023-02-20 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 24) / 78 = 69.23%
    • M-mode (Teichholz) = 68
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
• 2022-12-10 SONO - Joint soft tissue
  • Finding:
    • Focal engorgement and non-compressible to probe of left cephalic vein
    • Hyperechoic lesion was noted within left cephalic vein; however, partial flow was still noted
  • Impression And Suggestions:
    • Suspected left cephalic vein thrombosis
• 2022-11-21 Patho - kidney partial/total resection
  • PATHOLOGIC DIAGNOSIS
    • Retroperitoneum, tumor excision — Compatible with extraskeletal Ewing sarcoma/primitive neuroectodermal tumor(PNET)
    • Kidney, left, radical nephrectomy — Focal infarction and free of tumor involvement
      
    • Pathologic stage: pT2N0G2; Stage IIIA if cM0
      
  • MACROSCOPIC EXAMINATION
    • Procedure: Radical nephrectomy + retroperitoneal tumor excision
    • SpecimenSize: 16.5 x 12.3 x 5.6 cm and 590 gm, including left kidney: 9.5 x 5.9 x 4.8 cm and Gerota fascia: 2.5 cm in thickness
    • Tumor Site: Retroperitoneum
    • Tumor Size: 7.0 x 6.2 x 4.5 cm
    • Gross Tumor Pattern: Well circumscribed, dark brown and hemorrhagic mass
    • Representative parts are taken for section and labeled: A1= margins, A3-A10= tumor, A11= Retroperitoneal soft tissue, A12= kidney.
  • MICROSCOPIC EXAMINATION
    • Histologic type: Compatible with extraskeletal Ewing sarcoma/PNET
      
    • Mitotic rate: 5/10 high power fields
      
    • Necrosis: Present (5%)
    • Histologic Grade (FNCLCC): Grade 2
      • Tumor Differentiation: Score=3
      • Mitosis Count: Score=1 (0 to 9 mitosis per 10 HPF)
      • Necrosis: Score=1 (<50%)
    • Margins: Free; Distance of sarcoma from closest margin: 0.1 cm
      
    • Lymphvascular invasion: Present
      • Renal artery invasion: Present
        
    • Pathologic staging
      • Primary tumor: pT2 (tumor > 5 cm and <=10 cm)
        
      • Regional lymph nodes: Negative (0/4 regional LN) (Number of involved/Number of examined)
      • Distant metastasis: Not applicable
    • IHC: Cytokeratin(-), LCA(-), S100(-), CD56(focal+), Synaptophysin(-), and CD99(strong and diffuse membrane staining)
    • Kidney: Free of tumor with mild interstitial nephritis and focal infarction
• 2022-11-21 Patho - small intestine resection for tumore
  • Small intestine, jejunum, segmental resection – Heterotopic pancreas
  • The sections show a picture of heterotopic pancreas, composed of nests of admixture of pancreatic acini, ducts and islets in submucosa and mascularis propria. The adjacent small intestine shows mild acute serositis.
• 2022-11-17 Embolization (TAE) - abdomen
  • TAE of left renal artery via right common femoral artery puncture using Seldinger technique revealed:
    • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
    • Under local anesthesia, a 4 Fr arterial sheath was inserted into right common femoral artery smoothly.
    • The RH-catheter was inserted into left renal artery.
    • No definite tumor stain.
    • TAE of left renal artery was performed using 10mg some gelfoam pieces.
    • No procedure-related complication during the whole procedure. Thanks for your further care.
• 2022-11-16 CXR
  • Intimal calcification of thoracic aorta.
• 2022-11-07 CTA - abdomen
  • History and indication: left retroperitoneal massfor evaluation and surgery
  • With and without contrast CT of abdomen-pelvis revealed:
    • A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
    • Colonic diverticula.
    • Grade 4 fatty liver with left liver cyst (1.8cm).
    • Tiny renal cysts.
    • Normal appearance of spleen, pancreas, adrenals.
    • Gallbladder stones (up to 1.3cm).
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral basal lungs.
  • IMP:
    • A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
• 2022-10-31 Whole body PET scan
  • The left retroperitoneal tumor shown on the previous abdomen MRI reveals mildly increased FDG uptake; the nature is to be determined (liposarcoma or others ?), suggesting biopsy for further investigation.
    
  • Glucose hypermetabolic lesions in the esophagus, D/3 and bilateral palatine tonsils, probably chronic inflammation process, suggesting follow-up.
    
  • Glucose hypermetabolism in level II lymph nodes of bilateral cervical regions, probably reactive nodes.
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    
  • No other focal area of abnormal increased FDG uptake from head to bilateral thigh regions.
• 2022-10-29 Gynecologic ultrasonography
  • Uterus Position: AVF
    • Size: 69 x 33 mm
  • Endometrium
    • Thickness: 4.0 mm
  • Cul-De-Sac: No fluid
  • Bilateral adnexae: free
  • IMP: EM 4.0 mm
• 2022-10-13 Myocardial perfusion SPECT with treadmill
  • The Tc-99m MIBI stress myocardial perfusion SPECT performed after stress revealed mildly decreased perfusion of radioactivity to the apex of LV. The Tc-99m MIBI rest myocardial perfusion SPECT revealed reperfusion of radioactivity to the defect. The stress and rest LVEFs were 90% and 90%, respectively. The cine wall motion study revealed synchronized contraction of LV.
  • IMPRESSION:
    • Probably mild myocardial ischemia at the apex of LV.
    • Normal performance of global LV cardiac function.
• 2022-10-13 CT - low dose for lung cancer screening, without contrast
  • Low dose spiral CT of the chest without contrast enhancement for screening of lung tumor showed:
    • Lungs: Paraspinal fibrotic change at right lower lobe is found.
      • Minimal wedge shaped infiltration at left lower lobe, r/o recent inflammation.
  • IMP: Right lower lobe paraspinal fibrosis. Suspected focal fibrosis at left lower lobe
• 2022-10-13 MRI - cerebrovascular
  • Without-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial FLAIR images and axial DWI), cerebral TOF MRA revealed:
    • Mild brain atrophic change. Mild periventricular white matter small vessel disease.
      
    • Tortuosity of intracranial and extracranial arteries in MRA studies (including bilateral subclavian arteries, CCAs, ICAs, ECAs, MCAs, ACAs, PCAs and VAs and BA).
  • IMP: Mild Brain atrophy. Mild periventricular white matter small vessel disease. Mild arteriosclerosis with vessel tortuosity.
• 2022-10-13 MRI - upper abdomen with and without contrast
  • Imaging study of upper abdomen for health examination revealed:
    • Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, suspected liposarcoma or others.
    • Hepatic cyst at left lobe liver up to 2.1cm is found.
  • IMP:
    • Retroperitoneal tumor at left side, 7.3cm, r/o liposarcoma. Suggest further treatment.
• 2022-04-16 Gynecologic ultrasonography
  • Uterus Position: AVF
    • Size: 58 x 35 mm
  • Endometrium
    • Thickness: 3.2 mm
  • Cul-De-Sac: No fluid
  • Bilateral adnexae: free
  • IMP: EM 3.2 mm
• 2020-08-08 Gynecologic ultrasonography
  • Uterus Position: AVF
    • Size: 55 x 33 mm
  • Endometrium
    • Thickness: 4.3 mm
  • Cul-De-Sac: No fluid
  • Bilateral adnexae: free
  • IMP: EM 4.3 mm

[MedRec]

• 2023-10-25 SOAP Infectious Disease Peng MingYe
  • S: Right leg dog bite 3 days ago, now wound healing, no surrounding erythema or swelling
  • A: No sign of wound infection or cellulitis, topical Biomycin first
  • Prescription
    • Biomycin (neomycin, tyrothricin) BID TOPI
• 2023-02-17 ~ 2023-02-21 POMR Hemato-Oncology
  • Discharge diagnosis
    • Malignant neoplasm of retroperitoneum
    • Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0
    • Positve of anti-HBc
    • Anxiety
  • Present illness
    • This is a 59-year-old female with past history of
      • Hypertension, under medication control
      • s/p LM on 2018-07
      • Dysthymic disorder, under medication control
      • s/p hernia operation
      • s/p uterine myoma operation
    • According to the patient,left kidney tumor was noted after examination. She came to our uro OPD for further examination. MRI showed Retroperitoneal tumor at left side, 7.3cm, r/o liposarcoma.Surgery was suggested.
      • 2022/10/31 PET scan showed 1. The left retroperitoneal tumor shown on the previous abdomen MRI reveals mildly increased FDG uptake; the nature is to be determined (liposarcoma or others ?) 2. Glucose hypermetabolic lesions in the esophagus, D/3 and bilateral palatine tonsils, probably chronic inflammation process, suggesting follow-up. 3. Glucose hypermetabolism in level II lymph nodes of bilateral cervical regions, probably reactive nodes. 4. Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
      • 2022/11/07 Abdomen CTA showed a heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
      • 2022/11/17 Abd TAE was done and smooth.
      • 2022/12/26 Focal engorgement and non-compressible to probe of left cephalic vein showed suspected left cephalic vein thrombosis.
    • RT to the preOP tumor bed (Lt kidney region): 36 Gy/ 18 fx since 2022/12/14-2023/01/22.
    • Under the impression of Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0, so she was admission for adjuvant C/T on 2023/02/17.
  • Course of inpatient treatment
    • After admission, she received Baraclude 0.5mg/tab (Entecavir) 1# qdac for postive og anti-HBc. Anxiety improves after session with psychologist before chemotherapy. Regimen Q3W as alternating between team A and B every three weeks for approximately 17 times.
      • Team A = Vincristin 2mg (D1) 10 mins + Adriamycin 37.5mg/m2 (D1-D2) 15 mins + Endoxan 1200mg/m2 (D1) 1 hour on 2023/2/20-2/21.
      • Team B = IFx 1800mg/m2 (D1-D5) drip 1 hour + VP-16 100mg/m2 (D1-D5) drip 1-2 hrs (next time).
    • Under the stable condition without GI tract problem, so she can be discharge on 2023/02/21. OPD follow up is arranged.
• 2023-01-19 SOAP Hemato-Oncology
  • O: s/p adjuvnat R/T with 44 Gy/ 22 fx to the pre-OP tumor bed, from 2202-12-13 or -14 to 2023-01-12
• 2022-12-22 SOAP Hemato-Oncology
  • A/P
    • Strategy: Adjuvant R/T followed by adjuvant C/T
    • Already suggest discuss with her psychiatrist for the phobia of C/T
• 2022-12-06 SOAP Radiation Oncology
  • Plan: Adjuvant RT then adjuvant C/T is suggested. CT-simulation will be arranged on 2022/12/08. Plan to deliver 44~45 Gy/ 22~25 fx to the preOP tumor bed. RT will start around 12/12 or 13.

[consultation]

• 2023-03-15 Nephrology
  • Q
    • This is a 59-year-old female with past history of
      • Hypertension, under medication control
      • s/p LM on 2018-07
      • Dysthymic disorder, under medication control
      • s/p hernia operation
      • s/p uterine myoma operation.
    • Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0, she received adjuvant chemotherapy on 2023/02/20-21(C1).
      • Regimen Q3W as alternating between team A and B every three weeks for approximately 17 times.
        • Team A = Vincristin 2mg (D1) 10mins + Adriamycin 37.5mg/m2 (D1-D2) 15mins + Endoxan 1200mg/m2 (D1) 1hour on 2023/2/20-2/21.
        • Team B = IFx 1800mg/m2 (D1-D5) drip 1hour + VP-16 100mg/m2 (D1-D5) drip 1-2hrs (next time).
    • This time, she suffered from poor intake for 2 weeks. Blood analysis showed Impaired renal function (BUN/Cr: 39/2.19 mg/dl and hyperkalemia: 5.2 mmol/L)
    • For acute kidney injury, favor dehydration due to poor intake related, we need your further evaluation and management.
  • A
    • This 59-year-old madam with a history of retroperitoneum sarcoma, s/p operation, pT2N0G2; Stage IIIA if cM0, received adjuvant chemotherapy (Vincristine, Adrimycin, Endoxan) on 2023/2/20-21(C1). I’m consulted for impaired renal function. The patient stated her appetite was decreasing after last hospitalization, but she tried to drink water around 2000ml per day and she ate fish, eggs and mild with salty flavor recently. She has started taking Entecavir and Chinese herbal medicine recently. She denied use of medications from other hospital, LMD or pharmacy. She also did not use of NSAIDs recently. There’s no fever, chills, diarrhea, decreasing urine output, or obvious body weight loss. Renal echo on 2023/03/15 shows no evidence of hydronephrosis of right kidney.
    • Impression: AKI, dehydration? Medication (Chinese herbal medicine or entecavir)?
    • Suggestion:
      • Hydration with saline based intravenous fluid, such as D5S or NS and follow up her renal function. You could also follow up serum calcium next time while checking the laboratory data.
      • Check urinalysis.
      • May temporarily discontinuation of Chinese herbal medicine if renal funcition dose not improve or even worse.
    • Thank you for your consultation. I’ll follow up this patient.
• 2022-11-24 Cardiology
  • Q
    • For hypertension control
    • This is a 59-year-old female with past history of
      • Hypertension, under Norvasc 1# QD, Cardiolol 1# QD (previously PRNQD), Atanaal PRNQ8H, control
      • s/p LM on 2018-07
      • Dysthymic disorder
      • s/p hernia operation
      • s/p uterine myoma operation
    • This time she was admitted for TAE (2022/11/17) and open radical nephrectomy (2022/11/18).
    • In recent 4 days,her BP control was not good,highest up to 180-190.
    • She suffered from stomache distension, GERD-like sensation,nausea, vomitting in recent three days. Pantoprazole and imperan was prescribed
    • 2022/11/21: Creatinine: 1.37, eGFR: 41.94, CrCl 48, height: 158cm, weight: 72.4kg
    • We consult for your further evaluation and management, thank you!
  • A
    • I was consulted for poor BP control
    • O
      • Formerly controoled with Norvasc 1# QD and inderal 1# QD
      • Lab
        • 2022-11-21 BUN 8 mg/dL
          
        • 2022-11-21 Creatinine 1.37 mg/dL
          
        • 2022-11-19 BUN 26 mg/dL
          
        • 2022-11-19 Creatinine 1.94 mg/dL
          
      • EKG: NSR
      • CXR: normal heart size
    • Impression:
      • Hypertension, poor contorl
    • Sugggestion:
      • The causes of poor control of BP during admission, including insomnia, pain, NS hydration, abdomen distension and any other discomfort, if present such problem, please correct it.
      • May uptitrate Norvasc to 1# BID PO
      • if high BP > 150/90 mmHg still, may add Carvedilol (6.25) 1# BID PO
• 2022-11-22 Psychosomatic medicine
  • Q
    • For post-op anxiety evaluation and medication adjustment.
    • This is a 59-year-old female with past history of
      • Hypertension,under medication control
      • s/p LM on 2018-07
    • She had regular follow up in our psy OPD before, and was diagnosed with dysthymic disorder, and GAD.
    • Medication Zoloft 1# QD and Eurudin 0.5# HS was used now.
    • This time,under the impression of left kidney tumor, suspected liposarcoma, she was admitted to our ward for scheduled TAE (2022/11/17), open radical nephrectomy and resection of segmental of small intestine (2022/11/18).
    • After operation, she complained about having nightmare during these days. She was abnormally sensitive to pain and very scared, even scared of nurses.
    • She is in a very anxious mood. We consulted for your further evaluation and management, thank you!
  • A
    • This 59 y/o married woman, now still work as an administrative staff, has been followed up in our PSY OPD since 2020/07 for low and anxious mood, anhedonia, insomnia, psychomotor retardation, muscle tension, distracted attention, fatigue, guilty feeling or inattention, suicidal and negative thinking for more than 6 months. Stressor: the passing of her mother at that time. After regularly took meds in our PSY OPD, her mood symptoms improved, but still has decreased sleep lasting: only sleeping for 3 hours, because she didn’t want to rely on sleeping pills, she took only half a tablet of Eurodin.
    • In recent few days, she developed low and anxious, even agitated mood, hypervigilance, decreased frustration tolerance, phobic and avoidant behaviors, guilty feelings, worthlessness feelings, grief reaction, suicidal ideation, rumination of the past events, following the stressors: her father passed away recently, she has to be hospitalized and can’t participate in the funeral arrangements, experienced sudden pain during TAE and was shocked by the doctor’s reaction, felt terrible because she was too scared and it took three attempts to complete the examination, felt extremely nervous and scared about undergoing invasive treatments, cried when the TAE area hurt, and thought about jumping off a building at that time.
    • She also had transient VH following the procedure, seeing ice cream and SpongeBob. (ChatGPT: In the context of psychology or psychotherapy, “VH” typically stands for “vividness of mental imagery” or “vividness of hallucinations.”)
    • MSE: tearfulness, low and anxious mood, distressful feelings, anticipatory anxiety about the following procedure: removing stitches.
    • IMP:
      • Adjustment reaction with anxious and fearfulness mood
      • r/o Persisted depressive disorder
      • Generalized anxiety disorder
    • Suggestion:
      • Carthasis and mental support, discuss the coping skill.
      • Keep Zoloft and Eurodin. Anxiedin 0.5mg 1# BID. Alprazolam 0.5mg 1# PRNQ8H if anxious or before procedure.
      • Arrange PSY OPD follow up.
• 2022-11-18 Diagnostic Radiology
  • Q
    • This is a 59-year-old female with past history of
      • Dysthymic disorder
      • s/p hernia operation
      • s/p uterine myoma operation
    • This time she was admitted for TAE and open radical nephrectomy.
    • 2022/10/13 MRI: Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, r/o liposarcoma or others
    • 2022/11/07 CTA: Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, r/o liposarcoma, suspect Psoas muscle invsion and renal vessel invasion.
    • We consulted for left kidney and Tumor TAE,thank you !
  • A
    • According to the clinical history and imaging findings, TAE is indicated.

[chemotherapy]

• 2023-12-08 - vincristine 2mg NS 50mL 10min D1 + cyclophosphamide 1200mg/m2 2000mg NS 500mL 1hr D1 (omitting doxorubicin for single kidney and SOB)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-01 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 1650mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 120mg NS 500mL 2hr] D1-3 (less ifosfamide)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
• 2023-09-22 - vincristine 2mg NS 50mL 10min D1 + cyclophosphamide 1200mg/m2 2000mg NS 500mL 1hr D1 (omitting doxorubicin for single kidney and SOB)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-25 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 1650mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 120mg NS 500mL 2hr] D1-3 (less ifosfamide)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
• 2023-07-26 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
• 2023-07-06 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 1650mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 120mg NS 500mL 2hr] D1-3 (less ifosfamide)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
• 2023-06-19 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
• 2023-05-24 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 2000mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 130mg NS 500mL 2hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
• 2023-04-18 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
• 2023-03-20 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 2000mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 130mg NS 500mL 2hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
• 2023-02-20 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophosphamide 1200mg/m2 2000mg NS 500mL D1
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Granocyte (lenograstim 250ug) CGRAN01

• 2023-04-23 3# 2023-04-18 IPD
• 2023-03-28 3# 2023-03-28 OPD
• 2023-03-27 3# 2023-03-14 IPD
• 2023-03-25 2# 2023-03-25 EPD
• 2023-03-24 2# 2023-03-14 IPD
• 2023-03-14 1# 2023-03-14 IPD
• 2023-03-07 2# 2023-03-07 OPD
• 2023-03-01 3# 2023-03-01 OPD

WBC

• 2023-04-11 WBC 6.19 x10^3/uL 2023-04-23 G-CSF x3
• 2023-03-28 WBC 1.93 x10^3/uL * 2023-03-28 G-CSF x3
• 2023-03-23 WBC 2.23 x10^3/uL * 2023-03-24 G-CSF x2, 2023-03-25 G-CSF x2, 2023-03-27 G-CSF x3
  
• 2023-03-20 WBC 12.17 x10^3/uL 2023-03-20 ifosfamide + etoposide
• 2023-03-19 WBC 28.21 x10^3/uL
  
• 2023-03-17 WBC 1.99 x10^3/uL *
  
• 2023-03-14 WBC 3.29 x10^3/uL 2023-03-14 G-CSF x1
  
• 2023-03-07 WBC 2.41 x10^3/uL * 2023-03-07 G-CSF x2
  
• 2023-03-01 WBC 0.35 x10^3/uL * 2023-03-01 G-CSF x3
• 2023-02-17 WBC 3.17 x10^3/uL 2023-02-20 vincristine + doxorubicin + cyclophosphamide
  
• 2023-01-19 WBC 3.65 x10^3/uL

VDC/IE (vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide) - Bone Cancer - Version 3.2023 - 2023-04-04 - https://www.nccn.org/professionals/physician_gls/pdf/bone.pdf - BONE-B, 2 OF 6, p27

• ref
  • Addition of ifosfamide and etoposide to standard chemotherapy for Ewing’s sarcoma and primitive neuroectodermal tumor of bone. N Engl J Med 2003;348:694-701.
  • Randomized controlled trial of interval compressed chemotherapy for the treatment of localized Ewing sarcoma: A report from the Children’s Oncology Group. J Clin Oncol 2012;30:4148-4154.

Treatment for Localized Disease, Neoadjuvant chemotherapy - Treatment of Ewing sarcoma - 2023-06-20 - https://www.uptodate.com/contents/treatment-of-ewing-sarcoma

• Interval-compressed VDC/IE
  • For patients age < 18 years with localized ES, we recommend interval-compressed therapy with alternating cycles of vincristine/doxorubicin/cyclophosphamide (VDC) and ifosfamide/etoposide (VDC/IE) given every two weeks with hematopoietic growth factor support, rather than every three weeks without growth factor support.

Interval compressed chemotherapy for Ewing sarcoma - 2023-06-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F110260

• ref
  • Protocol supplement from: Womer RB, West DC, Krailo MD, et al. Randomized controlled trial of interval-compressed chemotherapy for the treatment of localized Ewing sarcoma: a report from the Children’s Oncology Group. J Clin Oncol 2012; 30:4148. Available at: http://ascopubs.org/doi/suppl/10.1200/jco.2011.41.5703/suppl_file/Protocol_JCO.2011.41.5703.pdf (Accessed on November 29, 2016).
• Induction chemotherapy
  • Regimen A
    • Timing
      • Weeks 1, 5, and 9
    • Drug
      • Vincristine
        • 2 mg/m2 (maximum 2 mg)
        • IV over 1 minute
        • day 1
      • Doxorubicin
        • 37.5 mg/m2
        • IV over 1 to 15 minutes
        • days 1 and 2
      • Cyclophosphamide
        • 1200 mg/m2
        • IV over 30 to 60 minutes
        • day 1, with mesna
      • Filgrastim
        • 5 mcg/kg per day (maximum 300 mcg)
        • starting day 3
          • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
  • Regimen B
    • Timing
      • Weeks 3, 7, and 11
    • Drug
      • Ifosfamide
        • 1800 mg/m2
        • IV over 1 hour
        • days 1 to 5, with mesna
      • Etoposide
        • 100 mg/m2
        • IV over 1 to 2 hours
        • days 1 to 5
      • Filgrastim
        • 5 mcg/kg per day (maximum 300 mcg)
        • starting day 6
          • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
• Consolidation chemotherapy (Local therapy between weeks 13 and 15. Surgery at week 13, if it is planned. Start of RT delayed to week 15 if surgery also undertaken.)
  • Regimen A
    • Timing
      • Surgery alone - Weeks 15 and 19
      • RT alone - Weeks 13 (with the start of RT) and 25
      • Surgery and RT - Weeks 15 (with the start of RT) and 27
    • Drug
      • Vincristine
        • 2 mg/m2 (maximum 2 mg)
        • IV over 1 minute
        • day 1
      • Doxorubicin
        • 37.5 mg/m2
        • IV over 1 to 15 minutes
        • days 1 and 2
      • Cyclophosphamide
        • 1200 mg/m2
        • IV over 30 to 60 minutes
        • day 1, with mesna
      • Filgrastim
        • 5 mcg/kg per day (maximum 300 mcg)
        • starting day 3
          • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
  • Regimen B
    • Timing
      • Surgery alone - Weeks 17, 21, 25, and 29
      • RT alone - Weeks 15, 19, 23, and 27
      • Surgery and RT - Weeks 17, 21, 25, and 29
    • Drug
      • Ifosfamide
        • 1800 mg/m2
        • IV over 1 hour
        • days 1 to 5, with mesna
      • Etoposide
        • 100 mg/m2
        • IV over 1 to 2 hours
        • days 1 to 5
      • Filgrastim
        • 5 mcg/kg per day (maximum 300 mcg)
        • starting day 6
          • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
  • Regimen C
    • Timing
      • Surgery alone - Weeks 23 and 27
      • RT alone - Weeks 17 and 21
      • Surgery and RT - Weeks 19 and 23
    • Drug
      • Vincristine
        • 2 mg/m2 (maximum 2 mg)
        • IV over 1 minute
        • day 1
      • Cyclophosphamide
        • 1200 mg/m2
        • IV over 30 to 60 minutes
        • day 1, with mesna
      • Filgrastim
        • 5 mcg/kg per day (maximum 300 mcg)
        • starting day 3
          • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.

==========

2023-12-08

[reconsidering doxorubicin in VDC/IE regimen for enhanced efficacy]

The VDC/IE regimen typically includes doxorubicin as a component, but it has been excluded since 2023-09-22. Given that the last 2D echocardiography on 2023-07-31 showed a LVEF of 70% with no apparent cardiotoxicity from doxorubicin, reintroducing doxorubicin could be considered if the patient tolerates it well. This would ensure the completeness of the regimen and potentially enhance its therapeutic effectiveness.

The patient’s condition of having a single kidney should not necessitate the omission of doxorubicin, as there is no requirement for dosage adjustment of doxorubicin for any level of kidney impairment.

The risk of cardiomyopathy associated with doxorubicin is related to the cumulative dose, with incidences ranging from 1% to 20% for cumulative doses between 300 mg/m2 and 500 mg/m2. According to our hospital records, the patient’s cumulative dose is still significantly below 300 mg/m2. Additionally, the chemotherapy preparation room is vigilant in monitoring cumulative doses, ensuring they do not exceed the safe lifetime limit, and will notify the relevant parties as the patient approaches this threshold.

2023-07-27

Upon review of the PharmaCloud database and hospital HIS5 records, no medication reconciliation issues were identified.

[leukopenia and anemia]

The administration of the alternating chemotherapy regimen of VDC/IE and the nadir of WBC (< 1K/uL) and HGB (< 9g/dL) are as follows. It seems that the trough of WBC occurs around the 10th day after the administration of VDC, indicating a stronger correlation with VDC in terms of timing than with IE. As for HGB, the changes are not as dramatic as for WBC, but it can be confirmed that during the patient’s receipt of the VDC/IE regimen, the overall HGB level shows a decreasing trend. In addition, it’s worth mentioning that the patient received several transfusions and G-CSF during the treatment period, which are also factors influencing WBC and HGB.

• 2023-07-26 VDC regimen
• 2023-07-12 HGB 7.9 g/dL
• 2023-07-06 IE regimen
• 2023-06-28 WBC 0.16 x10^3/uL
• 2023-06-28 HGB 8.1 g/dL
• 2023-06-19 VDC regimen
• 2023-06-01 HGB 8.6 g/dL
• 2023-05-24 IE regimen
• 2023-04-27 WBC 0.33 x10^3/uL
• 2023-04-18 VDC regimen
• 2023-03-20 IE regimen
• 2023-03-17 HGB 8.7 g/dL
• 2023-03-01 WBC 0.35 x10^3/uL
• 2023-02-20 VDC regimen

2023-06-20

• Based on the PharmaCloud database, all of this patient’s medical requirements have been addressed at our hospital over the past three months. Therefore, we have not identified any issues related to medication reconciliation.
• The patient is currently undergoing an alternating chemotherapy regimen of VDC/IE, and has been admitted for her 3rd round of VDC treatment during this hospitalization. Although no instances of hemorrhagic cystitis have been reported after the first two doses of cyclophosphamide, the protocol of the source trial for this treatment (http://ascopubs.org/doi/suppl/10.1200/jco.2011.41.5703/suppl_file/Protocol_JCO.2011.41.5703.pdf) specifically mandates the use of mesna with cyclophosphamide and ifosfamide (see page 11). If the decision is made to continue administering cyclophosphamide without mesna, it would be prudent to increase the patient’s hydration and strongly encourage frequent voiding.

2023-04-19

• To prevent potential neutropenia, granulocyte colony-stimulating factor (G-CSF) is prescribed prophylactically.
• This patient primarily seeks medical care at our hospital, and no medication reconciliation issues have been found for the time being.

700599605

231208

[exam findings]

• 2023-12-20 CT - chest
  • Indication: right breast cancer s/p chemotherapy dyspnea r/o ILD
  • Chest and abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Lungs: areas of decreased attenuation at RML, LLL, and RLL.
      • linear opacities at lower medial region of RLL.
    • Mediastinum and hila: no enlarged LN or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion.
    • Vessels:
      • the great vessels in the hila and mediastinum are normal in distribution and appearance. no coronary arterial calcificatiion.
    • eart: normal size of cardiac chambers.
    • Chest wall and visible lower neck: s/p Lt mastectomy.
    • Visible abdominal contents:
      • unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
    • Visualized bones: unremarkable.
  • Impression:
    • suspect mild obstructive small airway disease in lungs.
    • mild linear atelectasis or interstial inflammation at lower medial region of RLL.
• 2023-08-31, -03-16 SONO - abdomen
  • Fatty metamorphosis of pancreas
  • Mild fatty liver.
• 2023-07-18 Patho - breast biopsy (no need margin)
  • Breast, left, core needle biopsy — Chronic inflammation, fibrosis, and hematoma
• 2023-07-17 Patho - soft tissue debridement
  • Breast, right, debridement — mastitis with necrosis
• 2023-04-12 Patho - breast simple/partial mastectomy
  • PATHOLOGIC DIAGNOSIS
    • Tumor, R’t breast, nipple sparing simple mastectomy — Invasive carcinoma of no special type with focal neuroendocrine differentiation, 10%
    • Skin and nipple, ditto — Free of tumor invasion
    • Surgical margins and base, ditto — Free of tumor invasion, 0.3 cm at closest base margin
    • Lymph nodes, R’t axillary, dissection — Free of tumor metastasis (0/5)
    • AJCC Pathologic Anatomic Stage — pT2N0, if cM0, stage IIA; Prognostic Stage — Stage IA
  • MACROSCOPIC EXAMINATION
    • Breast: 18.3 x 16.3 x 5.2 cm
    • Skin: 13.9 x 4.9 cm
    • Nipple: detached, 1.7 x 1.2 x 1.0 cm
    • Tumor: 3.3 x 2.7 cm
    • Resection margins: Free, 0.3 cm away from closest base
    • Representative sections as follows: A1: nipple, A2: four unlabelled peripheral margins, A3: base, A4–A6: lesion at skin site, A7: skin, A8-A9: non-tumor breast, A10-A14: tumor [Reference: F2023-00159, FSA1-A2: R’t axillary sentinel LNs, FSB: breast safety margin, FSC: tumor site safety margin]
  • MICROSCOPIC EXAMINATION
    • Histologic type: Invasive carcinoma of no special type with focal neuroendocrine differentiation, 10%
    • Size of invasive carcinoma: 3.3 x 2.7 cm
    • Histologic grade (Nottingham histologic score): grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
    • Margins: Free, 0.3 cm from closest base margin and at least 3.6 cm away from unlabelled peripheral margins
    • Nodal status: free of tumor metastasis (0/5)
    • Treatment Effect: N/A
    • Lymphovascular space invasion: Present
    • Perienural invasion: not identified
    • Lesion at skin site: 0.9 x 0.6 cm, ruptured epidermal cyst with foreign body reaction and abscess
    • Immunohistochemistry:
      • Please refer to S2023-05808
      • E-cadherin(+), synaptophysin(+, focal), chromogranin-A(-) and P63(-) for tumor
• 2023-04-10 CT - abdomen
  • Findings
    • Heterogeneous density of pancreatic head and body. Some LNs at hepatic hilar region.
    • A nodule (1.1cm) at duodenum.
    • Liver cysts (up to 0.6cm).
    • Cystic lesions (1.2cm, 3.5cm) at bil. adnexa.
    • Duodenal diverticulum.
  • IMP:
    • Heterogeneous density of pancreatic head and body. Some LNs at hepatic hilar region.
    • A nodule (1.1cm) at duodenum.
• 2023-03-28 Patho - breast biopsy (no need margin)
  • Breast, right, 11 o’clock, core needle biopsy — Invasive carcinoma of no special type
  • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid to ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
  • Immunohistochemical study demonstrates:
    • ER: positive (moderate, 95%)
    • PR: positive ( strong, 90%)
    • Her2/neu: negative (1+)
    • Ki-67 inedex: 30%
    • E-cadherin: positive
    • p63:negative.
• 2023-03-22 Tc-99m MDP bone scan
  • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, mandible, a lower C or upper T-spine, left sternoclavicular junction, bilateral shoulders, S-I joints, hips, knees, and feet.
• 2023-03-14 Patho - breast biopsy (no need margin)
  • DIAGNOSIS:
    • Breast, right, 1 o’clock, core needle biopsy — Invasive carcinoma of no special type
    • Breast, right, 11 o’clock, core needle biopsy — fibrocystic change
  • Immunohistochemical study demonstrates
    • ER: positive (strong, > 95%),
    • PR:positive (moderate, 80%),
    • Her2/neu: negative (1+),
    • p63: negative,
    • Ki-67 inedex: 10%.

[MedRec]

• 2023-12-20 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • S: Zoladex (goserelin) 3M since 2023-12-20
  • A: Dermatitis, hand foot syndrome after chemotherapy
  • Prescription x3
    • Nolvadex (tamoxifen citrate 10mg) 1# BID
• 2023-11-06 SOAP Gastroenterology Chen JianHua
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-10-26 ~ 2023-10-31 POMR Plastic and Reconstructive Surgery Wei LinGui
  • Discharge diagnosis
    • Cellulitis over medial supra-malleolar region of right lower leg
    • Right breast invasive carcinoma, pT2N0M0, stage IIA. ER(95%) PR(90%) HER(1+) Ki67:30%. ECOG:1
    • Carrier of viral hepatitis B
  • CC
    • Suffered from right leg redness for a month ago
  • Present illness
    • This 42-year-old female patient was a viral hepatitis B carrier for 10 years with regular medicine control.
    • She also was a victim of Right breast invasive carcinoma s/p simple mastectomy and axillary lymph node sentinel lymph node + bilteral low-costal advancement flaps resurface of bilateral anterior thoracic soft tissue defects and left prophylactic mastectomy on 2023/04/11.
    • Pathology showed invasive carcinoma of no special type with focal neuroendocrine differentiation, 10%, size 3.3 cm, Gr 2, pT2N0M0, stage IIA.
    • She received 3rd adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 on 2023/06/14.
    • She suffered from right leg redness for a month ago, because using the fascia gun too hard. Physical assessment revealed right leg wound about 3X3 cm, which was red, swollen, locally heated, and swelling painful, with no discharge or foul smell.
    • Under the impression of right leg cellulitis, she was admitted for antibiotic treatment. she was admitted to our PS ward for further vealuation and treatment.  
  • Course of inpatient treatment
    • After admission, right foot wound redness, swelling, local heat, no discharge and foul smell.
    • Under antibiotic with Soonmelt 1200mg Q8H.
    • Right leg wound care with Aq-BI wet.
    • Analgesic agent was given.
    • Attention wound condition.
    • Because her wound was well healing and her whole condition was stable, she was discharged and OPD follow-up was arranged.
  • Discharge prescription
    • Curam (amoxicillin 875mg, clavulanic acid 125mg; 1000mg) 1# Q12H 7D
• 2023-10-04 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • O: neutrpenia 187, give g-CSF x3
  • P: 5th chemotherapy with Taxotere
  • Prescription
    • cephalexin 500mg 1# QID 3D
    • Granocyte (lenograstim 250ug) SC 3D
• 2023-09-27 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • P: Taxotere since 2023/09/27
• 2023-09-20 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-09-08
    • The patient’s liver enzymes have increased due to chemotherapy.
    • So chemotherapy is not recommended at this time.
    • The patient will receive a combination of R/T + Tamoxifen + menopausal hormone therapy. The pharmacist will be consulted to determine whether anti-hormone drugs have any impact on hepatitis.
• 2023-09-11 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • A/P: GOT,GPT elevation–>hold chemotherapy
• 2023-04-10 ~ 2023-04-16 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Right breast invasive carcinoma status post bilateral nipple sparing mastectomy + right sentinel lymph node biopsy + bilateral low-costal advancement flaps resurface of bilateral anterior thoracic soft tissue defects on 2023/04/11. cT2N0M0, stage IIA. ECOG:0
    • Carrier of viral hepatitis B
  • CC
    • noted a palpable mass at right breast over 2 months.
  • Present illness
    • This 42-year-old female patient has past history of carrier of viral hepatitis B over 10 years with regular medicine control. She denied cancer history. She went to Janpan on 2023/03.
    • She noted a palpable mass at right breast over 2 months. She came to our OPD for help. Breast sono showed a lesion right breast tumor (1’region, 11’region) r/o malignancy suggest biopsy.
    • Core needle biopsy revealed invasive carcinoma, ER positive (strong, >95%), PR positive(moderate, 80%), Her2/neu negative(1+), p63 negative, Ki-67 inedex 10%. CA-153 14.159 U/ml, CEA 1.383 ng/ml.
    • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis.
    • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
    • PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 3x3 cm without discharge. The nipple was dimping without exudative nor bloody discharge and right nipple retraction. The right breast skin had no cellulite change.
    • Under the impression of right breast invasive carcinoma, she was admitted for surgery of right nipple sparing mastectomy + SLNB and left breast prophylactic simple mastectomy .        
  • Course of inpatient treatment
    • After admission, right nipple sparing mastectomy + SLNB and left breast prophylactic simple mastectomy was performed on 2023/04/11. The wound is clean and dry.
    • Under the stable condition, she was discharged today, wound will be follow up in OPD.
  • Discharge prescription
    • Acetal (acetamnophen 500mg) 1# QID
    • Zcough (benzonatate 100mg) 1# TID
    • Actein (acetylcysteine 200mg) 1# TID

[surgical operation]

[chemotherapy]

• 2023-11-29 - docetaxel 75mg/m2 143mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-11-09 - docetaxel 75mg/m2 145mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-10-18 - docetaxel 75mg/m2 140mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-09-27 - docetaxel 75mg/m2 140mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-07-18 - cyclophosphamide 600mg/m2 1118mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-06-14 - cyclophosphamide 600mg/m2 1127mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr
  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
• 2023-05-24 - cyclophosphamide 600mg/m2 1127mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-05-03 - cyclophosphamide 600mg/m2 1127mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

TAC (Docetaxel, Doxorubicin and Cyclophosphamide) (breast) - https://www.swagcanceralliance.nhs.uk/wp-content/uploads/2020/10/TAC-1.pdf

==========

2023-12-21

A review of the patient’s medical records on 2023-12-20, revealed the development of dermatitis or hand-foot syndrome following chemotherapy treatment.

It is noteworthy that the patient is concurrently receiving 3 medications for her breast cancer - docetaxel, tamoxifen, and goserelin (Zoladex Depot - goserelin 10.8mg/syringe, SC on 2023-12-20, Q3M) - all of which have been associated with dermatological adverse reactions in the literature. The reported incidence of these reactions for each medication is as follows:

• Docetaxel:
  • Alopecia: 56% to 76% (potentially permanent)
  • Dermatological reactions: 20% to 48% (5% with severe presentation)
  • Nail disease: 11% to 41%
  • Onycholysis: <1%
• Tamoxifen:
  • Skin changes: 6% to 19%
  • Skin rash: 13%
  • Alopecia: 5%
  • Diaphoresis: 6%
• Goserelin:
  • Acne vulgaris (females): 42%
  • Diaphoresis (females: 16% to 45%; males: 6%)
  • Seborrhea (females: 26%)
  • Alopecia (females: 1% to 5%)
  • Ecchymoses (females: 1% to 5%)
  • Hair disease (females: 4%)
  • Pruritus: 2%
  • Skin discoloration (females: 1% to 5%)
  • Skin rash: 6%
  • Xeroderma (females: 1% to 5%)

The development of subsequent skin symptoms may be difficult to definitively attribute to docetaxel, and further observation and follow-up is warranted.

As for the skin symptoms that have already occurred, the preliminary recommendation is to prescribe Sinphraderm and/or Mycomb to relieve them.

2023-12-08

The TAC regimen, which includes docetaxel at 75 mg/m2 Q3W (initiated on 2023-09-27), followed 4 courses of doxorubicin and cyclophosphamide from 2023-05-03 to 2023-07-18. Docetaxel has been linked to dermatologic side effects such as alopecia (56% to 76%, with potential permanence), skin reactions (20% to 48%; severe reactions in 5%), and nail disorders (11% to 41%), as per UpToDate. To address these skin issues, a consultation with a dermatologist is recommended. The aim is to manage the patient’s comfort effectively while maintaining the current chemotherapy schedule and dosage.

Leukopenia episodes were noted on 2023-08-09, 2023-10-04, and 2023-11-15. Prompt administration of G-CSF was carried out in response to these occurrences. Currently, there are no indications of leukopenia.

• 2023-11-15 WBC 2.68 x10^3/uL
• 2023-10-04 WBC 1.03 x10^3/uL
• 2023-08-09 WBC 2.21 x10^3/uL

700811854

231207

[exam findings]

• 2023-11-17 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Old fracture of right clavicle.
• 2023-11-17 ECG
  • Sinus rhythm with short PR
  • Low voltage QRS
  • Borderline ECG
• 2023-11-15, -11-13, -11-07 KUB
  • S/P CBD and p-duct stenting.
  • Degeneration and spondylosis of L-S spine.
  • Non-specific small bowel and colon gas pattern.
• 2023-11-06 Endoscopic Retrograde Cholangiopancreatography, ERCP
  • Indication: biliary decompression
  • Symptoms: panc CA with Jaundice
  • Diagnosis:
    • Obstructive jaundice, pancreatic head cancer related, s/p TPS, EST and biliary stenting
    • GB non-opacification
    • S/P P duct stenting
    • Reflux esophagitis
  • Suggestion:
    • f/u amylase & lipase
• 2023-11-03 Peripheral Vascular Test - Artery, lower limbs
  • Atherosclerosis: Mild
  • Conclusions:
    • Bilateral common femoral arteries distal segment mild plaques, no stenosis
    • Right superficial femoral artery very proximal segment and distal segment mild plaques, no stenosis; left superficial femoral artery very proximal segment mild plaques, no stenosis
    • Bilateral popliteal arteries proximal segment mild plaques, no stenosis
    • Bilateral posterior tibial arteries no significant stenosis
    • Right anterior tibial artery middle segment plaques with mild stenosis; left anterior tibial artery no significant stenosis
• 2023-10-30 PET scan
  • Increased FDG uptake in the pancreatic head region, compatible with the adenocarcinoma of pancreas with regional lymph node metastasis.
    
  • Two small nodules 5 mm in S5 and S6 of the liver showm on the previous abdomen MRI, however, reveal no increased FDG uptake. Please correlate with other imaging modalities for further evaluation.
  • Increased FDG accumulation in bilateral kidneys, bilateral ureters, and colon, probalby physiological uptake of FDG.
• 2023-10-28 CT - chest
  • Indication: For pancreas head tumor survey
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Calcified coronary arteries is found.
      • The lung fields are clear.
      • Senile fibrotic change is noted at lung fields.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
    • Visible abdomen:
      • Low density lesion at pancreatic uncinate process measuring 5.4cm in largest dimension. Regional lymphadenopathy (n＝2) are found.
      • The IHDs and CBD are dilated probably due to tumor compression.
      • One enhanced dot at liver dome is found. The lesion is too small to be characterized.
      • There is no evidence of destructive bone lesion.
      • Linear gallstone is found.
      • Suggest clinical correlation
  • Imp:
    • pancreatic cancer at uncinate process of the pancreas. 5.4cm with regional lymphadenopathy
    • Gallstone.
• 2023-10-27, -10-24 CXR
  • Old fracture of right clavicle.
  • Atherosclerosis of the aorta.
  • Ground glass opacity in bilateral lower lungs.
  • Normal appearance of trachea and bil. main bronchus.
• 2023-10-23 Patho - pancreas biopsy
  • Labeled as “pancreas”, EUS fine needle biopsy — adenocarcinoma.
  • Section shows necrotic tissue with adenocarcinoma.
  • IHC stains: CA19-9 (+), CK7 (+), CK20 (focal +), CEA (+), CK19 (+).
• 2023-10-23 SONO - abdomen
  • Diagnosis:
    • Pancreatic head tumor
    • Fatty liver, mild
    • Liver calcification, right
    • CBD dilatation
    • Bilateral IHD dilatation
    • GB stone
    • Renal cysts, LK
    • Minimal ascites
    • Right pleural effusion
  • Suggestion:
    • the two liver tumors noted by MRI in S5 and S6 could not be found.
• 2023-10-20 MR Cholangiography, MRCP
  • Indication: r/o Pancreatic head tumor
    • 20231017 CEA:5.14 ng/mL (<5), CA199:487.67 U/mL (<35).
  • Findings:
    • There is a well-defined, mild heterogeneous mass in the pancreatic head, measuring 4.6 cm in size (the largest dimension), causing marked dilatation of the CBD, CHD, IHDs, and pancreatic duct.
      • This mass shows hypointensity on T1WI and mild hyperintensity on both T2WI and DWI. During dynamic study, this tumor shows poor contrast enhancement.
      • Adenocarcinoma of the pancreatic head (T3) is highly suspected.
      • Please correlate with EUS.
    • There is one enlarged node 1 cm in RMQ mesentery that is c/w metastatic node (N1).
    • There are two small nodules 5 mm in S5 and S6 of the liver, showing equivocal mild hyperintensity on T2WI (Srs:3 Img:18) and marked hyperintensity on DWI (Srs:104 Img:19).
      • Metastases (M1) are highly suspected.
      • Please correlate with sonography.
      • Follow up MRI 3 months later is indicated.
    • A stone 4 x 1 cm in the gallbladder is suspected. Please correlate with sonography.
    • There are several renal cysts on both kidney and the largest one measuring 2.1 cm in size at left upper pole.
    • Minimal right side Pleura effusion is highly suspected.
    • Mild ascites is highly suspected. Please correlate with sonography.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage): T: T3 (T_value) N: N1 (N_value) M: M1 (M_value) STAGE: IV (Stage_value)
• 2023-10-17 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 25) / 91 = 72.53%
    • M-mode (Teichholz) = 72
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated both atria and RV, grade 1 LV diastolic dysfunction
    • Mild AR, MR, TR
• 2023-10-16 CXR
  • Fracture of right clavicle.
  • Atherosclerosis of the aorta.
• 2023-10-16 ECG
  • Sinus bradycardia
  • Left axis deviation
• 2023-10-15 ECG
  • Sinus rhythm with short PR with occasional Premature ventricular complexes
  • Left axis deviation
  • Abnormal ECG

[MedRec]

• 2023-10-15 SOAP Medical Emergency Chen YuLong
  • S: JUST AAD FROM DaJia KuangTien Hospital, TOCC(-)
    • GENERAL DISCOMFORT 2 DAYS AGO, BW LOSS FOR 10+ KG IN RECENT 6 MO
    • PH; HTN, DM NKDA
    • Cloud:
      • 2023/10/14
        • WBC 7.2k Hb12.3 MCV 90.1 PLT 141k
        • K 3.17 Na 140 Glu 193 BUN 16 Cr 1.19 GPT 279 Ti- CRP 0.2 Alb 3.1 TBI 1.9 GGT 293 ALP 133 Lip 42 NH 3 56
        • PT 10.5 sec APTT 29.2sec
        • PH 7.428 PCO2 34.6
        • Urine Light Yellow, Clear
      • Stool (2023/10/15) Brown Soft N/A
    • 2023/10/15 Discharge diagnosis (DaJia KuangTien Hospital)
      • Biliary sepsis due to acute cholangitis
      • Biliary obstruction due to suspect malignant tumor at pancreatic head
      • Acute gastric erosions with H. pylori
      • GERD Gr.A
      • CAD with 3 VD
      • DM
      • HCVD
    • Medication：
      • GLIMET
      • CONCOR 1.25
      • QTERN 5MG/10MG (Dapagliflozin；Saxagliptin)
      • Aspirin
      • Isosorbide 5-Mononitrtate (60)
      • NORVASC
      • DOXABEN XL
  • O:
    • Vital Sign: BP:105/62; HR:85; BT:36.5’C; RR:16;
    • Con’s:E4V5M6
    • SpO2:96%
    • MILD ICTERIC, ANEMIC
    • CLEAR BS, RHB
    • ABD; SOFT AND CONVEXED, NONTENDER
    • EXT; NO EDEMA
  • Preliminary impression: C25.9 Malignant neoplasm of pancreas, unspecified
    • Pancrea head tumor, ?GB stones, CBD dilatation, ALT 279, TBI 1.9, GGT 293, Alp 133, AAD from DaJia KuangTien Hospital. No fever, V/S stable in ER observation. OA GI
    • HTN; DM
• 2023-10-11 SOAP General and Gastrointestinal Surgery
  • S
    • Chief complaint: a palpable mass over L’t upper back for years
    • Present illness: According to the patient & family, the patient suffered from a palpable mass over L’t upper back for years. Due to pain, sign & symptom exacerbation, the patient called at our OPD for help.
    • Past history: No Hx of operation, No Hx of type 2 DM, HTN
    • Allergy: NKA
    • Travel Hx: Nil
    • Family Hx: No significant finding in pedigree
  • O
    • Skin: a 4x4 cm plapble soft mass over L’t upper back with local tenderness,
  • A
    • L’t back tumor
  • P
    • suggest excision or closely observation, education, & OPD follow up
      
    • F/U the tumor yearly

700348263

231206

[lab data]

2023-07-26 HBsAg Nonreactive
2023-07-26 HBsAg (Value) 0.24 S/CO
2023-07-26 Anti-HBs 39.06 mIU/mL
2023-07-26 Anti-HBc Nonreactive
2023-07-26 Anti-HBc-Value 0.31 S/CO
2023-07-26 Anti-HCV Nonreactive
2023-07-26 Anti-HCV Value 0.11 S/CO

[exam findings]

• 2023-12-02 KUB
  • There is no evidence of destructive bone lesion.
  • Stool impaction at the abdominal cavity is noted.
  • Non-specific bowel gas at abdominal cavity is found.
  • s/p stent placement at right iliac region.
• 2023-12-02 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • Massive right pleural effuison
  • There is no evidence of destructive bone lesion.
• 2023-11-22 SONO - chest
  • Echo diagnosis
    • Pleural effusion, moderate, to massive right
    • Atelectasis, RLL
• 2023-10-27 PET
  • A glucose hypermetabolic lesion in the right lower lung field and multipe small glucose hypermetabolic lesions in the upper and lower lobes of left lung, compatible with multiple lung metastases.
  • Prominent glucose hypermetabolism in the right lateral chest wall. Metastasis should be watched out.
  • Glucose hypermetabolism in a lymph node in the right anterior prevascular space and in a right paratracheal lymph node, suggesting metastatic lymph nodes.
  • Glucose hypermetabolism in a focal area in the right supraclavicular fossa. A metastatic lymph node can not be ruled out.
  • Mild glucose hypermetabolism in a pleura-based focal area in the anterior aspect of the upper lobe of right lung. The nature is to be determined (inflammation? metastasis of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys and bilateral ureter. Physiological FDG accumulation may show this picture.
• 2023-10-03 CT - chest
  • Indication: ca of lung, pStage IIIB, pT3N2M0.
  • Comparison was made with CT on 2023/04/14
    • Lungs:s/p right upper lobe lobectomy, staple line along superior posterior Rt major fissure.
      • no abnormal nodule or mass in the Rt remnant lungs or bronchial stump. a 5mm nodule in inferior lingular segment.
      • mosaic attenuation changes in both lungs on inspiratory images.
    • Mediastinum and hila: enlarged LNs in Rt paratracheal space and Rt anterior prevascular space.
      • extensive coronary arterial calcification
    • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: dilated right (3.3cm) and left pulmonary arteries.
    • Heart: normal size of cardiac chambers. midseptal hypertrophy of IVS and extensive calcified mitral annulus
    • Pleura: moderate Rt-sided effusion with loculation.
    • Chest wall and visible lower neck: unremarkable.
    • Extensive atherosclerotic change of the abdominal aorta.
    • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • enlarged Rt mediastinal LNs, lymph nodes recurrent tumor? moderate pleural effusion and pulmonary hypertension.
      
    • lingular nodule 5mm.
    • extensive 2V-CAD.
• 2023-08-01 Nerve Conduction Velocity, NCV
  • Findings
    • MNCV: decreased CMAPs amplitude of left median nerve and left tibial nerve; slow motor conduction of bilateral ulnar nerves across elbow
    • SNCV: decreased SNAPs amplitude of all examined nerves; slow sensory conduction velocity of bilateral median and ulanr nerves
    • F-wave: delayed responses of right ulnar and left tibial nerves
    • H-reflex: delayed responses of bilateral lower limbs
    • Thermal quantitative sensory test showed abnormal warm threshold in left upper and lower limbs.
  • Conclusion
    • This NCV study suggested bilateral lumbosacral radiculopathy with left tibial axonal injury, bilateral ulnar neuropathy across elbow, bilateral median distal neuropathy with the possibility of right lower cervical radiculopathy.
    • Thermal quantitative sensory test suggested small fiber neuropathy.
    • Please correlate with clinical features.
• 2023-06-26 Patho - lung total/lobe/segmental
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, upper lobe, lobectomy —- Squamous cell carcinoma, moderately differentiated
    • Lymph node, lobar, lymphadenectomy —- Squamous cell carcinoma, metastatic (1/4)
    • Lymph node, right, group No.2+4, lymphadenectomy —- Squamous cell carcinoma, metastatic (2/3)
    • Lymph node, right, group No.7, lymphadenectomy —- Squamous cell carcinoma, metastatic (1/ 4)
    • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/2)
    • Lymph node, right, group No.10, lymphadenectomy —- Squamous cell carcinoma, metastatic (2/4)
    • Lymph node, right, group No.11, lymphadenectomy —- Squamous cell carcinoma, metastatic (1/2)
    • Lymph node, right, group No.12, lymphadenectomy —- Squamous cell carcinoma, metastatic (3/4)
    • AJCC 8th edition pTNM Pathology stage: pStage IIIB, pT3N2(if cM0)
  • MACROSCOPIC EXAMINATION:
    • Specimen: Lung, size: 16.2 x 9.5 x 3.5 cm, 210 g
      • Lymph nodes, 6 bottles, group 2+4, 7, 9, 10, 11, 12; maximal size: 2.6 x 1.5 cm
    • Tumor Site: Periphery
    • Tumor Size: Solitary: 6.0 x 4.5 x 2.8 cm
    • Gross tumor patterns: poorly defined
      
    • Tissue for sections: A1: bronchial and vascular resection margins; A2: parenchymal resection margin; A3: lymph node, lobar; A4: lung, non-tumor; A5-8: tumor; B: lymph node, group 2+4; C: lymph node, group 7; D: lymph node, group 9; E: lymph node, group 10; F: lymph node, group 11; G: lymph node, group 12.
  • Microscopic Description
    • Tumor Focality: Single tumor
    • Histologic Type (select all that apply): Invasive squamous cell carcinoma, keratinizing
      
    • Histologic Grade: G2: Moderately differentiated
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Not identified
    • Lymphovascular Invasion (select all that apply): Present, Lymphatic and Venous
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 1.9 cm
      • Specify closest margin: parenchymal resection margin
      • Bronchial resection margin: 2.1 cm
    • Treatment Effect: No known presurgical therapy
    • Regional Lymph Nodes: please see diagnosis
    • Extranodal Extension: Not identified
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
      • Primary Tumor (pT): pT3: Tumor >5 cm but <=7 cm in greatest dimension;
        
      • Regional Lymph Nodes (pN): pN2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
    • Additional Pathologic Findings (select all that apply): None identified
• 2023-06-12 Cardiopulmonary Exercise Testing
  • Conclusions
    • submaximal exercise by RER < 1.09
    • low exercise capacity (VO2 50%, WR 23%)
    • spirometry was moderate obstructive ventialtory impairment with significant reversibility (FVC 78 -> 90%, FEV1 66 -> 83%)
    • low inpiratory muscle strength (MIP 51%, MEP 84%)
    • No SpO2 desaturation below 90%
    • normal cardiac response during exercise
    • slow HR response slope during exercise
    • work efficiency low
    • anaerobic threshold indeterminant
    • oxygen pulse normal
    • BP response high
    • EKG: no specific findings
    • Health-related quality of life, CAT= 5,
  • Impression and suggestion:
    • Treat underlying asthma
    • Exercise training for low exercise capacity
    • Treat obstructive ventilatory impairment
    • Perform breathing exercise for low respiratory muscle strength
    • Survey and treat slow HR response
• 2023-06-09 Tc-99m MDP bone scan
  • Mildly increased activity in the middle to lower T-spines, some L-spines and sacrum. Degenerative change may show this picture.
  • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Increased activity in bilateral shoulder, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2023-06-08 PET
  • A glucose hypermetabolic lesion in the upper lobe of right lung, compatible with primary lung malignancy.
  • Glucose hypermetabolism in a right paratracheal lymph node. The nature is to be determined (inflammation? a metastatic lymph node of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the right pulmonary hilar region. Inflammation is more likely.
  • Increased FDG accumulation in the colon, both kidneys and left ureters. Physiological FDG accumulation may show this picture.
• 2023-06-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (155 - 39) / 155 = 74.84%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, septal hypertrophy; impaired LV relexation
    • Mild MR, mild AR, mild to moderate TR
    • Mild pulmonary hypertension
    • Preserved RV systolic function
• 2023-06-07 ECG
  • Left axis deviation
  • Left anterior fascicular block
• 2023-05-29 Patho - pleural/pericardial biopsy
  • Lung, RUL, CT-guide biopsy —- squamous cell carcinoma, moderately differentiated
    
  • Sections show solid sheets of hyperchromatic tumor cells infiltrating in a fibrotic stroma with focal tumor necrosis. Focal keratinization is seen.
  • The immunohistochemical stains reveal CK5/6(+), p40(+), TTF-1(-), and CD56(focal +). The results are supportive for the diagnosis.
• 2023-04-19 24hr Holter ECG
  • Baseline was sinus bradycardia (average HR: 53bpm, range between: 48-61bpm)
  • Chronotropic incompetence noted
  • A few isolated VPCs / VPC couplets
  • A few isolated APCs / APC couplets
  • 4 episodes of short-run AT, max 21 beats
  • No long pause
• 2023-04-19 MRA - brain
  • acute ischemia stroke
  • Image quality: no gross motion artifacts
    • moderate dilated intraventricular and extraventricular CSF spaces
    • old lacunar infarction in the bilateral basal ganglia and right thalamus.
    • unremarkable change in the skull base
    • MRA of the intracranial vessels revealed mild stenosis at left distal VA; mild prominent bilateral PCom infundibuli.
  • IMP:
    • no evidence of recent infarction
• 2023-04-18 Neurosonology
  • Moderate atheromatous lesions in L CCA bifurcation; mild to moderate atheromatous lesions in R distal CCA to CCA bifurcation; mild atheromatous lesions in R ICA and ECA.
  • Elevated resistance (RI) and decreased flow in bilateral cervical VAs, suspect distal stenosis.
  • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows except relatively elevated flow velocity in R M1 (PS/ED= 126/15 cm/s)
  • Normal bilateral ophthalmic arterial flows.
• 2023-04-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (146 - 30) / 146 = 79.45%
    • M-mode (Teichholz) = 79
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA, LV and AoR, LVH, grade 1 LV diastolic dysfunction
    • Mild AR, MR, TR and PHTN
• 2023-04-15 CT - brain
  • Indication: acute ischemia stroke
  • Without contrast helical Head CT - 4mm thickness in each slice from the axial and saggital projections showed
  • Image quality: no motion artifacts
    • mild dilated intraventricular and extraventricular CSF spaces
    • unremarkable change in the brain parenchyma
    • unremarkable change in the skull base
    • artherosclerotic change at the bilateral distal VAs and bilateral cavernous ICAs.
  • IMP: no acute intracranial hemorrhage
• 2023-04-14 CT, CTA - brain (head, neck)
  • Head CT with IV contrast enhancement shows:
    • Marked artherosclerotic change of biilateral CCA, ICA and intracrenial arteries is found.
    • The ACAs, MCAs and VA are patent.
    • Marked prominent sulci, fissue and dilated ventricles indicate brain atrophy.
    • No evidence of ICH, SAH or SDH.
    • No evidence of space occupying lesion in the brain parenchyma is found.
    • Suggest clinical correlation
  • IMp:
    • Marked artherosclerotic change of biilateral CCA, ICA and intracrenial arteries is found.
    • The ACAs, MCAs and VA are patent.
• 2023-04-14 CT - chest
  • hest CT without IV contrast ehnancement shows:
    • Mass like lesion at right upper lobe measuring 5.6cm in largest dimension is found.
    • Calcified coronary arteries is found.
  • Imp:
    • Right upper lobe lung mass, lung cancer is favored.
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-04-14 CT - brain
  • Imp
    • Brain atrophy
    • No evidence of ICH, SAH or SDH.
    • No evidence of space occupying lesion in the brain parenchyma is found.
• 2023-04-14 ECG
  • Normal sinus rhythm
  • Left anterior fascicular block
  • Abnormal ECG
• 2017-09-07 Surgical pathology Level IV
  • PATHOLOGIC DIAGNOSIS
    • Prostate, right, needle biopsy — Prostatic adenocarcinoma (Gleason score 7 = 4 + 3) involving 3 of 5 strips of prostatic tissue by the number of involved strips or 60 % by the involved volume of the specimen.
      • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
  • MACROSCOPIC EXAMINATION
    • Size: 5 strips, with the longest piece measuring 1 x 0.1 x 0.1 cm.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Prostatic adenocarcinoma
    • Histologic Grade: (Gleason score 7 = 4 + 3)
      
    • Tumor Quantitation: involving 3 of 5 strips of prostatic tissue by the number of involved strips or 60 % by the involved volume of the specimen.
      • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
• 2017-09-07 Surgical pathology Level IV
  • PATHOLOGIC DIAGNOSIS
    • Prostate, left, needle biopsy — Prostatic adenocarcinoma (Gleason score 7 = 4 + 3) involving 4 of 5 strips of prostatic tissue by the number of involved strips or 80 % by the involved volume of the specimen.
      • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
  • MACROSCOPIC EXAMINATION
    • Size: 5 strips, with the longest piece measuring 1 x 0.1 x 0.1 cm.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Prostatic adenocarcinoma
    • Histologic Grade: (Gleason score 7 = 4 + 3)
      
    • Tumor Quantitation: involving 4 of 5 strips of prostatic tissue by the number of involved strips or 80 % by the involved volume of the specimen.
      • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.

[MedRec]

• 2023-11-19 ~ 2023-11-22 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Squamous cell carcinoma over right upper lobe, pT3N2M0 stage IIIB, post operation 3 dimensions video-assisted thoracoscopic surgery right upper lobe lobectomy and radical lymph node dissection on 2023/06/26.
    • Essential (primary) hypertension
    • Prostate cancer status post androgen deprivation therapy
    • Enlarged prostate with lower urinary tract symptoms
    • Right lower limb peripheral arterial occlusion disease post stent x 1
    • Acute ischemic stroke status post Tissue plasminogen activator on 2023/04/14
    • Zoster without complications, herpes zoster on the right chest region
    • Right side pleural effusion
  • CC
    • for on port-A and chemotherapy
  • Present illness
    • This is a 79-year-old male with past history of
      • Squamous cell carcinoma over right upper lung, moderately differentiated, cT3N0Mx, pT3N2M0, pStage IIIB.
      • Prostate cancer status post androgen deprivation therapy;
      • Acute ischemic stroke status post tissue plasminogen activator on 2023/04/14
      • Right lower limb peripheral arterial occlusion disease post stent x 1
      • Hypertension.
    • He used to smoking 2~3 packs per day for about 40 year and quit smoking for 17 years. According to patient statement and his medical record, he was brought to our ER due to acute ischemic stroke status with dizziness, upper limbs weakness and slurry speech which was noted at around 7 pm on 2023/04/14. Brain CT showed no evidence of hemorrhage. Chest X-ray and lung computer tomograph revealed mass like lesion at right upper lobe, measuring 5.6cm in size at lung window setting.
    • Therefore, He was then refered to out patient department of chest surgeon for further investigation. Computer tomograph guide biopsy was performed on 2023/05/29 and pathology roport showed squamous cell carcinoma, moderately differentiated.
    • Then, he was admission for cancer survey on 2023/06/07 and he was done PET on 2023/06/08 showed
      • A glucose hypermetabolic lesion in the upper lobe of right lung, compatible with primary lung malignancy.
      • Glucose hypermetabolism in a right paratracheal lymph node.
    • WBBS on 2023/06/09 showed Mildly increased activity in the middle to lower T-spines, some L-spines and sacrum. Degenerative change may show this picture.
    • Cariac echogram showed 1. Adequate LV systolic function with normal resting wall motion 2. Dilated LA, septal hypertrophy; impaired LV relexation 3. Mild MR, mild AR, mild to moderate TR 4. Mild pulmonary hypertension 5. Preserved RV systolic function.
    • Bronchoscope on 2023/06/12 showed no obvious abnrmality.
    • He was underwent operation for 3D VATS RUL lobectomy + RLND on 2023/06/26.
    • RT dose: 6000cGy/30 fractions (6 MV photon) to RUL bronchial stumo and mediastinal /SCF, 2023/7/27 to 9/07.
    • Oral navelbine on 7/26, 8/02, 8/09, 8/16, 8/23, 8/30, 9/05.
    • Chest CT, 2023/10/03: enlarged Rt mediastinal LNs, lymph nodes recurrent tumor? moderate pleural effusion and pulmonary hypertension.
    • PET, 2023/10/27: A glucose hypermetabolic lesion in the right lower lung field and multipe small glucose hypermetabolic lesions in the upper and lower lobes of left lung, compatible with multiple lung metastases.
    • 2023-10-31 tumor progression, suggest C/T with CDDP+Gemzar
    • 2023-10-16 herpes zoster on the right chest region under Famvir 250 mg PO TID x 5 days.
    • This time, he was admitted for on port-A and chemotherapy.  
  • Course of inpatient treatment
    • After admission, consult CS for Port-A implantation on 2023/11/20, he can tolerance procedure well.
    • He received weekly Gemcitabine (1000mg/m2) + Cisplatin (30mg/m2) on 2023/11/21 (C1D1) smoothly.
    • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
    • Tramacet 37.5 & 325mg/tab 1# PO Q6H for pain control.
    • Right side pleural effusion was noted, pleural puncture was done on 2023/11/22, pleural effusion, moderate, to massive right, 1200ml serosanguious fluid was drained and sent for routine, BCS, bacteria/TB/fungus cultures and cell block and TB-PCR.
    • Atelectasis, RLL.
    • Hypertension with Exforge F.C. 5mg & 160mg/tab 1# PO QD.
    • Enlarged prostate with lower urinary tract symptoms with Urief F.C 8mg/tab 1# PO QN, Minirin Melt 60mcg/tab 1# PO HS.
    • Acute ischemic stroke status post Tissue plasminogen activator on 2023/04/14 with Bokey 100mg/cap 1# PO QD, Rivotril 0.5mg/tab 0.5# PO RRNHS if cramp, Nicametate Citrate 50 mg/tab 1# PO QD.
    • PD-L1 (22C3) was sent on 2023/11/22. Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, he was discharged on 2023/11/22 and OPD followed up later.    
• 2023-05-24 ~ 2023-05-30 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Right upper lung mass, pending pathology on 2023/05/29
    • Essential (primary) hypertension
    • Cerebral infarction, unspecified
    • Enlarged prostate with lower urinary tract symptoms
    • Past history of right lower limb Peripheral Arterial Occlusion Disease post stent x1
  • CC
    • BW loss 4kg and need do the tumor survey
  • Present illness
    • This 78-year-old male has histories of HTN, PAOD post stenting under anti-platelet therapy for 6 years at VGHTPE, left /p TKR, prostate cancer, T3bN0M0 under androgen deprivation therapy. Last time, he suffered from dizziness, upper limbs weakness and slurry speech around 7PM. Study image brain CT and chest x-ray were arranged, it revealed no evidence of hemorrhage by brain CT and pleural based mass like lesion at right upper lobe.
    • After Neurologist consulting, he received tPA therapy for acute ischemic stroke with National Institute of Health Stroke Scale 8 points. Post tPA therapy, the brain CTA was folllow-up, it revealed marked artherosclerotic change of biilateral CCA, ICA and intracrenial arteries. Due to lung mass, the chest CT was arranged, it revealed right upper lobe lung cancer (5.6cm) T3N0M0.
    • This time, he has BW loss 4kg in one month, but no cough, SOB or fever. He was admitted for lung biopsy on 2023/05/24.
  • Course of inpatient treatment
    • After admission, he hold Aspirin for lung biopsy 3 days. Radiologiest was consulted and aspiration smoothly on 2023/05/29. No evidence of pneumothorax after lung biopsy for 4 hours. Under the stable condition, he can be discharged on 2023/05/30. OPD follow up is arranged.
• 2023-04-14 ~ 2023-04-20 POMR Neurology Chen PeiYa
  • Discharge diagnosis
    • Acute ischemic stroke status post Tissue plasminogen activator on 2023/04/14 (TOAST classification 4, cancer related )
    • Right upper lobe lung cancer, undetermined
    • Prostate cancer status post androgen deprivation therapy
    • Left lower limb peripheral arterial occlusive disease
    • Essential (primary) hypertension
    • Modified ranking scale 0
  • CC
    • acute dizziness, limbs weakness and slurred speech around 7PM pm 4/14
  • Present illness
    • This 78-year-old male has histories of HTN, PAOD post stenting under anti-platelet therapy (aspirin) and prostate cancer s/p androgen deprivation therapy but lost follow-up.
    • He was normal until acute generalized weakness during dinner at around 7pm on 4/14. He could barely stand on his own and presented with slurred speech. Therefore he was sent to our ER. At ER, his consciousness was E4V5M5-6 and he presented with dysarthria and generalized weakness with lower limb more prominent weakness. Vital signs showed BT 36.6’C, HR 74, RR 18, BP 187/88mmHg. NIHSS was 8. Brain CT showed no evidence of hemorrhage and and CXR revealed pleural based mass like lesion at right upper lobe.
    • After evaluation and explanation to the family about the indication as well as risk of IV rt-PA therapy, he underwent rt-PA therapy (93.9Kg, 0.6mg/kg, total 56mg) smoothly. Due to lung mass, the chest CT was arranged with brain CTA which confirmed no large vessle occlusion and revealed right upper lobe lung cancer (5.6cm) T3N0M0. Then within a hour of rtPA therapy, his symptoms/signs were recovered. Hence he was admitted to SICU for post-rtPA therpay monitor and management.
  • Course of inpatient treatment
    • At SICU, we gave adequate IV hydration and kept post-rtPA therapy monitor with tight control BP. Transient oral cavity blood clot and mild bleeding were noted during the first few hours and the patien claimed that tooth extraction was done about 3 days before this event.
    • Follow-up brain CT on 3/15 showed no acute intracranial hemorrhage. There was no recurrent symptoms or focal weakness noted after admission. With stablized and improved condition, he was transfered to ward for subsequent managment and treatment.
    • After transfer, we arranged associated survey for stroke risk factor evaluation. CPA/TCD revealed moderate atheromatous lesion in carotid arteries and other cerebral atherosclerosis. ABI study suggested left lower limb PAOD. Heart echography showed LVEF 79% without significal structural abnormality. 24 hours Holter EKG report was pending. We consulted physiatrist for rehabilitation activitiy.
    • About cancer issue, we had explained to the patient about further evaluation and mangement which were necessary and we will arrange oncologist for it. With good recovery, the patient asked to be discharged soon. Hence he was discharged with oral medication and scheduled OPD follow-up including urology and oncology.
  • Discharge prescription
    • Bokey (aspirin 100mg) 1# QD
    • Diovan (valsartan 160mg) 1# QD
    • Duodart (dutasteride 0.5mg, tamsulosin 0.4mg) 1# QD
    • Norvasc (amlodipine 5mg) 1# QD
• 2018-02-05 Urology Lin JiaDa
  • S: PCa T3bN0M0, ADT since 2017/10/16 (androgen deprivation therapy)
  • Diagnosis
    • Enlarged prostate with lower urinary tract symptoms [N40.1]
    • Malignant neoplasm of prostate [C61]
  • Prescription
    • Leuplin depot (leuprorelin 3.75mg) Q1M SC
    • Harnalidge (tamsulosin 0.4mg) 1# QDAC
    • Androcur (cyproterone acetate 50mg) 1# TID

[consultation]

• 2023-04-14 Neurology
  • Q
    • CVA Call
  • A
    • This 78 y/o man has a history of PAOD s/p stent and on Aspirin, HTN, and prostate cancer. He was normal until acute generalized weakness during dinner. He could barely stand on his own and presented with slurred speech. Therefore he was sent to our ER.
      • NE E4V5M5-6
        
      • CNs: normal EOM
      • moderate dysarthria
      • MP upper >4/>4 lower >3/>3
      • sensation: intact
      • FNF: no dysmetria
      • brain CT: no ICH
      • NIHSS 001 000 1122 00010 (8) at 21:05
      • CXR: right lung field mass lesion
    • impression: acute ischemic stroke
    • suggestion:
      • give rt-PA therapy 56mg (93.9Kg., 0.6mg/kg, total 56mg) with family’s agreement
      • do brain + chest CTA, consider EVT if LVO
      • arrange neurology ICU admission.
  • A 22:30
    • brain CTA: no LVO
    • improved dysarthria and MPs
    • had explained to the family

[chemotherapy]

• 2023-11-28 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + cisplatin 30mg/m2 40mg NS 350mL 3hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-11-21 - gemcitabine 1000mg/m2 1800mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 350mL 3hr
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2023-12-06

[leukopenia improved]

The administration of Granocyte (lenograstim) for 3 consecutive days, starting from 2023-12-03, has effectively improved the patient’s condition of leukopenia.

• 2023-12-06 WBC 2.78 x10^3/uL
  
• 2023-12-04 WBC 0.91 x10^3/uL
  
• 2023-12-02 WBC 0.33 x10^3/uL

2023-12-04

[leukopenia]

Two rounds of the gemcitabine and cisplatin regimen were given on 2023-11-21 and 2023-11-28. A leukopenia episode occurred on 2023-12-02, reaching a nadir WBC count of 0.33K/uL, and was treated with three consecutive days of Granocyte (lenograstim 250ug). Following this treatment, an initial increase in white blood cell count was observed.

• 2023-12-04 WBC 0.91 x10^3/uL
  
• 2023-12-02 WBC 0.33 x10^3/uL nadir
• 2023-11-28 WBC 2.21 x10^3/uL
  
• 2023-11-20 WBC 3.28 x10^3/uL
  
• 2023-10-31 WBC 4.52 x10^3/uL

The second session of treatment involved a reduced dose compared to the first, utilizing two-thirds of the gemcitabine dose and 80% of the cisplatin dose. The use of G-CSF did not present any issues.

[thrombocytopenia]

Thrombocytopenia has developed, and leukocyte-reduced platelet pheresis (LRP) is being administered (2023-12-04). Please continuously monitor the patient’s PLT levels.

• 2023-12-04 PLT 29 *10^3/uL
  
• 2023-12-02 PLT 51 *10^3/uL
  
• 2023-11-28 PLT 96 *10^3/uL
  
• 2023-11-20 PLT 164 *10^3/uL
  
• 2023-10-31 PLT 171 *10^3/uL

[EGFR testing for SCC lung cancer]

Based on the available evidence, testing for EGFR mutations in patients with squamous cell carcinoma (SCC) of the lung is a topic of debate and ongoing research. While EGFR mutations are more commonly associated with lung adenocarcinoma, there is evidence to suggest that a small percentage of SCC patients also harbor EGFR mutations (Si et al., 2022; Nishimura et al., 2023). The presence of EGFR mutations in SCC lung cancer patients is important because these mutations can predict sensitivity to EGFR tyrosine kinase inhibitors (TKIs) (Shigematsu & Gazdar, 2006). However, the efficacy of EGFR-TKIs in SCC patients with sensitive EGFR mutations remains unclear (Chang et al., 2021). Additionally, the prevalence of EGFR mutations in SCC patients has been reported to be about 1-5% Si et al. (2022).

• Ref:
  • Si et al (2022). Clinical outcomes of egfr-tkis in advanced squamous cell lung cancer. Neoplasma, 69(04), 976-982. https://doi.org/10.4149/neo_2022_220329n348
  • Nishimura et al (2023). Next‐generation sequencing clarified why first‐line treatment with osimertinib was ineffective in an autopsied case of egfr‐mutated lung squamous cell carcinoma. Thoracic Cancer, 14(7), 709-713. https://doi.org/10.1111/1759-7714.14807
  • Shigematsu et al (2006). Somatic mutations of epidermal growth factor receptor signaling pathway in lung cancers. International Journal of Cancer, 118(2), 257-262. https://doi.org/10.1002/ijc.21496
  • Chang et al (2021). Epidermal growth factor receptor mutation status and response to tyrosine kinase inhibitors in advanced chinese female lung squamous cell carcinoma: a retrospective study. Frontiers in Oncology, 11. https://doi.org/10.3389/fonc.2021.652560

700040427

231205

[exam findings]

[MedRec]

• 2023-07-11 ~ 2023-07-15 POMR Colorectal Surgery Chen ZhuangWei
  • Discharge diagnosis
    • Rectal cancer with lumen narrowing and impending obstruction, cT4bN1M1a, stage IVa (r/o right upper lobe, right lower lobe and left upper lobe metastases) status post Loop-T colostomy and port-A implatation on 2023/07/12
    • Prostatic acinar adenocarcinoma (Gleason score 9 = 4 + 5 ), grade group 5, iPSA 129, stage cT4N1M0, very high risk group, status post radiotherapy, chemotherapy, and status during androgen deprivation therapy
    • Carrier of viral hepatitis B
    • Hypertension
  • CC
    • Tenesmus about 20 times per day, abdominal fullness, sometimes fecal incontinence and weight loss 10kg for about 3 months.
  • Present illness
    • A 66-year-old male had history of
      • Prostate adenocarcinoma, Gleason score 4+5, PSA 129, cT4N1M0, grade group 5 status post transurethral resection of the prostate on 2022/09/28, status post adjuvent concurrent chemoradiotherapy (2022/11~2023/2) and Androgen deprivation therapy (2023/2~), well controlled.
      • Bladder stone status post cystolithotripsy on 2021/11/01
      • Hepatitis B carrier
      • Hypertension
    • This time, he sufferred from tenesmus about 20 times/day, abdominal fullness, sometimes fecal incontinence and weight loss 10kg in 3 months. He visited GI OPD and sigmoidoscopy revealed a ulcerative tumor at lower rectum with lumen narrowing.
    • Lab data revealed CEA 166.710 ng/ml. Biopsy showed adenocarcinoma. So, he was referred to CRS OPD. At OPD, digital examination revealed a palpable tumor lesion at middle rectum, 6cm from anal verge.
    • Chest and abdominal CT revealed thickening wall at the rectum abutting to seminal vesicle. Bilateral upper lung and right lower lung nodules, suspect metastasis. cT4bN1M1a, stage IVA.
    • PET CT also showed 1. Glucose hypermetabolism in the rectum with invasion to seminal vesicle, 2. Three glucose hypermetabolic lesions in the upper and lower lobes of the right lung and upper lobe of the left lung respectively. Lung metastases can not be ruled out.
    • After discussion with patient, he was admitted for T-loop colostomy and port-A implanation for chemotherapy and target therapy.
  • Course of inpatient treatment
    • After admission, we consulted GS for port-A implanation. Pre-op and anesthesia assessment was done. Loop-T colostomy and port-A implanation were performed smoothly on 2023/07/12.
    • After operation, no specific complain except for mild decreased appetite, bloating and wound pain, subsided by medicine.
    • Under relative stable condition, we arranged his discharge on 2023/07/15 and OPD follow up.
  • Discharge prescription
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

• 2023-07-12
  • Surgery: T-loop colostomy        
  • Finding: T-colon was identified and T-loop colostomy was created at RUQ abdomen wall. The whole procedure was smooth. 

[radiotherapy]

[immunochemotherapy]

• 2023-12-04 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 375mg D5W 250mL 90min + leucovorin 400mg/m2 830mg NS 250mL 2hr + fluorouracil 2400mg/m2 5000mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-10-30 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-10-09 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4850mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-09-18 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-08-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 780mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-08-14 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 790mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-07-26 - + irinotecan 160mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
• 2022-12-21 - docetaxel 75mg/m2 120mg NS 250mL 1hr (docetaxel, Q3W)
• 2022-11-21 - docetaxel 75mg/m2 140mg NS 250mL 1hr (docetaxel, Q3W)

==========

2023-09-18

The patient recently obtained a 28-day supply of Norvasc (amlodipine) and Diovan (valsartan) on 2023-09-12, to manage his primary hypertension. These drugs have been added to the active medication list, and there were no reconciliation issues identified.

700101071

231204

[diagnosis] - 2023-03-20 admission note

• Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites
• Peripheral T-cell lymphoma T3N3M1 stage4
• Type 2 diabetes mellitus without complications
• Essential (primary) hypertension
• Mixed hyperlipidemia
• Constipation, unspecified
• Chronic viral hepatitis B without delta-agent
• Insomnia, unspecified

[past history] - 2023-03-20 admission note

• Type 2 diabetes mellitus and hypertension for 20+ years under medications treatment.
• Mixed hyperlipidemia for 5 years with medications control and cancle medications treatment recently
• Past operation history: VATS exciosion of mediastinal nodules on 2022/12/06

[exam findings]

• 2023-09-13 MRI - brain
  • Without-contrast multiplanar cerebral MRI revealed (Image quality: no gross motion artifacts)
    • moderate dilated intraventricular and extraventricular CSF spaces
    • punctate white amtter gliosis in the supratentorial brain; mild bilateral periventricular leukoaraiosis; old lacunar infarction in the bilateral basal ganglia.
    • unremarkable change in the skull base
  • IMP: brain atrophy; no evidence of brain tumors.
• 2023-09-12 PET
  • The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple lymph nodes on both sides of the diaphragm. In comparison with the previous study on 2022/12/16, the glucose hypermetabolism in some neck lymph nodes, some axillary lymph nodes, mediastinal and bilateral pulmonary hilar lymph nodes and some inguinal lymph nodes are a little more evident. Lymphoma in a little more progression should be considered.
  • Inhomogenously and mildly increased FDG uptake in the spleen and in the bone marow of the skeleton. Lymphoma involving the spleen and bone marow can not be ruled out. Please correlate with other clinical findings for further evaluation.
  • Mildly increased FDG uptake in some focal areas in the lower lobes of bilateral lungs. Inflammation may show this picture.
• 2023-09-11 CT - chest
  • Comparison was made with CT on 2023/06/16
    • interval increased size and number of multiple enlarged LNs at neck, bilateral axillary regions, mediastinum, retroperitoneum, mesentery and bil. inguinal regions as compared with previous CT on 6/16.
    • Lungs:a 6mm solid nodule at medial LLL and focal nodular septla thickening at RLL-superior segment.
      • mosaic attenuation changes in both lungs on inspiratory images.
    • extensive 3-vessls coronary arterial calcification
      • small anterior pericardial effusion.
    • Pleura: no effusion
    • moderate splenomegaly.
    • no abnormal density and size of the liver, GB, both adrenal glands, pancreas, and both kidneys.
  • Impression:
    • T-cell lymphoma involving both sides of diaphgram s/p C/T, in progression as compared with previous CT on 2023/06/16.
    • LLL and RLL lesions, secondary involvvement or infection.
• 2023-06-16 CT - abdomen
  • History: T cell lymphoma
  • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status can not be determined without IV contrast.
  • Findings: Comparison prior CT dated 2022/12/15.
    • Prior CT identified multiple enlarged LNs at neck, bil. axillary regions, mediastinum, gastrohepatic ligament, celiac trunk, para-aortic space, para-cava space, mesentery and bil. inguinal regions are noted again, marked decreasing in size that is c/w T-cell lymphoma S/P C/T with partial response.
    • Prior CT identified splenomegaly (the largest dimension: 15.5 cm) is noted again, stationary.
    • Prior CT identified some nodules (up to 7mm) at bil. lungs are noted again, mild decreasing in size.
  • IMP:
    • T-cell lymphoma S/P C/T show partial response.
• 2023-06-10 Nasopharyngoscopy
  • Findings:
    • lump in throat and odynophagia for one month, patient has strong gap reflex, hard to assess NP and larynx by mirror
  • Diagnosis/conclusion
    • Nasopharyngoscope findings: Smooth NP, Laryngx: mild edematous change of laryngeal mucosa
• 2023-04-13 SONO - nephrology
  • right mild hydroureter
  • left renal cyst
• 2023-04-12 KUB
  • increased air in nondistended loops of small bowel over LUQ and RUQ, could be paralytic ileus.
  • The size & contour of the kidneys, visualized portion of spleen and liver, and psoas shadows, properitoneal & pelvis fat lines, are unremarkable.
  • Rt L5-S1 facet joint osteoarthritis.
  • s/p foley catheter insertion in the urinary bladder.
• 2023-02-27 CXR
  • Atherosclerotic change of aortic arch
  • Linear infiltration over both lung zone are noted. please correlate with clinical symptom to rule out inflammatory process.
  • Please correlate with CT.
• 2023-02-27 Nerve Conduction Velocity, NCV
  • Findings
    • The NCV study showed (1) absence of CMAP in left peroneal nerve, (2) prolonged distal motor latency in bilateral median, bilateral ulnar, and left tibial nerves, (3) reduced CMAP amplitude in all the sampled nerves, (4) decreased motor nerve conduction velocity in all the sampled nerves, (5) absence of SAP in left sural nerve, (6) reduced SAP amplitude in left median and ulnar nerves, (7) decreased sensory nerve conduction velocity in all the sampled nerves.
    • The F-wave study showed (1) absence of F-wave in left peroneal nerve, (2) prolonge minimal F-wave latency in all the sampled nerves.
    • The H-reflex study showed (1) absence of H-wave in left tibial nerve, (2) prolonged H-wave latency in right tibial nerve.
    • The EMG showed (1) poor recruitment of MUAP in right biceps brachii and right rectus femoris muscles, (2) fasciculation, fibrillation, and poor recruitment of MUAP in right tibialis anterior muscles.
  • Conclusion
    • The above findings suggest sensorimotor polyneuropathy with demyelinating pattern. Advise clinical correlation.
• 2023-02-15 MRI - L-spine
  • diffuse high SI change on T2WI in the bilateral L-spine posterior perivertebral muslces and bilateral gluteal muscles.
  • herniated disc in the L4/5 idsc.
  • discitis in the L4/5 disc.
• 2023-02-14 CXR
  • Atherosclerotic change of aortic arch
  • Linear infiltration over left lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Few nodular opacities projecting at left lung are suspected.
  • Please correlate with CT.
• 2023-02-13 SONO - abdomen
  • cholecystopathy
  • renal cyst, LK
  • small amouont ascites
• 2022-12-20 ECG
  • Sinus tachycardia
  • poor wave progression
• 2022-12-16 Whole body PET scan
  • The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple lymph nodes on both sides of the diaphragm.
  • Inhomogenously increased FDG uptake in the spleen and in the bone marow of the skeleton. Lymphoma involving the spleen and bone marow should be considered. Please correlate with other clinical findings for further evaluation.
• 2022-12-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 25) / 75 = 66.67%
    • M-mode (Teichholz) = 66
  • Preserved LV and RV systolic function with normal wall motion
  • Grade 1 LV diastolic dysfunction
• 2022-12-15 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Positive for malignant T-cell lymphoma
  • Microscopically, it shows bone marrow tissue with presence of aggregations of T-cell lymphomatous cells.
  • Immunohistochemical stain reveals CD5(+), CD3(+), CD20(-), CD117(-), CD34(-), CD71(focal+), MPO(+),and CD138(-).
• 2022-12-15 CT - abdomen
  • Findings
    • Enlarged LNs at neck, bil. axillary regions, mediastinum, retroperitoneum, peritoneal cavity and bil. inguinal regions.
    • Splenomegaly.
    • Some nodules (up to 7mm) at bil. lungs.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP
    • Lymphoma as described.
• 2022-12-08, -12-06 CXR
  • s/p right chest tube in place, its tip directed medially, projecting over 6th intercostal space
  • minimal right pneumothorax .
  • widening of Rt paratracheal stripe
  • Platelike lung atelectasis over Lt lower lung zone
• 2022-12-06 Patho - lymph node region resection
  • Lymph node, right, paratracheal, excision — Malignant T-cell lymphoma
  • Specimen submitted in formalin consists of 4 pieces of tan, irregular tissue measuring up to 5.0 x 2.0 x 1.5 cm. Several enlarged lymph nodes, measuring up to 3.5 x 2.0 x 1.5 cm, are founs and all for section in 3 cassettes A1-3 (A1-2: the same level).
  • Sections show lymph nodes with diffusely infiltration of medium-sized lymphocytes. Vascular proliferation and hyperplasia of follicular dendritic cells are seen.
  • The immunohistochemical stains reveal CK(-), CD3(+), CD5(+), CD4(+), CD8(+), CD20(-), CD56(-), Granzyme B(-), TdT(-), BCL2(+), CD30(-), CD10(-), BCL6(-), PD1(-), ICOS(-), and SAP(-).
  • The results are consistent with peripheral T-cell lymphoma, NOS. Please correlate with the clinical presentation and image study.
• 2022-11-22 CT - chest
  • Findings
    • Lungs:
      • an oval-shaped LUL-S1/2 solid nodule adjacent to the najor fissure (7.6 mm srs).
      • an oval-shaped RML solid nodule(4mm srs).
      • favor intrapulmonary lymph node
      • normal pulmonary attenuation on inspiratory images, with mild patchy areas air-trapping in both lower lobes.
      • differential diagnosis include obstructive chronic airway disease, hypersensitive pneumonitis, and bronchiolitis obliterans,
    • Mediastinum and hila: enlarged LNs in the visceral space and small LNs in visceral and left anterior prevascular spaces
    • Vessels:
      • calcified plaques of the coronary arteries, extensive in LAD artery
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: multiple enlarged LNs at supraclavicular fossae and both axillary regions.
    • Visible abdominal contents: moderate splenomegaly,
  • Impression:
    • lymphoma or other hematological disease or metastatic tumors in aforementioned regions.
    • suspected obstructive small airways disease in lowef lobes of lungs.
• 2019-10-14 Thyroid Ultrasound
  • Suspected Autoimmune thyroid disease

[MedRec]

• 2022-12-14 ~ 2022-12-23 POMR Hemato-Oncology Wan XiangLin
  • Discharge diagnosisw
    • Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites
    • Gout, unspecified
    • Hyponatremia
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Mixed hyperlipidemia
    • Constipation, unspecified
    • Chronic viral hepatitis B without delta-agent
    • Insomnia, unspecified
  • CC
    • for lymphoma staging work-up
  • Present illness
    • This 59 year-old patient has past history of type II diabetes mellitus and hypertension for 20+ years under medications treatment; mixed hyperlipidemia for 5 years and cancle medications treatment recently; new diagnosis lymphoma in 2022/12.
    • According patient’s statement, he suffered from dry cough persist for 3 months. He denied has fever, chilliness, chest pain, chest tightness or hemoptysis noted occured. Chest CT revealed mediastinum and hila has enlarged LNs in the visceral space and small LNs in visceral and left anterior prevascular spaces; impression of lymphoma or other hematological disease or metastatic tumors in aforementioned regions; r/o obstructive small airways disease in lowef lobes of lungs. The patient also told of appetite decrease and body weight loss about 10 kg in recent 6 months (abdout 70 kg decrease to 57 kg). Operation of video-assisted thoracoscopic surgery exciosion of mediastinal nodules was performed smoothly on 2022/12/06. Pathology oral presentation T cell lymphoma, waiting for formal report.
    • This time, he was admitted for staging work-up with whole body CT, bone marrow, PET-CT, Port-A insetion.
  • Course of inpatient treatment
    • After admission, bone marrow was done on 2022/12/15 and the report showed positive for malignant T-cell lymphoma.
    • Pathology showed Lymph node, right, paratracheal, excision — Malignant T-cell lymphoma, peripheral T-cell lymphoma, NOS on 2022/12/15.
    • ROMICON-A  20,20,90mg/cap 1# PO TID、Actein 66.7 mg/gm 1pk PO TID for cough.
    • Abdominal CT (from ABD to Chest) on 2022/12/15 showed enlarged LNs at neck, bil. axillary regions, mediastinum, retroperitoneum, peritoneal cavity and bil. inguinal regions; splenomegaly; some nodules (up to 7mm) at bil. lungs => IMP: Lymphoma as described, atherosclerosis of aorta, iliac arteries.
    • PET scan on 2022/12/16 showed 1. The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple lymph nodes on both sides of the diaphragm; 2. Inhomogenously increased FDG uptake in the spleen and in the bone marow of the skeleton.
    • 2D echo on 2022/12/16 showed LVEF 66%, preserved LV and RV systolic function with normal wall motion, grade 1 LV diastolic dysfunction.
    • Port-A implantation on 2022/12/19, given Acetal 500 mg/tab 1# PO PRNQ6H if VAS>3.
    • Hyponatremia (Na 129 mmol/L) with N/S 1500ml hydration from 2022/12/14.
    • Type 2 diabetes mellitus with Glimet F.C 2mg & 500mg/tab 1# PO BIDCC, Dibose F.C. 100mg/tab 1# PO BIDCC and Soliqua 3mL/pre-filled pen 16 Unit SC QN, monitor blood sugar by one touch, due to Hypoglycemia was noted, adjust to 12 unit SC QN.
    • Hypertension with Aprovel 300mg/tab (Irbesartan) 1# PO QD and Aspirin 100 mg/cap 1# PO QD.
    • Mixed hyperlipidemia with Tulip F.C. 20mg/tab 1# PO QD.
    • Constipation with Through 12mg/tab 1# PO HS.
    • Chronic viral hepatitis B (Anti-HBc : reactive) with Vemlidy 25 mg/tab 1# PO QDCC.
    • Insomnia with Anxiedin 0.5mg/tab # PO PRNHS if insomnia.
    • Discussion with patient and family about disease condition and future treatment on 2022/12/19 and transfer service to Dr. Wan on 2022/12/20.
    • After transferring to Dr. Wan’s service, we checked HTLV-1,2 which showed nonreactive. After discussion with the patient and his family, they decided to undergo chemotherapy.
    • Chemotherapy (CHOP) prepare including blood test, normal saline 500ml + rolikan 40ml BID, Feburic 1# QD were arranged. We then arranged chemotherapy with CHOP on 2022/12/22.
    • Also, we checked finger sugar QIDAC, and adjusted insulin dosage to Tresiba 8 Unit HS + NovoRapid 4 Unit TIDAC with scale by meta doctor’s suggestion.
    • He had no significant discomfort after chemotherapy. Under stable condition, he discharged on 2022/12/23 and OPD follow up was arranged.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQID
    • Actein (acetylcysteine 200mg) 1# TID
    • Feburic (febuxostat 80mg) 1# QD
    • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Through (sennoside 12mg) 1# HS
    • Ulstop (famotidine 20mg) 1# QD
    • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
    • Compesolon (prednisolone 5mg) 9# QD
    • Compesolon (prednisolone 5mg) 9# QN
    • Alpraline (alprazolam 0.5mg) 1# PRNHS
• 2022-12-05 ~ 2022-12-09 POMR Chest Surgery Xie MinXiao
  • Discharge diagnosis
    • Malignant T-cell lymphoma status post video-assisted thoracoscopic surgery exciosion of mediastinal nodules on 2022-12-06
    • Mediastinal lymphadenopathy status post video-assisted thoracoscopic surgery exciosion of mediastinal nodules on 2022-12-06
    • Type 2 diabetes mellitus without complications
    • Essential hypertension
    • Mixed hyperlipidemia
  • Course of Inpatient Treatment
    • After admission, pre-op assessment was done.
    • Operation of video-assisted thoracoscopic surgery exciosion of mediastinal nodules was performed smoothly at 2nd admission day. No complication was noted. Prophylactic antibiotics was prescribed for 1 day.
    • Dysuria was noted after removal foley and ICP U/O 350 ml ST at post op day 1, Bethanechol were prescribed and voiding smoothly by patient himself.
    • Right chest tube with LPS -18 cmH2O was done. Chest tube was removed at post-op 2nd day. He was discharged under stable hemodynamics at post-op 3rd day.
  • Prescription
    • Actein (acetylcysteine 66.7mg) 1# TID
    • MgO 250mg 1# TID
    • Wecoli (bethanechol 25mg) 1# TIDAC
    • Acetal (acetaminophen 500mg) 1# QID
    • Sindine (povidone iodine) QD EXT (for wound dressing change)
• 2022-11-29 SOAP Chest Surgery
  • P
    • arrange admission on 12/5
    • VATS mediastinal nodule excision on 12/6.
• 2022-11-28 SOAP Chest Medicine
  • S: dry cough persist for 3 months, no short of breath
  • O: 2022/11/22 CT: lymphoma or other hematological disease or metastatic tumors in aforementioned regions; r/o obstructive small airways disease in lowef lobes of lungs; calcified plaques of the coronary arteries, extensive in LAD artery
  • P
    • refer to chest surgeon for mediastinal lymphadenopathy suspected lymphoma
    • refer to oncologist for mediastinal lymphadenopathy suspected lymphoma
• 2017-10-30 SOAP Metabolism
  • S: Drugs will be collected at our hospital in the future. referred to the PharmaCloud.
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
  • Prescription
    • Aprovel (irbesartan 300mg) 1# QD
    • Tulip (atorvastatin 20mg) 1# QOD
    • Bokey (aspirin 100mg) 1# QD
    • Forxiga (dapagliflozin 10mg) 1# QDCC
    • Glimet (glimepiride 2mg, metformin 500mg) 1# QDCC
• 2017-10-23 SOAP Ophthalmology
  • Diagnosis
    • Vitreous hemorrhage, right eye [H43.11]
    • Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema [E11.351]
• 2017-10-18 SOAP Metabolism
  • S: type 2 DM since 2012 , hypertension , irregular Tx before , hyperlipidemia , hyperuricemia, poor control, family Hx of DM: (+)
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
• 2017-10-17 SOAP Ophthalmology
  • S
    • refer from LMD vitrous hemorrha OD
    • Blurred visionBlurred vision
    • DM for fundus exam
    • DM+, HTN-, NKA
  • Diagnosis
    • Vitreous hemorrhage, right eye [H43.11]
  • Prescription
    • Trand (tranexamic acid 250mg) 1# BID

[consultation]

• 2023-05-12 Ear Nose Throat
  • Q
    • for right ear pain & sorethroat R/O otitis media
    • He complained of right ear pain & sorethroat for days. We need expertise to evaluate his condition thanks!
  • A
    • Ear: bilateral cerumen impaction, after removal, bilateral ear drum intact without middle ear effusion.
    • Oral cavity and oropharynx: injected posterior pharyngeal wall.
    • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx and hypopharynx. Patent airway.
    • Impression: Impending acute tonsillitis, bilateral cerumen impaction
    • Plan: Please give sulconazole solution Exelderm for bilateral ear, and please provide Curam for 5 days and analgesic agent if not contraindicated.
• 2023-02-09 Dermatology
  • Q
    • This 60 year-old patient has past history of type II diabetes mellitus and hypertension for 20+ years under medications treatment; mixed hyperlipidemia for 5 years and cancle medications treatment recently; new diagnosis lymphoma in 2022/12.
    • He was under CHOP (cyclophosphenide + doxorubicin + vincrinstine + compesolon) chemotherpay with C1 on 2022/12/22 and C2 on 2023/01/13. This time, he was admitted for C3 CHOP chemotherapy.
    • We strongly need your expertise for lips rash and ulcer, suspected Herpes skin rash. Mucosa inside the mouth showed no ulcer, but there were ulcer noted at his lips. Due to immunosuppression state under chemotherapy, we strongly need your expertise for evaluation and management. Thank you very much.
      
  • A
    • The patient had sufferred from perioral scaling crust with erythematous macules (upper and lower lips and corners of the mouth) with mild stinging and itchy sensation.
      
    • Under the impression of exfoliative chelitis with secondary candidasis.
    • The following sugeetion:
      • Tetracycline onit 2 tube topical bid use first (First, apply it broadly, which can be used as a base for lip balm).
      • Mycomb cream 1 tube topical bid use over regional erythematous scaling lesions (use it locally on areas with surrounding redness and flaking skin).

[surgical operation]

• 2022-12-06 - Op Method: VATS exciosion of mediastinal nodules
  • Finding: Multiple enlarged mediastinal LNs.

[chemoimmunotherapy]

• 2023-06-16 - cyclophosphamide 750mg/m2 800mg NS 250mL 30min + doxorubicin 50mg/m2 40mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, 75% Endoxan for poor renal function, 60% Adriamycin for GPT 88)

  •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug                       + NS 250mL

• 2023-05-15 - cyclophosphamide 750mg/m2 790mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, reduced Endoxan for poor renal function)

  •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL

• 2023-03-24 - cyclophosphamide 750mg/m2 780mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, reduced Endoxan for poor renal function)

  •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL

• 2023-02-14 - cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 60mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP)
  • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
• 2023-01-13 - cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 74mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP)
  • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
• 2022-12-22 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 80mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID D1-5 (CHOP)
  • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL

==========

2023-07-17

It appears that there is a suspicion of AKI in this patient due to the decline in renal function.

• 2023-07-16 Creatinine 4.13 mg/dL
  

• 2023-07-03 Creatinine 1.68 mg/dL

• 2023-07-16 eGFR 15.77
  

• 2023-07-03 eGFR 44.52

• 2023-07-16 BUN 71 mg/dL
  

• 2023-07-03 BUN 29 mg/dL

Based on the patient’s current renal status, the dosage of drugs in the active formulary has been reviewed and no adjustment is required.

2023-06-26

• According to the PharmaCloud database, our hospital has been the sole provider of all required medical services and medications for this patient for the past 3 months.

• Our endocrinologist recently prescribed a refillable regimen of Tresiba Flex Touch (insulin degludec), Relinide (repaglinide), Trajenta (linagliptin), Aprovel (irbesartan), Tulip (atorvastatin), and Bokey (aspirin) on 2023-06-20. These drugs were added to the patient’s active medication list. As a result, no medication reconciliation issues were identified.

• The most recent administration of CHOP was on 2023-06-16, and subsequent lab results indicate that leukopenia is still progressing. The use of G-CSF is covered by NHI when WBC < 1000/uL or ANC < 500/uL. Therefore, if the patient’s lab results meet these criteria, the use of G-CSF could be an appropriate management strategy. Please continue monitoring the patient’s WBC and ANC levels to make informed decisions about future treatment strategies.

  • 2023-06-26 WBC 1.24 x10^3/uL
    
  • 2023-06-25 WBC 1.43 x10^3/uL
    
  • 2023-06-14 WBC 4.84 x10^3/uL

2023-06-15

• Upon review of the PharmaCloud database, it is observed that the patient has exclusively sought medical care at our hospital for the past three months. No issues related to medication reconciliation have been identified.

• The patient’s renal function has remained insufficient over the past month, with an eGFR of 26 on 2023-06-15. The dose of cyclophosphamide in the CHOP regimen has been adjusted in response to this renal insufficiency. Please continue to monitor the patient’s renal function and consider whether further dose adjustments are necessary.

  • 2023-06-15 Creatinine 2.64 mg/dL
    
  • 2023-06-14 Creatinine 2.92 mg/dL
    
  • 2023-05-26 Creatinine 2.41 mg/dL
    
  • 2023-05-15 Creatinine 2.11 mg/dL
    
  • 2023-06-15 BUN 54 mg/dL
    
  • 2023-06-14 BUN 56 mg/dL
    
  • 2023-05-26 BUN 64 mg/dL
    
  • 2023-05-15 BUN 44 mg/dL

• In addition, the LFT also demonstrated an increase in ALT. According to Folyd’s 2006 recommendations, when a patient’s transaminases are 2 to 3 times the ULN, the dose of doxorubicin should be reduced to 75% of the standard dose. (The manufacturers’ guidelines suggest adjusting doses based on serum bilirubin levels. However, the most recent test results show that this patient’s bilirubin level is within the normal range.)

  • 2023-06-14 S-GPT/ALT 88 U/L
    
  • 2023-05-26 S-GPT/ALT 27 U/L

2023-05-12

• Based on the PharmaCloud database, the patient has only visited our hospital for medical needs in the past three months. After reviewing the database, no medication reconciliation issues were identified.

• Lab results on 2023-05-11 indicate creatinine 3.26 mg/dL, eGFR 20.72, BUN 83 mg/dL, demonstrating the patient’s renal insufficiency. The rationale for dose adjustment in the CHOP regimen for patients with renal impairment is as follows:

  • cyclophosphamide
    • There are no dosage adjustments provided in the manufacturer’s labeling
    • Aronoff 2007
      • CrCl >=10 mL/minute: No dosage adjustment required.
      • CrCl <10 mL/minute: Administer 75% of normal dose.
    • KDIGO 2012: Lupus nephritis
      • CrCl 25 to 50 mL/minute: Administer 80% of normal dose.
      • CrCl 10 to <25 mL/minute: Administer 70% of normal dose.
  • doxorubicin
    • There are no dosage adjustments provided in the manufacturer’s labeling; however, adjustments are likely not necessary given limited renal excretion.
  • vincristine
    • No dosage adjustment necessary
  • prednisolone
    • No dosage adjustment necessary

• The cyclophosphamide dose has been reduced to 75% since the last administration on 2023-03-24 as indicated without an issue.

• The other medications listed in the active prescription should be used with caution, considering the patient’s renal insufficiency (ref: UpToDate):

  • cimetidine
    • There are no dosage adjustments provided in the manufacturer’s labeling; use with caution. Severe kidney impairment: 300 mg every 12 hours; may increase frequency with caution. When hepatic impairment is also present, further reductions in dosage may be necessary.
    • Alternate recommendations (Aronoff 2007):
      • GFR >50 mL/minute: No dosage adjustment necessary.
      • GFR 10 to 50 mL/minute: Administer 50% of normal dose.
      • GFR <10 mL/minute: 300 mg every 8 to 12 hours.
  • silodosin
    • CrCl >50 mL/minute: No dosage adjustment necessary.
    • CrCl 30-50 mL/minute: 4 mg once daily.
    • CrCl <30 mL/minute: Use is contraindicated.
  • tenofovir alafenamide
    • Tenofovir is renally cleared, and exposures are increased in patients with CrCl <30 mL/minute and those receiving hemodialysis. Close monitoring for adverse effects in the advanced stages of kidney dysfunction is recommended.
    • Kidney impairment prior to treatment initiation:
      • CrCl >=15 mL/minute: No dosage adjustment necessary.
      • CrCl <15 mL/minute: Use is not recommended.

• Please continue to monitor regularly and consider dose adjustments as needed based on patient renal function.

2023-03-21

• The acute kidney injury (AKI) episode that occurred in late Feb 2023 appears to have subsided.
  • 2023-03-21 Creatinine 2.78 mg/dL
    
  • 2023-03-20 Creatinine 3.24 mg/dL
    
  • 2023-03-02 Creatinine 2.60 mg/dL
    
  • 2023-02-27 Creatinine 3.43 mg/dL
    
  • 2023-02-25 Creatinine 3.80 mg/dL
    
  • 2023-02-23 Creatinine 4.66 mg/dL
    
  • 2023-02-22 Creatinine 5.21 mg/dL
    
  • 2023-02-21 Creatinine 5.15 mg/dL
    
  • 2023-02-14 Creatinine 1.50 mg/dL
    
  • 2023-02-10 Creatinine 1.13 mg/dL
    
  • 2023-02-09 Creatinine 1.22 mg/dL
    
  • 2023-02-08 Creatinine 1.84 mg/dL
    
  • 2023-01-20 Creatinine 0.95 mg/dL
    
  • 2023-01-12 Creatinine 1.00 mg/dL
    
  • 2023-01-06 Creatinine 1.41 mg/dL
    
  • 2023-01-03 Creatinine 1.16 mg/dL
    
  • 2023-01-01 Creatinine 1.15 mg/dL
• 2023-03-21 CrCl 19mL/min, eGFR 24.98.
  • Silodosin use is not recommended for patients with a CrCl below 30 mL/minute.
  • Metformin use is contraindicated for patients with an eGFR below 30 mL/minute/1.73m2.
  • For patients with an eGFR between 15 and 60 mL/min/1.73m2, glimepiride use may result in reduced renal clearance of active metabolites, increasing the risk of hypoglycemia.
  • Acarbose use is generally not advised for patients with a serum creatinine level above 2 mg/dL or a CrCl below 25 ml/minute/1.73m2, as the systemic area under the curve (AUC) may increase six-fold.

2023-01-13

• Since around 2022/2023 new year’s eve, there has been no sign of neutropenia in the lab data.
  • 2023-01-12 WBC 9.41 x10^3/uL
    
  • 2023-01-06 WBC 51.96 x10^3/uL
    
  • 2023-01-03 WBC 1.66 x10^3/uL
    
  • 2023-01-01 WBC 0.16 x10^3/uL
    
  • 2022-12-30 WBC 0.30 x10^3/uL
    
  • 2022-12-22 WBC 6.75 x10^3/uL
    
  • 2022-12-14 WBC 9.13 x10^3/uL
    
  • 2022-12-05 WBC 7.96 x10^3/uL
    
  • 2022-11-29 WBC 10.69 x10^3/uL
• A grade 4 neutropenia developed around new year’s eve, just about 10 days after the patient had received last chemotherapy on 2022-12-22. The date of this chemotherapy was 2023-01-12, approximately one to two weeks after that date, when the Chinese New Year holiday is approaching. In order to prevent potential neutropenia during the long holidays, it is recommended to take steps in advance.

701506934

231201

[lab data]

2023-11-30 HBsAg Nonreactive
2023-11-30 HBsAg (Value) 0.35 S/CO
2023-11-30 Anti-HBc Reactive
2023-11-30 Anti-HBc-Value 6.35 S/CO
2023-11-30 Anti-HCV Nonreactive
2023-11-30 Anti-HCV Value 0.12 S/CO

[exam findings]

• 2023-11-29 CT - abdomen
  • Without and with contrast Abdomen CT showed
    • A fat containing tumor, about 82mm x 83mm x 79mm, in the right kidney was noted.
    • Partial calcified rim was noted in the lower pole of the right kidney.
    • High density fat stranding in the right perirenal space was noted.
    • Some air within the lesion was noted.
  • IMP:
    • r/o Angiomyolipoma in the right kidney with rupture and superimposed infectious process. Please correlate with U/A.

[consultation]

• 2023-11-29 Urology
  • Q
    • CC: cough and fever (up to 39’C) on and off for a month
    • Phx: renal tumor s/p
    • 2023-11-10 CT: A 8.4-cm right renal angiomyolipoma with hydronephrosis, rupture, and presence of adjacent hematoma.
  • A
    • This 42 y/o female has intermittent for about 1 month.
      • According to her statement, low grade fever happened weeks ago.
      • In mid November, she suffered from sudden weakness and was sent to ER at Chang-hua where abdominal echo showed right renal mass.
      • She was then transferred to Chang-hua Christian Hospital for further evaluation.
      • Abdominal CT on 11/23 revealed a 8cm right renal tumor with hematoma formation.
      • TAE was done but fever persisted in the following days.
      • She received antibiotic treatment but the condition was not improved.
      • Therefore, the patient decided to came to our ER for personal reason.
      • At our ER, lab data showed abnormal differential count.
      • Mild leukocytosis with elevated CRP level were also noted.
      • Furthermore, thrombocytosis to 1055k/ul was revealed in hemogram.
      • Follow-up abdominal CT showed stable size of right renal tumor and hematoma.
    • Imp:
      • Right renal tumor rupture, status post TAE on 2023/11/23
      • Thrombocytosis and abnormal differential count, cause to be determined
    • Plan:
      • Pain control
      • Please do further survey for hematology problem that could cause thrombocytosis and abnormal differential count.
      • Since the patient just received TAE about 1 week ago, there might be inflammation or tissue reaction. Emergent surgery was not indicated if her vital sign is stable.
      • Follow-up abdominal image would be needed if there is possibility of renal abscess formation
      • Please contact us if there is any related problem

==========

2023-12-01

[thrombocytosis]

Thrombocytosis improves, cause remains unclear.

• 2023-12-01 PLT 686 *10^3/uL
  
• 2023-11-30 PLT 863 *10^3/uL
  
• 2023-11-29 PLT 1055 *10^3/uL

Elevated D-dimer levels, in conjunction with elevated fibrinogen, can further indicate the increasing risk of thrombosis and cardiovascular complications. The combination of elevated fibrinogen and D-dimer levels is considered a stronger risk factor for thrombosis than either one alone. Close monitoring is essential.

• 2023-11-30 Fibrinogen (quant) 581.5 mg/dL
  
• 2023-11-30 D-dimer 5399.00 ng/mL(FEU)

701373652

231130

[diagnosis] - 2023-03-23 admission note

• Adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 ~ 2023/02/21, plus Panitumumab from 2023/02/21, progression of LNs, bones and liver metastases s/p FOLFOX from 2023/03/09
• Localized skin eruption due to drugs and medicaments taken internally
• Chronic viral hepatitis B without delta-agent
• Iron deficiency anemia, unspecified
• Hypertension
• Constipation, unspecified
• Encounter for antineoplastic chemotherapy

[past history]

• Hypertension for many years, regular medication with Norvasc                   

[allergy]

• NKDA

[family history]

• No known congenital disease was noted  
• No cancer in his family  

[lab data]

• 2022-11-18 Anti-HCV Nonreactive
  
• 2022-11-18 Anti-HCV Value 0.07 S/CO
  
• 2022-11-18 Anti-HBc Reactive
  
• 2022-11-18 Anti-HBc-Value 6.67 S/CO
  
• 2022-11-18 Anti-HBs 74.91 mIU/mL
  
• 2022-11-02 HBsAg(nuclear medicine) Negative
  
• 2022-11-02 HBsAg Value(nuclear medicine) 0.446

[exam findings]

• 2023-09-07, -06-08 CT - abdomen
  • S/P colon operation. Mild regression of LNs and liver metastases. Stable condition of bony metastases.
• 2023-03-09 CT - abdomen
  • History and indication: Adenocarcinoma of sigmoid colon with liver metastasis
  • IMP: S/P colon operation. Progression of LNs, bones and liver metastases.
• 2023-02-03 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spot in the right rib cage and increased activity in the maxilla, mandible, L4-5 spines, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
  • IMPRESSION:
    • Increased activity in the L4-5 spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Some faint hot spot in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2022-12-15 All-RAS + BRAF mutation
  • Tissue block No. S2022-19716 A3
  • RESULTS
    • All-RAS:
      • There was no variant detect in the KRAS/NRAS gene.
    • BRAF
      • There was no variant detect in the BRAF gene.
• 2022-12-15 KUB
  • There are Eqivocal osteoblastic change at L-spine and bilateral ilium that may be bony metastases? Please correlate with bone scan.
• 2022-12-08 ECG
  • Left anterior fascicular block
  • Minimal voltage criteria for LVH, may be normal variant
  • Septal infarct, age undetermined
• 2022-11-30 Patho - liver bipsy needle/wedge
  • Liver, CT guide biopsy — Metastatic adenocarcinoma, consistent with colorectal primary
  • The sections show moderately differentiated adenocarcinoma, composed of nests columnar neoplastic cells, arragned in glandular and cribrifrom patterns, in fibrous stroma. Dirty tumor necrosis is present.
  • IHC shows: CK7(-), CK20(focal +) and CDX2(+). The finding is consistent with metastatic colorectal adenocarcinoma.
• 2022-11-29 Patho - peritoneum biopsy
  • Labeled as “LN at retroperitoneum”, CT guided biopsy — poorly differentiated carcinoma.
  • IHC stains: CK (+), Ki-67 (15%), trypsin (-), CK20 (-), S-100 (-), CD56 (-), LCA (-), CD3 (-), CD20 (-), chromogranin A(-), synaptophysin (-).
  • Section shows round blue cell tumor with pseudo-lumina or pseudo-rossette-like pattern.
• 2022-11-10 - Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, sigmoid colon, laparoscopic sigmoid colectomy —- Adenocarcinoma, moderately differentiated
      
    • Resection margins: free
    • Lymph node, mesocolic, dissection -
      • Negative for malignancy (0/24)
      • Four tumor deposits are seen
    • Lymph node, IMA / SMA, dissection —- Not received
    • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1c(if cM0) or pStage IVB, pT3N1c(if cM1b(by CT finding)); please correlate with the clinical presentation.
  • Gross Description:
    • Operation procedure: laparoscopic sigmoid colectomy
    • Specimen site: sigmoid colon
    • Specimen size: 10.5 cm in length
      
    • Tumor size: 6.5 x 5.0 x 1.5 cm; annularly ulcerated
    • Tumor location: 2.6 cm and 1.5 cm away from the two resection margins, respectively.
    • Depth of invasion grossly: mesocolic soft tissue
    • Mucosa elsewhere: a polyp measuring 0.7 x 0.5 x 0.4 cm is seen
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as: A1: colon, non-tumor; A2: polyp; A3-6: tumor; A7-10: lymph node, mesocolic; B: proximal cut end; C: distal cut end.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: very close, Distance of tumor from margin: < 1 mm
        
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Present
    • Tumor Budding: Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: not available
    • Tumor Deposits: Present, Specify number of deposits: 4
    • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 0/24
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
      • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
      • Regional Lymph Nodes (pN): pN1c: No regional lymph nodes are positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/mesorectal tissues.
      • Distant Metastasis (pM): CT finding: if cM1b: Metastasis to two or more sites or organs is identified without peritoneal metastasis
    • Additional Pathologic Findings
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
      • A tubulovillous adenoma is seen.
• 2022-10-31 CT - abdomen
  • History and indication: Advanced sigmoid cancer (15-20AAV), s/p tattooed
    
  • Findings
    • Wall thickening of S-colon with adjacent fat stranding and regional LAP. Enlarged LNs at retroperitoneum.
    • Poor enhancing tumors in liver.
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • Collapse of gallbladder.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral basal lungs.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)

[MedRec]

• 2022-11-17 SOAP Hemato-Oncology Xia HeXiong
  • P
    • Arrange Port-A on 2022-11-22
    • After SDM with patient for the selection of bevacizumab or cetuximab/panitumumab, patient choice cetuximab/panitumumab
• 2022-11-17 SOAP Colorectal Surgery Xiao GuangHong
  • A: Sigmoid cancer with obstruction, liver metastasis, Stage IV
  • P: Suggest colectomy first then target + chemotherapy due to partial obstruction then re-evaluation of liver resection
• 2022-11-08 ~ 2022-11-22 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Advanced sigmoid cancer with nearly total obstruction with retroperitoneal lymph nodes and liver metastasis, cT4aN2bM1b, stage: IVB status post 3 dimensions Laparoscopic sigmoid colectomy on 2022/11/09
    • Malignant neoplasm of sigmoid colon
    • Hypertension
  • CC
    • Abdominal fullness, frequent defecation, tarry stool and body weigh loss 2kg within 1 years
  • Present illness
    • This is a 74-year-old male with underlying disease of hypertension. This time, he suffered from abdominal fullness, frequent defecation, tarry stool and body weigh loss 2kg within 1 years. Tracing back to his history, he had been to LMD (Dr Chen ZiLiang) for medical help and advanced sigmoid cancer (15-20AAV), s/p tattooed was told. Thus, he came to our CRS Dr. Xiao’s OPD for second opinion and Abdominal CT survey. Blood test done on 10/31 revealed HB 7.2 g/dL and no other special finding. Abdominal CT done on 10/31 showed colonrectal cancer T4aN2bM1b, STAGE:IVB. Due to above finding he was admitted to our ward for further pre-operation survey.
  • Course of inpatient treatment
    • This 74-year-old male patient was a case of sigmoid colon cancer, T4aN2bM1b, STAGE:IVB. He admitted on 2022-11-08 and 3D Laparoscopic sigmoid colectomy was performed on the days of admission. The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable. He was discharged on 2022-11-12 and will follow up in our out-patient department next 2 week
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
• 2022-11-03 SOAP Colorectal Surgery Xiao GuangHong
  • A: Suggest colectomy first then target + chemotherapy due to partial obstruction

[consultation]

• 2023-03-23 Dermatology
  • Q
    • The 74 y/o man has adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 plus Panitumumab from 2023/02/21. Red hot swelling sensation over face s/p target therapy with Panitumumab.
    • For paronychia and keloid with pus on the chest, sent culture on 2023/03/22, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • The patient had sufferred from paronychia with granulation formation over toenail and keloid with seocndary wound formation over chest.
      
    • Under the impression of paronychia with granulation, keloid with seocndary wound & bacterial infection.
      
    • The following sugeetion:
      • paronychia over fingernail, Tetracycline onit 1 tube topical bid use.
      • for limbs and hand xerosis, sinphraderm cream 1 tube topical QN use.(enahcne mositurization)
      • for keloid wound, keep wound CD and might consider Siliverzine cream 1 tube antibiotic use for wound occlusion effect.
• 2023-03-09 Dermatology
  • Q
    • The 74 y/o man has adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 plus Panitumumab from 2023/02/21. Red hot swelling sensation over face s/p target therapy with Panitumumab. follow up in your OPD on 2023/03/02.
    • For red hot swelling sensation over face, We need your consultation for evaluation. Thanks a lot!!!
  • A
    • The patient had sufferred from facial flush with scales and pruritus. Besides, dry xerosis was noted over lower legs.
      
    • Under the impression of seborrheic dermatitis and xerotic dermatitis
    • The following sugeetion:
      • for fisuriform wound protection, Tetracycline onit 1 tube topical bid use first.
      • for facial erythema, Free gel 1 tube topical bid use over erythematous rash over face (Can be used extensively on the face).
      • for itchy papules and sclaes, Mycomb cream 1 tube topical PRN bid use.

[MedRec]

• 2023-03-30 SOAP Dermatology
  • S: refill medication use
  • Prescription
    • Allegra (fexofenadine 60mg) 1# BID
    • Free Gel (metronidazole) BID TOPI
    • tetracycline BID EXT
• 2023-03-22 SOAP Hemato-Oncology
  • O: Cancer Treatment Chemoradiotherapy/Targeted Therapy Side Effects Assessment (2023-03-22)
    • Skin rash: G2: Moderate rash, or single moist desquamation, mostly in skin folds and moderate edema
• 2023-03-02 SOAP Dermatology
  • S: red hot swelling sensation over face, cancer target therapy.
  • O: Bilateral facial flush with tightness and burning sensation for weeks.
    • Impression: rosacea
  • P:
    • Education about drug side effec and explain
    • Strongly suggested OPD f/u
  • Prescription
    • Allegra (fexofenadine 60mg) 1# BID
    • doxycycline 100mg 1# BID
    • Free Gel (metronidazole) BID TOPI
• 2023-01-05 SOAP Hemato-Oncology
  • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-11-22
    • target + chemotherapy due to partial obstruction then re-evaluation of liver resection
• 2022-11-17 SOAP Hemato-Oncology
  • O: Now on FOLFIRI +/- anti-EGFR
  • P: After SDM with patient for the selection of bevacizumab or cetuximab/panitumumab, patient choice cetuximab/panitumumab
• 2022-11-03 SOAP Colorectal Surgery
  • A: Suggest colectomy first then target + chemotherapy due to partial obstruction

[surgical operation]

• 2022-11-09
  • Surgery: 3D Laparoscopic sigmoid colectomy    
  • Finding: Sigmoid cancerwith nearly total obstruction, much stool in proximal colon and D-colon dilatation

[immunochemotherapy]

• 2023-11-29 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2h4 + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-30 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2h4 + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-02 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-14 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-22 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-31 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-18 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-29 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-16 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-31 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX, Oxa 75)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-04 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX, Oxa 65)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-11 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-23 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-09 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-21 - panitumumab 6mg/kg 500mg NS 250mL 1hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-03 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-16 - irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-26 - irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-12 - irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

[note]

Acneiform eruption secondary to epidermal growth factor receptor (EGFR) and MEK inhibitors 2023-04-12 https://www.uptodate.com/contents/acneiform-eruption-secondary-to-epidermal-growth-factor-receptor-egfr-and-mek-inhibitors

• Acneiform eruption is the prototypical cutaneous adverse reaction associated with all epidermal growth factor receptor (EGFR) inhibitors, which include monoclonal antibodies and oral small molecules used for the treatment of certain advanced or metastatic cancers, such as non-small cell lung cancer (afatinib, erlotinib, gefitinib, osimertinib, mobocertinib, necitumumab, amivantamab), pancreatic cancer (erlotinib), breast cancer (lapatinib, neratinib), colon cancer (cetuximab, panitumumab), and head and neck cancer (cetuximab). Acneiform eruption is also one of the most frequent adverse effects of inhibitors of the EGFR downstream mitogen-activated protein kinase kinase (MEK) signaling pathways MEK1 and MEK2 (eg, trametinib, cobimetinib, binimetinib, selumetinib), especially when used as monotherapy.
• Several studies have noted an association between acneiform eruption and increased overall response rate or survival.
• Preemptive therapy
  • We suggest prophylactic oral antibiotics in conjunction with topical corticosteroids for patients initiating treatment with EGFR inhibitors. Treatment is started on the same day as EGFR inhibitor therapy and continued for six weeks. We typically use doxycycline 100 mg twice a day, minocycline 100 mg daily, or oxytetracycline 500 mg twice daily for six weeks. Alternative antibiotics include cephalosporins (eg, cefadroxil 500 mg twice daily) or trimethoprim-sulfamethoxazole (160 mg/800 mg twice daily).
  • A low-potency topical corticosteroid (eg, hydrocortisone 2.5%, alclometasone 0.05% cream) is applied twice daily to the face and chest.

==========

2023-10-31

CT scans from 2023-09-07 and 2023-06-08 both indicate mild regression of lymph nodes (LNs) and liver metastases, with a stable condition of bony metastases. This suggests that the Vectibix + FOLFOX regimen, initiated in Mar 2023, continues to be effective against the disease.

[potential folate-dependent anemia]

The patient has been on long-term iron supplementation, yet the MCV value is at the upper limit of the normal range (97.3 fL on 2023-10-30). While iron deficiency anemia typically presents with a low MCV, the observed decrease in HGB might be attributed to potential Vitamin B12 deficiency, folate deficiency, liver disease, or bone marrow dysfunction.

5-FU, a component of the FOLFOX regimen, disrupts DNA synthesis in cells. It acts by inhibiting the enzyme thymidylate synthase, which relies on folate for its activity. By inhibiting this enzyme, 5-FU can decrease the availability of active folate forms within cells. It’s plausible that the patient’s reduced HGB is related to folate deficiency.

2023-08-23

After reviewing HIS5 records, there are no medication reconciliation issues. PharmaCloud is not accessible currently.

2023-08-01

There are no medication reconciliation issues after review of PharmaCloud and HIS5 records.

2023-06-30

According to the PharmaCloud database, our hospital has been the only medical institution providing care and prescriptions for this patient over the past three months. The Hemato-Oncology department is solely responsible for the patient’s recent medications. Hence, no medication reconciliation issues were detected.

2023-05-04

• An episode of leukopenia with a WBC count of less than 3K/uL (2.92K/uL on 2023-05-03) was observed for the first time since the patient started chemotherapy in mid-December 2022. It is important to closely monitor the patient’s WBC and check whether the leukopenia persists.
• Over the past 7 months, the patient’s anemia has improved with the administration of Foliromin (ferrous sodium citrate). Given the expected decrease in marginal benefit of iron supplementation as the mean corpuscular volume (MCV) approaches 100 fL, it is recommended to either discontinue the medication or decrease the frequency from twice daily (BID) to once daily (QD) and/or assess body iron stores such as ferritin, transferrin to ensure that iron levels are adequate.
• The patient’s rash, which is a side effect of the EGFR inhibitor panitumumab, is currently being managed with self-provided topical ointments without complications.

2023-04-12

• Lab data on 2023-04-06 showed normal readings.

• The patient’s anemia has improved with the use of Foliromin (ferrous sodium citrate) for the past 6 months. It is recommended to either discontinue or reduce the frequency of the medication from twice daily (BID) to once daily (QD) due to an expected decline in the marginal effect of iron supplementation, as the mean corpuscular volume (MCV) is approaches 100 fL.

  • 2023-04-06 HGB 12.0 g/dL
    
  • 2023-03-22 HGB 11.7 g/dL
    
  • 2023-03-07 HGB 11.8 g/dL
    
  • 2023-02-21 HGB 11.5 g/dL
    
  • 2023-02-02 HGB 11.3 g/dL
    
  • 2023-01-05 HGB 10.1 g/dL
    
  • 2022-12-22 HGB 9.9 g/dL
    
  • 2022-11-28 HGB 8.5 g/dL
    
  • 2022-10-31 HGB 7.2 g/dL
    
  • 2023-04-06 MCV 96.6 fL
    
  • 2023-03-22 MCV 94.2 fL
    
  • 2023-03-07 MCV 92.3 fL
    
  • 2023-02-21 MCV 93.8 fL
    
  • 2023-02-02 MCV 88.2 fL
    
  • 2023-01-05 MCV 82.4 fL
    
  • 2022-12-22 MCV 79.4 fL
    
  • 2022-11-30 MCV 76.7 fL
    
  • 2022-11-28 MCV 77.9 fL
    
  • 2022-10-31 MCV 71.7 fL

• In late Feb/early Mar 2023, the patient developed a localized skin eruption secondary to the epidermal growth factor receptor (EGFR) inhibitor panitumumab. He is currently adequately being treated with a topical regimen of tetracycline, metronidazole, silver sulfadiazine, and urea.

2023-03-24

• Although the CT scan on 2023-03-09 showed progression of lymph nodes, bone, and liver metastases, the CEA readings have been trending down towards normal. The two trends are not consistent with each other.
  • 2023-03-22 CEA 2.67 ng/mL
    
  • 2023-03-08 CEA 6.12 ng/mL
    
  • 2023-01-06 CEA 7.53 ng/mL
• The chemotherapy regimen was changed from FOLFIRI to FOLFOX on 2023-03-09. The FOLFIRI regimen was used a total of five times prior to the change.
• The patient has been experiencing continued dermatologic adverse reactions, and a dermatologist has been consulted on 2023-03-23. To alleviate these symptoms, the dermatologist has prescribed topical medication for the patient.
• Other FOLFOX-related adverse events, in addition to the dermatologic adverse events caused by panitumumab, are not significant. Mild anemia, loss of appetite and constipation all have corresponding medications.

2023-03-08

• 2022-11-10 a segment of colon was surgically removed due to a tumor that tested positive for EGFR.
• 2022-12-15 no variants were detected in the KRAS/NRAS genes.
• The patient is eligible for reimbursement for panitumumab and combination therapy with FOLFIRI or FOLFOX as a first-line treatment for metastatic colorectal cancer with EGFR RAS gene wildtype. The patient received his first dose of panitumumab during his previous hospitalization during 2023-02-21 ~ 23.
• Panitumumab can cause various dermatologic adverse reactions. Skin or ocular toxicity from panitumumab typically develops after 12 days and resolves in about 14 weeks. The severity of dermatologic toxicity is predictive of response, with grades 2 to 4 skin toxicity correlating with improved progression-free survival and overall survival compared to grade 1 skin toxicity (Peeters 2009; Van Cutsem 2007). The patient developed a red, hot, and swollen sensation on his face and saw our dermatologist who prescribed oral fexofenadine, doxycycline, and topical metronidazole for one week on 2023-03-02. The prescription is only valid until 2023-03-09. It is recommended to check if the dermatologic symptoms have improved before deciding whether to refill the prescription.

2022-12-01

• 2022-11-30 Hemoglobin 8.2 g/dL, MCV 76.7 fL, Ferritin 9.5 ng/mL, 2022-11-29 iron-bound Fe 36 ug/dL. Initialization of Foliromin (ferrous sodium citrate 50mg/tab) 1# QD is recommended.
• 2022-11-30 the SBP remained around 170 ~ 190 mmHg under the single antihypertensive agent Norvasc (amlodipine 5mg/tab) 1# QD. An addition of Labtal (labetalol 200mg/tab) 1# BID might be an option to alleviate hypertension.

701496429

231130

{DLBCL}

[exam findings]

• 2023-09-22 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 31.7) / 91 = 65.16%
    • M-mode (Teichholz) = 65.2
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Trivial AR and MR, mild TR and PR
    • Impaired LV relaxation
    • Mildly thick IVS and LVPW
• 2023-09-21 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Pleura effusion of left costal-phrenic angle
  • Old fibrothorax at left CP angle.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2023-09-15 Patho - peritoneum biopsy
  • Peritoneum, CT-guide biopsy — Diffuse large B-cell lymphoma, GCB type
  • Specimen submitted in formalin consists of 2 strips of tan, irregular tissue measuring up to 1.3 x 0.1 x 0.1 cm.
  • Section shows cores of atypical large lymphoid cells.
  • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), MUM1(+), c-MYC(+), Cyclin D1(-), CD30(-), CD56(-), and CD5(-). The Ki-67 is about 60%.
• 2023-09-13 PET
  • Glucose hypermetabolism lesions in bilateral lower neck regions, SCF, mediastinum, bilateral para-aortic space, common iliac chains, and pelvis, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    
  • Glucose hypermetabolism lesions in the left pleural effusion, pleurae of the left upper, left lower and right upper lungs, and in skeleton including T11 spine, L5 spine and sacrum, highly suspected lymphoma with involvement of lungs and bone marrow.
    
  • Highly suspected lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-09-11 CT - abdomen
  • History and indication: Hydronephrosis with AKI, suspected Malignancy
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Enlarged LNs at retroperitoneum and pelvic cavity.
    • Wall thickening of rectum and S-colon.
    • Bil. pleural effusion with adjacent lung collapse.
    • Liver and renal cysts (up to 2.1cm).
    • Tiny gallbladder stones.
    • Atherosclerosis of aorta.
    • S/P bilateral double J catheters insertion.
    • S/P foley catheter indwelling. Wall thickening of urinary bladder.
  • IMP:
    • Enlarged LNs at retroperitoneum and pelvic cavity.
    • Wall thickening of rectum and S-colon.
    • Bil. pleural effusion with adjacent lung collapse.
    • Wall thickening of urinary bladder.
• 2023-09-06 Patho - colon biopsy
  • Colorectum, ascending colon and biopys removal — Tubular adenoma with low grade dysplasia.
• 2023-09-01 CT - abdomen
  • CC: swelling all over the body for 3-4 days, decreased urination, dyspnea on exertion, abd. fullness +.
    • no fever, no vomiting, constipation +, dark color stool?
    • back pain noted for one week, no trauma.
  • PH: HTN under medical Tx
  • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status can not be determined without IV contrast.
  • Findings:
    • Wall thickening at the rectosigmoid junction is suspected that may be normal variation and tumor. Please correlate with colonoscopy.
    • There are multiple enlarged nodes in the perirectal space, bilateral internal iliac chain, bilateral external iliac chain, and bilateral common iliac chain.
      • In addition, there are multiple enlarged nodes in para-aortic space and para-cava space, causing bilateral hydroureteronephrosis (obstructive uropathy). There are few small nodes in the mesentery.
    • Lymphoma is highly suspected.
      • The differential diagnosis includes metastatic nodes.
    • There is a hypodense lesion 1.7 cm in S6 of the liver.
      • The differential diagnosis includes Metastasis and lymphoma.
    • There are bilateral Pleura effusion and old fibrothorax at left CP angle.
    • Both lobe thyroid show enlarged in size and few hypodense nodules.
      • Please correlate with sonography to R/O nodular goiter.
    • There is multiple enlarged nodes in left hilum and left anterior mediastinum.
    • There is fatty stranding at the subcutaneous fat layer of the lower pelvic wall.
    • There is minimal ascites in the Morison pouch.
  • IMP:
    • Lymphoma is highly suspected.
      • The differential diagnosis includes multiple metastatic nodes.
      • Please correlate with contrast enhanced dynamic CT.
    • Wall thickening at the rectosigmoid junction is suspected that may be normal variation and tumor. Please correlate with colonoscopy.

[MedRec]

• 2023-09-01 ~ 2023-09-23 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Peritoneum, CT-guide biopsy — Diffuse large B-cell lymphoma, GCB type, immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), MUM1(+), c-MYC(+), Cyclin D1(-), CD30(-), CD56(-), and CD5(-). The Ki-67 is about 60%.
    • Hydronephrosis, status post double J (DJ) stent insertion, bilateral on 2023/09/08
    • Urinary tract infection with Urine culture: After 48 hours < 1000 CFU/ml on 2023/09/01
    • Gastric fungated ulcer, middle body, and Gastric ulcers, Forrest classification type III, antrum, and Reflux esophagitis LA Classification grade A (panendoscopy on 2023/09/05)
    • Colon polyp, ascending colon and Internal hemorrhoid (colonoscopy on 2023/09/05)
    • Hypertension
    • Paroxysmal atrial fibrillation
  • CC
    • edema in bilateral legs for 1 week, with dyspnea on exertion
  • Present illness
    • This patient is a 82-year-old male with underlying Af and hypertension. This time, he came with the complaint of edema in bilateral legs for 1 week, with dyspnea on exertion. According to the patient, he did not have a past history of kidney or liver diseases, and had never experienced similar symptoms before. Therefore he came to our ER for help.
    • At the ER, his vital signs were BP:143/65; PR:84; BT:35.2’C; RR:18; Con’s:E4V5M6; SpO2:97%. During physical examination, crackles were heard in bilateral lung fields.
    • Lab data revealed hyperkalemia, metabolic acidosis and elevated BUN and creatinine levels. Urinalysis showed nitrate (3+) and WBC (>100 HPF).
    • CT was performed which revealed
      • Lymphoma is highly suspected. The differential diagnosis includes multiple metastatic nodes. Please correlate with contrast enhanced dynamic CT.
      • Wall thickening at the rectosigmoid junction is suspected that may be normal variation and tumor. Please correlate with colonoscopy.
    • Urologist was consulted and suggested.
    • The CT showed multiple lymph node with compression effect of bilateral ureter ( right side beneath IVC, Aorta- IVC and left side lateral to Aorta) tumor stent may not pass.
    • PCND for acute renal failure may be more effective (right side seems better).
    • Foley for better record of urine output is recommended Under the impression of post-renal AKI and UTI, antibiotics were given, and a Foley catheter was inserted.
    • He was then admitted to our ward for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, Lasix was administered for AKI with edema in bilateral legs.
    • GU was also consulted for multiple lymph node with compression effect of bilateral ureter.
    • Empiric antibiotics with Rocephin was administered from 9/1(D5) due to right lower lung and left lung infiltration, pending culture.
    • Owing to still anemia susepct GI bleeding, EGD was performed on 2023/9/5 showed Gastric fungated ulcer, middle body, AW, s/p biopsy, r/o malignancy (B); Gastric ulcers, Forrest classification type III, antrum, GC, body, AW and PW, s/p biopsy (A) Reflux esophagitis LA Classification grade A.
    • Pathology showed
      • Stomach, body, AW, s/p biopsy (A), Chronic gastritis, H pylori NOT present.
      • Stomach, middle body, AW, s/p biopsy (B), Chronic gastritis, H pylori NOT present.
    • Colonscopy also done on 2023/09/05 showed Tubular adenoma with low grade dysplasia.
    • PPI with Nexium was prescribed.
    • As the renal function continued to deteriorate, the urology department was contacted, and a D-J catheter was implanted on 2023/9/08.
    • (selfpaid) PET was performed on 2023/09/13 for suspect lymphoma which revealed There was increased FDG uptake in lymph nodes in bilateral lower neck regions, SCF, mediastinum, in bilateral para-aortic space, common iliac chains, and pelvis. In addition, there was increased FDG uptake in the left pleural effusion and pleurae of the left upper, left lower and right upper lungs and in skeleton including T11 spine, L5 spine and sacrum.
    • CT guide biopsy was performed on 2023/9/15 and the pathology proved Diffuse large B-cell lymphoma, GCB type.
    • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), MUM1(+), c-MYC(+), Cyclin D1(-), CD30(-), CD56(-), and CD5(-). The Ki-67 is about 60%.
    • Bone marrow aspiration and biopsy was done on 2023/9/19 and report which showed negative for malignancy.
    • He was transferred to our ward for chemotherapy on 9/21 23.
    • C1 chemotherapy with R-COP was given on 9/22 23, smoothly without obviuous side effect.
    • He was discharged on 9/23 23 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • MgO 250mg 1# TID
    • Norvasc (amlodipine 5mg) 1# QD
    • Nexium (esomeprazole 40mg) 1# QDAC (for 2023-09-05 EGD result)
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
    • Compesolon (prednisolone 5mg) 9# BID 4D (9/22 ~ 9/26 18:00 end)

[chemotherapy]

• 2023-12-21 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
• 2023-11-29 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
• 2023-11-02 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
• 2023-10-11 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
• 2023-09-22 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1200mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO

==========

2023-12-22

A review of PharmaCloud and HIS5 records revealed no medication discrepancies. However, the patient’s serum LDH level has shown a concerning upward trend this month. Previously, it remained stable following the initiation of the R-COP regimen on 2023-09-22. This recent rise warrants considering an update of the medical images to better assess the effectiveness of the treatment on the underlying disease.

• 2023-12-21 LDH 348 U/L
• 2023-12-19 LDH 285 U/L
• 2023-12-11 LDH 156 U/L
• 2023-12-04 LDH 181 U/L

2023-11-30

[hypoalbuminemia]

Hypoalbuminemia is emerging, and Plasbumin (human albumin) treatment was started on 2023-11-29.

• 2023-11-28 Albumin(BCG) 2.8 g/dL
• 2023-11-14 Albumin(BCG) 3.2 g/dL
• 2023-11-07 Albumin(BCG) 3.5 g/dL

Given the patient’s recent lab results indicating normal liver and kidney function, the likelihood of hypoalbuminemia resulting from albumin loss in urine due to nephrotic syndrome or reduced hepatic albumin synthesis is lower. Please verify if the patient is experiencing malnutrition and/or edema.

2023-11-06

[leukopenia]

Episodes of leukopenia were noted approximately 1 to 2 weeks following the first cycle of R-COP on 2023-09-22 and the second cycle on 2023-10-11, specifically on 2023-10-04 and 2023-10-24. Granocyte (lenograstim) was appropriately administered for two periods of three consecutive days on these dates. Currently, there are no signs of leukopenia.

• 2023-11-02 WBC 14.02 x10^3/uL
• 2023-10-24 WBC 1.46 x10^3/uL **
• 2023-10-11 WBC 9.39 x10^3/uL
• 2023-10-09 WBC 6.92 x10^3/uL
• 2023-10-06 WBC 11.69 x10^3/uL
• 2023-10-05 WBC 3.04 x10^3/uL
• 2023-10-04 WBC 0.87 x10^3/uL ***
• 2023-09-27 WBC 9.86 x10^3/uL
• 2023-09-20 WBC 7.14 x10^3/uL
• 2023-09-18 WBC 6.52 x10^3/uL
• 2023-09-11 WBC 9.71 x10^3/uL
• 2023-09-07 WBC 8.61 x10^3/uL
• 2023-09-04 WBC 8.06 x10^3/uL
• 2023-09-02 WBC 7.49 x10^3/uL
• 2023-09-01 WBC 6.92 x10^3/uL

According to the National Health Insurance medication reimbursement regulations, short-acting G-CSF injections, such as filgrastim and lenograstim, are indicated for use after intravenous chemotherapy for hematologic malignancies. This patient should meet the criteria for such coverage.

700360518

231129

[diagnosis] - 2023-05-01 admission note

• Diffuse large B-cell lymphoma, intra-abdominal lymph nodes
• Other malaise
• Malignant neoplasm of pyloric antrum
• Cardiomegaly
• Peritonitis, unspecified
• Enterococcus as the cause of diseases classified elsewhere
• Resistance to vancomycin
• Type 2 diabetes mellitus with diabetic chronic kidney disease
• Chronic kidney disease, stage 3 (moderate)
• Heart failure, unspecified
• Chronic atrial fibrillation
• Alcoholic cirrhosis of liver with ascites
• Hypo-osmolality and hyponatremia
• Hypocalcemia
• Other disorders of plasma-protein metabolism, not elsewhere classified
• Pleural effusion in other conditions classified elsewhere
• Chronic obstructive pulmonary disease, unspecified
• Mixed hyperlipidemia
• Enlarged prostate with lower urinary tract symptoms
• Unspecified symptoms and signs involving the genitourinary system
• Other ascites
• Hyperkalemia

[past history]

• HFmrEF
• Af under edoxaban
• DM
• dyslipidemia
• alcoholic liver cirrhosis.    

[allergy]

• NKDA     

[family history]

• Father: pancreatic cancer
• Mother: hypertension

[exam findings]

• 2023-10-05 ECG
  • Atrial fibrillation with rapid ventricular response
  • Low voltage QRS of limb leads
  • Nonspecific ST abnormality
  • Abnormal ECG
• 2023-08-30 SONO - abdomen
  • Real-time sonographic evaluation of the abdomen findings:
    • The liver shows normal in size and echogenicity but mild irregular contour that may be cirrhosis.
      • Portal vein flow: patent.
      • Bile ducts: not dilated.
    • The gallbladder appears normal in wall thickness and size.
      • There is no evidence of stone, polyp or sludge.
        
    • The pancreatic head and body shows normal in size and texture.
      • The pancreatic tail is obscured by overlying bowel gas.
    • The spleen shows enlarged in size (long axis: 15.81 cm) and echogenicity without focal lesion.
    • Abdominal aorta and IVC show unremarkable finding.
    • There is no evidence of para-aortic lymphadenopathy or ascites.
    • Both kidney show normal echopattern and size.
      • There is no evidence of stone or hydronephrosis.
  • Impression:
    • No focal wall thickening or mass lesion in the gallbladder. Follow up is indicated.
    • Cirrhosis of the liver with portal hypertension is suspected.
• 2023-08-30 Maximal Venous Outflow (MVO), Segmental Venous Capacitance (SVC)
  • Conclusion:
    • No evidence of DVT, bilateral upper arm
    • Bilateral upper arm MVO/SVC is normal
  • Suggestion:
    • keep anticoagulation as lixiana, because of history of atrial fibrillation if no contraindication.
• 2023-08-30 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (186 - 98) / 186 = 47.31%
    • M-mode (Teichholz) = 47
  • Conclusion:
    • Dilated LV with global hypokinesis; impaired LV systolic function.
    • Mild RV hypertrophy with preserved RV systolic function.
    • Aortic valve sclerosis with mild AR; mild MR; mild to moderate TR.
    • Possible mild to moderate pulmonary hypertension (the estimated systolic PA pressure 53 mmHg).
    • Mild aortic root calcification; mildly dilated proximal ascending aorta (35 mm).
    • Atrial fibrillation; severely dilated LA/RA.
    • No intracardiac vegetation was found by TTE study.
• 2023-08-25 CT - abdomen
  • Indication: Double hit diffuse large B-cell lymphoma with stomach and intra-abdominal lymph nodes involvement, status post laparoscopic subtotal gastrectomy and D2 lymph node dissection on 2023/03/23, Lugano stage III
  • Findings:
    • S/P subtotal gastrectomy
    • There is splenomegaly and the greatest cranial-caudal dimension measuring 15 cm. The liver shows mild irregular contour that may be cirrhosis. please correlate with clinical condition.
    • There is focal wall thickening at the gallbladder body, measuring 7 mm in wall thickness, that may be tumor.
    • There are several enlarged nodes in para-aortic space and para-cava space that is c/w lymphoma. Follow up is indicated.
    • There is mild bilateral Pleura effusion.
      • There is a calcification 7 mm in RUL of the lung that is c/w old granuloma. In addition, there are few enlarged nodes in paratracheal space. Follow up is indicated.
  • Impression:
    • Splenomegaly.
    • There is focal wall thickening at the gallbladder body, measuring 7 mm in wall thickness, that may be tumor. Follow up is indicated.
    • There are several enlarged nodes in para-aortic space and para-cava space that is c/w lymphoma. Follow up is indicated.
• 2023-06-12 ECG
  • Atrial fibrillation
  • Low voltage QRS
  • Abnormal ECG
• 2023-05-24 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Spondylosis of the T-spine
• 2023-05-02 KUB
  • Spondylosis of the L-spine is noted.
  • Disc space narrowing with marginal osteophyte formation at left lateral aspect of L4-5.
  • Splenomegaly is highly suspected.
• 2023-04-17 PET
  • Glucose hypermetabolism lesions in the gastric wall (Deauville score 5), in the celiac chain (Deauville score 5), in the left sub-diaphragm lymph nodes (Deauville score 5), in soft tissue in the RLQ of abdomen (Deauville score 5), and in lymph nodes of peritonium (Deauville score 5), highly suspected diffuse large B-cell lymphoma with involvement of stomach and intraabdominal lymph nodes.
    
  • Glucose hypermetabolism lesion in a peri-cardial lymph node (Deauville score 5), highly suspected diffuse large B-cell lymphoma with involvement of regional lymph node.
  • Diffuse large B-cell lymphoma, c-stage III or IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2023-03-30 KUB
  • Degeneration and spondylosis of L-S spine.
  • S/P operation with retention of surgical clips.
• 2023-03-30 CXR
  • S/P operation with retention of surgical clips.
  • Degeneration of T-L spine.
  • Right catheterization to SVC in position.
  • Normal appearance of trachea and bil. main bronchus.
  • Left pleural effusion.
  • Cardiomegaly.
• 2023-03-26 ECG
  • Atrial fibrillation with rapid ventricular response with premature ventricular or aberrantly conducted complexes
• 2023-03-24 Patho - stomach subtotal/total (tumor)
  • Diagnosis
    • Stomach, antrum, laparoscopic subtotal gastrectomy (S2023-5511) with frozen section for margins (F2023-124) — Diffuse large B cell lymphoma, non-germinal center type.
      • IHC stains: CD3 and CD20: a predominant B cell sub-population. Bcl-2 (+), Bcl-6 (+), CD10 (-), MUM-1 (+, > 30%), c-myc (-), Ki-67: 95%, CK (-), CD23 (-) .
    • Margins, bilateral cut ends: free. radial surface postive for tumor.
    • Lymph node, perigastric, D2 dissection — free. CD3, CD20, Bcl-2, and Bcl-6 demonstrate a reactive pattern.
    • Omentum, omentectomy — Free
  • Microscopic Description:
    • Histologic Type - Diffuse large B cell lymphoma, non-germinal center type.
    • Histologic Grade - high grade, non-germinal center type.
    • Tumor Extension - Tumor invades the serosa (visceral peritoneum)
    • Margins
      • Proximal margin: uninvolved
      • Distal margin: uninvolved
      • Radial margin: involved
    • Lymphovascular Invasion: not identified
    • Perineural Invasion: not identified
    • Regional Lymph Nodes: free
      • S2023-5511A: LN1 (0/0); B1-3: LN3 (0/10); C1-4: LN4 (0/8); D1-2: LN5-6 (0/17); E1-2: LN7-8-9 (0/7); F1-2: LN12 (0/5); G1-4: omentum (0/1);
        
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition) : Further work up is needed for staging.
• 2023-03-22 ECG
  • Atrial fibrillation
  • Low voltage QRS
  • Abnormal ECG
• 2023-03-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (186 - 106) / 186 = 43.01%
    • M-mode (Teichholz) = 43
  • Conclusion:
    • Dilated LV with global hypokinesis; impaired LV systolic function.
    • Mild RV hypertrophy with mild global hypokinesis and borderline RV systolic function.
    • Aortic valve sclerosis with mild AR; mild MR; mild to moderate TR.
    • Possible mild pulmonary hypertension (the estimated systolic PA pressure 46 mmHg).
    • Mild aortic root calcification.
    • Atrial fibrillation; severely dilated LA/RA.
• 2023-03-06 Flow Volume Loop
  • Mild obstructive ventilatory impairment
• 2023-03-04 Esophagogastroduodenoscopy, EGD
  • Superficial gastritis, s/p CLO test
  • Gastric ulcer, antrum, suspected malignancy, s/p biopsy
• 2023-03-04 SONO - abdomen
  • Liver parenchymal disease (suboptimal exam of liver)
  • mild gallbladder wall thickening
  • splenomegaly
  • chronic renal parenchymal disease
  • bilateral pleural effusion
• 2023-03-02 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • S/P NG tube placement.
  • Increased pulmonary vasculature is found.
  • Osteopenia of the bony structure is noted.
• 2022-10-06 ECG
  • Atrial fibrillation
  • Low voltage QRS of limb leads
  • Abnormal ECG
• 2022-10-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (190 - 102) / 190 = 46.32%
    • M-mode (Teichholz) = 46
    • 2D (M-simpson) = 48
  • Conclusion:
    • Dilated LA, LV, RA, RV and IVC; mildly abnormal LV systolic function with global hypokinesia
    • Moderate MR, mild AR, mild to moderate TR and trivial PR
    • Preserved RV systolic function
    • Atrial fibrillation with HR 62~83 bpm.
• 2019-12-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (224 - 102) / 224 = 54.46%
    • M-mode (Teichholz) = 54
  • Conclusion:
    • Dilated LV with mild global hypokinesis and borderline LV systolic function.
    • Preserved RV systolic function.
    • Moderate MR and moderate TR (both due to chamber dilatation); mild AV sclerosis with trivial AR.
    • Possible mild to moderatre pulmonary hypertension (the estimated systolic PA pressure 50 mmHg).
    • Atrial fibrillation; severely dilated LA/RA.

[MedRec]

• 2023-04-24 SOAP Hemato-Oncology
  • S
    • 3 daughters (the elderest daughter works in another hospital)
    • her daughter came to OPD for him
• 2023-04-12 SOAP General and Digestive Surgery
  • A:
    • Gastric antrum lymphoma, cT4N0M0, stage II, ECOG:1, s/p laparoscopic subtotal gastrectomy and D2 lymph node dissection on 2023/03/23
    • Peritonitis, culture: VREfm (E.faecium)
    • Heart failure, New York Heart Association functional classification II
    • Chronic kidney disease, stage 3
    • Chronic atrial fibrillation
    • Alcoholic liver cirrhosis
    • Type 2 diabetes mellitus
    • Mixed hyperlipidemia
    • Hypocalcemia
    • Hypoalbuminemia
    • Hypo-osmolality and hyponatremia
    • Pleural effusion, bilateral sides
    • Massive ascites
    • Suspected Chronic Obstructive Pulmonary Disease
    • Enlarged prostate with lower urinary tract symptoms
  • P:
    • refer to ONC for further study and chemotherapy evaluation
    • PPI, vita B12, education, & OPD follow up
• 2018-04-19 SOAP Cardiology
  • S: adjust carvedilol dose; add ARB for BP control
  • Prescription
    • Blopress (candesartan 8mg) 1# QD
    • Uretropic (furosemide 40mg) 1# Q3D
    • Lixiana (edoxaban 30mg) 1# QD
    • Robestar (rosuvastatin 10mg) 0.5# QD
    • Through (sennoside 12mg) 2# HS
    • Glucobay (acarbose 100mg) 1# BID
    • Syntrend (carvedilol 6.25mg) 1# QD
• 2017-03-16 SOAP Cardiology
  • Diagnosis
    • Heart failure, unspecified [I50.9]
    • Atrial fibrillation [I48.2]
    • Cirrhosis of liver without mention of alcohol [K74.69]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Mixed hyperlipidemia [E78.2]
    • Neuralgia and neuritis, unspecified [M79.2]
  • Prescription
    • Robestar (rosuvastatin 10mg) 0.5# QD
    • Through (sennosides 12mg) 2# HS
    • Glucobay (acarbose 100mg) 1# BID
    • Syntrend (carvedilol 6.25mg) 0.5# QD
    • Bokey (aspirin 100mg) 1# QD
    • Aldactin (spironolactone 25mg) 0.5# QD

[consultation]

• 2023-03-06 General and Digestive Surgery
  • Q
    • for management of gastric cancer. Pending pathology.
    • This 70 y/o man with history of heart failure, Af, DM, hyperlipidemia, alcoholic liver cirrhosis with medication (Lixiana) control. This time, he suffered from passage tarry stool, vomiting blood, general weakness, dizziness since 20230227 morning. Abdominal CT showed gastric cancer T3N0M0. Under the impression of Gastrointestinal hemorrhage and suspected gastric cancer, he was admitted to MICU for further care on 2023-02-27.
    • After admitted MICU, the patient received anti with Sintrix (2/27~) for Infection prevention. kept NPO and high does PPI pump (2/27~3/2), then taper to Pantoloc 40mg IVD Q12H (3/2~), also disconnect Lixiana since 2/26. IV fluid for supply. Blood transfusion with LRBC for correct anemia (Hb: 7.9 => 9.2). There was no coffee ground or tarry stool was noted after try oral diet. However, dyspnea on exertion with breathing sound wheezing grade 1 was note, broncodilator with Butanyl plus Ipratran was prescribed. IV fluid and Const-K for correct imbalance electrolyte. The symptom got improvement after medical treatment, he will transfer to ward for further treatment and arrange 2nd PES (for supected gatric cancer biopsy).
      
    • At GI ward, his vital signs stable. Checked breathing sound: no wheezing. Try oral intaking but his care giver said easy choking.
    • Second look of EGD and the biopsy were all done, Now, we need your management of gastric cancer. Thanks a lot !!!
  • A
    • S:
      • Due to CT and panendoscopy highy suspected gastric antrm cancer, surgical treatment is consulted.
    • O: vital signs: stable, no fever
      • abdomen: soft, ovoid, normal bowel sound, no tenderness, no rebounding pain
        
      • lab data: see chart
    • A: Gastric antrum Ca, cT3N2M0, stage III, ECOG I
    • P:
      • I will take over this case for pre-op evaluation including heart echo and lung function test and nutritional support such as PPN
      • If heart & lung function is OK and the patietn is willing to receive operation, I will arrange laparoscopic resection later.

[surgical operation]

• 2023-03-23
  • Surgery
    • Laparoscopic subtotal gastrectomy and D2 lymph node dissection
    • Post-OP Dx: gastric antrum Ca, cT3N2M0, stage III, ECOG 1       
  • Finding
    • An ulcerative tumor about 5x7 cm over antrum, lesser curvature site of antrum posterior wall with suspect serosal invasion.
    • Enlarged lymph nodes over area 3, 5, 7, 8, 9, 12 were noted.
    • Proximal cutting end 10 cm form tumor and distal cutting end 1 cm from tumor. Both cutting ends were margin free via frozen section.

[immunochemotherapy]

• 2023-09-28 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-07-18 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-06-13 - rituximab 375mg/m2 693mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-05-24 - rituximab 375mg/m2 693mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-05-03 - rituximab 375mg/m2 660mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-COP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2

==========

2023-11-29

[proactive measures for leukopenia and renal function management]

After initiating the 5th cycle of R-COP/R-mCHOP on 2023-09-28, the patient experienced leukopenia in early Oct.

• 2023-11-29 WBC 7.84 x10^3/uL
• 2023-11-28 WBC 2.68 x10^3/uL *
• 2023-11-10 WBC 4.23 x10^3/uL
• 2023-10-23 WBC 4.01 x10^3/uL
• 2023-10-16 WBC 5.72 x10^3/uL
• 2023-10-13 WBC 5.46 x10^3/uL
• 2023-10-10 WBC 0.76 x10^3/uL ***
• 2023-10-09 WBC 0.72 x10^3/uL ***
• 2023-10-05 WBC 2.64 x10^3/uL *
• 2023-09-28 WBC 3.18 x10^3/uL

With a new session scheduled during this hospital stay, there’s a possibility of another leukopenia episode. Therefore, it may be advisable to have prophylactic G-CSF ready for use.

The patient has impaired renal function, but it is not severe enough to require dose adjustments for current medications. However, if the eGFR falls below 50 or creatinine exceeds 1.5, it’s important to consider adjusting the doses of Allegra (fexofenadine) and Lixiana (edoxaban).

• 2023-11-28 BUN 28 mg/dL
  
• 2023-11-28 Creatinine 1.36 mg/dL
  
• 2023-11-28 eGFR 54.90 ml/min/1.73m^2

2023-07-07

[reconciliation]

• According to the PharmaCloud database, besides our hospital, this patient has also visited a local dermatology clinic for problems related to skin and subcutaneous tissue infections on 2023-06-25, and for irritant contact dermatitis on 2023-06-04. Both times, he was prescribed medications for 7 days and 3 days respectively, which are now expired. No reconciliation issues were identified in this context.
• Our cardiologist had prescribed Lixiana (edoxaban), Blopress (candesartan), Hexal (carvedilol), Dibose (acarbose), Glimet (glimepiride, metformin), and Galvus Met (vildagliptin, metformin) on 2023-06-15. All these drugs are included in the current active medication list without any identified reconciliation issues.

[to adjust Dibose (acarbose) from BID to BIDCC]

• The optimal usage of Dibose (acarbose) involves taking it with the first bite of each main meal or immediately before starting a meal to ensure maximum effectiveness. Therefore, it is suggested that the patient’s current BID prescription should be adjusted to BIDCC. Ref: The effect of the timing and the administration of acarbose on postprandial hyperglycaemia. Diabet Med. 1995;12(11):979-984. doi:10.1111/j.1464-5491.1995.tb00409.x

2023-05-03

• Given the patient’s history of heart failure, doxorubicin may not be an appropriate component of the treatment regimen. Instead of R-CHOP, R-COP was chosen as the treatment regimen to avoid the potential cardiotoxic effects of doxorubicin.

• On 2023-05-03, the progress note indicated that the patient had increased frequency of vomiting and difficulty with oral intake due to NG tube cough. Metoclopramide, a dopamine (D2) receptor antagonist, is currently prescribed. If symptoms persist, the addition of serotonin (5-HT3) receptor antagonists (such as ondansetron, granisetron, or palonosetron) and/or neurokinin-1 (NK1) receptor antagonists (such as aprepitant, fosaprepitant, rolapitant, or netupitant) may be considered. These medications work through different mechanisms to control nausea and vomiting and may provide additional relief for the patient.

• Dibose (acarbose) should be taken with the first bite of each main meal or just before starting a meal for best results. Acarbose works by slowing down the digestion of carbohydrates in the intestines, helping to control blood sugar levels. Taking it at the beginning of a meal ensures its optimal effect on carbohydrate digestion. It is recommended to change the medication from current BID to BIDCC.

700884793

231129

[exam finding]

• 2023-10-04 SONO - abdomen
  • Parenchymal liver disease
  • Liver cyst, S6/7
  • post ERBD in CBD and left IHD
  • Pneumobilia, mild, left IHD
  • Renal cyst, left
  • Suspicious, focal dilated main pancreatic duct, pancreatic neck
  • Ascites, moderate
• 2023-10-01 Abdomen - Standing (Diaphragm)
  • S/P metalic stent implantation at the bile duct and duodenum.
  • S/P plastic stent implantation at the left lobe IHD and duodenum.
  • Fecal material store in the colon.
  • There is ascites. Please correlate with sonography.
  • Disc space narrowing with marginal osteophyte formation of L4-5.
• 2023-09-27 Endoscopic Retrograde Cholangiopancreatography, ERCP
  • Indication: CBD stricture s/p metal stent placement, with obstruction
  • Symptoms: Jaundice
  • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
  • Anesthesia: IV anesthesia
  • Equipment: TJF-260V
  • Management:
    • After C duct cannulation, retrieval balloon lithrotripsy was done before cholangiography and much sludge and pus were swept out from IHD and CBD. Selective cannulation of left IHD was done and mild dilated left IHD was found. One 14cm 7 Fr Gadelius Through The Mesh™ stent was performed at left IHD.
  • Diagnosis:
    • Malignant biliary stricture, s/p metal stent, with obstruction with much sludge and pus in IHD and CBD, s/p retrieval balloon lithrotripsy
    • Mild left IHD dilatation, s/p stenting with plastic stent
    • Chronic cholangitis
    • Duodenal swelling mucosa with luminal narrowing, 2nd portion
    • Reflux esophagitis, Gr. A
• 2023-09-23 CT - abdomen
  • History and indication: Fever
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Some soft tissues in peritoneal cavity.
    • Liver and renal cysts (up to 3.9cm).
    • Normal appearance of spleen, pancreas, adrenals.
    • Invisible gallbladder. S/P CBD stenting. Mild dilatation of biliary tree and p-duct.
    • Small caliber of extrahepatic portal vein.
    • Degeneration and spondylosis of L-S spine.
  • IMP:
    • Some soft tissues in peritoneal cavity.
    • S/P CBD stenting. Mild dilatation of biliary tree and p-duct.
    • Small caliber of extrahepatic portal vein.
• 2023-09-23 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Abnormal ECG
• 2023-08-02 CT - abdomen
  • Findings:
    • S/P metalic stent implantation at the CHD, CBD and duodenum.
    • Prior CT identified dilatation of the IHDs on both hepatic lobes are noted again, mild decreasing in size.
    • Prior CT identified pancreatic duct dilatation is noted again, mild increasing in size.
    • The mesentery root shows fatty stranding and several enlarged nodes. please correlate with clinical condition.
    • S/P cholecystectomy.
    • There is no focal lesion in both lung and mediastinum.
    • A renal cyst measuring 3.9 cm in left upper pole is noted.
    • Abdominal aorta shows atherosclerosis and ectasia 2.2 cm.
  • Impression:
    • S/P metalic stent implantation at the CHD, CBD and duodenum.
    • Prior CT identified dilatation of the IHDs on both hepatic lobes are noted again, mild decreasing in size.
    • Prior CT identified pancreatic duct dilatation is noted again, mild increasing in size.
    • The mesentery root shows fatty stranding and several enlarged nodes. please correlate with clinical condition.
• 2023-06-05 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • s/p biliary stent placement at CBD is found. Dilated IHDs and proximal CBD is found.
    • The pancreatic duct is dilated.
    • Minimal pneumobilia is found.
    • The liver, spleen, pancreas, both kidneys and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
    • Left renal cyst up to 4.02cm is found.
    • The spleen, liver, pancreas and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
    • The urinary bladder is well distended without soft tissue lesion.
    • No evidence of abnormal soft tissue mass at pelvic cavity.
    • No definite inguinal or pelvic sidewall LAP
  • Imp:
    • s/p biliary stent placement at CBD is found. Dilated IHDs and proximal CBD is found.
    • The pancreatic duct is dilated. No signficant soft tissue mass is found. But correlation with other finding is suggested.
• 2023-03-07 MRI - MR Cholangiography, MRCP
  • History and indication: Malignant neoplasm of biliary tract
  • With and without contrast MRI of liver revealed:
    • S/P CBD stenting with artifact. S/P cholecystectomy. Mild dilatation of IHD.
    • Liver and renal cysts (up to 3.9cm).
  • IMP:
    • S/P CBD stenting with artifact. S/P cholecystectomy. Mild dilatation of IHD.
• 2022-11-08 Abdomen - standing (diaphragm)
  • Degeneration and spondylosis of L-S spine.
  • Contrast medium retention in the bowel.
  • S/P CBD stenting.
• 2022-11-07 Endoscopic Retrograde Cholangiopancreatography, ERCP
  • Indication: CBD stricture s/p metal stent placement
  • Symptoms: for pre-Op. evaluation
  • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
  • Anesthesia: IV anesthesia
  • Equipment: TJF-260V
  • Diagnosis:
    • Malignant biliary stricture s/p metal stent with no evidence of narrowing site
    • Chronic cholangitis
    • Juxta-papillary diverticulum
    • Reflux esophagitis, Gr. A
    • Gastric angioectasias, low body
• 2022-11-08 SONO - abdomen
  • Indication: CBD cancer
  • Symptoms: fever
  • Diagnosis:
    • Asymmetric CBD wall thickening
    • Pneumobilia, both lobes
      
    • Metallic stent in the CBD
    • Prob. Parenchymal liver disease
• 2022-08-08 CT - abdomen
  • History and indication
    • cholangiocarcinoma
  • Findings
    • A cystic lesion (4.3cm) at left kidney. Tiny liver and renal cysts.
    • Invisible gallbladder. S/P CBD stenting with pneumobilia.
  • IMP:
    • S/P CBD stenting with pneumobilia.
    • No interval change of peritoneal lesions.
• 2022-07-06 CT - abdomen
  • History and indication
    • tea color urine for 10 days due to obstructive jaundice
    • SGOT: 103, SGPT: 141, HBsAG (-), antiHCV(-) (2022-01)
    • 20220114 CT: Cholangiocarcinoma at the CHD is noted.
      • Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected.
      • cT2N2M1, cStage:IV
    • 20220214 CBD tumor, serosa, laparotomy — Poorly cohesive carcinoma with signet-ring cell differentiation
  • Findings:
    • Prior CT identified soft tissue lesions in the omentum at LUQ abdomen are noted again, stationary.
    • Prior CT identified several enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, and para-aortic space (non-regional nodes) are noted again, mild decreasing in size.
    • S/P metalic stent implantation from CHD to duodenum.
    • S/P cholecystectomy.
    • Pneumobilia on left lobe IHD is noted.
    • There is no evidence of IHD dilatation.
    • A renal cyst measuring 4 cm in left upper pole is noted.
    • Abdominal aorta shows atherosclerosis and ectasia 2.2 cm.
    • There is no focal lesion in both lung and mediastinum.
    • Prior CT identified few hepatic cysts in both lobes are noted again, stable in size. The largest one 0.8 cm in S8.
      
  • Impression
    • Prior CT identified soft tissue lesions in the omentum at LUQ abdomen are noted again, stationary.
• 2022-05-24 KUB
  • S/P clips projecting at the liver hilum.
  • S/P metalic stent implantation at CHD, CBD and duodenum.
  • Pneumobilia on left lobe IHDs.
  • Fecal material store in the colon.
• 2022-05-23 Endoscopic Retrograde CholangioPancreatography, ERCP
  • diagnosis
    • Malignant biliary stricture s/p FCSEMS (Kaffes stent, 5 cm and 8 mm ) (FCSEMS = Fully Covered, Self Expanding Metal Stent)
    • Chronic cholangitis
    • Juxta-papillary diverticulum
    • Reflux esophagitis, Gr. A
  • suggestion
    • f/u amylase & lipase
• 2022-05-22 ECG
  • Normal sinus rhythm
  • Left anterior fascicular block
  • Abnormal ECG
• 2022-05-12 SONO - abdomen
  • Liver cyst, right lobe
  • Post cholecystectomy
  • Mild left IHD dilatation
  • Pneumobilia, left
  • Post CBD stenting
  • Renal cyst, left kidney
• 2022-05-04 CT - abdomen
  • Pneumobilia on left lobe IHD is noted.
  • Carcinomatosis is suspected. Please correlate with ascites cytology.
• 2022-04-20 Cholangiography
  • Cholangiography via PTCD catheter administration revealed:
    • Patency of the catheter and stent.
    • S/P operation with retention of surgical clips.
• 2022-04-18 ECG
  • Normal sinus rhythm
  • Left anterior fascicular block
• 2022-04-18 Endoscopic Retrograde CholangioPancreatography, ERCP
  • diagnosis
    • Biliary stricture s/p plastic stent exchange
    • Chronic cholangitis
    • Reflux esophagitis Gr.A
  • suggestion
    • f/u amylase & lipase
• 2022-03-12 Percutaneous transhepatic cholangio drain, PTCD (drainage)
  • The necessarity and risks of the procedure was well explanined to patient family before the PTCD. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
  • Dilatation of the biliary tree (by CT images). S/P CBD stenting.
  • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree via left IHD smoothly.
  • No procedure-related complication during the whole procedure.
• 2022-03-09 CXR
  • Atherosclerotic change of aortic arch
• 2022-03-09 CT - abdomen
  • Cholangiocarcinoma at the CHD and metastatic nodes show stationary.
  • Mild ascites is noted.
• 2022-02-15 Patho - duodenum biopsy
  • PATHOLOGIC DIAGNOSIS
    • CBD tumor, serosa, laparotomy — Poorly cohesive carcinoma with signet-ring cell differentiation
    • Gallbladder, open cholecystectomy — Chronic cholecystitis and free from tumor
    • Lymph nodes, post-pancreatic region (LN 16), frozen section — Free from tumor metastasis (0/11)
  • MICROSCOPIC EXAMINATION
    • CBD tumor, serosa: poorly cohesive carcinoma characterized by tumor cells arranged in linear or individual pattern with signet-ring cell differentiation.
      • Immunohistochemistry of CK(+), CK7(+), CK20(+, focal) and CDX2(+) for tumor.
    • Gallbladder: chronic cholecystitis with serosal hemorrhage and free from tumor invasion
    • Lymph nodes, post-pancreatic region (LN 16): free from tumor metastasis (0/11)
• 2022-02-14 CXR
  • S/P operation with retention of surgical clips.
  • S/P Port-A infusion catheter insertion.
  • S/P CBD stenting.
  • Right CVP inserted to SVC in position.
  • Ground glass opacity in RLL.
• 2022-01-26 SONO - abdomen
  • CBD wall thickening with upstram ductal dilatation
  • pneumobilia, both lobes
  • stent in the CBD
  • pancreatic cystic lesion
  • Prob. Parenchymal liver disease
• 2022-01-25 Body fluid cytology
  • Bile duct brushing: atypia
• 2022-01-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 26) / 87 = 70.11%
  • Conclusion
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild MR, TR
• 2022-01-24 Endoscopic Retrograde CholangioPancreatography, ERCP
  • diagnosis
    • Biliary stricture s/p brushing cytology & plastic stent placement
    • Chronic cholangitis
    • Reflux esophagitis Gr.A
  • suggestion
    • f/u amylase & lipase
• 2022-01-14 CT - abdomen
  • Cholangiocarcinoma at the CHD is highly suspected.
    • Please correlate with CEA, CA199, ERCP and biopsy.
    • Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected.
    • According to American Joint Committee on Cancer(AJCC)staging system, 8th edition for bile duct cancer: T2 N2 M1, Stage:IV
  • Mild wall thickening at the gastric antrum and duodenum is noted. Please correlate with gastroscopy.
• 2022-01-14 SONO - abdomen
  • Parenchyaml liver disease
  • Hepatic cyst
  • Bilateral IHD dilatation
  • Bilateral renal cysts
  • Pancreatic cyst
• 2019-11-17 ECG
  • Sinus bradycardia
  • Left anterior fascicular block
  • Nonspecific ST abnormality
• 2018-08-06 CT - abdomen
  • Distention of urinary bladder with irregular wall. Enlargement of prostate.
  • A cystic lesion (4.0cm) at left kidney.

[consultation]

• 2023-11-15 Infectious Disease

  • A
    • The is a case of cholangiocarcinoma at common hepatic duct. Cholangitis is suspected.
    • Agree with your use with finibax.
    • Please adjust antibiotic according to culture results and clinical conditions.

• 2023-09-25 Gastroenterology (not completed)

• 2023-09-25 Infectious Disease

  • Q
    • Empiric antibiotics with Cefotaxime was administered.
    • Under the impression of Cholangiocarcinoma, cT2N2M1, stage IV suspect cholangitis. He was admitted for further management.
    • Due to B/C: GNB, so we need your help for antibiotic evaluation, thanks a lot!!
  • A
    • B/C: GNB, E. coli.
    • Agree with your use of brosym for the GNB sepsis.
    • Please keep IV antibiotics for 7~10 days.
    • Please adjust antibiotic according to culture results and clinical conditions.

• 2022-04-20 Radiation Oncology

  • Q
    • This is a 71 year-old male had past histories of
      • BPH s/p RaSP + bil TAPP on 2018/12/05.
      • Polyp status post polypectomy on 2019/11/12.
      • Common bile duct poorly cohesive carcinoma with signet-ring cell differentiation, pT4N0M0, stage IIIB.
      • Unresectable Bile duct tumor status post open cholecystectomy and port-A insertion on 2022/02/14.
      • Cholangitis with dilatation of the biliary tree. S/P CBD stenting.Percutaneous Transhepatic Cholangiography and Drainage on 2022/03/12.
      • He was regular follow up at our GI OPD.
      • Due to ERCP revealed Biliary stricture s/p plastic stent exchange on 20220418, we need arrange cholangiography, thank you~
  • A
    • According to the clinical condition and imaging findings, cholangiography is indicated.

• 2022-03-12 Radiation Oncology

  • Q
    • This 71-year-old male,a case of Common bile duct poorly cohesive carcinoma with signet-ring cell differentiation, pT4N0M0, stage IIIB under XRT since 20220301, chemotherapy with 5-FU (200mg/m2) on 20220307~20220311. Spiking fever was noted on 20220311 morning, laboratory test revealed hyperbilirubinemia. Empiric antibiotics with Flumarin was administered. We need your expertise for further management, thanks.
  • A
    • According to the clinical condition and imaging findings, PTCD is indicated.

• 2022-02-15 Radiation Oncology

  • Q
    • He was admitted for CBD tumor resection.
    • Because of unresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein.
    • The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14.
    • Pathology report was pending.
    • After explanation, he preferred neoadjuvant CCRT
    • After CCRT surgery will be asssessed in the future.
    • Therefore, we need your expertise to evaluate, manage his current condition.
  • A
    • Subjective:
      • History: This is a 71 years old male suffered from obstructive jaundice s/p ERCP with Biliary stricture s/p brushing cytology & plastic stent placement on 2022/01/24. He was admitted for CBD tumor resection. Because of unresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein was noted during OP. The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14. Pathology report was pending. Neoadjuvant CCRT was suggested by Tumor Board.
        • Previous RT: denied.
        • Other disease: BPH s/p RaSP+bilateral TAPP on 2018/12/05. Polyp status post polypectomy on 2019/11/12.
        • Family history: denied.
      • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
      • Widower. Caregiver: his only son. Job: retired business. Mild economic stress.
      • Language: Mandarin. Taiwanese.
      • Religion:
    • Objective:
      • General Condition-ECOG: 1.
      • PE, 2022/02/15: No SCF LAPs.
      • Pathology, 2022/2/14, pending.
      • OP finding: distended GB and dilated proximal CBD; an indurated hard tumor at distal CBD with serosa, right hepatic artery and portal vein invasion, tumor extended to pancreatic head; multiple LN at para-aorta and hepatoduodenal ligament and common hepatic artery.
      • Images:
        • CT, 2021/12/17: There is mild wall thickening (8 mm in wall thickness) and abrupt narrowing at the CHD, causing marked dilatation of proximal CHD and both lobe IHDs. Cholangiocarcinoma at the CBD is highly suspected. There are several enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, and para-aortic space (non-regional nodes) that may be metastatic nodes. Imp: 1. Cholangiocarcinoma at the CHD is highly suspected. Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for bile duct cancer: T2 N2 M1, Stage:IV
        • CXR, 2022/01/17: No metastasis.
      • CA199: 103.38 (2022/1/15).
    • Diagnosis:
      • Cholangiocarcinoma, distal CBD with serosa, right hepatic artery and portal vein invasion with gastrohepatic ligament, hepatoduodenal ligament and para-aortic space s/p brushing cytology & plastic stent placement on 2022/01/24, s/p open cholecystectomy and port-A insertion on 2022/02/14; ECOG: 1.
    • Suggest: Radiotherapy.
      • Goal: Curative (Preoperative).
      • RT Plan:
        • Target & Volume: CBD tumor and LAPs.
        • Technique: VMAT & IGRT.
        • Dose & Fractionation: 4500cGy/25 fractions.
      • Plan: CCRT is suggested for locoregional control. CT simulation is arranged on Feb 22 09:30 am. Possible treatment toxicity (radiation gastritis and enteritis) is told. Diet education & psychological support is given.

• 2022-02-14 Gastroenterology

  • Q
    • For changing of biliary tract metallic stent evaluation and management.
    • This is a 71 years old male had past histories of
      • BPH s/p RaSP + bil TAPP on 2018/12/05.
      • Polyp status post polypectomy on 2019/11/12.
    • ERCP with Biliary stricture s/p brushing cytology & plastic stent placement on 2022/01/24.
    • He was admitted for CBD tumor resection.
    • Because of nonresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein.
    • The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14.
    • After explanation, he preferred neoadjuvant chemotherapy, and for biliary tract management, metallic stent was suggested.
    • Therefore, we need your help to performed the procedure (ERCP)
  • A
    • Please confirm if he needs Radiation therapy or not before metalic stenting.

• 2022-01-25 General and Gastrointestinal Surgery

  • Q
    • Suspected cholangiocarcinoma for further management
    • This is a 71 years old male had past histories of 1.) BPH s/p RaSP + bil TAPP on 20181205. 2.) Polyp status post polypectomy on 20191112.
    • This time, due to he suffered from jaundice and tea color urine for 10+ days. There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastirc pain, no tarry/bloody stool, no TOCC found. He visited to our GI OPD for help. At GI OPD, follow up blood test that showed hyperbilirubinemia, no leukocystosis nor PT prolong found. Abdominal sonography wsa done revealed parenchyaml liver disease; hepatic cyst; bilateral IHD dilatation; bilateral renal cysts and pancreatic cyst. Abdominal CT with contrast was also done for further survey which revealed cholangiocarcinoma at the CHD is highly suspected. ERCP was arrnged and showed 1. Biliary stricture s/p brushing cytology & plastic stent placement 2. Chronic cholangitis 3. Reflux esophagitis Gr.A. So we need you evaluation and suggestion of this patient. Thank you very much ~
  • A
    • Assessment
      • A case impressed of CBD tumor with obstruction suspected malignancy
    • Suggestion
      • arrange f/u cardiopulmonary function
      • check tumor marker of CEA, CA199
      • triflow training (self-paid)
      • arrange GS OPD on 20220208
      • planing for further operation with total CBD resection after TBI < 6

[surgical operation]

• 2022-02-14
  • Surgery
    • open cholecystectomy
    • port-A insertion
  • Finding
    • distended GB and dilated proximal CBD
    • an induration hard tumor at distal CBD with serosa, right hepatic atery and portal vein invasion, tumor extended to pancreashead
    • multiple LN at pararota and hepatoduodenal ligament adn common hepatic artery
• 2022-12-05 Suprapubic prostatectomy
  • pre-op, post-op diagnosis: BPH
  • PCS code: 79404C
  • findings: adenoma 51 gm was resected, bilateral mixed type.

[radiotherapy]

• 2022-03-01 ~ 2022-04-08 - 5000cGy/25 fractions (15 MV photon).

[chemoimmunotherapy]

• 2023-11-08 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-10-18 - pembrolizumab 100mg NS 100mL 30min + gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (Keytruda + gemcitabine + cisplatin)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-10-11 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-12 - pembrolizumab 100mg NS 100mL 30min + gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (Keytruda + gemcitabine + cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-05 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-22 - pembrolizumab 100mg NS 100mL 30min + gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (Keytruda + gemcitabine + cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-15 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-01-16 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3960mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
• 2022-12-26 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3980mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
• 2022-11-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3970mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
• 2022-11-17 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3980mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
• 2022-09-29 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3960mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
• 2022-09-14 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 660mg 2hr + fluorouracil 2400mg 3970mg 46hr (neoadjuvant FOLFIRINOX, Q2W)
• 2022-08-31 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3950mg 46hr
• 2022-08-17 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
• 2022-07-29 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
• 2022-07-14 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
• 2022-06-28 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 640mg 2hr + fluorouracil 2400mg 3800mg 46hr
• 2022-06-14 - oxaliplatin 70mg/m2 100mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3800mg 46hr
• 2022-05-19 - oxaliplatin 60mg/m2 90mg 2hr + irinotecan 140mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3800mg 46hr
• 2022-05-03 - oxaliplatin 60mg/m2 90mg 2hr + irinotecan 140mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3700mg 46hr
• 2022-03-28 - fluorouracil 200mg/m2 300mg 24hr D1-2
• 2022-03-21 - fluorouracil 200mg/m2 300mg 24hr D1-2
• 2022-03-17 - fluorouracil 200mg/m2 300mg 24hr D1-2
• 2022-03-07 - fluorouracil 200mg/m2 300mg 24hr D1-2

==========

2023-11-29

[Brosym dosage assessment for the patient with jaundice and poor renal function]

This patient has severe jaundice and poor kidney function, and is currently being treated with Brosym (cefoperazone, sulbactam) 4g IVD Q12H.

• 2023-11-27 AST 90 U/L
  
• 2023-11-27 ALT 54 U/L
  
• 2023-11-27 BUN 36 mg/dL
  
• 2023-11-27 Creatinine 1.32 mg/dL
  
• 2023-11-27 eGFR 56.51 ml/min/1.73m^2
  
• 2023-11-27 Bilirubin total 13.76 mg/dL
  
• 2023-11-27 Bilirubin direct 7.85 mg/dL
  
• 2023-11-27 Alkaline phosphatase 208 U/L
  
• 2023-11-27 r-GT 181 U/L

Sanford Guide:

• Cefoperazone is extensively excreted in bile and the serum half-life is usually prolonged with urinary excretion of the drug increased in patients with hepatic diseases and/or biliary obstruction. Even with severe hepatic dysfunction, therapeutic concentrations of Cefoperazone are obtained in bile and only a 2- to 4-fold increase in half-life is seen.
• Dose modification may be necessary in cases of severe biliary obstruction, severe hepatic disease or in cases of renal dysfunction associated with either of those conditions.
• In patients with hepatic dysfunction and concomitant renal impairment, dosage should not exceed 2 g/day of Cefoperazone without close monitoring of serum concentrations.

The current dosage of Brosym is twice the recommended amount according to the Sanford Guide. Please consider reducing the dosage based on the clinical situation.

2023-11-16

[biweekly gemcitabine-cisplatin and monthly pembrolizumab demonstrate sustained response]

The current treatment regimen, which includes biweekly administrations of gemcitabine and cisplatin, along with monthly pembrolizumab, initiated on 2023-08-15, seems to remain effective. This effectiveness is indicated by the decreasing trend in CA-199 levels and the stable readings of CEA.

• 2023-11-14 CA-199 (NM) 79.720 U/ml

• 2023-11-07 CA-199 (NM) 78.021 U/ml

• 2023-10-24 CA-199 (NM) 190.180 U/ml

• 2023-10-17 CA-199 (NM) 208.840 U/ml

• 2023-09-19 CA-199 (NM) 210.380 U/ml

• 2023-09-08 CA-199 (NM) 148.890 U/ml

• 2023-08-25 CA-199 (NM) 593.460 U/ml

• 2023-08-22 CA-199 (NM) 850.900 U/ml

• 2023-07-28 CA-199 (NM) 1253.210 U/ml

• 2023-05-26 CA-199 (NM) 23.184 U/ml

• 2023-03-10 CA-199 (NM) 11.934 U/ml

• 2022-11-18 CA-199 (NM) 11.891 U/ml

• 2022-11-07 CA-199 10.940 U/mL

• 2022-10-07 CA-199 (NM) 8.593 U/ml

• 2022-08-10 CA-199 (NM) 9.805 U/ml

• 2022-05-05 CA-199 (NM) 8.925 U/ml

• 2022-04-29 CA-199 (NM) 18.368 U/ml

• 2022-03-09 CA-199 (NM) 21.032 U/ml

• 2022-01-15 CA-199 103.380 U/mL

• 2023-11-14 CEA (NM) 7.340 ng/ml

• 2023-11-07 CEA (NM) 6.487 ng/ml

• 2023-10-24 CEA (NM) 7.002 ng/ml

• 2023-10-17 CEA (NM) 8.315 ng/ml

• 2023-09-19 CEA (NM) 5.347 ng/ml

• 2023-09-08 CEA (NM) 6.293 ng/ml

• 2023-08-25 CEA (NM) 7.052 ng/ml

• 2023-08-22 CEA (NM) 7.820 ng/ml

• 2023-07-28 CEA (NM) 6.275 ng/ml

• 2023-05-26 CEA (NM) 3.872 ng/ml

• 2023-03-10 CEA (NM) 4.042 ng/ml

• 2022-11-18 CEA (NM) 3.139 ng/ml

• 2022-11-07 CEA 3.090 ng/mL

• 2022-10-07 CEA (NM) 3.624 ng/ml

• 2022-08-10 CEA (NM) 2.325 ng/ml

• 2022-05-05 CEA (NM) 2.259 ng/ml

• 2022-04-29 CEA (NM) 3.142 ng/ml

• 2022-03-09 CEA (NM) 1.678 ng/ml

• 2022-01-15 CEA 3.380 ng/mL

[assessing the risk of edema in the context of increasing hypoalbuminemia]

The patient is exhibiting a trend of worsening hypoalbuminemia. Factors such as impaired liver function, suspected cholangitis, and infection could be contributing to this condition. It is advisable to check for the presence of edema, as indicated by the weight increase from 56.4 kg on 2023-11-08 to 60.8 kg on 2023-11-15.

• 2023-11-15 Albumin (BCG) 2.5 g/dL
• 2023-11-08 Albumin (BCG) 2.5 g/dL
• 2023-11-01 Albumin (BCG) 2.8 g/dL
• 2023-10-18 Albumin (BCG) 3.3 g/dL
• 2023-10-11 Albumin (BCG) 2.9 g/dL
• 2023-10-04 Albumin (BCG) 2.8 g/dL
• 2023-10-02 Albumin (BCG) 2.8 g/dL
• 2023-09-28 Albumin (BCG) 2.7 g/dL
• 2023-09-26 Albumin (BCG) 2.6 g/dL
• 2023-09-12 Albumin 3.1 g/dL
• 2023-09-05 Albumin 3.0 g/dL
• 2023-08-22 Albumin 3.2 g/dL
• 2023-08-15 Albumin 3.0 g/dL
• 2023-07-25 Albumin 3.0 g/dL
• 2023-01-16 Albumin 3.9 g/dL
• 2023-01-09 Albumin 3.6 g/dL
• 2022-12-26 Albumin 4.0 g/dL

701470461

231129

[MedRec]

• 2023-02-06 ~ 2023-02-21 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Multiple myeloma not having achieved remission
    • Multiple myeloma, IgG type, ISS stage II
    • Spondylosis without myelopathy or radiculopathy, lumbar region
    • Low back pain
  • CC
    • back pain for 5 month
  • Present illness
    • This is a 66-year-old male with history of Hypertension, hyperlipidemia and Gout for 20 years, BPH s/p for 3 years, Colon polyps s/p for 10 years with regular medication control, he was admitted due to back pain since Oct 2022.
    • This time, he suffered from fall down in Oct 2022 and took analgesic agent for one month ago but in vain and visited to YiLan YangMing Hospital for aid and was admitted at that hospital in Dec 2022 due to L 4/5 listhesis s/p Bil MIS Rt L 4/5 transforaminal laminectomy + discectomy for nerve root decompression + i-TLIF cage implantation + Bil L 4-5 TPS fixation + Lt L4/5 laminotomy on 111/12/24 & BPH S/P LASER.
    • Two months later follow-up spine x-ray showed compression fracture and bone cement was done on 2023-02-02. Owing to difficulty urinating was noted and foley cather was inserted on 2023-02-04. Poor appetite, body weight loss about 5 kg and both lower legs weakness and massive yellowish sputum were also since 2023-01-21. Will arranged spine biopsy on 2023-02-06 at YiLan YangMing hospital but the patient was refused and transferred to our ER for treatmetn.
    • Under the impression of back pain for 5 month, R/O spine tumor, R/O prostate cancer with multiple bone mets, R/O multiple myeloma and increase infilitration over both lungs R/O aspiration pneumonia. He was admitted for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, pain control with Tramacet 37.5 & 325mg/tab 1# PO Q6H.
    • Consult NS for evaluation and management, persue tumor marker report; on brace prn; May consult radiologist for CT guide biosy (left T11 vertebrae body?); or bone marrow biopsy as your expertise.
    • R/O aspiration pneumonia, antibiotic with Cefuroxime 1500mg IVD Q8H from 2023/02/06~2023/02/13, tapper to oral form with Cinolone 250mg/tab 3# PO Q12H* 7days.
    • Bome marrow on 2023/02/08, pathology showed myeloma. IHC stains: CD138: 20-25%, kappa and lambda: a predominant kappa sub-population;  CD117: %; CD34: <1 %; MPO: 20 % (of the nucleated cells).
    • Consult dental for Xgeva use, no deep caries were noticed. no pathological findings could be obtained due to lack of dental panoramic film and mild periodontitis of full mouth was noticed. Xgeva 120mg/1.7mL/vial 1vial was give on 2023/02/14.
    • VTD regimen for MM, Bortezomib is applied, Thado 50mg/cap 2# PO HS since 2023/02/14, Limeson 4mg/tab 10# PO QW3 since 2023/02/15.
    • Patient tolerated the treatment of multiple myeloma. With the stable condition, he was discharged on 2023/02/21 and OPD followed up later.  
• 2023-02-06 SOAP Medical Emergency Hu YuHui
  • S
    • Admitted at National Yang Ming Chiao Tung University Hospital in 2022/12:
      • L 4/5 listhesis s/p Bil MIS Rt L 4/5 transforaminal laminectomy + discectomy for nerve root decompression + i-TLIF cage implantation + Bil L 4-5 TPS fixation + Lt L4/5 laminotomy on 2022/12/24 BPH S/P LASER
    • 2023-02-02 chest/abdomen CT:
      • Multiple osteolytic lesions at thoracic vertebra and suspicious bilateral ribs.
      • D/Dx: metastasis, multiple myeloma, metabolic bone disorder.
      • Suggest further clinical evaluation.
  • A
    • Preliminary impression:
      • M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region

[chemotherapy]

• 2023-11-19 - melphalan 100mg/m2 160mg NS 500mL 1hr D1-2 (D-2,-1 conditioning regimen prior to APBSCT D0 2023-11-21)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-09-26 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

• 2023-09-19 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

• 2023-07-07 - cyclophosphamide 3000mg/m2 4800mg NS 500mL 2hr (for PBSC harvest)

• 2023-06-16 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

• 2023-06-09 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

• 2023-06-02 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

• 2023-05-26 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

• 2023-05-19 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

• 2023-05-12 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

• 2023-05-05 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

• 2023-04-28 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

• 2023-04-21 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

• 2023-04-14 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

• 2023-04-07 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

• 2023-03-31 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

• 2023-03-24 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

• 2023-03-17 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

• 2023-03-09 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-11-29 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

• Cycle length: 28 days.

• Regimen

  • Bortezomib
    • 1.3 mg/m2 SC
    • Given as a single SC injection.
    • Days 1, 8, 15, and 22
  • Thalidomide
    • 100 mg for first 14 days then 200 mg per day thereafter by mouth.
    • Take with water on an empty stomach at least one hour after the evening meal.
    • Daily, days 1 through 21
  • Dexamethasone (“low dose”)
    • 40 mg by mouth
    • Take with food (after meals or with food or milk) in the morning.
    • Days 1, 8, 15, and 22

==========

2023-11-29

[APBSCT day 8: minor WBC rise, no PLT improvement]

Today is Day 8 post-APBSCT, and there is a slight increase in the WBC level observed. However, the PLT remains low and has not shown any signs of rising.

• 2023-11-29 WBC 0.73 x10^3/uL D08

• 2023-11-27 WBC 0.03 x10^3/uL D06

• 2023-11-26 WBC 0.02 x10^3/uL D05 nadir

• 2023-11-25 WBC 0.53 x10^3/uL D04

• 2023-11-24 WBC 4.25 x10^3/uL D03

• 2023-11-23 WBC 11.14 x10^3/uL D02

• 2023-11-22 WBC 3.81 x10^3/uL D01

• 2023-11-20 WBC 5.23 x10^3/uL D-1

• 2023-11-29 PLT 18 *10^3/uL D08
  

• 2023-11-27 PLT 53 *10^3/uL D06
  

• 2023-11-26 PLT 78 *10^3/uL D05
  

• 2023-11-25 PLT 28 *10^3/uL D04
  

• 2023-11-24 PLT 51 *10^3/uL D03
  

• 2023-11-23 PLT 75 *10^3/uL D02
  

• 2023-11-22 PLT 98 *10^3/uL D01
  

• 2023-11-20 PLT 143 *10^3/uL D-1

Based on the lab results from 2023-11-29, the patient’s liver and kidney functions are normal, indicating no need for dosage adjustments due to liver or renal concerns.

[tube feeding]

Concor 5mg - For administration, employ the Simple Suspension Method (SSM). This involves dissolving the tablet in warm drinking water, leaving it for 5-10 minutes, and occasionally stirring or gently shaking the container until the tablet fully dissolves. Once dissolved, it can be administered through a feeding tube. This technique is particularly useful for dissolving tablets and capsules in warm water, making them suitable for suspension and feeding tube administration.

Harnalidge 0.4mg - Since Harnalidge (tamsulosin 0.4mg) is not appropriate for tube feeding, it is advised to transition to Urief (silodosin 8mg) as a suitable alternative to meet the patient’s requirements.

2023-11-16

[minutes of interprofessional practice and family meeting]

Today, at 11:00 on 2023-11-16, an interprofessional practice and family meeting was convened by the attending physician, Dr. Gao, in the conference room of Ward 11A. The patient, along with his wife and only son, attended the meeting.

Dr. Gao provided the patient and his family with a comprehensive explanation about the current status of the disease, prognosis, the expected outcomes and risks associated with autologous PBSCT, and asked several questions to assess whether the family fully understood the situation.

Before the meeting, I visited the family and informed that the patient’s bilirubin levels were slightly elevated, but renal function was normal, and there was currently no need to adjust dosages due to liver or kidney function status.

As the patient’s hearing has been gradually declining, I suggested during the post-meeting casual conversation that, once the transplantation procedure is completed and the patient is in a stable condition, he should consider consulting an otolaryngologist to explore further corrective measures, such as getting a hearing aid.

701456176

231127

[exam findings]

[MedRec]

• 2023-09-21 SOAP Hemato-Oncology Xia HeXiong
  • S: NGS BRCA2 C9515G (Leu3172A) > Uncertain Significance
  • P: Due to aberrant BRCA2 -> The follow-up CY will include the ovarian site.
• 2023-08-30 ~ 2023-09-01 POMR Hemato-Oncology Xia HeXiong
  • Admission diagnosis
    • Left breast invasive carcinoma, cT1cM0N0, stage IA.ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. ECOG:0.
  • Discharge diagnosis
    • Malignant neoplasm of unspecified site of left female breast
    • Left breast invasive carcinoma, cT1cM0N0, stage IA, ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%, s/p chemotherapy with Liposome Doxorubicin/Cyclophosphamide from 2023/08/31~
    • Chronic viral hepatitis B without delta-agent
    • Hyperlipidemia, unspecified
  • CC
    • for prepare chemotherapy        
  • Present illness
    • This 46-year-old female patient had 1). Mitral Valve prolape without follow up it for many years ago; 2). HBV with follow up it for many years ago; 3). Hyperlipidemia with medicine control for many years. She denied any TOCC histories in recent 3 months.
    • She noted a mass at left bresat on 2023/05 by health examination. She came to our outpatient department for help.
    • Breast sono on 2023/06/15 showed Left subareolar, size: 1.10x0.76 cm and 1.45x1.29 cm, ill-defined irregular shape lesion, suggested biopsy. Right 2/1.20 cm , size: 1.06x1.90 cm, fibroadenomas as described. Left breast core needle biopsy was done on 2023/06/20 showed invasive carcinoma. ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. CEA: 0.744 ng/ml, CA-153 :10.386 U/ml.
    • Chest CT on 2023/06/30 showed 1). nodular lesion with enhancement at left breast measuring 1.91cm in largest dimension is found; 2). There is no evidence of mediastinal LAP. 3). No evidence of bilateral pleural effusion. 4). The liver, spleen, pancreas, both kidneys and adrenals are intact.
    • Bone scan on 2023/07/03 showed a hot area in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
    • Physical examination: symmetrical of bilateral breasts. a hard, nontender, movable mass and irregular margin at left breast around 2x2 and 2x2 cm without discharge. The left nipple without dimping, exudative nor bloody discharge and no retraction. The left breast skin had no cellulite change. a hard, nontender, movable mass and irregular margin at right breast around 2x2 cm without discharge. The right nipple without dimping, exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
    • She received left breast simple mastectomy + sentinel lymph node biopsy and right breast partial mastectomy were performed on 2023/07/26.
    • This time, she was admitted for prepare chemotherapy.        
  • Course of inpatient treatment
    • After admission, arrange echocardiography for survey before chemotherapy, was done on 2023/08/31 showed LVEF: 75.6%, atypical mitral valve and tricuspid valve proplapse, adequate LV and RV performance with normal wall motion at resting state, mild MR, TR, normal LV and RV relaxation, then she receive Liposome Doxorubicin (30mg/m2, self paid) + Cyclophosphamide (600mg/m2) on 2023/08/31 smoothly.
    • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
    • Strocain 5mg/tab 1# PO TIDAC for stomach discomfort.
    • Chronic viral hepatitis B with Baraclude 0.5mg/tab 1# PO QDAC.
    • Hyperlipidemia wity Tulip F.C 20mg/tab 1.5# PO QOD.
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, she was discharged on 2023/09/01 and OPD followed up later.
  • Discharge prescription
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Sinpharderm Cream (urea) BID TOPI
    • Emend (aprepitant 125mg) 1# QD
    • Tulip (atorvastatin 20mg) 0.5# QOD (QN)
• 2023-08-16 SOAP Hemato-Oncology Xia HeXiong
  • S: For further management
    • HBsAg (+), Anti-HBc (+), Anti-HBs (-), AHCV (-)
    • Mitral valve prolapse
    • Hyperlipidemia (+)
  • A
    • left breast cancer, TNBC, Ki-67: 10%, pT1cN0M0
  • P
    • Arrange admission for heart echo. Liopo-Dox / Cyclophoasmide x 4 followed by docetaxel x 4
    • Genetic test BRCA1/2
• 2023-07-26 ~ 2023-07-29 POMR General and Gastrointestinal Surgery Chen YenZhi
  • Discharge diagnosis
    • Left breast invasive carcinoma status post simple mastectomy+sentinel lymph node biopsy on 2023/07/26. cT1cM0N0, stage IA. ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. ECOG:0.
    • Right breast fibroadenoma status post partial mastectomy on 2023/07/26.
  • CC
    • noted a mass at left bresat on 2023/05 by health examination.
  • Present illness
    • This 46-year-old female patient had 1). Mitral Valve prolape without follow up it for many years ago; 2). HBV with follow up it for many years ago; 3). Hyperlipidemia with medicine control for many years. She denied any TOCC histories in recent 3 months.
    • She noted a mass at left bresat on 2023/05 by health examination. She came to our outpatient department for help.
    • Breast sono showed Left subareolar, size: 1.10x0.76 cm and 1.45x1.29 cm, ill-defined irregular shape lesion, suggested biopsy. Right 2/1.20 cm , size: 1.06x1.90 cm, fibroadenomas as described.
    • Left breast core needle biopsy showed invasive carcinoma. ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. CEA: 0.744 ng/ml, CA-153 :10.386 U/ml.
    • Chest CT showed 1). nodular lesion with enhancement at left breast measuring 1.91cm in largest dimension is found; 2). There is no evidence of mediastinal LAP. 3). No evidence of bilateral pleural effusion. 4). The liver, spleen, pancreas, both kidneys and adrenals are intact.
    • Bone scan showed a hot area in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
    • Physical examination: symmetrical of bilateral breasts. a hard, nontender, movable mass and irregular margin at left breast around 2x2 and 2x2 cm without discharge. The left nipple without dimping, exudative nor bloody discharge and no retraction. The left breast skin had no cellulite change. a hard, nontender, movable mass and irregular margin at right breast around 2x2 cm without discharge. The right nipple without dimping, exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
    • Under the impression of left breast invasive carcinoma and right breast tumor, she was admitted for surgery of 1). left simple mastectomy + sentinel lymph node biopsy; 2) right partial mastectomy.
  • Course of inpatient treatment
    • After admission, left breast simple mastectomy + sentinel lymph node biopsy and right breast partial mastectomy were performed on 2023-07-26.
    • The post-operative course was relatively smooth without complication. The wounds are clean and dry.
    • Under the stable condition, she was discharged today and the final report will be follow up at outpatient department.
  • Discharge diagnosis
    • Acetal (acetaminophen 500mg) 1# QID
    • MgO 250mg 1# QID
    • Gaslan (dimehylpolysiloxane 40mg) 1# TID
    • Through (sennoside 12mg) 1# HS

[surgical operation]

[chemotherapy]

• 2023-11-25 - docetaxel 75mg/m2 100mg NS 250mL 1hr (D, Q3W)
  • dexamethasone 4mg + metoclopramide 10mg + NS 250mL
• 2023-11-02 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
• 2023-10-12 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
• 2023-09-21 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
• 2023-08-31 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2

701499763

231127

[exam findings]

• 2023-10-30 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 18.9) / 101 = 81.29%
    • M-mode (Teichholz) = 81.3
  • Conclusion:
    • Dilated aortic root, normal AV with mild AR
    • Normal MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, mild TR, normal IVC size
• 2023-10-30 Miniprobe Endoscopic Ultrasound
  • Diagnosis：
    • Esophageal cancer, middle to lower esophagus, multifocal: T3Nx at least (lesion C), T1b (lesion B), unspecified T stage at lesion A
    • Hypopharyngeal cancer
    • Suboptimal study of EUS (related to difficulty in water immersion and suboptimal patient’s tolerance due to frequent coughing)
  • Suggestion:
    • Correlate with other imaging
• 2023-10-28 MRI - brain
  • Large area of old infarction over left anterior amd middle MCA territories.
  • Passive dilatation of left lateral ventricle.
• 2023-10-27 PET
  • Glucose hypermetabolism involving the right hypopharynx and posterior pharyngeal wall, compatible with primary hypopharyngeal malignancy.
  • Glucose hypermetabolism in bilateral retropharyngeal lymph nodes, bilateral neck level III and IV and left supraclavicular lymph nodes, suggesging metastatic lymph nodes.
  • Glucose hypermetabolism in the L5 spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
  • Glucose hypermetabolism in some focal areas in the middle and lower portions of the esophagus and in multiple lymph nodes around the EG junction. Synchronous esophageal malignancy with multiple regional lymph node metastases may show this picture.
  • Mild glucose hypermetabolism in the right shoulder and in bilateral pulmonary hilar lymph nodes. Inflammatory process may show this picture.
• 2023-10-26 CT - chest
  • Indication: suspect esophageal cancer
  • Chest CT with and without IV contrast ehnancement shows:
    • Lymphadenopathy at bilateral thoaracic inlet is found. Compatible with hypopharyngeal cancer meta.
    • Wall thickening at lower esophagus with extension into gastric cardiac portion is found measuring 8.5cm in largest dimension. Esophageal cancer is considered. Regional lymph nodes are found at perigatric region (n＝5)
    • Mild to moderate Emphysematous change over both lungs is found.
    • Calcified coronary arteries is found.
    • Dilatation of the infrarenal aorta measuring 2.4cm is found.
    • Wall thickening at cardiac portion of the stomach. Suggest correlate with endoscopy to exclude synchronous gastric cancer.
    • Diffuse wall thickening at hypophrynx with regional lymphadenopathy. Extensive hypopharyngeal cancer is considered.
  • Imp:
    • Esophageal cancer with gastric cardiac extension and regional lymphadenopathy.
    • Synchronous esophageal cancer.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-10-25 Tc-99m MDP bone scan
  • Faint hot spots in the posterolateral aspect of the right 10th rib and right scapula, respectively, and increased activity in the lower C-spine and right S-I joint, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in some T-spine, right shoulder, right elbow, and left S-I joint.
• 2023-10-25 Patho - esophageal biopsy
  • Esophagus, lower, biopsy — Squamous cell carcinoma, moderately differentiated
  • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident. Tumor necrosis is present.
• 2023-10-24 MRI - larynx
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
    • A large right hypopharyngeal tumor, extending to left site, highly suspect with right carotid space invasion.
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • Enlarged right retropharyngeal LN and bil. neck LNs. Highly with ENE (+) at left low neck, supraclavicular fossa.
  • IMP:
    • Right hypopharyngeal CA, T4bN3Mx stage IVB
  • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T: 4b(T_value) N: 3b(N_value) M: 0(M_value) STAGE: IVB (Stage_value)
• 2023-10-24 EGD
  • Diagnosis:
    • Tumor, lower esophagus, s/p biopsy, suspect metastasis, r/o primary lesion
    • C/W hypopharyngeal cancer
  • Suggestion:
    • Pursue pathology report
• 2023-10-24 SONO - abdomen
  • Findings
    • Hypoechoic leison up to 2.8cm was noted near the S3 and EC junction.
  • Diagnosis:
    • Suspect lymph node metastasis
  • Suggestion:
    • EGD and CT study
• 2023-10-12 Patho - larynx biopsy
  • Labeled as “Right arytenoid papillary tumor”, LMS biopsy — squamous cell carcinoma.
  • Section shows squamous cell carcinoma.
  • IHC stains: Ki-67: 70%, p16 (-).
• 2023-10-02 Nasopharyngoscopy
  • smooth NP, right posterior pharyngeal wall bulging tumor, also right vocal plasy??

[MedRec]

• 2023-10-02 SOAP Ear Nose Throat Huang YunCheng
  • S:
    • lump in throat, dysphagia and easy choking for3 months
    • patient has strong gap reflex, hard to assess NP and larynx by mirror
  • O:
    • Nasopharyngoscope findings: Smooth NP, right posterior pharyngeal wall bulging tumor, also right vocal plasy??
    • breathing smooth
  • P:
    • suggest LMS biopsy

[consultation]

• 2023-11-02 Oral and Maxillofacial Surgery
  • Q
    • This 56-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06.
    • This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01.
    • He admitted for cancer workup, after the examination done, hypopharyngeal cancer and esophageal cancer were diagnosed. CCRT was indicated.
    • We had consult your expertise on 10/24. You suggest that extraction of all hopeless teeth (12,17,23,27,38 and 44) .
    • The patient has shceduled port-A implant and juojenostomy on 2023/11/03.
    • The patients to have a tooth extraction during the thoracic surgery, but after reconfirming with the thoracic department, the surgery might only start around noon. The patient won’t be discharged in the short term, so we can arrange for the tooth extraction to be done in separate sessions
  • A
    • Dear doctor, we will arrange the surgery.
• 2023-10-26 Gastroenterology
  • Q
    • For arrange miniprobe EUS
    • This 55-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06.
    • This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01.
    • Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor.
    • He recevied laryngomicrosurgery on 2023/10/11. Pathology result squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-).
    • Under the impression of hypopharyngeal cancer. This time, the patient was admitted for cancer work-up.
    • Laryngeal MRI was arranged and showed right hypopharyngeal CA, T4bN3Mx, stage IVB.
    • Abd echo arranged and showed hypoechoic leison up to 2.8cm was noted near the S3 and EC junction, suspect lymph node metastasis.
    • PES arrange and showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion.
    • Bone scan was done on 10/25 and pending result. We consulted CS for suspect eshopharygeal cancer evalution, which suggest arrange miniprobe EUS. We need your help, thank you very much!!
  • A
    • This is a 55-year-old male who was admitted due to newly found right hypopharyngeal cancer.
      • EGD showed a few polypoid and nodularity lesions noted 30cm below incisors to EC junction, suspect metastasis, r/o second primary cancer.
      • We are consulted for EUS.
    • S
      • dysphagia, solid and liquid food
      • smoking and betelnut before, quit
    • O
      • E4V5M6, cons clear
      • Conjunctiva: not pale
      • Sclera: anicteric
      • Abdomen: soft and flat, no tenderness
    • Impression
      • Right hypopharyngeal cancer, T4bN3Mx
      • Suspected esopharyngeal malignancy, suspect second primary cancer
    • Suggestions
      • EUS may be arranged.
• 2023-10-26 Radiation Oncology
  • A: The patient’s history was reviewed and patient was examined.
    • S: For CCRT due to hypopharyngeal carcinoma and esophageal carcinoma.
      • PI: The patient suffered from right MCA infarct on 2023/06. He complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01. Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor. He recevied laryngomicrosurgery on 2023/10/11.
        • Pathology showed squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-). The diagnosis was right hypopharyngeal carcinoma, stage cT4bN3M0, stage IVB. In addition, PES showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion. Referred for CCRT.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
      • Previous RT Hx: (-)
    • O: ECOG: 2
      • PE: neck and bil SCF: a palpable nodal lesion over right middle neck. CVA with right upper limb weakness.
      • CXR (2023-10-11): Tortuosity of the aorta with atherosclerotic change.
      • Pathology (S2023-20303, 2023-10-16): Labeled as “Right arytenoid papillary tumor”, LMS biopsy — squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-).
      • Abd sono (2023-10-24): Hypoechoic leison up to 2.8cm was noted near the S3 and EC junction. Diagnosis: Suspect lymph node metastasis.
      • UGI panendoscopy (2023-10-24): Tumor, lower esophagus, s/p biopsy, suspect metastasis, r/o primary lesion. C/W hypopharyngeal cancer.
      • MRI of larynx (2023-10-24): Right hypopharyngeal CA, T4bN3Mx stage IVB
        
      • Bone scan (2023-10-25): Faint hot spots in the posterolateral aspect of the right 10th rib and right scapula, respectively, and increased activity in the lower C-spine and right S-I joint, the nature is to be determined (post-traumatic change or other nature?)
      • Pathology (S2023-21165, 2023-10-26): Esophagus, lower, biopsy — Squamous cell carcinoma, moderately differentiated
    • A:
      • Squamous cell carcinoma, p16 (-), of the right hypopharynx, stage cT4bN3M0 (stage IVB).
      • Squamous cell carcinoma of the low third esophagus.
    • P:
      • CCRT is indicated for this patient with the following indicators: hypopharyngeal carcinoma, stage cT4bN3M0 (stage IVB); esophageal carcinoma.
      • Goal: palliation
      • Treatment target and volume: 1. hypopharyngeal tumor to bilateral neck; 2. low third esophageal carcinoma and peripheral area.
        
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the hypopharyngeal tumor to bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor bed and involved nodal lesion. 5040cGy/28 fractions of the esophageal tumor (if surgery no tplanned).
        
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0900, 2023-11-2.
      • Please consult Dental department for pre-RT dental evaluation and management.
• 2023-10-25 Hamato-Oncology
  • Q
    • For CCRT further evaluation
    • This 55-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06.
    • This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01.
    • Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor.
    • He recevied laryngomicrosurgery on 2023/10/11. Pathology result squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-).
    • Under the impression of hypopharyngeal cancer. This time, the patient was admitted for cancer work-up.
    • Laryngeal MRI was arranged and showed right hypopharyngeal CA, T4bN3Mx, stage IVB.
    • Abd echo arranged and showed hypoechoic leison up to 2.8cm was noted near the S3 and EC junction, suspect lymph node metastasis.
    • PES arrange and showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion.
    • Bone scan was done on 10/25 and pending result. We consulted CS for suspect eshopharygeal cancer evalution, which arrange staging for eshopharygeal cancer, neoadjuvant CCRT will be first considered.
    • We need your help for CCRT further evaluation. Thank you very much!!
  • A
    • This 55 year old man had inderline disease of right MCA infarction on 2023/06. We are consulted CCRT for 1. Hypopharygear cancer, cT4bN3Mx, stage IVB and 2. Suspect esophageal cancer, pending pathology result.
    • Suggestion:
      • We will discuss with patient about CCRT.
      • Pending esophageal cancer biopsy result and complete esophageal cancer staging (chest CT+/-contrast, PET/CT scan…).
      • Additionally, Please check HBsAg, Anti HBc, Anti HBs, Anti HCV before chemotherapy.
      • And arrange port A and jejunostomy before chemotherapy.
• 2023-10-24 Thoracic Surgery
  • Q
    • For suspect esophageal caner
    • This 55-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06. This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01. Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor.
    • He recevied laryngomicrosurgery on 2023/10/11. Pathology result squamous cell carcinoma. Under the impression of hypopharyngeal cancer. This time, the patient was admitted for cancer work-up. Laryngeal MRI was arranged and showed right hypopharyngeal CA, T4bN3Mx, stage IVB. Abd echo arranged and showed hypoechoic leison up to 2.8cm was noted near the S3 and EC junction, suspect lymph node metastasis. PES arrange and showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion. We need your help for further evaluation. Thank you very much!!
  • A
    • I will arrange staging for eso. ca. After staging, I will explain the following management with him and his family.
    • Neoadjuvant CCRT will be first considered. Feeding jejunostomy and port-A insertion will be arranged before treatment.
• 2023-10-24 Oral and Maxillofacial Surgery
  • Q
    • For tooth evaluation
    • This time, the patient was admitted for cancer work-up. We will arrange CCRT for him. We need your help for tooth evaluation. Thank`s a lot
  • A
    • After examing the intraoral condition.
    • Possible treatment plan
      • Treatment option A
        • extraction of all hopeless teeth (12,17,23,27,38 and 44) to prevent RT-related osteonecrosis and risk of cellulitis
        • Possible risk: relative contraindication due to recent right MCA infarction this June.
      • Treatment option B
        • conservative treatment (toothbrushing)
        • Possible risk: osteonecrosis and risk of cellulitis
    • patient’s father and his wife understands and will consider about it. thank you for your consultation

[radiotherapy]

[chemotherapy]

• 2023-11-21 - NS 500mL 1hr (before CDDP) + cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-11-06 - NS 500mL 1hr (before CDDP) + cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-11-27

[Akynzeo use for prolonged nausea control post-chemotherapy]

On 2023-11-21, the patient was administered cisplatin at 40mg/m2, with premedication including dexamethasone, diphenhydramine 30mg, palonosetron 250ug, and NS hydration.

Post-treatment, the patient experienced nausea and vomiting for an additional three days, leading to the prescription of metoclopramide.

For subsequent chemotherapy sessions, it may be beneficial to consider Akynzeo, available in this hospital. Akynzeo, containing netupitant, an NK-1 receptor antagonist with a 96-hour half-life, could provide prolonged anti-emetic effects.

[hypomagnesemia and hypokalemia]

Cisplatin is a common cause of hypomagnesemia and hypokalemia due to renal magnesium (Mg) and potassium (K) losses.

• 2023-11-27 K (Potassium) 3.1 mmol/L
  

• 2023-11-24 K (Potassium) 3.8 mmol/L
  

• 2023-11-23 K (Potassium) 4.9 mmol/L

• 2023-11-27 Mg (Magnesium) 1.8 mg/dL

• 2023-11-06 Mg (Magnesium) 1.9 mg/dL

Magnesium (MgO) and potassium (Const-K) supplements are currently in use. There is no problem with the supplementation.

[mild hyponatremia]

Based on the laboratory data, mild hyponatremia has been consistently observed for the past month and a half, and it may be considered to investigate the possible underlying causes.

• 2023-11-27 Na (Sodium) 133 mmol/L
• 2023-11-24 Na (Sodium) 134 mmol/L
• 2023-11-23 Na (Sodium) 133 mmol/L
• 2023-11-06 Na (Sodium) 133 mmol/L
• 2023-10-11 Na (Sodium) 134 mmol/L

[elevated BUN]

Cisplatin primarily injures the S3 segment of the proximal tubule. Urea undergoes a more complex process involving reabsorption and secretion in different parts of the tubules, while creatinine is not significantly reabsorbed after filtration. The elevated BUN may be a vague indication of cisplatin nephrotoxicity.

• 2023-11-27 BUN 35 mg/dL
• 2023-11-23 BUN 21 mg/dL
• 2023-11-14 BUN 15 mg/dL

2023-11-06

Every oral medication listed as currently active is suitable for administration via a feeding tube.

700032025

231124

[MedRec]

• 2023-11-14 SOAP Heamto-Oncology He JingLiang
  • S: ca of stomach with liver mets
  • P: arrange C/T with FOLFOX
• 2023-11-14 SOAP Gastroenterology Gong ZiXiang
  • S
    • Gastric cancer with liver metastasis, r/o HCC or cholangiocarcinoma (r/o double cancer) -> refer to GS, Oncology, keep PPI
      • GS suggest: tissue aquitition is needed for liver tumor
  • O
    • 2023/11/03 CT: ABD — whole abdomen, pelvis - Impression (Imaging stage): T4aN2M1, stage: IVB
      • There is a huge heterogeneous poor enhancing mass in S4-7-8 of the liver, measuring 9 cm in size
    • 2023/10/30 PATHO - Stomach, cardia, biopsy — poorly differentiated adenocarcinoma
      • IHC stain— Her2/neu: negative (0)
  • Prescription
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
    • Pariet (rabeprazole 20mg) 1# QDAC
• 2017-01-26 SOAP Cardiology Xu ShunYi
  • Diagnosis
    • Pure hyperglyceridemia [E78.1]
    • Essential hypertention, unspecified [I10]
    • Chronic airway obstruction (COPD) ,NEC [J44.9]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type [E11.9]
  • Prescription x3
    • Diovan (valsartan 160mg) 0.5# QD
    • Norvasc (amlodipine 5mg) 1# QD
    • Concor (bisoprolol 5mg) 0.5# QD

[consultation]

• 2023-11-20 Radiation Oncology
  • Q
    • for liver mass for R/T
    • This is a 71-year-old male with past history of HTN and hyperlipidemia, Type 2 DM, Ankylosing Spondylitis and Gastric adenocarcinoma, cT4aM1N2, stage IVB status with metastatic nodes with huge heterogeneous poor enhancing mass in S4-7-8 of the liver, measuring 9 cm in size.
    • He used to smoking 1 packs per week for about 20-30 year and had tea, coffee ocasionally.
    • According to patient statement and his medical record, he had burning sensation at night, poor digestion progressive for a half year, more severe on October. He went to our GI OPD for help.
    • EsophagoGastroDuodenoscopy was arranged on 10/30 and showed gastric ulcer, cardia, AW-LC, suspected malignancy, s/p biopsy.
    • Abdominal CT was arranged on 11/03 and revealed Adenocarcinoma of the stomach and HCC 9 cm in S4-7-8 of the liver is highly suspected, imaging stage: T4aN2M1,stage:IVB.
    • Panendoscopy biopsy pathological report revealed poorly differentiated adenocarcinoma. CT guide of liver was arranged for R/O HCC huge central type.
    • Liver, CT-guided biopsy showed Adenocarcinoma. This time, he was admitted for on port-A and chemotherapy.
    • We sincerely need your professional assistance!!
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For radiotherapy of the metastatic liver tumor.
      • PI: The patient was a case of gastric adenocarcinoma, stage cT4aN2M1 (IVB), status with metastatic nodes with huge heterogeneous poor enhancing mass in S4-7-8 of the liver, measuring 9 cm in size. Pathology (S2023-22725, 2023-11-15) showed liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with metastatic gastric adenocarcinoma. Referred for radiotherapy of the metastatic liver tumor.
      • Family history: (father: hepatoma)
      • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
      • Personal Hx: DM (-); HTN (+); HBV (+); ankylosing spondylitis
      • RT Hx: (-)
    • O: ECOG: 1
      • PE: neck and bil SCF: neg; abdomen: mild induration of the upper abdomen.
      • UGI panendoscopy (2023-10-30): Reflux esophagitis LA Classification grade A. Superficial gastritis, s/p CLO test. Gastric ulcer, cardia, AW-LC, suspected malignancy, s/p biopsy. CLO test: Negative.
      • Pathology (S2023-21538, 2023-11-1): ADDENDUM: IHC stain — Her2/neu: negative (0). DIAGNOSIS: Stomach, cardia, biopsy — poorly differentiated adenocarcinoma
      • CT scan of abdomen (2023-11-14): 1. Adenocarcinoma of the stomach. 2. HCC 9 cm in S4-7-8 of the liver is highly suspected. The differential diagnosis includes Metastasis. Please correlate with dynamic MRI. 3. Detailed findings, please see description.
      • Pathology (S2023-22725, 2023-11-15): Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with metastatic gastric adenocarcinoma
    • A: Poorly differentiated adenocarcinoma of the stomach, stage cT4aN2M1(IVB) with liver metastasis.
    • P: Radiotherapy is indicated for this patient with the following indicators: large metastatic liver tumor
      • Goal: palliation
      • Treatment target and volume: metastatic liver tumor
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the metastatic liver tumor.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2023-11-22.

[radiotherapy]

[chemotherapy]

• 2023-11-23 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

700377453

231124

[exam findings]

[MedRec]

• 2023-04-17 ~ 2023-04-21 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Sigmoid tumor obstruction status post T-loop colostomy on 2023/04/17
  • CC
    • diffuse abdominal distension with no stool passage for 10 more days
  • Present illness
    • This 48-year-old male denied any systemic diseases. According to patient’s statement and previous medical record, the patient felt diffuse abdominal distension with no stool passage for 10 more days. He also had intermittent cramping pain with nausea and vomiting since 2 days ago. Associated with poor appetite and fatigue. The patient denied having fever, diarrhea, bloody stool, tarry stool, chest pain. Due to symptoms persisted, the patient visited our emergency department.
    • At our triage, vital signs were stationary. No fever noted. Physical examination showed distended abdomen without tenderness over four quardrant. No muscle guarding, no rebounding pain found. Laboratory data showed elevated CRP level (1.86 mg/dL). KUB showed increased air in nondistended loops of small bowel over LUQ, and colonic segments, visible rectal air, and scanty amount of fecal material filled D-colon and rectum, paralytic or partial mechanical ileus.
    • Abdominal CT showed apple core like narrowing of the sigmoid colon measuring 3.5cm in largest dimension is found. The colon is severely dilated. One fistula tract is found abutting from sigmoid colon narrowing region is found. Sigmoid colon fistula is more favored but colon cancer cannot be excluded. CRS doctor was consulted and emergent colostomy was suggested.
    • With the impression of obstruction ileus, the patient received T-loop colostomy on 2023/04/17 and admitted to our ward for postoperative management.
  • Course of inpatient treatment
    • After admission, we arranged post-op care and colostomy care. Education of colostomy was also done. He was under regular diet due to well bowel movement without abdominal discomfort. He was able to tolerate diet.
    • Sigmoidoscopy was arranged which suspected sigmoid cancer obstruction, biopsy was done and the pathology report was still pending.
    • He discharged on 4/21 due to stable condition and OPD follow up was arranged.
  • Discharge prescription
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# PRNQ6H

[surgical operation]

[immunochemotherapy]

• 2023-11-21 - (Avastin + FOLFIRI) Xia He Xiong

• 2023-11-01 - (Avastin + FOLFIRI) Xia He Xiong

• 2023-10-13 - (Avastin + FOLFIRI) Xia He Xiong

• 2023-09-22 - (FOLFIRI) Xia He Xiong

• 2023-09-01 - (FOLFIRI) Xia He Xiong

• 2023-08-22 - (FOLFOX) Chen XinHong

• 2023-08-07 - (FOLFOX) Xiao GuangHong

• 2023-07-24 - (FOLFOX) Xiao GuangHong

• 2023-07-10 - (FOLFOX) Xiao GuangHong

• 2023-06-26 - (FOLFOX) Xiao GuangHong

• 2023-06-12 - (FOLFOX) Xiao GuangHong

• 2023-05-29 - (FOLFOX) Xiao GuangHong

700617345

231124

[lab data]

2023-04-07 Anti-HBs 64.07 mIU/mL
2023-04-07 Anti-HBc Nonreactive
2023-04-07 Anti-HBc Value 0.08 S/CO
2023-04-07 Anti-HCV Nonreactive
2023-04-07 Anti-HCV Value 0.06 S/CO
2023-04-07 HBsAg Nonreactive
2023-04-07 HBsAg (Value) 0.47 S/CO

[exam findings]

• 2023-10-03 CT - abdomen
  • S/P hysterectomy.
  • Liver cyst, 0.4cm in S2-3.
  • R/O left renal cyst, 0.5cm.
• 2023-07-17 EGD
  • Reflux esophagitis LA Classification grade A (minimal)
  • Superficial gastritis, antrum
• 2023-03-29 Patho - uterus (with or without SO) neoplastic
  • Diagnosis:
    • Uterus, endometrium, total hysterectomy with frozen section — endometrioid adenocarcinoma grade 2.
    • Uterus, myometrium, total hysterectomy — tumor invasion, 1 mm; <1/2 thichness of the thickness of the myometrium; one myoma present.
    • Uterus, cervix, total hysterectomy — free
    • Ovaries and fallopian tubes, bilateral, BSO — No malignancy. Endometriosis and corpora lutea present.
    • Lymph node, bilateral pelvic and para-aortic, dissection — Free
      
    • Omentum, partial omentectomy — Free
    • pT1a pN0 (if cM0); AJCC 8th edition Pathology stage: IA
      
  • Gross description:
    • Procedure (select all that apply) - staging surgery: Total hysterectomy and bilateral salpingo-oophorectomy, partial Omentectomy: uterus: 10 x 8 x 5 cm with polypoid endometrial tumor at fundus. Left ovary: 3.5 x 2.5 x 1.5 cm. Left tube: 5.5 x 1 x 1 cm; right ovary: 3.5 x 2.5 x 1.5 cm; right tube: 5 x 1 x 1 cm. Omentum: 6 x 3.5 x 1.5 cm
      • For information about lymph node sampling, please refer to the Regional Lymph Node section.
    • Tumor Site (select all that apply)- Endometrium, fundus, > 4.5 cm from cervical margin.
    • Tumor Size:
      • Greatest dimension: 5 cm
        • Additional dimensions (centimeters): 3.5 x 0.5 cm
    • Sections are taken and labeled as:
      • Tissue for section: A: left external iliac lymph nodes; B: left obturator lymph nodes; C: right external iliac lymph nodes; D: right obturator lymph nodes; E: left para-aortic lymph nodes; F: right para-aortic lymph nodes; G1: left ovary; G2: left tube; G3: right ovary; G4: right tube; G5-8: endometrial tumor; G9: non-tumrous endometrium and uterine corpus and myoma; H1-3: omentum.
  • Microscopic Description:
    • Histologic Type: Endometrioid carcinoma
    • Histologic Grade: FIGO grade 2 (low-grade)
    • Myometrial Invasion: present, 1 mm in depth; < 1/2 thichness of the thickness of the myometrium
    • Uterine Serosa Involvement - Not identified
    • Cervical Stromal Involvement - Not identified
    • Other Tissue / Organ Involvement: Not identified
    • Bilateral ovaries: free
    • Omentum: free
    • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
      • Ectocervical/Vaginal Cuff Margin: ree
      • Parametrial/Paracervical Margin: Free
    • Lymphovascular Invasion: Absent
    • Regional Lymph Nodes: free= 0/48= A: left external iliac lymph nodes (0/10); B: left obturator lymph nodes (0/10); C: right external iliac lymph nodes (0/11); D: right obturator lymph nodes (0/11); E: left para-aortic lymph nodes (0/3); F: right para-aortic lymph nodes (0/3).
      • Right Pelvic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): free 0/22
      • Left Pelvic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): 0/20
      • Para-aortic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): free (0/6)
    • Additional Pathologic Findings - myoma
• 2023-03-23 CT - abdomen
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T1a(T_value) N:N0(N_value) M:M0(M_value) STAGE: IA_(Stage_value)
• 2023-03-16 Patho - endometrium curretage / biopsy
  • Uterus, endometrium, D＆C — endometrioid carcinoma with focal clear cell carcinoma
  • Sections show atypical crowded and cribriform endometrioid carcinoma (grade 1) with focal clear cell carcinoma.
  • Immunohistochemically, the endometrioid carcinoma shows PAX8(+), WT-1(-), p53(No aberrant expression), Napsin A(-), and PR(+).
  • Immunohistochemically, the clear cell carcinoma shows PAX8(+), WT-1(-), p53(No aberrant expression), Napsin A(+), and PR(-).

[MedRec]

• 2023-04-11 SOAP Radiation Oncology Huang JingMin
  • A: Endometrioid carcinoma with focal clear cell carcinoma of the uterine endometrium, stage pT1a pN0 (cM0); AJCC 8th edition Pathology stage: IA, s/p staging surgery.
  • P: Radiotherapy is indicated for this patient with the following indicators: invasive clear cell carcinoma, stage IA.
    • Goal: curative
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT and IVRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions via IVRT to vaginal cuff mucosa surface.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her mother. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-04-25.
• 2023-04-11 SOAP Hemato-Oncology Xia HeXiong
  • S: This 36 year old woman is a case of Endometrioid adenocarcinoma grade 2. pT1a pN0 (if cM0); AJCC 8th edition Pathology stage: IA  post Staging surgery on 2023/03/29
    
  • Plan:
    • Arrange CCRT with CDDP and then C/T with TP
    • Simulation on 2023/04/25
    • May start weekly CDDP on 2023-05-02
• 2023-03-28 ~ 2023-04-07 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Endometrioid adenocarcinoma grade 2.pT1a pN0 (if cM0); AJCC 8th edition Pathology stage: IA  post Staging surgery on 2023/03/29
    • Abnormal vaginal bleeding
    • Epilepsy
  • CC
    • Abnormal intermittent uterine bleeding for 1 year
  • Present illness
    • This is a 36 y/o woman who had no sexual history, G0P0, LMP 2023/03/26, menstral cycle irregular with duration/interval of 7/28-30 days.
    • She had past history of (1) epilepsy s/p epilepsy surgery twice (2013, 2014) and vagus nerve stimulation therapy (2021.08.25), currently on anticonvulsant drugs, (2) Mixed hemorrhoids. She is allergic to carbamezepine. She denied oral contraceptives or hormone use.
    • According to the patient, she noticed abnormal intermittent uterine bleeding for 1 year. During menstration, heavy menstrual bleeding was noticed which she must use night sanitary pads and change at least 3 times a day, blood clots could be found, with fresh red color. She denied dysmenorrhea. Intermenstrual spotting with scanty, brownish discgarge was noted during the past 6 months. Epileptic seizures were triggered by menstration, and during menstration the frequency and duration of seizure increase. She denied abdominal pain, nausea, vomiting, tarry or bloody stool, constipation, unintentional body weight loss, or disuria or urinary frequency.
    • She turned to our GYN OPD for help, and some examination was done. The transvaginal sono on 2023.03.07 revealed endometrial polyp in size of 13*12mm. Hysteroscopy was performed on 2023.03.08 and multiple endometrial polyps with abberant vessels were found. D&C on 2023.3.16 revealed endometrioid carcinoma with focal clear cell carcinoma and chronic cervicitis. Abdominal CT was also done on 2023.03.23 and revealed soft tissue in the uterine cavity, r/o endometrial malignancy, stage T1aN0M0. Tumor marker showd CA125 = 34.5 U/mL; CEA = 2.16 ng/mL. And Hb level was 7.6 g/dL. Under the impression of endometrial clear cell carcinoma, she was admitted on 2023.03.28 for staging operation.        
  • Course of inpatient treatment
    • The patient was admitted on 03/29/2023 and underwent laparoscopic GYN cancer staging surgery (bil salpingo-oophoretomy + BPLND + partial omentectomy) and laparoscopic adhesiolysis the next day.
    • The surgical pathology revealed, The surgical pathology frozen section, endometrioid adenocarcinoma grade 2. Pathology stage: IA , pT1a pN0 (if cM0); AJCC 8th edition.
    • The Gyn tumor conference suggest further chemotherapy and radiotherapy for her after operation. Arrange port-A for checmotherapy and removed JP drain on 04/06. The vital sign was stable after surgery. She is discharged on 04/07/2023 and her followup appointment is scheduled on next week.
  • Discharge prescription
    • cephalexin 500mg 1# QID
    • Acetal (acetaminophen 500mg) 1# QID
    • Gaslan (dimethylpolysiloxane 40mg) 2# TID
    • Through (sennoside 12mg) 2# HS

[consultation]

• 2023-04-06 Neurology
  • Q
    • For evaluation of epilepsy therapy during chemo/radiotherapy.
    • The 36-year-old female patient with underlying of epilepsy under medication and s/p vagal nerve stimulator in 2021 was admitted on 03/29/2023 and underwent laparoscopic GYN cancer staging surgery (bil salpingo-oophoretomy + BPLND + partial omentectomy) and laparoscopic adhesiolysis the next day. The surgical pathology revealed: endometrioid adenocarcinoma grade 2; Pathology stage: IA , pT1a pN0 (if cM0); AJCC 8th edition. Her postoperative course was uneventful. Her Eating and urination by self voiding was smooth. The vital sign was stable after surgery. The Gyn tumor conference was arranged and chemo/radiotherapy will be arranged.
    • Due to her underlying of epilepsy with medication and vagal nerve stimulator, we need your expertise for evaluation of treatment.
    • Current medication: Lacosamide, Lamotrigine, Clobazam, Topiramate, Perampanel, Rufinamide.
  • A
    • This 36 year fenalt P’t is a case of Epilsy since 10+ years old and persis poor control even under 6 ASMs within therapy range and lesionnectomy. VNS was placed last year but still under titration of stimulation amplitudes and frequent.
    • She admitted to our GYN ward for sndometrioid adenccarcinoma and received bil salpingo-oophoretomy + BPLND + partial omentectomy on 3/29. Now, due to need further chemo/radiotherapy, we were consulted for evaluation the condition and further suggestion.
    • Imp:
      • Drug resistent epilepsy under ASMs and VNS
      • endometrioid adenocarcinoma s/p bil salpingo-oophoretomy + BPLND + partial omentectomy
    • Suggestion:
      • Due to all ASM within therapeutic dosage and no obvious drug-drug interation, we suggested keep present treatment.
      • Keep VNS therapy, needn’t adjust during chemo/radiotherapy
      • We had explained to patient and family that seizure rate may elevated during chemo/radiotherapy. But treatment plan of epilepsy needn’t adjust right now.
      • We also explained the possibility of status epiepticus and promised Neuroogist will help as soon as possible.
      • If seizure attack and persist over 5 minutes, give ativan iv 2 amp st, and depakine iv 30mg/kg quickly loading within 5~10 minutes. Consult Neuro emergency for further management of status epilepticus.

[surgical operation]

• 2023-04-06
  • Surgery
    • Operation
      • Port-A (47080B)
      • Fluoroscopy (32026C)        
  • Finding
    • Insertion via right subclavian vein.
    • Port: Polysite, 3007, 7Fr,
    • Fluorosopy: catheter tip in SVC above RA
• 2023-03-29
  • Surgery
    • Diagnosis: Endometrial cancer
    • Surgery: Staging surgery
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder
    • Bilateral adnexa: grossly normal
    • CDS: mild adhesion (+), ascites (+)
    • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • Omentum: grossly normal
    • Estimated blood loss: 300 mL
    • Blood transfusion: nil
    • Complication: nil
  • Procedure
    • Put the patient on the lithotomy position
    • Vaginal douching, insert Foley catheter, skin disinfection with beta-iodine, and skin draping.
    • Make midline vertical skin incision and open the abdominal wall layer by layer.
    • Serous ascites, send for cytology
    • Apply auto-retractor and pack up the intestine to expose the uterus.
    • Clamp, ligate and cut left round ligament
    • Clamp, cut andligate left infundibulo-pelvic ligament
    • Repeat step 6-7 at the right side.
    • Dissect the densely adherent posterior leaf of broad ligaments overlying the uterosacral ligaments bilaterally.
    • Dissect and reflect the bladder downwards and off the uterus.
    • Clamp, cut andligate the ascending branches of uterine arteries bilaterally at the level of isthmus of cervix.
    • Clamp, cut and ligate the paracervical vessels along lateral borders of cervix step by step downwards bilaterally till the level of lateral vaginal fornix.
    • Cut the uterus and grasp the vaginal stump
    • Suture the bilateral angles of vaginal stump with 1-0 Vicryl
    • Suture the vaginal stump with 1-0 Vicryl
    • Step by step clamp, cut and ligate the omentum.
    • Irrigate the pelvic cavity with normal salin.
    • Check bleeding and hemostasis.
    • Insert J-VAC X 2 at the cul-de-sac.
    • Close the abdomen layer by layer.
    • Skin approximation.
• 2023-03-16
  • Surgery
    • Diagnosis: R/O endometrial hyperplasia
    • Surgery: Fractional dilatation and curettage        
  • Finding
    • Uterus: Anteversion, 7 cm.
    • Scanty endocervical and some endometrial tissue were curetted out.
    • Mild laceration wound at 4 o’clock of the hymen.
    • Estimated blood loss:5 mL, Blood transfusion: nil, complication: nil.        
  • Procedure
    • Put the patient on lithotomy position.
    • Douching, skin disinfection and skin draping as usual.
    • Sounding: Anteversion, 7 cm.
    • Cervical dilatation to Hegar No. 7.
    • Curette the endocervical canal and uterine cavity.
    • Check bleeding.
    • Pack one piece of Bosmin gauze in the vagina to compress the hymen laceration wound.

[radiotherapy]

• 2023-05-04 ~ 2023-06-16 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.

[chemotherapy]

• 2023-11-23 - paclitaxel 105mg/m2 160mg NS 500mL 3hr + cisplatin 45mg/m2 70mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3 + lorazepam 2mg IVD Q12H D1-3
• 2023-10-30 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3 + lorazepam 2mg IVD Q12H D1-3
• 2023-10-04 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3 + lorazepam 2mg IVD Q12H D1-3
• 2023-09-12 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-03 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-14 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-08 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-01 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-25 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-18 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-11 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-04 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-11-24

[reduced chemotherapy dosage in this hospitalization]

The dosage of the paclitaxel-cisplatin regimen given during this hospital stay was decreased to 60% of the previous amount, taking into account the patient’s ability to tolerate the treatment.

While the CEA and CA125 markers are within normal limits, the rising CA199 levels may indicate underlying conditions that are yet to be identified and warrant further investigation.

• 2023-11-14 CA199 1260.46 U/mL
  
• 2023-10-17 CA199 1545.37 U/mL
  
• 2023-09-06 CA199 633.28 U/mL
  
• 2023-08-22 CA199 351.27 U/mL
  
• 2023-07-26 CA199 3.92 U/mL
  
• 2023-05-02 CA199 3.90 U/mL

2023-10-31

The drugs prescribed by VGHTPE on 2023-10-16 are currently in use, no medication discrepancy is found.

2023-10-03

The drugs rufinamide, lamotrigine, topiramate, lacosamide, perampanel, and clobazam refilled on 2023-09-08 to treat the patient’s “localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus” are currently in use with no discrepancy found.

2023-09-12

No medication discrepancy has been found.

2023-08-04

[reconciliation]

This patient recently refilled a 30-day prescription on 2023-07-24, provided by Taipei Veterans General Hospital, for rufinamide, lamotrigine, topiramate, lacosamide, perampanel, and clobazam to manage her “localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus.” However, these medications are not currently in use. Please verify if there is no longer a need for these drugs.

2023-07-14

[leukopenia]

The organization of WBC level changes is as follows, where * represents WBC < 3K/uL, ** represents WBC < 2K/uL. Leukopenia, which occurred in late May and worsened in mid-June, is more likely the result of the cumulative effects of multiple CCRTs when considering the treatment timeline. After each dose of Granocyte (lenograstim 250ug) administered on 2023-06-29 and 2023-07-01, leukopenia is currently no longer present.

2023-07-13 WBC 5.96 x10^3/uL 2023-07-06 WBC 4.03 x10^3/uL
2023-06-29 WBC 1.64 x10^3/uL ** Granocyte (lenograstim 250ug) 06/29, 07/01 2023-06-15 WBC 1.59 x10^3/uL ** concurrent CDDP 06/08 2023-06-07 WBC 2.05 x10^3/uL * concurrent CDDP 06/01 2023-05-31 WBC 2.02 x10^3/uL *
2023-05-24 WBC 2.22 x10^3/uL * concurrent CDDP 05/18, 05/25 2023-05-17 WBC 3.21 x10^3/uL concurrent CDDP 05/11 2023-05-10 WBC 3.47 x10^3/uL concurrent CDDP 05/04 2023-05-02 WBC 5.00 x10^3/uL
2023-03-30 WBC 10.44 x10^3/uL
2023-03-28 WBC 3.01 x10^3/uL
2023-03-08 WBC 3.31 x10^3/uL
2021-07-12 WBC 3.97 x10^3/uL

[paclitaxel administered, leukopenia needs to be monitored in the coming weeks]

• It is worth noting for the future that the paclitaxel, which we started administering today on 2023-07-14, is also expected to cause bone marrow suppression. Among these, neutropenia is the main dose-limiting hematologic toxicity of paclitaxel. Severe, grade 4 neutropenia and febrile neutropenia have been reported. Neutrophil nadir is generally rapidly reversible. The onset is intermediate, with neutrophil nadir typically occurring at a median of 11 days. Risk factors include higher doses, longer duration of infusion, and extent of prior cytotoxic chemotherapy.
• In addition to paclitaxel, cisplatin is also being used simultaneously. The latter causes leukopenia (25% to 30%; nadir: Day 18 to 23; recovery: By day 39; dose-related).
• Therefore, it is suggested to closely monitor the patient over the next few weeks.

700648329

231124

[lab data]

2023-08-04 Anti-HBc Reactive
2023-08-04 Anti-HBc-Value 7.10 S/CO
2023-08-04 Anti-HBs 205.76 mIU/mL
2023-08-04 HBsAg Nonreactive
2023-08-04 HBsAg (Value) 0.27 S/CO
2023-08-04 Anti-HCV Nonreactive
2023-08-04 Anti-HCV Value 0.10 S/CO

[exam findings]

• 2023-08-25 Venous Ultrasound
  • Report: Thrombus None
    • Right side:
      • SVC: 3.3 mmHg ; 3.9 mmHg ;
      • MVO/SVC: 100 % ; 100 % ;
      • Average MVO/SVC: 100 %
    • Left side:
      • SVC: 11.0 mmHg ; 11.4 mmHg ;
      • MVO/SVC: 78 % ; 82 % ;
      • Average MVO/SVC: 80 %
  • Conclusion:
    • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
    • Right lower limb soft tissue edema; mild right long saphenous vein engorgement
• 2023-08-23 ECG
  • Normal sinus rhythm
  • T wave abnormality, consider anterior ischemia
  • Prolonged QT
  • Abnormal ECG
• 2023-08-21 Peripheral Vascular Test - Artery. lower limbs
  • Atherosclerosis: Minimal
  • Doppler : Normal
  • Conclusions:
    • Patent bilateral CFA, SFA, PFA and popliteal arteries.
      • Mild atherosclerosis with mild stenosis at bilateral PTAs, ATAs and DPAs.
    • Tissue edema at right leg.
• 2023-08-18 Cell block
  • 50 cc brown turbid pleural effusion — Positive for malignancy
    
  • The smears and cell block show lymphocytes, reactive mesothelial cells and some atypical epithelial cells which immunocytochemistry shows GATA-3(+), TTF-1(-), and P40(-). According to clinical information and cytomorphologic findings, it is compatible with metastatic breast carcinoma.
• 2023-08-17 CXR (erect)
  • Bilateral pleural effusion.
  • Multiple nodules at bil. lungs.
• 2023-08-12, -08-11 CXR (erect)
  • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-08-11 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade B with ulcer, suspect Mallory-Weiss syndrome, s/p biopsy
    • Superficial gastritis
    • Gastric polyps, body
  • Suggestion:
    • pursue pathology
    • PPI and sucralfate therapy
• 2023-08-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (77 - 39) / 77 = 49.35%
    • M-mode (Teichholz) = 70
  • Conclusion
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Trivial MR and trivial TR
    • Preserved RV systolic function
• 2023-08-08 Tc-99m MDP bone scan
  • Increased activity in the lower T-spines and L3-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in biateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2023-08-07 PET
  • Increased FDG uptake in the left breast, compatible with the primary breast cancer.
    
  • Increased FDG uptake in the left mid- and high-axillary lymph nodes, highly suspected breast cancer with regional lymph nodes metastases.
  • Increased FDG uptake in multiple lobes of bilateral lungs and in both lobes of the liver, highly suspected cancer with distant metastases.
    
  • Left breast cancer, cTxN3aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-08-04 Patho - breast biopsy
  • DIAGNOSIS: Breast, left, biopsy — ductal carcinoma in situ, intermediate-grade
  • Microscopically, section shows intermediate-grade ductal carcinoma in situ characterized by a proliferation of atypical ductal epithelial cells with central necrosis of comedo-type. The tumor cells exhibit round to oval nuclei, nuclear pleomorphism, hyperchromasia and increased N/C ratio.
    
  • Immunohistochemical stain reveals
    • ER: negative
    • PR: negative
    • Her2/neu: positive(3+)
    • CK5/6: negative
    • p63: positive for myoepithelium.
• 2023-08-04 SONO - breast
  • Left breast malignancy with axillary lymph nodes metastasis.
    
  • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
• 2023-08-03 CXR
  • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-06-20 CT - abdomen
  • History and indication: abdominal pain
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Left breast tumor (5.4cm).
    • Multiple lung and liver tumors.
    • Right renal stone (3mm).
  • IMP:
    • Left breast cancer with lung and liver metastases.

[MedRec]

• 2023-09-28 SOAP Hemato-Oncology Xia HeXiong
  • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-08-11
    • Use TCHP first, and then add R/T if needed based on the effectiveness.
• 2023-08-03 ~ 2023-09-18 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Left breast ductal carcinoma in situ, intermediate-grade with left mid- and high-axillary lymph nodes, bilateral lungs and in both lobes of the liver, cTxN3aM1, stage IV, ER(-), PR(-), Her/neu(3+)
    • Malignant neoplasm of unspecified site of unspecified female breast
    • Intraductal carcinoma in situ of left breast
    • Abnormal results of liver function studies
    • Chronic viral hepatitis B without delta-agent, Anti-HBc (+)
    • Anemia, unspecified
    • Fever, unspecified
    • Agranulocytosis secondary to cancer chemotherapy
    • Abnormality of albumin
    • Hypokalemia
    • Hypomagnesemia
  • CC
    • breast ca is considered, admission for biopsy of left side breast
  • Present illness
    • The 57 years-old woman deny any past medical history. Initial symptoms with left side breast mass redness and swelling was found since 2018, no treatment. Since 2021, she return to taiwan received Chinese medicine treatment until now, but progression in 2023/04.
    • She visted to LMD, free echo showed much tumor in abdominal then referral to our ER. She suffered from shortness of breathing off and on, bilateral low leg edema and poor appetite for least two months. body weight loss 14 kg more than a year. Denied TOCC history in recent three months.
    • Accroding to the abdominal CT image on 2023/06/20, report showed Left breast cancer with lung and liver metastases.
    • This time, she was admitted, the PE showed left side breast mass, bilateral low leg edema 3-4+.
    • Under the impression of Left breast cancer with lung and liver metastases, so she admitted to our ONC ward for biopsy.
  • Course of inpatient treatment
    • After admission, left side breast mass 6x6 cm was found, highly suspected malignancy, 2023/06/20 CT image showed Left breast cancer with lung and liver metastases. Check lab and tumor marker and viral hepatitis. Consult Diagnostic Radiology and arrange breast sono and biopsy of breast on 2023/08/04.
    • Breast sono showed Left breast malignancy with axillary lymph nodes metastasis, biopsy was done, pathology showed Breast, left, biopsy — ductal carcinoma in situ, intermediate-grade, ER:negative, PR:negative, Her/neu:positive(3+), CK5/6:negative, p63:positive for myoepithelium, and sent Major Illness (+).
    • Cancer survey was arranged: PET on 2023/08/07 showed 1. Increased FDG uptake in the left breast, compatible with the primary breast cancer, 2. Increased FDG uptake in the left mid- and high-axillary lymph nodes, highly suspected breast cancer with regional lymph nodes metastases, 3. Increased FDG uptake in multiple lobes of bilateral lungs and in both lobes of the liver, highly suspected cancer with distant metastases, 4. Left breast cancer, cTxN3aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan;
    • Bone scan on 2023/08/08 showed 1. Increased activity in the lower T-spines and L3-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation, 2. Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation, 3. Increased activity in biateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
    • Cardiac echo on 2023/08/09 showed LVEF:70%, 1. Adequate LV systolic function with normal resting wall motion, 2 .Septal hypertrophy, 3. Trivial MR and trivial TR, 4. Preserved RV systolic function. Tramacet 37.5 & 325mg/tab 1# PO QD and 1# PO Q6HPRN for painn control.
    • Malignant fungating wound was noted, no acute bleeding, consult wound care practitioner for woun care, wound CD with Biomycin ointment 40gm/tube and Framycin Gause Dressing 18mg/patch cover.
    • Bao-gan 150mg/cap 1# PO TID was given for Abnormal results of liver function studies.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for AntiHBc (+).
    • Family meeting on 2023/08/09, discussion with patient and daughter ablut disaease condition and treatment plan, and consult CS for Port-A implantation on 2023/08/11.
    • Anemia was noted, blood transfusion to correct with LRBC 2unit for 2days (8/10, 8/11).
    • Collect stool/routine for check showed OB:3+, add ULSTOP F.C 20mg/tab 1# PO BID and arrange PES on 2023/08/11 showed Reflux esophagitis LA Classification grade B with ulcer, suspect Mallory-Weiss syndrome, s/p biopsy, Superficial gastritis, Gastric polyps, body. Then shift to Nexium 40mg/tab 1# PO QDAC. PES sent pathology for survey, report ulcer.
    • Add Plasbumin-20, 20% 10g/50mL/bt 1bot self paid mix lasix 1amp IVD QD *3day for low leg edema and suspect lung edema and bil. leg edema, add Plasbumin-20, 20% 10g/50mL/bt 1bot (self paid) mix lasix 1amp IVD BID.
    • She receive chemotherapy with Docetaxel (35mg/m2) on 2023/08/12, Dorison 1# po BID and Famotidine 1# po BID x3 day for prevention chemotherapy allergy from 2023/08/11~2023/08/13.
    • Shortness of breathing off and on, follow up D-dimer showed high, arrange Doppler for survey on 2023/08/21 showed 1. Patent bilateral CFA, SFA, PFA and popliteal arteries, Mild atherosclerosis with mild stenosis at bilateral PTAs, ATAs and DPAs, 2. Tissue edema at right leg, Venous Duplex was arrange on 2023/08/25 no DVT.
    • Consult hospice care for lymphatic massage for low leg edema relief on 2023/08/25.
    • Arranged chest echo for chest tapping on 2023/08/15, hepatomegaly was noted; minimal amount pleural effusion; thoracocentesis was not performed due to high risk of complications. Left thorax: no pleural effusion.
    • Progression shortness of breathing, arranged chest echo for chest tapping again on 2023/08/18 showed right side minimal amount of pleural effusion, 600cc serosangious fluid was aspirated for analysis.
    • Fever was noted, CRP: 9.9 mg/dL, Cravit 250mg/50mL/bot 750mg IVD QD from 2023/08/16~2023/08/20.
    • After chemotherapy with Docetaxel (35mg/m2) on 2023/08/12, Neutropenia was noted on 2023/08/21, Granocyte 250mcg/vial 250 mcg SC QD was given from 2023/08/21~2023/08/23 and Tapimycin 4.5g/vial 4.5 gm IVD Q6H from 2023/08/21~2023/08/24, due to Blood culture showed no growth and no fever, stop use.
    • Family meeting on 2023/08/19, discussion with patient and daughter about disaease condition and treatment plan again.
    • No infection status, she received chemotherapy with Liposome Doxorubicin (20mg/m2) + Cyclophosphamide (300mg/m2) on 2023/08/28(C1), received 2nd chemotherapy on 2023/09/11 (C2).
    • Fever was noted, empirical antibiotic with Tapimycin 4.5g/vial 4.5g IVD Q6H for infection control from 2023/09/01~2023/09/08, due to Blood culture showed no growth and no fever, stop use.
    • Acetal 500 mg/tab 1# PO Q6H for suspect tumor fever. Left eye redness and itch was noted, diagnosis was Allergic conjunctivitis, os. Emedastine 1gtt BID os, Inform red flags, come back earlier if s/s worsen and OPD f/u. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/18 and OPD followed up later.  
  • Discharge prescription
    • BaoGan (silymarin 150mg) 1# TID
    • Baraclude (entecavir 0.5mg) 1# HS
    • Cough Mixture (platycodon) 5mL TID
    • MgO 250mg 1# TID
    • Nexium (esomeprazole 40mg) 1# QODAC
    • Spironolactone 25mg) 1# BID
    • Through (senosside 12mg) 1# HS hold if diarrhea
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# QD
    • Transamin (tanexamic acid 250mg) 1# PRNQD SKIN for wound bleeding
    • Biomycin Ointment (neomycin, tyrothricin) 1# QD TOPI
    • Framycin Gause Dressing (fradiomycin 18mg/patch) 1# PRNQD EXT for wound care use
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ12H if VAS > 3
• 2023-08-02 SOAP Hemato-Oncology Xia HeXiong
  • P: Arrange admission for biops. Consult GS for breast biopsy or sono-guided biopsy and lab.
• 2023-06-23 SOAP Hemato-Oncology He JingLiang
  • S
    • multiple liver and lung mets
    • ca of breast is considered
    • suggest breast biopsy

[chemotherapy]

• 2023-11-07 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 400mg/m2 600mg NS 500mL 1hr (AC(Lipo))
  • dexamethasone 4mg + granisetron 3mg + NS 250mL
• 2023-10-18 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 400mg/m2 600mg NS 500mL 1hr (AC(Lipo))
  • dexamethasone 4mg + granisetron 3mg + NS 250mL
• 2023-10-04 - liposome doxorubicin 20mg/m2 20mg D5W 250mL 2hr + cyclophosphamide 300mg/m2 500mg NS 500mL 1hr (AC(Lipo))
  • dexamethasone 4mg + granisetron 3mg + NS 250mL
• 2023-09-11 - liposome doxorubicin 20mg/m2 20mg D5W 250mL 2hr + cyclophosphamide 300mg/m2 500mg NS 500mL 1hr (AC(Lipo))
  • dexamethasone 4mg + granisetron 3mg + NS 250mL
• 2023-08-28 - liposome doxorubicin 20mg/m2 20mg D5W 250mL 2hr + cyclophosphamide 300mg/m2 500mg NS 500mL 1hr (AC(Lipo))
  • dexamethasone 4mg + granisetron 3mg + NS 250mL
• 2023-08-12 - docetaxel 35mg/m2 60mg NS 250mL 1hr (DHP(SC/loading))
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL

==========

2023-11-24

[abnormal liver function test results point to possible liver damage]

Laboratory findings indicate elevated liver function test (LFT) values, suggesting possible liver damage.

• 2023-11-23 AST 79 U/L
  
• 2023-11-23 ALT 48 U/L
  
• 2023-11-23 Bilirubin total 1.08 mg/dL
  
• 2023-11-23 Bilirubin direct 0.39 mg/dL
  
• 2023-11-23 DBI/TBI 36.11 %

The patient has been receiving Baraclude (entecavir) and BaoGan (silymarin), and is prescribed Nexium (esomeprazole 40mg), taken as 1# QOD, no medication problem identified.

[dosing adjustments in hepatic impairment: guidelines for AC(Lipo) components]

The AC(Lipo) regimen being administered to this patient includes pegylated liposomal doxorubicin and cyclophosphamide.

• Liposomal Doxorubicin Dosing for Hepatic Impairment (Adults):
  • General Note: No specific dosage adjustments in the U.S. manufacturer’s labeling. However, reduction is advised for serum bilirubin >= 1.2 mg/dL.
  • Dosage Adjustments:
    • Krens 2019 Recommendations:
      • Bilirubin >1.2 to <3 mg/dL: Reduce to 75% of original dose.
      • Bilirubin 3 to 5 mg/dL: Reduce to 50% of original dose.
      • Bilirubin >5 mg/dL: Not recommended.
    • Canadian Labeling (Caelyx) Recommendations:
      • Bilirubin 1.2 to 3 mg/dL:
        • Breast/Ovarian Cancer: Start with 75% of normal dose; may increase to full dose in cycle 2 if tolerated.
        • AIDS-related Kaposi Sarcoma: Start with 50% of normal dose.
      • Bilirubin >3 mg/dL:
        • Breast/Ovarian Cancer: Start with 50% of normal dose; may increase to 75% in cycle 2, then to full dose in subsequent cycles if tolerated.
        • AIDS-related Kaposi Sarcoma: Start with 25% of normal dose.
• Cyclophosphamide Dosing for Hepatic Impairment (Adults):
  • General Note: No specific dosage adjustments in the manufacturer’s labeling. Efficacy may be reduced in severe hepatic impairment.
  • Dosage Adjustments:
    • Floyd 2006 Recommendations:
      • Serum bilirubin 3.1 to 5 mg/dL or transaminases >3 times ULN: Administer 75% of dose.
      • Serum bilirubin >5 mg/dL: Avoid use.
    • Krens 2019 Recommendations:
      • Mild/Moderate Impairment: Likely no adjustment needed.
      • Severe Impairment: Not recommended due to reduced efficacy risk.

2023-11-07

Medication not found to be mismatched.

2023-10-05

No discrepancy in the medication is found.

The AST to ALT ratio has been greater than 1 since the earliest available data from 2023-08-03. Please exclude the possibility of alcohol abuse in this patient. In addition, the subsequent initiation of cyclophosphamide from 2023-08-28 may also lead to hepatotoxicity.

2023-08-30

[leukopenia]

A single dose of docetaxel (35mg/m2) was administered on 2023-08-12 before an episode of leukopenia was observed on 2023-08-21. Following a single injection of Granocyte (lenograstim 250ug), no further episodes of leukopenia have been observed to date.

2023-08-28 WBC 15.29 x10^3/uL
2023-08-23 WBC 19.11 x10^3/uL
2023-08-21 WBC 1.84 x10^3/uL 2023-08-16 WBC 6.88 x10^3/uL
2023-08-14 WBC 12.40 x10^3/uL
2023-08-12 WBC 7.95 x10^3/uL
2023-08-10 WBC 10.92 x10^3/uL
2023-08-03 WBC 9.67 x10^3/uL
2023-06-19 WBC 11.37 x10^3/uL
2023-08-28 Neutrophil 82.5 %
2023-08-25 Neutrophil 77.4 %
2023-08-23 Neutrophil 55.7 %
2023-08-21 Neutrophil 7.6 % 2023-08-16 Neutrophil 77.2 %
2023-08-14 Neutrophil 94.2 %
2023-08-10 Neutrophil 68.9 %
2023-08-03 Neutrophil 74.5 %
2023-06-19 Neutrophil 76.0 %

[monitor cardiac function going forward]

While 2D transthoracic echocardiography on 2023-08-09 showed preserved right ventricular systolic function, ECG on 2023-08-23 showed T-wave abnormalities consistent with anterior ischemia and prolonged QT interval. Since anthracyclines such as doxorubicin may prolong the QT interval, it would be prudent to monitor the condition after administration of (liposomal) doxorubicin (on 2023-08-28).

2023-08-09

2023-08-04 breast biopsy pathology IHC revealed: ER (-), PR (-), Her2/neu (3+), CK5/6 (-), p63 (+ for myoepithelium).

NHI coverage for pertuzumab is applicable under the following conditions: 1. Pertuzumab, in combination with trastuzumab and docetaxel, is used to treat patients with HER2-positive (IHC3+ or FISH+) metastatic breast cancer who have not previously received treatment with anti-HER2 therapy or chemotherapy for metastasis. 2. Prior approval is required for usage, and after approval, efficacy assessment data must be provided every 18 weeks for re-application. If the disease worsens, re-application should not be pursued. The maximum coverage duration for each patient is limited to 18 months.

If doxorubicin is intended for use, it is advisable to conduct a pre-treatment 2D transthoracic echocardiography to establish the baseline heart function.

701502017

231124

[MedRec]

• 2023-10-19 SOAP Hemato-Oncology Xia HeXiong
  • S
    • Hx of breast cancer, ER 1% (weak) PR (-), Her-2 1+, Ki67 78%
      • Neoadjuvant TC x 4 followed by EC x 4 -> SD
      • R/T to primary
      • maintain with xeloda x 6 months
      • Follow up
    • Now recurrence over brain, lung, liver, bone, completed with lower limbs weakness
  • O
    • Anti-HCV (-), AntiHBs (+), AntiHBs (-), AntiHBc (-)
    • 2023-10-19: BP:105/76; HR:91;
    • 2023-10-09 CT of abeomen
      • Multiple liver mets
      • R/O bilateral renal mets
      • R/O bone mets with pathological fracture at L2 vertebra
    • 2023-10-09 CT of chest
      • Compatible with right breast cancer, smaller
      • Multiple metastases at bilateral lungs and left pleura
    • 2023-10-09 CT of Brain
      • Multiple metastases at brain and left cerebellum
      • A prominent right partoid LN
  • A/P
    • Suggest Enhertu
    • Suggest R/T to brain and bone and Arrange Port-A insertion

[consultation]

• 2023-10-20 Radiation Oncology
  • Q
    • This 45-year-old woman had past history of Right breast cancer, ER (1%, weak), PR (-), Her-2 (1+), status post
      • Neoadjuvant chemotherapy with TC (Docetaxel + Cyclophosphamide) x 4 followed by EC (Epirubicin + Cyclophosphamide) x 4 –＞ stable disease
      • Partial mastectomy and sentinel lymph node dissection in 2022/6
      • Radiotherapy to primary tumor
      • Maintain with Xeloda (Capecitabine) x 6 months
    • She used to follow up at NTUH.
    • CT on 2023/10/9 showed (1) multiple metastases at brain and left cerebellum (2) multiple metastases at bilateral lungs and left pleura (3) multiple liver metastases, r/o bilateral renal metastases, r/o bone metastases with pathological fracture at L2 vertebra. Oral Dexamethasone was prescribed for brain metastases.
    • She went to our Oncology OPD for help on 2023/10/19. Under the impression of right breast cancer, with recurrence and metastasis over brain, lung, liver, and bone, she was admitted to our ward for further evaluation and management.  
    • We need your expertise for evaluation and management of radiotherapy for brain and bone metastases, thank you!
  • A
    • She is now sufferred from brain swelling sensation and lower back pain. Suggest bone scan and brain MRI (previous MRI at NTUH on 2023/7/29 showed no metastasis).
    • CT-simulation will be arranged on 10/24.
    • Plan to devlier 30 Gy/ 10 fx to the whole brain first, around 10/25 or 26.
    • RT for the lower back bone metastatses will wait for bone scan result for better treatment field design.
    • Thank you very much.

[MultiTeam]

• 2023-11-24 Multi-Team Recommendations - Palliative Care
  • Referral Date: 2023-11-24
  • Response Content:
    • The co-care nurse and Dr. Xia from the family medicine department visited together.
    • Outside the ward, they explained the concept of palliative care to the patient’s husband, who expressed a wish for home-based palliative care (residing in XinZhuang).
    • The co-care nurse explained that the patient, being conscious, needs to fill out an advance directive for palliative care.
    • During the visit, the patient was observed with closed eyes and a furrowed brow, using nasal cannula, and breathing with slight difficulty.
    • The patient reported headaches, coughing, pain from a bedsore on the buttocks, and aching in the hips and legs.
    • The main complaint was a desire to go home and “die at home,” expressing a wish not to be resuscitated and to be comfortable without suffering.
    • The advance directive for palliative care was completed.
    • The co-care nurse suggested preparing an oxygen concentrator and an electric bed at home, and to return home once pain management is under control.
    • The co-care nurse will assist in inquiring about local home-based palliative care resources and will provide the information to the family next Monday.
    • The co-care nurse’s contact number was left for further inquiries about palliative care.
  • Conclusion and Recommendations: Joint Palliative Care
  • Responder: Chen Hui
  • Response Date: 2023-11-24 18:20
• 2023-11-01 Multidisciplinary Team Recommendations - Psycho-Oncology
  • Referral Date: 2023-10-19
  • Reason for Referral: Other: Cancer Inpatient Brief Health Scale Score >= 10 points
  • Conclusion:
    • • On 10/20, the patient was visited with her husband present. She was holding her forehead, indicating a headache. Pain medication had been prescribed, but she was still unaware of the treatment plan.
      • On 10/26, during another visit when a friend was visiting and her husband was working outside the ward, she mentioned her headache had lessened. She expressed that her husband was having a hard time as he was taking care of everything. As a couple, they wanted to know how the treatment would proceed. She advised ’not to think, but to be optimistic (tears fell), and wondered what to do with negative thoughts.
      • She had difficulty reading due to loss of vision in her left eye. Her friend mentioned reading three pages a day and recording it to send to her, which made her smile and said she would assign this task to her husband too.
    • 15. Breast cancer diagnosis in October 110, post-CCRT surgery in June 111, brain metastasis in July 112, and bone, liver, and lung metastases in October. She was admitted to our hospital on 10/19 seeking a second opinion, with a BSRS score of 12 points (moderate).
    • 1. Focused on caring for the patient’s emotional adjustment, encouraging self-dialogue methods as suggested in the book “The Healing Power Within.”
    • (AP) The patient’s family is inclined towards active cooperation with the current possible treatment methods. The team is requested to continue assisting with symptom relief, discussing the treatment plan, and being mindful of the timing for palliative co-care.
  • Counseling Psychologist Huang XiaoFang
  • Responder: Huang XiaoFang
  • Response Date: 2023-10-27 17:50
• 2023-10-23 Multidisciplinary Team Recommendations - Social Services
  • Referral Date: 2023-10-19
  • Reason for Referral: Other: Inpatient Brief Health Scale Score >= 10 points
  • Case Status: No case opened
  • Reason for Not Opening Case: Consultation with the patient and her husband on 2023-10-20
  • Family Situation:
    • The patient is 45 years old and married. Her husband accompanied her during the hospital stay.
  • Assessment and Treatment:
    • During the ward visit, the patient appeared somewhat indifferent, only mentioning that she had slept better the previous night, without elaborating further. Her husband also noted that she had slept better the previous night and during the conversation, it was understood that the patient did not use sleeping pills. It was mainly the relief of pain and other discomforts that improved her sleep. The patient and her husband were informed that if they need to talk to a social worker in the future, they can proactively notify the team, and they were receptive to this.
    • This consultation assessed that the patient’s family support is adequate, with no emerging issues at present. If there is a need for social worker assistance in the future, a referral can be made again. Thank you.
  • Responder: Luo Yuquan”
  • Response Date: 2023-10-20

[immunochemotherapy]

• 2023-11-20 - trastuzumab deruxtecan 5.4mg/m2 100mg D5W 100mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-11-24

Enhertu (trastuzumab deruxtecan) dosing

• Kidney Impairment
  • CrCl >=30 mL/minute: No dosage adjustment necessary. Monitor more frequently for interstitial lung disease in patients with moderate impairment.
  • CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling (a recommended dose has not been established).
• Hepatic Impairment
  • Mild (total bilirubin ≤ ULN and any AST > ULN or total bilirubin >1 to 1.5 times ULN and any AST) or moderate (total bilirubin >1.5 to 3 times ULN and any AST) impairment: No dosage adjustment necessary. Monitor closely for toxicities in patients with moderate impairment.
  • Severe impairment (total bilirubin >3 to 10 times ULN and any AST): There are no dosage adjustments provided in the manufacturer’s labeling (a recommended dose has not been established).

Lab data

• 2023-11-23 AST 136 U/L
  
• 2023-11-23 Bilirubin total 0.64 mg/dL
  
• 2023-11-23 Creatinine 0.23 mg/dL
  
• 2023-11-23 eGFR 347.44 ml/min/1.73m^2

Although the suggested dosage of the medication is 5.4mg/m2, the dose actually given was only around 40% of this recommendation. This significant reduction in dosage may lead to less than optimal treatment outcomes. (Enhertu is currently not covered by the NHI).

Please monitor for and promptly investigate signs and symptoms including cough, dyspnea, fever, and other new or worsening respiratory symptoms. Permanently discontinue fam-trastuzumab deruxtecan in all patients with >= grade 2 ILD/pneumonitis. Advise the patient of the risk and the need to immediately report symptoms.

701279426

231123

[exam findings]

• 2023-09-27 CT - abdomen
  • History
    • 20210428 CT: rectal cancer, T3N0M1a, STAGE: IVA
    • 20211124 S/P LAR: Adenocarcinoma of rectum with liver metastasis, ypT2N1M1a, ypStage IVA
  • FINDINGS: Comparison: prior CT dated 2023/06/27.
    • Prior CT identified multiple metastases on both hepatic lobes are noted again, increasing in size that are c/w multiple liver metastases S/P C/T with progressive disease.
    • There is soft tissue nodule 8 mm at RLL of the lung that is c/w lung metastasis.
    • S/P LAR with autosuture retention over the rectum.
    • There are several hepatic cysts in both lobes and the largest one is measured about 4.1cm in size at S6.
    • In addition, there are several soft tissue masses in the uterus that are compatible with myomas.
  • Impression:
    • Multiple liver metastases S/P C/T show progressive disease.
      
    • Lung metastasis 8 mm at RLL is noted.
    • Follow up CT of the abdomen (include lung) 3 months later is indicated.
• 2023-06-27 CT - abdomen
  • History and indication:
    • Adenocarcinoma of rectum with liver metastasis, ypT2N1M1a, ypStage IVA status post closure of loop ileostomy on 2021/11/24, liver metastasis in progression on 2023/03/04
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Rectal cancer s/p operation.
    • Progression of liver metastases.
    • A nodule (4mm) at RLL.
    • Some osteolytic lesions in spine r/o metastases.
    • Enlargement of uterus with nodules r/o myomas.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Rectal cancer s/p operation.
    • Progression of liver metastases.
    • A nodule (4mm) at RLL.
• 2023-03-04 CT - abdomen
  • With and without contrast enhancement CT of abdomen shows:
    • Colon cancer, s/p operation.
    • Progression of liver metastasis.
    • Presence of uterine myomas.
  • Impression
    • Colon cancer, s/p operation
    • Multiple liver metastasis, in progression
• 2022-11-28 CT - abdomen
  • Indication
    • Malignant neoplasm of rectum
    • Secondary malignant neoplasm of liver and intrahepatic bile duct
  • Abdominal and Chest CT with and without IV contrast ehnancement shows:
    • S/p port-A placement with its tip at left brachiocephalic vein.
    • s/p LAR.
    • Low density lesions are found at both lobes of liver up to 4.38cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-08-02, the lesions are stationary.
  • Imp:
    • Colon cancer s/p LAR.
    • Diffuse liver meta. stationary.
• 2022-08-02 CT - abdomen
  • Clinical history: 57 y/o female patient with Rectal cancer, T3NoM1a status post laparoscopic low anterior resection, ileostomy on 2021/09/01.
  • With and without contrast enhancement CT of abdomen–whole:
    • Post-op at the colon.
    • There are multiple liver tumors in both lobes of liver, could be due to liver metastasis, stationary.
    • There are uterine tumors, could be due to uterine myomas.
    • Right anterior chest wall tumor, 1.2cm, stationary.
  • Impression:
    • Psot-op at the colon.
    • Liver tumors, r/o metastasis, stationary.
    • Right anterior chest wall tumor, 1.2cm, stationary.
    • Uterine tumors, r/o myomas.
• 2022-04-16 CT - abdomen
  • History and indication: 56 y/o female, a pt of rectal CA wt liver mets
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Rectal cancer s/p operation.
    • Stable condition of liver metastases.
    • Some osteolytic lesions in spine r/o metastases.
    • Enlargement of uterus with nodules r/o myomas.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • Rectal cancer s/p operation with adjacent fatstranding.
    • Stable condition of liver and spine metastases.
• 2021-11-04 Tc-99m MDP bone scan
  • Mildly increased activity in the lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, elbows, hips and knees, compatible with benign joint lesions.
• 2021-10-28 CT - abdomen
  • History and indication: 56 y/o female, a pt of rectal CA wt liver mets
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Rectal cancer s/p operation with adjacent fatstranding.
    • Stable condition of liver metastases.
    • Some osteolytic lesions in spine r/o metastases.
    • Enlargement of uterus with nodules r/o myomas.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • Rectal cancer s/p operation with adjacent fatstranding.
    • Stable condition of liver metastases.
    • Some osteolytic lesions in spine r/o metastases.
• 2021-09-02 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Large intestine, rectum, laparoscopic low anterior resection —- Adenocarcinoma, moderately differentiated, s/p chemotherapy
      
    • Ovary, right, oophorectomy —- Consistent with endometrioma
    • Ovary, left, oophorectomy —- Negative for malignancy
      
    • Fallopian tube, bilateral, salpingectomy —- Negative for malignancy
      
    • Uterus, myometrium, myomectomy —- Leiomyoma
      
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection —- Negative for malignancy (0/14) —- A tumor deposit is found
      
    • Lymph node, IMA / SMA, dissection —- Not received
      
    • AJCC 8th edition Pathology stage: ypStage IVA, ypT2N1c(if cM1a)
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: laparoscopic low anterior resection, bilateral salpingo-oophorectomy, myomectomy
      
    • Specimen site: rectum
      
    • Specimen size: Rectum: 9.5 cm in length; right ovary:5.8 x 4.3 x 2.6 cm; right fallopian tube: 4.8 cm in length and 0.4 cm in diameter; left ovary: 2.7 x 2.0 x 1.0 cm; left fallopian tube: 5.5 cm in length and 0.4 cm in diameter; myoma: 2.8 x 2.8 x 2.0cm
      
    • Tumor size: 1.6 x 1.4 cm
      
    • Tumor location: 6.5 cm and 0.9 cm away from the two resection margins, respectively
      
    • Depth of invasion grossly: muscularis propria
      
    • Mucosa elsewhere: congestion
    • The right ovary is cystic and containing chocholate material.
      
    • The left ovary and bilateral fallopian tubes are unremarkable. The cut surfaces of the leiomyoma show whorls of bundles without hemorrhage, or necrosis.
      
    • Representative sections are taken and labeled as: A1-4: tumor; A5:colon, non-tumor; A6: circumferential resection margin; A7-12: lymph nodes, mesocolic; B: proximal resection margin; C: distal resection margin; D1: right fallopian tube; D2-4: right ovary; E1: left fallopian tube; E2: left ovary; F: myoma.
      
  • MICROSCOPIC EXAMINATION
    • Histology: adenocarcinoma
      
    • Histology Grade: moderately differentiated
      
    • Depth of invasion: muscularis propria
      
    • Angiolymphatic invasion: Present.
      
    • Perineural invasion: Present.
      
    • Discontinuous extramural tumor extension: Not identified.
      
    • Circumferential (radial) margin of rectum: Uninvolved, 15 mm from the margin,
      
    • Lymph node metastasis, mesocolic:0/14
      
    • Lymph node metastasis, IMA / SMA: not received
      
    • Extranodal involvement: Not identified.
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): pT2: Tumor invades the muscularis propria
        
      • Regional Lymph Nodes (pN): pN1c: No regional lymph nodes are positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/mesorectal tissues.
        
      • Distant Metastasis (pM): if cM1a
        
    • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
      
    • Additional pathologic findings:
      • S2021-07002: ADDENDUM: IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
        
      • A tumor deposit is found in mesorectal tissues.
        
      • Tumor Budding: Low score (0-4)
        
      • The right cystic ovarian tissue reveals aggregation of hemosiderin ladened histiocytes. No resiual epithelium is seen. The morphology is consistent with a endometrioma.
        
      • The left ovary and bilateral fallopian tubes are unremarkable and free of malignancy.
        
      • The leiomyoma reveals whorls of bland smooth muscle bundles without hypercellularity, nuclear atypia or mitosis.
        
    • TNM descriptors: y (Post-treatment).
      
    • Tumor regression grading S/P CCRT: Modified Ryan scheme for tumor regression score: 2, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response).
• 2021-07-27 CT - abdomen
  • Indication: Colon cancer, S/P neoadjuvant C/T
  • Abdominal CT with and without enhancement revealed:
    • Several low density lesions (n＞10) are found at both lobes of liver up to 1.93cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2021-04-28, these lesions decreased in size.
    • Increased intestinal gas is found.
    • Swelling of the rectum is found up to 2.01cm in largest dimension. In regression.
    • Several uterine myomas are found.
    • Right ovarian cyst up to 5.3cm in largest dimension.
  • Imp:
    • Rectal cancer with liver meta. The primary tumor and metastatic lesions regressed.
• 2021-05-11 PET
  • Prominent glucose hypermetabolism in the rectum, compatible with primary malignancy of the rectum.
  • Multiple glucose hypermetabolic lesions in both lobes of the liver. Multiple liver metastases may show this picture. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in both lobes of the thyroid gland. The nature is to be determied (thyroiditis? hyperthyroidism?). Please also correlate with other clinical findings for further evaluation.
• 2021-05-10 CT - chest
  • Indication: stage W/U to exclude lung mets.
  • Impression:
    • no evidence of lung metastasis.
    • hepatic metastatic tumors and simple cysts.
• 2021-05-04 Patho - colorectal polyp
  • Rectal cancer s/p biopsy — Adenocarcinoma.
  • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).

[MedRec]

• 2021-05-21 ~ 2021-05-23 POMR Hemato-Oncology Zhang ShouYi
  • Discharge diagnosis
    • Malignant neoplasm of rectum
    • Rectum cancer with liver metastasis
  • CC
    • for #1 chemotherapy with FOLFIRI
  • Present illness
    • This 56-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later. She came to our Pro Huang SiCheng arranged abd CT & colonscopy in May 2021.
    • Surgical pathology with rectal cancer s/p biopsy (5/4 21) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+). Stomach, fundus, s/p biopsy (5/4 21): Hyperplastic polyp.
    • Image study with abd CT (4/28 21) showed a cystic lesion, 5 x 4.7 cm in R adnexa, R/I endometrioma or cystic tumor. several soft tissue masses in the uterus that are compatible with myomas. Several poor enhancing lesions on both hepatic lobes, R/I mets. D/D: cysts with old hemorrhage or atypical hemangioma? The largest one (2.6 cm) in S6. several hepatic cysts in both lobes, the largest one (2.9 cm) in size at S6. soft tissue mass-like lesion or fecoloma 2.8 cm in the rectum. Imp: T3N0M1a stage IVA.
    • She came to referred to our hemato-oncologic clinic on 5/8 21 for pre-Op neoadjuvant C/T by Dr Xiao GuangHong due to rectal cancer with suspected liver mets.
    • Dr Xiao GuangHong suggested to do pre-Op neoadjuvant C/T first then wlll do abd CT then Op.
    • HBsAg, anti-HBc, anti-HCV (5/11 21) showed negative.
    • K-RAS / N-RAS mutation test was done and report was pending.
    • Port-A was inserted on 5/12 21.
    • XRT started since 5/20 21 by Dr Huang JingMin for rectal tumor.
    • We explain to pt & her sister about the indication & risk / benefit of pre-Op neoadjuvant C/T wt FOLFIRI / Avastin IV Q2W x 4~6 then do abd CT & Op.
    • The chest CT (5/10 21) showd no evidence of lung metastasis; hepatic metastatic tumors and simple cysts.
    • The PET scan (5/12 21) revealed Prominent glucose hypermetabolism in the rectum, compatible with primary malignancy of the rectum. Multiple glucose hypermetabolic lesions in both lobes of the liver. Multiple liver metastases may show this picture. Please correlate with other clinical findings for further evaluation. Mild glucose hypermetabolism in both lobes of the thyroid gland. The nature is to be determied (thyroiditis? hyperthyroidism?).
    • Today. she was admitted for #1 palliative chemotherapy with FOLFIRI on 5/21 21.
  • Course of inpatient treatment
    • After admission, chemotherapy with Campto (160mg/m2) plus Leucovorin (400mg/m2) and 5-FU (2800mg/m2) were given on 5/21-5/23 21, smoothly without obvious side effect. She was discharged on 5/23 21 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • loperamide 2mg 1# PRNQ6H if watery diarrhea > 3 times
• 2021-05-11 SOAP Radiation Oncology Huang JingMin
  • S:
    • For radiotherapy due to rectal cancer.
    • PI: The patient is a case of rectal CA with suspectde liver mets Dx in May 2021. She suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage wks later.
    • Family history: (-)
    • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
    • Personal Hx: DM (-); HTN (-)
    • Previous RT Hx: (-)
  • O:
    • ECOG: 0
    • PE: neck and bil SCF: neg.
    • CT scan of abdomen (2021-04-28): 1. There is a cystic lesion measuring 5 x 4.7 cm in right adnexa without contrast enhancement that may be endometrioma or cystic tumor. Please correlate with CA125. In addition, there are several soft tissue masses in the uterus that are compatible with myomas. 2. There are several poor enhancing lesions on both hepatic lobes that may be metastases. The differential diagnosis include cysts with old hemorrhage or atypical hemangioma? Please correlate with sonography and MRI.
    • The largest one measuring about 2.6 cm in S6 (Srs:4 Img:34). 3. There are several hepatic cysts in both lobes and the largest one is measured about 2.9 cm in size at S6. 4. A soft tissue mass-like lesion or fecoloma 2.8 cm in the rectum. Stage cT3N0M1a.
    • Colonoscopy (2021-05-04):One mass was noted in the rectum 8 cm from AV. Diagnosis: Rectal cancer s/p biopsy
    • Pathology (S2021-07002, 2021-05-05): ADDENDUM: IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+). DIAGNOSIS: Rectal cancer s/p biopsy — Adenocarcinoma. An addendum report of the result of IHC stains of EGFR, PMS2, MSH6, MSH2, and MLH1 will be followed.
      
    • CT cscan of lung (2021-05-10): no evidence of lung metastasis. hepatic metastatic tumors and simple cysts.
    • Lab:
      • 2021/04/27 CA125 = 11.9 U/mL
      • 2021/04/27 CA199 = 188.31 U/mL
      • 2021/04/27 CEA = 13.18 ng/mL
  • A:
    • Adenocarcinoma of the rectum, stage cT3N0M1a, with liver metastases.
  • P:
    • Radiotherapy is indicated for this patient with the following indicators: stage cT3N0M1a.
    • Goal: palliation.
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her sister. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 11AM, 2021-05-12.
• 2021-05-08 SOAP Hemato-Oncology Zhang ShouYi
  • S
    • referred to our hemato-oncologic clinic on 5/8 21 for pre-Op neoadjuvant C/T by Dr Xiao GuangHong
      • rectal CA wt suspected liver mets.
    • Dr Xiao GuangHong suggested to do pre-Op neoadjuvant C/T first then wlll do abd CT then Op (5/8 21).
  • P
    • will do HBsAg, anti-HBc, anti-HCV (5/8 21).
    • will do K-RAS / N-RAS mutation test (5/8 21).
    • will consult Dr Chen YanZhi for Port-A installation (5/8 21).
    • will consult Dr Huang JingMin for R/T to rectal tumor.
    • will do PET scan to evaluate liver tumor & pelvic tumor (5/8 21).
    • will do chest CT to exclude lung mets (5/8 21).
    • explain to pt & her sister about the indication & risk / benefit of pre-Op neoadjuvant C/T wt FOLFIRI / Avastin IV Q2W x 4~6 then do abd CT & Op. (5/8 21).
    • will give post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-CCRT adjuvant C/T wt PF ( 2 days ) IV Q2W x 4~6 mo.
      
    • Adm on 5/6 16 for #1 palliative C/T wt Oxaliplatin + PF ( 2 days ) IV Q2W.
    • RTC 1 wk later on 5/4 20 for CBC & DC, CXR, abd no report.
• 2021-05-06 SOAP Colerectal Surgery Xiao GuangHong
  • S
    • Rectal cancer
    • Liver metastasis; Ovarian tumor
  • O
    • 2021/05/04 Colonoscopy: Rectal cancer s/p biopsy
      • Pathology: Rectal cancer s/p biopsy — Adenocarcinoma.
        • An addendum report of the result of IHC stains of EGFR, PMS2, MSH6, MSH2, and MLH1 will be followed.
  • P
    • Suggest chemotherapy + target therapy then evaluation of resection
• 2021-04-29 SOAP Colorectal Surgery Xiao GuangHong
  • S:
    • First visit, ovarian tumor, liver metastasis
  • O:
    • 2021/04/27 CA199 = 188.31
    • 2021/04/27 CEA = 13.18
    • 2021/04/27 HGB = 10.5
    • 2021/04/28 CT: ABD — whole abdomen, pelvis
      • Metastases on both hepatic lobes are suspected.
        • The differential diagnosis include cysts with old hemorrhage or atypical hemangioma? Please correlate with sonography and MRI.
      • Right adnexa lesion, nature?
        • The differential diagnosis include endometrioma or cystic tumor.
        • Please correlate with CA125.
      • A soft tissue mass-like lesion or fecoloma 2.8 cm in the rectum is suspected. Please correlate with physical examination.
  • P:
    • Arrange colonoscopy and inform the risk of complication including bleeding and perforation

[consultation]

• 2023-03-22 Dermatology
  • Q
    • for skin rash, itchy for 10 days
    • This 57-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later. She came to our Pro Huang SiCheng arranged abd CT & colonscopy in May 2021.
    • This time, she is admitted for chemotherapy, then she complaints the skin rash, and itchy for 10days when after chemotherapy, so we need your help, thanks a lot!!
  • A
    • The patient had sufferred from reddish papules on the neckalce and grouped pigmented macules over buttock (previous erythematous papules with fine vesicles)
      
    • Under the impression of intertrigo eczmea over neck, favor post-herpes simplex infection over buttock.
      
    • The following suggetion:
      • Mycomb cream 1 tube as a good choice for neck lesions.
        
      • for pigmentation macules over buttock, consider Sinphraderm 1 tube topical QN use over the residual pigmentation lesions of the buttock.
      • enhane body mositurization after body clean to prevent furtehr xerosis skin texture.
• 2023-03-04 Obstetrics and Gynecology
  • Q
    • This 57-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later.
      
    • Surgical pathology with rectal cancer s/p biopsy (5/4 21) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+). Stomach, fundus, s/p biopsy (5/4 21): Hyperplastic polyp.
    • Image study with abd CT (4/28 21) showed a cystic lesion, 5 x 4.7 cm in R adnexa, R/I endometrioma or cystic tumor. several soft tissue masses in the uterus that are compatible with myomas.
    • She was admitted for #16 chemotherapy with Avastin (self-paid)/FOLFOX today, however, blood was noted after wiping.     
    • We would like to consult you for your expertise, thank you.
  • A
    • This is a 57-year-old female patient with rectal cancer with liver metastasis in May 2021, s/p CCRT, currently admitted for #16 Avastin (self-paid)/FOLFOX.
      • She received concurrent laparoscopic bilateral salpingo-oophorectomy on 2021-09-01 for right ovarian tumor, and pathology showed right ovarian endometrioma, with left ovary and bilateral tubes all negative for malignancy.
      • According to the patient, she noted blood while wiping after defecation 2 days ago.
    • O
      • G0, sex(-), menopause around 52-53 y/o
      • PV: narrowing atrophic vagina (suspect radiotherpy related), no active bleeding nor blood clots noted.
      • TVS: AVF uterus 66x39mm, endometrium 4.7mm, subserosal and intramural myomas (15x11, 16x13, 15x10), pelvis free of other GYN lesion, no ascites.
    • Imp: bleeding point not favored GYN origin due to thin endometrium (<5mm) and no endometrial lesions (eg, polyp or submucosal myoma) noted
      • Suggest survey other origin of the bleeding
      • Educated the patient to receive pap smear at OPD f/u
    • Contact us if any problems!!
• 2023-03-03 Colorectal Surgery
  • Q
    • This 57-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later.
      
    • Surgical pathology with rectal cancer s/p biopsy (5/4 21) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+). Stomach, fundus, s/p biopsy (5/4 21): Hyperplastic polyp.
    • Image study with abd CT (4/28 21) showed a cystic lesion, 5 x 4.7 cm in R adnexa, R/I endometrioma or cystic tumor. several soft tissue masses in the uterus that are compatible with myomas.
    • She was admitted for #16 chemotherapy with Avastin (self-paid)/FOLFOX today, however, blood was noted after wiping.     
    • We would like to consult you for your expertise, thank you.
  • A
    • This is a 57-year old woman with anal bleeding after defecation for 2 days
    • DRE:
      • mild internal hemorrhoids, acute anal fissure over 6 o’clock region
      • yellowish stool
    • A/P:
      • add alcos anal onitment bid and prn topic use
      • add laxative drugs, such as MgO 2# Bid
      • if s/s persisted than sigmoidoscopy should be considered

[radiotherapy]

[chemotherapy]

• 2023-06-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4120mg NS 500mL 46hr (Avastin + FOLFOXIRI; Q2W)

• 2023-05-18

• 2023-04-20

• 2023-03-21

• 2023-03-03 - (Avastin + FOLFOX; Q2W)

• 2023-02-01 - (Avastin + FOLFOX; Q2W)

• 2022-12-23 - (Avastin + FOLFOX; Q2W)

• 2022-12-02 - (Avastin + FOLFOX; Q2W)

• 2022-11-15 - (Avastin + FOLFOX; Q2W)

• 2022-10-20 - (Avastin + FOLFOX; Q2W)

• 2022-09-16 - (Avastin + FOLFOX; Q2W)

• 2022-08-18 - (Avastin + FOLFOX; Q2W)

• 2022-08-01 - (Avastin + FOLFOX; Q2W)

• 2022-07-08 - (Avastin + FOLFOX; Q2W)

• 2022-06-17 - (Avastin + FOLFOX; Q2W)

• 2022-04-26 - (Avastin + FOLFOX; Q2W)

• 2022-04-08 - (Avastin + FOLFOX; Q2W)

• 2022-03-08 - (Avastin + FOLFOX; Q2W)

• 2022-02-10 - (Avastin + FOLFOX; Q2W)

• 2022-01-07 - (Avastin + FOLFOX; Q2W)

• 2021-12-21 - (Erbitux + FOLFOX; Q2W)

• 2021-11-03 - (Erbitux + FOLFOX; Q2W)

• 2021-10-18 - (Avastin + FOLFIRI; Q2W)

• 2021-09-29 - (Avastin + FOLFIRI; Q2W)

• 2021-07-29 - (Avastin + FOLFIRI; Q2W)

• 2021-07-09 - (Avastin + FOLFIRI; Q2W)

• 2021-06-25 - (Avastin + FOLFIRI; Q2W)

• 2021-06-07 - (Avastin + FOLFIRI; Q2W)

• 2021-05-21 - (Avastin + FOLFIRI; Q2W)

FOLFOXIRI chemotherapy for metastatic colorectal cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F70559

• Cycle length: 14 days.
• Regimen
  • Irinotecan
    • 165 mg/m2 IV
    • Dilute with 500 mL D5W to a final concentration of 0.12 to 2.8 mg/mL and administer over 60 minutes.
    • Day 1
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute with 500 mL D5W and administer over two hours after irinotecan. Administer concurrently with leucovorin in separate bags via y-line connection. Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • LEVOleucovorin
    • 200 mg/m2 IV
    • Dilute with 250 mL D5W and administer over two hours, concurrent with oxaliplatin.
    • Day 1
  • Fluorouracil (FU)
    • 2400 to 3200 mg/m2 IV
    • Dilute in 500 to 1000 mL D5W and administer over 48 hours, after leucovorin. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL). The original protocol used 3200 mg/m2, but many United States oncologists use a lower starting dose (2400 mg/m2) and escalate as tolerated to reach a final dose of 3200 mg/m2.
    • Day 1

FOLFIRINOX chemotherapy for metastatic pancreatic cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

• Cycle length: 14 days.
• Regimen
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 180 mg/m2 IV
    • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 400 mg/m2 IV bolus
    • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
    • Day 1
  • FU
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

• Cycle length: 14 days.
• Regimen
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 150 mg/m2 IV
    • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

==========

2023-11-23

[rising tumor markers and progressive disease]

This patient has a history of multiple lines of treatment for her cancer, including:

• Avastin + FOLFOXIRI (since March 2023 and undergoing)
• Avastin + FOLFOX (January 2022 to March 2023)
• Erbitux + FOLFOX (November 2021 to December 2021)
• Avastin + FOLFIRI (May 2021 to October 2021)

Both CEA and CA199 have been rising for the past two months, consistent with the progressive disease seen on the CT scan on 2023-09-27.

• 2023-11-21 CEA (NM) 382.930 ng/ml
  

• 2023-10-24 CEA (NM) 130.315 ng/ml
  

• 2023-09-26 CEA (NM) 95.670 ng/ml

• 2023-11-21 CA-199 (NM) 4220.750 U/ml
  

• 2023-10-24 CA-199 (NM) 2298.450 U/ml
  

• 2023-09-26 CA-199 (NM) 1177.830 U/ml

As the liver metastases are more severe, more intensive monitoring of liver function might be advisable.

[mixed acid-base disorder?]

Here’s a breakdown of the results of the venous blood gas (VBG - 2023-11-22) values:

• pH: 7.451
  • This is higher than the normal venous pH range (7.31-7.41), indicating mild alkalemia (increased alkalinity in the blood).
• HCO3 (Bicarbonate): 28.1 mmol/L
  • This is elevated. Normal venous HCO3 levels are typically around 22-26 mmol/L.
• ctCO2 (Total Carbon Dioxide): 29.4 mmol/L (23-27 mmol/L).
• Base Excess (BE) and BEecf: 3.6 mmol/L and 4.1 mmol/L, respectively
  • These values are slightly elevated, indicating a mild excess of base in the blood.
• SBC (Standard Bicarbonate): 27.4 mmol/L (22-26 mmol/L).
• O2 Saturation: 73.5%
  • The oxygen saturation might be a concern, depending on the clinical context.

The results suggest a mild metabolic alkalosis, as indicated by the slightly elevated pH and bicarbonate levels, along with a positive base excess.

Meanwhile, lactic acid was elevated (2023-11-22 2.5 mmol/L), this could indicate lactic acidosis, a condition where there is an accumulation of lactic acid in the body, often due to inadequate oxygen delivery to tissues (hypoxia), shock, or other metabolic issues.

In the context of the mild metabolic alkalosis suggested by the vein blood gas results, elevated lactic acid could point towards a mixed acid-base disorder. This is where more than one acid-base imbalance is occurring simultaneously.

O2 cannula 3L/min has been ordered and the updated SpO2 is 95% (2023-11-23).

700324847

231122

[exam findings]

• 2023-05-27 MRI - brain
  • No brain nodule or metastasis.
• 2023-05-15 KUB
  • Bilateral pleural effusion.
  • Presence of ileus.
  • Intact bony structure(s).
• 2023-05-15 CXR
  • Bilateral pleural effusion.
  • Ground glass opacities in bil. lungs.
• 2023-05-12 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Loculated bilateral pleural effusion at bilateral interlobular fissure and lower hemithorax is found.
      • Consolidation over right lower lobe and left lower lobe is found.
      • Enlarged lymph nodes are found at bilateral paratracheal region.
      • Patent airway is found.
    • Visible abdomen:
      • Moderate ascites formation is found.
      • Increased intestinal gas is found.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
  • IMp:
    • Pneumonic patch at both lungs with bilateral massive pleural effusion.
    • Moderate ascites formation.
• 2023-05-12 CXR
  • Bilateral Pleura effusion.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Enlargement of cardiac silhouette.
• 2023-05-05 SONO - CXR
  • Echo diagnosis:
    • right side minimal amount of pleural effusion
    • left side small amuont of pleural effusion, 600cc serosangious fluid was drained out for symptom relief.
• 2023-04-24 SONO - breast
  • Suggestion and Plan
    • Calcifications in right breast.
    • R/O enlarged lymph nodes in left axillary region, suggest biopsy.
      
  • BI-RADS: Category 4a: low suspicious abnormality-biopsy should be considered.
• 2023-04-22 MRI - pelvis
  • With and without contrast enhancement MRI:
    • Cystic tumor, 8.6cm in right adnexa, with mural soft tissue, r/o right ovarian malignancy.
    • Another cystic tumor, with internal hemorrhage, 2.8cm in left adnexa, r/o ovarian malignancy with hemorrhage.
    • There are enlarged lymph nodes in bilateral obturator regions and right common iliac region, r/o lymph nodes metastasis.
    • Presence of ascites.
    • There are soft tissue tumors in the mesentery, r/o peritoneal carcinomatosis.
    • Left pleural effusion.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T: T3c_(T_value) N: N1b(N_value) M: M1(M_value) STAGE: IV (Stage_value)
      
  • Impression:
    • Ovarian cystic tumor with carcinomatosis and lymph nodes, left pleural effusion, r/o ovarian malignancy with carcinomatosis, lymph nodes metastasis and left pleural effusion. cstage T3cN1bM1.
• 2023-04-20 Gynecologic ultrasonography
  • R/O Pelvis mass: 101 x 78mm (Multuple papillary, solid mass: 26 x 25mm)
  • R/O LT Ovarian mass
• 2023-04-19 CT - abdomen
  • Findings:
    • There is ascites and soft tissue nodules in the omentum. Carcinomatosis is suspected. Please correlate with ascites cytology.
    • There is a mild hyperdense lesion in the pelvis at pre-contrast CT, measuring 9.1 x 10.4 x 8.5 cm (width x depth x cranial-caudal length) in size, and poor enhancement in portal venous phase images except suspicious few ill-defined enhancing mural nodules.
      • The uterus shows posterior displacement by the upper described mass.
      • Cystic adenocarcinoma of the ovary is highly suspected.
      • Please correlate with GYN. sonograph, MRI and CA125.
    • There is a mild hyperdense lesion in left adnexa at non-enhanced CT, measuring 3.4 cm in size, and it shows poor enhancement in portal venous phase images except a mural nodule shows enhancement.
      • Cystic tumor of left ovary is highly suspected.
      • The differential diagnosis includes left ovarian cyst with hemorrhage.
    • S/P pigtail catheter implantation at right CP angle.
      • There is massive left side Pleura effusion.
  • Impression:
    • Carcinomatosis is suspected. Please correlate with ascites cytology.
    • Cystic adenocarcinoma of the ovary is highly suspected. Please correlate with GYN. sonograph, MRI and CA125.
• 2023-04-18 CT - chest
  • Findings
    • moderate Lt pleural effusion and residual minimal Rt pleural effusion s/p pigtail drain placement.
    • lungs:extensive, patchy and centrilobular ground-glass opacities with interbular septal thickening, at both lower lobes.
      • minimal patchy ground-glass opacities at LUL.
      • dependent relaxation subsegmental atelectasis at LLL.
    • Mediastinum and hila: many enlarged LNs in the visceral space and left anterior prevascular space.
    • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • mild ascitic fluid and dirty omentum.
    • Visualized bones: unremarkable.
  • Impression:
    • bilateral lower lobes lung edema or pneumonitis and transudative left pleural effusion, due to connective tissue disease?
    • abdominal ascites, cause? due to lesion in pelvic cavity?
• 2023-04-18 Cell block - pleural effusion
  • Cytological diagnosis: Malignancy
  • Smears and cell block show clusters of pleomorphic tumor cells. Metastatic carcinoma is favored. Please correlate with the clinical presentation.
• 2023-04-17 Cell block - pleural effusion
  • Cytological diagnosis: Malignancy
    
  • Smears and cell block show clusters of pleomorphic tumor cells. The immunohistochemical stains reveal CK7(+), CK20(-), PAX8(+), WT-1(+), TTF-1(-), Napsin A(-), p40(-), GATA3(-), Calretinin(-), and CD56(-). The results are consistent with metastatic carcinoma from ovary. Please correlate with the clinical presentation.
• 2023-04-15 SONO - chest
  • Echo diagnosis:
    • Pleural effusion, massive amount, right, s/p pig-tail insertion
    • Pleural effusion, massive amount, left, s/p thoracentasis (1100ml)
• 2023-04-14 ECG
  • Sinus tachycardia
  • Anteroseptal infarct, age undetermined
  • Abnormal ECG
• 2018-05-16 Gynecologic ultrasonography
  • Suspected RT ovarian cyst
  • Suspected LT endometrioma

[MedRec]

• 2023-05-15 SOAP Emergency
  • S
    • Dyspnea for 2 days
    • s/p thoracocentesis on 5/12 700ml
    • Poor intake for 2 days
    • Nausea and vomiting after inake
    • Phx: Ovarian cancer
    • Allergy: NKA
• 2023-05-12 SOAP Hemato-Oncology
  • S: Today explain to patient 40 minutes for chemotherapy. But she still hestitate to receive chemotherapy.
  • P: explain the possibility of chemotherapy to control tumor, but patient still hestitate to receive C/T.
    • F/U weekly
    • refer to ER for chest tapping

[consultation]

• 2023-09-10 Urology

  • Q
    • This is a 52 y/o woman with Ovarian malignancy with carcinomatosis, lymph nodes metastasis and left pleural effusion. cstage T3cN1bM1, status post neo-adjuvant chemotherapy (paclitaxel and carboplatin).
    • She will be recieving Debluking surgery + HIPEC on 112-09-11. We sincerely needed your expertise on double J tube insertion. Thank you very much!
  • A
    • We will arrange the procedure

• 2023-06-08

• 2023-05-19

• 2023-05-18

• 2023-05-17

• 2023-04-21 Hemato-Oncology

  • Q
    • For ovarian cancer neuadjuvant chemotherapy
    • We have consulted GYN, who suggested neoadjuvant chemotherapy first, followed by debulking surgery and HIPEC.
    • Due to the above reasons, we sincerely need your expertise for the neoadjuvant chemotherapy. Thank you very much!
  • A
    • This 51 year old woman is a case of ovarian cancer with peritoneal carcinomatosis and bilateral pleura effusion. Pleura effusion cell block show pleomorphic tumor cells CK7(+), CK20(-), PAX8(+), WT-1(+), TTF1(-), NAPsin A(-), P40(-), GATA3(-),calretinin(-), and CD56(-), the result consistent with metastatic carcinoma from ovary.
    • Arrange 24 urine CCR, anti HBc, anti HBs, HBsAg, Anti HCV, breast echo and port A insertion. apply Major Disease” C56.9 stageIV.
    • We will arrange chemotherapy (palitaxel + carboplatin ) the next day of port A insertion (Expected to have chemotherapy next Tuesday). Arrange our OPD after discharge.

• 2023-04-20 Obstetrics and Gynecology

  • Q
    • For evaluation of suspected ovarian cystic adenocarcinoma
    • This is a 51-year-old female with no underlying diseases. She presented to our ER with progressive dyspnea for 3 weeks, while CXR showed massive bilateral plerual effusion. Bilateral thoracentesis and right pigtail drainage was performed for symptom relief. Examination of the drainage showed to be exudative in nature.
      • Cancer/Tumor:
        • 4/18 Chest CT: bilateral lower lobes lung edema or pneumonitis and transudative left pleural effusion, due to connective tissue disease? abdominal ascites, cause? due to lesion in pelvic cavity?
        • 4/19 Abdominal CT: 1. Carcinomatosis is suspected. Please correlate with ascites cytology. 2. Cystic adenocarcinoma of the ovary is highly suspected. Please correlate with GYN. sonograph, MRI and CA125.
      • Tumor markers: pending results
      • TB, fungus, infection: pending results
      • Autoimmune: negative
    • Due to the above reasons, we sincerely need your expertise to evaluate the pelvic mass, suspect ovarian cystic adenocarcinoma. Thank you very much!
  • A
    • This is a 51 y/o woman who was hospitalized due to pleural effusion. Image survey with abdominbal CT showed suspected carcinomatosis of which ovarian cystic adenocarcinoma was highly suspected. Tumor markers were checked with the results pending. We were consulted for evaluation.
      • CC: Progressive dyspnea for 3 weeks.
      • ObGyn history: Sex(+), P0, menopaused
      • Sono: Pelvic mass, 101 x 78 mm (multiple papillary, with solid mass: 26 x 25 mm)
    • Impression
      • Huge pelvic mass, malignancy could not be ruled out
    • Suggestion
      • Please pursue the level of tumor markers.
      • Arrange EGD and colonoscopy.
      • Surgical intervention (laparotomy and frozen section) is suggested for diagnostic and therapeutic value. If malignancy is proven intraoperatively, debulking surgery is indicated.
      • Further cancer staging if malignancy is proven.
    • Addendum to consultation response 2023-04-21 14:45:54
      • Highly suspected cystic adenocarcinoma of the ovary with carcinomatosis and malignant plerual effusion, at least cstage IVA
      • Well explained current treatment plan and survival rate:
        • arrange EGD and colonoscopy first
        • consulted GS for port-A insertion and consulted Oncologist for neoadjuvant chemotherapy 3-4 times and followed debulking surgery and HIPEC

[chemotherapy]

• 2023-11-22 - paclitaxel 175mg/m2 170mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr + [docetaxel 30mg/m2 30mg + cisplatin 30mg/m2 30mg + gentamicin 40mg + sodium bicarbonate 3800mg + NS 1000mL] IP 1hr (70%)

  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

• 2023-10-19 - paclitaxel 175mg/m2 170mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + sodium bicarbonate 3800mg + NS 1000mL] IP 1hr (70%)

  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

• 2023-09-11 - [liposome doxorubicin 30mg/m2 40mg D5W 250mL + carboplatin AUC 5 900mg NS 250mL] IP 90min

• 2023-08-21 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

• 2023-07-31 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

• 2023-07-06 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

• 2023-06-08 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

• 2023-05-18 - paclitaxel 175mg/m2 135mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr

  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

• 2023-04-25 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 375mg NS 250mL 2hr

  • dexamethasone 4mg 5# PO Q6H at D0 2300 and D1 0500 + dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2023-08-21

No medication reconciliation issues were found after reviewing PharmaCloud and HIS5.

2023-05-17

• The patient’s serum albumin level has shown a decrease, potentially due to nausea and vomiting post-ingestion and several days of insufficient nutrition intake. Severe hypoalbuminemia could potentially exacerbate the patient’s pleural effusion. It might be necessary to provide additional nutritional support.
  • 2023-05-12 Albumin 3.1 g/dL
    
  • 2023-04-22 Albumin 3.5 g/dL
• The recommendation is to include antiemetics as part of the premedication protocol for the upcoming dose of the current paclitaxel and carboplatin regimen.

700605406

231122

[exam findings]

• 2023-11-16 CT - abdomen
  • History and indication:
    • Primary cutaneous CD30-positive T-cell proliferations, primary cutaneous CD30-positive anaplastic large cell lymphoma (T cell and CD-30 positive), stage IV
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Swelling of left lower extremity. Skine thickening of left thigh. Enlarged LNs at retroperitoneum, pelvic cavity, left thigh and bil. inguinal regions. General subcutaneous edema.
    • A fatty tumor (3.1cm) at left pelvic cavity.
    • A poor enhancing nodule (1.5cm) at S7 of liver.
    • Some lucent lesions in sacrum.
    • Minimal ascites.
  • IMP:
    • Swelling of left lower extremity. Skine thickening of left thigh. Enlarged LNs at retroperitoneum, pelvic cavity, left thigh and bil. inguinal regions. Disease progression is noted.
    • General subcutaneous edema.
    • A fatty tumor (3.1cm) at left pelvic cavity.
    • A poor enhancing nodule (1.5cm) at S7 of liver.
    • Some lucent lesions in sacrum.
• 2023-09-15 Patho - bone marrow biopsy
  • PATHOLOGIC DIAGNOSIS
    • Bone marrow, biopsy — No evidence of T-cell lymphoma with bone marrow involvement
  • MICROSCOPIC EXAMINATION
    • The sections show hypercellular marrow (60%). M/E ratio = 6:1. The myeloid cells show good maturation. The megakaryocytes are increased in number with a few small megakaryocytes. No lymphoid aggregates.
    • IHC, scattered small CD3+ T-cells and CD20+ B lymphocytes in interstitium are present. No CD30+ T lymphocyte can be found. There is no evidence of T-cell lymphoma with bone marrow involvement. Suggest further bone marrow smear evaluation and clinic correlation.
• 2023-09-14 PET
  • The [F-18]Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 235 MBq of FDG. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
  • There was increased FDG uptake in the left supraclavicular lymph nodes (SUVmax early: 11.51, delay: 12.73), multiple abdominal and pelvic lymph nodes (SUVmax early: 18.92, delay: 20.04), multiple bilateral inguinal lymph nodes (SUVmax early: 17.54, delay: 19.32), some focal areas in the spleen (SUVmax early: 4.82, delay: 5.90) and multiple focal areas in the left upper thigh (SUVmax early: 13.20, delay: 16.80). Besides, there was increased FDG uptake in the bone marow of the skeleton (SUVmax early: 4.42, delay: 6.30).
  • IMPRESSION: The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm, spleen, bone marrow and left upper thigh (stage IV).
• 2023-09-13 Patho - skin cyst/tag/debridement
  • DIAGNOSIS:
    • Labeled as “left thigh”, incisional biopsy — T cell lymphoma
  • GROSS DESCRIPTION:
    • Specimen submitted in formalin consists of 1 piece(s) of tan, irregular tissue measuring 4.0 x 2.0 x 1.3 cm. Representative tissue for section(s) in 2 cassette(s).
  • MICROSCOPIC DESCRIPTION:
    • Sections show skin with infiltration of abundant atypical lymphoid cells with many pleomorphic large neoplastic cells. IHC stains: CD3 and CD20: a predominant T cell sub-population. The large cells are CD30 (+), CD15 (+), ALK (-), cutaneous cd30-positive t-cell lymphoproliferative disorder is considered.
• 2023-09-01 Patho - lymphnode biopsy
  • PATHOLOGIC DIAGNOSIS
    • Lymph node, groin, left, core needle biopsy— Peripheral T cell lymphoma, NOS
      
  • MACROSCOPIC DESCRIPTION
    • Operation procedure: core needle biopsy
    • Topology: left groin
    • Specimen size and number: 3 pieces, 1x 0.1x 0.1 cm
  • MICROSCOPIC EXAMINATION
    • Histology type:
      • T-cell neoplasms
      • Peripheral T-cell lymphoma, NOS
    • Immunohistochemical stain profiles: CK(-), CD3(+, diffuse), CD4(+, diffuse), CD20(focal + at background B cells), CD8(+), Ki-67 index: 50%, CD56 (focal +, < 5%), Granzyme B(-), EBV(-), CD15 (-), CD30 (+, 40%), CD10 (focal weak+), TdT(-), CD5(+), EBER(-)
    • ADDENDUM: IHC stain — ALK1: negative
    • ADDENDUM: Based on histopathologic and immunohistochemical features, the possibility of anaplastic large cell lymphoma (ALK negative) cannot be complelely excluded. Clinical correlation is necessary.
• 2023-08-28 Peripheral Vascular Test - Artery, lower limbs
  • Clinical diagnosis: Leg swelling
  • Conclusions: Patent bilateral lower limbs arteries. Increased flow velocities at left CFA, SFA and PFA.
• 2023-08-17 CTA - lower extremity
  • Indication: CT”V” r/o DVT
  • CTV of lower extremity shows:
    • multiple enlarged lymphadenopathy at bilateral inguinal regions, pelvic side wall and iliac chains, causing compression to left external iliac vein and left common femoral vein. There are also some smaller lymph nodes at left paraaortic region.
    • irregular skin thickening at left posterior thigh with enhancement, etiology to be determined.
    • swelling and subcutaneous edema of left lower extremity, probably due to venous compression by the left inguinal and iliac lymphadenopathy.
    • two 2.7cm fat attenuated nodules in the pelvic cavity, probably adnexal origin. Terotoma or others?
    • enlarged and heterogeneous enhancement of uterus.
    • mild ascites in the cul de sac.
    • a 1.5cm hypoenhancing nodule in S7 liver, nature to be determined.
  • Impression:
    • Multiple enlarged lymphadenopathy at bilateral inguinal regions, pelvic side wall and iliac chains, causing compression to left external iliac vein and left common femoral vein. Some smaller lymph nodes at left paraaortic region. Suggest tissue proof.
    • Irregular skin thickening at left posterior thigh. Suggest further evaluation.
    • Two fat-density nodules in the pelvic cavity, suspect teratoma? Enlarged uterus. Mild ascites. Suggest correlation with GYN ultrasound.
    • A 1.5cm hepatic nodule, nature to be determined.

[MedRec]

• 2023-09-12 ~ 2023-09-22 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Cutaneous T-cell lymphoma, unspecified, lymph nodes of multiple sites
    • Primary cutaneous CD30-positive T-cell proliferations, primary cutaneous CD30-positive anaplastic large cell lymphoma (T cell and CD-30 positive), stage IV
  • CC
    • For further survey of suspected subcutaneous T cell lymphoma
  • Present illness
    • The patient is a 39 y/o female with previous unerlying disease, with only medication history of HTN treatment recieved during pregnancy. This time, she was admitted for further survey of suspected subcutaneous T cell lymphoma.
    • According to the patient herself and her husband, she had noted multiple pruritic erytheamtous papule-vesicles over medial posterior side of left thigh for months (before pregnancy) with progressed erythematous change, but she did not search for medical help after labor.
    • She first went to PS OPD, and was referred to CVS afterwards. At CVS OPD, multiple check ups were done. Venous sonography reported: Venous thrombosis at bilateral superficial epigastric veins and superficial circumflex iliar veins were detected. The intra-abdominal veinous occlusion or compression couldn’t be ruled out completely, please correlate with clinical presentations and other image modalities.
    • CTA of lower extremitiy reported: 1. Multiple enlarged lymphadenopathy at bilateral inguinal regions, pelvic side wall and iliac chains, causing compression to left external iliac vein and left common femoral vein. Some smaller lymph nodes at left paraaortic region. Suggest tissue proof. 2. Irregular skin thickening at left posterior thigh. Suggest further evaluation. 3. Two fat-density nodules in the pelvic cavity, suspect teratoma? Enlarged uterus. Mild ascites. Suggest correlation with GYN ultrasound. 4. A 1.5cm hepatic nodule, nature to be determined.
    • Thus, she was prescribed with the medication of Eliquis and Furosemide, and was referred to GYNOPD for evaluation.
    • At GYN OPD, sonography reported: 1. Uterine myoma, 2. R/O Bilateral Teratoma, 3. R/O Lt adnexal mass: 90x50mm, so after explanation, she was referred to GS OPD for evaluation on the pelvic mass and bilateral teratoma.
    • After evaluation on previous history and image findings, sono guide biopsy of left inguinal lymph node was done by GS Dr. Li ChaoZhu, and pathology results later reported peripheral T cell lymphoma, so she was thus referred to Dr. Gao WeiYao’s OPD for furtehr management.
    • At Dr. Gao’s OPD. admission was arranged after evaluation on previous medical record and the patient’s condition. Besides from the skin lesion over her left thight, she also had accompanied symtpoms of fever up to 38.7’C with chillness for 2-3 days which could be partially relieved by antipyretics, night sweats for 1-2 weeks, and LLQ abdominal distension pain for a week. She had no headache or dizziness, no cough or rhinorrhea, no chest pain or dyspnea, no nausea or vomiting, no diarrhea or urinating pain.
    • Under the impression of suspected subcutaneous T cell lymphoma, she was admitted for further evaluation and management.
  • Course of inpatient treatment
    • After admission, we did routine follow up on the patient’s lab data, chest X-ray and EKG, and since the patient’s left thigh skin lesion was suspected cutaneous T cell lymphoma, we consulted PS doctor for skin biopsy.
    • PET/CT was arranged and done, and we consulted CVS doctor for port-A insertion. Skin biopsy and port-A insertion were combined and done on 2023-09-13, and the patient did not show continuous bleeding.
    • PET/CT was done on 2023-09-14, and the report showed lymphoma involving multiple lymph node regions on both sides of the diaphragm, spleen, bone marrow and left upper thigh (stage IV).
    • Antibiotic of Targocid was used since admission due to the patient had fever going on and off, and there was no more fever noted since 2023-09-13.
    • Chemotherapy with CHOEP had started on 2023-09-18, and lab data was followed up every day.
    • The patient showed no fever, no nausea or vomiting, no abdominal pain or dysuria during chemotherapy, but her body weight had increased 5kg in recent 1 week with edema noted at left thigh, so we added IV form of Lasix 20mg QD.
    • Under stable condition, the patient was discharged on 2023-09-22, with oral medications brought back and OPD follow up arranged on 2023-09-26.
  • Discharge prescription
    • Compesolon (prednisolone 5mg) 10# QN
    • Uretropic (furosemide 40mg) 1# PRNQD (if BW increase)
• 2023-03-30 ~ 2023-04-02 POMR Obstetrics and Gynecology Zhang YinGuang
  • Discharge diagnosis
    • Term pregnancy at 40+4 weeks with mild preeclampsia for labor induction status post vaginal delivery on 2023/03/31
    • Mild to moderate pre-eclampsia, third trimester
    • Second degree perineal laceration during delivery
    • Streptococcus, group B, as the cause of diseases classified elsewhere
  • CC
    • Pregnancy at 40+3 weeks for labor induction        
  • Present illness
    • This 39 y/o, G2P1 (termination at GA 20 weeks due to cleft palate and holoprocencephaly), married woman with history of HTN which start medication control since pregnancy was currently pregnant at 40+3 weeks of gestation (LMP: 2022/05/28, EDC: 2023/03/27). She did not smoke, drink alcohol, or use illicit drugs.
    • She had received routine prenatal care at our hospital where normal maternal status and fetal development were diagnosed. There was no RPR/VDRL, HBsAg, HbeAg, Rubella IgG, HIV Ab, HPV 16 & 18, or Group B Streptococci infection. No gestational complication such as pregnancy induced hypertension, preclampsia or gestational diabetes mellitus. The labetalol 0.5# BID used for HTN control and aspirin used for preeclampsia prevention. Transabdominal ultrasound on 38+5 week revealed estimated fetal body weight (EFBW) as 3328gm. After discussed with the patient, she came to our delivery room on 2023/03/30 for the scheduled induction.
    • On examination, the blood pressure was 133/96mm Hg, the pulse 80 beats per minute, other vital signs and the remainder of the examination were normal. The fundus was firm; the height was consistent with the gestational age. Bilateral lower limbs edema 1+ noted on admission. Pelvic examination showed the cervix was 1 cm dilated and poor effaced. The fetal heart-rate tracing showed a rate of 130 to 139 beats per minute. She was then admitted to our ward for preparation of delivery. 
  • Course of inpatient treatment
    • This is a 33 years old female. G2P2 pregnancy at 40+4 weeks and admitted due to labor induction. Under local anesthesia, vaginal delivery was performed on 03/31/2023. A live female newborn with body weight 2925 gm, height 47 cm. Apgar score:9->9, EBL:200 ml. The breast engorgement without mass. EP wound without swelling and healed well. Uterine contraction was well. The Lochia showed redness and normal amount. Urination by self voiding was smooth. She was discharged & RTC after 6 weeks.
  • Discharge prescription
    • MgO 250mg 1# QID
    • Acetal (acetaminophen 500mg) 1# QID
    • Alcos-Anal Oint (sodium oleate) BID EXT
    • Through (sennoside 12mg) 1# HS
• 2023-03-04, 2022-11-12, -08-20 SOAP Cardiology Liu GuanLiang
  • Diagnosis: Primary HTN
  • Prescription x3
    • Trandate (labetalol 200mg) 0.5# BID

[consultation]

• 2023-09-13 Cardiology
  • Q
    • The patient is a 39 y/o female with previous unerlying disease, with only medication history of HTN treatment recieved during pregnancy. She had noted multiple pruritic erytheamtous papule-vesicles over medial posterior side of left thigh for months (before pregnancy, currently 5 months after labor) with progressed erythematous change, and after multiple evaluation, she was diagnosed with peripheral T cell lymphoma.
    • This time, she was admitted for further survey of suspected subcutaneous T cell lymphoma, and skin biopsy was arranged ib 9/13 12:00.
    • We need your expertise on the patient’s port-A insertion, thank you very much!
  • A
    • I have had the pleasure of involving with this patient’s care. In brief, the patient is a 39 year old female seen in consultation for opinion regarding treatment options for port-A insertion for chemotherapy access.
      • The pt’s hx/Dx was noted for 1. Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb
      • Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites
      • Lab/CXR reviewed.
    • SUGGESTION & PLAN:
      • Port-A insertion will be arranged on today right side, LMA combined with Dr Wei

[chemotherapy]

• 2023-11-17 - cyclophosphamide 750mg/m2 1500mg NS 250mL + doxorubicin 50mg/m2 100mg NS 100mL 10min + vincristine 2mg/m2 2mg NS 50mL 10min + etoposide 100mg/m2 200mg NS 500mL 1hr D1-3 + prednisolone 50mg PO BID D1-5 [CHOEP]
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
• 2023-10-16 - cyclophosphamide 750mg/m2 1400mg NS 250mL + doxorubicin 50mg/m2 96mg NS 100mL 10min + vincristine 2mg/m2 2mg NS 50mL 10min + etoposide 100mg/m2 190mg NS 500mL 1hr D1-3 + prednisolone 50mg PO BID D1-5 [CHOEP]
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
• 2023-09-18 - cyclophosphamide 750mg/m2 1400mg NS 250mL + doxorubicin 50mg/m2 96mg NS 100mL 10min + vincristine 2mg/m2 2mg NS 50mL 10min + etoposide 100mg/m2 190mg NS 500mL 1hr D1-3 + prednisolone 50mg PO BID D1-5 [CHOEP]
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3

==========

2023-11-22

[brentuximab vedotin] (not posted)

Health Insurance Medication Coverage Regulations (2023-10-24 version)

• Brentuximab vedotin (such as Adcetris) is limited to use in adult patients with systemic anaplastic large cell lymphoma (sALCL):
  • 1. For use in combination with cyclophosphamide, doxorubicin, and prednisone in adult patients with previously untreated systemic anaplastic large cell lymphoma (sALCL) that is ALK-negative.
  • 2. For the treatment of relapsed or refractory systemic anaplastic large cell lymphoma (sALCL).
  • 3. Use requires prior review and approval:
    • I. For patients mentioned in (1): The initial application for treatment is limited to 4 cycles. Subsequent applications should include assessment data from previous treatment results. If the patient has achieved complete remission, an additional 2 cycles may be covered; if the condition worsens, use must be discontinued. Health insurance coverage is limited to a maximum of 6 cycles.
    • 2. For patients mentioned in (2): Each application for treatment is limited to 4 cycles. Subsequent applications should include assessment data from previous treatment results. If the patient has achieved complete remission, an additional 4 cycles may be covered; if the condition worsens, use must be discontinued.
    • 3. The total lifetime coverage for the same patient under (1) and (2) is limited to a maximum of 16 cycles.

[family meeting] (not posted)

On the morning of 2023-11-22, at 10:00 AM in the 11A ward meeting room, a family meeting for the patient was convened by the attending physician, Dr. Gao. Attendees included the patient, her father, mother, elder sister, younger brother, and husband.

During the meeting, Dr. Gao thoroughly explained the current status of the disease, prognosis, and the conditions for health insurance coverage of targeted medications. The meeting particularly focused on ensuring that the patient’s family support network has a correct understanding of the condition and can provide timely support to the patient. The patient was also encouraged to actively raise any questions or concerns she might have during the treatment process and seek assistance from the medical team.

In an informal conversation after the meeting, outside the patient’s room, I further explained to the patient and her family about the risks of “tumor lysis syndrome” and “infusion reaction,” as well as the key points to cooperate with during treatment. The patient seemed willing to comply with the treatment.

700384230

231121

[lab data]

2023/03/17 Anti-HBc (NM) = Positive; 2023/03/17 HBsAg (NM) = Negative; 2023/03/17 HBsAg Value (NM) = 0.454; 2023/03/17 Anti-HBs (NM) = Positive; 2023/03/17 Anti-HCV (NM) = Negative;

[MedRec]

• 2023-10-04 ~ 2023-10-16 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Ampulla vater ductal adenocarcinoma invading pancreatic head, pT3bN0(cM0) Stage: IIB status post pancreato-duodenectomy whipple procedure with reconstruction with lymph node dissection on 2023/08/07 s/p chemotherapy with FOLFOX from 2023/10/12~
    • Chronic viral hepatitis B without delta-agent
    • Cachexia
    • Constipation, unspecified
  • CC
    • For prepare chemotherapy.
  • Present illness
    • This 63-year-old man patient suffered from discharged from our GI ward for obstructive jaundice then distal CBD with stnosis s/p ERCP with stent.
    • After discharge, he was keep follow up at our OPD. Body weight loss 16kg (70 -> 61 -> 54kg) from 2022/12 ~ 2023/05 ~ 2023/10.
    • Laparoscope choledocho-duodenostomy LC and Distal CBD biopsy on 2022/12/15 and Gallbladder, laparoscopic cholecystectomy pathology showed acute cholecystitis and Common bile duct, distal pathology showed chronic inflammation.
    • Abdominal CT on 2023/02/10 showed 1. Metastasis 1.5 x 1 cm in S6 liver is highly suspected, the differential diagnosis include atypical hemangioma, please correlate with MRI and biopsy. 2. Prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size. 3. Poor enhancing lesions in the hepatic hilum and ligamentum teres are suspected that may be metastatic nodes or lymphedema?
    • Abdominal echo on 2023/03/06 showed liver parenchymal disease, probable liver tumor: S6, GB sac not seen, pneumobilia, bilateral renal cysts and fatty infiltration of pancreas.
    • Liver MRI on 2023/03/15 showed 1. Prior CT identified a well-defined poor enhancing lesion 1.5 x 1 cm in S6 of the liver at portal venous phase images is not noted in the current MRI. 2. Prior CT identified poor enhancing lesions in the hepatic hilum and ligamentum teres are noted again, stationary, follow up is indicated and mild dilatation of both lobe IHDs and CHD.
    • PES on 2023/04/13 showed reflux esophagitis LA Classification grade A, superficial gastritis and duodenitis with stenosis, proximal of 2nd portion, s/p biopsy. Duodenum, proximal of 2nd portion, biopsy showed chronic erosive duodenitis.
    • EUS on 2023/05/11 showed rule out pancreatic tumor, head, abdominal lymphadenopathy and mild dilated left intrahepatic duct.
    • Abdominal SONO on 2023/05/12 showed 1. S/P cholecystectomy. 2. Pneumobilia. 3. There are several renal cysts on both kidney and the largest one measuring 2.86 cm in size at left upper pole. 4. Otherwise, no significant abnormal finding is noted.
    • Abdominal CT on 2023/07/07 showed prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size, in addition, there are several new developed enlarged nodes in the omentum and mesentery of RUQ abdomen.
    • EUS on 2023/07/19 showed 1. Lymphadenopathy, liver hilum and peripancreas, s/p CEH/EUS-FNB 2. Dilated CBD & MPD 3. Duodenal stenosis, SDA.
    • Upper GI series on 2023/07/20 showed 1. Luminal narrowing with irregularity contour at duodenum 1-2nd portion. 2. Flow of contrast medium into the IHDs and CBD (s/p duodenocholedochostomy?).
    • Pancrease fine needle biopsy showed soft tissue with marked bland lymphoid cells infiltration, in favor of chronic pancreatitis. IHC stains: CD3 and CD20: no predominant subpopulation.
    • Abdominal echo on 2023/07/20 showed postcholeycstectomy, pneumobilia, renal cyst, bilateral, dilated main pancreatic duct and abdominal lymphadenopathy.
    • Pancreato-duodenectomy whipple procedure with reconstruction on 2023/08/07 and pathology showed ampulla vater adenocarcinoma invading pancreatic head, IHC stains: CK7(+), CK20(-), CA19-9(weak +), CA125(-), CK19(+), pT3bpN0(if cM0); pStage: IIB, at least.
    • Port-A catheter implantation on 2023/10/03. Poor appetite with weaknees and weekly to LMD for intravenous nutrition injection from 2023/08.
    • Now, he was admitted to ward for prepare chemotherapy.  
  • Course of inpatient treatment
    • After admitted, Bfluid (self pay) + Lyo-povigent (self pay) and IVF suplementation for poor appetiet.
    • Gascon 1# po TID, Mopride 1# po TID and Cimetidine 1# po TID for abdominal distention.
    • Panadol 1# po PRNQ6H for Port-A wound pain control.
    • Explain his condition to his family (wife and son) on 2023/10/09.
    • Chemotherapy with FOLFOX (Oxalip (self pay) 50mg/m2, LV 300mg/m2, 5FU 300mg/m2 and 2400mg/m2) (C1D1) from 2023/10/12 ~ 2023/10/14.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H fro nausea and vomiting.
    • Chronic viral hepatitis B without delta-agent (Anti HBc(+)) with Vemlidy 1# po QD.
    • Cachexia with Megest 10ml po QD.
    • Constipation with Sennoside 2# po HS and MgO 2# po TID.
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, he was discharged on 2023/10/16 and OPD followed up later.   
  • Discharge prescription
    • Gasmin (dimethylpolysiloxane 40mg) 1# TID
    • Megest (megestrol 40mg/mL) 10mL QD
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • MgO 250mg 2# TID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2023-09-14 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • Based on the pathological report, the pancreaticobiliary ad mixed typeis favored. The ajuvant treatemnt is favored.
    • Options:
      • Adjuvant chemotherapy alone
      • Adjuvnat chemotherapy plus CCRT
    • Regimens (Patient is weak and poor nutirion, may consider not too strong C/T, and nutrition support during admission)
      • HDFL / Capecitabine
      • Gem alone
      • Gem/CDDP
      • Gem/Cap
      • FOLFOX/CapOx -> Favored
      • mFOLFIRINOX
• 2023-07-19 ~ 2023-08-18 POMR General and Gastrointestinal Surgery Wu ChaoQun
  • Discharge diagnosis
    • Ampulla vater ductal adenocarcinoma invading pancreatic head, pT3bN0(cM0) Stage: IIB status post pancreato-duodenectomy whipple procedure with reconstruction with lymph node dissection on 2023/08/07. ECOG:1
    • Gastro-esophageal reflux disease with esophagitis
    • Essential (primary) hypertension
    • Acute pancreatitis, unspecified
    • Cholangitis
  • CC
    • enlarged nodes in hepatoduodenal ligament for scheduled EUS FNB
  • Present illness
    • This 62-year-old man with past medical history of
      • Hypertension.
      • Gout.
      • Hyperlipidemia.
      • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15.
    • He was regular follow up at GS OPD.
    • At GS OPD, abdominal CT was performed on 2023/07/07 and reported prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size,there are several new developed enlarged nodes in the omentum and mesentery of RUQ abdomen. CA 199 from 903.59 U/mL(2023/05/02) up to 1317.82 U/mL(2023/06/08). He had poor appetite, general weakness and weight loss 14 kg (2022/12 70kg -> 2023/07 56kg) after operation. Fever up to 38.4 on 2023/07/17 and deep yellowish urine for 3 days were found. There was no URI symptoms, no chest tightness, no TOCC history found.
    • Under the impresison of enlarged nodes in hepatoduodenal ligament and new developed enlarged nodes in the omentum and mesentery of RUQ abdomen,he was admitted for scheduled EUS FNB.
  • Course of inpatient treatment
    • After admission, NPO with adquaet IV fluid supportwith PPN, Empirical antibiotic with Brosym was given.
    • The EUS FNB was performed smoothly on 2023/07/19, and reported
      • Lymphadenopathy, liver hilum and peripancreas, s/p CEH/EUS-FNB
      • Dilated CBD & MPD
      • Duodenal stenosis, SDA.
    • The Double contrast study of UGI series revealed:
      • Luminal narrowing with irregularity contour at duodenum 1-2nd portion.
      • Flow of contrast medium into the IHDs and CBD (s/p duodenocholedochostomy?)
    • Try liquid diet as toelrable and mild abdomen distension was noted depite medication treatment.
    • The pathology of Pancreas biopsy reported pancrease fine needle biopsy — soft tissue with marked bland lymphoid cells infiltration, in favor of chronic pancreatitis. IHC stains: CD3 and CD20: no predominant subpopulation. Consulted GS then he was tranferred to our ward for further treatment and pre-operation evaluation.
    • He underwent operation of Whipple on 2023/08/07, then he was transferred to SICU for post op care. We kept infection control with Brosym use. After trying weaning from ventilator, extubation was done smoothly on 2023/08/08, and he was then transfered to ordinary ward for care.
    • We monitor his vital sign and condition closely. Adequate pain control was given for patient. During the hospitalization course he has some numbness of right legs resulting from PCA usage. The problem resolved after we contacted anesthetia department and halt PCA usage. Throughout the hospitalization course there was no major complication.
    • Under stable vital sign and condition we discharged him with OPD follow up and take home medication.
  • Discharge prescription
    • Celebrex (celecoxib 200mg) 1# Q12H
    • MgO 250mg 1# TID
    • Mopride (mosapride citrate 5mg) 1# TID
    • Protase (pancrelipase 280mg) 1# TIDCC
    • Rich (lansoprazole 30mg) 1# QDAC
    • Through (sennoside 12mg) 2# HS
    • Xyzal (levocetirizine 5mg) 1# HS
    • Flu-D (fluconazole 150mg) 1# QD
    • Cravit (levofloxacin 500mg) 1.5# QDAC
• 2022-12-14 ~ 2023-01-02 POMR General and Gastrointestinal Surgery Wu ChaoQun
  • Discharge diagnosis
    • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15
    • Intraabdomen leakage with infection (Candida, Enterococcus and Escherichia coli)
    • Wound infection due to Enterococcus releved
    • Hyperlipidemia, unspecified
    • Essential (primary) hypertension
  • CC
    • Distal CBD stricture then s/p stent was noted since 3 months ago
  • Present illness
    • This 62-year-old man with past medical history of
      • hypertension,
      • gout,
      • hyperlipidemia.
      • distal CBD with stenosis s/p ERBD with stent on 2022/09/26.
    • According for his statement and medical record, he was discharged from our GI ward for obstructive jaundice then distal CBD with stnosis s/p ERCP with stent. After discharge, he was keep follow up at our OPD. Furhter MRI was performed and showed stenosis of distal CBD. S/P CBD stenting. A cystic lesion (1.0cm) in ucinate process of pancreas. Enlargement of pancreatic head. Mild dilatation of p-duct (3.6mm).
    • Due to no evidence of tumor or cancer result, he referred to our OPD for surgical intervention. He denied of nausea, vomit, abdominal pain, jaundice or loss of body weight in recently. After fully explain of surgical method, laparoscopic choledochoduodenostomy with cholecystectomy was planning. This time. he was admitted to our ward for surgical management.
  • Course of inpatient treatment
    • After admission, he received laparoscope choledocho-duodenostomy and cholecystectomy was processed successfully on 2022/12/15. Post operaively, we observed patient recovery and keep empiric antibiotic, stool softener and analgesic agent were administered and the wound management was performed. He try to introduced soft diet and can tolerate well to oral intake. However, bile leakage was noted since 2022/12/20. Then we kept NPO and nutrition support with PPN.
    • Bile culture showed CRKP and E-coli, we keep antibiotic with Tienam + Doripenam + Unasym support.
    • Due to intraabdomen leakage, GI was also consulted then ERBD was indicated. However, bile leakage was reduced on 2022/12/26, then ERBD procedure was canceled. On the other side, wound reddness with pus dischrge was noted, then we kept Aqucel-Ag wet for wound care. His generally well beings and relativley stable. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable.
    • JP drainage with no pus dischrge then removal was done smoothly on 2022/12/31, then final ascites culture showed candida. Infection men was also consulted who suggest keep Flucon support.
    • Under improved general condition, he was allowed to discharge today and OPD follow up was arranged.
  • Discharge prescription
    • Celebrex (celecoxib 200mg) 1# QD
    • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
    • Ulstop (famotidine 20mg) 1# QD
    • Mopride (mosapride citrate 5mg) 1# TID
    • Flu-D (fluconazole 150mg) 1# QD
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
• 2022-09-25 ~ 2022-09-28 POMR Gastroenterology Hong Yulong
  • Discharge diagnosis
    • Suspect malignant biliary obstrcution with lymphadenopathy, status post brushing and biopsy on 2022/09/26
    • Biliary obstrcution ststus post endoscopic retrograde biliary drainage with placement of a plastic stent
  • CC
    • For ERCP + IDUS
  • Present illness
    • This 62-year-old man with past medical history of hypertension, gout, hyperlipidemia. He was regular follow up at Rheu OPD.
    • He just discharged from GI ward for Obstructive jaundice s/p ERCP, Distal biliary stenosis, s/p precut with NKF, s/p EST, s/p ERBD with placement of a plastic stent.
    • Due to Painless jaundice for 2 wks visited GI OPD then admission, CT and MRI showed distal CBD stricture but no obvious tumor noted. ERCP showed distal CBD stricture also s/p ERBD, jaundice improving after ERCP then discharge.
    • For further survay, the EUS (on 2022/08/26) showed dilated CBD and sludge but no tumor. Had talked about IDUS. He agreed then arrange admssion 2022/09/25 for ERCP + IDUS on 2022/09/26. There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastric pain, no tarry stool. He also denied TOCC history.
  • Course of inpatient treatment
    • After abmission to GI ward, ERCP and IDUS were arranged after explain indication and risk.
    • ERCP with IDUS was performed smoothly on 2022/09/26 and revealed suspect malignant biliary obstrcution with lymphadenopathy, s/p STERIS Infinity brushing and biopsy, s/p ERBD with placement of a plastic stent.
    • The pathology was pending. Analgesic agent for pain relief was prescribed. There was no fever episode after procedure.
    • Oral intake trying was administered and there was no abdominal discomfort.
    • Follow up laboratory data revealed mild leukocytosis and elevaeted pancreas enzyme.
    • Some patient in the same room was diagnosed to have COVID-19 infection then he was discahrged this early morning.
    • OPD follow-up was arranged.
• 2022-08-08 SOAP Rheumatology and Immunology Chen JunXiong
  • Diagnosis
    • M10.00 - Idiopathic gout, unspecified site
    • M06.4 - Inflammatory polyarthropathy
    • E78.5 - Hyperlipidemia, unspecified
  • Prescription x3
    • Tulip (atorvastatin 20mg) 1# QD
    • colchichine 0.5mg 1# QD
    • Euricon (benzbromarone 50mg) 1# BID
• 2022-07-21 ~ 2022-07-26 POMR Gastroenterology Hong Yulong
  • Discharge diagnosis
    • Distal common bile duct stenosis with obstructive jaundice, nature to be determinated
    • Chronic kidney disease
    • Duodenal ulcer
    • Acute diarrhea
  • CC
    • tea color urine and clay stool for 5 days
  • Present illness
    • This is a 62-year-old man with past medical history of 1. hypertension, 2. gout, 3. hyperlipidemia. He was regular follow up at Rheu OPD. He was admitted due to tea color urine and clay stool for 5 days.
    • According to the patient himself and the past medical record, he suffered from tea color urine and clay stool for 5 days. He denied abdominal pain or weight loss. He had a health exam on 2022/07/05 and elevated ALT up to 143 was noted. He then visited our hospital for help. There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastric pain, no tarry stool.She also denied TOCC history.
    • At OPD, the laboratory tests showed AST/ALT 205/398, TBI/DBI 6.87/4.52, CRE 1.71. CT was done and showed dilatation of bilateral IHDs and CBD with segmental wall thickening at distal CBD; no CBD stone or tumor was found in the exam.
    • Under the impression of obstructive jaundice. He was admitted to GI ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, ERCP was performed on 2022/07/22 and distal CBD stanosis was noted but definite cause unknown. Platic stent was inserted. Besides, DU was also noted during the exam so oral Pariet was used. Blood test showed elevated pancreatic enzymes but no significant abdominal pain, the he start intake again.
    • Pancras MRI + MRCP was performed on 2022/07/23 and no definite lesion was seen in the CBD or pancreatic head. The jaundice improving after stent insertion.
    • The IgG4 level was normal. Because IgG4 related disease still couldn’t be excluded, EUS + FNB was arranged on 2022/07/26 to check tumor or random biopsy.
    • However, diarrhea about 10 times was noted since 2022/07/25 especially after the evening despide medication use.
    • The patient decided not to receive the EUS examination just because diarrhea couldn’t improve soon (bad mood).
    • Then he was discharged on 2022/07/26 and GI OPD follow-up was arranged.
  • Discharge prescription
    • Smecta (dioctahedral smecitite) 1# TIDAC
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Buscopan (hyoscien-N-butylbromide 10mg) 1# TIDAC

[consultation]

• 2023-08-17 Hemato-Oncology
  • Q
    • Ampulla vater cancer s/p whipple for further chemotherapy
    • This 62-year-old man with past medical history of
      • Hypertension.
      • Gout.
      • Hyperlipidemia.
      • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15.
    • He was regular follow up at GS OPD.
    • He noted for CBD stricture with repet pancreatitis for half years. This time, he was admitted and received further operation of Whipple’s op on 2023/08/07.
    • Final pathology showed ampulla vater cancer invading pancreatic head with ductal adenocarcinoma. pT3bpN0(cM0); pStage: IIB.
    • Now, he tolerance well of semi-liquid diet. We need your help for further adjuvant chemotherapy for this case. Thanks for your time!!
  • A
    • This 62 year old man is a case of ampulla vater adenocarcinoma. pT3bpN0(cM0); pStage: IIB s/p Whipple’s op on 2023/08/07. He had underline disease of HTN, Gout, Hyperlipidemia, and Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15. We are consulted for cancer treatment.
    • Please arrange port A insertion. We will discuss with patient about further ajuvant chemotherapy (5-FU + leucovorin or gemcitabine (self-paid) or other regiment). Please arrange our OPD after discharge. Thanks for your consultation.
    • Ref:
      • The ESPAC-3 trial demonstrated significant improvements in DFS and overall survival (OS) with use of postoperative gemcitabine or 5-fluorouracil (5-FU) as adjuvant chemotherapy versus observation in resectable ampullary adenocarcinoma.
      • ESPAC-3 study results showed no significant difference in OS between 5-FU/leucovorin versus gemcitabine following surgery. When the groups receiving adjuvant 5-FU/leucovorin and adjuvant gemcitabine were compared, median survival was 23.0 months and 23.6 months, respectively.
• 2023-07-25 General and Gastrointestinal Surgery
  • Q
    • This 62-year-old man with past medical history of
      • Hypertension.
      • Gout.
      • Hyperlipidemia.
      • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15.
    • He was regular follow up at GS OPD.
    • At GS OPD,abdominal CT was performed on 2023/07/07 and reported prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size,there are several new developed enlarged nodes in the omentum and mesentery of RUQ abdomen.
    • CA 199 from 903.59 U/mL(2023/05/02) up to 1317.82 U/mL(2023/06/08).
    • He had poor appetite,general weakness and weight loss 14 kg (2022/12 70kg -> 2023/07 56kg) after operation.
    • Fever up to 38.4 on 2023/07/17 and deep yellowish urine for 3 days were found.
    • There was no URI symptoms, no chest tightness, no TOCC history found.
    • Under the impresison of enlarged nodes in hepatoduodenal ligament and new developed enlarged nodes in the omentum and mesentery of RUQ abdomen, he was admitted for scheduled EUS FNB.
    • The EUS FNB pathology was pending, we need your expertise for his Distal common bile duct stricture Thanks~
  • A
    • Please TPN for nutrition support for pre-op
    • Further OP method: Whipple op or GJ bypass
• 2022-12-31 Infectious Disease
  • Q
    • bile leakage with intraabdomen infection
    • ascites showed CRKP, E-coli, enterococcus, and yeast
    • This 62 y/o male was a case of distal CBD stricture with stent since 3 months ago. This time, he was admitted and received laparoscope choledocho-duodenostomy and LC on 2022/12/15. However, post operation with bile leakage was noted since 2022/12/20.
    • Bile culture showed CRKP, enterococcus and E-coli, we keep antibiotic with Tienam + Doripenam + Unasym support. Unbilical wound infection was also noted and culture also revealed enterococcus. 2022/12/29 recheck ascites still show yeast like and WBC: 13300, CRP:2.21 was noted.
    • Now, we kep tienam + oral ciproxin and zyvox + flucon support for intraabdomen infection control. We need your help for further antibiotic recommendation.
  • A
    • Consultation for Zyvox and Culin (Tienam) antibiotic use.
      • Postoperative polymicrobial cholangitis and umbilical wound infection case.
      • Inital ascites culture showed CRKP and Enterococcus faecalis on 2022/12/16, follow up ascites culture on 2022/12/20 revealed MDR-E.coli and Eneterococcus.
      • The latest ascites on 2022/12/29 showed Yeast.
      • Patient is receiving the 2nd week Culin, oral Cipro, iv fluconazole and newly-added oral Zyvox.
      • Antibioticv adjustment indicated.
    • Suggestion:
      • Culin de-escalted to Brosym,
      • DC Zyvox, since no MRSA or VRE evidence.
      • DC oral Cipro since no effect for E.coli.
      • Continue iv fluconazole for the most possible Candida superinfection.
• 2022-12-23 Gastroenterology
  • Q
    • post laparoscope choledocho-duodenostomy with bile leakage for endo stent
    • This 62 y/o male was a case of distal CBD stricture with stent since 3 months ago. This time, he was admitted and received laparoscope choledocho-duodenostomy and LC on 2022/12/15. However, post operation with bile leakage was noted since 2022/12/20. Bile culture showed CRKP and E-coli, we keep antibiotic with Tienam + Doripenam + Unasym support. We need your help for endo stent replacement for bile leakage control. Thanks for your time!!
  • A
    • Pre-ERCP evaluation
      • Indication: post operation bile leakage
      • Medication anti-coagulant: denied
      • Previous operation history: laparoscope choledocho-duodenostomy and LC
    • Suggestion
      • Please check amylase and lipase “before” ERCP
      • Set IC in right arm (if no contraindication)
      • ERCP intervention could be arranged on 2022/12/26 in the afternoon
        • well inform-consent to the patient and the family, including the current condition, the indication for ERCP, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, biliary tract infection, post-ERCP pancreatitis, post-ERCP bleeding, etc.)
        • if the patient and families all understand ERCP intervention, may take the risk, and sign permit for ERCP, we would arrange ERCP
        • please keep NPO at least 8 hours before ERCP as possible
        • correct bleeding tendency, and avoid any antiplatelets/anticoagulants before ERCP;
      • Keep current empirical antibiotics use and IV line before ERCP, and closely follow up the patient’s clinical condition for fear of further septic shock due to biliary tract infection;
      • Please inform us if any clinical sign deterioation before and after ERCP

[surgical operation]

• 2023-08-07
  • Surgery
    • Pancreato-duodenectomy whipple procedure with reconstruction.
    • Including:
      • Partial gastrectomy
      • pancreato-duodenal anastomosis +
      • Billroth II
      • Braun anastomosis
  • Finding
    • Severe adhesion of previous operation site.
    • Solid medium-hard of Vater region was noted from resecction tissue, malignancy suspected.
    • Pending pathology report.
• 2022-12-15
  • Surgery
    • laparoscope choledocho-duodenostomy
    • LC
    • Distal CBD biopsy
  • Finding
    • distal CBD stricture with stent in place

[chemotherapy]

• 2023-11-20 - oxaliplatin 75mg/m2 125mg D5W 250mL 2hr + leucovirin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-11-01 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovirin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-12 - oxaliplatin 50mg/m2 80mg D5W 250mL 2hr + leucovirin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-11-21

After the surgical operation on 2023-08-07 (Pancreato-duodenectomy Whipple procedure with reconstruction, which included partial gastrectomy, pancreato-duodenal anastomosis, Billroth II, and Braun anastomosis), the tumor marker CA199 significantly decreased from four digits to two digits.

• 2023-11-20 CA199 55.17 U/mL
  
• 2023-09-14 CA199 59.52 U/mL
  
• 2023-08-03 CA199 1754.46 U/mL
  
• 2023-06-08 CA199 1317.82 U/mL
  
• 2023-05-03 CA199 903.59 U/mL
  
• 2023-04-13 CA199 806.27 U/mL
  
• 2023-03-06 CA199 698.53 U/mL
  
• 2023-01-31 CA199 653.74 U/mL

Lab data from 2023-11-20 indicates that, apart from slightly impaired renal function, liver function, electrolytes, and blood counts are largely within normal ranges.

No medication discrepancies identified.

700507094

231120

==========

2023-11-20

[vancomycin TDM]

U-Vanco (vancomycin) has been administered at a dose of 1000mg Q12H IVD since 2023-11-18, with scheduled administration times at 09:00 and 21:00. The blood sample was drawn on 2023-11-20 at 02:25:37, following the administration at 20:19 on 2023-11-19, and before the next dose at 12:47 on 2023-11-20. If the aim is to measure the trough level, the ideal time for blood sampling should be within half an hour before the next dose. Please confirm if the timing of the blood draw was correct.

If after confirmation, the blood draw timing is deemed accurate (indicating a vancomycin concentration of 22 mg/L is reliable), then the current dosage of 1000mg Q12H should be reduced to 750mg Q12H.

701504241

231120

[exam findings]

• 2023-11-18 CXR - abdomen
  • Clinical history: 83 y/o female patient with cecal soft tissue mass is suspected. Liver low density lesion. Colon cancer with liver meta?
  • With and without contrast enhancement CT of abdomen:
    • Thickening wall at the sigmoid colon with pericolonic infiltrates and abutting pelvic side wall, r/o sigmoid colon malignancy.
    • Edema/thickening wall at the cecum, syncrhonous colon malignancy?
      
    • Irregular cystic tumor, 2.4cm in S8 liver, complicated cyst or cystic metastasis? Suggest further study.
    • Bilateral renal cysts, up to 3.2cm in left kidney.
    • Liver cysts.
    • Fibrocalcified infiltrates in right upper lung.
    • Irregular contour of urinary bladder, r/o chronic cystitis.
    • T12 and L3 compresion fractures.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:Mx(M_value) STAGE:____(Stage_value)
  • Impression:
    • Sigmoid colon malignany, cstage T4N1Mx(cystic liver tumor, r/o complicated cyst or cystic metastasis, suggest further study).
    • Edema/thickening wall at the cecum, syncrhonous colon malignancy? Suggest colonoscope study.
• 2023-11-17 ECG
  • Sinus rhythm with Premature atrial complexes
  • Otherwise normal ECG
• 2023-11-17 CXR (erect)
  • Fibro-calcified shadows of right upper lung are noted, which may be due to old TB. Please correlate with clinical history.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis with scoliosis of the T-spine with convex to right side
• 2023-11-10 KUB
  • Fecal material store in the colon.
  • Spondylosis of the L-spine is noted.
  • Compression fracture of T12 and L3 vertebral body.
• 2023-11-06 CT - abdomen
  • Indication: a case of uterine ca s/p (10 yrs ago; loss F/U) RLQ pain for 1 m. appetite: OK. stool: OK. refer for GYN. dysuria (-). fever (-)tx at LMD in vain R/O colon leison
  • Abdominal CT without IV enhancement revealed:
    • Diffuse swelling of the cecum measuring 7.45cm in largest dimension is found. Some lymph nodes (n＝4) are found at RLQ of the abdomen.
    • Low density lesion at S7/8 of liver measuring 2.35cm in largest dimension. Nature?
    • Left renal cyst measuring 3.55cm is found.
    • The spleen, pancreas, both adrenals are intact.
  • Imp:
    • Cecal soft tissue mass is suspected.
    • Liver low density lesion.
    • Colon cancer with liver meta? Suggest further study.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)

700127430

231116

[lab data]

• 2021-09-01
  • HBsAg Nonreactive
  • HBsAg Value 0.36 S/CO
  • Anti-HBc Reactive
  • Anti-HBc Value 4.02 S/CO
  • Anti-HBc IgM Nonreactive
  • Anti-HBs >1,000mIU/mL

[exam findings] (not completed)

• 2023-11-16 CT - abdomen
  • History and indication: Ovarian Cancer, pT3bN0Mx, stage IIB
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. Stable condition of recurrent cancer at vaginal stump. S/P Port-A infusion catheter insertion. S/P right side double J catheter insertion. A nodule (2.0cm) at left pelvic cavity.
    • Colonic diverticula. Small size of left kidney.
    • Gallbladder stone (2.0cm). R/O distal CBD stones (2-3mm).
    • Atherosclerosis of aorta.
  • IMP:
    • S/P hysterectomy. Stable condition of recurrent cancer at vaginal stump.
• 2023-11-07 KUB
  • S/P double J catheter insertion in place, right side.
  • Round calcification, 2.2cm in RUQ, r/o gallbladder stone.
• 2023-11-07 SONO - kidney (urology)
  • Diagnosis: Left renal cyst
• 2023-11-07 Bladder Sonography
  • PVR:5.8ml
• 2023-09-06 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • A calcified gallstone is noted.
  • S/P double J catheter insertion, right side urinary tract.
• YYYY-MM-DD XXX…

[MedRec]

• 2017-01-06 SOAP Hemato-Oncology Wan XiangLin
  • S
    • Ovarian cancer, S/P op and C/T (C8, 20161109), for recheck, poor appetite after chemotherpay.
    • Gall stone at last abdominal CT examination.
    • S/P lab. test for tumor markers.
  • O
    • 20161205 abdominal CT
      • Findings
        • S/P operation.
        • Gall stone (1.5cm).
      • Impression:
        • S/P operation. No evidence of tumor recurrence.
        • Gall stone (1.5cm).
  • Diagnosis
    • Malignant ovary neoplasm [C56.2]
    • Leiomyoma of uterus, unspecified [D25.9]
  • Prescription
    • Agglutex (heparin 25000U/5mL) 5mL ST
    • NS 20mL ST
• 2017-01-06 SOAP Neurology
  • Diagnosis
    • Cerebral artery occlusion, with cerebral infarction [I63.50]
    • Malignant ovary neoplasm [C56.2]
    • Essential hypertension, benign [I10]
    • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
    • Myalgia and myositis,unspecified [M79.1]
  • Prescription x3
    • Eurodin (estazolam 2mg) 0.5# HS
    • Schnin (ginkgo biloba 9.6mg) 1# BID

[chemotherapy]

• 2023-11-15 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2023-10-13 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2023-09-06 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2023-08-02 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2023-07-04 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2023-05-30 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2023-03-28 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2023-02-15 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2023-01-13 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2022-01-06 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2021-11-26 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2021-11-06 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2021-10-14 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2021-09-23 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2021-09-02 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

700136377

231116

[lab data]

2023-05-05 Anti-HBc Reactive
2023-05-05 Anti-HBc-Value 6.66 S/CO
2023-05-05 Anti-HBs 414.12 mIU/mL
2023-05-05 Anti-HCV Nonreactive
2023-05-05 Anti-HCV Value 0.08 S/CO

[exam findings]

• 2023-08-26 CT - abdomen
  • History and indication: S-colon cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon operation. Right liver metastases s/p operation with biloma formation (2.9cm).
    • Left renal cyst (8mm).
    • Right ovary cyst (2.4cm).
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P colon operation. Right liver metastases s/p operation with biloma formation (2.9cm).
• 2023-04-20 All-RAS + BRAF gene mutation analysis
  • ALL-RAS: Detected (KRAS codon 146 GCA>CCA, p.A146P)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-04-20 Patho - liver partial resection
  • PATHOLOGIC DIAGNOSIS
    • Liver, S6, partial resection — Metastatic colonic mucinous adenocarcinoma
      
  • MACROSCOPIC EXAMINATION
    • Procedures: S6 partial resection
      
    • Specimen Size: 6.2 x 4.0 x 3.0 cm and 39.2 gm
      
    • Tumor Focality: Solitary
      
    • Tumor Site: S6
      
    • Tumor Size: 3.0 x 2.5 x 2.5 cm
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Not cirrhotic
      
    • Sections are taken and labeled as: A1-A5
  • MICROSCOPIC EXAMINATION
    • Diagnosis: Metastatic colonic mucinous adenoarcinoma
      
    • Histologic grade: Moderately differentiated
      
    • Tumor growth pattern: Pushing
      
    • Tumor pseudocapsule: Present
      
    • Tumor necrosis: Absent
      
    • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 1.7 cm
        
    • Vascular invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Non-neoplastic liver parenchyma: Moderate to mild lymphocytic portal inflammation, and mild fatty change (5%)
• 2023-04-19 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, sigmoid colon, colectomy —- Adenocarcinoma, moderately differentiated
      
    • Peritoneum, left abdominal wall, excision —- Adenocarcinoma, by direct invasion
    • Uterus, excision —- Negative for malignancy
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection —- metastatic adenocarcinoma (2/19)
    • Lymph node, IMA / SMA, dissection —- not received
    • AJCC 8th edition Pathology stage: pStage IVA, pT4bN1bM1a
      
  • Gross Description:
    • Operation procedure: sigmoid colectomy with a portion of left abdominal wall and uterus
    • Specimen site: sigmoid colon
      
    • Specimen size: Colon: 8.0 cm in length; left abdominal wall: 3 x 3 x 0.9 cm; uterus: 2 x 1 x 0.8 cm
      
    • Tumor size: 4 x 3.5 cm
    • Tumor location: 2.2 cm and 1.7 cm away from the two resection margins, respectively.
    • Depth of invasion grossly: left abdominal wall
    • Mucosa elsewhere: congestion
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as:
      • A1: colon, non-tumor; A2-6: tumor (A2 and A3: with left abdominal wall; A4: with uterus); A7-9: lymph node, mesocolic; A10: tumor, ink serosa; B: proximal cutend; C: distal cutend.
        
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor directly invades adjacent structures (specify: left abdominal wall)
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved, Distance of tumor from margin: 1 mm
        
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Present
    • Tumor Budding: Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
    • Tumor Deposits: Present, Specify number of deposits: 4
    • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 2/19
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT):pT4b: Tumor directly invades or adheres to adjacent organs or structures
        • Regional Lymph Nodes (pN): pN1b: Two or three regional lymph nodes are positive
        • Distant Metastasis (pM): pM1a: Metastasis to one site or organ is identified without peritoneal metastasis (S2023-07515)
    • Additional Pathologic Findings (select all that apply): None identified
• 2023-03-31 CT - abdomen
  • CC: One mass was noted in the sigmoid colon (25 cm from anal verge)
  • Indication: adenocarcinoma of the sigmoid colon, CT staging
  • Findings:
    • There is segmental circumferential asymmetrical wall thickening at the sigmoid colon, measuring 8 cm in length, with irregular contour and suggestive direct invasion left round ligament.
      • It is c/w adenocarcinoma of the sigmoid colon (T4b).
      • In addition, there are seven enlarged nodes in the adjacent mesocolon that are c/w metastatic nodes (N2b).
    • There is a poor enhancing mass 2.6 cm in S6 of the liver that is c/w metastasis (M1a).
    • There are several renal cysts on both kidney and the largest one measuring 0.8 cm in size at left middle pole.
    • There is no focal lesion in both lung and mediastinum.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
• 2023-03-31 Patho - colorectal polyp
  • DIAGNOSIS:
    • Colon, sigmoid, 25 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
      
  • GROSS DESCRIPTION:
    • Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 0.5 x 0.3 x 0.1 cm. All for section in one cassette.
  • MICROSCOPIC DESCRIPTION:
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).

[MedRec]

• 2023-04-18 ~ 2023-04-27 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Adenocarcinoma of sigmoid with direct invasion to left abdominal wall, and liver metastasis , cT4bN2bM1a, stage IVA status post sigmoid colectomy and liver resection on 2023/04/19, pStage IVA, pT4bN1bM1a
  • CC
    • intermittent lower abdominal pain for three months
  • Present illness
    • This is a 74-year-old female without any underlying diseases. She suffered from intermittent lower abdominal pain for three months. Bowel habit change with loose stool for one year was also mentioned. She had no diarrhea, no tarry stool, no anal fresh bleeding, no significant body weight loss. She then visited colon and rectum surgery outpatient department for help. After series of work-up, she was diagnosed with adenocarcinoma of sigmoid with liver metastasis, cT4bN2bM1a, stage4a. This time, she was admitted to our ward for sigmoid colectomy and liver resection on 2023/04/19.   - Course of inpatient treatment
    • After admission with ward routine, operation of sigmoid colectomy and liver resection were done on 2023/04/19 under general anesthesia. After the operation, wound healing went well without erythema change. Chewing cookies, toast, rice with gum was started at op day. The wound pain was tolerated under PCEA. Lab data checked on 4/20 showed Hb 7.9, WBC 11730, GOT 192, GPT 216, total bilirubin 0.38, direct bilirubin 0.07, CRP 6.76. Blood transfusion of LPRBC 2u and K1 supplement were arranged. Empirical antibiotic with Cefoxitin and self-pay Plasbumin were given for three days. There were no nausea and no vomiting. Flatus and stool passage were noted after operation. She was able to tolerate low residual diet. During her stay at our ward, there were no fever.
    • The final pathology report revealed liver, S6, partial resection metastatic colonic mucinous adenocarcinoma; large intestine, sigmoid colon, colectomy, adenocarcinoma, moderately differentiated/peritoneum, left abdominal wall, excision, adenocarcinoma, by direct invasion; Uterus, excision, negative for malignancy, pT4bN1bM1a.
    • Under stable condition, she discharged on 2023/04/27 and OPD follow up was arranged.
  • Discharge prescription
    • Deflam-K (diclofenac 25mg) 1# PRNQ8H
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
    • MgO 250mg 1# TID
• 2020-02-24 SOAP Neurosurgery Dai BoAn
  • Diagnosis
    • Other spondylosis with myelopathy, site unspecified [M47.10]
    • Other spondylosis with radiculopathy, lumbar region [M47.26]
  • Prescription
    • U-Ca (calcitriol 0.25ug) 1# QD
    • CaCO3 500mg 2# QD
    • Vit B1 (thiamine 100mg) 1# QD
    • Arcoxia (etoricoxib 60mg) 1# QD
    • Stidine (tizanidine 2mg) 1# HS

[consultation]

• 2023-10-26 Dermatology
  • Q
    • The patient is an 74-year-old female with a history of Adenocarcinoma of sigmoid with direct invasion to left abdominal wall and liver metastases, cT4bN2bM1a, stage IVA status post sigmoid colectomy and liver resection on 2023/04/19, pT4bN1bM1a, pStage IVA s/p chemotherapy with FOLFOX from 2023/05/24~.
    • She presented left armpit with redness and itchy was found about for 2 weeks. We need your further evaluation and management.
  • A
    • Under the impression of tinea corprois et intertrigo eczema over axilla.
      
    • The following sugeetion:
      • Zalain cream 1 tube topical bid use over large area of axilla first.
        
      • Mycomb cream 1 tube topical PRN bid use over itchy area.
• 2023-08-10 Dermatology
  • Q
    • The patient is an 73-year-old female with a history of Adenocarcinoma of sigmoid with direct invasion to left abdominal wall and liver metastases, cT4bN2bM1a, stage IVA status post sigmoid colectomy and liver resection on 2023/04/19, pT4bN1bM1a, pStage IVA s/p chemotherapy with FOLFOX from 2023/05/24~.
    • She presented with Hand-foot syndrome was found, after chemotherapy. we need your further evaluation and management.
  • A
    • The patient had sufferred from reedish swelling over digitals.
      
    • Under the impression of hand foot syndrome with remssion stage.
    • The following sugeetion:
      • Enhance skin mositurzation first. Topysm cream 1 tube topical bid use over erythematous swelling lesions.
      • Sinphraderm 1 tube topical QN use over thick/ scales lesions.

[surgical operation]

• 2023-04-19
  • Surgery: S6 partial resection of liver
  • Finding: 3 x 2.5 x 2.5 cm metastatic tumor
• 2023-04-19
  • Surgery: Sigmoid colectomy     
  • Finding
    • tumor direct invasion to uterus and left abdominal wall    
    • Splenic flexure was mobilized    

[chemotherapy]

• 2023-10-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-28 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-14 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-28 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, reduced Oxa)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-24 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, reduced Oxa due to ANC 1076)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-10 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-23 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-07 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-24 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-27

There were no issues found during medication reconciliation, and based on the patient’s latest lab results indicating normal renal and liver function, no dose adjustments are required.

700352403

231113

[MedRec]

• 2018-12-07 ~ 2018-12-14 POMR Gastroenterology Li ZhongXian
  • Discharge diagnosis
    • K63.3 - Post polypectomy wound with propable recent bleeding
    • K52.9 - Colitis of A colon
    • C20 - Malignant rectum neoplasm, DUKE C(T3N1M0) s/p surgery and chemotherapy
    • E87.1 - Hyponatremia
    • I11.9 - Hypertensive heart disease
  • CC
    • Passage of bloody stool and fever, general weakness, abdominal pain for one day AFTER COLON POLYPECTOMY
  • Present illness
    • This 73 year old MAN had history of
      • HCVD
      • cerebral artherosclerosis
      • rectal cancer s/p surgery with lung metastses and had been taking drugs for many years as prescribed.
    • He regularly follow up with appointment at Neurolgy and Oncology specialist.
    • He just received colon scope examination yesterday afternoon and polypectomy was performed.
    • After discharged, he presented with passage of bloody stool and fever, general weakness, abdominal pain.
    • Hence the patient was brought to our ER for evaluation and management.
    • An examination of the patient’s abdomen in the ER showed soft and flat, no abdomen tenderness, no rebound tenderness, no icteric sclera, no pale conjuctiva A series of examinations including blood routine, blood biochemistry, cultures, urine routine and image were performed.
    • CT of the abdomen showed Bowel wall thickeing at ascending colon. Nature to be determined; propable left renal cyst; propable left adrenal tumor.
    • Under the tentative diagnosis of LGI bleeding.Propable post polypectomy wound bleeding and Leukocytosis and fever.
    • Propable colitis of A colon, the patient was admitted for further evaluation and treatment.
  • Course of inpatient treatment
    • Patient was admitted to our hospital due to passage of bloody stool and fever,general weakness,abdominal pain for one day.CT of the abdomen showed Bowel wall thickeing at ascending colon.
    • One day before admission, he received polypectomy at our surgery departement. Under the impression of lower GI bleeding, we underwent colon fiberoscopy and sawed polypectomy site was identified at A-colon and a clip was placed no bleeding was seen.
    • We observed his condition after colonscopy.There was no bloody stool after medical treatment. Abdominal pain improved. Normal yellow color stool passage was told.
    • We also consulted social worker for post colon polypectomy condition. The issue was reported and will keep close contact with family members and patient.Under stable condition he was discharge and OPD follow up
  • Discharge prescription
    • Ulstop (famotidine 20mg) 1# BID
    • Trand (tranexamic acid 250mg) 1# BID
    • Cero (cefaclor 250mg) 2# Q8H
• 2017-01-02 SOAP Neurology Lin XinGuang
  • Diagnosis
    • Cerebral atherosclerosis [I67.2]
    • Essential hypertention, unspecified [I10]
    • Neuralgia, neuritis, and radiculitis, unspecified [M79.2]
    • Intervertebral disc disorder with myelopathy, unspecified region [M51.9]
    • Arthropathy, unspecified,unspecified sites [M12.9]
  • Prescription x3
    • Ancogen (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRN
    • Licodin (ticlopidine 100mg) 1# QD
    • Trandate (labetalol 200mg) 1# QD
    • Norvasc (amlodipine 5mg) 1# BID
    • Trileptal (oxcarbazepine 600mg) 1# BID

==========

2023-11-13

[reconciliation]

On 2023-10-18, the patient attended JingMei Hospital for treatment of polyneuropathy and received a 28-day prescription for mecobalamin, chlorzoxazone, brotizolam, and trazodone. These medications have not been recorded in the current medication list. Please verify if this constitutes a discrepancy.

700041739

231110

[MedRec]

• 2021-05-17 ~ 2021-05-24 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • Cecal adenocarcinoma with mesocolon and visceral peritoneum involvement, moderately differentiated, EGFR (+) PMS2(+) MSH6(+) MSH2(+) MLH1 (+), pT4aN2b(cM0) stageIIIC, status post right hemicolectomy on 2021-05-18
    • Iron deficiency anemia, unspecified
  • CC
    • Intermittent right lower quadrant abdominal pain with lower grade fever since 1 month ago
  • Present illness
    • This 64 years old male who denied systemic or surgic history presented with RLQ abdominal pain for 1 week in April of 2021. He went to local clinics with 3-day antibiotics and analgesics and condition much improved, but the pain progressively recurred 2 days later. He traveled to ChangHua on 2021/04/10 and fever with RLQ pain were noted. He visited ChangHua Christian Hospital and was diagnosed with acute appendicitis by CT. He was transferred to our ED due to living nearby. Antibiotic treatment with Flumarin was given and his fever was subsided. However, stool occult blood revaled 3+ then add PPI for prevent gastric ulcer. He was discharged after one week of treatment. PES and colonoscopy were arranged and cecal tumor with lumen obstruction at 130cm AAV was noted. Tracing back his clinical symptom and sign, he had abdominal fullness and decreased appetite. No body weight loss of bloody/tarry stool was noted.
    • The pathology disclosed adnocarcinoma of cecum. Therefore, he was referred to CRS OPD and surgical intervention was recommanded. After knowning the benefits and the risks of the operation, he was admitted to our ward for right hemicolectomy.
  • Course of inpatient treatment
    • The patient was admitted to our ward after finishing the pre-op assessments. The COVID-19 rapid test showed negative result. Mild anemia was found in hemogram. Other data were within normal limits. He received right hemicolectomy on 110-05-18 uneventfully. (1) Cecal cancer with obstruction, (2) anastomosis by GIA 75/4.8mm x2, and (3) One jp drain at pelvic area were noted intraoperatively. The patient tolerated the procedure well. He tried water and oral chewing on the operation day. Flatus and stool passage occurred on 110-05-20. Oral feeding with low residue soft diet was recruited then. The pathology showed cecal adenocarcinoma pT4aN2b(cM0) stageIIIC and we had applied Major Illness. Foley catheter and J-vac were removed smoothly during recovering course. Under a realtive stable clinical condition, he was discharged and OPD f/u will be arranged on 2021-05-31.
  • Discharge prescription
    • Meitifen (diclofenac 75mg) 1# PRNQD
    • MgO 250mg 2# BID
    • Acetal (acetaminophen 500mg) 1# QID
• 2021-04-10 ~ 2021-04-17 POMR General and Gastrointestinal Surgery Zhang JianHui
  • Discharge diagnosis
    • Acute appendicitis with perforation and tumor formation
    • Anemia
  • CC
    • RLQ abdominal pain for 1 week.
  • Present illness
    • This 64 years old male who denied systemic or surgic history presented with RLQ abdominal pain for 1 week. At the second day, he went to local clinics with 3-day antibiotics and analgesics and condition much improved, But 2 days after the pain progressively recurred. Today when he traveled to ChangHua, fever and RLQ pain were noted and came to ChangHua Christian Hospital diagnosed with acute appendicitis by CT then transferred to our ED due to living nearby.
    • Arrived ER, vital sign TPR: 36.5/100/19, BP:152/96mmHg, clear of consciousness. Physical examination showed abdomen soft and flat, RLQ tenderness, no rebound tenderness, no muscle guarding. Under the impression of acute appendicitis with perforation and tumor formation, GS doctor was consulted who suggest admitted for antibiotic treatment and further care.
  • Course of inpatient treatment
    • After admission, Blood examination was done that revealed leukocytosis and Anemia, then antibiotic with Flumarin was given. We check stool occult blood revaled 3+ then add PPI for prevent gastric ulcer. After improved of condition and lab data. He was discharged today and take medication with antibiotic and PPI. He will be follow up at GS and GI OPD.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNTID
    • MgO 250mg 1# TID
    • Pariet (rabeprazole 20mg) 1# QDAC stool OB 3+
    • Cinolone (ciprofloxacin 250mg) 2# BIDAC
    • Through (sennoside 12mg) 1# PRNHS
• 2021-04-10 SOAP Medical Emergency He YaoCan
  • Diagnosis:
    • K35.80 Unspecified acute appendicitis
  • Prescription:
    • Lifoxitin (cefoxitin 1g/vial) 1 ST IVD
    • NS 500mL ST IVD

[surgical operation]

• 2022-12-14
  • Surgery
    • Right ureteral catheterization
  • Finding
    • High bladder neck
    • No gross bladder tumor in the urinary bladder
    • A 6Fr. ureteral catheter inserted into right ureter
• 2022-12-14
  • Surgery
    • Resection of retroperitoneal tumor, small bowel resection with anastomosis    
  • Finding
    • Retroperitoneal tumor with dense invaded to right testicular vessel and small bowel mesentery, close to right ureter (Right RP was inserted)
    • Iatrogenic small bowel perforation due to enterolysis and dense adhesion
• 2021-05-18
  • Surgery
    • Right hemicolectomy        
  • Finding
    • Cecal cancer with obstruction
    • Anastomosis by GIA 75/4.8mm x2
    • One jp drain at pelvic area

[chemotherapy]

• 2023-11-09 A-FOLFIRI He JingLiang

• 2023-10-19 A-FOLFIRI He JingLiang

• 2023-09-22 A-FOLFIRI He JingLiang

• 2023-09-01 A-FOLFIRI He JingLiang

• 2023-08-07 A-FOLFIRI He JingLiang

• 2023-07-24 A-FOLFIRI He JingLiang

• 2023-07-06 A-FOLFIRI He JingLiang

• 2023-06-15 A-FOLFIRI He JingLiang

• 2023-05-19 A-FOLFIRI Wan XiangLin

• 2023-05-05 A-FOLFIRI Wan XiangLin

• 2023-04-07 A-FOLFIRI Wan XiangLin

• 2023-03-20 A-FOLFIRI Wan XiangLin

• 2023-03-03 FOLFIRI Wan XiangLin

• 2023-02-14 FOLFIRI Zhang ShouYi

• 2022-12-27 FOLFIRI Zhang ShouYi

• 2021-10-28 XELOX Xiao GuangHong

• 2021-10-07 XELOX Xiao GuangHong

• 2021-09-16 XELOX Xiao GuangHong

• 2021-08-26 XELOX Xiao GuangHong

• 2021-08-05 XELOX Xiao GuangHong

• 2021-07-15 XELOX Xiao GuangHong

• 2021-06-24 XELOX Xiao GuangHong

• 2021-06-03 XELOX Xiao GuangHong

Medication

• UFT

700130863

231110

{S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019-09-11 s/p post-Op adjuvant chemotherapy FOLFOX finishing in 2020-04 with periotneal seeding s/p laparoscope rt diaphram tumor excision 2021-06-09}

[past history]

• Left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch

• Gastric polyp, body s/p biopsy (biopsy: Hyperplastic polyp) in 2019/08

• past operation

  • S/P ovarian cystectomy 30+ years ago
  • S/P tubal ligation surgery 30+ years ago

• double cancer

  • Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11.
  • RUL cancer, adenocarcinoma,pT1NoMi(cMx), stage IA1 if cM0, status post 3D VATS RUL lobectomy + RLND on 2019/09/30.
  • Left port-a implantation was done on 2019/10/07.
  • Lung, right upper lobe, lobectomy 2019/09/11 pathology showed minimally invasive adenocarcinoma, pT1miN0(cMx), Stage IA1 if cM0.

[lab data]

• 2021-07-19 All-RAS mutations assay
  • S2021-8200
  • There was no variant detected in the KRAS/NRAS gene.
• 2021-06-30 BRAF mutations assay
  • S2021-08200
  • There was no variant detected in the BRAF gene.
• 2021-06-25 EGFR
  • S2021-08200
  • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen.
• 2021-06-29 Anti-HBc Reactive
  
• 2021-06-29 Anti-HBc-Value 1.89 S/CO
  
• 2021-06-10 Anti-HBs 33.61 mIU/mL
  
• 2021-06-10 HBsAg Nonreactive
  
• 2021-06-10 HBsAg (Value) 0.40 S/CO
  
• 2021-06-10 Anti-HCV Nonreactive
  
• 2021-06-10 Anti-HCV Value 0.22 S/CO

[exam findings]

• 2023-09-25 KUB
  • Contrast medium in collecting system
  • L2 pathologic fracture
• 2023-09-25 CXR
  • Right apical pleural thickening
  • A pathologic fracture of L2
• 2023-09-25 CT - abdomen
  • Indication: Sigmoid cancer with peritoneal carcinomatosis
  • Abdominal CT with and without enhancement revealed:
    • Low density lesions are found at S7/8 of liver measuring 2.46cm, S5/6 measuring 1.86cm and S2 measuring 1.97cm in largest dimension. In comparison with CT dated on 2023-06-21, these nodules are new. Liver meta is considered.
    • Several soft tissue nodules are found in the peritoneal space, peritoneal seeding is considered. In enlargement.
    • Wall thickening at rectum is found. Stable.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • s/p double J catheter placement at both sides.
    • s/p right upper lobe lobectomy.
    • S/p port-A placement with its tip at Superior vena cava.
    • Loculated effusion at right apical lung is found.
  • Imp:
    • rectal cancer with peritoneal tumor seeding, in progression. New liver meta and bone meta.
• 2023-08-02 KUB
  • S/P double J catheter insertion in place, both sides.
  • Lumbar spondylosis.
• 2023-08-01 ECG
  • Normal sinus rhythm
  • Left anterior fascicular block
• 2023-06-21 CT - abdomen
  • History:
    • 20190902 CT: S-colon cancer, cT3N2aM0 s/p LAR n 2019/09/11 s/p post-Op adjuvant C/T wt FOLFOX finishing in 2020/04,
    • 20190826 CT: lung: an irregular GGO 16 mm with central solid component 5mm in RUL. path: Minimal invasive adenocarcinoma, pT1miNoMo, pStage:IA1
    • 20210531 CT: Multiple metastases at peritoneal cavity.
    • 20211203 CT: Omentum metastases S/P C/T show stable disease.
  • FINDINGS: Comparison prior CT dated 2023/03/29.
    • Prior CT identified an enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion 1.1 cm is noted again, mild increasing in size to 1.5 cm.
      • Tumor seeding S/P C/T with stable disease is highly suspected.
    • S/P LAR with autosuture retention over the sigmoid colon.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
    • Liver and renal cysts (up to 2.4cm).
      • S/P double J catheter insertion, right and left side urinary tract.
      • There are marked bilateral hydroureteronephrosis.
      • Please correlate with retrograde pyelography.
    • There is no focal lesion in mediastinum.
      • There is a lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
      • please correlate with clinical history.
  • IMP:
    • Tumor seeding in the rectum S/P C/T show stable disease. please correlate with clinical condition.
    • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
    • There are marked bilateral hydroureteronephrosis. Please correlate with retrograde pyelography.
• 2023-05-30 CXR
  • Prior plain chest film identified Patchy opacity projecting at right apical lung with lung volume decrease is noted again, stationary.
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2023-03-29 CT - abdomen
  • FINDINGS: Comparison prior CT dated 2022/12/28.
    • Prior CT identified an enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion is noted again, marked decreasing in size to 1.1 cm.
      • Tumor seeding S/P C/T with stable disease is highly suspected.
    • S/P LAR with autosuture retention over the sigmoid colon.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
    • Liver and renal cysts (up to 2.4cm).
    • There is no focal lesion in mediastinum.
      • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
      • please correlate with clinical history.
    • Others
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen.
      • There is no ascites or lymphadenopathy.
      • There is no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
  • IMP:
    • Tumor seeding in the rectum S/P C/T show stable disease. please correlate with clinical condition.
    • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
• 2023-01-30 PET
  • Glucose-hypermetabolism lesions in the perirectal region and in bilateral inguinal lymph nodes are new compared with the previous study on 2021-05-17, the nature is to be determined, suggesting biopsy for investigation.
    
  • Glucose-hypermetabolism in bilateral mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes, probably reactive nodes.
    
  • Glucose-hypermetabolism in the left adrenal region, probably benign or malignant tumor of the left adrenal gland.
    
  • Increased FDG accumulation in the left kidney and ureter, suggesting left GU tract obstruction (resulting from perirectal tumor ?).
    
  • A glucose hypometabolism lesion in the right upper lung, compatible with right lung cancer s/p treatment.
• 2023-01-12 Sigmoidoscopy
  • Left lateral rectal wall scar , suspect extrarectal tumor with regression
• 2023-01-09 KUB
  • S/P double J catheter insertion in place, left side.
  • Non-specific bowel gas pattern.
  • Calcifications in LUQ, r/o left renal stones.
  • Lumbar spondylosis.
• 2023-01-09 Body fluid cytology - urine
  • Atypia, favor reactive change
  • Smears show lymphocytes, crystals and instrument-associated cellular urothelial clusters with mild nuclear atypia and crush artifact, favor reactive atypia and less likely a neoplasm. Follow up.
• 2023-01-05 ECG
  • Normal sinus rhythm
  • S1-S2-S3 pattern, consider pulmonary disease, RVH, or normal variant
  • Left anterior fascicular block
  • Abnormal ECG
• 2022-12-28 CT - abdomen
  • FINDINGS: Comparison prior CT dated 2022/06/10.
    • Prior CT identified a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion is noted again, marked decreasing in size and poor margination.
      • Tumor seeding S/P C/T with partial response is highly suspected.
    • S/P LAR with autosuture retention over the sigmoid colon.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
    • Liver and renal cysts (up to 2.4cm).
    • There is no focal lesion in mediastinum.
      • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
      • please correlate with clinical history.
  • IMP:
    • Tumor seeding in the rectum S/P C/T show partial response. please correlate with clinical condition.
    • Multiple omentum metastases S/P C/T show stable disease.
• 2022-10-27, -03-21 Anoscopy
  • Mixed hemorrhoid and posterior fissure
• 2022-09-29 CT - abdomen
  • History and indication: Sigmoid cancer with peritoneal seeding and local recurrence s/p OP, s/p R/T, s/p C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Mild regression of peritoneal seeding.
    • Liver and renal cysts (up to 2.4cm).
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • Mild regression of peritoneal seeding.
• 2022-09-23, -09-21 KUB
  • Fecal material store in the colon.
  • S/P LAR with autosuture retention over the sigmoid colon.
• 2022-09-03 Foot Lt
  • left 5th metatarsal neck fracture
  • Acceptable alignment with few callus
• 2022-06-10 CT - abdomen
  • FINDINGS: Comparison prior CT dated 2022/03/11.
    • There is a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion, measuring 3.2 x 2.1 cm in size (Srs:7 Img:115) .
      • Tumor seeding is highly suspected.
      • The differential diagnosis include rectal cancer.
    • S/P LAR with autosuture retention over the sigmoid colon.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
    • Liver and renal cysts (up to 2.4cm).
    • There is no focal lesion in mediastinum.
      • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
      • please correlate with clinical history.
  • IMP:
    • Tumor seeding in left lateral anterior aspect of the rectum with left uterine cervix and vaignal invasion is suspected.
      • The differential diagnosis include rectal cancer. please correlate with clinical condition.
    • Multiple omentum metastases S/P C/T show stable disease.
• 2022-03-20 CXR
  • Opacification of right apical lung.
• 2022-03-20 KUB
  • Presence of ileus.
  • Degeneration and spondylosis of L-S spine.
• 2022-03-20 ECG
  • Normal sinus rhythm
  • Left anterior fascicular block
• 2022-03-11 CT - abdomen
  • FINDINGS: Comparison prior CT dated 2021/12/03.
    • S/P LAR with autosuture retention over the sigmoid colon.
    • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
    • Liver and renal cysts (up to 2.4cm).
    • There is no focal lesion in mediastinum.
      • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
      • please correlate with clinical history.
  • IMP:
    • Multiple omentum metastases S/P C/T show stable disease.
• 2021-12-23 Nasopharyngoscopy
  • Findings: smooth NPx, oropharynx, hypopharynx; bloody crust coating over right inferior and bilateral middle turbinates.
  • Conclusion: epistaxis, no nasal or nasopharynx tumor found
• 2021-12-16, -10-07 CXR
  • Patchy opacity projecting at right apical lung with lung volume decrease was noted. Please correlate with CT.
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2021-12-03 CT - abdomen
  • FINDINGS: Comparison prior CT dated 2021/09/03.
    • S/P LAR with autosuture retention over the sigmoid colon.
    • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild decreasing in size (up to 1.5cm, srs:302, img:73,75,79,83,87,90,93,96,98,101).
    • Prior CT identified a mixed soft tissue and fat lesion in left upper pelvis wall is not noted in the current CT.
    • Liver and renal cysts (up to 2.4cm).
    • There is no focal lesion in mediastinum.
      • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
      • please correlate with clinical history.
  • IMP:
    • Multiple omentum metastases S/P C/T show stable disease.
• 2021-09-03 CT - abdomen
  • FINDINGS:
    • S/P LAR with autosuture retention over the sigmoid colon.
    • Multiple soft tissue nodules in the omentum are noted that are compatible with omentum metastases (up to 1.9cm, srs:301, img:71,74,78,85,89,91,95).
    • There is a mixed soft tissue and fat lesion in left upper pelvis wall (Srs:301 Img:82) that may be tumor seeding or post-operative change.
    • Liver and renal cysts (up to 2.4cm).
  • IMP:
    • Multiple omentum metastases S/P C/T show stable disease.
    • Metastasis or post-operative change in left upper pelic wall ?
• 2021-06-09 Patho - colon ca s/p at 2018 with intraabd recurrent, including bilat diaphragm, T-colon stomach surface and rt liver surface
  • Tumor, R’t diaphragm, biopsy - Metastatic colonic adenocarcinoma
  • IHC: CK7(-), CK20(+), CDX2(+) and TTF-1(-) for tumor.
  • IHC: EGFR (+, weakly); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+)
  • According to clinical information and above histopathologic findings, it indicated a case of metastatic colonic adenocarcinoma.
• 2021-05-31 CT - whole abdomen, pelvis
  • S/P colon operation. Multiple metastases at peritoneal cavity.
• 2021-05-17 Whole body PET scan
  • Glucose-hypermetabolism in the right mediastinal lymph nodes, probably recurrent lung cancer with regional lymph nodes involvement.
    
  • Glucose-hypermetabolism in the left mediastinal lymph nodes and left pulmonary hilar lymph nodes, probably reactive nodes or recurrent lung cancer with regional lymph nodes involvement.
    
  • Glucose-hypermetabolism in bilateral adrenal regions, probably recurrent lung cancer with bilateral adrenal glands metastases.
  • Glucose-hypermetabolism in peritoneal lymph nodes in the epigastric region, right hypochondriac region, and bilateral lumbar regions of abdomen, probably recurrent colon cancer with peritoneal metastases.
    
  • S-colon cancer s/p treatment with tumor recurrence, rcTxNxM1c, stage IVC (AJCC 8th ed.); right lung cancer s/p treatment with tumor recurrence, rcTxN2-3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2021-05-14 MRI - MR Cholangiography (MRCP)
  • Multiple cysts on both hepatic lobes.
• 2019-08-26 CT - lung cancer screening (Low-dose CT)
  • RUL lung cancer TmiNOMO stage IA1
• 2019-10-09 Patho - Uterus, cervix, biopsy
  • Chronic cervicitis with reactive aypia
  • IHC, the epithelial cells are negative for p16 and ki-67 proliferation index <5%.
• 2019-10-01 Patho - Lung, right upper lobe, lobectomy
  • Minimally invasive adenocarcinoma
    
  • Lymph nodes, group 2+4, 7, 11; RLND - No metastatic carcinoma
    
  • pTNM Pathology stage: pT1miN0(cMx), Stage IA1 if cM0
• 2019-09-12 Patho - Malignant sigmoid colon neoplasm
  • Sigmoid colon, LAR - Adenocarcinoma, moderately differentiated
  • Lymph node, mesocolic, dissection - Positive for tumor metastasis (4/16) with extracapsular extension (3/4)
  • AJCC pathologic stage - pT4bN2aMx, stage IIIC at least
• 2019-09-02 CT - liver, spleen, biliary duct
  • T3N2aMx
• 2019-08-29 Whole body PET scan
  • A glucose hypermetabolic lesion in the sigmoid colon, compatible with colon malignancy.
  • A faint glucose hypermetabolic lesion in the upper lobe of right lung. The nature is to be determined.
  • Glucose hypermetabolism in the right pulmonary hilar region. The nature is to be determined.
  • Mild glucose hypermetabolism in the left lobe of the thyroid gland.
• 2019-08-26 Patho - colon, sigmoid or rectosigmoid junction, biopsy
  • Ademocarcinoma
  • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).

[MedRec]

• 2023-10-19, -07-20, -04-11, -01-17 SOAP Psychosomatic Medicine Li JiaFu
  • Diagnosis
    • F32.1 - Major Depressive Disorder, Single Episode, Moderate
    • G47.00 - Insomnia, Unspecified
  • Prescription x3
    • Lexapro (escitalopram 10mg) 0.5# QN
    • Mirtapine Orally Disintegrating (mirtazapine 30mg) 1# QN
• 2023-10-17 SOAP Hemato-Oncology Xia HeXiong
  • P: Already provide two options:
    • TAS-102 plus self-pay bevacizumab -> Favored by patient and family
    • Regorafenib
    • Trial
  • Prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Stogamet (cimetidine 300mg) 1# BID
• 2023-09-05 SOAP Hemato-Oncology Xia HeXiong
  • Prescription
    • Xeloda (capecitabine 500mg) 2# BID 28D
    • Sinpharderm Cream (urea) BID TOPI
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Stogamet (cimetidine 300mg) 1# BID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# HS
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
• 2023-04-06 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • Because the maximal effect of Erbitux-FOLFIRI is achieved based on the findings of CT on 2023-03-29, oral C/T is suggested on 2023-04-06.
  • Prescription
    • Xeloda (capecitabine 500mg) 2# BID 28D
    • Sinpharderm Cream (urea) BID TOPI
• 2019-09-29 ~ 2019-10-08 POMR Thoracic Surgery Xie MinXiao
  • Discharge diagnosis
    • C34.91 - Minimally invasive adenocarcinoma of lung ove right upper lobe status post three dimensional video-assisted thoracic surgery right upper lobectomy and radical lymph node dissection on 2019/09/30, pT1miN0M0, Stage IA1.
    • C18.7 - Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11
  • CC
    • Abnormal findings were noted on CT during health exam
  • Present illness
    • This 76 years old famale patient has history of
      • Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11
      • left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch
      • s/p ovarian cystectomy
      • s/p tubal ligation surgery 30+ years ago.
    • This time, she had been received health examination and the chest CT revealed RUL part solid nodule (about 16 mm), seems stationary as compared with CT on 2018/08/15, favors malignant nodule. Whole body PET scan revealed glucose hypermetabolic lesion in the sigmoid colon, upper lobe of right lung, right pulmonary hilar region. She was referred to our CRS OPD (Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 was dignosed, status post laparoscopic anterior resection and enterolysis on 2019/09/11) and CS OPD for further evaluation and primary lung cancer was impressed. After discussing with the patient and her family on the benefits of surgical treatment as well as subsequent risks and possible complications, she was admitted for VATS RUL lobectomy + RLND.
  • Course of inpatient treatment
    • After admission, pre-op assessment was done. Operation of 3D VATS RUL lobectomy and RLND was performed smoothly on 2019/09/30. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Right chest tube with free drainage was done due to mild air leak. Chest tube was removed and left port-a implantation was done on 2019/10/07. We also consulted hemo-onlcologist and radiation-oncologist for further treatment. She was discharged under stable hemodynamics on 2019/10/08. CT simulation will be arranged on 2019/10/09 and treatment will be started 4-5 days later. She will be admitted to hemo-onlcology ward for adjuvant chemotherpay on 2019/10/15.
  • Discharge prescription
    • Bafen (baclofen 5mg) 1# Q12H
    • Mopride (mosapride citrate) 1# TID Zofran (ondansetron 8mg) 1# QD
• 2019-09-10 ~ 2019-09-16 POMR Colorectal Surgery Xiao GuangHong
  • Discharge diagnosis
    • C18.7 - Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis
    • J98.4 - Part solid nodule (about 16 mm) in right upper lobe, suspect primary lung cancer
  • CC
    • admission for surgical treatment of sigmoid cancer with partial obstruction, cT3N2aM0
    • intermittent upper abdominal fullness and had passage of bloody stool twice in 2019/08.
  • Present illness
    • This 76 years old famale patient has history of left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch; and s/p ovarian cystectomy and s/p tubal ligation surgery 30+ years ago.
    • This time, she had been received health examination and colonscopy showed colon Ca, sigmoid colon or rectosigmoid junction with stenosis s/p biopsy; mixed hemorrhoid on 2019/08/26. The biopsy proved adenocarcinoma. She also complained of intermittent upper abdominal fullness and had passage of bloody stool twice in 2019/08. The lund CT revealed RUL part solid nodule (about 16 mm), seems stationary as compared with CT on 2018/08/15, favors malignant nodule. Whole body PET scan revealed glucose hypermetabolic lesion in the sigmoid colon, upper lobe of right lung, right pulmonary hilar region. She was referred to our CRS OPD and CS OPD for further evaluation and primary lung cancer was impressed. Arrange abdominal CT revealed S-colon cancer, cstage T3N2aMx on 2019/09/02. Surgical treatment of 3D laparoscopic LAR was suggested. After fully explaination, she was admitted to our ward for preoperative preparation and surgical treatment.
  • Course of inpatient treatment
    • After admission with ward routine and blood examination were done. Operation of laparoscopic anterior resection and enterolysis under general anesthesia were performed on 2019/09/11. NPO and IV fluids support; analgesics treatment for pain relief. Nausea with vomit were noted post op day and improved after IV fluids hydration and medications by Novamin were treated. The wound healing well and no erythema change. Chewing cookies, toast, rice with gum was started at op day. No nausea and no vomiting, flatus passage. Try eat semi-liquid diet at post-op day 2 with tolerance and then on low residual diet was started at post-op day 3. Well bowel movement and stools passage (+) with diet well tolerated. No fever and no complication. Removal of JP drain at post-op day 3. Discharged in general condition stable on 108/09/16 and will follow up in our out-patient department next week. Suspected primary lung cancer by lund CT and whole body PET scan result; she will further evaluation and treatment at CS OPD.
  • Discharge diagnosis
    • Lactam (acetaminophen 500mg) 1# PRNQ6H
• 2017-02-21 SOAP Gastroenterology Lin XianHong
  • Diagnosis
    • Pure hypercholesterolemia [E78.0]
    • Dyspepsia & other specified disorders of function of stomach [K30]
  • Prescription x3
    • Dexilant (dexlansoprazole 60mg) 1# QDAC

[consultation]

• 2022-12-10 Dermatology
  • Q
    • This 80-year-old woman patient is a case of S-colon cancer, cT3N2aM0, stage IVC s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy with FOLFOX finishing in 2020/04 with periotneal seeding s/p laparoscope right diaphram tumor excision on 2021/06/09 s/p palliative chemotherapy with FOLFIRI from 2021/07/01~2022/07/27 and Avastin from 2021/10/08~2022/07/27 with tumor seeding in left lateral anterior aspect of the rectum with left uterine cervix and vaignal invasion s/p radiotherapy to anal tumor s/p palliative chemotherapy with Erbitux/FOLFIRI from 2022/09/08. She was adnmitted for chemotheraopy with Erbitux/FOLFIRI(C4D1).
    • This time, for right thumb nail gap redness, swelling with pain, suspected paronychia.
  • A
    • This patient suffered from dyskeratotic nails for months and erytheamtous patches for days
    • Imp:
      • Tinea unguim
      • Asteatotic dermatitis
    • Suggestion:
      • Excelderm solution (sulconazole) x 4 BT/Bid
      • Mycomb (nystatin, neomycin, triamcinolone acetonide, gramicidin) x 4 tubes/bid
• 2022-08-27 Psychosomatic Medicine
  • Q
    • This 79-year-old woman patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy wt FOLFOX finishing in 2020/04 with periotneal seeding s/p laparoscope rt diaphram tumor excision on 2021/06/09. He was admitted for palliative chemotherapy. This time, for depression, anxiety. Now, for evaluate drug therapy. Thank you.   
  • A
    • This 79-year-old woman, our YiDe Mama. She was diagnosed as colon cancer in 2018. She could tried hard to cope with it, untill 2021/5, she developed RLQ pain and exams revealed relapse and metastesis of cancer. She started to develop low and anxious mood, unspokable distress, lack of pleasure and poor appetite, and rumination of negative thoughts. Psychiatrist was consulted in 2021/11 and she also started a conseling with onco-psychologist. The mood condition has been partially improved under mirtazapine 30mg 1# HS, however she still percieved low and tense mood (invisible stress all day), lack of appetite, preoccupation on the somatic distress, ruminated thoughts about the intrafamilial issue (worried that her daughters will not get along well), some demoralize feelings about treatment (she feels that chemotherapy is a long way off, and there is no hope). She tried to cope with walking outside with daughter and watching TV show but lack of true pleasure.
    • She denied obvious impairment on cognitive function, denied sleep problem nor suicidal ideation.
    • MSE: Low and anxious mood, inner tension, ruminated and negative thoughts, hopelessness and demoralized feelings. lack of pleasure and motivation.
    • IMP: Depressive disorder
      • suspected Adjustment disorder with depressive mood
    • Suggestion:
      • Keep mirtazapine 30mg 1# HS.
      • Add sulpiride 50mg 1# HS for adjuctive therapy of depression.
      • Carthasis and empathy. Psychoeducation to the family and the patient.
      • Arrange PSY OPD follow up.
• 2021-11-18 Mental Health
  • Clinical impression:
    • Depressive disorder
    • Adjusment disorder
  • Clinical course:
    • This 78-year-old female patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis s/p post-Op C/T with periotneal seeding s/p laparoscope rt diaphram tumor excision. She was admitted for chemotherapy with Avastin/FOLFIRI(C5D1).
    • We were consult for depressed mood and poor appetite.
    • According to past medical record, during admission in July for chemotherapy, psychiatric department was consulted once for panic symptoms, but no further OPD follow up.
    • At bedside, the patient is conscious clear, lying on the bed resting, with her daugher at the bedside. She started to percieved dysphoric and low mood since she was diagnosed with cancer on 2018, but she tried hard to modify her mindset and cope with the distress, and able to maintain acceptable mood. Until this year 2021-05, she suffered from right lower abdominal pain, and PET scan found metastatis of the cancer, and started to recieved treatment again.
    • Recently, she noted that she began to be easily irritable and dysphoric, unspoken stressfulness feeling, high inner tention, decrease of reward sensation and low mood, decrease appetite, negative thoughts, sleep disturbance (poor maintainence, unstable), got worse in recnent 2 weeks.
    • She received psychotherapy in recent half year, feel better at first, but noticing unable to control now.
  • MSE:
    • Kempt, polite. Frowning and distressful look. Sometimes she smiles when talk about the people who support her so much.
    • Coherent and relevant speech, articulate
    • Fair attention lasting
    • Depressed mood, low drive and energy, fatigue
    • Ruminated thought
    • Denied hopeless or helplessness, denied suicide ideation
    • Poor appetite and insomnia
  • Suggestion:
    • Psychoeducaiton and emotional support
    • Add mirtapine (30) 1#HS for depressive mood, enhacing appetite. Eurodin 1#HS for insomnia
    • Arrange psychiatric OPD follow up
• 2021-07-20 Mental Health
  • Psychiatric impression:
    • Panic attack
    • Suspected anxiety disorder
  • Psychiatric history:
    • This 78-year-old female patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy (FOLFOX) finishing in 2020/04 and peritoneal seeding s/p laparoscope Rt. diaphragm tumor excision 2021/06/09. Palliative chemotherapy with FOLFIRI(Campto 90mg/m2, LV 400mg/m2, 5FU 2400mg/m2)(C1D15) was done during 2021/07/15~2021/07/17. We were consult for anxiety. According to the patient, she suffered from episodic chest tightness, dizziness, general weakness, tremors and feeling loss of control since early July. She also perceived low mood and negative thinking intermittently for several weeks. During this admission, frequent experience of chest tightness, hands tremor, limb numbness and parathesia (hot and cold sensation). She feeling frustration form physical discomfort and these panic like symptoms.
  • MSE:
    • Coherent and relevant speech
    • Fair attention lasting
    • Depressed mood, low drive and energy, fatigue
    • Ruminated thought
    • Denied hopeless or helplessness, denied suicide ideation
    • Poor appetite and insomnia with terminal type under stilnox
  • Suggestion:
    • Psychoeducaiton and emotional support
    • Add mirtapine (30) 0.5mg HS
    • Arrange psychiatric OPD follow up
• 2021-06-09 Hemato-Oncology
  • Q
    • for chemotherapy
    • This is a 78y/o female with past history of 1) Adenocarcinoma of sigmoid colon with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11, s/p post-Op adjuvant C/T wt FOLFOX finishing in 2020/4; 2) Bilateral thyroid tumors status post bilateral thyroidectomy on May 26, 2020; 3) Minimal invasive adenocarcinoma of lung over RUL, s/p VATS segmentectomy + RLND, pT1miN0M0, stage IA1 on 2019/09/30; 4) s/p ovarian cystectomy; 5) s/p tubal ligation surgery 30+ years ago.
    • This time she was visited our OPD due to LLQ abdominal pain for about 3 months, which several examination were arranged, MRI on 5/14 showed multiple cysts on both hepatic lobes;
    • Whole body PET scan on 5/18 revealed 1. Glucose-hypermetabolism in the right mediastinal lymph nodes, probably recurrent lung cancer with regional lymph nodes involvement. 2. Glucose-hypermetabolism in the left mediastinal lymph nodes and left pulmonary hilar lymph nodes, probably reactive nodes or recurrent lung cancer with regional lymph nodes involvement. 3. Glucose-hypermetabolism in bilateral adrenal regions, probably recurrent lung cancer with bilateral adrenal glands metastases. 4. Glucose-hypermetabolism in peritoneal lymph nodes in the epigastric region, right hypochondriac region, and bilateral lumbar regions of abdomen, probably recurrent colon cancer with peritoneal metastases. 5. S-colon cancer s/p treatment with tumor recurrence, rcTxNxM1c, stage IVC (AJCC 8th ed.); right lung cancer s/p treatment with tumor recurrence, rcTxN2-3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
    • Abdominal CT on 5/31 showed Multiple metastases (up to 2.4cm) at peritoneal cavity. Therefore under impression of multiple tumor recurrance and metastases, she was admitted to GS ward on 6/3.
    • She received operation with laparoscopic and showed multiple tumor seedind was noted right diaphragm (2) and right liver surface, gasric antrum surface(1), left diaphragm (2). T-colon (3) left lower quadrant (1), PCI: 9/39 and liver metas was noted. So further percedure with laparoscope right diaphram tumor excision and HIPEC with Oxalip 300mg/M2(408mg) for 60mins was processed successfully on 6/9. We need your help for further chemotherapy evaluation of 5FU since 6/10. Thanks for your time!!
  • A
    • Patient examined and Chart reviewed. A case of sigmoid colon cancwer is noted. I am conslted for further management.
    • My suggestions would be:
      • Please prescribe the 5-FU as follows: 5-FU 1200 mg/m2 NS 500 mL IVD 24 hours for 2 days, LV 120 mg/m2 in NS 500 mL IVD 24 hours for 2days.
      • Please arrange my OPD appointment after being discharged.
      • Any issue, please let me know.
• 2020-03-30 Colorectal Surgery
  • Q
    • This 77 years old famale patient has history denocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 108/09/11 (Bloody stool on 108/8) under chemotherapy as FOLFOX. Due to hemorrhoid with bleeding bother her, so we need your help for management.
  • A
    • We had visited the patient that she was a case of mild mixed hemorrhoids.
    • PE:
      • No induration, no redness, no perianal pain
      • No palpable mass around low rectum, no obvious bloody clot on gloves
    • IMP:
      • Mild mixed hemorrhoids, no obvious external hemorrhoid
    • Suggest:
      • Alcos-anal ointment was considered
      • Change habit of stool passage
      • Education about sitz bath and have more water/fiber food
      • Arrange CRS OPD if she still have hemorrhoidal problems

[surgical operation]

• 2023-01-09
  • Surgery
    • Ureterorenoscopic exam & double-J stenting (tumor stent), left.        
  • Finding
    • Left lower and upper ureter stricture and kinking.
• 2021-06-09
  • Surgery
    • Laparoscope rt diaphram tumor excision
    • HIPEC with oxalip 300mg/m2 for 60 mins
  • Finding
    • right diaphragm (2) and right liver surface
    • gasric antrum surface (1), left diaphragm (2). T-colon (3) left lower quadrant (1)
    • PCI: 9/39 and liver mets
    • ascite: nil
• 2020-05-26
  • Surgery
    • L’t lobectomy + right partial thyroidectomy
  • Finding
    • enlargement of left thyroid gland with multiple goiter lesions and trachea deviation noted
    • some goiter lesions over right thyroid gland also noted
• 2019-09-30 Thoracoscopic Lobectomy
• 2019-09-11 Laparoscopic anterior resection and anastomosis, sigmoid colon resection, tumor

[radiotherapy]

[immunochemotherapy]

• 2023-03-24 - cetuximab 500mg/m2 500mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-08 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-24 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-06 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-13 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-09 - irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-25 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-07 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-07 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-09-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-09-08 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-08-26 - irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-08-12 - irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-07-27 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-07-15 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-06-29 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-06-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-06-01 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-05-20 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-05-06 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-04-24 - irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-04-08 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-03-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-03-11 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-02-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-02-07 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-01-14 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-12-30 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-12-15 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-12-03 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-11-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-11-05 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-10-22 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 175mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-10-08 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-09-20 - irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-09-03 - irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
• 2021-08-20 - irinotecan 120mg/m2 140mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
• 2021-07-15 - irinotecan 120mg/m2 140mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
• 2021-07-01 - irinotecan 90mg/m2 120mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
• 2021-06-10 - leucovorin 120mg/m2 165mg 24hr D1-2 + 5-Fu 1200mg/m2 1635mg 24hr D1-2
• 2021-06-09 - oxaliplatin 300mg/m2 408mg 90min
• 2021-04-13 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
• 2021-03-30 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
• 2021-03-16 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
• 2021-03-02 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
• 2021-02-14 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
• 2021-01-31 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
• 2021-01-09 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

==========

2023-11-10

[Lonsurf combination therapy for mCRC: dosage considerations in patients with low BSA]

Both tumor markers CEA and CA199 trend upward in 2023.

• 2023-10-17 CEA 79.30 ng/mL

• 2023-09-05 CEA 34.28 ng/mL

• 2023-07-18 CEA 20.55 ng/mL

• 2023-05-30 CEA 12.06 ng/mL

• 2023-05-05 CEA 5.88 ng/mL

• 2023-04-03 CEA 4.42 ng/mL

• 2023-03-08 CEA 4.25 ng/mL

• 2023-01-31 CEA 3.12 ng/mL

• 2023-01-06 CEA 2.70 ng/mL

• 2023-10-17 CA199 389.11 U/mL

• 2023-09-05 CA199 69.02 U/mL

• 2023-07-18 CA199 71.84 U/mL

• 2023-05-30 CA199 60.36 U/mL

• 2023-05-05 CA199 56.00 U/mL

• 2023-04-03 CA199 82.57 U/mL

• 2023-03-08 CA199 85.56 U/mL

• 2023-01-31 CA199 83.54 U/mL

• 2023-01-06 CA199 69.10 U/mL

On 2023-10-17, at the patient’s Hemato-Oncology outpatient department visit, it was recorded that the patient and her family have opted for further treatment with TAS-102 (Lonsurf) along with bevacizumab, which they will be self-financing.

Lonsurf (two dosage combinations: trifluridine 15mg + tipiracil 7.065mg; trifluridine 20mg + tipiracil 9.42mg) is a temporary purchase item in our hospital currently.

Lonsurf combination therapy for patients with metastatic colorectal cancer: Oral 35 mg/m2/dose (based on the trifluridine component) twice daily on days 1 to 5 and days 8 to 12 of a 28-day cycle (in combination with bevacizumab; maximum per dose: trifluridine 80 mg); continue until disease progression or unacceptable toxicity.

The patient has a relatively low BSA. 2023-10-09 BH 150cm, BW 40.8kg -> BMI 18.1kg/m2, BSA 1.30m2.

Recommended trifluridine/tipiracil metastatic colorectal cancer dosagea according to the patient’s BSA will be 45mg (based on the trifluridine component) BID, i.e., [trifluridine 15mg + tipiracil 7.065mg] 3# BID.

2023-03-09

• The patient has been diagnosed with major depressive disorder and a sleep disorder and is currently receiving regular follow-up care from our psychologist. The medications Lexapro (escitalopram) and Mirtapine (mirtazapine) are appropriately added to her active drug list and there are no issues with reconciliation.
• Lab data showed that her TSH and T4 levels have been within the normal range for the past six months. Her hypothyroidism is being well-managed with a weekly dosage of 850ug of Eltroxin (levothyroxine).
• New glucose-hypermetabolism lesions detected in perirectal region and bilateral inguinal lymph nodes in 2023-01-30 PET scan. Nature of lesions unknown. In addition, the PET result also revealed that glucose-hypermetabolism has been detected in bilateral mediastinal and pulmonary hilar lymph nodes, which are likely reactive nodes. (The patient underwent a 3D VATS RUL lobectomy and RLND on 2019-09-30, for her adenocarcinoma in the RUL, which was classified as pT1NoMi(cMx), stage IA1 if cM0.)
• There are no issues with the current prescription.

2022-06-30

• CT images on 2022-06-10 showed a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vaginal invasion. A number of small soft tissue nodules were identified in the omentum (mets) and were still stable in size as compared to prior CTs under FOLFIRI (administered since 2021-07). Therefore, the newly developed lesion might be different from the original in some respects.

2022-06-02

• The patient received FOLFOX during 2020-01 to 2020-04 and has been receiving FOLFIRI since 2021-06 (plus bevacizumab since 2021-10).
• A time series of CT scans showed that the size of omentum mets stayed stable from 2021-09 to 2022-03-11 (most recent). The regimen is considered to be effective at keeping the disease stable.
• Hypothyroidism is still an active problem and Eltroxin (levothyroxine) can be found in recent PharmaCloud records. It is recommended that levothyroxine be prescribed as a self-carried item until the problem is resolved.

2022-03-11

• the last exam report is dated on 2021-12-23, no updated image; CEA, CA199 readings remain stable around 9ng/mL, 53U/mL, respectively; most WBC and CBC items and all the liver, kidney function tests (reported on 2022-03-09) were in normal range; the systolic blood pressure was slightly higher (159mmHg) at 13:14 2022-03-11.
• the underlying diseases are treated with the drugs in the current medication list without issue.

2022-02-08

• according to time-serial CT images, CEA, CA199 readings, the disease remains stable in recent months under current regimen.
• no drug allergy recorded in database, no issue found with active medication.

2021-08-13

[loss of appetite]

visiting the patient (with her daughter accompanied) at around 16:20 on 2021-08-13.

S:

• the patient does not feel like to eat these days.

O:

• poor appetite, not eat much.
• cachexia still in problem list.

A:

• chemo not applied yet since this hospitalization, not chemo induced poor appetite for sure, could be psychogenic.
  • psychological counselor had visited the patient on 2021-08-09.
• some appetite stimulant could be of help.

Suggestion

• Megejohn (megestrol 160mg/tab) PO QD could be an option to serve as appetite stimulant.
  • dronabinol and oxandrolone are not available in the hospital.

700171570

231109

[exam findings]

[MedRec]

• 2023-08-18 SOAP Cardiology Xie JianAn
  • Prescription x3
    • Xarelto (rivaroxaban 15mg) 1# QDCC
    • Ulstop (famotidine 20mg) 1# QD
    • Concor (bisoprolol 1.25mg) 1# QD
• 2023-08-05 ~ 2023-08-18 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of left ovary -> Debulking surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + bilateral paraaortic lymph node dissection + infracolic omentectomy + cytoreductive surgery) on 2023-08-07
    • Malignant neoplasm of right ovary
  • CC
    • Abdominal bloating since April this year.
  • Present illness
    • This is a 58 years old female, denied sexual experience before and menopaused at 53 years old, with underlying disease of
      • Ovarian cancer with carcinomatosis and multiple metastatic nodes, cT3N1 stage III at least, status post neoadjuvant chemotherapy with paclitaxel + carboplatin on 2023/05/22, 06/12, 07/04.
      • Right lower limbs deep vein thrombosis, under Rivaroxaban 1# QDCC PO since 2023/04/21 and CV OPD follow up.
    • According to the patient, she had noted abdominal bloating for 3 weeks since April 2023. She denied nausea, vomiting, tarry or bloody stool, dysuria, poor appetite, body weight loss or vaginal bleeding. She first went to our GI OPD for help. The KUB checked and showed much stool in the colon. The medication was used, but the symptoms had limited improvement.
    • She then revisited GI OPD and laboratory data on 2023/04/22 with elevated CEA 17.24 ng/mL and D-dimer 7318 ng/mL. Abdominal CT on 05/05 reported ascites and highly suspected ovarian cancer with carcinomatosis and multiple metastatic lymph nodes and one ill-defined mass over liver S4 that may be metastasis.
    • Therefore, she was transferred to our GYN OPD and the GYN sonography showed ascites and masses in pelvis (1) 128x76mm, RI: 0.67 and (2) 125x83mm. The CA125 found 782.1 U/mL and D-dimer dropped to 5085 ng/mL.
    • Acites with cell block on 05/16 showed positve for maligancy, favor ovarian origin [IHC stain — CK7(+), CK20(-), PAX8(+), WT-1(+)]. Bone scan on 05/19 showed negative for bone metastasis.
    • The tumor conference suggested chemotherapy for advanced ovarian cancer, she was admitted to HEMA ward with Port-A insertion on 05/19 and 3 courses of neoadjuvant chemotherapy with paclitaxel(175mg/m2) plus carboplatin (AUC:5, 600mg) were administered on 2023/05/22, 06/12, 07/04 respectively. Patient tolerated the chemotherapy.
    • For further management of her ovarian cancer with carcinomatosis and multiple metastatic nodes, cT3N1 stage III at least, she was admitted today to GYN ward for Debulking and HIPEC 2023/08/07.
  • Course of inpatient treatment
    • The surgical pathology revealed carcinosarcoma,pathology stage: ypT3cN1bM1b; FIGO IVB , right JP drain was removed then on 2023-08-17.
    • The Gyn tumor conference suggest further chemotherapy and radiotherapy for her after operation. self voiding was smooth. The vital sign was stable.
    • She is discharged on 2023-08-18 aftrenoon and her followup appointment is scheduled on next week.
  • Discharge prescription
    • naproxen 250mg 1# TID
    • MgO 250mg 2# QID
    • cephalexin 500mg 1# QID
    • Miyarisan BM (clostridium butyricum miyairi 40mg) 1# TID
    • Nexium (esomeprazole 40mg) 1# QDAC (relux esophagitis LA classification grade A 5/16 EGD)
    • Gaslan (dimethylpolysiloxane 40mg) 2# TID
    • Biomycin (neomycin, tyrothricin) BID TOPI

[consultation]

• 2023-08-05 Urology
  • Q
    • Currently, patient with good appetite and ambulation, she stopped anticoagulant on 7/31. Laboratory data with leukopenia (2.71x10^3/uL) due to chemotherapy and no other significant findings. We will arrange debulking on 8/7 followed by Tenckhoff tube insertion with HIPEC by VS Li ChaoShu.
    • We need your expertise on urinary catheter insertion for this patient.
  • A
    • We will arrange bilateral DBJ insertion on 08/07. Surgical consent has been signed and the purpose of the procedure has been explained to the patient.
• 2023-05-18 Hemato-Oncology
  • Q
    • This is a 58 y/o female suspect ovarian cancer with carcinomatosis and multiple metastatic lymph nodes and ascites cell block showed IHC stain — CK7(+), CK20(-), PAX8(+), WT-1(+) carcinomatosis. Under the impression of ovarian cancer stage III, the tumor conference suggest chemotherapy. She may need your help. Thank you!
  • A
    • We are consulted for neoajuvant chemotherapy.
    • We had discuss with patient about further neoajuvant cheomotherapy with paclitaxel and carboplatin. Patient agree with systemic chemotherapy after realizing the benefit and side effect of chemotherapy.
    • Please arrange port A insertion and check 24 urine CCR. Due to lower back pain, r/o bone meta, please arrange bone scan. In addition, we will take over this case.

[surgical operation]

• 2023-08-07
  • Operation
    • Excision of intraabdominal malignancy tumors
    • Omentectomy
    • Adhesionolysis
    • HIPEC
    • Tenckhoff tube insertion   - Finding:
    • Several scatted tumors in pelvic cavity and right paracolic gutter
    • PCI: total = 6
      • [##] region – score
      • [00] central – 0
      • [01] RU – 0
      • [02] epigastrium – 0
      • [03] LU – 0
      • [04] left flank – 0
      • [05] LL – 2
      • [06] pelvis – 2
      • [07] RL – 2
      • [08] right flank – 0
      • [09] upper jejunum – 0
      • [10] lower jejunum – 0
      • [11] upper ileum – 0
      • [12] lower ileum – 0
    • HIPEC regimen: Lipo-dox 30mg/m^2 + carboplatin AUC 5
    • Drain: 15 Fr J-VAC x2 in the pelvic cavity
    • HIPEC log    
• 2023-08-07
  • Op Method:
    • Diagnosis:
      • Ovarian cancer with carcinomatosis and multiple metastatic nodes, cT3N1 stage III at least, status post neoadjuvant chemotherapy with Taxol/Carboplatin x 3 cycles.
    • Operation:
      • Debulking surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + bilateral paraaortic lymph node dissection + infracolic omentectomy + cytoreductive surgery)   - Finding:
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder, peritoneum dut to tumor mass accupied. One cervical myoma, 7x5cm, intramural type was noted.
    • Adnexa:
      • LOV: 5x4 cm , capsule intact, with multi-cystic papillary tumor grow out from surface and invasion to posterior uterine wall , intra-op rupture(-)
      • ROV: 6x5 cm , capsule intact, capsule intact, with multi-cystic papillary tumor grow out from surface and invasion to posterior uterine wall, intra-op rupture(-)
      • Fallopian tube: bilateral grossly normal
    • CDS: invisible due to tumor mass occupied.
    • Ascites: bloody , about 50ml, washing cytology was done
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
    • Omentum: multiple hard, variablesized nodules (5~20 mm in diameter)
      • infracolic omentectomy was done.
    • Liver: grossly normal & smooth. Subdiaphragmatic surface: miliary tumor seeding(-)
    • Appendix: grossly normal.
    • Bladder: severe adhesion to anterior uterine wall, with several papillary tumor lesions over the bladder surface, s/p excision.
    • Other: Tumor seeding(+++); multiple papillary tumor lesions over sigmoid and descending colon,s/p excision.
    • Residual tumor: R0=no residual tumor; optimal debulking surgery was achieved.
    • Estimated blood loss:600ml
    • Blood transfusion:pRBC
    • Complication:   

[chemotherapy]

• 2023-11-09 - bevacizumab 7.5mg/m2 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-10-09 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 5 700mg NS 250mL 2hr + [docetaxel 30mg/m2 55mg + cisplatin 30mg/m2 55mg + gentamicin 40mg + NaHCO3 2800mg + NS 800mL] IP 1hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-09-18 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 4 500mg NS 250mL 2hr + [docetaxel 30mg/m2 54mg + cisplatin 30mg/m2 54mg + gentamicin 40mg + NaHCO3 2800mg + NS 800mL] IP 1hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

• 2023-08-28 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 4 500mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

• 2023-08-24 - bevacizumab 5mg/kg 600mg NS 500mL 90min (Avastin)

• 2023-08-07 - [liposome doxorubicin 30mg/m2 60mg D5W 250mL + carboplatin AUC 5 750mg NS 250mL] IP 90min (HIPEC)

• 2023-07-04 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 500mL + aprepitant 125mg PO D1-2

• 2023-06-12 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 500mL + aprepitant 125mg PO D1-2

• 2023-05-22 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 500mL + aprepitant 125mg PO D1-2

==========

2023-11-09

[sustained response to neoadjuvant and adjuvant therapy]

The patient underwent 3 cycles of paclitaxel and carboplatin neoadjuvant chemotherapy between 2023-05-22 and 2023-07-04. On 2023-08-07, she underwent surgery for ovarian cancer debulking, removal of intraabdominal malignant tumors, omentectomy, adhesiolysis, and HIPEC. Since then, she has received several cycles of paclitaxel and carboplatin adjuvant therapy. Both tumor markers, CA125 and CEA, continue to decrease, suggesting that the treatment is still effective.

• 2023-10-20 CA-125 (NM) 24.145 U/ml

• 2023-10-03 CA-125 (NM) 30.618 U/ml

• 2023-09-11 CA-125 (NM) 53.641 U/ml

• 2023-08-29 CA-125 (NM) 58.890 U/ml

• 2023-07-25 CA-125 (NM) 105.698 U/ml

• 2023-07-07 CA-125 (NM) 945.500 U/ml

• 2023-06-27 CA-125 (NM) 1417.280 U/ml

• 2023-06-06 CA-125 (NM) 1071.020 U/ml

• 2023-05-13 CA-125 782.100 U/mL

• 2023-10-20 CEA (NM) 6.433 ng/ml

• 2023-10-03 CEA (NM) 7.930 ng/ml

• 2023-09-11 CEA (NM) 9.771 ng/ml

• 2023-08-29 CEA (NM) 8.772 ng/ml

• 2023-07-25 CEA (NM) 74.188 ng/ml

• 2023-07-07 CEA (NM) 113.983 ng/ml

• 2023-06-27 CEA (NM) 95.131 ng/ml

• 2023-06-06 CEA (NM) 22.970 ng/ml

• 2023-04-22 CEA 17.240 ng/mL

2023-09-18

Based on the PharmaCloud database, our hospital has been the exclusive healthcare provider for this patient in the past three months. Additionally, according to HIS5 records, our cardiologist issued a repeat prescription on 2023-08-18, which included Xarelto (rivaroxaban), Ulstop (famotidine), and Concor (bisoprolol). All of these medications have been added to the active medication list, and there were no issues identified during the reconciliation process.

701045543

231109

[exam findings]

• 2023-11-08 CT - abdomen
  • With and without contrast enhancement CT of abdomen shows:
    • s/p resection of rectosigmoid junction and end sigmoid colostomy.
    • Dilatation of small bowel with collapse of distal ileum and colon, r/o obstruction
      
    • A low density lesion, 1.6 x 0.6cm, in right liver dome (S4). Liver cysts.
    • Mild fat stranding in pelvis.
    • No enlarged lymph nodes in para-aortic and pelvic regions.
    • No bony destructive lesion on these images.
  • Impression
    • Post-OP change
    • Small bowel obstruction
    • Right liver dome lesion, stationary
• 2023-11-07 KUB
  • Dilatation of small bowel
• 2023-11-02 PET
  • Glucose hypermetabolism in the lower pelvic region near the previous operative area. Recurrent malignancy can not be ruled out. Please correlate with other clinical findings for further evaluation. However, no prominent FDG uptake was noted in the S7 dome of the subphrenic space.
  • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
  • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2023-09-22 CT - abdomen
  • Findings: Comparison prior CT dated 2023/05/13.
    • S/P Hartmann operation and autosuture in the sigmoid colon.
    • S/P hysterectomy.
    • Prior CT identified a soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is noted again, decreasing in size to 1 cm.
    • There are several hepatic cysts in both lobes and the largest one 1.6 cm in size at S4.
  • Impression:
    • S/P Hartmann operation and autosuture in the sigmoid colon.
      • There is no evidence of tumor recurrence.
    • Prior CT identified a soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is noted again, decreasing in size to 1 cm.
      • Follow up is indicated.
• 2023-08-18 KUB
  • Radiopaque spots at pelvic region.
  • Presence of ileus.
• 2023-06-15 SONO - breast
  • Diagnosis: Bil. fibroadenomas
  • BI-RADS: 2. benign finding
• 2023-05-19 Mammography
  • Indication: Screening.
  • No previous mammography is available for comparison.
  • Mammography of bilateral breasts with craniocaudal (CC) and mediolateral oblique (MLO) views shows:
    • Composition: The breast tissue is heterogeneously dense, and this may decrease the sensitivity of mammography.
    • No definite masses.
    • No asymmetric density.
    • No clustered microcalcification.
    • No architectural distortion.
    • Benign coarse calcifications in bilateral breasts.
    • Diffuse punctate round microcalcifications loosely scattered in left breast, favor benign.
  • Final assessment:
    • BI-RADS category 2, Benign finding.
    • Suggest annual mammographic follow up.
• 2023-05-13 CT - abdomen
  • Abdominal CT with and without IV contrast ehnancement shows:
    • Visible Chest:
      • Bilteral tiny nodules at both thyroid glands is found.
      • One enhanced nodule at right breast measuring 1.6cm is found. Breast tumor is favored. Suggest mamography and sonography.
      • The lung fields are clear.
      • Patent airway is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • s/p LAR and colostomy with its orifice at LLQ.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs
      • The urinary bladder is well distended without soft tissue lesion.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
  • Imp:
    • s/p LAR and colostomy.
    • No evidence of recurrent/residual tumor in the study.
    • Right breast tumor. 1.6cm. Suggest further study.
• 2023-03-27 KUB
  • S/P colostomy of left lower abdominal wall
  • S/P metalic autosuture projecting at the middle pelvis.
  • Transitional vertebra of L5-S1, left side.
• 2023-03-24 CT - abdomen
  • With and without contrast enhancement CT of abdomen shows:
    • s/p Hartmann operation and descending colostomy.
    • Dilatation of small bowel and collapse of colon, r/o obstruction.
    • Presence of ascites.
    • Several liver cysts, up to 1.8cm. A soft tissue density, 1.6cm, at liver dome, stationary.
    • No enlarged lymph nodes in para-aortic and pelvic regions.
    • No bony destructive lesion on these images.
  • Impression
    • s/p Hartmann operation
    • Small bowel obstruction
    • Ascites
• 2023-03-23 KUB
  • s/p descending colostomy
  • A metallic clip over pelvis
• 2023-03-10 PET
  • A glucose hypermetabolic lesion in the lower pelvic region near the previous operative area. Either residual malignancy or post-operative inflammation may show this picture. However, no prominent FDG uptake was noted in the S7 dome of the subphrenic space.
  • Glucose hypermetabolism in a focal area in the right paraaortic region. The nature is to be determined (inflammatory process? a metastatic lymph node of low FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in some focal areas in the colon. The nature is to be determined (physiological FDG accumulation? other nature?). Please also correlate with other clinical findings for further evaluation.
• 2023-02-17 CT - abdomen
  • History:
    • 20221117 CT: S-colon CA wt uterus invasion, cT4bN2bM0, stage IIIC
    • 20221223 CT: S-colon CA with perforation is highly suspected.
    • 20221224 S/P Hartmann operation:S-colon CA wt uterus invasion and involving bil. ovaries (Two sites?).pT4bN0M1b; pstage: IVB.
  • Findings:
    • S/P Hartmann operation and autosuture in the sigmoid colon.
      • S/P hysterectomy.
    • There is mild dilatation of the terminal ileum.
      • please correlate with clinical condition.
        
    • A soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is highly suspected, nature? Follow up is indicated.
    • There are several hepatic cysts in both lobes and the largest one 1.6 cm in size at S4.
    • There is no focal lesion in both lung and mediastinum.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
    • There is no evidence of ascites and lymphadenopathy.
      
    • The abdominal aorta and IVC are grossly unremarkable.
    • There is no evidence of intrinsic or extrinsic bladder mass.
  • Impression:
    • S/P Hartmann operation and autosuture in the sigmoid colon.
      • There is no evidence of tumor recurrence.
    • There is mild dilatation of the terminal ileum.
      • please correlate with clinical condition.
        
    • A soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is highly suspected, nature? Follow up is indicated.
• 2023-02-03 KUB
  • Stool retention in the bowel.
• 2023-01-13, -01-06, -01-05 KUB
  • Presence of ileus.
• 2022-12-26 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, rectosigmoid colon, exploratory laparotomy with Hartmann operation — Adenocarcinoma, moderately differentiated
      
    • Resection margins: bilateral margins free; radial margin involved.
    • Lymph node, mesocolic, dissection — free (0/13)
    • pT4b pN0 pM1b, at least; Pathology stage: IVB, at least. NOTE: Please correlate with clinical and image findings.
      
  • Gross Description:
    • Procedure - exploratory laparotomy with Hartmann operation
    • Tumor Site - Rectosigmoid region
    • Tumor Size: 4.5 x 3.5 x 3.5 cm.
      
    • Macroscopic Tumor Perforation: Present
      
    • Macroscopic Intactness of Mesorectum - Incomplete
    • Sections are taken and labeled as: A1-2: bilateral cut ends; A3-8: tumor; A9-10: lymph nodes.
  • Microscopic Description:
    • Histologic Type - Adenocarcinoma
    • Histologic Grade - G2: Moderately differentiated
    • Tumor Extension - Tumor invades the visceral peritoneum and involving myometrium as well as bilateral ovaries.
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Involved
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Not identified
    • Tumor Budding- none.
    • Type of Polyp in Which Invasive Carcinoma Arose: none.
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes - free
      • Number of Lymph Nodes Involved/Examined: 0/13
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) - not applicable.
      • Primary Tumor (pT) - pT4b: Tumor directly invades or adheres to adjacent organs or structures
      • Regional Lymph Nodes (pN) - pN0: No regional lymph node metastasis
      • Distant Metastasis (pM) - pM1b: Metastasis to two or more sites or organs is identified without peritoneal metastasis
    • Additional Pathologic Findings - None identified
    • Ancillary Studies – result of S2022-20393. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • REFERENCE: S2022-23261: uterus and bilateral adnexae: involved by tumor.
• 2023-12-26 Patho - uterus with or without SO non-neoplastic/prolapse
  • DIAGNOSIS:
    • Uterus, cervix, total abdominal hysterectomy — No pathological changes.
    • Uterus, endometrium, total abdominal hysterectomy — Polyp, Proliferative phase
    • Uterus, corpus, total abdominal hysterectomy — adenocarcinoma, invasion of myometrium.
    • Adenxae, bilateral, bilateral salpingo-oophorectomy — adenocarcinoma, involving bilateral ovaries.
  • GROSS DESCRIPTION:
    • Specimen submitted in formalin consists of one uterus weighing 230 gm and measuring 10 x 6 x 3 cm. The external surface of the uterus is mucoid in appearance. On cut, there are multiple foci of mucoid tumor invading the outer half of the myometrium.
    • The endometrial cavity is 5 x 4 x 3 cm in size and the endometrium is 0.2 cm in thickness. One polyp measuring 0.8 x 0.3 x 0.3 cm is present in the endometrial cavity. The cervix measuring 4 x 3 x 2 cm is normal in appearance. The left ovary and tube measuring 6 x 4 x 3 cm and 5 x 0.5 x 0.4 cm and the right ovry and tube measuring 8 x 7 x 6 cm and 5 x 0.5 x 0.5 cm show tumor invasion of bilateral ovaries. Representative tissue for sections in the following cassettes: A1-2: left ovary and tube; A3-6: right ovary and tube; A7-10: endometrium and uterine corpus; A11: cervix.
  • MICROSCOPIC DESCRIPTION:
    • Section of the cervix shows no pathological changes. The endometrium and polyp show proliferative phase. The myometrium shows adenocarcinoma with abundant mucinous pools invading the external half of the myometrium. The bilateral ovaries are involved by adenocarcinoma with abundant mucinous pools.
• 2022-12-23 CT - abdomen
  • Findings:
    • There is pneumoperitoneum with more gas bubbles in the lower pelvis omentum, and mild fatty stranding of the omentum that is c/w hollow organ perforation and highly suspicious sigmoid colon cancer perforation?
      • please correlate with clinical condition.
    • There is smudggy appearnace of the lower pelvis omentum that may be peritonitis or carcinomatosis?
    • Prior CT identified sigmoid colon cancer and regional LNs metastases is noted again, stationary.
      • The proximal colon, beyond sigmoid colon, shows dilatation and Eqivocal pneumatosis?
      • Sigmoid colon cancer induce near complete obstruction is suspected.
    • There are several hepatic cysts in both lobes and the largest one 1.6 cm in size at S4.
    • Prior CT identified left ovary dermoid cyst (3.9cm), Right ovary cyst (6.2cm), and some csytic lesions (up to 1.3cm) in the uterus are noted again, stationary.
  • Impression:
    • Pneumoperitoneums is noted.
    • Sigmoid colon cancer perforation is highly suspected.
• 2022-11-25 All-RAS + BRAF mutations assay
  • Detected (KRAS codon 12 GGT>GAT, p.G12D)
  • There was no variant detect in the BRAF gene.
• 2022-11-28 KUB
  • Transitional vertebra of L5-S1, left side.
• 2022-11-22 Exercise Electrocardiogram Bruce
  • Findings
    • The patient exercised according to the BRUCE for 06:14 min:s, achieving a work level of max METS: 7.3.
    • The resting heart rate of 59 bpm rose to a maximal heart rate of 130 bpm.
    • This value represents 71 % of the maximal, age-predicted heart rate.
    • The resting blood pressure of 110/76 mmHg, rose to a maximum blood pressure of 159/70 mmHg.
    • The exercise test was stopped due to Dyspnea, Frequent PVCs, Fatigue.
  • Conclusion
    • Resting ECG: normal sinus rhythm
    • Arrhythmia: VPC bigeminy during exam
    • Interpretation: No significant ST-T change during exercise and recovery phases.
    • Conclusion Inconclusive, submaximal stress
• 2022-11-22 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 35) / 108 = 67.59%
    • M-mode (Teichholz) = 67.9
  • Conclusion
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Mild MR, PR
• 2022-11-18 Patho - colorectal polyp
  • Colorectum, rectosigmoid 15 cm above anal verge, biopsy — Adenocarcinoma.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • Specimen submitted in formalin consists of 2 pieces of tan, irregular tissue measuring 0.4 x 0.2 x 0.1 cm.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
• 2022-11-17 CT - abdomen
  • History and indication: Abdominal pain
  • Findings
    • Wall thickening of S-colon with uterus invasion and regional LAP.
    • Liver cysts (up to 1.3cm).
    • Suspected left ovary dermoid cyst (3.9cm). Right ovary cyst (6.2cm). Some csytic lesions (up to 1.3cm) in uterus.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2022-11-17 ECG
  • Sinus rhythm with short PR
  • T wave abnormality, consider inferior ischemia
  • Abnormal ECG
• 2022-11-17 Sigmoidoscopy
  • Findings
    • Rectosigmoid cancer with partial obstruction at 15 cm from AV, biopsy was done
    • Tattooing was performed
  • Diagnosis
    • Rectosigmoid cancer with partial obstruction s/p biopsy and tattooed
  • Suggestion
    • Elective colectomy
  • Complication
    • No immediate complication

[MedRec]

• 2023-03-03 SOAP Gastroenterology Su WeiZhi
  • S: AFP 11, anti-HBs (+)
  • Prescription x3
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2022-12-05 SOAP Gastroenterology Su WeiZhi
  • S: Anti-HBc (+); HBsAg (-) HBV DNA undetectable, check anti-HBs
  • Prescription x3
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2022-11-23 ~ 2023-11-28 POMR Hemato-Oncology Zhang ShouYi
  • Discharge diagnosis
    • Malignant neoplasm of sigmoid colon
    • S-colon CA wt uterus invasion, cT4b N2b M0, stage III
  • CC
    • for #1 CCRT with FOLFOX
  • Present illness
    • This 46-year-old female, a pt of S-colon CA wt uterus invasion, cT4b N2b M0, stage III, Dx in Nov 2022 by Dr Xiao GuangHong, suffered from initial presentation of bloody stool passage since Sep 2022 and body weight loss 3-5kg, poor appetite were also noted.
    • Image study with sigmoidoscopy (11/17 22) showed rectosigmoid cancer with partial obstruction at 15 cm from AV, s/p biopsy. Abd CT (11/17 22) revealed Wall thickening of S-colon with uterus invasion and regional LAP.Imp: T4b N2b M0, stage III,
    • Surgical pathology with colorectum, rectosigmoid 15 cm above anal verge, biopsy (11/18 22) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • She referred to our hemato-oncologic clinic on 11/21 22 for pre-Op CCRT by Dr Xiao GuangHong.
    • We explain to pt & her husband about the indication & risk / benefit of pre-Op CCRT with FOLFOX plus R/T then do abd CT for response evaluation.
    • HBsAg, anti-HCV (11/22 22) showed negative and anti-Hbc: positive under anti-virus Tx.
    • R/T to rectal tumor by Dr Wang YuNong on 11/28 22.
    • Will give pre-Op adjuvant CCRT with mFOLFOX6 IV Q2W x 6 plus R/T.
    • Today, she was admitted for #1 pre-Op adjuvant CCRT with mFOLFOX6 IV Q2W x 6 on 11/23 22.
  • Course of inpatient treatment
    • After admission, repeat pathology (11/18 22) proved Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Chemotherapy with Oxalip (70mg/m2) plus leucovorin (400mg/m2) and 5-FU (2800mg/m2) were given on 11/25-11/27 22, smoothly without obvious side effect.
    • She complained of abdominal pain and constipation post C/T and KUB showed massive stool impaction in colon.
    • Ultracet 1# po was given for pain control.
    • She felt abdominal pain much better and she was discharged on 11/28 22 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
    • Megejohn (megestrol acetate 160mg) 1# QD
• 2022-11-21 SOAP Radiation Oncology Wang YuNong
  • A: Advanced RS cancer with uterus, ovary invasion, cT4bN2bM0
  • P: Suggest CCRT then OP
    • CT-simulation will be arranged on 11/24. Plan to deliver 45 Gy/ 25 fx to the pelvis.
    • Then boost the S-colon tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 11/28.

[consultation]

• 2023-11-08 Colorectal Surgery
  • Q
    • right abdominal pain since yesterday, radiation to periumbilical area
    • nausea and vomiting, once eating
    • watery stool from colostomy noted today
    • Past history:
      • Sigmoid colon cancer with uterus invasion, cT4b N2b M0, stage III status post Hartmann operation (resection of rectosigmoid junction and end S colostomy ) on 2022/12/24. T4bN0M1b stage IVb
      • Hepatitis B, Anti-Hbc : positive
      • Allergy: denied
  • A
    • S: Sigmoid colon cancer with uterus invasion, cT4b N2b M0, stage III status post Hartmann operation (resection of rectosigmoid junction and end S colostomy ) on 2022/12/24. T4bN0M1b stage IVb under paliative chemotherapy, CEA keeping growing.
    • O: ileus is noted and consider carcinomatosis and ileus.
    • P: pleasea medical treatment first.
• 2023-03-24 Colorectal Surgery
  • Q
    • CC: low abd pain for 5 hours
      • vomiting once
      • mild epigastric pain +
      • chest pain +
      • no headache, no dyspnea, no diarrhea, no fever
    • past history:
      • Sigmoid colon cancer with uterus invasion, cT4b N2b M0, stage III status post Hartmann operation (resection of rectosigmoid junction and end S colostomy) on 2022/12/24. T4bN0M1b stage IVb s/p OP
    • nka
  • A
    • suspect ileus by CT image, still has defecation.
    • medical treatment first including antibiotics treatment
• 2022-12-23 Colorectal Surgery
  • Q
    • for tenderness at RLQ, LLQ noted, suspect S-colon rupture.
    • This 46-year-old female, a pt of S-colon CA wt uterus invasion, cT4b N2b M0, stage III, Dx in Nov 2022 by Dr Xiao GuangHong, suffered from initial presentation of bloody stool passage since Sep 2022 and body weight loss 3-5kg, poor appetite were also noted.
    • she was admitted for #3 pre-Op adjuvant CCRT with mFOLFOX6 IV Q2W x 6 on 12/22 22. Then the patient complaints abdomen pain since last night, and took the painkillers with Tramacet twice, not useful.
    • She suffered from tenderness at RLQ, LLQ noted, follow-up abdomen CT, and pending report, so we need your help, thanks a lot!
  • A
    • suspect RS colon cancer with obstruction and rupture with sepsis
    • suggest emergent Hartman’s operation and ICU care.
• 2022-12-23 General and Gastrointestinal Surgery
  • Q (same question as colorectal surgery on the same day)
    • Due to symptoms got worse, CT was arranged and hollow organ perforation is suspected.
  • A
    • O: vital signs: BP:97/56; HR:78; BT:36.8’C; RR:18; SpO2:96%
      • abdomen: soft, ovoid, decrease bowel sound, low abdojminal tenderness and muscle guarding, positive rebounding pain, tympanic percussion
      • lab data: see chart
      • CT: free air accumulation in low abdomen
    • A: hollow organ perforation, suspect colon tumor related perforation
    • P: Please consult CRS for further evaluation

[surgical operation]

• 2022-12-24
  • Surgery
    • Impression:
      • Advanced RS cancer with uterus , ovary invasion, cT4bN2bM0, stage IIIC
      • r/o rupture of right ovarian cyst
      • Pelvic adhesion
    • Procedure:
      • Abdominal total hysterectomy+ bilateral salpingoophorectomy  +pelvic/abdominal adhesiolysis
  • Finding
    • Uterus: one 2x1cm subserosal uterine myoma at left anterior uterine wall; severe adhesion between posterior wall to sigmoid colon and CDS.
    • RAD: suspected rupture of right ovarian cyst before, r/o tumor invasion, severe adhesion to sigmoid colon, adhesion lysis was performed smoothly
    • LAD: a 4x3 cm left ovarian cystic lesion
    • CDS: severe adhesion between lower sigmoid colon and posterior uterine wall, adhesion lysis was performed.
    • Estimated blood loss: 400ml
    • Blood transfusion: pRBC 4U
    • Complication: nil  
• 2022-12-24
  • Surgery: Hartmann operation (resection of RS colon and end S colostomy )
  • Finding
    • tumor of S colon invasion to uterin + bilateral ovary and right side ovary necrosis and rupture with S colon cancer.
    • much pus/ascites over abdomen

[radiotherapy]

[chemotherapy]

• 2023-10-18 - irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
• 2023-09-26 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-08-30 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-08-02 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-07-05 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-06-07 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
• 2023-05-11 - irinotecan 180mg/m2 295mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
• 2023-04-13 - irinotecan 170mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2400mg/m2 3840mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
• 2023-03-16 - irinotecan 160mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2400mg/m2 3840mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
• 2023-02-16 - irinotecan 160mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
• 2022-12-08 - oxaliplatin 70mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3970mg NS 500mL 46hr (FOLFOX Q2W)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + NS 250mL
• 2022-11-25 - oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)
  • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + NS 250mL

==========

2023-11-09

[monitoring CEA levels post-Hartmann surgery: signs of emerging resistance to FOLFIRI regimen]

The Hartmann procedure was performed on 2022-12-24, after which the tumor marker CEA significantly decreased to within normal limits and remained so until August 2023. Recently, there has been an increase in the CEA levels, which could indicate the potential emergence of resistance to the current treatment regimen FOLFIRI which has been initiated since 2023-02-16.

• 2023-11-07 CEA (NM) 16.050 ng/ml **
• 2023-10-24 CEA (NM) 13.781 ng/ml **
• 2023-10-03 CEA (NM) 9.779 ng/ml *
• 2023-09-22 CEA (NM) 8.919 ng/ml *
• 2023-09-05 CEA (NM) 7.765 ng/ml *
• 2023-08-01 CEA (NM) 4.826 ng/ml
• 2023-07-04 CEA (NM) 3.796 ng/ml
• 2023-02-20 CEA (NM) 4.302 ng/ml
• 2022-11-25 CEA (NM) 73.723 ng/ml ***
• 2022-11-23 CEA (NM) 75.097 ng/ml ***

[small bowel obstruction]

On 2023-11-08, a CT scan revealed a small bowel obstruction (SBO) in the patient, with a prior episode of postoperative ileus evidenced by KUB imaging in January 2023.

Patients with SBO may experience significant fluid loss, metabolic acidosis or alkalosis, and electrolyte imbalances. This is particularly true for patients with prolific vomiting from a proximal SBO, those with symptoms lasting several days before presentation, or those with an obstruction that results in large-volume fluid sequestration within the bowel. The patient is currently on an intravenous regimen of normal saline 500mL twice daily and Taita No.5 solution 500mL every 12 hours, which is considered an appropriate treatment.

In cases of SBO with significant distension, nausea, and/or vomiting, nasogastric tube decompression may be considered. Patients with these symptoms likely have a complete or high-grade obstruction; decompression can improve comfort and minimize the worsening of distension due to swallowed air.

Antibiotics are indicated if there is a suspicion of bowel compromise, such as ischemia, necrosis, or perforation.

2022-12-23

• Loperamide is an opioid medication that is used to treat diarrhea. Loperamide works by slowing the movement of the intestines, which helps to reduce the frequency of diarrhea.
• Lactulose is a type of laxative that is used to treat constipation and to help regulate bowel movements. Lactulose works by drawing water into the intestines, which helps to soften stools and make them easier to pass.
• When loperamide and lactulose are coadministered (the current situation), there is no specific expected effect on the body.

700763275

231107

[exam findings]

• 2023-12-14 Gynecologic ultrasonography
  • CUL-DE-SAC: No fluid
    
  • Other: ATH+BSO
  • IMP: No obvious uterine or ovarian lesion
• 2023-11-28 CT - abdomen
  • History and indication: Bilateral ovarian cancers (high-grade serous carcinoma) with peritoneal and lymphonode metastasis, AJCC Pathologic staging: pT3cN1a, stage IIIC.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Ovary cancer with peritoneal carcinomatosis s/p operation.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Ovary cancer with peritoneal carcinomatosis s/p operation.
    • No definite mass lesion in peritoneal cavity.
• 2023-08-30 Patho - soft tissue tumor, extensive resection
  • PATHOLOGIC DIAGNOSIS
    • Ovarian mass, right, frozen + debulking surgery — High-grade serous carcinoma
      • Fallopian tube, left, ditto — Free of tumor invasion
    • Ovary, left, ditto — High-grade serous carcinoma
      • Fallopian tube, right, ditto — Free of tumor invasion
    • Endometrium, uterus, debulking surgery — Free of tumor invasion
    • Myometrium, uterus, ditto — Tumor invasion, leiomyomas with calcification and ossification
    • Cervix, uterus, ditto — Free of tumor invasion
    • Parametria, bilateral, ditto — Tumor invasion
    • Omentum ttissue, omentectomy — Tumor invasion
    • Central peritoneal tumor, excision — Tumor invasion
      • Left peritoneal tumors, excision — Tumor invasion
      • R’t and L’t peritoneal tumors, excision — Tumor invasion
    • Lymph node, L’t iliac, dissection — Tumor metastasis (3/7) without extracapsular extension (0/3)
    • Lymph node, L’t obturator, ditto — Tumor metastasis (1/8) without extracapsular extension (0/1)
    • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/7)
    • Lymph node, R’t obturator, ditto — Free of tumor metastasis (0/6)
      
    • AJCC Pathologic staging: pT3cN1a, if cM0; stage IIIC
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: frozen + debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + peritoneal tumor excision)
    • Specimen type: uterus, peritoneal tumors, omentum and lymph nodes
    • Specimen size:
      • L’t ovary (frozen): multiple fragments, up to 8.3 x 7.8 x 4.3 cm with blood
      • L’t fallopian tube (frozen): normal appearance, 4.2 cm in length, up to 0.4 cm in diameter
      • R’t ovary (frozen): ruptured solid mass, 6.6 x 6.5 x 2.9 cm
      • R’t fallopian tube (frozen): normal appearance, 4.3 cm in length, up to 0.4 cm in diameter
      • Uterus: 6.3 x 5.2 x 4.5 cm, 79 gm, tumor seeding at anterior and posterior surface and parametria. Besides, two firm hard myomas measure up to 4.4 x 3.2 x 2.2 cm are also included
      • Omentum: 38 x 18 x 3.2, diffusely tumor invasion with solid and nodular patterns
      • Central peritoneal tumor: one piece, 6 x 4.3 x 3.6 cm
      • Left peritoneal tumors: multiple pieces, up to 2.6 x 1.7 x 1.2 cm
      • Right and left peritoneal tumors: multiple pieces, up to 2.2 x 0.8 x 0.7 cm
    • Tumor site: uncertain, favor left ovary, but clinical correlation is needed
    • Tumor size: multiple fragments, up to 8.3 x 7.8 x 4.3 cm
      
    • Tumor appearance: solid and cystic mass
    • Specimen integrity: ruptured
    • Lymph nodes: pelvic lymph nodes
    • Representative sections as A1-A2: myomas, A3: parametrium, A4 and A10: anterior surface of uterus, A5: posterior surface of uterus, A6: L’t mesosalpinx, A7-A8: cervix, A9: endometrium+ myometrium, B1-B2: omentum, C1-C2: central peritoneal tumor, D: left peritoneal tumors, E: R’t and L’t peritoneal tumors, F: L’t iliac LNs, G: L’t obturator LNs, H: R’t iliac LNs, I: R’t obturator LNs [Reference: frozen section: F2023-00385 FSA: R’t ovarian tumor, A1: R’t fallopian tube and A2-A5: R’t ovarian mass, FSB: L’t ovary tumor, B1: L’t fallopian tube and B2-B8: L’t ovary tumor]
  • MICROSCOPIC EXAMINATION
    • Histologic type: serous carcinoma
    • Histologic grade: high grade
    • Tumor side ovarian surface involvement: present
    • Contralateral ovary involvement: present
    • Right tube involvement: absent
    • Left tube involvement: absent
    • In situ adenocarcinoma in right ＆/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: present
    • Left adnexa soft tissue involvement: present
    • Pelvic soft tissue involvement: present
    • Bilateral parametria: tumor invasion
    • Uterine serosa involvement: present
    • Omentum involvement: tumor invasion
    • Uterine Cervix involvement: absent
    • Endometrium involvement: absent
    • Myometrium involvement: minimal tumor invasion, leiomyomas with calcification and ossification
    • Lymph nodes metastasis: tumor metastasis (4/28) without extracapsular extension (0/4) in total number
    • Immunohistochemistry: WT-1(+), PAX-8(+), P53(aberrant expression), ER(+), Napsin-A(-) and vimentin(-)
    • Ascites cytology: Negative
    • Perineural invasion: present
    • Lymphovascular space invasion: present
• 2023-08-28 EGD
  • Reflux esophagitis, lower esophagus, LA classification, grade A
  • Superfical gastritis, antrum
  • Gastric submucosal leison, fundus
• 2023-08-07 CT - abdomen
  • Indication
    • Periumbilical pain
    • Irritable bowel syndrome with diarrhea
  • Abdominal CT with and without enhancement revealed:
    • Massive ascites formation is found.
    • Soft tissue mass at bilateral ovaries up to 8.4cm at left side and 5.9cm at right side is found. Ovarian meta is favored.
    • Diffuse nodular lesions at peritoneum and mesentery is found. Cancerous peritonitis with omental cake is considered.
    • The stomach is collapsed.
    • No significant soft tissue mass is found along the course of the colon.
    • Prominent uterine cervix is found.
  • Imp:
    • cancerous peritonitis with bilateral ovarian mass, origin?
    • Prominent uterine cervix is suspected.
• 2023-08-07 Gynecologic ultrasonography
  • R/O LT mass (90mmX74mm)
  • Asites (+)
• 2023-08-05 SONO - abdomen
  • Diagnosis:
    • probable liver parenchymal disease
    • ascites: moderate to large amount
    • suspected mass lesions in lower abdomen, size 8.2cm and 5.3cm
  • Suggestion:
    • suggest CT scan

[MedRec]

• 2023-09-24 ~ 2023-09-26 POMR Hemato-Oncology He JingLiang
  • Discharge diagnosis
    • Bilateral ovarian cancers (high-grade serous carcinoma) with peritoneal and lymphonode metastasis < AJCC Pathologic staging: pT3cN1a, stage IIIC > C 56.9
    • Chronic viral hepatitis B without delta-agent
  • CC
    • for C1 chemotherapy with Taxol / Carboplatin
  • Present illness
    • This 55-year-old woman, a patient of bilateral ovarian cancers (high-grade serous carcinoma) with peritoneal and lymphonode metastasis < AJCC Pathologic staging: pT3cN1a, stage IIIC was diagnosed on 2023-09-04, suffered from bowel behavior change fron once per day to 6 times per day and body weight gain since 2023/07. Abdominal fullness with nausea, periumbilical pain and sometimes dyspena. She visited to our GYN OPD for further evaluation and survey.
    • Image study with abdominal sono (2023-08-05) showed probable liver parenchymal diseaseascites: moderate to large amount, suspected mass lesions in lower abdomen. Gyn sono (2023-08-07) revealed R/O LT mass:(90mmX74mm), Asites(+) and abdominal CT (2023-08-07) showed cancerous peritonitis with bilateral ovarian mass, origin? Prominent uterine cervix is suspected. Frozen section report (2023-08-29) proved 1. R’t ovarian tumor, FSA — Adenocarcinoma, 2. L’t ovarian tumor, FSB — Adenocarcinoma. Ascites cytology (2023-08-31) showed negative.
    • Operation Procedure: frozen + debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + peritoneal tumor excision) on 2023-09-04 which showed ovarian mass, right, frozen + debulking surgery — High-grade serous carcinoma. Myometrium involvement: minimal tumor invasion, leiomyomas with calcification and ossification. Lymph nodes metastasis: tumor metastasis (4/28) without extracapsular extension (0/4) in total number. Immunohistochemistry: WT-1(+), PAX-8(+), P53(aberrant expression), ER(+), Napsin-A(-) and vimentin(-) AJCC Pathologic staging: pT3cN1a, if cM0; stage IIIC.
    • The tumor marker showed CA-125: 337U/ml on 2023-09-21. Hepatitis markers showed HBsAg, Anti-HCV: negative and anti-Hbc: positive.
    • Today, she was admitted for C1 chemotherapy with Taxol/Carbopaltin on 2023-09-24.
  • Course of inpatient treatment
    • After admission, Limeson 5# po q6h & q12h before C/T was given for preventive allergy.
    • Chemotherapy with Taxol (175mg/m2) plus Carboplatin (AUC:5) were administered on 2023-09-25, smoothly without obvious side effect.
    • Entecavir 1# po qd was added for anti-Hbc positive.
    • She was discharged on 9/26 23 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • MgO 250mg 1# TID
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# HS
• 2023-09-21 SOAP Obstetrics and Gynecology Chen GuoHu
  • O
    • sonar: unremarkable findings, ascites about 50c.c -> ascites 20c.c
    • change dressing: wound ok, remove stitchs
• 2023-09-18 ~ 2023-09-21 POMR General and Gastrointestinal Surgery Li ChaoShu
  • Discharge diagnosis
    • Left pneumothroax
    • Bilateral ovarian cancers (high-grade serous carcinoma) with peritoneal and lymphonode metastasis < AJCC Pathologic staging: pT3cN1a, stage IIIC > C 56.9
    • Neoplastic (malignant) related fatigue
  • CC
    • Chest X-ray exam revealed left pneumothorax post port-a inserted
  • Present illness
    • This is a 55 years old, pP0, SEX(-) female with history of
      • bilateral ovarian high-grade serous carcinomas with peritoneal and LN metastasis; AJCC Pathologic staging: pT3cN1a, stage IIIC.
      • right benign follicular nodule s/p right thyroidectomy on 2020/10/16.
    • Port-A infusion catheter insertion was performed on 2023/09/18 morning, left chest pain radiation to back was noticed at afternoon while receiving post-op Chest X-ray exam ,which revealed left pneumothorax. Thus, she was called back to our ER for initial treament, O2 nasal canula 2L was given and then adimitted to GS ward for further intervention and observation.
  • Course of inpatient treatment
    • After admittion, Port-A catheter implatation on the left side was performed on 2023/09/18. The post-operative course was relatively smooth but CXR revealed left pneumothorax. As such, was admitted for further intervention and observation. There was no special complain and improved of CXR. Under the stable condition, she was discharged today and will be arrange OPD follow up.
• 2023-09-18 SOAP Medical Emergency He YaoCan
  • S: insert artificial vessal for C/T of ovarian cancer earlier today.
  • A: preliminary impression: 93.9 Pneumothorax, unspecified
• 2023-09-14 SOAP Hemato-Oncology He JingLiang
  • A/P: C/T with carboplatin + paclitaxel
• 2023-08-27 ~ 2023-09-08 POMR Obstetrics and Gynecology Chen GuoHu
  • Discharge diagnosis
    • Bilateral ovarian cancers (high-grade serous carcinoma) with peritoneal and lymphonode metastasis < AJCC Pathologic staging: pT3cN1a, stage IIIC > C 56.9
    • Female pelvic peritoneal adhesions (postinfective)
    • Acute posthemorrhagic anemia
    • Iron deficiency anemia secondary to blood loss (chronic)
    • bilateral ovarian cancers (adenocarcinoma) with carcinomatosis -> debulking surgery on 2023-08-29
  • CC
    • Abdominal fullness and nausea for 2 months.
  • Present illness
    • This is a 55 years old, pP0, SEX(-) female with a history of right benign follicular nodule s/p right thyroidectomy on 2020/10/16.
    • According to the patient, she had noted bowel behavior change fron once per day to 6 times per day and body weight gain since 2023/07. Abdominal fullness with nausea, periumbilical pain and sometimes dyspena also were found. She first came to our GI OPD for help on 2023/08/04. The abdominal echogram showed moderate to large amount ascites and suspected two mass lesion in the lower abdomen.
    • The abdominal CT on 2023/08/07 revealed cancerous peritonitis with bilateral ovarian mass measured 8-10 cm and massive ascites. She was transferred to GYN OPD for further survey.
    • The GYN sonography showed uterus 56*23mm, EM 6.2mm with a fundal myoma 4X4cm, left adnexa mass 90x74mm with solid part and massive ascites. The tumor marker examination revealed CA125 level was 3487 U/mL, CEA level was 0.87 ng/mL and CA199 level was < 0.8U/mL.
    • Under the impression of cancerous peritonitis with bilateral ovarian mass, suspected bilateral ovarian cancers with carcinomatosis, she was admitted for cancer survey and surgical intervention.
  • Course of inpatient treatment
    • After admission, preoperative evaluation was done, and there were no contraindications for surgery. Hence, debulking surgery and enterolysis were performed on 2023/08/29. A total amount of 7000 c.c. ascites was suctioned out during the surgery, and total blood loss was 1700 c.c.
    • After total hysterectomy, bilateral salpingo-oopherectomy, bilateral pelvic lymph node dissection, tumor resection and partial omentectomy were done, a 15 Fr JP drain was inserted into the cul de sac and the wound was closed. However, hypotension and rapid blood filling into the VAC were noted. CVC was inserted by the anesthesiologist.
    • Despite aggresive component therapy and Levophed use, her systolic blood pressure remained around 40-70 mmHg. The wound was re-opened for a second look before extubation. Massive blood clots were removed, with an accumulation of total blood loss of 5500 c.c. Multiple oozing sites were identified, and were handled with suture techniques, compression and Surgicel use.
    • She received a total blood transfusion of pRBC 18U, FFP 16U and PH 1U. The wound was closed again after her bleeding stablized. Due to massive intraoperative bleeding and unstable condition, she was transferred to ICU afterwards.
    • During SICU, blood transfusion pRBC 6U, FFP 4U and Plt 1U was given for her anemia. Antibiotic with cefazolin, gentamycin, SABS was given. Smoothly extubation after well weaning profile was performed on 2023/09/01. We gave PPI and nutrition support. Pain relief was done with PCA shift to morphine PRN. Her general condition became stable and she was transfered to GYN ward on 2023/09/02.
    • During GYN ordinary ward, the patient was under stable vital signs, and the abdominal wound was about 16cm in length, without active bleeding. The wound had steri-strip cover, without infection signs; a right JP drain was checked with decreased amount and light red color, and was removed on 2023/09/06. TPN and albumin for nutrition support were given at first and she was changed to feed with oral diet as tolerance. Normal bowel movement and smooth voiding after foley removal were observed.
    • The Pathology result showed bilateral ovarian high-grade serous carcinomas with peritoneal and LN metastasis; AJCC Pathologic staging: pT3cN1a, stage IIIC.
    • Under a stable condition, the patient may be discharged on 2023/09/07 and OPD follow-up is mandatory for further discussion on futher management.
  • Discharge prescription
    • cephalexin 500mg 1# QID
    • Actein (acetylcysteine 200mg) 1# TID
    • C.B. Ointment BID TOPI
    • MgO 250mg 1# QID
    • Cough Mixture (platycodon) 5mL TID
    • Acetal (acetaminophen 500mg) 1# QID
    • Eurodin (estazolam 2mg) 1# PRNHS if insomia
    • Uretropic (furosemide 40mg) 0.5# QD
• 2023-08-10 SOAP Obstetrics and Gynecology Chen GuoHu
  • O
    • 2023/08 CA125 3487, CEA 0.87, CA199 <0.8
    • 2023/08 abdominal CT report Imp:
      • cancerous peritonitis with bilateral ovarian mass, origin?
      • Prominent uterine cervix is suspected.
• 2023-08-07 SOAP Obstetrics and Gynecology Chen GuoHu
  • S
    • 55y/o sex(-)?
      
    • prev abd op(-)
    • menopause
    • prev follow up in 2019
    • F/U myoma
    • abd sono - 2 mass in low abd 8cm and 4xcm, myomas?
    • abd fullness and nausea, occaional SOB
    • abd CT was arranged
  • O
    • 2014-08-07 pap smear by ENT cotton swap (-)
    • 2014/08 FSH:86.99/LH:125.31/E2:144.80
    • 2014/08/07 CA-125：9.425 U/ml
    • 2014-11-14 hymen incision + hysteroscopic polypectomy + D&C on 2014-11-14 (-)
    • 2019-05-02 sonar: AVF 99 x 37 mm, EM 7.4mm; myoma (calcilication) 45x30 mm
    • 2023-08-07 vaginal sonar (TVS) - EM 0.67cm
      • LOV tumor 9x8cm, solid part(+)
      • ascites(+) > 2000c.c
  • P
    • arrange tumor marker + CXR,
    • suggest lapa (ATH + BSO, change to debulking if LOV cancer confirmed by frozen)
• 2023-08-05 SOAP General and Gastrointestinal Surgery Chen YanZhi
  • S
    • acites? refer to GS survey.
    • HBV(-), HCV(-)
  • O
    • RUQ and LUQ tenderness, no rebounding pain
    • no tarry stool/bloody stool
    • abdomiinal pain(+)
    • no vaginal bleeding(+)
    • no tarry/bloody stool passage
    • no hematemesis
    • umbilical mass, suspect tumor carcinomatosis, suspect GI or GYN cancer related
  • Prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
• 2023-08-04 SOAP Gastroenterology Xu RongYuan
  • S
    • change of bowel habit fron one time/day to 6 times/day in recent one month
    • BW:52.7 to 55.2; abdominal fullness; suspected ascites
  • O
    • PE: abdomen: mild ovoid in shape, soft, mild periumbilica tenderess
• 2020-10-15 ~ 2020-10-17 POMR General and Gastrointestinal Surgery Lai JieWen
  • Discharge diagnosis
    • Right thyroid tumor status post right thyroidectomy on 2020/10/16
  • CC
    • For receiving thyroid operation.
  • Present illness
    • Miss Guo, a 52-year-old service industrial worker, was admitted to our ward for receiving thyroid operation.
    • According to the patient’s statements and previouscharts, she denied any other specific systemic, hereditary, or malignant disease histories. Around 1~2 years before admission, the patient gradually noticed that she had palpable difference between bil. neck (right side was enlarged then the left side).
    • She received further examinations and regular OPD follow up at our Metabolism Dr. Guo’s OPD since 2018/04 under the tentative diagnosis as right thyroid nodule, and no specific positive findings were noted by the fine needle aspiration.
    • However, further follow up fine needle aspiration (FNAB) on 2020/09 showed atypia results, but the patient denied intermittent fever, chillness, general weakness, fatigue, involuntary weight loss, dyspnea, dysphagia, palpitation, easy sweating, any specific voice changes, or bil. upper/lower limbs numbness in recent 1 year (Addendum: The patient reported that she felt hoarseness in recent 2 months but the symptoms got relatively improvement after having some water).
    • Due to above clinical information, the posibillity of malignancy could not be ruled out. She was then referred to our GS Dr. Lai’s OPD for receiving further evaluation of surgical intervention. After fully explanation and discussion to the patient and her families about the current conditions, she decided to visit our hospital for seeking further medical attention.
    • At our hospital, the patient was sitting on the bed with mild distress apperance and alert consciousness. Physical examinations showed no specific positive findings on her HEENT, chest, and abdomen areas. Her neck showed no specific goiter, no specific palpable mass, nor swallowing disability. Further lab data, ECG, and chest roentography all showed no specific positive findings except incomplete right bundle branch block on the V2 lead.
    • According to the above clinical information, right thyroid tumor with the atypia FNAB results, was the tentative diagnosis. She was then admitted to our ward for receiving right thyroidectomy on 2020/10/16.
  • Course of inpatient treatment
    • After admitted to our ward, we arranged right thyroidectomy for the patient on 2020/10/16. She tolerated the operation well and then was sent back to our ordinary ward for further evaluation and treatment. Her admission period status post surgical intervention was smooth and uneventful except left upper limb numbness was noted on 2020/10/16 night. Further calcium level follow up showed no specific positive findings. We then arranged surgical wound CD since 2020/10/17 and showed good wound status without speicific local redness/swelling/purulent discharge.
    • Her surgical wound pain got relatively improvement status post having Acetaminophen 500 mg/tab 1tab PO QID. Since all the patient’s general conditions were relatively stable without specific toxic signs or any other specific discomfort sensations such as severe dysphagia, dyspnea, aggrevated hoarseness, or all 4 limbs numbness. We arranged discharged for her on 2020/10/17 with further OPD follow up of the patient’s surgical wound recovery status, and final pathology reports.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Antica (orciprenaline, bromhexine, doxylamine; 120mL/bot) 10mL TID
    • Strocain (oxethazaine 5mg, polymigel 244mg) 1# TIDAC
• 2019-05-02 SOAP Obstetrics and Gynecology Hong ZhengXiu
  • Diagnosis
    • Menopausal or female climactericstates [N95.1]
    • Other insomnia [G47.00]
    • Leiomyoma of uterus, unspecified [D25.9]

[surgical operation]

• 2023-08-29
  • Surgery
    • debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + pelvic tumor excision) + enterolysis
  • Finding
    • left ovary and tube (spontaneously ruptured during surgery, completely removed ex vivo)
      • LOV – 10x8cm tumor with soft solid mass, suspected LOV cancer,
      • Frozen report – adenocarcinoma
      • left tube – adhered
    • right ovary and tube (spontaneously ruptured during surgery, completely removed ex vivo)
      • ROV – 8x7cm tumor with soft solid mass, suspected ROV cancer,
      • Frozen report – adenocarcinoma
      • left tube – adhered
    • uterus: corpus seemed free of cancer invasion; uterine myoma 4x4cm noted, but ant and post surface seemed involved by cancer seeding
    • omentum – indurated, suspected cancer invasion
    • central peritoneal soft solid tumors, 6x6cm over low pelvis (CDS site between cervix and rectum), cancer invasion likely
    • left peritoneal soft solid tumors, 4x4cm over left low pelvis, cancer invasion likely
    • right and left peritoneal soft solid tumors, over bil round ligaments, cancer invasion likely
    • left iliac LNs
    • left obturator LNs
    • right iliac LNs
    • right obturator LNs
    • liver, bowels – seemed free of cancer invasion
    • After the operation, suboptimal debulking surgery was achieved.
    • Residue tumor: small tumors 1-2cm, on the appendix surface; small tumor 1x1cm on the mesentary area; 2x2cm 2~3# on the top of right diaphragm
    • A 7 mm JP drain was placed in CDS
    • ascites 7000c.c , sent for cytology
• 2020-10-16
  • Surgery: R’t lobectomy + neck lymph node excision
  • Finding
    • Some well-defined goiter lesions over R’t thyroid gland noted
    • Some enlarged pre-trachea LNs noted

[chemotherapy]

• 2023-12-22 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mL NS 250mL 3hr + carboplatin AUC 5 460mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-11-27 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mL NS 250mL 3hr + carboplatin AUC 5 460mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-11-07 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 540mg NS 250mL 1hr (Avastin + paclitaxel + carboplatin; Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-10-16 - paclitaxel 175mg/m2 245mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-09-25 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2023-12-22

Lab results remained largely unremarkable on 2023-12-21. Medication reconciliation confirmed no discrepancies.

Notably, the addition of bevacizumab to the paclitaxel + carboplatin regimen since 2023-11-07 has been associated with a sustained decline in CA-125 levels. Additionally, no adverse events related to bevacizumab, such as hypertension, gastrointestinal perforation, bleeding, or thromboembolic events, have been reported to date.

• 2023-12-11 CA-125 (NM) 74.990 U/ml
  
• 2023-11-20 CA-125 (NM) 121.277 U/ml
  
• 2023-10-30 CA-125 (NM) 237.600 U/ml

2023-11-07

Upon review of the PharmaCloud database, the patient’s medication records are consistent with no discrepancies.

Following the cytoreductive surgery performed on 2023-08-29 and 2 subsequent cycles of the paclitaxel and carboplatin regimen administered on 2023-09-25 and 2023-10-16, there was a significant reduction in the tumor marker CA-125.

• 2023-10-30 CA-125 (NM) 237.600 U/ml
  
• 2023-10-09 CA-125 (NM) 431.500 U/ml
  
• 2023-09-21 CA-125 (NM) 337.560 U/ml
  
• 2023-08-07 CA 125 3487.0 U/mL

Avastin (bevacizumab) has been added to the treatment protocol beginning with the 3rd cycle. The patient should be closely monitored for signs of hypertension, gastrointestinal perforation, bleeding or thromboembolic events.

701464962

231107

[exam findings]

• 2023-10-24 CT - abdomen
  • History and indication: Malignant neoplasm of rectum
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Rectal cancer s/p operation.
    • Multiple nodules in liver.
    • Renal cysts (up to 0.8cm).
    • A cystic lesion (2.8cm) at right iliacus muscle.
    • Tiny gallbladder stones.
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • Emphysema at bil. upper lungs. Some GGO at bil. lungs.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Rectal cancer s/p operation. Multiple liver metastases.
• 2023-10-24, -09-21, -08-17 Sigmoidoscopy
  • Rectal cancer s/p op, anastomotic leakage with improvement
• 2023-08-04 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, rectum, status post concurrent chemoradiotherapy, Transanal Transabdominal Total Mesorectal Excision — adenocarcinoma, moderately differentiated. Margins free.
    • Lymph node, pericolonic, dissection — metastatic adenocarcinoma.
    • Anastomosis, proximal site, excision — free
    • Anastomosis, distal site, excision — free
    • ypT3 ypN1b (if cM0); ypStage: IIIB, at least
  • Gross Description:
    • Procedure - Transanal Transabdominal Total Mesorectal Excision: 12 x 5 x 5 cm
    • Tumor Site - Rectum, 0.5 cm from resection margin
      
    • Tumor Size: 6 x 4.5 x 4.5 cm.
      
    • Macroscopic Tumor Perforation: Not identified
    • Macroscopic Intactness of Mesorectum - Complete
    • Sections are taken and labeled as: A1-6: tumor; A7: tumor cut ends; A8-15: lymph nodes; B: Anastomosis, proximal site; C: Anastomosis, distal site.
  • Microscopic Description:
    • Histologic Type - Adenocarcinoma
    • Histologic Grade - G2: Moderately differentiated
    • Tumor Extension - Tumor invades through the muscularis propria into pericolorectal tissue
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved
      • Distance of tumor from margin: 5 mm
        
    • Lymphovascular Invasion: Not identified
    • Perineural Invasion: Not identified
    • Tumor Budding
      • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2) - Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes
      • Number of Lymph Nodes Involved/Examined: 3/15 with extranodal extension.
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition) ; yp Stage: IIIB, at least.
      • TNM Descriptors (required only if applicable) - y (posttreatment)
      • Primary Tumor (pT) - pT3: Tumor invades through the muscularis propria into pericolorectal tissues
      • Regional Lymph Nodes (pN) - pN1b: Two or three regional lymph nodes are positive
      • Distant Metastasis (pM) - if cM0
      • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.”, “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, medical department (director) and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
    • Additional Pathologic Findings (select all that apply) - None identified
    • Ancillary Studies : result of S2022- 22864 : IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2023-07-17 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Stable condition of rectal cancer.
    • Renal cysts (up to 0.8cm).
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • Emphysema at bil. upper lungs. Some GGO at bil. lungs.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Stable condition of rectal cancer.
• 2023-07-13 Sigmoidoscopy
  • ectal cancer s/p CCRT; a ulcerative mass at 10 cm from AV
• 2023-07-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 18.7) / 104 = 82.02%
    • M-mode (Teichholz) = 82.0 - 75.0
  • Conclusion:
    • Normal AV with mild AR
    • Normal MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
    • Dilated LA
• 2023-04-11 CT - abdomen
  • History and indication:
    • A case of newly diagnosed rectal cancer at 10-14 cm AAV Advanced rectal cancer, cT4aN2bM0 pre-op CCRT
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Stable condition of rectal cancer.
    • Renal cysts (up to 0.8cm).
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • Emphysema at bil. upper lungs.
  • IMP:
    • Stable condition of rectal cancer.
• 2023-04-11 ECG
  • Sinus bradycardia with occasional Premature ventricular complexes
• 2023-04-11 Colonoscopy
  • Rectal cancer s/p CCRT, mild regression
• 2023-03-16 CT - abdomen
  • History and indication:
    • Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Mild regression of rectal cancer.
    • Renal cysts (up to 0.8cm).
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • Emphysema at bil. upper lungs.
  • IMP:
    • Mild regression of rectal cancer.
• 2023-03-01 CXR
  • Atherosclerotic change of aortic arch
• 2023-02-06 KUB
  • Spondylosis of the L-spine is noted.
• 2023-01-30 CXR
  • Atherosclerotic change of aortic arch
• 2023-01-04 ECG
  • Sinus bradycardia with 1st degree A-V block
  • Nonspecific ST abnormality
• 2022-12-22 Patho - colrectal polyp
  • Rectum, 10 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
  • The sections show adenocarcinoma, moderately differentiated, composed of low columnar to couboidal neoplastic cells, arranged in glandular and cribrifrom patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
  • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
• 2022-12-20 Sigmoidoscopy
  • Rectal cancer s/p biopsy
  • Rectal polyp s/p polypectomy
• 2022-12-19 CT - abdomen
  • History and indication: A case of newly diagnosed rectal cancer at 10-14 cm AAV
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent fat stranding and regional LAP.
    • Renal cysts (up to 0.8cm).
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • Emphysema at bil. upper lungs.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T: T4a(T_value) N: N2b(N_value) M: M0(M_value) STAGE: IIIC(Stage_value)

[MedRec]

• 2023-02-16 SOAP Colorectal Surgery
  • A/P
    • radiotherapy on 2023-01-05 ~ 2023-02-13
    • CCRT with FOLFOX IV Q2W x 4~6 months
• 2023-02-21 SOAP Radiation Oncology
  • O: RT (2022-12-30 ~ 2023-02-13): 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions (15 MV photon) of the rectal tumor bed area.
• 2023-02-06 SOAP Hemato-Oncology
  • S: c/o vague abd discomfort, KUB: stool impact, give Lactulose.
• 2023-01-10 SOAP Hemato-Oncology
  • S
    • HBsAg, anti-HCV (12/26 22): negative. anti-HBc: positive… on Baraclude
    • On R/T to rectal tumor by Dr Huang Jingmin.
    • Owing to advanced stage of rectal CA, pre-Op CCRT wt FOLFOX is preferred rather than lower dose 5-FU 24 hr QD x 5 per wk x 6 plus R/T (20230110).
    • #1 pre-Op CCRT wt mFOLFOX6 IV Q2W x 3 plus R/T on 20230103.
    • Adm on 20230130 for #2 pre-Op CCRT wt mFOLFOX6 IV Q2W x 3 plus R/T.
• 2023-01-03 ~ 2023-01-05 POMR Hemato-Oncology
  • Discharge diagnosis
    • Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC).
    • Chronic viral hepatitis B without delta-agent, 2022/12/26 Anti-HBc: postive
    • Porta catheter insertion at right Internal Jugular Vein on 2023/01/4
  • Present illness
    • This a 77 year-old male, who has hypertension for years, a patient of Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC), diagnosis in Dec 2022.
    • He suffered from initial presentation of jaundice & clay-colored stool in May 2016. The palpatedv small elastic nodule, 3 cm in size, painless & non-tender, movable at upper back from June 2015. So, he went to GS OPD for help on 2022/12/19.
    • Follow-up Abdomen CT (12/19 22): Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC).
    • Sigmoidoscopy : Rectal cancer s/p biopsy. Rectal polyp s/p polypectomy on 2022/12/20.
    • The rectum, 10 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated. IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+) on 2022/12/20.
    • He was referred to our hemato-oncologic clinic on 12/26 14 by Dr Xiao Guanghong for CCRT with FOLFOX Q2W IV x 4-6 months.
    • Consult Dr. Huang Jingmin for CCRT enaluation. Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed. Starting on 2022/12/30.
    • HBsAg, Anti-HBc, Anti-HCV: negative on 12/26 22.
    • Port-a insertion on 2023/1/4 by Dr. Chen Yanzhi
    • This time, he is admitted for CCRT with FOLFOX Q2W IV x 4-6 months.
  • Course of Inpatient Treatment
    • After be admitted, he received radiotherapy with deliver 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed, since 2022/12/30 until now.
    • CCRT with #1 FOLFOX (oxalip 6070mg/m2, covorin 400mg/m2, 5-FU 2400mg/m2) IV Q2W x 6 on 1/3-1/5 22, Imperan + Promeran for vomitin, hydration, and Baraclude 0.5mg/tab 1tab QDAC for Anti-HBC(+). The port-a catheter insertion at right Internal Jugular Vein on 2023/01/04.
    • After chemotherapy, he denied having a fever, chillness, vomiting, diarrhea, and the surgery wound condition stably.
    • Under the stable condition, he can be discharged on 2023/01/05, the OPD follow-up and the next admission will be arranged.
• 2022-12-22 SOAP Radiation Oncology
  • A: Adenocarcinoma, moderately differentiated, of the rectum, EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+), stage cT4aN2bM0 (IIIC).
  • P: Radiotherapy is indicated for this patient with the following indicators: stage T4aN2bM0
    • Goal: curative
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2022-12-27.
• 2022-12-22 SOAP Colorectal Surgery
  • A: Advanced rectal cancer , cT4aN2bM0
  • P: Suggest pre-op CCRT (favor TNT) then OP
• 2022-12-19 SOAP Colorectal Surgery
  • S
    • A case of newly diagnosed rectal cancer at 10-14 cm AAV
    • PH: HTN
      
  • O
    • pre-op study
    • Arrange sigmoidoscopy for R/O colonic lesion

[surgical operation]

• 2023-08-02
  • Surgery
    • Transanal Transabdominal Total Mesorectal Excision        
  • Finding
    • Large rectal cancer s/p CCRT, narrow pelvis and the tumor and rectum occupied the pelvic cavity     
    • Tumor location: 8 cm from Av    

[radiotherapy]

• 2022-12-30 ~ 2023-02-13 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions (15 MV photon) of the rectal tumor bed area.

[chemotherapy]

• 2023-11-06 - irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (FOLFIRI Q2W 80% dose)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
• 2023-06-23 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 200mL 2hr + fluorouracil 2400mg/m2 4380mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-06-09 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 200mL 2hr + fluorouracil 2400mg/m2 4380mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-05-26 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 200mL 2hr + fluorouracil 2400mg/m2 4380mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-05-11 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4410mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-26 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4435mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-12 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4415mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-15 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4450mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-01 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-13 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-30 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4450mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-03 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4510mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-11-07

The patient’s repeat prescription from WanFang Hospital, which includes clopidogrel, nicorandil, indapamide, nifedipine, rosuvastatin, and benzbromarone, was last filled on 2023-10-17. However, not all of these medications are listed as currently active. Verification is required to determine if the medications not in use have been intentionally discontinued.

2023-05-29

• According to the PharmaCloud database, the patient had visited WanFang Hospital and a local clinic for upper respiratory symptoms in late March and early May. However, the prescriptions from these healthcare providers have now expired. No medication reconciliation issues were identified during this patient’s current admission.

2023-05-12

• According to the PharmaCloud database, the patient visited WanFang Hospital on 2023-03-27 for his unspecified chronic bronchitis and visited Dr. Wu’s local clinic on 2023-03-29 for an unspecified acute upper respiratory infection. To date, no current respiratory problems have been reported and no medication reconciliation issues have been identified.
• The patient underwent radiotherapy with 4500 cGy/25 fractions (15 MV photon) to the pelvic region and 5040 cGy/28 fractions (15 MV photon) to the rectal tumor bed from 2022-12-30 to 2023-02-13. Concurrently, the patient has been receiving chemotherapy with the FOLFOX regimen since 2023-01-03. The initial treatment plan was to reduce the tumor size for possible surgical resection. However, the CT scans of 2023-04-11 showed stable disease compared to 2023-03-16, which showed a slight regression, suggesting that the treatment may not be as effective as it once was. It would be recommended to obtain new tumor marker lab data to assist in evaluating the efficacy of the current treatment.

701476645

231106

[exam findings] (not completed)

• 2023-10-13 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Fusiform like necrotic tumor at left breast measuring 4.2cm in largest dimension is found. In comparison with CT dated on 2023-07-28, the lesion is stationary.
    • Lymphadenopathy at left axillary region is found. In enlargement.
    • Minimal interstitial change at bilateral lungs is found. However, the changes improved markedly as compared with previous CT.
  • Imp:
    • Left breast tumor. stable
    • Left axillary lymphadenopathy, in marked enlargment
    • The opacities over bilateral lungs regressed markedly.
• 2023-09-11 Patho - lymph node region resection
  • PATHOLOGIC DIAGNOSIS
    • Breast, left, partial mastectomy — Invasive carcinoma of no special type
    • Resection margin, breast, left, partial mastectomy — Free of carcinoma
    • Lymph node, axillary sentinel and axillary, LND — Metastatic carcinoma (2/4)
    • AJCC 8 th edition, Pathology stage: ypT2N1a(cM0); Anatomic stage IIB; Prognostic stage IIIA
  • MACROSCOPIC EXAMINATION
    • Breast Size: 14.5 x 11.5 x 3.8 cm
    • Skin Size: 13.0 x 3.4 cm
    • Nipple: Not retracted
    • Tumor Size: 3.4 x 1.8 x 1.0 cm
      
    • Resection Margin: Free, 1.2 cm from the deep margin
    • Lymph node: Axillary sentinel and axillary
    • Representative parts are taken for section and labeled: F2023-00408. FSA1= 12’, 3’, 6’ margins, FSA2= 9’ and deep margins, FSB= axillary sentinel LNs, A1= nipple, A2= skin + tumor, A3-A6= tumor, A7= non-tumor. S2023-18125= axillary lymph nodes
  • MICROSCOPIC EXAMINATION
    • Microscopy
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 3.4 x 1.8 x 1.0 cm
        
      • Histologic grade (Nottingham histologic score): Grade 3 (score= 8)
      • Skin involvement: Absent
      • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
    • Margins: Negative; Closest margin: 12 mm from deep margin
    • Nodal status: Metastatic carcinoma (2/4)
      • number of lymph node examined: 2 (sentinel), 2 (axillary)
      • number with macrometastases (>2mm): 2
      • number with micrometastases (>0.2~2mm and/or >200 cells): 0
      • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
      • Extranodal extension: Present
    • Treatment Effect:
      • Treatment effect in the breast: Probable or definite response to presurgical therapy in the invasive carcinoma
      • Treatment effect in the lymph nodes: Two sentinel lymph nodes metastasis. Another two axillary lymph nodes show fibrous scar, possibly related to prior lymph node metastasis with pathologic complete response
    • Lymphovascular invasion: Present
    • Perineural invasion: Absent
    • Tumor-infiltrating lymphocytes: 5%
  • IMMUNOHISTOCHEMICAL STUDY (S2023-06120)
    • ER (Ab): Negative
    • PR (Ab): Negative
    • HER-2/Neu (Ab): Negative (score 1+)
    • Ki-67: 80-90%
• 2023-09-11 Patho - lymph node region resection
  • PATHOLOGIC DIAGNOSIS
    • Breast, left, partial mastectomy — Invasive carcinoma of no special type
    • Resection margin, breast, left, partial mastectomy — Free of carcinoma
    • Lymph node, axillary sentinel and axillary, LND — Metastatic carcinoma (2/4)
    • AJCC 8 th edition, Pathology stage: ypT2N1a(cM0); Anatomic stage IIB; Prognostic stage IIIA
  • MACROSCOPIC EXAMINATION
    • Breast Size: 14.5 x 11.5 x 3.8 cm
    • Skin Size: 13.0 x 3.4 cm
    • Nipple: Not retracted
    • Tumor Size: 3.4 x 1.8 x 1.0 cm
      
    • Resection Margin: Free, 1.2 cm from the deep margin
    • Lymph node: Axillary sentinel and axillary
    • Representative parts are taken for section and labeled: F2023-00408FSA1= 12’, 3’, 6’ margins, FSA2= 9’ and deep margins, FSB= axillary sentinel LNs, A1= nipple, A2= skin + tumor, A3-A6= tumor, A7= non-tumor. S2023-18125= axillary lymph nodes
  • MICROSCOPIC EXAMINATION
    • Type
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 3.4 x 1.8 x 1.0 cm
        
      • Histologic grade (Nottingham histologic score): Grade 3 (score= 8)
      • Skin involvement: Absent
      • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
    • Margins: Negative; Closest margin: 12 mm from deep margin
    • Nodal status: Metastatic carcinoma (2/4)
      • number of lymph node examined: 2 (sentinel), 2 (axillary)
      • number with macrometastases (> 2mm): 2
      • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
      • number with isolated tumor cells (<= 0.2mm and <= 200 cells): 0
    • Extranodal extension: Present
    • Treatment Effect:
      • Treatment effect in the breast: Probable or definite response to presurgical therapy in the invasive carcinoma
      • Treatment effect in the lymph nodes: Two sentinel lymph nodes metastasis. Another two axillary lymph nodes show fibrous scar, possibly related to prior lymph node metastasis with pathologic complete response
    • Lymphovascular invasion: Present
    • Perineural invasion: Absent
    • Tumor-infiltrating lymphocytes: 5%
  • IMMUNOHISTOCHEMICAL STUDY (S2023-06120)
    • ER (Ab): Negative
    • PR (Ab): Negative
    • HER-2/Neu (Ab): Negative (score 1+)
    • Ki-67: 80-90%
• 2023-08-17 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (72 - 11.3) / 72 = 84.31%
    • M-mode (Teichholz) = 84
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Mild MR, TR and PR, trivial AR
    • No regional wall motion abnormalities
• 2023-08-10 Flow volume loop chart
  • r/o mild restrictive ventilatory defect
• 2023-07-28 CT - chest
  • Indication: Left breast invasive carcinoma, cT2N0M0, stage IIA. ER(-, 0%), PR(-, 0%), Her2/neu(-, 1+), Ki-67: 80-90%. ECOG performance: 0
  • Chest CT with and without IV contrast ehnancement shows:
    • Some lymph nodes are found at both sides of the mediastinum.
    • Diffuse ground glass opacities over both lungs are found. Chemothorapy related pneumonitis is suspected.
    • Necrotic mass at left breast measuring 2.9cm is noted. Stable.
    • Minimal bilateral pleural effusion is noted.
  • Imp:
    • Diffuse ground glass opacities over both lungs are found. Chemothorapy related pneumonitis is suspected.
• 2023-07-01 CT - chest
  • Indication: left breast cancer
  • Chest CT with and without IV contrast ehnancement shows:
    • S/p port-A placement with its tip at Superior vena cava.
    • Mass like lesion at left breast measuring 3.34cm is found. In comparison with CT dated on 2023-03-30, the lesion is stationary.
    • Small lymph nodes are found at left axillary region.
  • Imp:
    • Left breast cancer with left axillary lymph nodes s/p C/T. Stationary.
• 2023-06-05 SONO - breast
  • diagnosis
    • Highly suspicious of malignancy,with sonographic positive axillary LAP
  • treatment
    • Open biopsy
  • suggestion
    • Follow up breast sonography in next OPD visit, Admission for surgical intervention
  • BI-RADS:
    • 6-Known Biopsy - Proven Malignancy
• 2023-04-14 Patho - lymphnode biopsy
  • Labeled as “left axilla”, biopsy — invasive carcinoma.
  • Section shows lymph node with invasive carcinoma.
  • IHC stain: GATA-3 (+).
• 2023-04-14 Tc-99m MDP bone scan
  • Mildly increased activity in the lower L-spines, bilateral S-I joints and sacrum. Degenerative change may show this picture.
  • Some faint hot spots in bilateral rib cages and a faint hot spot in the left pubic bone. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, hips, right knee and both feet, compatible with benign joint lesions.
• 2023-04-13 Flow volume loop chart
  • Mild restrictive ventilatory impairment
• 2023-04-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (50 - 9) / 50 = 82.00%
    • M-mode (Teichholz) = 82
  • Conclusion:
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Trivial MR; trivial AR; mild PR.
• 2023-04-12 PD-L1 (22C3)
  • Tissue block No.: S2023-06120
  • RESULTS：
    • Combined Positive Score(CPS) assessment: CPS＜1
    • Combined Positive Score(CPS): 0.5
• 2023-04-12 Mammography
  • Impression: Dense breast.
    • Focal asymmetry in left breast, around 12’region, clinical proven malignancy.
    • Benign calcifications in bilateral breasts.
  • BI-RADS: Category 6-proven malignancy.
• 2023-03-31 Patho - breast biopsy (no need margin)
  • Breast tumor, left 1/3 cm region, core needle biopsy — Invasive carcinoma of no special type
  • Microscopically, the sections show a picture of invasive carcinoma of no special type characterized by tumor cells arranged in linear or nest pattern infiltrating in the stroma with focal necrosis and microcalcification.
  • Immunohistochemistry shows P63(-), E-cadherin(+), ER(-, 0%), PR(-, 0%), Her2/neu(-, Dako score 1+) and Ki-67: 80-90% for tumor.
• 2023-03-30 CT - chest
  • Indication: Disorder of breast, unspecified; Unspecified lump in breast
  • Chest CT with and without IV contrast ehnancement shows:
    • Low density lesion at left breast with marginal enhancement measuring 2.63cm in largest dimension. Breast cancer is considered first but infection cannot be excluded.
    • Enlarged lymph nodes are found at left axillary region.
  • Imp:
    • Left breast tumor. 2.63cm, r/o breast cancer or others.
    • Lymphadenopathy at left axillary region.
• 2023-03-27 SONO - breast
  • diagnosis
    • Highly suspicious of malignancy,with sonographic negative axillary LNs
  • treatment
    • Sono-guided biopsy, Core-needle biopsy, Open biopsy
  • suggestion:
    • Arrange mammography, Arrange breast MRI, Arrange excisional biopsy, Admission for surgical intervention
  • BI-RADS:
    • 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken

[MedRec]

• 2023-04-12 ~ 2023-04-15 POMR General and Gastrointestinal Surgery Wang ShengLin
  • Discharge diagnosis
    • Left breast invasive carcinoma status post port-A insertion on 2023/4/13. cT2N0M0, stage IIA. ER(-, 0%), PR(-, 0%), Her2/neu(-, 1+), Ki-67: 80-90%.
    • For 1st neoadjuvant chemotherpy with Lipo-dox + Endoxan + Keytruda.
  • CC
    • noted a palpable mass at left breast on 2023/03.
  • Present illness
    • This 70-year-old women patient denied any past history including DM, HTN, HBV, heart disease or cancer. She denied any TOCC histories in recent 3 months.
    • She noted a palpable mass at left breast on 2023/03. Then she came to our OPD for help. Breast SONO showed Left breast heterogenous hypoechoic lesion at 1/3cm, size:2.63cmx2.63cm, highly suspicious of malignancy, suggested core needle biopsy. Chest CT showed 1) Left breast tumor. 2.63cm, r/o breast cancer or others. 2) Lymphadenopathy at left axillary region. Left breast core needle biposy showed invasive carcinoma, ER(-, 0%), PR(-, 0%), Her2/neu(-, 1+), Ki-67: 80-90%. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss. PE:1). symmetrical of bilateral breasts. a hard, nontender, movable mass and irregular margin at left breast around 5*5cm without discharge. The left nipple was dimping without exudative nor bloody discharge and no retraction. The bilateral breast skin had no cellulite change. no clinical palpable mass in left axillary. SDM for this patient.
    • Neoadjuvent chemotherapy with Lipo-dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 and Keytruda. Operation, in the future were suggest.
    • Under the impression of left breast invasive carcinoma, she was admitted for surgery of port a insertion and 1st neoadjuvant chemotherpy with Lipo-dox 35mg/m2 + Endoxan 600mg/m2 and Keytruda.
  • Course of inpatient treatment
    • After admission, port-A insertion was performed on 2023/04/13. Bone scan and abdomen echo showed no obvious lesion for metastasis. Cardiac echo showed LVEF:82%. Lung funsion test showed Mild restrictive ventilatory impairment. SONO Guiding for marker clips for left breast tumor was done on 2023-04-14. Sono-guided biopsy for left axillary lymph node was dones on 2023-04-14, final report was pending. 1st neo-adjuvant chemotherapy with Lipo dox + Endoxan and keytruda were given. The port-A wound is clean and dry. No discomfort after chemotherapy. Under the stable condition, she was discharged today, wound will be follow up OPD. And arrange next admission three weeks later.
  • Discharge prescription
    • MgO 250mg 1# TID
    • Through (sennoside 12mg) 1# HS
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Acetal (acetaminophen 500mg) 1# QID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Emend (aprepitant 125mg) 1# QD

[surgical operation]

• 2023-09-08
  • Surgery
    • Left partial mastectomy + ALND (2/2)
  • Finding
    • Left breast cancer at 12/1cm, size: 2.5x2.2cm
    • Left axillary sentinel lymph node metastasis (2/2) -> ALND
• 2023-03-31
  • Surgery
    • Left breast core needle biopsy
  • Finding
    • Left breast heterogenous hypoechoic lesion at 1/3cm, size: 2.63cmx2.63cm

[immunochemotherapy]

• 2023-11-03 - paclitaxel 80mg/m2 120mg NS 250mL 120min (T QW adjuvant)
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-10-27 - paclitaxel 80mg/m2 120mg NS 250mL 120min (T QW adjuvant)
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-10-20 - paclitaxel 80mg/m2 120mg NS 250mL 120min (T QW adjuvant)
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-10-13 - paclitaxel 80mg/m2 118mg NS 250mL 120min (T QW adjuvant)
  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
• 2023-06-30 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 928mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-06-05 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 913mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL + lenograstim 250ug
• 2023-05-12 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 919mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-04-15 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 52mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 899mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-11-06

[leukopenia; G-CSF administration is usually begun 24 to 72 hours after cessation of chemotherapy]

Continuing from the previous pharmacist note replied on 2023-10-30.

New episodes of leukopenia were observed in late Oct and early Nov. Granocyte (lenograstim) was administered on 2023-11-03, just prior to paclitaxel chemotherapy.

• 2023-11-03 WBC 1.97 x10^3/uL
  
• 2023-10-27 WBC 1.86 x10^3/uL
  
• 2023-10-20 WBC 5.36 x10^3/uL
  
• 2023-10-13 WBC 5.27 x10^3/uL

Timing of G-CSF - When used for primary and secondary prophylaxis, therapy is usually begun 24 to 72 hours after cessation of chemotherapy. (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation)

• Macaire et al. (2020) conducted a study on the impact of granulocyte colony-stimulating factor (G-CSF) on FOLFIRINOX-induced neutropenia. They found that pegylated-G-CSF administration 24 hours after the end of chemotherapy may be an optimal schedule to reduce neutropenia. (Impact of granulocyte colony‐stimulating factor on folfirinox‐induced neutropenia prevention: a population pharmacokinetic/pharmacodynamic approach. British Journal of Clinical Pharmacology, 86(12), 2473-2485. https://doi.org/10.1111/bcp.14356)
• Mackey et al. (2020) emphasized that delaying supportive G-CSF therapy to 6-7 days after chemotherapy can mitigate myelosuppressive effects. (The timing of cyclic cytotoxic chemotherapy can worsen neutropenia and neutrophilia. British Journal of Clinical Pharmacology, 87(2), 687-693. https://doi.org/10.1111/bcp.14424)
• Salem et al. (2016) compared different post-chemotherapy G-CSF administration regimens and suggested that administration from Days 2-5 or Days 5-9 cycles may have optimal effects on immune cell recovery and antigen-specific immune responses. (Effect of administration timing of postchemotherapy granulocyte colony-stimulating factor on host-immune cell recovery and cd8+ t-cell response. Journal of Immunotoxicology, 13(6), 784-792. https://doi.org/10.1080/1547691x.2016.1194917)
• Yankelevich et al. (2008) mentioned that delaying G-CSF until 5 days after completion of chemotherapy has not resulted in a longer duration of neutropenia. (Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Experimental Hematology, 36(1), 9-16. https://doi.org/10.1016/j.exphem.2007.08.019)

2023-10-30

[leukopenia]

Several episodes of leukopenia have been observed since the start of immunochemotherapy on 2023-04-15. The most recent episode occurred on 2023-10-27 with WBC at 1.86K, neutrophil and band at 58.9%, and ANC at 1095. This coincided with the administration of adjuvant paclitaxel. Paclitaxel has a known association with leukopenia (90%; grade 4: 17%). It’s generally not recommended for patients with solid tumors who have a baseline neutrophil count below 1500/uL. If there’s a high risk of infection, the use of G-CSF is recommended.

• 2023-10-27 WBC 1.86 x10^3/uL **
• 2023-10-20 WBC 5.36 x10^3/uL
• 2023-10-13 WBC 5.27 x10^3/uL
• 2023-09-06 WBC 4.46 x10^3/uL
• 2023-08-10 WBC 5.95 x10^3/uL
• 2023-08-03 WBC 5.20 x10^3/uL
• 2023-07-31 WBC 6.15 x10^3/uL
• 2023-07-29 WBC 1.85 x10^3/uL **
• 2023-07-28 WBC 3.71 x10^3/uL
• 2023-07-06 WBC 5.56 x10^3/uL
• 2023-06-30 WBC 5.41 x10^3/uL
• 2023-06-12 WBC 2.71 x10^3/uL *
• 2023-06-05 WBC 2.71 x10^3/uL *
• 2023-06-05 WBC 3.31 x10^3/uL
• 2023-05-18 WBC 3.32 x10^3/uL
• 2023-05-11 WBC 3.92 x10^3/uL
• 2023-05-05 WBC 1.44 x10^3/uL **
• 2023-04-20 WBC 5.36 x10^3/uL
• 2023-04-12 WBC 4.24 x10^3/uL

701487478

231106

[exam findings]

• 2023-03-15 MRI - abdomen (Yonghe Cardinal Tien Hospital)
  • Irregular to nodular thickening of gallbladder wall, neogrowth cannot be ruled out, suggest further evaluation;
  • Enlarged lymph nodes in hepatic hilar, retropancreatic, paraaortic and aortocaval regions, up to 1.5cm in size, more in favor of metastatic lymphadenopathy.

[MedRec]

• 2023-07-11 SOAP Hemato-Oncology He JingLiang
  • S: 2023-07-11 first C/T with CDDP + gemzar
  • Prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Hepac Lock Flush (heprarin sodium) 10mL IRRI
• 2023-06-25 ~ 2023-07-01 POMR General and Gastrointestinal Surgery Li ChaoZhu
  • Discharge diagnosis
    • Malignant neoplasm of gallbladder
    • Gallbladder cancer, adenocarcinoma, billiary type, poorly differentiated, pT2bN1(cM1), stage IV with multiple retroperitoneal and left supraclavicular (Virchow’s node) lymph nodes metastases status post laparoscopic cholecystectomy and lymph node dissection on 2023-0626; ECOG 0
    • post Port-A insertion on 2023-06-30
  • CC
    • noted tea-colored urine, intermittent right epigastric dull pain without radiating to back on 2023/01.
  • Present illness
    • This is a 61 years old woman patient, she denied any past history including cancer, hypertention, diabetes mellitus, cancer and heart disease. She denied any TOCC histories in recent 3 months.
    • She noted tea-colored urine, intermittent right epigastric dull pain without radiating to back on 2023/01. No aggravating factors and relieving factors. She went to Yonghe Cardinal Tien Hospital and National Taiwan University Hospital for help. Abdomen magnetic resonance imaging showed 1). Irregular to nodular thickening of gallbladder wall, neogrowth cannot be ruled out, suggest further evaluation; 2). Enlarged lymph nodes in hepatic hilar, retropancreatic, paraaortic and aortocaval regions, up to 1.5cm in size, more in favor of metastatic lymphadenopathy, on 2023/3/15 in Yonghe Cardinal Tien Hospital. Due to personal reason, she for persaol reason came to our outpatient department for help. Abdominal sono showed suspicious of gallblader tumor.
    • Physical examination showed pink conjunctiva and anicteric sclera, abdomen: soft and ovoid, normal bowel sound. No tenderness, Murphy’s sign positive, rebounding pain and no tympanic percussion. She denied fever, fatigue or appetite change. She had jaundice, but no clay stool.
    • Under suspicious of gallblader tumor was impressed. After fully explaination the treatment surgical of method, this patient decided to treat surgically. She admitted for laparscopic cholecystectomy and further management.       
  • Course of inpatient treatment
    • After admission, laparoscopic cholecystectomy and laparoscopic lymph node dissection (for the pathologic report disclosed malignancy) was performed on 2023/06/26. The post-operative course was relatively smooth.
    • Due to pathology report showed Gallbladder adenocarcinoma, lymph node metastatic carcinoma, arrange bone scan, the report showed some faint hot spots in the skull.
    • Consult Hematologic-Oncology and Radiation Oncology for future treatment.
    • Consult psychosomatic medicine and an oncology psychologist for insomnia at night and psychological suicide risk factors: 13 points.
    • Follow up PET for bone scan showed some faint hot spots in the skull. PET scan showed 1). Glucose hypermetabolism in multiple lymph nodes in the retropancreatic, aortocaval and bilateral paraaortic regions, compatible with multiple metastatic lymph nodes; 2).Glucose hypermetabolism in multiple left supraclavicular lymph nodes. Metastatic lymph nodes should be watched out.
    • Port-A insertion was performed on 2023/06/30. Arrange SONO Guide biopsy-Lymph nodes (left neck) on 6/30.
    • The wound is clean and dry. Under the stable condition, she was discharged today and final report will be follow up in OPD.
  • Discharge prescription
    • MgO 250mg 1# TID
    • Acetal (acetaminophen 500mg) 1# TID
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Eurodin (estazolam 2mg) 1# HS

[chemmotherapy]

• 2023-11-06 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2400mg/m2 3900mg NS 500mL 45hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2023-10-11 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C5D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
• 2023-10-04 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C5D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
• 2023-09-20 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C4D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
• 2023-09-13 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C4D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
• 2023-08-30 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C3D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
• 2023-08-23 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C3D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
• 2023-08-09 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C2D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
• 2023-08-02 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C2D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
• 2023-07-19 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C1D8)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
• 2023-07-11 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C1D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL

Gemcitabine and cisplatin for locally advanced or metastatic biliary tract and pancreatic cancer - 2023-11-06 - https://www.uptodate.com/contents/image?imageKey=ONC%2F89633

• Cycle length: 21 days.

• Duration of therapy: Maximum of 8 cycles.

• Regimen

  • Cisplatin
    • 25 mg/m2 IV daily
    • Dilute in 1000 mL NS with 20 mEq (20 mmol) of potassium chloride and 2 grams (8 mmol) of magnesium sulfate and administer over 60 minutes. Do not administer with aluminum needles or IV sets. Follow infusion with 500 mL NS over 30 minutes.
    • Days 1 and 8
  • Gemcitabine
    • 1000 mg/m2 IV daily
    • Dilute in 250 mL NS (concentration no more than 40 mg/mL) and administer over 30 minutes after cisplatin and IV fluid.
    • Days 1 and 8

==========

2023-11-06

[reconciliation]

The patient recently renewed her prescriptions for lorazepam and alprazolam on 2023-10-31 at a community pharmacy. Alprazolam is listed as currently in use, but lorazepam is not included in the active medication list. It might be advisable to ascertain if lorazepam is no longer required.

700282560

231105

[diagnosis] - 2023-04-06 admission note

• Acute promyelocytic leukemia, not having achieved remission
• Gout, unspecified

[lab data]

2023-06-28 CMV IgM Nonreactive
2023-06-28 CMV IgM Value 0.04 Index
2023-06-28 FLT3/ITD Presence of mutation * 2023-06-28 NPM1 Undetectable
2023-06-28 PML-RARA 0.0000
2023-06-28 BCR／abl Undetectable
2023-06-28 CMV viral load assay Target not detecetedIU/mL

2023-04-22 CMV IgM Nonreactive
2023-04-22 CMV IgM Value 0.08 Index
2023-04-22 CMV_IgG Reactive
2023-04-22 CMV_IgG Value 49.0 AU/mL

2023-02-01 CMV viral load assay Target not detecetedIU/mL

2023-01-27 CMV_IgG Reactive
2023-01-27 CMV_IgG Value 22.8 AU/mL
2023-01-27 CMV IgM Nonreactive
2023-01-27 CMV IgM Value 0.12 Index

2023-01-20 BM chromosome analyz
- CYTOGENETICS LABORATORY REPORT - Chromosome Analysis： - Tissue Examined：Bone marrow - Staining Method：G-Banding - Colony number：NA - Bands level：350 - Chromosome Counts： - 45-()、46-(20)、47-()、Other-() Total-(20) - Karyotype：46,XY[20] - Interpretation： - Analysis of this bone marrow sample shows a male having 46,XY[20] karyotype. No chromosomal abnormality was detected. - Note： - ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

2023-01-17 FLT3-D835 Undetectable
2023-01-12 PML-RARA Presence of mutation *

2023-01-12 BCR/abl Undetectable
2023-01-12 FLT3/ITD Presence of mutation * 2023-01-12 NPM1 Undetectable

2023-01-10 CMV IgM Nonreactive
2023-01-10 CMV IgM Value 0.21 Index
2023-01-10 CMV_IgG Reactive
2023-01-10 CMV_IgG Value 11.8 AU/mL
2023-01-10 Anti-HBc Nonreactive
2023-01-10 Anti-HBc-Value 0.70 S/CO
2023-01-10 HBsAg Nonreactive
2023-01-10 HBsAg (Value) 0.33 S/CO
2023-01-10 Anti-HCV Nonreactive
2023-01-10 Anti-HCV Value 0.13 S/CO

[exam findings]

• 2023-06-01 CXR
  • Increased lung markings on both lower lung are noted.
• 2023-06-20 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Acute myeloid leukemia
  • Microscopically, it shows hypercellularity of marrow (approximately > 95%). Blasts are markedly increased in numbers (> 40%) and highlighted by CD34 and CD117.
  • Immunohisotchemical stain reveals CD138 (focal+, 1~2%), MPO (+), CD71 (focal+, sparse), CD61 (focal+, sparse), TdT (focal +).
• 2023-04-07, -02-27, -02-21 Body fluid cytology - CSF
  • negative
• 2023-02-02 SONO - abdomen
  • splenomegaly
  • accessory spleen
• 2023-01-19 Patho - bone marrow biopsy
  • Bone marrow, iliac, s/p chemotherapy, biopsy — hypocellularity.
  • IHC stains: CD117: <1 %; CD34: <1 %; MPO: 45-50%, CD61: <5 %; CD71: 45-50 % (of the nucleated cells).
  • REFERENCE: S2023-00105: Bone marrow, biopsy — Compatible with acute myeloid leukemia
  • Section shows piece(s) of bone marrow with 10% cellularity and M:E ratio of approximately 1:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are reduced in number.
• 2023-01-10 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (143 - 44) / 143 = 69.23%
    • M-mode (Teichholz) = 69
  • Conclusions
    • Dilated LV; normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR.
    • PICC catheter in right atrium.
• 2023-01-03 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with acute myeloid leukemia
  • The sections show hypercellular marrow (90%). The marrow space is replaced by a population of medium to large-sized immature cells with oval nucleus and moderate amount cytoplasm. The CD71+ erythroid precursors are marked decreased. Increased CD34+ and/or CD117+ blasts, constitue 40% of marrow cells. Some of blasts are positive for MPO (50%). Scattered CD68+ cells (10%) can be found. The finding is compatible with acute myeloid leukemia. Suggest bone marrow smear evaluation and clinic correlation.
• 2023-01-02 CT - abdomen
  • History and indication: Suspect perirectal abscess
  • IMP:
    • Wall thickening of rectum with adjacent fat stranding suspected malignancy.
    • Some LNs (up to 0.9cm) at paraaortic region.
    • Some calcifications at right adrenal gland.
    • Splenomegaly with focal low attenuation suspected infarct.
• 2023-01-02 Anoscopy
  • Findings
    • Stool color: normal
    • Rectal mucosa: normal
    • Anal canal: abnormal
  • Impression
    • Bloody mucus in rectum
    • Rectal edema at left & right lateral, anterior wall

[MedRec]

• 2023-10-31 ~ 2023-11-05 POMR Family Medicine Chen ZhengYu
  • Discharge diagnosis
    • Acute myeloid leukemia, FLT3/ITD mutation and NPM1 undetectable
  • CC
    • for SOB, gastric pain for 3 days and vomit blood since ysterday
  • Present illness
    • This 37-year-old man has history of acute promylocytic leukemia and perineal abscess. He received induction chemotherapy with I3A7 on 2023/01/9. Followed bone marrow biopsy on 2023/01/27 showed hypocellularity. IHC stains: CD117: <1%; CD34: <1%; MPO: 45-50%, CD61: <5%; CD71: 45-50 % (of the nucleated cells). Compatible with acute myeloid leukemia.
    • C1 reinduction chemotherapy with D3A7 was administered on 2023/02/23. C1 IT chemotherapy (Cytosar 50mg/MTX 12mg/ Hydrocortisone 30mg) weekly *5 on 2023/02/20. C2 IT on 2023/02/27. C2 Consolidation chemotherapy with D3A5 on 2023/04/07 plus C3 IT on 2023/04/07.
    • 2023/06/20 repeat bone marrow showed acute myeloid leukemia, hypercellularity of marrow (approximately > 95%). Blasts are markedly increased in numbers ( > 40%) and highlighted by CD34 and CD117. Immunohisotchemical stain reveals CD138 (focal+, 1~2%), MPO (+), CD71 (focal+, sparse), CD61 (focal+, sparse), TdT (focal +).
    • We change newly chemotherapy with C1 FLAG on 2023/06/21. C2 FLAG on 2023/07/16.
    • Rydapt 25mg/cap (Midostaurin) 2# q12h treatment during neutropenia stage. Bone marrow was done for bone marrow suppression. Family conference was done on 2023/08/17. Social worker was consulted for economic evaluation.
    • C3 FLAG-IDA as (Fudarabine 30mg/m2 = 50mg qd since 2023/08/29 ~ 2023/09/03, Ara-C 1500mg/m2 = 3150 qd since 2023/08/30 ~ 2023/09/03, Venectoclax 100 mg qd since 2023/08/29 ~ 2023/09/04 and Posaconazole 300mg qd since 2023/08/29.)
    • KP bacteremia and pneumonia over LUL during hospitalization.
    • VS explainted his refractory condition maybe can’t PBSCT.
    • Patient understood and wish hospice care later.
    • This time, he has SOB, gastric pain for 3 days and vomit blood since ysterday. Due to progress of SOB, so he was brought to our ED for help on 2023/10/30 night. At ED, he has gum bleeding and hypothermia 35.8’C. The lab data showed leukocytosis, severe anemia and thrombocytopenia. Initial blood transfusion with LRP, transamine and steroid for symptom control. Under the impression of refractory AML, so he was admitted for management on 2023/10/31.
  • Course of inpatient treatment
    • The patient was admitted to palliative ward on 31st October.
    • The patient suffered from LUQ pain while breathing, therefore we upgraded the pain control agents from tramadol to Morphine (3mg Q6H). The first two days it was effective. However, Nausea and vomitting remained, only partially improved after the presciption of Gasmin PO 1# BID and antihistamine.
    • However, the patient’s condition went down on 4th, he experienced short of breathe, Decan and steroid was given and only limited effect was seen.
    • On 5th, he was found collapsed on the ground when the caregiver was away for few minutues, duty doctor was informed and the death announcement was made at 0831 2023-11-05.

[consultation]

• 2023-07-28 Colorectal Surgery
  • Q
    • The 37 y/o man has AML /p chemotherapy with neutropenic stage. Due to anal pain and swelling, so we need your help for management.
  • A
    • This is a 37- year old man with anal pain for days
    • DRE:
      • anal fissure over 6 and 12 o’clock region, swelling over anal region
      • no obvious abscess formation
    • A: perianal pain and anal fissure, R/I AML induced
    • P:
      • warm water sitz bath
      • alcos anal ointment topic use
      • pain control
      • control underlying disease
• 2023-07-05 Denatal
  • Q
    • This 37 year old male is a case of Acute promylocytic leukemia status post induction chemotherapy with D3A7 on 2023/01/09, Consolidation chemotherapy with D3A7 plus weekly IT on 2023/02/20, transformation to Acute myeloid leukemia, FLT3/ITD mutation in 2023-06. FLAG was administered on 2023/06/21-27. However, a swelling mass was noted on left buccal. We need your expertise for further management, thanks
  • A
    • Patient complains of left lower facial pain.
    • Take panoramic radiography for examination.
    • #35 suspect dental caries with no symptoms.
    • Oral hygiene instructions with ultra-soft tooth brush.
    • Suggest follow up closely and visit dental OPD endodontic clinic if symptoms persist.
• 2023-05-02 Dermatology
  • Q
    • for skin rash, redness and itchy around waist, and bilateral groins due to suspect allergy
    • This 36 y/o male patient is a case of acute promyelocytic leukemia post induction chemotherapy. Due to neutropenia fever, so gave antibitic with Cefepime, Targocid treatment since 2023/04/19, then he suffered from skin rash, rednessand itchy around waist, and bilateral groins due to suspect allergy.
    • We would like to consult your expertise, thank you!
  • A
    • The patient had sufferred from erythematous macules with hyperpigmentation change over trunk and axilla.
      
    • Under the impression of frictional eczema with secondary candidasis infestation.
    • The following suggetion:
      • keep regional body dry and clean.
      • Zalaine cream 1 tube topical QN use for large area of the pigmetation lesions and Mycomb cream 1 tube topical bid use over itchy lesions.
      • consider sinbaby lotion 1 bot topical PRN use for body occlussion/pruritus control.
• 2023-03-15 Colorectal Surgery
  • Q
    • This is a 36 years old male with acute promylocytic leukemia and perineal abscess under chemotherapy
    • He suffered from intermittent perianal pain and swelling. High fever was noted and perianal pain progressed. He denied diarrhea or constipation. He visited our CRS outpatient department for help. Digital rectal examination showed no blood on the finger, nor palpable mass in the distance of finger length, nor palpable abscess cavity. Anoscopy showed normal color stool, normal rectal mucosa, while bloody mucus in rectum, rectal edema at left & right lateral, anterior wall were noted.
    • We would like to consult your expertise, thank you!
  • A
    • DRE: mild tendernes(+), no definite perianal abscess or fistula formation, mild hemorrhoids
    • A: Anal pain, R/O perianal infection
    • P:
      • Neomycin ointment bid use
      • Because no definite perianal abscess or fistula formation, surgical intervention is not necessary at present
      • CRS OPD follow-up
      • Please inform us if any problems
• 2023-03-07 Infectious Disease
  • Q
    • Backline controlled antibiotics, consultation with an infectious disease specialist is required.
  • A
    • This is acse of AML with neutropenic fever.
    • Agree with your use of mepem and targocid.
    • Please adjust antibiotic according to culture results and clinical conditions.
• 2023-01-28 Colorectal Surgery
  • Q
    • This 36 y/o male patient is a case of acute promyelocytic leukemia post induction chemotherapy with WBC tending to improve but still in severe neutropenic stage. We need your expertise for anal pain evaluation and recommendation, sincerely thanks.
  • A
    • I’ve visited this case.
    • PR: left lateral perianal superficial fistula tract and shallow ulcer, well drained  no abscess formation and no perianal infection sign
    • Suggestion
      • Treat underlying disease
      • Biomycin oint topical use
      • Pain control using NSAID or Paran (acetaminophen) if no contraindication
• 2023-01-03 Hemato-Oncology
  • Q
    • For suspect acute leukemia,
    • This 36 year old man without underlying history was admitted with suspect perianal abscess.
    • Digital rectal examination showed no blood on the finger nor palpable mass in the distance of finger length. No palpable abscess cavity.
    • Anoscopy showed normal color stool, normal rectal mucosa, bloody mucus in rectum, rectal edema at left & right lateral, anterior wall.
    • Lab data showed
      • WBC (163720), Blast (66%), promyelocyte (3%), myelocyte (1%), metamyelocyte (1%)
      • Hb (9.4), PLT (26000), Cr (1.56), total bilirubin (2.6), AST (75), ALT(65)
      • Under the impression of suspect perianal abscess and suspect acute leukemia, he was admitted to our ward for further care.
  • A
    • Recommendation:
      • bone marrow with special stain, flowcytometer and chromosome study is indicated for this patient.
      • alkalinzation of urine with sodium bicarbonate to prevent tumor lysis syndrome
      • emperic antibiotics

[chemotherapy]

• 2023-07-19 - fludarabine 30mg/m2 50mg NS 100mL 30min D1-6 + cytarabine 2000mg/m2 4200mg NS 500mL 4hr D1-5 (FLAG, Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-6
• 2023-06-21 - fludarabine 30mg/m2 50mg NS 100mL 30min D1-6 + cytarabine 2000mg/m2 4200mg NS 500mL 4hr D1-5 (FLAG, Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-6
• 2023-04-12 - [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal)
• 2023-04-07 - daunorubicin 45mg/m2 90mg NS 100mL 30min D1-3 + cytarabine 2000mg/m2 4000mg NS 500mL 3hr Q12H D1-5 + [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal) D1
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
• 2023-02-27 - [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal)
• 2023-02-23 - daunorubicin 45mg/m2 80mg NS 100mL 30min D1-3 + cytarabine 200mg/m2 390mg NS 500mL 24hr D1-7
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
• 2023-02-21 - [cytarabine 50mg + methotrexate 12mg + hydrocortisone 30mg] IT (intrathecal)
• 2023-01-09 - idarubicin 12mg/m2 24mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 200mg NS 500mL 24hr D1-7
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1

Granocyte (lenograstim 250ug) CGRAN01

• 2023-03-03 ~ 2023-03-14
• 2023-01-18 ~ 2023-01-31

G-CSF (filgrastim 150ug) CGCSF01

• 2023-03-03 ~ 2023-03-14
• 2023-01-18 ~ 2023-01-31

2023-01-13 - tretinoin 50mg

[note]

Rydapt (midostaurin) — 2023-08-31 - https://www.uptodate.com/contents/midostaurin-drug-information

• Dosing - Adult - Acute myeloid leukemia (AML), FLT3-positive: Oral:
  • Induction: 50 mg twice daily on days 8 to 21 of each induction cycle (in combination with daunorubicin and cytarabine); administer a second induction cycle if there is definitive evidence of (clinically significant) residual leukemia.
  • Consolidation: 50 mg twice daily on days 8 to 21 of each 28-day consolidation cycle (in combination with high-dose cytarabine) for 4 consolidation cycles.
  • Maintenance (off- label): 50 mg twice daily on days 1 to 28 of each 28-day maintenance cycle for 12 cycles or until relapse, whichever occurs first.

Chemotherapy regimens for relapsed or refractory acute myeloid leukemia (AML) in adults — 2023-07-04 - https://www.uptodate.com/contents/image?imageKey=HEME%2F82823

• Cytarabine plus daunorubicin
  • Common nonhematologic side effects seen in the majority of patients include stomatitis (mostly mild), alopecia, nausea and vomiting (10 percent severe), and diarrhea (mostly mild). Daunorubicin can be associated with an infusion reaction and cardiac arrhythmias; a flu-like syndrome and rash due to cytarabine may be seen during induction.
  • Re-induction with cytarabine plus daunorubicin will produce a complete remission in approximately 50 percent of patients with a first remission lasting longer than one year[1].
• High-dose cytarabine (HiDAC)
  • The most common nonhematologic toxicities are nausea and vomiting, abnormal liver chemistries, diarrhea, conjunctivitis, rash, and cerebellar dysfunction. Toxicity is high in most patients over the age of 60 years.
  • HiDAC may be effective in 35 to 40 percent of patients resistant to conventional dose cytarabine regimens[2].
• High-dose cytarabine plus mitoxantrone (HAM)
  • In addition to the side effects described for HiDAC above, nonhematologic toxicities include stomatitis, infections, and neutropenic fever. Infrequent transient, mild cardiac failure and tachyarrhythmias have also been reported.
  • If an anthracycline (eg, daunorubicin) was not used during initial induction, the combination of HiDAC plus the synthetic anthracycline analogue, mitoxantrone, may produce higher response rates than HiDAC alone[3].
• High-dose cytarabine plus etoposide
  • In addition to the side effects described for HiDAC above, nonhematologic toxicities include hepatic toxicity, peripheral neuropathy, and anaphylactic-like reaction.
  • HiDAC plus etoposide results in similar response rates as HiDAC alone with a nonsignificant trend towards longer remission duration[4].
• Mitoxantrone plus etoposide
  • Nonhematologic toxicities include stomatitis, nausea, infections, and neutropenic fever. Infrequent transient, mild cardiac failure and tachyarrhythmias have also been reported.
  • Mitoxantrone and etoposide given together for five days is a commonly used regimen to treat refractory or relapsed AML and has demonstrated complete response rates of approximately 40 percent[5].
• Mitoxantrone, etoposide, cytarabine (MEC)
  • Side effects are similar to those described for mitoxantrone plus etoposide above, but also include hepatic dysfunction.
  • MEC demonstrates a trend towards higher complete response rates for patients <60 years old and those with unfavorable risk cytogenetics when compared with mitoxantrone plus etoposide alone[6].
• Gemtuzumab ozogamicin (GO) as a single agent or plus cytarabine and mitoxantrone
  • Serious adverse reactions to GO include fatal anaphylaxis, hemorrhage, teratogenicity, and hepatic injury including sinusoidal obstruction syndrome (also known as hepatic veno-occlusive disease), plus side effects similar to mitoxantrone plus cytarabine, above.
  • GO as a single agent or in combination with mitoxantrone plus cytarabine can achieve complete remission in up to 25 to 35 percent[7].
• Fludarabine, cytarabine, plus G-CSF (FLAG)
  • Studies including older adults have reported mild nonhematologic toxicity, most commonly with mucositis.
  • FLAG has reported complete remission rates of 45 to 55 percent in patients with primary refractory or relapsing AML[8].
• Cladribine, cytarabine, G-CSF (CLAG)
  • Nonhematologic toxicity is generally mild to moderate (grade I/II) and includes fever/infection, mucositis, nausea and vomiting, diarrhea, and alopecia.
  • CLAG results in a complete remission in approximately 50 percent of patients, with a median duration of response of 16 weeks[9].
• Cyclophosphamide plus high-dose etoposide
  • The most common non-hematologic toxicities include fever/infection, mucositis, hepatic toxicity, and hemorrhagic cystitis.
  • Approximately 42 percent of patients with resistant AML will achieve a complete remission[10].
• Patients with resistant or relapsed AML should be encouraged to enroll on a clinical trial. While a number of chemotherapy regimens have been used for patients with resistant or relapsed disease, none results in acceptable long term remission rates. Many of these combinations are dose-intensive and cannot easily be applied in older patients. Since these regimens have not been directly compared, a choice is primarily based upon clinical experience and patient co-morbidities. A selection of these regimens is described above. Although response rates are presented for some of these regimens, an individual’s chance of responding to a particular regimen is influenced not only by prior exposure to chemotherapy but also by other patient- and leukemia-associated factors. In theory, the preferred regimen to treat relapsed AML would exclude agents at dose levels which the patient has been exposed to recently.

Cytarabine — 2023-04-12 - https://www.uptodate.com/contents/cytarabine-conventional-drug-information

• Dosing: Adult - Note: Antiemetics may be recommended to prevent nausea and vomiting; IV doses >1,000 mg/m2 are associated with a moderate emetic potential. Consider hydration and antihyperuricemic therapy to prevent tumor lysis syndrome.
  • Acute lymphoblastic leukemia (off-label dosing):
    • Induction regimen, relapsed or refractory: IV: 3,000 mg/m2 over 3 hours daily for 5 days (in combination with idarubicin [day 3]).
    • Dose-intensive regimen: IV: 3,000 mg/m2 over 2 hours every 12 hours days 2 and 3 (4 doses/cycle) of even numbered cycles (in combination with methotrexate; alternates with Hyper-CVAD).
    • CALGB 8811 regimen:
      • Early-intensification phase: SUBQ: 75 mg/m2/dose days 1 to 4 and 8 to 11 (4-week cycle; repeat once).
      • Late-intensification phase: SUBQ: 75 mg/m2/dose days 29 to 32 and 36 to 39.
    • Linker protocol: Adults <50 years of age: IV: 300 mg/m2/day days 1, 4, 8, and 11 of even numbered consolidation cycles (in combination with teniposide).
    • CALGB 10403 regimen (as part of multi-agent, multicourse chemotherapy; refer to protocol for further details):
      • Adults <40 years of age:
        • Remission consolidation phase (course 2): IV, SUBQ: 75 mg/m2 on days 1 to 4, 8 to 11, 29 to 32, and 36 to 39.
        • Delayed intensification phase (course 4): IV, SUBQ: 75 mg/m2 on days 29 to 32 and 36 to 39.
  • Acute myeloid leukemia remission induction
    • Standard-dose; in combination with other chemotherapy agents): IV: 100 mg/m2/day continuous infusion for 7 days or 200 mg/m2/day continuous infusion (as 100 mg/m2 over 12 hours every 12 hours) for 7 days.
    • 7 + 3 regimens (a second induction course may be administered if needed; refer to specific references): IV: 100 mg/m2/day continuous infusion for 7 days (in combination with daunorubicin or idarubicin or mitoxantrone) or (Adults <60 years) 200 mg/m2/day continuous infusion for 7 days (in combination with daunorubicin).
    • Low-intensity therapy (off-label dosing):
      • Adults >=65 years of age: SUBQ: 20 mg/m2/day for 14 days out of every 28-day cycle for at least 4 cycles or 10 mg/m2 every 12 hours for 21 days; if complete response not achieved, may repeat a second course after 15 days.
      • Adults >=60 years of age (and ineligible for intensive chemotherapy): SUBQ : 20 mg/m2 once daily on days 1 to 10 every 28 days (in combination with venetoclax) until disease progression or unacceptable toxicity.
      • Adults >=55 years of age (and unsuitable for intensive therapy): SUBQ : 20 mg (flat dose) twice daily on days 1 to 10 every 28 days (in combination with glasdegib) until disease progression or unacceptable toxicity.
  • Acute myeloid leukemia consolidation (off-label use):
    • 5 + 2 regimens: IV: 100 mg/m2/day continuous infusion for 5 days (in combination with daunorubicin or idarubicin or mitoxantrone).
    • 5 + 2 + 5 regimen: IV: 100 mg/m2/day continuous infusion for 5 days (in combination with daunorubicin and etoposide).
    • Single-agent: Adults <=60 years of age: IV: 3,000 mg/m2 over 3 hours every 12 hours on days 1, 3, and 5 (total of 6 doses); repeat every 28 to 35 days for 4 courses.
  • Acute myeloid leukemia salvage treatment (off-label use):
    • CLAG regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with cladribine and G-CSF); may repeat once if needed.
    • CLAG-M regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with cladribine, G-CSF, and mitoxantrone); may repeat once if needed.
    • FLAG regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with fludarabine and G-CSF); may repeat once if needed.
    • GCLAC regimen: Adults 18 to 70 years:
      • Induction: IV: 2,000 mg/m2 over 2 hours once daily for 5 days (in combination with clofarabine and filgrastim; administer 4 hours after initiation of clofarabine); may repeat induction once if needed.
      • Consolidation: IV: 1,000 mg/m2 over 2 hours once daily for 5 days (in combination with clofarabine and filgrastim; administer 4 hours after initiation of clofarabine) for 1 or 2 cycles.
    • HiDAC (high-dose cytarabine) ± an anthracycline: IV: 3,000 mg/m2 over 1 hour every 12 hours for 6 days (total of 12 doses).
    • MEC regimen: IV: 1,000 mg/m2/day over 6 hours for 6 days (in combination with mitoxantrone and etoposide) or
      • Adults <60 years of age: IV: 500 mg/m2/day continuous infusion days 1, 2, and 3 and days 8, 9, and 10 (in combination with mitoxantrone and etoposide); may administer a second course if needed.
  • Acute promyelocytic leukemia induction (off-label dosing): IV: 200 mg/m2/day continuous infusion for 7 days beginning on day 3 of treatment (in combination with tretinoin and daunorubicin).
  • Acute promyelocytic leukemia consolidation (off-label use):
    • In combination with idarubicin and tretinoin: High-risk patients (WBC >=10,000/mm3): Adults <=60 years of age:
      • First consolidation course: IV: 1,000 mg/m2/day for 4 days.
      • Third consolidation course: IV: 150 mg/m2 every 8 hours for 4 days.
    • In combination with idarubicin, tretinoin, and thioguanine: High-risk patients (WBC >10,000/mm3): Adults <=61 years of age:
      • First consolidation course: IV: 1,000 mg/m2/day for 4 days.
      • Third consolidation course: IV: 150 mg/m2 every 8 hours for 5 days.
    • In combination with daunorubicin:
      • First consolidation course: IV: 200 mg/m2/day for 7 days.
      • Second consolidation course:
        • Age <=60 years and low risk (WBC <10,000/mm3): IV: 1,000 mg/m2 every 12 hours for 4 days (8 doses).
        • Age <50 years and high risk (WBC >=10,000/mm3): IV: 2,000 mg/m2 every 12 hours for 5 days (10 doses).
        • Age 50 to 60 years and high risk (WBC >=10,000/mm3): IV: 1,500 mg/m2 every 12 hours for 5 days (10 doses).
        • Age >60 years and high risk (WBC >=10,000/mm3): IV: 1,000 mg/m2 every 12 hours for 4 days (8 doses).
  • Chronic lymphocytic leukemia (off-label use): OFAR regimen: IV: 1,000 mg/m2/dose over 2 hours days 2 and 3 every 4 weeks for up to 6 cycles (in combination with oxaliplatin, fludarabine, and rituximab).
  • Hodgkin lymphoma, relapsed or refractory (off-label use):
    • DHAP regimen: IV: 2,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) for 2 cycles (in combination with dexamethasone and cisplatin).
    • ESHAP regimen: IV: 2,000 mg/m2 day 5 (in combination with etoposide, methylprednisolone, and cisplatin) every 3 to 4 weeks for 3 or 6 cycles.
    • Mini-BEAM regimen: IV: 100 mg/m2 every 12 hours days 2 to 5 (total of 8 doses) every 4 to 6 weeks (in combination with carmustine, etoposide, and melphalan).
    • BEAM regimen (transplant preparative regimen): IV: 200 mg/m2 twice daily for 4 days beginning 5 days prior to transplant (in combination with carmustine, etoposide, and melphalan).
  • Non-Hodgkin lymphomas (off-label use):
    • BEAM regimen (transplant-preparative regimen): IV: 200 mg/m2 twice daily for 3 days beginning 4 days prior to transplant (in combination with carmustine, etoposide, and melphalan) or 100 mg/m2 over 1 hour every 12 hours for 4 days beginning 5 days prior to transplant (in combination with carmustine, etoposide, and melphalan).
    • Burkitt lymphoma:
      • CALGB 9251 regimen: Cycles 2, 4, and 6: IV: 150 mg/m2/day continuous infusion days 4 and 5.
      • CODOX-M/IVAC regimen:
        • Adults <=60 years of age: Cycles 2 and 4 (IVAC): IV: 2,000 mg/m2 every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
        • Adults <=65 years of age: Cycles 2 and 4 (IVAC): IV: 2,000 mg/m2 over 3 hours every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
        • Adults >65 years of age: Cycles 2 and 4 (IVAC): IV: 1,000 mg/m2 over 3 hours every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
      • Hyper-CVAD alternating with high-dose methotrexate/cytarabine regimen:
        • Adults <60 years of age: Cycles 2, 4, 6, and 8: IV: 3,000 mg/m2 every 12 hours days 2 and 3 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate and leucovorin), alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) plus rituximab (in cycles 1 to 4) and CNS prophylaxis.
        • Adults >=60 years of age: Cycles 2, 4, 6, and 8: IV: 1,000 mg/m2 every 12 hours days 2 and 3 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate and leucovorin) alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) with rituximab (in cycles 1 to 4) and CNS prophylaxis.
    • Mantle cell lymphoma:
      • R-DHAP regimen: Adults <=65 years of age: IV: 2,000 mg/m2 every 12 hours on day 2 (total of 2 doses/cycle) every 3 weeks (in combination with rituximab plus dexamethasone and cisplatin) for 4 cycles or 2,000 mg/m2 every 12 hours on day 2 (total of 2 doses/cycle; in combination with rituximab plus dexamethasone and cisplatin) alternating with R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) for 6 cycles (3 cycles each of R-CHOP and R-DHAP).
      • RBAC regimen: IV: 500 to 800 mg/m2 over 2 hours (starting 2 hours after bendamustine) on days 2 through 4 every 28 days for up to 6 cycles (in combination with rituximab and bendamustine).
      • Nordic regimen:
        • Adults <=60 years of age: IV: 3,000 mg/m2 over 3 hours every 12 hours for a total of 4 doses (in combination with rituximab) for 2 cycles alternating with Maxi-CHOP (dose-intensified CHOP) for 3 cycles (total of 5 cycles).
        • Adults >60 years of age: IV: 2,000 mg/m2 over 3 hours every 12 hours for a total of 4 doses (in combination with rituximab) for 2 cycles alternating with Maxi-CHOP for 3 cycles (total of 5 cycles).
      • Hyper-CVAD alternating with high-dose methotrexate/cytarabine regimen:
        • Adults <=60 years of age: Cycles 2, 4, 6, and 8: IV: 3,000 mg/m2 every 12 hours days 3 and 4 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate, leucovorin, and rituximab), alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, dexamethasone, and rituximab).
        • Adults >60 years of age: Cycles 2, 4, 6, and 8: IV: 1,000 mg/m2 every 12 hours days 3 and 4 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate, leucovorin, and rituximab) alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, dexamethasone, and rituximab).
    • Relapsed or refractory non-Hodgkin lymphomas:
      • DHAP regimen:
        • Adults <=70 years of age: IV: 2,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) every 3 to 4 weeks for 6 to 10 cycles (in combination with dexamethasone and cisplatin).
        • Adults >70 years of age: IV: 1,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) every 3 to 4 weeks for 6 to 10 cycles (in combination with dexamethasone and cisplatin).
      • ESHAP regimen: IV: 2,000 mg/m2 over 2 hours day 5 every 3 to 4 weeks for 6 to 8 cycles (in combination with etoposide, methylprednisolone, and cisplatin).
  • Primary CNS lymphoma (off-label use): IV: 2,000 mg/m2 over 1 hour every 12 hours days 2 and 3 (total of 4 doses) every 3 weeks (in combination with methotrexate and followed by whole brain irradiation) for a total of 4 courses or 3,000 mg/m2 (maximum dose of 6,000 mg) over 3 hours on days 1 and 2 every 4 weeks for 2 cycles (administer cytarabine after 5 to 7 cycles of the induction R-MPV regimen [rituximab, methotrexate, leucovorin, vincristine, and procarbazine] and whole brain radiation therapy) or 2,000 mg/m2 over 2 hours every 12 hours days 1 to 4 (total of 8 doses) as consolidation therapy (in combination with etoposide); cytarabine/etoposide is administered following remission induction with methotrexate, leucovorin, temozolomide, and rituximab.
  • Meningeal leukemia: Intrathecal therapy: Note: Optimal intrathecal chemotherapy dosing should be based on age rather than on body surface area (BSA); CSF volume correlates with age and not to BSA. Dosing provided in the manufacturer’s labeling is BSA-based.
  • Off-label uses or doses for intrathecal therapy:
    • CNS prophylaxis (ALL): Intrathecal: 100 mg weekly for 8 doses, then every 2 weeks for 8 doses, then monthly for 6 doses (high-risk patients) or 100 mg on day 7 or 8 with each chemotherapy cycle for 4 doses (low risk patients) or 16 doses (high-risk patients) or 70 mg on day 1 of remission induction cycle 1 (adults <40 years of age).
      • or as part of intrathecal triple therapy (TIT): Intrathecal: 40 mg days 0 and 14 during induction, days 1, 4, 8, and 11 during CNS therapy phase, every 18 weeks during intensification and maintenance phases.
    • CNS prophylaxis (APL, as part of TIT): Intrathecal: 50 mg per dose; administer 1 dose prior to consolidation and 2 doses during each of 2 consolidation phases (total of 5 doses).
    • CNS prophylaxis (Burkitt lymphoma; component of CODOX-M/IVAC regimen): Intrathecal: 70 mg on days 1 and 3 of cycles 1 and 3 (CODOX-M cycle).
    • CNS prophylaxis (Burkitt lymphoma; component of Hyper-CVAD alternating with cytarabine/methotrexate regimen): Intrathecal: 100 mg on day 7 of each 21-day treatment cycle.
    • CNS leukemia treatment (ALL, as part of TIT): Intrathecal: 40 mg twice weekly until CSF cleared.
    • CNS lymphoma treatment: Intrathecal: 50 mg twice a week for 4 weeks, then weekly for 4 to 8 weeks, then every other week for 4 weeks, then every 4 weeks for 4 doses.
    • CNS treatment (Burkitt lymphoma; component of CODOX-M/IVAC regimen): Intrathecal: 70 mg on days 1, 3, and 5 of cycles 1 and 3 (CODOX-M cycle) and 70 mg on days 7 and 9 of cycles 2 and 4 (IVAC cycle).
    • Leptomeningeal metastases treatment: Intrathecal: 25 to 100 mg twice weekly for 4 weeks, then once weekly for 4 weeks, then a maintenance regimen of once a month or 40 to 60 mg per dose.
  • Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance.

FLAG-IDA for acute myeloid leukemia — 2023-07-04 - https://aml-hub.com/medical-information/flag-ida-for-acute-myeloid-leukemia

FLAG-Ida for Acute Myeloid Leukaemia (AML) — 2023-07-04 - https://media.leukaemiacare.org.uk/wp-content/uploads/FLAG-Ida-for-Acute-Myeloid-Leukaemia-AML-Web-Version.pdf

FLAG (fludarabine + high-dose cytarabine + G-CSF): an effective and tolerable protocol for the treatment of ‘poor risk’ acute myeloid leukemias — https://pubmed.ncbi.nlm.nih.gov/7526088/

• Twenty-eight patients with poor prognosis acute myeloid leukemia (AML) received therapy with two courses of fludarabine 30 mg/m2/day + ara-C 2 g/m2/day (days 1-5) and G-CSF 5 mg/kg/day (FLAG) (from day 0 to polymorphonuclear recovery).

==========

2023-08-31

[Posanol (posaconazole) initial dose may be insufficient]

For prophylactic treatment against invasive fungal infections, the package insert recommends administering Posanol (posaconazole) at a dose of 300 mg twice on the first day, followed by 300 mg daily thereafter.

Failing to administer the medication twice on the initial day could potentially compromise or delay its intended effects.

2023-08-01

[pancytopenia]

Rydapt (midostaurin 25 mg) 2# PO Q12H has been initiated since 2023-07-28. The package insert recommends taking the medication with food. Please ensure that the patient takes the medication with food Q12H.

The following adverse drug reactions and incidences are associated with midostaurin:

• Hematologic and oncologic:
  • Anemia (60%; grade >=3: 38%)
  • Leukopenia (61%; grade >=3: 19%)
  • Lymphocytopenia (66%; grade >=3: 42%)
  • Neutropenia (49%; grade >=3: 22%)
  • Thrombocytopenia (50%; grade >=3: 27%)
• Hepatic:
  • Hyperbilirubinemia (29%)
  • Increased gamma-glutamyl transferase (35%)
  • Increased serum alanine aminotransferase (31%)
  • Increased serum alkaline phosphatase (39%)
  • Increased serum aspartate aminotransferase (32%)

Since pancytopenia had already developed before this drug administration, it would be difficult to distinguish to what extent the subsequent pancytopenia would gradually be attributed to midostaurin (if any).

2023-07-27

[pancytopenia]

Both fludarabine and cytarabine, which are components of the FLAG regimen, are known to cause bone marrow suppression, especially fludarabine.

The patient received two cycles of the FLAG regimen, one on 2023-06-21 and the other on 2023-07-19. The first cycle resulted in a 5-day period (2023-06-28 to 2023-07-02) of WBC < 1K/uL, and the second cycle resulted in WBC < 1K/uL since 2023-07-24, which has not yet returned to levels above 1K/uL. Thrombocytopenia was previously mentioned in the pharmacist’s note. The HGB levels show a similar trend to the PLT levels. In addition, the patient has received several blood transfusions this year on different dates (2023-01-02, 2023-01-06, 2023-01-11, 2023-01-18, 2023-01-22, 2023-01-26, 2023-01-28, 2023-01-30, 2023-02-03, 2023-03-03, 2023-03-07, 2023-03-11, 2023-03-17, 2023-04-14, 2023-04-18, 2023-04-22, 2023-04-26, 2023-04-30, 2023-06-19, 2023-06-28, 2023-07-17, 2023-07-21, 2023-07-25) and also received G-CSF in the first quarter of this year.

2023-07-07

The FLAG regimen was initiated on 2023-06-21. However, the current thrombocytopenia event had started even before the regimen was administered. Visually estimating the platelet count before and after the FLAG administration, the values were approximately within the range of 50 +- 25 K/uL, and there was no clear downward trend. This is because the patient had received multiple transfusions to maintain PLT a certain level.

2023-07-06 PLT 55 x10^3/uL
2023-07-04 PLT 25 x10^3/uL
2023-07-02 PLT 48 x10^3/uL
2023-06-30 PLT 23 x10^3/uL
2023-06-28 PLT 62 x10^3/uL Blood Transfution
2023-06-26 PLT 37 x10^3/uL
2023-06-25 PLT 47 x10^3/uL
2023-06-24 PLT 73 x10^3/uL
2023-06-23 PLT 28 x10^3/uL Blood Transfution 2023-06-22 PLT 40 x10^3/uL
2023-06-21 PLT 54 x10^3/uL FLAG 2023-06-20 PLT 47 x10^3/uL
2023-06-19 PLT 19 x10^3/uL Blood Transfution 2023-06-08 PLT 70 x10^3/uL
2023-05-04 PLT 247 x10^3/uL
2023-05-02 PLT 176 x10^3/uL
2023-05-01 PLT 137 x10^3/uL Blood Transfution (2023-04-30)

The risk of bleeding generally increases with platelet counts below 40 to 50 K/uL, but there isn’t a strong linear correlation between platelet count and bleeding risk. If major or life-threatening bleeding occurs, platelet transfusions should be administered without delay.

2023-07-04

[FLT3 inhibitors]

• Laboratory data from 2023-01-12 and 2023-06-28 indicated the presence of FLT3/ITD mutation.

• There are two FDA approved FLT3 inhibitors for AML included in the National Health Insurance Medication Reimbursement Regulations, namely:

  • Midostaurin (such as Rydapt)
    • This is reserved for use in combination with standard induction and consolidation chemotherapy in adult patients newly diagnosed with FLT3 mutation positive AML.
    • Patients with acute promyelocytic leukemia (APL) must be excluded.
    • For first-time use during the standard induction period, pre-examination is not required, and it is limited to two courses. If complete remission is not achieved after two courses, further use is prohibited.
    • For continuous use, it must be approved after pre-examination. Applications must include the results and date of the FLT3 mutation positive test, the record of chemotherapy prescription, and the evaluation of treatment effect. Each renewal application is limited to two courses and must include the evaluation results from the previous treatment to confirm no disease progression. The total treatment courses are capped at six per patient.
    • If a patient undergoes hematopoietic stem cell transplantation, this drug will no longer be covered.
  • Gilteritinib (such as Xospata)
    • This is restricted to use in adult patients with FLT3-mutated relapsed or refractory acute myeloid leukemia (R/R AML) who are planning to undergo hematopoietic stem cell transplantation. It is limited to use before transplantation, with a maximum of six treatment courses per patient. Patients must have received at least one chemotherapy course including an anthracycline drug.

• Currently, Rydapt is a temporarily procured drug at our hospital, and Xospata does not have a built drug code yet. If any of these two drugs is considered further use, a temporary procurement procedure must be carried out.

2023-04-19

[neutropenia follow-up]

• The patient received daunorubicin for a 3-day course and cytarabine for a 5-day course at a dosage of 2000mg/m2 with 4000mg every 12 hours, on 2023-04-07. The patient’s WBC count dropped below 1000/uL beginning on 2023-04-14. As a result, lenograstim at 250ug and filgrastim at 150ug have been given daily from that date onwards. However, the patient’s WBC count has not yet returned to normal levels at this time.
  • 2023-04-18 WBC 0.10 x10^3/uL
    
  • 2023-04-16 WBC 0.15 x10^3/uL
    
  • 2023-04-14 WBC 0.56 x10^3/uL
    
  • 2023-04-12 WBC 1.51 x10^3/uL
• The patient is in good spirits and has no chills. His diet and sleep are satisfactory, and his diarrhea symptoms have improved as of the morning of 2023-04-19.
• Please remain vigilant for any signs of infection.

2023-04-12

[leukopenia]

• On 2023-01-09, the patient started a regimen containing anthracycline and cytarabine (idarubicin for 3 days + cytarabine for 7 days), which led to more than 2 weeks of leucopenia with a WBC count of less than 1000/uL. More than 5 weeks later, on 2023-02-23, the second dose was shifted to daunorubicin for 3 days and cytarabine for 7 days. This time, the duration of WBC less than 1000/uL was approximately halved to 1 week. Although the patient was administered G-CSF (filgrastim 150ug) and Granocyte (lenograstim 250ug) on 2023-03-03, WBC count did not appear to increase soon after.

• On 2023-04-07, the patient received daunorubicin for 3 days and cytarabine for 5 days at a more intensive dose of 2000mg/m2 amounting to 4000mg every 12 hours. After the administration, the WBC count has not dropped below 1000/uL and there has been a reduction in the severity of leukopenia to date.

• WBC lab data

  • 2023-04-12 WBC 1.51 x10^3/uL
    
  • 2023-04-10 WBC 4.54 x10^3/uL
    
  • 2023-04-06 WBC 13.52 x10^3/uL
    
  • 2023-03-24 WBC 6.18 x10^3/uL
    
  • 2023-03-17 WBC 7.11 x10^3/uL
    
  • 2023-03-15 WBC 8.61 x10^3/uL
    
  • 2023-03-13 WBC 1.41 x10^3/uL
    
  • 2023-03-11 WBC 0.49 x10^3/uL
    
  • 2023-03-09 WBC 0.54 x10^3/uL
    
  • 2023-03-07 WBC 0.48 x10^3/uL
    
  • 2023-03-05 WBC 0.83 x10^3/uL
    
  • 2023-03-03 WBC 0.73 x10^3/uL
    
  • 2023-03-01 WBC 1.58 x10^3/uL
    
  • 2023-02-27 WBC 2.56 x10^3/uL
    
  • 2023-02-23 WBC 5.71 x10^3/uL
    
  • 2023-02-20 WBC 8.15 x10^3/uL
    
  • 2023-02-08 WBC 6.31 x10^3/uL
    
  • 2023-02-03 WBC 13.64 x10^3/uL
    
  • 2023-02-01 WBC 18.52 x10^3/uL
    
  • 2023-01-30 WBC 3.21 x10^3/uL
    
  • 2023-01-28 WBC 1.06 x10^3/uL
    
  • 2023-01-26 WBC 0.56 x10^3/uL
    
  • 2023-01-24 WBC 0.66 x10^3/uL
    
  • 2023-01-22 WBC 0.34 x10^3/uL
    
  • 2023-01-20 WBC 0.24 x10^3/uL
    
  • 2023-01-18 WBC 0.28 x10^3/uL
    
  • 2023-01-16 WBC 0.63 x10^3/uL
    
  • 2023-01-14 WBC 0.44 x10^3/uL
    
  • 2023-01-13 WBC 1.02 x10^3/uL
    
  • 2023-01-11 WBC 43.50 x10^3/uL
    
  • 2023-01-10 WBC 83.37 x10^3/uL
    
  • 2023-01-09 WBC 89.32 x10^3/uL
    
  • 2023-01-08 WBC 90.19 x10^3/uL
    
  • 2023-01-06 WBC 90.16 x10^3/uL
    
  • 2023-01-04 WBC 93.88 x10^3/uL
    
  • 2023-01-02 WBC 163.72 x10^3/uL

2023-01-13

• There was neutropenia of grade 2 (2023-01-13 1.02K/uL) as well as suspected tumolysis syndrome (2023-01-11 P 7.3mg/dL, Ca 2.0mmol/L, uric acid 8.3mg/dL) in this patient. please consider whether G-CSF is necessary in the next few days.
• Rolikan (sodium bicarbonate) has been prescribed since 2023-01-13. The role of urinary alkalinization with either acetazolamide and/or sodium bicarbonate is unclear and controversial. In the past, alkalinization to a urine pH of 6.5 to 7 or even higher was recommended to increase uric acid solubility, thereby diminishing the likelihood of uric acid precipitation in the tubules. However, this approach has fallen out of favor for the following reasons: 1. There are no data demonstrating the efficacy of this approach. In addition, the only available experimental study suggested that hydration with saline alone is as effective as alkalinization in minimizing uric acid precipitation.; 2. Alkalinization of the urine has the potential disadvantage of promoting calcium phosphate deposition in the kidney, heart, and other organs in patients who develop marked hyperphosphatemia once tumor breakdown begins. (ref: https://www.uptodate.com/contents/tumor-lysis-syndrome-prevention-and-treatment).
• Febuxostat is administered to this patient currently. The level of uric acid has decreased to 3.8 mg/dL as of 2023-01-13.

700295999

231103

[exam findings]

• 2023-08-21 Patho - uterus (with or without SO) neoplastic
  • Diagnosis:
    • Ovary, left, debulking surgery — Mixed carcinoma (composed of 70% of low-grade serous carcinoma and 30% of Malignant Brenner tumor), and Ovarian abscess
    • Ovary, right, debulking surgery — Mixed carcinoma, and Ovarian abscess
    • Fallopian tube, bilateral, debulking surgery — Negative for malignancy
    • Cervix, debulking surgery — Endocervical polyp
    • Endometrium, debulking surgery — Negative for malignancy
    • Myometrium, debulking surgery — Adenomyosis, and multiple leiomyomas
    • Serosa, debulking surgery — Serous carcinoma seeding (revise)
    • Appendix, debulking surgery — Serous carcinoma seeding
    • Omentum, debulking surgery — Negative for malignancy
    • Lymph node, left iliac, dissection — Negative for malignancy
    • Lymph node, left obturator, dissection — Negative for malignancy
    • Lymph node, right iliac, dissection — Negative for malignancy
    • Lymph node, right obturator, dissection — Metastatic carcinoma
    • Lymph node, left paraaortic, dissection — Negative for malignancy
    • Lymph node, right paraaortic, dissection — Negative for malignancy
    • AJCC 8th edition pathology stage: pT3aN1a (if cM0); FIGO stage IIIA1i; Prognostic stage IIIA2
  • Gross description:
    • Procedure (select all that apply)
      • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy + appendectomy)
      • Specimen size:
        • Left ovary: 10x 8 x 6 cm in size, 220 gm in weight
        • Right ovary: 10x 9 x 5 cm in size, 240 gm in weight
        • Uterus: 9x 7.5 x 4.5 cm cm in size, 120 gm in weight
        • Appendix: 5.5 cm in length and 0.4 cm in greatest diameter
        • Omentum: 42x 14x 2 cm in size
        • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
    • Specimen Integrity
      • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.
      • Specimen Integrity of Right Ovary (if applicable): ruptured
      • Specimen Integrity of Left Ovary (if applicable): ruptured
      • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
      • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
    • Tumor Site:
      • Note: Please select the primary tumor site only
      • Bilateral ovaries
    • Ovarian Surface Involvement (required only if applicable)
      • Present (Left)
    • Fallopian Tube Surface Involvement (required only if applicable)
      • Absent
    • Tumor Size
      • Note: For bilateral tumors, please report maximum dimension for each primary tumor, specifying by laterality.
      • Greatest dimension (centimeters), left side: 8 cm
        • Additional dimensions (centimeters): 6 x 5 cm
      • Greatest dimension (centimeters), right side: 8 cm
        • Additional dimensions (centimeters): 7 x 4 cm
    • Sections are taken and labeled as:A1:left iliac, A2:left obturator, A3:right iliac, A4-5:right obturator, A6:left paraaortic, A7:right paraaortic, A8:CX, A9:right adnexae, A10-12:corpus and myomas, A13-16:left ovarian tumor, A17-19:right ovarian tumor, A20:serosa, A21:appendix, A22:omentum
  • Microscopic Description:
    • Histologic Type:
      • Mixed carcinoma (composed of 70% of low-grade serous carcinoma component and 30% of Malignant Brenner tumor component)
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
      • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.)
      • WHO Grading System: Not applicable
    • Implants (required for advanced stage serous/seromucinous borderline tumors only)
      • Note: Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.
      • Present (specify sites): appendix and serosa
    • Other Tissue/ Organ Involvement (select all that apply):
      • Not identified
    • Largest Extrapelvic Peritoneal Focus (required only if applicable)
      • Microscopic
    • Peritoneal/Ascitic Fluid
      • Malignant (positive for malignancy); N2023-03213
        
    • Regional Lymph Nodes:
      • Lymph node, left iliac: Negative for metastasis ( 0 / 3 )
      • Lymph node, left obturator: Negative for metastasis ( 0 / 7 )
      • Lymph node, right iliac: Negative for metastasis ( 0 / 3 )
      • Lymph node, right obturator: Positive for Metastasis (1/ 12)
      • Lymph node, left paraaortic, dissection— Negative for metastasis ( 0 / 5 )
      • Lymph node, right paraaortic, dissection— Negative for metastasis ( 0 / 7 )
    • Additional Pathologic Findings
      • Adenomyosis
      • Intramural, submucosal and subserosal leiomyomas
      • Endocervical polyp
    • Immunostains - Napsin A (-), WT-1 (focal+), p53 wild-type, p16 (-), GATA3 (+), CK20 (-), vimentin (focal+).
• 2023-08-21 Body fluid cytology - ascites
  • Malignancy - positive for malignancy present;
    
  • GROSS DESCRIPTION: 40 ml turbid
  • MICROSCOPIC DESCRIPTION: few clusters of adenocarcinoma, many red blood cells, lymphocytes and mesothelial cells present.
• 2023-08-17 CT, CTA - chest
  • Indication: advance ovary cancer
  • Chest CT with and without IV contrast ehnancement shows:
    • Some fluid accumulation at abdominal cavity is found. Dirty appearance of the mesentery is also noted. Suggest correlate with tumor marker.
    • Suggest clinical correlation
  • Imp:
    • No evidence of pulmonary embolism nor aortic dissection is found.
    • Some fluid accumulation at abdominal cavity is found. Dirty appearance of the mesentery is also noted. Suggest correlate with tumor marker.
• 2023-08-15 SONO - abdomen
  • Diagnosis:
    • Hepatic cyst
    • Renal cyst, right
    • Renal lesion, left, rule out angiomyolipoma, rule out renal stone
  • Suggestion:
    • Please correlate with other image study
• 2023-08-14 Gynecologic Ultrasonography
  • Findings
    • Uterus Position : AVF
      • Size: 80 * 49 mm
    • Endometrium:
      • Thickness: 7.3 mm
    • Adnexae:
      • ROV: Mass: 117 * 75 mm
      • LOV: Mass: 96 * 74 mm
    • CUL-DE-SAC: No fluid
      
  • IMP:
    • R/O Bilateral Ovarian mass
• 2023-07-03 Patho - soft tissue tumor, extensive resection (Y1)
  • DIAGNOSIS:
    • Tissue, labeled as “epiploic appendages”, LSC biopsy — Invasive carcinoma
    • NOTE: The differential diagnosis includes serous carcinoma, endometrioid carcinoma,and etc.
  • Microscopically, it shows nests of invasive carcinoma with psammoma bodies, stromal fibrosis and mixed inflammatory infiltrate.
  • Immunohistochemical stain reveals CK (+), p53: wild-type (focal patchy+, < 10%), WT-1 (focal+), PAX8 (-), calretinin (-).
  • ADDENDUM: IHC stain — CK7 (+), CK20 (-), GATA3 (focal+), Napsin A (-), ER (focal weak+). Correlation with image and clinical findings is advised.
• 2023-06-24 CT - abdomen
  • Clinical history: 57 y/o female patient with watery discharge noted for a year, pinkish discharge today, received chinese medicine, covid (+) last May.
  • With and without contrast enhancement CT of abdomen–whole:
    • There are heteregeneous tumors in bilateral adnexa(4.6cm in right adnexa and 5.2cm in left adnexa), r/o malignancy.
    • Uterine tumor, 2.4cm, r/o uterine myoma.
    • Cystic tumor, 3.1x1.6cm in right subhepatic region, r/o peritoneal seeding.
    • Small left renal cysts.
    • There are small aortocaval region lymph nodes.
    • Minimal ascites.
    • There are small peritoneal nodules, r/o carcinomatosis.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T3c(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIIc__(Stage_value)
      
  • Impression:
    • Bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0.
    • Small aortocaval region lymph nodes.
• 2023-04-26 Clinical Dementia Rating
  • CDR score: 0.5
• 2023-04-26 Mini-Mental State Examination
  • MMSE score: 28
• 2023-02-22 CT - brain
  • No evidence of intracranial lesion.
• 2023-01-09 Mammography
  • BI-RADS category 1, Negative.
• 2023-08-14 Gynecologic Ultrasonography
  • Uterine myoma

[MedRec]

• 2023-08-31 Psychosomatic Medicine Chen WenJiang
  • Prescription x3 (doubling of doses to date since 2022-08-15)
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Valdoxan (agomelatine 25mg) 0.5# HS
• 2023-08-11 ~ 2023-08-29 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of unspecified ovary
    • Ovarain cancer -> mixed carcinoma (composed of 70% of low-grade serous carcinoma and 30% of Malignant Brenner tumor) AJCC 8th edition pathology stage: pT3aN1a (if cM0); FIGO stage IIIA1i; Prognostic stage IIIA2
    • Bilateral tubo-ovarian abscess
    • Abdominal pain
  • CC
    • for fever and abdominal pain since 8/11
  • Present illness
    • This 57 years old female with history of asthma and anxiety under medication control. She was menopaused at 51 years old. She had previous followed up at our GYN OPD for urine incontinence and vaginal itchness.
    • Since May 2023, lower abdominal fullness and FLANK SORENESS WAS noted and she came to our GYN OPD on 2023/05/18, the GYN echogram revealed left ovarian mass 2.5x2.2cm and mild adenomyosis. Intermittent right lower abdominal pain WAS also occurred. She went to GI OPD for help and symptomatic treatment given. The colonscopy arranged. Pink vaginal discharge noted on 06/21 and the vaginal sonography found bilateral ovarian mass, 5.5x4cm at right side and 5x3.1cm at left side. The abdominal CT on 06/26 revealed bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0. The tumor marker CEA 19.87 ng/mL and CA125 4621.9 U/mL on 06/23. The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey. She underwent exploratory laparoscopy for biopsy on 2023/07/03, the pathology showed invasive carcinoma.
    • Due to high D-dimer (> 10000) with Clexan 60 mg injection on 7/5 and 7/6. Port-A insertion on 2023/07/07. C1 neoadjuvant Taxel + Carbo on 2023/07/24.
    • This time, she has fever and abdominal distention with tenderness, so she was brought to our ED for help on 2023/8/11. There were no nausea/vomiting, no cough,no dysuria, no abdominal pain, no diarrhea, but vegina discharge got more.
    • At ER, vital signs: BP:132/61mmHg, PR:123bpm, BT:39’C, RR:20/min, Con’s:E4V5M6, SpO2:94%. Lab revealed WBC 8970/uL, with neutrophil predominant: 73%. CRP:13.7mg/dL, HGB = 9.4 g/dL.
    • Under the impression of Malignant neoplasm of unspecified ovary, the patient was admitted to our hema ward for further evaluation and treatment.
    • CA125                       
      • 2023-06-23 4621.9 U/mL                
      • 2023-08-07 7804.2 U/ml        
  • Course of inpatient treatment
    • The patient was admitted the hematology and oncology ward. Consultation GYN arrange sonography show right ovarian mass 117x75 mm side. The tumor marker CA125 4621.9 -> 8/7 7804.2 (U/mL), D-dimer > 10000, with Clexan 60 mg Q12H.
    • She and underwent GYN cancer debulking surgery (Abdominal Total Hysterectomy + bil salpingo-oophoretom + BPLND+ infracolic omentectomy + appendectomy) on 08/21/2023. Her postoperative course was uneventful. Her Eating and urination by self voiding was smooth. The vital sign was stable after surgery. JP drain was removed then on 08/25 and 08/28 morning. The Gyn tumor conference was arranged thursday.
    • She is discharged on 008/29/2023 pm and her followup appointment is scheduled on next week.
  • Discharge prescription
    • Actein (acetylcysteine 200mg) 1# TID
    • Bokey (aspirin 100mg) 1# QD
    • Acetal (acetaminophen 500mg) 1# Q4H
    • Through (sennoside 12mg) 2# HS
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • cephalexin 500mg 1# QID
• 2023-07-23 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Invasive carcinoma of bilateral ovarian, c-stage T3cN0M0, cstage IIIc post 1st neoadjuvant chemotherapy on 20230725
  • CC
    • for first chemotherapy
  • Present illness
    • This 57 years old female with history of asthma and anxiety under medication control. She was menopaused at 51 years old. She had previous followed up at our GYN OPD for urine incontinence and vaginal itchness. Since May 2023, lower abdominal fullness and FLANK SORENESS WAS noted and she came to our GYN OPD on 2023/05/18, the GYN echogram revealed left ovarian mass 2.5x2.2cm and mild adenomyosis. Intermittent right lower abdominal pain WAS also occurred. She went to GI OPD for help and symptomatic treatment given. The colonscopy arranged. Pink vaginal discharge noted on 06/21 and the vaginal sonography found bilateral ovarian mass, 5.5x4cm at right side and 5x3.1cm at left side. The abdominal CT on 06/26 revealed bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0. The tumor marker CEA 19.87 ng/mL and CA125 4621.9 U/mL on 06/23. The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey.
    • She underwent exploratory laparoscopy for biopsy on 2023/07/03, the pathology showed invasive carcinoma.
    • Due to high D-dimer (> 10000) with Clexan 60 mg injection on 7/5 and 7/6. Port-A insertion on 2023/07/07.
    • This time, she was admitted for first chemotherapy on 2023/7/23.
  • Course of inpatient treatment
    • After admission, she received dexamethasone 5# q6h on 7/24 2300 and 7/25 0500.
    • Baraclude 0.5mg/tab 1# qdac for postive of anti-HBc.
    • C1 Taxel + Carboplatin on 2023/7/25.
    • Primepram 1# tidac for prevent vomit.
    • Under the stable condition, she can be discharged on 2023/7/26. OPD follow up is arranged.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNTID
    • Emend (aprepitant 125mg) 1# PRNQDAC
• 2023-07-02 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of unspecified ovary
    • Bilateral ovarian cancer (for pelvic tissue biopsy report ) post Laparoscopic tumor biopsy on 2023/07/03
    • Abdominal pain
    • Myoma uteri
  • CC
    • Lower abdominal fullness for 2 months
  • Present illness
    • This 57 years old female with history of asthma and anxiety under medication control. She was menopaused at 51 years old. She had previous followed up at our GYN OPD for urine incontinence and vaginal itchness.
    • Since May 2023, lower abdominal fullness and FLANK SORENESS WAS noted and she came to our GYN OPD on 2023/05/18, the GYN echogram revealed left ovarian mass 2.5x2.2cm and mild adenomyosis. Intermittent right lower abdominal pain WAS also occurred. She went to GI OPD for help and symptomatic treatment given. The colonscopy arranged. Pink vaginal discharge noted on 06/21 and the vaginal sonography found bilateral ovarian mass, 5.5x4cm at right side and 5x3.1cm at left side.
    • The abdominal CT on 06/26 revealed bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0. The tumor marker CEA 19.87 ng/mL and CA125 4621.9 U/mL on 06/23.
    • After discussed with the patient, she was admitted for laparoscopic ovarian biopsy WILL BE arrange on 2023/07/03.
  • Course of inpatient treatment
    • The patient was admitted on 2023/07/02.The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey.
    • She underwent exploratory laparoscopy for biopsy on 2023/07/03. We gave her Cefazolin IV form for 2 day and then shifted her antibiotics to Cephalexin oral form.
    • Post-operation wound was dry and clean without dehiscence, discharge, or oozing. Her lab data on 2023/07/04 also showed no specific positive findings.
    • The pathology reported showed invasive carcinoma.
    • Due to high D-dimer (> 10000) with Clexan 60 mg injection on 7/5 and 7/6.
    • After GYN tumor conference on 2023/07/06 and the neo-adjuvant will be arrange. We was consulted GS/GU for port-A insertion and breast echo and cystoscopic on 2023/07/07.
    • Since all her general conditions were all improved and relatively stable, we arranged discharge on 2023/07/07 and Gyn/HemOnc OPD follow up of her recovery status and surgical wound conditions.     
  • Discharge prescription
    • Bokey (aspirin 100mg) 1# QD
    • MgO 1# QID
    • Acetal (acetaminophen 500mg) 1# QID
    • cephalexin 500mg 1# QID
• 2022-08-15 Psychosomatic Medicine Chen WenJiang
  • Prescription x2
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Valdoxan (agomelatine 25mg) 0.5# HS
• 2022-08-15 Chest Medicine Su WenLin
  • Prescription x2
    • Actein (acetylcysteine 600mg) 1# BID
    • Allegra (fexofenadine 60mg) 1# BID
    • Symbicort Turbuhaler (budesonide, formoterol) 2 puff BID INHL
    • Trisonin Nasal Spray (triamcinolone acetonide micronized 55ug/dose, 120dose/bt) 2 puff QD

[consultation]

• 2023-08-18 Urology
  • Q
    • For arrange insert ureteral catheter
    • This is a 57y/o, G2P2 (NSD X 2), menopause (+, 51y/o) woman with invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc, s/p laparoscopic tumor biopsy and 1st neoadjuvant chemotherapy in 2023/07.
    • This time, she was hospitalized due to symptoms of abdominal pain. Due to increased vaginal discharge, we were consulted for evaluation. She will accept the debulking surgery + HIPEC on 08/21/2023 on call. We need your expertise to evaluate this patient. Thank you very much!
  • A
    • Due to advance pelvic tumor, DBJ may be inserted during pelvic surgery
• 2023-08-16 Obstetrics and Gynecology
  • Q
    • The 57 y/o woman has advance of ovarian cacner /p neoadjuvant chemo as C1 Taxel + Carbo on 2023/7/24. We need your help for surgical intervention next Monday.
  • A
    • This is a 57y/o, G2P2 (NSD X 2), menopause (+, 51y/o) woman with invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc, s/p laparoscopic tumor biopsy and 1st neoadjuvant chemotherapy in 2023/07.
    • This time, she was hospitalized due to symptoms of abdominal pain. Due to rapid tumor progression, we were consulted for evaluation.
    • ObGyn history
      • G2P2, NSD X 2
      • Menopause (+, 51y/o)
      • Invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc
      • 2023/07/03 Exploratory laparoscopy for tumor biopsy and cell block
      • 2023/07/25 Paclitaxel + Carboplatin C1D1
    • Lab
      • CA125 06/23: 4621.9 -> 8/7: 7804.2 -> 8/15: 13679.2 (U/mL)
      • 2023-08-16
        • WBC 8.95K
        • Hb 8.9g/dL
        • BCS WNL
        • CRP 14.0 mg/dL
        • D-dimer > 10000
    • Impression
      • Advanced ovarian cancer with tumor progression
    • Suggestion
      • Please give LPpRBC 3U transfusion for anemia.
      • Please give Clexane for elevated D-dimer.
      • We plan to transfer her to the GYN ward on W5 08/18. Bowel prepare on W5.
      • We will arrange surgery on W1 08/21: debulking surgery with self-paid HIPEC.
• 2023-08-16 General and Gastrointestinal Surgery
  • Q
    • The 57 y/o woman has advance of ovarian cacner. We need your help for surgical intervention tomorrow. Thanks!
  • A
    • I’ll arrange combined opeartion for her (CRS + HIPEC).
• 2023-08-14 Obstetrics and Gynecology
  • Q
    • The 57 y/o woman has Invasive carcinoma of bilateral ovarian, c-stage T3cN0M0, cstage IIIc post 1st neoadjuvant chemotherapy on 20230725. She has fever with abdominal and vagina discharge. We need your help for management.
  • A
    • This is a 57y/o, G2P2 (NSD X 2), menopause (+, 51y/o) woman with invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc, s/p laparoscopic tumor biopsy and 1st neoadjuvant chemotherapy in 2023/07.
    • This time, she was hospitalized due to symptoms of abdominal pain. Due to increased vaginal discharge, we were consulted for evaluation.
    • CC
      • Abdominal pain and increased vaginal discharge for/since
    • ObGyn history
      • G2P2, NSD X 2
      • Menopause (+, 51y/o)
      • Invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc
      • 2023/07/03 Exploratory laparoscopy for tumor biopsy and cell block
      • 2023/07/25 Paclitaxel + Carboplatin C1D1
    • Lab
      • CA125 06/23: 4621.9 -> 8/7: 7804.2 (U/mL)
      • 2023-08-11
        • WBC 8.97K
        • Hb 9.4g/dL
        • BCS WNL
        • CRP 13.7 mg/dL
        • U/A clear
    • PV
      • Mild amount of light yellow discharge -> s/p culture
      • No active bleeding
      • smooth cervix
    • Sono
      • Uterus: AVF, 80*49mm
      • EM: 7.3mm
      • RT mass: 117*75mm
      • LT mass: 96*74mm
      • CDS: no fluid
    • Impression
      • Advanced ovarian cancer
    • Suggestion
      • keep current neoadjuvant chemotherapy for bilateral ovarian cancer
      • please treat side effect of chemotherapy as your expertise
      • pending vaginal culture report
• 2023-07-06 Urology
  • Q
    • For cystoscopy
    • Patient underwent Exploratory laparoscopy for biopsy on 07/03/2023. pathology report showed Invasive carcinoma. After GYN tumor conference.(cystoscopy is suggested). We need consult you for further management. Thank a lot!
  • A
    • We will arrange CUS on 2023/07/06 pm.

[chemotherapy]

• 2023-11-03 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-10-10 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-09-18 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-07-25 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL

701503831

231103

• 2023-10-31 CXR
  • Increased infiltration in both lung fields
  • Partial atelectasis of left lung
  • s/p port A insertion
• 2023-10-31 CT - brain
  • No definite intracranial lesion
• 2023-10-31 ECG
  • Sinus tachycardia
  • ST & T wave abnormality, consider inferior ischemia
  • ST & T wave abnormality, consider anterolateral ischemia

==========

2023-11-03

[tube feeding]

All of the oral medications on the active medication list can be administered through a feeding tube.

700787059

231101

[exam findings]

• 2023-10-07 CT - abdomen
  • Indication: Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, hold Glimet F.C 2mg & 500mg/tab (10/5~10/7)
  • With and without contrast enhancement CT of abdomen shows:
    • Colon and rectal CA, s/p operation. Nodular lesions in RUQ, in progression.
    • A cystic lesion, 2.6cm, in liver dome.
    • Some lymph nodes in para-aortic region.
  • Impression
    • Colon and rectal CA, s/p operation
    • Peritoneal nodules in RUQ, in progression
    • Para-aortic lymph nodes
• 2023-06-29 CT - abdomen
  • History and indication:
    • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I s/p CCRT and chemotherapy with FOLFOX, s/p Low AR + loop ileostomy and Right hemicolectomy and chemotherapy with FOLFOX
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon operation. Some nodules at bil. lungs.
    • A poor enhancing lesion (2.5cm) at liver dome.
    • Renal cysts (up to 3.6cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • S/P colon operation. Some nodules at bil. lungs.
    • A poor enhancing lesion (2.5cm) at liver dome.
• 2023-06-24 CXR
  • Cardiomegaly is noted.
  • S/p port-A placement with its tip at Superior vena cava.
  • Tortous aorta with calcification is noted.
  • Faint aveolar opacity over left upper lobe is found.
  • Emphysematous change over both lungs.
• 2023-06-21 Joint soft tissue sonography
  • Left shoulder supraspinatus calcific tendinopathy
• 2023-06-16 Shoulder Lt
  • Normal bone alignment
  • moderate decreased left shoulder joint space
  • moderate left subacromial spur formation.
  • a nodular lesion in the left upper lung field
• 2023-04-04, -03-21, -03-17, -03-14 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • Old fracture of right clavicle shows mild angulation deformity but good union.
• 2023-03-27 Ga-67 Whole body inflammation scan with SPECT
  • The whole-body gallium-67 inflammation scan with SPECT was performed at the 24th and 48th hour after injecting 6 mCi of Ga-67 to the patient. The images showed increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hilar regions and in the posterior aspect of bilateral lower lung fields and in both kidneys.
  • IMPRESSION:
    • Increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hilar regions and in the posterior aspect of bilateral lower lung fields. Infection/inflammation involving these regions should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mildly increased radiotracer uptake in both kidneys. The nature is to be determined (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
• 2023-03-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (97.3 - 25.3) / 97.3 = 74.00%
    • M-mode (Teichholz) = 74.0
  • Conclusion:
    • Thickened AV with no AR
    • Thickened MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Normal LV wall motion
    • No PR, trivial TR, normal IVC size
• 2023-03-11 CTA - chest
  • Findings
    • Bil. pleural effusion with adjacent lung collapse. Ground glass opacities at bil. lungs.
    • S/P operation. Minimal ascites.
    • Renal cysts (up to 3.6cm).
    • S/P Port-A infusion catheter insertion.
  • IMP
    • Bil. pleural effusion with adjacent lung collapse. Ground glass opacities at bil. lungs.
• 2023-03-11 ECG
  • Sinus tachycardia
  • Left bundle branch block
• 2023-03-10 KUB
  • Presence of ileus.
  • Degeneration and spondylosis of L-S spine.
• 2023-02-16 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Tumor, ascending colon, R’t hemicolectomy (s/p CCRT) — Mucinous adenocarcinoma
    • Resection margins, bilateral, ditto — Free of tumor invasion
    • Lymph node, mesocolic, dissection — Free of tumor metastasis (0/18)
    • Appendix — Free of tumor invasion
    • AJCC pathologic stage — ypT3N0, if cM0, stage IIA
  • MACROSCOPIC EXAMINATION
    • Operation procedure: R’t hemicolectomy
    • Specimen site: Ascending colon, terminal ileum and appendix
    • Specimen size: (a) A-colon: 27.7 cm in length, up to 8.4 cm in circumference, (b) Terminal ileum: 2.3 cm in length, 2.3 cm in diameter and (c) Appendix: 2.2 cm in length, 0.7 cm in diameter
    • Tumor size: 4.7 x 3.8 cm
    • Tumor location: ascending colon, 14.8 and 9 cm away from bilateral resection margins
    • Tumor appearance: protruding mass
    • Depth of invasion grossly: pericolonic fat
    • Representative sections as follows: A1: ileum + colonic resection margin, A2: appendix, A3-A6: tumor, A7-A10: lymph nodes
  • MICROSCOPIC EXAMINATION
    • Histology: mucinous adenocarcinoma
    • Histology Grade: G2, moderately differentiated
      
    • Depth of invasion: pericolonic fat
    • Angiolymphatic invasion: not identified
    • Perineural invasion: not identified
    • Discontinuous extramural tumor extension: not present
    • Circumferential (radial) margin of rectosigmoid: not involved
    • Lymph node metastasis, mesocolic: free of tumor metastasis (0/18)
    • Lymph node metastasis, IMA / SMA: N/A
    • Extranodal involvement: N/A
    • Pathological TNM Stage: ypT3N0
    • Type of polyp in which invasive carcinoma arose: N/A
    • Additional pathologic findings: mucin production
    • TNM descriptors: Y
    • Tumor regression grading S/P CCRT: grade 5
• 2023-02-16 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Tumor, rectum, laparoscopic LAR (s/p CCRT) — Adenocarcinoma
    • Resection margins, ditto — Free of tumor invasion
    • Lymph nodes, mesocolic, dissection — Tumor metastasis (1/6)
    • AJCC pathologic stage — ypT4aN1a, if cM0, stage IIIB
  • MACROSCOPIC EXAMINATION
    • Operation procedure: laparoscopic LAR
    • Specimen site: rectum
    • Specimen size: 7.7 cm in length, 3.1 cm in diameter
    • Tumor size: 1.5 x 1.3 cm with perforated hole 2.6 x 0.9 cm
    • Tumor location: 4.5 cm and 0.5 cm away from bilateral resection margins
    • Tumor appearance: subserosal nodule and perforated hole
    • Depth of invasion grossly: visceral peritoneum
    • Proximal margin: 3.2 x 1.2 x 0.9 cm
    • Distal margin: 1.8 x 1.3 x 0.9 cm
      
    • Representative sections as follows: A1-A3: perforated hole (ink) + subserosal tumor, A4-A6: perforated hole (ink) + mucosa, A7-A9: LNs, B: Proximal margin and C: distal margin
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
    • Histology Grade: G2, moderately differentiated
      
    • Depth of invasion: visceral peritoneum (<0.1 cm from serosa layer)
    • Angiolymphatic invasion: present
    • Perineural invasion: present
    • Discontinuous extramural tumor extension: absent
    • Circumferential (radial) margin of rectosigmoid: not involved
    • Lymph node metastasis, mesocolic: Tumor metastasis (1/6)
    • Lymph node metastasis, IMA / SMA: N/A
    • Extranodal involvement: not involved (0/1)
    • Pathological TNM Stage: ypT4aN1a
    • Type of polyp in which invasive carcinoma arose: N/A
    • TNM descriptors: Y
      
    • Tumor regression grading S/P CCRT: G3
• 2023-02-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 34) / 105 = 67.62%
    • M-mode (Teichholz) = 68
  • Conclusion
    • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Prominent posterior mitral annulus calcification with mild MR; mild aortic valve sclerosis .
    • Mild aortic root calcification with sessile atheromas.
• 2023-01-31 Sigmoidoscopy
  • Rectal cancer s/p CCRT , significant tumor regression
• 2023-01-26 CT - abdomen
  • History and indication:
    • Locally advanced rectal cancer with large pelvic LNs A-colon cancer with intussusception (no obstruction sign) –> Suggest pre-op CCRT for better resectability and local control, 20221205 RT finish
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Much regression of rectal and A-colon cancer and metastatic LAP. A tiny nodule at RML.
    • Renal cysts (up to 3.6cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • Much regression of rectal and A-colon cancer and metastatic LAP. A tiny nodule at RML.
• 2022-10-28 All-RAS + BRAF mutations assay
  • All-RAS mutations assay
    • Detection range
      • KRAS codon 12, 13, 59, 61, 117, 146
      • NRAS codon 12, 13, 59, 61, 117, 146
    • Results
      • Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • Interpretation
      • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • BRAF mutations assay
    • Detection range
      • BRAF codon 600
    • Results
      • There was no variant detected in the BRAF gene.
    • Interpretation
      • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
• 2022-10-24 CXR
  • Ground glass opacity in RLL.
• 2022-10-17 CT
  • Indication: synchronous rectal cancer and A-colon cancer
  • Findings
    • Chest:
      • Small lymph nodes are found at both sides of the mediastinum.
      • No evidence of bilateral pleural effusion.
      • Calcified coronary arteries is found.
      • The lung fields are clear.
      • No pleural effusion is found.
    • Visible abdomen:
      • DIffuse wall thickening at rectum about 4.2cm in length with regional lymphadenopathy is found. Rectal cancer is considered. Regional lymphadenopathy is found.
      • Annular lesion at ascending colon near hepatic flexure about 3cm is found. suspected colon cancer with intussusception.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • Non-specific bowel gas at abdominal cavity is found.
      • There is no evidence of destructive bone lesion.
      • No definite inguinal or pelvic sidewall LAP
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • Suggest clinical correlation
  • IMp:
    • Rectal cancer with regional lymphadenopathy, T4N2M0
    • Ascending colon cancer. T2N0M0.
• 2022-10-17 ECG
  • Normal sinus rhythm
  • Left axis deviation
• 2022-10-06 Patho - colorectal polyp
  • Colorectum, ascending colon, biopsy — Adenocarcinoma.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
• 2022-10-06 Patho - colorectal polyp
  • Colorectum, rectum about 11 cm above anal verge, biopsy — Adenocarcinoma.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
• 2022-10-06 Colonoscopy
  • Colon cancer, rectum, s/p biopsy
  • Colon polyp, sigmoid colon, s/p polypecotmy + cliping
  • Colon polyp, descending colon, s/p polypectomy + cliping
  • Colon cancer, ascending colon, s/p biopsy
  • Internal hemorrhoid

[MedRec]

• 2023-05-16 SOAP Metabolism and Endocrinology
  • Diagnosis
    • NIDDM with unspecified complication, not stated as uncontrolled [E11.8]
    • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
  • Prescription
    • Glimet (glimepiride 2mg, metformin 500mg) 0.5# BID
    • Trajenta (linogliptin 5mg) 1# QL
• 2023-03-11 POMR Cardiology
  • Discharge diagnosis
    • Severe sepsis with septic shock
    • Bacteremia with Serratia marcescens on 2023/03/11 and pan-drug resistant (PDR) Klebsiella pneumoniae on 2023/03/22
    • Port A catheter infection with pan-drug resistant (PDR) Klebsiella pneumoniae (by tip culture on 2023/03/24), status post removal on 2023/03/24
    • Urinary tract infection with urosepsis by urine culture grewed Enterobacter cloacae complex on 2023/03/11
    • Non-ST elevation myocardial infarction, favor Type 2 myocardial infarction by infection related
    • Type 2 diabetes mellitus
    • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 112/02/14
    • Iron deficiency anemia
    • Gastrointestinal (GI) bleeding (stool occult blood 1+)
    • Hypokalemia, resolved
    • Hypomagnesemia, resolved
    • Hypocalcemia, improving
    • Constipation
  • CC: fever and chillness at 20230311 night
  • Present illness
    • This 79 y/o male patient has the past history of
      • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 2023/02/14
      • Type 2 diabetes mellitus with OHA control
      • Postoperative Ileus
    • the patient regular follow up at our OPD and just admitted at our proctology service from 2023/02/14 to 2023/03/09 for his adenocarcinoma of the rectum operation.
    • According to the statement of the patient’s families and ER medical record. This time, the patient suffered from fever and chillness at 22:00, so he was sent to our ER on 20230310. At MER, his GCS was E4V5M6 and vital signs showed BP:149/76 mmHg; HR:120 BPM; BT:38.4’C; RR:20 BPM; SpO2:95%. Covid-19 rapid test showed negative. The patient complained upper back pain at 00:05. However, consciousness changed to GCS:E4V1M4 at 00:22 combined with cold sweating, air hunger and blood pressure couldn’t measure, so bosmin 1mg iv stat was given.
      • The laboratory disclosed increased in cardiac enzyme Troponin I:46.8->3918.7->14527.3pg/mL, CK:163ng/mL, D-dimer:7591.06ng/mL, Lactic acid:4.8mmol/L, CPR:1.15mg/dl, band:5.0%, urine analysis (NIT:2+, WBC:>=100 and bacteria:3+) and ABG showed hypoxia (PO2:31.7, SpO2:63.7%). CXR revealed presence of ileus. The first EKG showed sinus tachycardia, the secondary EKG (post Bosmin) showed ST depression in V4~V6, suspect AMI and the third and fourth EKG restored to normal sinus rhythm. Arranged chest CTA disclosed bilateral pleural effusion with adjacent lung collapse, ground glass opacities at bilateral lungs. Cardiology was consulted and who suggested that the subsequent ECG change is associated with bosmin effect, which will lead to transient vasoconstriction, not true MI. Also, KUB revealed presence of ileus and degeneration and spondylosis of L-S spine. Under the impression of Urinary tract infection with urosepsis, NSTEMI, he was admitted to MICU for further evaluation and management on 2023/03/11.
  • Course of inpatient treatment
    • After admitted to MICU, we administered empirical antibiotic with IV Cravit (03/11~03/15) according to his previous (2023/03/01) urine culture grew Enterobacter cloacae complex for infection control and IV hydration for favor poor intake with dehydration and septic shock status, DAPT with Bokey and plavix for AMI and PPI with Nexium for prevent stress ulcer.
      • Echocardiography was done on 03/13 disclosed LVEF: 74%, 1.Thickened AV with no AR; 2.Thickened MV with mild MR; 3.Normal LV chamber size and wall thickness; 4. Preserved LV and RV systolic function; 5.Normal LV wall motion; 6. No PR, trivial TR, normal IVC size. Later, hypokalemia and hypomagnesemia were found, thus 0.298%KCL in NaCL and MgSO4 were given. The blood culture x 2 set grew Serratia marcescens and urine culture grew Enterobacter cloacae complex, single dose of tapimycin was used first on 3/13 and INF was consulted to adjust antibiotic for his infection control. Hb drop from 9.5 to 7.7 g/dl was also found, LPRBC transfusion was given to correct anemia. His condition was relative stable, he was transferred to cardiology general ward for further care on 03/14.
    • At ordinary ward, his consciousness was alert but weakness and vital signs were stable, no dyspnea or chest discomfort was complained, respiratory pattern smooth under nasal cannula support. Cravit was changed to Tapimycin (03/13, 03/15) for his bacteremia with Serratia marcescens and UTI with Enterobacter cloacae complex. Continue to use other current medication to control the underlying disease and closely monitor his vital signs and clinical symptoms.
      • The INF recommend antibiotic treatment with Tienam or Mepem for S. marcescens bacteremia and E. cloacae UTI for 7 to 10 days, thus Tapimycin was shifted to Tienam used on 03/16. We also arrange thallium scan for CAD survey and stool OB, ion profiles examination for his anemia surveyed. Then stool OB was 1+ and iron profiles reported Fe 19 ug/dL, TIBC 272 ug/dL, UIBC 253 ug/dL, so we kept Nexium used and added Foliromin F.C. 50mg/tablet (Sodium Ferrous Citrate). The thallium scan was done on 2023/03/17, and reported probably mild myocardial ischemia at the inferoapical wall and inferolateral wall. Medical treatment was prescribed first.
    • Another episode of fever with chills developed at 23:21 on 03/21, Cravit was added. Gallium whole body inflammation scan was arranged for fever survey. The tracking initial blood culture on 03/22 report GNB. Tienam plus Cravit was changed to Doripenem (03/23~03/26) after contacting the infection doctor. Due to recurrent bacteremia, suspected to be related port-A infection, we consulted with a general surgeon, and port-A was removed on 03/24 with the signed consent of the family.
      • The 2023/03/22 blood culture officially reported as PDR-Klebsiella pneumonia, so Doripenem was changed to Tygacil plus UFO (fosfomycin) after contacting the infectious department. Later, port-A TIP culture on 03/24 also grew PDR-Klebsiella pneumonia. All Abx was shifted to Zavicefta since 03/28 by ID suggestion. Gallium inflammation scan on 2023/03/29 reported increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hailer regions and in the posterior aspect of bilateral lower lung fields. Infection/inflammation involving these regions should be watched out. We followed his blood culture results after 3 days of Zavicefta treatment (03/31) and results are pending.
      • During 7-day treatment course of Zavicefta, he had no fever or other infection signs. On 4/4, lab data were all within acceptable range. Blood culture on 3/31 also showed negative findings. Under the stable hemodynamic status, he was discharged on 4/6.
• 2023-01-03 SOAP Hemato-Oncology
  • S: 2022-11-14 RAS G12D
• 2022-12-14 Radiation Oncology
  • O
    • RT (2022-10-27 ~ 2022-12-05): 4500cGy/25 fractions (15MV photon) of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
• 2022-11-24 Radiation Oncology
  • A/P
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-10-25
      • CCRT (Concurrent Chemoradiotherapy) first, then surgery.
      • For the liver nodule, it is suggested to evaluate with abdominal sonography for staging purposes.
• 2022-10-28 POMR Hemato-Oncology
  • Discharge diagnosis
    • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I
    • Malignant neoplasm of rectum
    • Type 2 diabetes mellitus with unspecified complications
    • Unspecified viral hepatitis B without hepatic coma
    • Other constipation
  • Present illness
    • This time, he admitted for concurrent chemoradiotherapy with 5-Fu on 2022/10/28 and 2022/10/31-2022/11/03 (5 days).
  • Course of inpatient treatment
    • After admission, CCRT with 5-Fu (225mg/m2 -> 350mg) x 5days on 2022/10/28, stop 2022/10/31-2022/11/03 treatment, change to FOLFOX regimen (Oxalip 85mg/m2 -> 110mg, Leucovorin 400mg/m2 -> 600mg, 5-Fu 2400mg/m2 -> 3700mg) from 2022/10/31 (well treatment for two site tumor), and explain to family (wife and son) and patient.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Type 2 diabetes mellitus with Monitor blood sugar QDAC
      • Glimet F.C 2mg/500mg/tab 1# PO BID.
      • Viral hepatitis B (Anti-HBc (+)) with Baraclude 0.5mg/tab 1# PO QDAC.
      • Constipation (suspect EMEND related, next cycle DC) with Bisacodyl supp 10mg/pill 2 supp RECT ST on 2022/11/02, Through 12mg/tab 1# PO HS, no stool passage add to 2# for MBD.
    • He can tolerance chemotherapy. The patient was discharged on 2022/11/03 under stable condition. ONC OPD follow up was advised.
• 2022-10-20 SOAP Radiation Oncology
  • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
• 2022-10-20 SOAP Colorectal Surgery
  • A
    • Locally advanced rectal cancer with large pelvic LNs
    • A-colon cancer with intussusception (no obstruction sign)
  • P
    • Suggest pre-op CCRT for better resectability and local control
• 2017-01-07 SOAP Metabolism
  • Diagnosis
    • NIDDM with unspecified complication, not stated as uncontrolled [E11.8]
    • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
  • Prescription
    • Pitator (pitavastatin 2mg) 1# QD
    • Glimet (glimepiride 2mg, metformin 500mg) 0.5# TID

[consultation]

• 2023-08-09 Dermatology
  • Q
    • This 79-year-old man patient is a case of Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC s/p concurrent chemoradiotherapy and chemotherapy with FOLFOX from 2022/10/31~2023/06/09(for 9 cycles) with tumor dense invasion/adhesion to anterior pelvic wall, lymph node enlarged narropw pelvis s/p Low anterior resection + loop ileostomy and Right hemicolectomy on 2023/02/15 with bil.lung and liver metastases s/p chemotherapy of FOLFIRI from 2023/06/30 and Avastin from 2023/07/13. He was admitted for chemotherapy with Avastin(C3)/FOLFIRI(C2D15).
    • This time, for left toe wound of injuried. Now, for evaluate left toe wound medication therapy. Thank you.
  • A
    • The patient had sufferred from thicekening nail bed with scales and erosive wound formation.
      
    • Under the impression of onychomycosis and onycholysis with wound formation
    • The following suggestion:
      • for wound lesion, Tetracyclie onit 1 tube topical bid use.
      • for tinea unguium, Exelderm lotion 1 bot. topical bid use over nail-fold (to put the drug into the affected area between the nail seams).
• 2023-03-15 Infectious Disease
  • Q
    • for Serratia bacteremia
    • This 79 y/o male patient has the past history of
      • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 2023/02/14
      • Type 2 diabetes mellitus with OHA control
      • Postoperative Ileus
    • This time,the impression of
      • Urinary tract infection with urosepsis (20230301 urine culutre yeild Enterobacter cloacae complex)
      • NSTEMI
      • Syncope, suspect dehydration related
    • He was admitted to MICU for further evaluation and management on 2023-03-11. We gave empirical antibiotic with Cravit (since 20230311) used. His Blood culture (20230311) yeild serratia marcescens. We really need your experience for treatment suggestion, thanks!!!
  • A
    • Hx review as mentioned above and Lab data check
    • Suggestion:
      • Recommend antibiotic Rx with Tienam or Mepem for S. marcescens bacteremia and E. cloacae UTI for 7 to 10 D
      • Repeat B/C
      • Monitor CRP
• 2023-03-11 Cardiology
  • A
    • This patient presented with sepsis syndrome in advanced colon C, not acute coronary syndrom
      • The CXR didnot show medistianl wideing, the aortic dissection is less likely
      • The subsequent ECG change is associated with bosmin effect, which will lead to transient vasoconstriction
      • not true MI
    • please treat underlying diseae, maintain optimal Bp
      • f/u echocardiography for wall motin assessment
• 2023-03-07 Dermatology
  • Q
    • For bilateral perianal skin rash
    • This is a 79-year-old male with past history of synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy.
      • He went through low anterior resection, loop ileostomy and right hemicolectomy on 20230215.   
      • During the surgery, advanced rectal cancer s/p CCRT , tumor dense invasion/adhesion to anterior pelvic wall, LN enlarged Narropw pelvis was found.
      • After surgery, ileus was noted and NG decompression was applied. Now NG has been removed.
    • However, he experienced bilateral multiple perianal rash for 2 days.
      • The rash was painless but pruritus.
      • No vesicles were noted.
      • Mycomb was applied for now.
    • We need your expertise for further evaluation. Thank you so much for your help.
  • A
    • The patient had sufferred from annular lesions with peripheral active borders on the bilateral thigh and genital area.
      
    • Under the impression of tinea cruris et intertrigo eczema.
    • The following suggetion:
      • Exelderm cream 1 tube topical QN use over large area of lesions after body clean and Mycomb cream 1 tube topical PRN Bid use over regional erythema itchy area.
        
      • keep body dry, clean and avoid further friction or compression.

[radiotherapy]

• 2022-10-27 ~ 2022-12-05 - 4500cGy/25 fractions (15MV photon) of the pelvic, and 4680cGy/26 fractions of the rectal tumor bed area. (20221201 OPD)

[chemoimmunotherapy]

• 2023-10-31 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-09 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-18 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-09 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-30 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-09 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-05-12 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-04-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-01-06 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-12-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-07 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-25 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-14 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-31 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-28 - fluorouracil 225mg/m2 350mg NS 250mL 10min D1-5 (CCRT)
  • [dexamethason 4mg + NS 250mL] D1-5

==========

2023-11-01

[hyperglycemia]

During this hospital stay, the patient’s blood glucose levels have consistently been elevated (216 -> 376 -> 294 mg/dL).

It is advisable to introduce acarbose 50mg PO TIDCC, with the patient instructed to take each dose at the beginning of every main meal.

2023-09-19

On 2023-08-08, our endocrinologist provided a repeat prescription for Glimet (glimepiride, metformin) and Trajenta (linagliptin), which the patient is currently taking without discrepancies. However, the patient’s blood glucose levels have been consistently high, >= 285 mg/dL for these 2 days. As a recommended addition to his treatment plan, the prescription of Dibose (acarbose 100mg) is advised to be taken as 0.5# TID, with the first bite of each main meal.

2023-07-28

Glimet (glimepiride, metformin) and Trajenta (linagliptin) were refilled on 2023-07-05 as a repeat prescription prescribed by our endocrinologist on 2023-05-16. Both medications have been added to the active medication list without any identified issues.

At 20:14 on 2023-07-27, there was a spike in blood glucose to 269 mg/dL. If this elevation persists, it may require re-evaluation and possible modification of the antidiabetic treatment plan.

There appears to be an upward trend in liver enzyme levels. Given this situation, the addition of BaoGan (silymarin) could be considered as an optional measure if there are no other specific concerns.

• 2023-07-25 S-GPT/ALT 73 U/L

• 2023-07-13 S-GPT/ALT 50 U/L

• 2023-07-13 S-GPT/ALT 51 U/L

• 2023-06-28 S-GPT/ALT 31 U/L

• 2023-06-15 S-GPT/ALT 28 U/L

• 2023-07-25 S-GOT/AST 49 U/L

• 2023-07-13 S-GOT/AST 34 U/L

• 2023-07-13 S-GOT/AST 33 U/L

• 2023-06-28 S-GOT/AST 26 U/L

• 2023-06-15 S-GOT/AST 27 U/L

2023-06-29

According to the PharmaCloud database, our hospital has been the sole provider of the patient’s medical services for the past three months. On 2023-06-24, our Thoracic Department issued a 7-day prescription for Curam (amoxicillin, clavulanic acid), Actein (acetylcysteine), Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), and MgO. Due to changes in the patient’s condition, Curam and MgO are not currently on the active formulary, indicating that these medications may no longer be needed. Therefore, no evidence of medication reconciliation discrepancies was identified.

701496820

231101

[lab data]

2023-09-20 Anti-HBc Reactive
2023-09-20 Anti-HBc Value 3.40 S/CO
2023-09-20 Anti-HBs 191.16 mIU/mL
2023-09-20 Anti-HCV Nonreactive
2023-09-20 Anti-HCV Value 0.12 S/CO
2023-09-20 HBsAg Nonreactive
2023-09-20 HBsAg (Value) 0.32 S/CO

[exam findings]

• 2023-09-28 Pure Tone Audiometry
  • Reliabilty Fair
  • PTA
    • R’t : 94 dB HL, moderate to profound mixed type HL
    • L’t : 54 dB HL, mild to profound SNHL.
• 2023-09-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (70 - 24) / 70 = 65.71%
    • M-mode (Teichholz) = 71.1
  • Conclusion:
    • Adequate LV,RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild MR, AR
• 2023-09-05 Nasopharyngoscopy
  • Finding: NPC
  • NpScope: right NP crusting and exudate coating

[MedRec]

• 2023-10-11 SOAP Hemato-Oncology Xia HeXiong
  • Prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Granocyte (lenograstim 250ug) QD SC 3D
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • MgO 250mg 2# TID
    • Smecta (dioctahedral smectite 3g) 1# PRNQ8H
    • NS 500mL ST IVD
• 2023-09-25 ~ 2023-10-06 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Malignant neoplasm of nasopharynx, unspecified
    • Nonkeratinizing, undifferentiated nasopharyngeal carcinoma, cT3N1M0, Stage III, s/p CCRT with proton (6996cGy/33 Fx, from 2022/09/19~2022/11/07), s/p chemotherapy with gemcitabine plus cisplatin (from 2022/08/10~2022/10/19), recurrence in 2023/05, rT4N0M0, Stage IVA, s/p docetaxel plus cisplatin from 2023/06/07~2023/08/30, progression with involving with right nasopharyngeal space, parapharyngeal space, skull base and very close to ICA
    • Anemia, unspecified
    • Hypomagnesemia
    • Chronic viral hepatitis B without delta-agent
    • Enlarged prostate with lower urinary tract symptoms
    • Other insomnia not due to a substance or known physiological condition
  • CC
    • for scheduled chemotherapy        
  • Present illness
    • This 70 y/o man was quite robust before. He had the initial presentation with right side hearing loss for one more months.
    • He visited CGMH where the diagnosis of nonkeratinizing, undifferentiated NPC was made by the biopsy on 2022-07-20. The initial stage was cT3N1M0, Stage III.
    • Then he received the CCRT with proton (6996cGy/33 Fx, from 2022-09-19 to 2022-11-07) and biweekly gemcitabine plus cisplatin (from 2022-08-10 to 2022-10-19).
    • The follow-up nasopharyngoscopic examination found a suspicious lesion and the biopsy was done on 2023-05-02.
    • The result of biopsy confirmed the recurrence. On 2023-05-26, the follow-up MRI showed the disease was in progression, with a clinical stage of rT4N0M0, Stage IVA.
    • On 2023-06-16, the PET-CT confirmed the local residual tumor. Then he received the salvage chemotherapy with biweekly docetaxel plus cisplatin from 2023-06-07 to 2023-08-30.
    • On 2023-08-18, the follow-up MRI disclosed the tumor still in progression, involving with right nasopharyngeal space, parapharyngeal space, skull base and very close to ICA, which was unresectable.
    • Denied TOCC history in recent three months. Then he visited our hospital for further management.
  • Course of inpatient treatment
    • After admission, collect 24hr Ccr on 2023/09/26 showed 83.7 mL/min and arrange 2D echo for survey, on 2023/09/27 showed LVEF:71.1%, Adequate LV, RV systolic function with normal wall motion, Impaired LV relaxation, Mild MR, AR.
    • PTA was done on 2023/09/28 showed R’t : 94 dB HL, moderate to profound mixed type HL、L’t : 54 dB HL, mild to profound SNHL.
    • Anemia was noted, BT LRBC 2unit on 2023/09/27.2023/09/28, then get improved.
    • Hypomagnesemia with MgO 250mg/tab 2# PO TID for support.
    • He received chemotherapy with MEPFL (Mitomycin-C 8mg/m2、Epirubicin 60mg/m2、Cisplatin 60mg/m2 on D1 / Leucovorin 30mg/m2、5-Fu 450mg/m2 on D8) from 2023/09/28 (C1D1), 2023/10/05(C1D8).
    • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
    • Enlarged prostate with lower urinary tract symptoms, TONE 25mg/tab 1# PO BID, Betmiga 50mg/tab 1# PO QDAC was given for relief.
    • Insomnia with Stilnox 10mg/tab 0.5# PO HS, Modipanol 1mg/tab 2# PO HS.
    • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for Anti-HBc:reactive.
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, he was discharged on 2023/10/06 and OPD followed up later.   
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • MgO 250mg 2# TID
    • Smecta (dioctahedral smecitite 3g) 1# PRNQ6H
• 2023-09-19 SOAP Hemato-Oncology Xia HeXiong
  • S: s/p CCRT (Proton) with Gem/Platinum
    • Due to recurrence, s/p docetaxel/Platinum
  • A/P:
    • Suggest admission for salvage C/T with MEPFL.
    • Admission for echocardiography, 24 hours CCr, audiometry
• 2023-09-08 SOAP Ear Nose Throat Huang YunCheng
  • O: r/o r T3N0M0, suggest repeat CCRT or proton therapy?
    • He has received chemotherapy + proton therapy, but still recurrence tumor noted, He looked for 2nd opinion.
  • A: salvage sugery is not indicated due to near ICA
• 2023-09-05 SOAP Ear Nose Throat Huang YunCheng
  • S: NPC, s/p CCRT at LinKou ChangGung Hospital?
  • O: NpScope: right NP crusting and exudate coating
  • P: Apply course of treatment from LinKou ChangGung

[chemotherapy]

• 2023-10-31 - mitomycin-C 6mg/m2 10mg NS 100mL 30min + epirubicin 50mg/m2 80mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 24hr (MEPFL C2D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-05 - leucovorin 30mg/m2 50mg NS 250mL 1hr + fluorouracil 450mg/m2 700mg NS 250mL 2hr (MEPFL C1D8)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-09-28 - mitomycin-C 8mg/m2 12mg NS 100mL 30min + epirubicin 60mg/m2 90mg NS 250mL 30min + cisplatin 60mg/m2 90mg NS 500mL 24hr (MEPFL C1D1)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

Induction Chemotherapy With Mitomycin, Epirubicin, Cisplatin, Fluorouracil, and Leucovorin Followed by Radiotherapy in the Treatment of Locoregionally Advanced Nasopharyngeal Carcinoma - https://sci-hub.se/10.1200/JCO.2001.19.23.4305

• Neoadjuvant Chemotherapy
  • Serotonin antagonist and corticosteroids were routinely given for prophylaxis of nausea and vomiting.
  • The MEPFL chemotherapy consisted of intravenous (IV) administration of
    • D1
      • mitomycin 8 mg/m2,
      • epirubicin 60 mg/m2, and
      • cisplatin 60 mg/m2 on day 1 with hydration and diuresis.
    • D8
      • Fluorouracil 450 mg/m2 and
      • leucovorin 30 mg/m2 were given on day 8.
  • This cycle was repeated every 3 weeks if hemogram measurements were adequate (leukocyte count >= 3,500/L and platelet count >= 100,000).
  • If the leukocyte count was between 3,000 and 3,500/L or the platelet count was between 75,000 and 100,000/L on day 28, the subsequent cycle was modified by a 20% reduction in the dosage of mitomycin and epirubicin.
  • Three cycles were planned unless severe side effects occurred.
• Radiotherapy
  • Curative radiotherapy began within 3 weeks after completion of the last cycle of chemotherapy.
  • Megavoltage photons (6 MV) were used and the irradiation fields were designed according to the extension of the tumor.
  • The initial treated target volume was the gross target volume with a 2-cm margin in all directions and shrinkage to avoid excessive irradiation to the pons and spinal cord after 46 Gy.
  • All patients, except those with stage N3b disease, were treated with bilateral opposing portals to cover the primary tumor and neck; the fraction size was 2 Gy.
  • After 36 Gy, the primary and neck were treated by the split-field technique.
  • The primary was irradiated with shrinkage bilateral opposing fields, using 2.5 Gy as the fraction size, and an additional 10 Gy was given.
  • The intracranial lesion was excluded from the treatment portal after 46 Gy.
  • An additional 24 Gy in 10 fractions to the nasopharynx was delivered via bilateral anterior oblique infraorbital portals.
  • The accumulated radiation dose to nasopharynx was 70 Gy in 32 fractions, whereas the accumulated dose to intracranial lesion was 46 Gy in 22 fractions.
  • For patients with nasal or ethmoid involvement, the three-field technique (anterior field and bilateral opposing fields) was used instead of infra-orbital portals, with 24 Gy in 12 fractions.
  • The neck was treated using anterior-posterior opposing portals after 36 Gy in 18 fractions for patients with N0 to N3a disease, with the spinal cord shielded.
  • For N3b cases, the neck was treated using anterior-posterior opposing portals initially and blocked spinal cord after 40 Gy in 20 fractions.
  • The accumulated dose was 50 Gy in 25 fractions to uninvolved neck and 60 Gy in 30 fractions to involved regions.
  • An additional 5 Gy in two fractions was given to residual neck masses after 60 Gy.

==========

2023-11-01

Access to the patient’s PharmaCloud records is currently unavailable.

Following the initial cycle of the MEPFL regimen, leukopenia was noted for several days. Prompt intervention with G-CSF effectively alleviated this episode.

• 2023-10-31 WBC 4.60 x10^3/uL 10/31 MEPFL C2D1
• 2023-10-18 WBC 7.17 x10^3/uL
• 2023-10-11 WBC 0.99 x10^3/uL *** 10/11,12,13 Granocyte (lenograstim)
• 2023-10-04 WBC 2.53 x10^3/uL * 09/28 MEPFL C1D1, 10/05 MEPFL C1D8
• 2023-09-25 WBC 4.55 x10^3/uL
• 2023-09-19 WBC 4.55 x10^3/uL

The second cycle of the MEPFL regimen incorporated a “scaled-down” version of the “MEP” components (mitomycin 6mg/m2, epirubicin 50mg/m2, cisplatin 50mg/m2) compared to the first cycle (mitomycin 8 mg/m2, epirubicin 60 mg/m2, cisplatin 60 mg/m2), as per the original trial (https://doi.org/10.1200/jco.2001.19.23.4305). This modification aimed to mitigate the recurrence of such episodes.

There is no discrepancy found in the medication.

700307466

231031

[MedRec]

• 2022-09-05 ~ 2022-09-09 POMR General and Gastrointestinal Surgery Zhang YaoRen
  • Discharge diagnosis
    • Malignant neoplasm of unspecified site of right female breast
    • Right breast cancer with right axillary lymph nodes metastatic, cT4bN1M0. stage IIIB, ER (2+, 90%), PR (-) and HER2 (+, Dako score 3+) status post port implantation on 2022/09/06. ECOG:0
    • For neo-adjuvant chemotherapy with 1th Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg.
    • Hypertension
  • CC
    • for implantation port-a catheteriplatation and arrange neo-adjuvant chemotherapy with 1st TCPH (Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg)
  • Present illness
    • This 62-year-old female patient had past history of 1) hypertension 2) peritonitis s/p for 20+ years at TaiNan ChiMei Hospital. She denied any TOCC histories in recent 3 months.
    • She noted a mass at right breast for 1 years ago, it grew larger quickly recently. She came to DaLin TzuChi Hospital for help first. Breast sono guide biopsy, pathology showed invasive carcinoma, IHC staining: ER (positive, 100% tumor nuclei stained), PR (negative, 0% tumor nuclei stained), HER2/neu (positive, 3+) and Ki-67 index: 10. She tranferred to our hospital for sencond opinion. She denid of local edema, nipple bloody discharge or nipple retraction. After examination, palpabled a 5x4x2.5 xm firm mass with skin invasion over right breast. Sono guide biopsy of right axillary lymph nodes was performed. Pathology showed metastatic carcinoma. The tumor marker showed CA-153：16.684 U/ml, CEA：1.793 ng/ml. Tc-99m MDP whole body bone scan showed no obvious lesion for metastasis.
    • Under the impression of right breast invasive carcinoma with axillary LN metastsis, cTbN1M0, stage IIIB. After well explain including pathology and the possible treatment modality were well explained to the patient. She was admitted for for implantation port-a catheteriplatation and arrange neo-adjuvant chemotherapy with 1st TCPH (Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg).
  • Course of inpatient treatment
    • After admittion, follow up breast MRI for further survry. Breast MRI showed right breast malignancy with skin invasion and lymph node metastasis and left breast oval shaped tumor. After fully explaination the finally pathology. She underwent of Port-A catheter implatation on the left side on 2022/09/06. Arrange heart echo for cardiac toxicity of herceptin, data showed no obvious lesion for pre-chemo survey. We prescribed 1st neo-adjuvant chemotherapy with TCPH (Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg).
    • Arrange whole bady PET scan for cancer survry on 2022/09/08. The whole bady PET scan report showed glucose hypermetabolism in the right breast with skin invasion, compatible with primary breast malignancy with skin invasion, some right axillary lymph nodes. Metastatic lymph nodes may show this picture and mild glucose hypermetabolism in a focal area in the medial aspect of left breast. During the process, she complain of vomiting, cold sweats and itchy rashes on limbs. Therefore, extended chemotherapy injection time. Under the stable condition, she was discharged today and and OPD follow up was suggested next week.
  • Discharge prescription
    • Limeson (dexamethasone 4mg) 1# BID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Parmason Gargle Solution (chlorhexidine) BID GAR
    • Exforte (amlodipine 5mg, valsartan 160mg) 1# QD
    • Saline (nicametate citrate 50mg) 1# BID
    • Vit B6 (pyridoxine 50mg) 1# BID
    • Stilnox (zolpidem 10mg) 1# PRNHS
• 2022-08-31 SOAP General and Gastrointestinal Surgery Zhang YaoRen
  • S: breast lump. Rt breast ca proved by CNB on 2022-08-18 at DaLin TzuChi Hospital.
  • O
    • postmenopausal 50 y/o
    • menarche 15 y/o
    • G2P2
    • FH of breast ca (-)
    • HRT(-)
    • A 5x4x2.5 xm firm mass with skin invasion over rt breast
    • rt axillary papale LN
    • 2022-08-18 DaLin TzuChi Hospital
      • The specimen submitted consists of 4 strips of breast tissue, measuring up to 1.2x0.2x0.2 cm, fixed in formalin.
      • Grossly, the tissue is gray fleshy and soft. All for section.
      • Microscopically, the section shows an invasive carcinoma with focal duct differentiation. The tumor demonstrates moderate cellular atypia, in solid nests, Indian filing pattern, relative hyperchromatic nuclei, nucleoli, not infrequent mitoses, >10/10HPF and infiltrative pattern with marked tissue desmoplasia.
      • Immunohistochemically, the tumor cells positive for ER (100% tumor nuclei stained) and E-Cadherin, negative for PR (0% tumor nuclei stained), with a Ki-67 proliferating index of 10% in hot area. The stain for HER2/neu is positive (3+, complete intense circumferential membranous staining in >10% of invasive tumor cells).
      • The morphological picture is invasive carcinoma of no special type, grade II, score 6 (tubule formation: 2, nuclear pleomorphism; 2, mitotic count: 2).
      • Results of the IHC staining: ER (positive, 100% tumor nuclei stained), PR (negative, 0% tumor nuclei stained), HER2/neu (positive, 3+) and Ki-67 index: 10% in hot area.
      • IHC stains (Bondmax, Leica, Australia): ER (SP1/Zeta, 50X), PR (1E2/Ventana, 4X), HER2/neu (CB11/Leica, 200X), Ki-67 (GM010/Genemed, 300X) and E-cadherin (GM016/Genemed, 50X).

[surgical operation]

• 2023-06-13
  • Surgery
    • Dx: suspected epidermal cyst over posterior side of right ear
    • OP: excision
  • Finding
    • 1.5cm, egg-shaped, capsulated, subcutaneous tumor over posterior side of right ear
• 2023-01-10
  • Surgery
    • right breast MRM        
    • Intraop ICG reverse mapping of axillary lymphatic duct
  • Finding
    • breast tumor, 1.5cm, 8”/3cm
    • axillary multiple LN

[immunochemotherapy]

• 2023-09-13 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-08-23 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-07-31 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-07-06 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-06-12 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-05-22 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-04-27 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-04-06 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-03-16 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-02-22 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-01-30 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2023-01-09 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
• 2022-12-21 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 124mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-11-30 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-11-09 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-10-19 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-09-28 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-09-07 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr (pertuzumab loading)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2023-10-31

[grade 3 diarrhea]

Based on the bowel movement records from the HIS5’s TPR panel, the patient has not had any instances of bowel movements reaching seven times in a day during her last three hospital stays.

It has been documented that the occurrence of diarrhea is linked with trastuzumab (7% to 25%), pertuzumab (46% to 67%), and neratinib (diarrhea at 95%; severe diarrhea: 2%). Given that the use of trastuzumab and pertuzumab started in Sep 2022 and has been continuous since then, and neratinib was only introduced in mid-Sep 2023, and its likelihood of causing diarrhea is higher than the former two, it is plausible that the recent episode of grade 3 diarrhea is more likely attributed to neratinib.

The prescription of Smecta and loperamide is an appropriate measure.

The patients should be reminded to maintain a fluid intake of approximately 2 L/day to prevent dehydration. Once the diarrhea improves to grade 1 or returns to baseline, it is recommended to initiate loperamide at 4 mg with each subsequent dose of neratinib.

700301909

231030

[lab data]

2023-09-20 HBsAg (NM) Negative
2023-09-20 HBsAg Value (NM) 0.422
2023-09-20 Anti-HBc (NM) Positive
2023-09-20 Anti-HBc Value (NM) 0.01
2023-09-20 Anti-HCV (NM) Negative
2023-09-20 Anti-HCV Value (NM) 0.042
2023-09-20 Anti-HBs (NM) Positive
2023-09-20 Anti-HBs value (NM) 46.4 mIU/mL

[exam findings]

• 2023-09-15 All-RAS + BRAF
  • ALL-RAS: There was no variant detect in the KRAS/NRAS gene.
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-09-14 Patho - peritoneum biopsy
  • Peritoneum, biopsy — Adenocarcinoma, moderately differentiated, metastatic, consistent with colorectal origin
  • Section shows pieces of fibroadipose tissue with metastatic adenocarcinoma.
  • The immunohistochemical stains reveal CK7(-), CK20(+), and CDX2(+). The results are consistent with metastatic colorectal adenocarcinoma.
• 2023-09-01 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (125 - 41) / 125 = 67.20%
    • M-mode (Teichholz) = 68
  • Conclusion:
    • Normal LV filling pressure; impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis; mild MR.
    • Mildly dilated aortic root with mild calcification.
• 2023-08-22 Flow Volume Chart
  • r/o mild restrictive ventilatory defect
• 2023-08-14 Patho - colon biopsy
  • Colorectum, cecum base involving ileocecal junctioon (130 cm above anal verge), biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2023-08-04 CT - abdomen
  • Findings:
    • There is a heterogeneous poor enhancing mass in right lateral pelvis with directly attached the terminal ileum, cecum and rectosigmoid junction, measuring 7.7 cm (the largest dimension).
      • Adenocarcinoma of the terminal ileum is highly suspected.
      • The differential diagnosis includes lymphoma, malignant GIST and colon cancer with exophytic growing. Please correlate with colonoscopy.
      • In addition, this mass causes marked right hydroureteronephrosis and delayed contrast excretion of right kidney that is c/w Right pelvic mass with direct invasion M/3-L3 ureter induce obstructive uropathy.
    • There are seven enlarged lymph nodes in the sigmoid mesocolon and right internal iliac chain that are c/w metastatic nodes.
    • There are multiple soft tissue nodules in the omentum at RUQ and LUQ abdomen that are c/w carcinomatosis.
    • There is a homogeneous enhancing mass 2.3 cm in S6 of the liver that may be hemangioma. Please correlate with MRI.
    • In addition, there are three cysts on S5, S4, and S3 (the largest one 1.9 cm in S5).
  • Impression:
    • Adenocarcinoma of the terminal ileum with lymph nodes metastases and carcinomatosis is highly suspected.
    • The differential diagnosis includes lymphoma, malignant GIST, and colon cancer with exophytic growing.
• 2023-07-28 SONO - abdomen
  • Diagnosis:
    • suspicious, colonorectal tumor or pelvic tumor
    • Liver cyst, S8
    • Hydronephrosis, right
    • Renal stone, left
    • pancreatic body and tail masked by gas.
  • Suggestion:
    • arrange abd + pelvic CT
    • consider refer to Urology.

[MedRec]

• 2023-09-26 SOAP Urology Li MingWei
  • A
    • Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis status post diagnostic laparoscopy on 2023/09/14, cT4bN2bM1c, stage IVc
    • Right PCN was done on 2023/09/15
  • Prescription
    • Harnalidge (tamsulosin 0.4mg) 1# QN
• 2023-09-26 SOAP Hemato-Oncology Xia HeXiong
  • P: Admission for C/T with FOLFIRI +/- avastin
• 2023-09-26 SOAP Colorectal Surgery Chen ZhuangWei
  • A: Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis status post diagnostic laparoscopy on 2023/09/14, cT4bN2bM1c, stage IVc
  • P: refer to oncoligist for palliative chemotherapy, may bypass or ileistomy if obstructed symptoms got worse
• 2023-09-12 ~ 2023-09-18 POMR Colorectal Surgery Chen Zhuang Wei
  • Discharge diagnosis
    • Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis status post diagnostic laparoscopy on 2023/09/14, cT4bN2bM1c, stage IVc
    • Right hydronephrosis status post right ureteral catheterization on 2023/09/14 and right percutaneous nephrostomy on 2023/09/15
  • CC
    • peri-umbilical tenderness for 2 weeks with difficult defecation
  • Present illness
    • This is a 67 y/o male with past history of ICH on 2020/3. This time he was admitted due to peri-umbilical tenderness for 2 weeks with difficult defecation.
    • According to the patient statement, he suffered from peri-umbilical tenderness for 2 weeks with difficult defecation. He denied diarrhea, melena or hematocheizia. Due to above symptoms, he went to our GI OPD for help on 7/25. Abdominal ultrasound showed right hydronephrosis, suspicious S-colon/rectal lesion. And abdominal CT on 8/4 showed adenocarcinoma of the terminal ileum with lymph nodes metastases and carcinomatosis is highly suspected. Colonoscopy showed 1. Ulcerative tumor lesion was noted in the cecum base (130cm AAV) involving ileocecal junction 2. Mucosal chnage with external compression-like effect was found at RS-colon. Pathology showed adenocarcinoma. Under impression of newly found cecal adenocarcinoma, locally advanced with possible carcinomatosis, stage IVc, this time he was admitted for further evaluation and surgical intervention.
  • Course of inpatient treatment
    • This 67 years old male patient was a case of cecal adenocarcinoma. After admission, he complained right testicular region tenderness for two weeks. Right epididymitis was suspected and cravit was given. He underwent diagnostic laparoscopy and right ureteral catheterization on 2023/09/14. However, due to right ureteral catheterization failed with suspected tumor invasion of right upper ureter, right PCN was done on 2023/09/15. And Port-A was also done on 9/15 for palliative chemotherapy. The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable. He was discharged on 2023-09-18 and will follow up in our out-patient department next week.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQID
    • Cravit (levofloxacin 500mg) 1.5# QDAC
    • Harnalidge (tamsulosin 0.4mg) 1# HS
    • MgO 250mg 2# BID
    • Through (sennoside 12mg) 1# HS
• 2020-04-21 SOAP Neurosurgery
  • S: spontaneous ICH, conservative treatment 2020/03
  • Prescription x2
    • Depakine (valproic acid 500mg) 1# BID

[consultation]

• 2023-09-16 Radiation Oncology
  • Q
    • For right side PCN
    • This is a 67 y/o male was a case of newly found cecal adenocarcinoma, locally advanced with carcinomatosis and right hydronephrosis, stage IVc.
    • He underwent diagnostic laparoscopy and right ureteral catheterization on 2023/09/14.
    • Op finding: 1) Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis over the whole peritoneal cavity including abdominal wall and omentum; 2) Right lower ureter stricture, suspected tumor invasion of right upper ureter; 3) Suspected tumor invasion of right upper ureter, URS and guidewire can not pass through.
    • Due to right ureteral catheterization failed, we needs your expert experience for further evaluation and management. Thanks a lot !!
  • A
    • According to the clinical condition and imaging findings, right PCN is indicated.
• 2023-09-14 Hemato-Oncology
  • Q
    • For palliative chemotherapy
    • This is a 67 y/o male was a case of newly found cecal adenocarcinoma, locally advanced with possible carcinomatosis, stage IVc. He underwent diagnostic laparoscopy and right ureteral catheterization on 2023/09/14.
    • Op finding: 1) Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis over the whole peritoneal cavity including abdominal wall and omentum; 2) We got three pieces of seeding tumors over abdomen wall and omentum for pathology examination; 3) Right lower ureter stricture, suspected tumor invasion of right upper ureter.
    • After fully explained of the condition, palliative chemotherapy was suggested. So we needs your expert experience for further evaluation and management. Thanks a lot !!
  • A
    • Dear doctor: This 67 year old man is a case of cecal adenocarcinoma with carcinomatosis. We are consulted for pallative chemtoherapy.
    • For metastasis colon adenocarcinoma (Pending All RAS/BRAF), chemotherapy+/- target therapy is indicated. We had well explaint to patient and his wife. Please arrange our OPD after discharge.
    • Check HBsAg, Anti HBc, Anti HBs, Anti HCV and arrange port A insertion before chemotherapy.

[surgical operation]

• 2023-09-14
  • Surgery: Diagnostic laparoscopy     
  • Finding
    • Diagnostic laparoscopy was performed and whole peritoneal cavity was inspected.    
    • Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis over the whole peritoneal cavity including abdominal wall and omentum    
    • We got three pieces of seeding tumors over abdomen wall and omentum for pathology examination.
    • Right ureter catherter was performed by urologist but is difficult to be done smoothly due to tumor effect.    
    • We had informed above condition to his son during the operation, further management such as right PCN and port-A are needed. 

[immunochemotherapy]

• 2023-10-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-28 - irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-02

PharmaCloud data indicates that the patient has only been to our hospital within the last three months. Our urologist prescribed a refill of Harnalidge (tamsulosin) on 2023-09-26, and the medication is currently being used without any issues.

701306367

231030

[exam findings]

• 2023-08-01 Neck soft tissue
  • Placement of nasogastric tube and tracheostomy.
  • Straightening alignment of cervical spine.
  • Degenerative change of the spine with marginal spur formation.
• 2023-08-01 CXR
  • Normal heart size with tortuous aorta.
  • Placement of tracheostomy and nasogastric tube.
  • Multiple right ribs fracture, old.
  • Fibrocalcified nodules at RUL.
  • Bilateral clear costophrenic angles.
  • L2 compression fracture status post vertebroplasty.
• 2023-07-27 CXR
  • Tortuosity of the aorta with atherosclerotic change.
  • Fibrocalcified change over right apical lung, may be old TB.
  • Old fracture of multiple ribs.
  • S/P tracheostomy.
  • S/P N-G tube insertion.
• 2023-07-20 Tc-99m MDP bone scan
  • Increased activity in the lower C-spine and L2-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Some faint hot spots in bilaterla rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips, knees, right ankle and right foot, compatible with benign joint lesions.
• 2023-07-19 CT - neck
  • Right tongue squamous cell carcinoma, moderately differentiated, for cancer work up
  • With and Without contrast Neck CT showed
    • The neck airway was unremarkable.
    • heterogeneous enhancing tumors in the oral cavity, oropharynx and bilateral hypopharynx.
    • multipe necrotic lymph nodes in the left carotid space, riht submandibular space and right posterior cervical space
    • The major salivary glands were unremarkable.
    • The skull base and C-spine alignment were unremarkable
  • IMP: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck.
• 2023-07-18 EGD
  • Suboptimal study due to poor intolerance
  • Reflux esophagitis LA Classification grade C
  • Esophageal mucosal lesion, EC junction, s/p biopsy
  • Hiatal hernia
  • Superficial gastritis
  • Gastric erosions, antrum
• 2023-07-10 Patho - tongue biopsy
  • Tongue tumor, R’t, biopsy — Squamous cell carcinoma, moderately differentiated
  • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated of the tongue tumor tissue characterized by solid tumor nests infiltration with keratin formation, hemorrhage and necrosis.
  • Immunohistochemistry shows CK(+), P40(+), P16(-) and HPV(-) for tumor.
• 2023-07-08 Embolization (TAE) - neuro
  • The procedure was performed under general anaesthesia via right femoral artery approach with a Fr#8 angiocatheter sheath and guiding catheter.
  • Bilateral carotid angiograms reveal tumor stains over oropharyngeal space, supplied by bilateral lingual artery. .
  • Transarterial embolization of the tumor was then performed by infusion of particles (Embospheres).
  • Post embolization bilateral carotid angiograms show total embolization of this tumor.
• 2023-07-08 Carotid angiography bilat.
  • Tumor stains over oropharyngeal space, supplied by bilateral lingual artery.
• 2023-07-08 Aortography - thoracic
  • Type II aortic arch.
  • No critical stenosis of bilateral proximal carotid and vertebral arteries.
  • The whole procedure was smoothly done without apparent immediate complication and the patient stood it well under local anesthesia.
• 2023-07-08 CT, CTA - brain
  • Presence of huge lobulated mass lesion over oropharyngeal space, mainly at posterior tongue, with invasion of anterior part of the tongue and the epiglottis. Large necrotic area of this tumor. The tumor was mainly supplied by bilateral lingual arteries.
  • Several necrotic nodes over left-side of the neck.
  • S/P tracheostomy.
• 2023-04-11 Patho - doudenum biopsy
  • Duodenum, bulb, GC/PW, biopsy — Brunner’s gland hyperplasia
• 2023-04-11 EGD
  • Reflux esophagitis LA Classification grade C
  • Duodenal polyps, bulb, s/p biopsy
  • Hiatal hernia
  • Superficial gastritis
• 2023-04-03 EEG
  • This EEG were composed by continuous diffuse theta wave with 5-6 Hz, 10-20 uv in bilateral hemisphere with left side more severe. There were no obvious photic driving response.
  • This EEG suggest moderate diffuse cortical dysfunction left side more severe. Advise clinical correlation.
• 2023-03-30 CT - brain
  • Small amount of chronic subdural effusions along right convexity. Minimal amount of acute SDH over right temporal fossa.
  • Traumatic head injury with right frontal scalp and face swollen change.
  • Depressed left hemicranium with thickening dura. Compressed left cerebral hemisphere with large area of old infarction.
  • S/P V-P shunt insertion.

[MedRec]

• 2023-08-08 SOAP Hemato-Oncology
  • P: Arrange admission for CCRT with weekly CDDP
• 2023-08-04 SOAP Radiation Oncology
  • S: Diagnosis: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck. cT4aN2cM0 at least.
  • O: 2023/07/27~ RT to the oral cavity and bil. neck lymphatic drainage area: 12 Gy/ 6 fx.
  • P: Plan to deliver 50 Gy/ 25 fx to the oral cavity, oropharynx, and bil. neck lymphatic drainage area. Then boost the gross tumor and LAPs to 70 Gy/ 35 fx.
• 2023-07-08 ~ 2023-08-28 POMR Ear Nose Throat
  • Discharge diagnosis
    • Malignant neoplasm of overlapping sites of tongue, stage IV
    • Oropharyngeal tumor bleeding with hypovolemic shock
    • Hemoptysis
    • Acute hypoxemic respiratory failure post intubation
  • CC
    • cough with much blood sputum today, and poor intake fo 2 days
  • Present illness
    • This 51-year-old man has past history of 1.) old CVA with right weakness, 2.)　alcoholism　3.)　Traumatic brain injurys/p craniectomy 4.) Epilepsy 5.) s/p abdomen operation (colon).
    • According to statement of his ex-wife, he suffered from cough with much blood sputum today, and poor intake fo 2 days. He was brough to our hospital for help. At ER, Con’s:E4V5M6, TPR:37.1/112/18, BP:94/55mmHg; SpO2:99%, sudden massive blood from oral and desaturation, bradycardia, hypotension were noted, s/p Bosmin injection, difficult oral endotrachea tube installation, emergency tracheostomy with ventilator support was performed at ER. Laboratory studies showed leukocytosis, increase of segment, Imbalance electrolyte as hyperkalemia, hyponatremia. The chest film disclosed Fibrocalcified change over RUL.
    • Due to massive oral bleeding, so we arrange brain CT, which revealed 1. Presence of huge lobulated mass lesion over oropharyngeal space, mainly at posterior tongue, with invasion of anterior part of the tongue and the epiglottis. Large necrotic area of this tumor. The tumor was mainly supplied by bilateral lingual arteries. 2. Several necrotic nodes over left-side of the neck. Angiography was arranged and embolization was done. Empirical antibiotics, IV fluid challenge, and blood transfusion for hypovolemic shock were given. Under the impression of 1.) Acute hypoxemic respiratory failure post intubation 2.) oropharyngeal tumor bleeding with hypovolemic shock, he was admitted to MICU for further treatment.
    • He did not received vaccice included covid-19 and Influenza
  • Course of inpatient treatment
    • MICU 7/08-7/17
      • After admitted to MICU, on cricothyrotomy with ventilator support. Arrange tracheostomy on 7/9. Unstable hemodynamics under IVF hydration and levophed titration infusion.
      • Empiric antibiotic with tapimycin Tapimycin (7/8-) and Targocid (7/9-7/11) for infection treat. Give MgSO4, KCL IVD, Ca. gluconate and high P diet were given for correct imbalance electrolyte.
      • Transamin IV and Bosmin inhalation were given for hemoptysis. AEDs with dilantin IV shift to oral form and ativan PRN IVD for seizure control. Contact ENT for biopsy of right tongue tumor: Squamous cell carcinoma. Try T-mask overnight since 7/15 for weaning ventilator. He wil transfer to ENT ward for further care.
    • ENT ward 7/17-7/28
      • Under relative stable condition, we remove foley catheter and shift tracheostomy to shiley 6 # smoothly on 7/18.
      • Cancer work up was arranged, which revealed tongue tumor with extensive invasion the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck. Operation was not indicated due to massive invasion. Radiotherapy will be arranged from 7/27, and he will be discharged under relative stable condition.
  • Discharge prescription
    • Zalain Cream (sertaconazole nitrate 2%) BID TOPI
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
    • Phenytoin (diphenylhydantoin 100mg) 1# TID
    • Ulstop (famotidine 20mg) 1# BID
    • Parmason Gargle Soln (chlorhexidine) BID GAR
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
• 2023-03-31 ~ 2023-04-12 POMR Infectious Disease
  • Discharge diagnosis
    • Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction
    • Hypostatic pneumonia, unspecified organism
    • Contusion of unspecified part of head, initial encounter
    • Contusion of eyeball and orbital tissues, right eye, initial encounter
    • Altered mental status, unspecified
    • Unspecified adrenocortical insufficiency
    • Gastritis, unspecified, without bleeding
    • Gastro-esophageal reflux disease with esophagitis
  • CC
    • Drowsy conscious and poor appetite in recent three days.
  • Present illness
    • This is a 51 year-old male patient, who has underlying histories of alcoholism, Left TBI s/p craniectomy, s/p abd op (colon), is admitted for drowsy conscious and poor appetite in recent three days.
    • According to his ex-wife, he suffered from drowsy conscious and poor appetite after fall down with hit the head before three days ago. He also accompanying symptoms of headache, right eye swelling and ecchymosis.There is no TOCC or trauma hisory. He had no previous allergy to food or drug. There is no URI or UTI symptom in recent days.
    • He was brought to our ED for help.
    • At ED, vital signs showed tachycardia (BP:129/88; HR:104; BT:35.5; RR:18). PE showed ecchymosis, swelling, local heat, painful and tenderness over right eye, sclera congestion, pupils has light reflex. Laboratory data showed leukocytosis (13200/uL), elevated Hb (Hb:18.1 g/dl), CRP (7.06mg/dL), glucose (Glu:190 mg/dl), and normal liver and renal function. Blood gas (vein) showed respiratory acidosis with metabolic compensation. Urinalysis showed elevated urobilinogen (8 mg/dl), bilirubin (1+), no pyuria. CXR showed clear both lung field. Brain CT revealed small amount of chronic subdural effusions along right convexity. Minimal amount of acute SDH over right temporal fossa.
    • Under the impression of hypostatic pneumonia, dehydration, SDH, he is admitted to the Infection ward for evaluation and management on 2023-03-31.    
  • Course of inpatient treatment
    • During the hospital stay, we use parenteral cefuroxime for empirical treatment of hyposttaic pneumonia. Consciousness was monitor due to post head injury. Raise the head of the bed up 30 degree. Neurology consulted for treatment of SDH and headache. This EEG suggest moderate diffuse cortical dysfunction left side more severe. The adequate fluid hydration due to dehydration. The Foley catheter indwelling is for monitor and record urine amount. Oncology was consulted for suspect polycythemia. Patient received JAK2, BCR ABL, therapeutic phlebotomy (maintain the hematocrit < 45 percent) and bone marrow aspiration and biopsy.
    • Patient’s ex-wife complained of no stool passage above three days and abdominal distension. KUB revealed stool impaction. Laxative, antiflatulent were given. Hiccup is noted, we also addition prokinetic treatment. Patient’s ex-wife complained of dark green stool noted, stool is submitted for stool OB. We also give recheck Hb level and adrenal function survey. No bacterial growth on blood culture is noted. Mild decreased ACTH is noted, adrenocortical insufficiency was considered.
    • We give addition systemic steroid. Panendoscopy was arrange due to anemia and stool OB 4+. Panendoscopy revealed Reflux esophagitis LA Classification grade C
    • Duodenal polyps, bulb, s/p biopsy. Hiatal hernia. Superficial gastritis. PPI was given after panendoscopy examination. Voiding is smooth after removal foley catheter. No bacterial growth on blood culture is noted. Laboratory examinaiton revealed improve. No more fever occurs. Conscious clear. Respiratory pattern is smooth. Under stable condition, he is discharged on April 12, 2023.
  • Discharge prescription
    • cortisone acetate 25mg 0.5# QD
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Mopride (mosapride citrate 5mg) 1# TID
    • Through (sennoside 12mg) 1# HS
• 2021-07-27 SOAP Neurosurgery
  • S
    • Wedge compression fracture, L2 post vertebroplasty on 2021/07/16
    • Postoperatively, his symptom has been relieved.
  • P
    • Porlia infusion
  • Prescription
    • Prolia (denosumab 60mg) ST SC
• 2021-07-15 ~ 2021-07-16 POMR Neurosurgery
  • Discharge diagnosis
    • Wedge compression fracture, L2 post vertebroplasty on 2021/07/16
  • CC
    • Lower back pain for 3 weeks
  • Present illness
    • This is a 49 year-old male with alcoholism, Left TBI s/p craniectomy, s/p abd op (colon).
    • This time he was suffered from lower back pain after fell down when work since 6/28. The pain became worse so he came to our NS OPD for help on 7/5.
    • At OPD, PE showed MP RUE 3 RLE 3, LUE 4 LLE, SLRT -/- Lasguest test(+). L-spine X-ray showed L2 compresion fracture. MRI of L spine revealed: L2 subacute compression fracture. After discussion with the patient, surgery would be arranged.
    • Under the impression of L2 compression fracture, he was admitted for further management.
  • Course of inpatient treatment
    • After admission, we did pre-OP prepare. L2 body bone cement augmentation was arranged on 7/16. The patient’s condition and vital sign was stable after the surgery and his symptoms was mild improved. After assessment, he will discharge on 7/16 and OPD follow up.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Sindine Aq Soln (povidone iodine) QD EXT for L-spine wound

[consultation]

• 2023-10-19 Ear Nose Throat
  • Q:
    • PH extensive tumors in the oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck; cT4aN2cM0 at least.
  • A
    • S
      • Hemoptysis since last night by family
      • Fair saturation (SpO2: 97-99% under room air) but lip with cyanotic change when visiting
      • Cuff inflation (8 ml) for airway protection before visiting
      • PHx: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck
        • s/p CCRT with weekly CDDP ( 7000 cGy / 35 Fx, from 2023/07/27~2023/09/14)
    • O
      • Portable scope: no active bleeding over trachea after cuff inflation, bloody mucus over trachea
      • Local finding: no active bleeding or oozing over tracheostomy
      • much blood clot over left tongue necrotic wound, s/p bosmin gauze compression
    • A
      • Hemoptysis, favor oral cancer bleeding related
    • P
      • S/p bosmin gauze compression -> no active oral bleeding
      • Keep Cuff inflation for airway protection
      • If active oral bleeding, angiography for embolization may be indicated -> however, patent refused futher aggresive treatment (The patient is conscious and alert. The patient was informed that there is a life-threatening risk if bleeding continues and embolization is not performed. The patient nodded in understanding. When asked if they would accept the treatment, the patient shook their head to indicate refusal. The patient’s ex-wife was also informed of the same content. She understood and expressed respect for the patient’s wishes.)
• 2023-08-17 Family Medicine
  • Q
    • This 52 year-old man patient is a case of Tongue cancer with bilateral neck LAP metastasis, cT4aN2cM0, stage IVB s/p concurrent chemoradiotherapy from 2023/07/27. Concurrent chemotherapy with CDDP was on 2023/08/17. This time, for PS:4 with weakness and sign DNR. Now, for evaluate hospice combined care. Thank you.
  • A
    • Cons:E4V5M6. ECOG:4
    • We will arrange hospice combine care and follow up his condition.
    • Indication: Tongue cancer with bilateral neck LAP metastasis, cT4aN2cM0, stage IVB
    • Plan: Hospice combined care
• 2023-07-24 Dermatology
  • Q
    • Itching papule over peri-inguinal region was noticed for days. We need your expertise for further evaluation and treatment.
  • A
    • This patient suffered from erytehamtous patches on L’t thigh for days.
    • Imp: Tinea corprois
    • Suggestion:
      • Mycomb * 2 tubes/bid
      • Zalain cream * 2 tubes/bid
• 2023-07-21 Hemato-Oncology
  • Q
    • Operation may not be indicated due to masive tumor invasion. We need your expertise for concurrent or induction chemotherapy arrangement.
    • The patient’s caregiver is his ex-wife, and they have a 14-year-old underage daughter together.
  • A
    • This 51 year old man is a case of Tongue base squamous cell carcinoma, moderately differentiated, p16(-), HPV (-) with tumor bleeding, status post angiography embolization on 2023/07/08, status post tracheostomy on 2023/07/09.
    • Neck CT revealed tumor invasion over oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck. We are consulted for CCRT. Please arrange port A insertion.
    • Check Anti HBc, HBsAg, Anti HCV. Arrange 24 urine CCR. Please arrange our OPD after discharge.
• 2023-07-21 Radiation Oncology
  • A
    • This time, he was admitted to our ward for oropharyngeal tumor bleeding. Biopsy over tongue revealed squamous cell carcinoma, moderately differentiated, p16(-), HPV (-). Neck CT revealed tumor invasion over oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck.
    • CCRT is indicated. CT-simulation will be arranged on 7/24. Plan to deliver 50 Gy/ 25 fx to the oral cavity, oropharynx, and bil. neck lymphatic drainage area. Then boost the gross tumor and LAPs to 70 Gy/ 35 fx. RT will start around 7/27. Thank you very much.
• 2023-07-19 Oral and Maxillofacial Surgery
  • Q
    • tongue cancer patient, for oral cavity evaluation
    • This is a 51-year old man with past history
      • Old cerebrovascular accident with right side weakness
      • Alcoholism　
      • Traumatic brain injury status post left craniectomy more than 20 years ago
      • Epilepsy under phenytoin
      • Unknown colon lesion status post operation
    • This time, he was admitted to our ward for massive tumor bleeding. Emergent tracheostomy with tongue tumor biopsy was perfromed smoothly, and pathology report showed moderately differentiated squamous cell carcinoma. As part of cancer evaluation, we need your expertise for oral cavity evaluation.
  • A
    • After examing the intraoral condition, poor oral hygiene and multiple deep caries were noticed.
    • As the patient is unwilling to open his mouth and refuse to accept further dental evaulation.
    • Extraction of hopeless teeth might be difficult.
• 2023-07-08 Ear Nose Throat
  • A1
    • If massive bleeding occurs again, you can pack the mouth with Bosmin gauze (4x4 unfolded gauze pieces tied together in a string).
  • A2 Supplementary Consultation Response: 2023-07-08 21:02:07
    • The procedure performed this time was a cricothyrotomy (non-tracheostomy procedure), and tracheostomy surgery will be needed in the coming days.
• 2023-04-05 Hemato-Oncology
  • Q
    • This 51 y/o man admitted due to hypostatic pneumonia. History of smoking and trauma s/p V-P shunt. Hb:18.1 g/dl, suspect polycythemia. So we need your help for further suggestion. Thanks.
  • A
    • Please check JAK-2, BCR ABL, and arrange theraputic phlebotomy (maintain the hematocrit ＜45 percent).
    • Bone marrow aspiration and biopsy is indicated. Thanks for your consultation.
• 2021-06-29 Neurosurgery
  • Q
    • CC: fell down 3 days ago? and low back pain and generalized weakness; decreased appetite; slurred speech as usual (according to the ex-wife)
    • PH: alcoholism, Left TBI s/p craniectomy on 1995, s/p abd op (colon?)
    • Allergy: denied
  • A
    • The patient had lower back pain and general weakness.
      • Recent Hx of chest trauma: undetectable
      • CT scan of the abdomen showed old fracture of right lower ribs with chronic pleural change.
      • Patient hand no chest pain and dyspnea
    • Suggestion:
      • OPD FU for CS condtion
      • Consult NS
• 2021-06-29 Neurosurgery
  • Q
    • CC: fell down 3 days ago? and low back pain and generalized weakness; decreased appetite; slurred speech as usual (according to the ex-wife)
    • PH: alcoholism, Left TBI s/p craniectomy on 1995, s/p abd op (colon?)
    • Allergy: denied
  • A
    • This patient suffered from back pain after a fall 3 days ago. At ER, his L spine films showed L2 compression fracture. Conservative therapy, including back brace, is suggested. OPD f/u is advised.

[radiotherapy]

[chemotherapy]

==========

2023-10-30 (not posted)

[patient’s weight is too light]

A dosage of 1# QD could be considered appropriate for this patient with a less severe condition, given his body weight of 37 kg. This dosage is approximately equivalent to 1.5# QD for a patient weighing 57 kg.

2023-08-11

[reconciliation]

The patient obtained a 28-day refill of the repeat prescription for Dilantin Kapseals (phenytoin) for his “absence epileptic syndrome, not intractable, with status epilepticus” from Taipei City Hospital on 2023-08-04. However, the patient is currently not taking phenytoin (according to the active medication list). It is recommended to assess whether the patient’s neurological symptoms persist and to determine the continued necessity of the drug.

701490021

231030

[lab data]

2023-09-14 Anti-HBc Reactive
2023-09-14 Anti-HBc-Value 1.30 S/CO
2023-09-14 Anti-HBs 127.72 mIU/mL

[MedRec]

• 2023-09-13 ~ 2023-09-18 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Ductal adenocarcinoma of pancreatic head with liver metastasis, pT3N2M1; Stage IV status post whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and lymph noder dissection on 2023/07/31
    • Malignant neoplasm of head of pancreas
    • Chronic viral hepatitis B without delta-agent
  • CC
    • for chemotherapy
  • Present illness
    • This 69 y/o female patient denied underlying diseases, diagnosis was Ductal adenocarcinoma of pancreatic head with liver metastasis, pT3N2M1, stage IV status post whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and lymph noder dissection on 2023/07/31.
    • Accroding to her statement, she had upper abdominal fullness and frequent postprandial vomiting for several times about these half month. Body weight loss wa noted (72kg -> 69kg for 1 month). There was no fever, no dyspnea, no diahrrea, no tarry/bloody stool passage. She went to ChiMei Hospital and image study showed 2-3 cm pancreatic head tumor. Lab data showed elevated AST/ALT, ALP, rGT and Total bilirubin level. She then went to our hospital for second opinion. Cholangiography MRI on 2032/07/11 showed a poor enhancing lesion (3.0x3.3x4.3cm) at pancreatic head with adjacent duodenal and CBD invasion causing biliary dilatation, some small LNs at retroperitoneum. Distention of gallbladder and stomach, a poor enhancing nodule (8mm) at S4-8 junction of liver、renal cysts (up to 2.3cm). Pancreatic Carcinoma T3N2M1, stage IV.
    • Endoscopic retrograde cholangiopancreatography on 2023/07/11 showed duodenal tumor with duodenum stricture: at SDA: post biopsy (failed cannulation), duodenal ulcer. Pathology showed intestine, small, duodenum, SDA, biopsy — Adenocarcinoma, IHC reveals CK7(+), CA19-9(-), CK20(1). Abdominal echo on 2023/07/12 showed probable liver parenchymal disease (incomplete exam of liver), suspected pancreas tumor (head portion), mild dilatation of pancreatic duct, gallbladder obscured, mild dilatation of CBD and bilateral IHD, right renal cyst, right pleural effusion: minimal amount.
    • Pathology showed Labeled as “pancreatic neck”, EUS needle biopsy — adenocarcinoma. IHC stains (using block S2023-13884): CA19-9 (-), CK7 (+), CK20 (-), CK19 (+), CEA (+). She received whipple op with partial gastrectomy, S4b/5 partial hepatectomy, LNstation 5,6,8,12,13 dissectio on 2023/07/31, pathology showed Liver, S4b, partial hepatectomy — Metastatic pancreatic adenocarcinoma; 1. Pancreas, Whipple operation with partial gastrectomy — Ductal adenocarcinoma, moderately differentiated; 2. Pathologic Staging: pT3N2M1, stage IV.
    • This time, she was admitted to our ward for chemotherapy with FOLFIRINOX (C1D1).
  • Course of inpatient treatment
    • After admission, she received chemotherapy with FOLFIRINOX (Oxalip 50mg/m2, Campto 100mg/m2, LV 300mg/m2, 5FU 300mg/m2 and 2400mg/m2) (C1D1) from 2023/09/14~2023/09/16 (hold 5-Fu due to fever was noted 2023/09/16, after Acetal 500 mg/tab 1# PO ST, then improving, keep continue 5-Fu).
    • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
    • Protase 1# po TID was given for pancreatic insufficiency.
    • Post chemotherapy with Oxalip given Hydroxocobalamin “T.F.” 1mg/mL/amp 1amp IM ST for avoid sensory peripheral neuropathies.
    • Blood-stinged was noted on toilet paper after urination today. No hematuria or other symptoms. consulted for GYN evaluation. Postmenopausal spotting, keep observation. Cervical polyp, keep observation. May arrange GYN OPD f/u after discharged, for recheck endometrial thickness (might consider to arrange endometrial sampling or D&C if persistent vaginal spotting or EM thickening).
    • Chronic viral hepatitis B with (Anti-HBc:reactive) with Vemlidy 25 mg/tab 1# PO QD.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/18 and OPD followed up later.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Protase (pancrelipase 280mg) 1# TIDCC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ12H
• 2023-09-05 SOAP Hemato-Oncology Xia HeXiong
  • P: Check Anti-HBs, Anti-HBc and Anti-HCV during admission. Already told the regimen:
    • GASL
    • GA
    • mFOLFOX
• 2023-07-10 ~ 2023-08-18 POMR General and Gastrointestinal Surgery Wu ChaoCun
  • Discharge diagnosis
    • Ductal adenocarcinoma of pancreatic head with liver metastasis, pT3N2M1; Stage IV status post whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and lymph noder dissection on 2023/07/31. ECOG:1
    • Pancreatic head cancer, with adjacent duodenal invasion and obstructive jaundice status post percutaneous transhepatic gallbladder drainage on 2023/07/12
    • Cholangitis
    • Obstruction of bile duct
  • CC
    • Frequent postprandial vomiting for about 2 weeks
  • Present illness
    • This 69 y/o female patient denied underlying diseases, like hypertension or type 2 diabete mellitus.
    • Accroding to her statement, she had upper abdominal fullness and frequent postprandial vomiting for several times about these half month. Body weight loss wa noted (72kg -> 69kg for 1 month). There was no fever, no dyspnea, no diahrrea, no tarry/bloody stool passage. She went to ChiMei Hospital and image study showed 2-3 cm pancreatic head tumor. Lab data showed elevated AST/ALT, ALP, rGT and Total bilirubin level. She then went to our hospital for second opinion.
    • Lab data on 7/10 showed no naemia, no CEA(3.2) CA199(1.07) level elevation, AST(337), ALT(652), Tbil(2.27), rGT(624), cholestasis type abnormal liver function and jaundice, suspected obstrution. Physical exam showed no fever, no dyspnea, no jaundice, no abdominal tenderness, normoactive bowel movement, no lower limbs pitting edema.
    • Under the impression of pancreatic head lesion causing obstructive jaundice and cholangitis, she was admitted to our ward for evaluation and management.
  • Course of inpatient treatment
    • After admitted, MRCP on 7/11 showed r/o pancreatic head tumor (2.2cm) with adjacent duodenal and CBD invasion causing biliary dilatation. Distension of gallbladder and stomach. A poor enhancing nodule (0.8cm) at S4/8 junction of liver. ERCP revealed duodenal tumor at bulb to SDA, s/p biopsy ; failed canulation.
    • PTGBD was also performed on 7/12 for bile drainage. EUS with FNB was performed on 7/12, for pancreatic mass-lesion biopsy.
    • The pathology of duodenal mass lesion showed adenocarcinoma and pancreatic mass fine needle biopst revealed malignancy.
    • GS was consulted then she was referred to GS service for further surgical intevention preparing.
    • TPN for nutrition supplement was given since 7/14.
    • Then she received whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and LN dissection was processed successfully on 7/31.
    • Post operaively, we observed patient recovery and keep empiric antibiotic, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed.
    • However, post operation with bile leakage via JP (no.2) was noted. Then we keep sandostatin support and keep well JP drainage.
    • Fever was noted on 8/4 and CXR showed ground glass opacity in bilateral lower lungs.
    • A+B inhalation and Aerobika for promote lung expansion since 8/4.
    • She try to introduced liquid diet with step by step after well flatus passage and can tolerate well for soft diet.
    • Leukocytosis was persisted then we check ascites culture on 8/7, then final report showed staphylococcus, then Zyvox support was used. However, high fever was noted on 8/16 then suspect of CVC infection and CVC removed then follow up tip culture and blood culture and removed of JP tube were done smoothly. Add antibiotic with Brosym and flucon support then fever was subside for 2 days. Recheck blood examination with no leukocytosis and CRP showed 4.8mg/dl. Under stated improvement of clinical symptoms, she was allowed to discharge today and OPD follow up was arranged.
  • Discharge prescription
    • Celebrex (celecoxib 200mg) 1# BID
    • Diovan (valsartan 160mg) 1# QD
    • LoraPsudo 24H SR FC (loratadine 10mg, pseudoephedrine 240mg) 1# QD
    • Megest (megestrol 40mg/mL) 10mL QD
    • Mopride (mosapride citrate 5mg) 1# TID
    • Rich (lansoprazole 30mg) 1# QDAC
    • Through (sennoside 12mg) 2# HS
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
    • Flu-D (fluconazole 150mg) 1# QD
    • Ceficin (cefixime 100mg) 2# BID
• 2023-07-10 SOAP Gastroenterology Chen JiangHua
  • S
    • 70 y/o
    • 2023/07/10 vice president Dr. Hsu’s VIP, A 2-3 cm panc head tumor referred for management
    • PI: Bw loss (+/-), GOT/GPT=841/1065, ALP=77, GGT=686, Bil(T)=1.9 mg/dl, Albumin=3.8 g/dl
    • She went to XinYing ChiMei Hospital where she is told to have panc tumor
    • PHx : HTN (-) DM (-) Op (-)
    • Drug allergy : (-)
      
  • O
    • PE: soft abdomen and anicteric sclera

[surgical operation]

• 2023-07-31
  • Surgery
    • whipple op with partial gastrectomy
    • S4b/5 partial hepatectomy
    • LNstation 5,6,8,12,13 dissection
  • Finding
    • 4 x 3.5 x 3.5 cm head tumor at pancreatic head
    • regional LN enlarge at 12
    • 1.2 x 1.2 x 1.0cm tumor at S4b/5
    • ascite(-)
    • seeding(-)

[chemotherapy]

• 2023-10-27 - oxaliplatin 50mg/m2 85mg D5W 250mL 2hr + irinotecan 100mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-10-09 - oxaliplatin 50mg/m2 85mg D5W 250mL 2hr + irinotecan 100mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX, DC 5-FU bolus, due to neutropenia was noted, post last time C/T)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-14 - oxaliplatin 50mg/m2 85mg D5W 250mL 2hr + irinotecan 100mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

700948807

231027

[exam findings]

• 2023-08-31 C-spine AP + Lat
  • Disc space narrowing and posterior spur at C3-4-5-6-7
• 2023-08-02 CT - abdomen
  • History and indication: D-colon cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Colon cancer s/p operation.
    • A nodule (5mm) at LLL.
    • Duodenal diverticulum.
    • Increased density of bil. breasts and lungs.
    • Liver and renal cysts (up to 1.6cm).
    • Retroversion of uterus.
    • Atherosclerosis of aorta, iliac arteries.
    • Disc space narrowing at L4/5.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Colon cancer s/p operation.
    • A nodule (5mm) at LLL.
• 2023-06-07, -03-22 CXR
  • Atherosclerotic change of aortic arch
  • S/P metalic autosuture at right upper lung with lung volume decrease.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-03-15 All-RAS + BRAF mutation
  • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-02-23 CXR
  • s/p right chest tube in place, its tip directed medially, projecting over 6th intercostal space
  • atelectasis of RUL
• 2023-02-21 Patho - lung total/lobe/segmental
  • PATHOLOGIC DIAGNOSIS
    • Lung, RUL, VATS RS2 segmentectomy — Metastatic adenocarcinoma, colorectal origin
    • Lymph node, LN 7, right, dissection — Negative for malignancy ( 0 / 3 )
    • Lymph node, LN 11, right, dissection — Negative for malignancy ( 0 / 6 )
    • Lymph node, LN 12, right, dissection — Negative for malignancy ( 0 / 4 )
    • AJCC 8th edition pathology stage (for colon cancer): pTxN0M1a; AJCC stage IVA
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure(s): VATS RS2 segmentectomy
    • Specimen Type:
      • Location: Right upper lobe
      • Lymph node dissection: yes (specify): LN7, LN 11, LN 12
    • Specimen Integrity: intact
      
    • Specimen Size: Greatest dimensions: 10x 5 x 2.5 cm
    • Tumor Site: Right upper lobe
    • Tumor number: Multiple (Number:2 )
    • Tumor Size: Greatest dimension: 0.6 cm and 0.2 cm, respectively
    • Gross tumor patterns:poorly defined
    • Gross Tumor Extension (specify) : Not identified
    • All for sections are taken and labeled as: F2023-70FS:tumor, F2023-70A1:tumor, F2023-70A2-13”RUL, A:LN7, B:LN11, C:LN 12
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Metastatic adenocarcinoma, colorectal origin
      
    • Histologic Grade: G2: Moderately differentiated
    • Microscopic Tumor Extension: not identified
    • Margins: Margins free, Distance from closest margin: 2 cm
    • Visceral Pleura Invasion: not identified
    • Lymph-Vascular Invasion: present
      
    • Perineural Invasion: not identified
      
    • Regional lymph Nodes:
      • Number examined: 13
      • Number involved: 0
    • Ancillary Studies: IHC stain — CK20(+), TTF-1(-), Napsin A(-), CK7(-)
• 2023-02-19 CXR
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • Blunting of left costophrenic angle due to pleural thickening
  • a small nodular opacity over medial RUL
  • extensive increased opacity over Lt and Rt lower lung zonesdue to breast shadows
  • partial atelectasis with bronchiectasis of inferior lingular segment
• 2023-02-09 SONO - abdomen
  • Propable liver cyst, left
  • Suspected fatty infiltration of pancreas
• 2023-02-07 CT - chest
  • a well-defined RUL solid nodule, increase in size (from 6mm to 8mm), and statonary of bronchiectasis and bronchiolitis at lingula, and several subpleural reticular opacities at LLL as compared with previous CT on 2022/11/03.
• 2022-11-09 Barium Enema
  • Double contrast study of LGI series revealed:
    • The contrast medium passage from anus to terminal ileum smoothly without obstruction.
    • S/P operation.
    • Colonic diverticula.
  • IMP: S/P operation. Colonic diverticula.
• 2022-11-03 CT - abdomen
  • History and indication: Colon cancer at splenic flexure
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Colon cancer s/p operation.
    • A nodule (6mm) at RUL.
    • Duodenal diverticulum.
    • Increased density of bil. breast.
    • Liver and renal cysts (up to 1.6cm).
    • Atherosclerosis of aorta, iliac arteries.
    • Disc space narrowing at L4/5.
  • IMP:
    • Colon cancer s/p operation.
    • A nodule (6mm) at RUL.
• 2022-05-05 SONO - abdomen
  • Diagnosis:
    • Propable liver cyst,left
    • Suspected fatty infiltration of pancreas
    • Propable left renal cyst
  • Suggestion:
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2021-11-04 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Large intestine, splenic flexure colon, SILS left hemicolectomy —- Adenocarcinoma, moderately differentiated
    • Resection margins: free
    • Lymph node, mesocolic, dissection — Negative for malignancy (0/12)
    • Lymph node, IMA / SMA, dissection —- N/A.
    • Pathology stage: pT3N0(if cM0); AJCC stage IIA
  • MACROSCOPIC EXAMINATION
    • Operation procedure: SILS left hemicolectomy
    • Specimen site:splenic flexure colon
    • Specimen size: colon: 15 cm in length
    • Tumor size: 2.5 cm
    • Tumor location: 3.5cm away from the closest resection margin
    • Depth of invasion grossly: perirectal soft tissue
    • Mucosa elsewhere: Not remarkable
    • Representative sections and labeled: A1-2:bilateral margins, A3-6:LNs, A7-10:tumor
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
    • Histology Grade: moderately differentiated
    • Depth of invasion: pericolorectal tissue
    • Angiolymphatic invasion: Present
• 2021-11-01 CT - chest
  • LLL curvilinear opacity (11 mm), focal atelectasis or a primary nodule, no lung metastasis, suggest f/u CT at 6 to 12 months later.
  • lingular bronchiectasis.
• 2021-11-01 SONO - abdomen
  • Liver cyst.
  • Hypoechoic nodule, 0.98x0.81cm in right lobe liver. Suggest follow up.
  • Right renal cyst.
• 2021-10-28 ECG
  • Sinus bradycardia
  • Low voltage QRS of limb leads
  • Borderline ECG
• 2021-10-20 CT - abdomen
  • History: diarrhea and abdominal pain for 3 ms. blood in stool (+). stool 3-4/day. cramp (+). fullness esp post meal. 2021/10/13 colonoscopy: One huge ulcerative tumor at just proximal to splenic flexure colon
  • Indication: colon cancer, splenic flexture, CT for staging
  • Findings:
    • There is soft tissue mass measuring 2 cm in the splenic flexure colon that is compatible with adenocarcinoma.
      • In addition, there are two lymph nodes in the adjacent mesocolon that may be metastatic nodes.
    • There is an ill-defined small poor enhancing nodule 5 mm in S8 of the liver that may be flow artifact, cyst or tumor. Please correlate with sonography.
    • A hepatic cyst measuring 1.6 cm in S2 is noted.
    • Two renal cysts 0.8 cm and 1 cm in left upper pole are noted.
      
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
• 2021-10-14 Patho - colorectal polyp
  • Colon tumor, 45-42 cm from anal verge, biopsy — Adenocarcinoma
    
  • Microscopically, the sections show a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with focal necrosis and desmoplasia.
  • Immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
• 2021-10-13 Colonoscopy
  • Colon polyp, A-colon, s/p biopsy removal (A)
  • Highly suspect colon cancer, just proximal to splenic flexure(occupied 45 to 42cm from AV), s/p biopsy (B)
  • Colon polyp, S-colon, s/p hot snare polypectomy (C)
  • Internal hemorrhoid

[MedRec]

• 2022-02-10 SOAP Colorectal Surgery
  • 20220210 UFT discotinue due to general malaise and poor appetite

[surgical operation]

• 2023-02-20
  • Surgery
    • VATS RS2 segmentectomy + LND.
  • Finding
    • One nodular lesion was noted over RS2 of RUL, size about 1.5cm in diameter.
    • Frozen section: adenocarcinoma.
    • One 20 Fr. straight chest tube was inserted via right 5th ICS.
• 2021-11-03
  • Surgery
    • SILS left hemicolectomy        
  • Finding
    • splenic flexure tumor, T3N1bMx Stage: IIIB
    • Anastomosis by GIA 75/4.8mm *2

[immunochemotherapy]

• 2023-10-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-21 - irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-30 - irinotecan 120mg/m2 180mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2021-11-22 ~ 2021-12-27, 2022-02-07 ~ 2022-06-09 - UFT (tegafur 100mg, uracil 224mg) 2# BID

==========

2023-10-27

Upon reviewing both PharmaCloud and HIS5 records, no medication discrepancies were detected. However, PharmaCloud indicates that the patient visited MinSheng Hospital and received a diagnosis of an unspecified UTI on 2023-10-18. It may be prudent to verify that the UTI has been resolved.

2023-08-08

Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf

• Dipeptiven should be mixed with a compatible amino acid carrier solution or an amino acid containing infusion regimen prior to administration. Patients with total enteral nutrition Dipeptiven is continuously infused over 20-24 hours per day.

2023-06-27

• Based on the information in the PharmaCloud database, our hospital has been the exclusive provider of all necessary medical services and medications for this patient for the past three months. All current medications have been prescribed by our hemato-oncology department. Therefore, no medication reconciliation issues have been identified.

• The recent lab results indicate a decreasing trend in the patient’s CEA level, potentially suggesting that the current regimen of FOLFIRI plus Avastin is effective. On the other hand, the gradually increasing CA199 level could imply a condition related to the pancreas, which aligns with the abdomen sonography conducted on 2023-02-09 suggesting suspected fatty infiltration of the pancreas? The latest lab results from 2023-06-26 showed normal readings in CBC, electrolytes, and renal and liver functions. The dosage of irinotecan in the FOLFIRI regimen has been increased to a regular dose (180mg/m2) during this hospitalization. No adjustments to the medication dosage are currently required.

  • 2023-06-16 CEA 2.54 ng/mL
    
  • 2023-05-05 CEA 3.14 ng/mL
    
  • 2021-10-20 CEA 10.61 ng/mL
    
  • 2023-06-16 CA199 109.70 U/mL
    
  • 2023-05-05 CA199 91.76 U/mL

700948877

231027

{Left overain cacner, High grade serous carcinoma, with liver mrtastasis, s/p Debulking surgery}

[lab data]

2022-05-15 HCV Genotyping Test HCV Not Detected
2022-05-13 HCV RNA-PCR (quantative) Target Not Detected IU/mL

2022-05-12 HBsAg Nonreactive
2022-05-12 HBsAg (Value) 0.41 S/CO
2022-05-12 Anti-HBc Reactive
2022-05-12 Anti-HBc-Value 6.22 S/CO
2022-05-12 Anti-HBs 0.79 mIU/mL
2022-05-12 Anti-HCV Reactive
2022-05-12 Anti-HCV Value 15.23 S/CO

[exam findings]

• 2023-08-16 SONO - abdomen
  • Diagnosis:
    • Fatty liver, mild
    • Liver tumor, S8, r/o hemangioma or metastasis
    • GB stone
    • suspicious, Renal stone, right
  • Suggestion:
    • encourage exercise and diet adjustment.
    • correlate with other image study.
• 2023-07-01 CT - abdomen
  • Impression:
    • S/P hysterectomy and oophorectomy.
    • Liver tumors in S7 and S8, r/o liver metastasis, mild progression.
    • R/O lymphocele in right pelvic cavity.
    • Gallbladder stones.
    • Small lung nodule in right lower lung, stationary.
• 2023-04-15 Gynecologic Ultrasonography
  • No obvious uterine or ovarian lesion
• 2023-04-01 CT - abdomen
  • Findings
    • s/p hyesterectomy and salpingo-oophorectomy.
    • A poor enhancing lesion, 0.9cm, in S8 of liver.
    • Para-aortic lymph node metastasis, stationary.
    • No evidence of bowel obstruction.
    • A cystic lesion, 3.6cm, in right inguinal region, stationary.
    • No bony destructive lesion on these images.
  • Impression
    • Ovarian cancer, s/p operation
    • Liver and lymph node metastasis with stable disease
• 2022-12-23 CT - abdomen
  • Findings: Comparison prior CT dated 2022/05/04.
    • S/P hysterectomy, oophorectomy, and omentum resection.
    • Prior CT identified two metastases 3 cm in S7 and 1.4 cm in S8 of the liver capsule area are noted again, decreasing in size that are c/w liver metastases S/P C/T with partial response.
      • In addition, prior CT identified a metastasis 0.7 cm in S8 of the liver dome is noted again, become calcification that is c/w metastasis S/P C/T with complete response.
    • Prior CT identified several metastatic nodes in para-aortic space are noted again, decreasing in size that are c/w metastatic nodes C/T with partial response.
    • There is mild wall thickening of left rectus sheath muscle at middle pelvis (Srs:303 Img:106) that may be tumor seeding or post-operative change. Follow up is indicated.
    • There is a cystic lesion 4 cm in right pelvis that may be lymphocele.
    • There is are few gallstones.
    • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
      
  • Impression:
    • Liver and LNs metastases S/P C/T show partial response.
    • There is mild wall thickening of left rectus sheath muscle at middle pelvis that may be tumor seeding or post-operative change. Follow up is indicated.
    • Lymphocele 4 cm in right pelvis is highly suspected.
• 2022-12-23 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis
  • Suggestion:
    • PPI use
• 2022-09-14 Gynecologic Ultrasonography
  • ATH + BSO
  • IMP: Suspect RT adnexal cyst: 49x29mm
• 2022-06-29 SONO - abdomen
  • Liver tumor, S4 and S7, suspected hemangioma
  • GB stone
• 2022-06-16 Pure tone audiometry, PTA
  • Reliability FAIR
  • Average RE 36 dB HL; LE 31 dB HL.
  • R’t normal to moderately severe SNHL.
  • L’t normal to moderate SNHL. - 2022-06-13 CXR
  • Blunted right costophrenic angle.
• 2022-05-19 Patho - ovary (tumor)
  • Diagnosis:
    • Lymph node, right iliac, dissection — Negative for malignancy (0/4)
    • Soft tissue, right iliac, excision — Metastatic serous carcinoma
    • Lymph node, right obturator, dissection — Negative for malignancy (0/5)
    • Lymph node, left iliac, dissection — Negative for malignancy (0/4)
    • Uterus, corpus, total hysterectomy — Negative for malignancy — Leiomyoma
    • Uterus, cervix, total hysterectomy — Negative for malignancy
    • Uterus, endometrium, total hysterectomy — Negative for malignancy
    • Ovary, right, oophorectomy — Metastatic serous carcinoma seeding on serosa
    • Fallopian tube, right, salpingectomy — Metastatic serous carcinoma seeding on serosa
    • Ovary, left, oophorectomy — High grade serous carcinoma
      
    • Fallopian tube, left, salpingectomy — Serous tubal intraepithelial carcinoma
    • Peritoneum, excision — Metastatic serous carcinoma
    • Omentum, infracolic omentectomy — Metastatic serous carcinoma
      
    • AJCC 8th edition: pStage IIIC, pT3cN0(if cM0), FIGO Stage: IIIC
      • or pStage IVB, pT3cN0(if cM1b), FIGO Stage: IVB
  • Microscopic Description:
    • Histologic Type:
      • Left ovary: High-grade serous carcinoma; The immunohistochemical stains reveal CK(+), PAX8(+), p53(aberrant expression (complete loss of expression)), WT-1(+), PR(-), and Napsin A(-).
      • Left fallopian tube: Serous tubal intraepithelial carcinoma (STIC) (0.2 x 0.1 mm)
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors): not available
      
    • Implants (required for advanced stage serous/seromucinous borderline tumors only): not available
      
    • Other Tissue/ Organ Involvement (select all that apply): bilateral ovaries and fallopian tubes, peritoneum, omentum, right iliac soft tissue
      
    • Largest Extrapelvic Peritoneal Focus (required only if applicable): Macroscopic (greater than 2 cm)
    • Peritoneal/Ascitic Fluid: N2022-01890: Negative for malignancy (normal/benign)
      
    • Regional Lymph Nodes: right iliac: 0/4; right obturator: 0/5; left iliac: 0/4
    • Additional Pathologic Findings: Leiomyomas are seen.
• 2022-05-19 Patho - colorectal polyp
  • Colon, D-colon, s/p hot snare polypectomy — Tubulovillous adenoma with low grade dysplasia.
• 2022-05-19 Patho - stomach biopsy
  • Stomach, low body, GC, s/p biopsy removal — Hyperplastic polyp
• 2022-05-11 Gynecologic Ultrasonography
  • Pelvis mass: (1) 146x108mm, (2) 34.20mm
• 2022-05-05 Gynecologic Ultrasonography
  • Multiple huge pelvic mass, the largest one is about 11.4x9.4cm without flow
• 2022-05-04 CT - liver, spleen, biliary duct, pancreas
  • Findings:
    • There is a well-defined lobulated heterogeneous mass in the uterine fossa, measuring 14.2 cm in size (the largest dimension), and non-visualization of the normal uterus.
      • Leiomyosarcoma of the uterus is highly suspected.
      • The differential diagnosis include ovarian cancer.
      • Please correlate with CA125.
    • There is ascites and smudggy appearance of the omentum that may be carcinomatosis? Please correlate with ascites cytology.
    • There are two well-defined poor enhancing masses measuring 3 cm in S7 and 1.4 cm in S8 of the liver capsule area with capsule defect that may be tumor seeding with indentation the liver capsule.
      • The differential diagnosis include liver metastases.
    • There is are several enlarged nodes in para-aortic space that may be metastatic nodes.
    • S/P Chest tube insertion, right.
      • Mild left side Pleura effusion is noted.
  • Impression:
    • Leiomyosarcoma of the uterus is highly suspected.
      • The differential diagnosis include ovarian cancer.
      • Please correlate with CA125.
    • Carcinomatosis is highly suspected.
      • Please correlate with ascites cytology.
    • Tumor seeding in S7 & S8 of the liver capsule are suspected.
      • The differential diagnosis include liver metastases.
    • Metastatic nodes in para-aortic space are suspected.
• 2022-05-04 CXR
  • resolution of Rt pleural effusion s/p chest tube and pigtail drain placement
  • small Lt pleural effusion
• 2022-05-03 SONO - abdomen
  • IMP: Gallbladder stones (0.74cm, 0.76cm, 0.70cm).
• 2022-05-02 Patho - lung wedge biopsy
  • Pleura, right, excision — chronic inflammation
  • Pleura, right, cyst, excision — cyst with chronic inflammation
  • Lung, RLL, wedge resection — pleural fibrosis and chronic inflammation
• 2022-05-02 CXR
  • signficiant regression of Rt pleural effusion s/p chest tube and pigtail drain placement
  • small Lt pleural effusion
• 2022-05-01 CXR
  • progression of moderate Rt pleural effusion as compared with previous image
  • thoracic aortic arch calcified atheriosclerotic plaque
  • small Lt pleural effusion
• 2022-04-22 CT - lung/mediastinum/pleura
  • Massive right pleural effusion and mild left pleural effusion with consolidation over right lower lobe and left lower lobe
  • Hepatic low density lesion.
• 2022-04-13 CXR
  • regression of Rt pleural effusion as compared with previous image
  • Linear band subsegmental atelectasis at Lt lung base
  • Thoracic aortic arch calcified atheriosclerotic plaque
• 2022-04-06 Cell block cytology
  • pathologic diagnosis
    • Dense inflammation, reactive change
      
  • macroscopic examination
    • 50 cc red turbid right pleural effusion
  • microscopic examination
    • Immunocytochemistry shows TTF-1(-), Napsin-A(-), P40(-), CK7(-) and calretinin(-) for carcinoma.
• 2022-04-06 CXR
  • moderate Rt pleural effusion
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • mild enlarged cardiac silhoutte
  • mild levoscoliosis of the spine
• 2022-04-06 SONO - chest
  • pleural effusion, moderate to massive, right
  • consolidation, RLL
• 2022-04-01 Bronchodilator test, BT
  • Moderate restrictive lung defect without significant reversibility
• 2022-03-30 SONO - abdomen
  • parenchymal liver disease
  • liver hemangioma, S8
  • GB stone
  • pancreatic head masked by gas
  • ascites, minimal
  • pleural effusion, bilateral
• 2022-03-22 Thyroid Ultrasound
  • Goiter
• 2022-03-03 SONO - chest
  • pleural effusion, trivial amounts
  • high risk of pneumothorax during chest tapping
  • hold chest tapping procedure
• 2022-03-02 CXR
  • Rt subpulmonary effusion or Linear band subsegmental atelectasis at lung base
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
  • mild levoscoliosis of the spine
• 2021-09-29, 2021-03-01, 2020-08-03, 2020-02-23 SONO - abdomen
  • Diagnosis
    • GB stones
    • Hepatic tumor, suspect hemangioma, S8
    • Probable parenchymal liver disease
    • Suspect renal stones, right
  • Suggestion
    • Please follow sonography in 3-6 mon
    • Please check tumor, hepatitis markers and LFTs q3-6 mon
• 2018-08-28 CT - abdomen
  • Small heaptic lesion at surface up to 1.9cm with marginal enhancement and filling in change is found. Hemangioma is considered.
• 2019-07-29, 2019-01-28, 2018-07-30, 2018-01-10 SONO - abdomen
  • Parenchymal liver disease
  • Liver tumor, nature?
  • Fatty infiltration of pancreas
  • GB stones
• 2017-06-26 SONO - abdomen
  • Diagnosis
    • suspect liver parenchyma disease, incomplete exam of liver
    • liver tumor suspected hemangioma
    • gallstones
• 2017-01-09 SONO - abdomen
  • Suspected, Parenchymal liver disease
  • GB stone
  • Suspected, Parenchymal renal disease

[MedRec]

• 2023-08-16 SOAP Gastroenterology
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2022-06-08 SOAP Hemato-Oncology Xia HeXiong
  • Plan
    • Arrange Port-A insertion
    • Admission for 24 houirs CCr, audiometry and then C/T with TP
• 2022-05-17 ~ 2022-05-23 POMR Obstetrics and Gynecology Zeng LunNa
  • Discharge diagnosis
    • Malignant neoplasm of left ovary
    • Left ovarian serous carcinoma, pT3cN0(if cM1b), FIGO Stage: IVB post Debulking surgery on 2022/05/19
    • Acute posthemorrhagic anemia due to blood lose about 1200 ml
  • CC
    • Accidentally found the pelvic mass, during last hospitalization   - Present illness
    • This is a 69 y/o woman with G3P3 and LMP at 54y/o. She had past history of (1) pleural effusion s/p 3D VATS RLL wedge + pleurodesis + pleural biopsy for pleural effusion with benign pathology report. Spotting was noted once 2 weeks ago and no bleeding was mentioned. Other associated symptoms included urinary frequency, weight loss and right lower abdominal dullness. There were no pale conjunctiva, dyspnea, general malaise, orthostatic hypotension ,nausea, vomiting, no tarry/bloody stoool and brittle nails noted.
    • During last hospitalization, abdominal CT done on 2022.05.04 and leiomyosarcoma of the uterus was highly suspected. Therefore, she was tranferred to our GYN OPD for help. The GYN echo done on 2022.05.11 revealed pelvic mass (1) 14.6cmx10.8cm and (2) 3.4x2.0cm. Tumor marker was examinated on the same day and showd CA125 = 678.3 U/mL; CA199 = 5.98 U/mL; CEA = 0.42 ng/mL.
    • Under the impression of leiomyosarcoma, she was admitted on 2022.05.17 for debulking surgery.
  • Course of inpatient treatment
    • The patient was admitted on 2022/05/17 and underwent debulking surgery with abdominal hysterectomy+bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + infracolic omentectomy on 2022/05/19. Due to blood loss 1200 ml and blood transfusion LP-RBC 4U and FFP 4U were given during operation.
    • We provided cefazolin IV form for 2 day and then shifted her antibiotics to cephalexin oral form. Post-operation wound was dry and clean without dehiscence, discharge, nor oozing. Her lab data on 2022/05/20 also showed no specific positive findings. Since all her general conditions were all improved and relatively stable, she discharged and she will have her OPD follow up next week.     
  • Discharge prescription
    • Keto (ketorolac 10mg) 1# QID
    • MgO 250mg 1# QID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# QID
    • cephalexin 500mg 1# QID
    • Cough Mixture (platycodon) 10mL QID
    • Anxiedin (lorazepam 0.5mg) 1# HS
• 2022-05-01 ~ 2022-05-05 POMR Thoracic Surgery Xie MinXiao
  • Discharge diagnosis
    • Right pleural effusion status post three dimensional video-assisted thoracic surgery right lower lung wedge resection and pleurodesis and pleural biopsy on 2022-05-02
  • CC
    • Chest pain and exertional dyspnea for several months
  • Present illness
    • This is a 69 y/o woman who has no known systemic disease. She was a smoker who has been smoking cigarrete 1/2 ppd for 10 years. Chest pain and exertional dyspnea were noted in the past few months. The patient denied dyspnea, cough, running nose, fever nor chillness. As a result, she came to our hospital for help.
    • At the OPD of Chest Medicine, physical examination revealed decreased breathing sound in right lung field and regular heart sound. Chest X-ray showed RUL nodule and right pleural effusion. Chest sonography showed right trivial pleural effusion. Thoracentesis was done and pleural fluid analysis revealed exudate lymphocyte predominant. Pulmonary function test revealed FVC55%, compatable with lung restriction.
    • Under the impression of right pleural effusion, the patient was admitted to our ward for 3D VATS RLL wedge resection + pleurodesis + pleural biopsy.
  • Course of inpatient treatment
    • During admission, her vital signs were stable. 3D VATS RLL wedge + pleurodesis + pleural biopsy was done on 2022/05/02. She tolerated the procedure well and no discomfort was complained afterwards. Under stable condition, she will be discharged on 2022/05/05 and will be followed up at OPD.        

[consultation]

• 2022-05-04 Obstetrics and Gynecology
  • Q
    • This 69 y/o woman with past hx of uterine myoma was admitted due to right pleural effusion. Three dimensional video-assisted thoracic surgery with right lower lung wedge resection, pleurodesis and pleural biopsy was done on 2022-05-02.
    • Urinary frequency was noted inrecent months. Body weight loss 5 kg was noted in 2 months. She denied abdominal pain, fullness, nor vaginal bleeding.
    • Abdominal CT on 2022-05-04 revealed a well-defined lobulated heterogeneous mass in the uterine fossa, measuring 14.2 cm in size (the largest dimension), and non-visualization of the normal uterus. Leiomyosarcoma of the uterus is highly suspected. The differential diagnosis include ovarian cancer.
    • Under the impression of suspected leiomyosarcoma of the uterus and ovarian cancer, we would like to consult you for evaluation.
  • A
    • S
      • 69 y/o, female, G4P3 (NSDx3)
      • Admitted on 2022/05/01 for VATS (Video-Assisted Thoracic Surgery)
      • Hx: s/p 3D VATS RLL wedge + pleurodesis + pleural biopsy on 2022/05/02
    • O
      • Abdominal CT on 5/4 revealed a well-defined lobulated heterogeneous mass in the uterine fossa
      • weight loss 5kg in 2months
      • WBC: 7510, Hb: 12.1
      • CT:
        • 1. Leiomyosarcoma of the uterus is highly suspected.
          • The differential diagnosis include ovarian cancer.
          • Please correlate with CA125.
        • 2. Carcinomatosis is highly suspected.
          • Please correlate with ascites cytology.
        • 3. Tumor seeding in S7 & S8 of the liver capsule are suspected.
          • The differential diagnosis include liver metastases.
        • 4. Metastatic nodes in para-aortic space are suspected.
          • sono: Multiple huge heterogenous pelvic mass, the largest is about 11.4x9.4cm without flow
        • CDS: no fluid
      • IMP:
        • Suspect uteine malignancy or ovarian cancer
      • P:
        • Please check CA125, CA199, CEA, SCC
        • OPD follow after 1 week

[surgical operation]

• 2022-05-19
  • Surgery
    • Diagnosis
      • Ovarian tumor suspected malignancy with intraperitoneal seeding and liver metastasis
    • Operation
      • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)   - Finding
    • Ovarian tumor, suspected malignancy.
    • Frozen: not performed
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, dense contact with bladder
    • Adnexa:
      • LOV: 14x10cm, capsule intact, adhesion to bowels and posterior uterine wall; intraoperative rupture (+) with papillary contents and necrotic tissue.
      • ROV: 5x4 cm, capsule not intact,adhesion to bowels and posterior uterine wall; intraoperative rupture (+) with papillary contents
      • Fallopian tube: bilateral engorged
    • CDS: invisible due to tumor mass occupied, totally obliterated
    • Ascites: bloody, about 300 ml, cytology was performed
    • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • s/p dissection of right iliac LNs, right obturator LNs and left iliac LNs
    • Omentum: infracolic omentectomy was done.
    • Liver: miliary tumor seeding(+), bean sized over liver surface
      • Subdiaphragmatic surface: miliary tumor seeding(+), bean sized
    • Appendix: not seen
    • After the operation, suboptimal debulking surgery was achieved.
    • Residual tumor: multiple tumor seeding over rectum, peritoneal wall s/p partial excision; suspected liver and subdiaphragmatic miliary tumor seeding
    • Partial intestine bowels adhesion
    • Due to the intestine was soaking in the ascites fluid, inflammation was noticed
    • Estimated blood loss: 1200ml (neovascular oozing)
    • Blood transfusion:s/p blood transfusion with pRBC 2u
    • Complication: none       
    • abdominal drainage tube x1 at right CDS
• 2022-05-02
  • Surgery
    • 3D VATS RLL wedge + pleurodesis + pleural biopsy.
  • Finding
    • One nodualr lesion was noted over RLL, suspected intrapulmonary LN. A mount of pleural effusion was also noted over right pleural cavity, about 1450mL.
    • One 24 Fr. straight chest tube and 14 Fr. pig-tail was inserted via right 8th ICS.

[chemotherapy]

• 2023-10-26 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 400mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-09-27 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 400mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-08-31 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 400mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-08-03 - paclitaxel 140mg/m2 200mg NS 500mL 3hr + carboplatin AUC 4 450mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-07-15 - paclitaxel 140mg/m2 200mg NS 500mL 3hr + carboplatin AUC 4 450mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-06-30 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2023-06-16 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2023-05-30 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2023-04-27 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2023-03-31 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2023-03-08 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2023-02-17 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2023-01-30 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2022-12-23 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2022-12-02 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2022-11-11 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2022-10-24 - bevacizumab 15mg/kg 600mg NS 400mL 1.5hr (Avastin maintenance)
  • dexamethasone 4mg + NS 250mL
• 2022-09-29 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-09-08 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-09-19 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-08-02 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-07-08 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-06-17 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-10-27

After reviewing the PharmaCloud and HIS5 records, no concerns were found.

The CA125 levels have been within the normal range since 2022-09-09. Following a CT scan on 2023-07-01 that indicated mild progression of liver metastasis, paclitaxel and carboplatin were reintroduced at a reduced dosage compared to their administration (x6) in 2022 Jun to Sep. The latest lab results are generally within normal limits.

701208485

231027

{pancreatic cancer T4N1M0 stage III}

[exam findings]

• 2023-08-28 MRI - pancreas

  • History and indication: Pancreatic cancer
  • With and without contrast MRI of pancreas revealed:
    • S/P CBD stenting with artifact. Mild dilatation of IHD.
    • Pancreatic head cancer (2.3cm) with distal p-duct dilatation.
    • Tiny liver cysts.
    • Mild splenomegaly. Small caliber of intrahepatic portal vein.
  • IMP:
    • S/P CBD stenting with artifact. Mild dilatation of IHD.
    • Pancreatic head cancer (2.3cm) with distal p-duct dilatation.
    • Mild splenomegaly.

• 2023-08-17 EGD

  • ERBD, Bonastent(SEMS), insitu
  • Post status IHD plastic stent removal
  • Duodenal shallow ulcers

• 2023-08-13 ERCP (Endoscopic Retrograde CholangioPancreatography)

  • Biliary stricture s/p removal of SEMS & s/p ERBD (Bonastent(SEMS) placement in right IHD, plastic stent in left IHD)
  • Chronic cholangitis

• 2023-05-26 MRI - pancreas

  • Findings:
    • S/P metalic stent implantation at CHD and CBD, causing artifact in the surrounding area.
      • The distal end of this stent may be retracted from the duodenum into the distal CBD. please correlate with clinical condition.
    • There is mild dilatation of IHDs. please correlate with clinical condition.
    • Prior MRI identified adenocarcinoma of the pancreatic head and body is noted again, stationary.
      • Total encasement of splenic vein and the trifurction of splenic vein, superior mesenteric vein, and portal vein is still noted.
    • The trifurcation of celiac trunk, common hepatic artery and splenic artery shows small size that is c/w tumor encasement.
    • A renal cyst measuring 0.8 cm in right upper pole is noted.
  • Impression:
    • Prior MRI identified adenocarcinoma of the pancreatic head and body is noted again, stationary. Follow up contrast enhanced dynamic CT 3 months later is indicated.

• 2023-02-13 MRI - pancreas

  • Findings
    • S/P CBD stenting with artifact. Mild dilatation of IHD.
    • Pancreatic head cancer (2.3cm) with p-duct stenting.
    • Tiny liver cysts.
  • IMP:
    • S/P CBD stenting with artifact. Mild dilatation of IHD.
    • Pancreatic head cancer (2.3cm) with p-duct stenting.

• 2023-02-10 PET scan

  • Mild glucose hypermetabolism in the head and body of the pancreas. Residual malignancy should be watched out. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the central portion of the uterus. Either hyperemia or inflammation may show this picture.
  • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
  • No prominent abnormal focal FDG uptake was noted elsewhere.

• 2023-01-09 T - L spine AP + Lat.

  • S/P metalic stent implantation from IHD to duodenum.

• 2022-12-26 ERCP (Endoscopic Retrograde CholangioPancreatography)

  • Biliary stricture s/p removal of SEMS & s/p Kaffet stent placement (8mm x 50mm)
  • Choledocholithiasis s/p retrieval balloon removal
  • Chronic cholangitis

• 2022-12-23 CT - abdomen

  • Findings
    • S/P metalic stent implantation at CHD and CBD.
      • The distal end of this stene may be retracted from the duodenum into the distal CBD.
      • In addition, There is moderate dilatation of IHDs and CHD.
      • Obstruction of the stent is highly suspected.
    • S/P pigtail catheter implantation at the gallbladder
      
    • Prior CT identified adenocarcinoma of the pancreatic head and body is noted again, stationary.
      • Total encasement of splenic vein and the trifurction of splenic vein, superior mesenteric vein, and portal vein is still noted.
    • The trifurcation of celiac trunk, common hepatic artery and splenic artery shows small size that is c/w tumor encasement.
    • A renal cyst measuring 0.8 cm in right upper pole is noted.
  • Impression:
    • Obstruction of the stent in the CHD and CBD is noted.
    • Prior CT identified adenocarcinoma of the pancreatic head and body is noted again, stationary.

• 2022-12-22 Percutaneous transhepatic gallbladder drainage, PTGBD

• 2022-12-22 SONO - abdomen

  • Pancreatic cancer in resolution, neck part (proved by EUSFNB)
  • CBD obstruction s/p SEMS
  • Parenchymal liver disease
  • splenomegaly

• 2022-12-07 KUB

  • S/P metalic stent implantation from IHD to duodenum.
  • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition or CT.
    
  • Fecal material store in the colon.

• 2022-12-06 ECG

  • Sinus tachycardia
  • Right axis deviation

• 2022-10-29 CT - abdomen

  • Findings
    • Pancreatic head cancer (2.1cm, mild regression).
    • S/P CBD stenting. Wall thickening of gallbladder. Dilatation of bil. IHDs.
    • Right renal cyst (0.9cm).
    • Left liver cyst (0.3cm).
  • IMP:
    • Pancreatic head cancer (2.1cm, mild regression).
    • S/P CBD stenting. Dilatation of bil. IHDs. Wall thickening of gallbladder.

• 2022-08-23 CT - abdomen

  • Findings
    • S/P biliary stenting. Stationary pancreatic head tumor as compare with CT study on 2022-06-23.
    • Right renal cyst, 0.8cm.
    • Cystic lesion, 2.8cm in left adnexa, r/o left ovarian cyst.
  • Impression:
    • Pancreatic head cancer, s/p stenting, with stationary.
    • Right renal cyst.
    • R/O left ovarian cyst.

• 2022-06-23 CT - abdomen

  • Findings
    • Pancreatic head cancer (2.8cm, stable).
    • S/P CBD stenting. Wall thickening of gallbladder. Left portal vein thrombosis.
    • Right renal cyst (0.9cm).
    • Left liver cyst (0.3cm).
  • IMP:
    • Pancreatic head cancer (2.8cm, stable).
    • S/P CBD stenting. Left portal vein thrombosis.

• 2022-05-24 KUB

  • S/P metalic stent implantation from IHD to duodenum.
  • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition or CT.

• 2022-04-11 CT - abdomen

  • Findings
    • Pancreatic head cancer (2.8cm).
    • S/P CBD stenting. Wall thickening of gallbladder. Left portal vein thrombosis.
    • Right renal cyst (0.9cm).
    • Left liver cyst (0.3cm).
  • IMP:
    • Pancreatic head cancer (2.8cm).
    • S/P CBD stenting. Wall thickening of gallbladder. Left portal vein thrombosis.

• 2022-02-21 KUB

  • S/P metalic stent implantation from IHD to duodenum.

• 2022-02-16 KUB

  • S/P biliary stenting?
  • Non-specific bowel gas pattern.
  • Calcifications in the pelvic cavity, could be due to phleboliths.
    
  • Mild lumbar spondylosis.

• 2022-01-24 ERCP (Endoscopic Retrograde CholangioPancreatography)

  • biliary obstruction s/p SEMS
  • chronic cholangitis

• 2022-01-14 CT - liver, spleen, biliary duct, pancreas

  • There is filling defects at left lobe portal vein that is c/w thrombosis and the etiology may be thrombophlebitis.
  • Adenocarcinoma of the pancreatic head-body with portal vein, splenic vein, and celiac trunk encasement is suspected.

• 2022-01-12 Patho - pancreas biopsy

  • Pancreas, head, EUSFNB — adenocarcinoma, moderately differentiated
    
  • Section shows pancreas tissue with infiltration of neoplastic glands in fibrous stroma.
  • IHC: CK(+)

• 2022-01-10 ERCP (Endoscopic Retrograde CholangioPancreatography)

  • biliary obstruction s/p brushing cytology & plastic stent placement
  • chronic cholangitis
  • reflux esophagitis

[MedRec]

• 2023-08-22 SOAP Radiation Oncology Wang YuNong
  • Plan
    • CT-simulation will be arranged according to CCRT date.
    • Plan to deliver 45 Gy/ 25 fx to the pancreatic tumor and adjacent lymphatic drainage area.
• 2023-08-22 SOAP Hemato-Oncology Xia HeXiong
  • Plan
    • Add IV Lorazepam and Olan. Shift Atropine to 0.5 mg SC
    • CCRT with weekly CDDP and pembrolizumab during 2023-09-05 admission

[chemotherapy] (not completed)

• 2023-10-28 - pembrolizumab 200mg NS 100mL 1hr
  • diphenhydramine 30mg + NS 250mL
• 2023-10-04 - carboplatin AUC 1.5 150mg NS 250mL 2hr D2 (carbo AUC 1.5, CCRT)

  •                       NS 250mL D1   + dexamethasone 4mg    + palonosetron 250ug                       + aprepitant 150mg PO + lorazepam 1mg

• 2023-09-26 - pembrolizumab 200mg NS 100mL 1hr D1 + carboplatin AUC 3 150mg NS 250mL 2hr D2 (carbo AUC 1.5, CCRT)
  • diphenhydramine 30mg D1 + NS 250mL D1-2 + dexamethasone 4mg D2 + palonosetron 250ug D2 + lorazepam 1mg D2 + aprepitant 125mg PO D2
• 2023-09-12 - cisplatin 40mg/m2 60mg NS 500mL 3hr D1 (CDDP, CCRT)
  • diphenhydramine 30mg D1 + NS 250mL D1 + dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 150mg PO D1-3
• 2023-09-05 - pembrolizumab 200mg NS 100mL 1hr D1 + cisplatin 40mg/m2 60mg NS 500mL 3hr D2 (CDDP, CCRT)
  • diphenhydramine 30mg D1 + NS 250mL D1-2 + dexamethasone 4mg D2 + palonosetron 250ug D2 + lorazepam 1mg D2 + aprepitant 125mg PO D2
• 2023-08-09 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + atropine 0.5mg SC D1 + lorazepam 1mg ST D1 Q12H D2 + aprepitant 125mg PO D1-3 + NS 250mL D1 + NS 500mL Q8H D2-3
• 2023-07-11 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL] D1 + aprepitant 125mg PO D1-3
• 2023-06-13 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL] D1 + aprepitant 125mg PO D1-3
• 2023-05-02 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
• 2023-04-10 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
• 2023-03-20 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 115mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 675mg NS 250mL + fluorouracil 2400mg/m2 4050mg NS 500mL 46hr
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
• 2023-02-20 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 117mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 650mg NS 250mL + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
• 2023-01-11 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 115mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 650mg NS 250mL + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
• 2022-11-29
• 2022-11-08
• 2022-10-18
• 2022-09-26
• 2022-08-15
• 2022-07-25
• 2022-07-12
• 2022-06-27
• 2022-06-13
• 2022-05-23
• 2022-05-04
• 2022-04-20
• 2022-03-30
• 2022-03-16
• 2022-03-02
• 2022-02-10 ~ undergoing - FOLFIRINOX + pembrolizumab

==========

2023-10-27

[leukopenia]

The WBC count hit its lowest point in 2023 on 2023-10-26 at 1.97K/uL. The latest administration of the chemotherapy drug carboplatin took place on 2023-10-04, while the most recent radiotherapy session was on 2023-10-06. Both chemotherapy and radiotherapy can lead to leukopenia.

• 2023-10-26 WBC 1.97 x10^3/uL *
• 2023-09-25 WBC 4.07 x10^3/uL
  
• 2023-09-18 WBC 6.05 x10^3/uL
  
• 2023-09-11 WBC 5.99 x10^3/uL
  
• 2023-09-05 WBC 5.88 x10^3/uL

Granocyte (lenograstim) has been prescribed to address the leukopenia, which is an undisputed intervention measure.

[timely medication switch resolves creatinine spike]

There was an increase in serum creatinine levels in late Sep compared to earlier baseline data. The cisplatin administered on 2023-09-12 was changed to carboplatin on 2023-09-26. Currently, a decrease in creatinine levels is being observed, indicating that the change in medication appears to have been a timely decision.

• 2023-10-26 Creatinine 0.72 mg/dL
• 2023-09-25 Creatinine 1.12 mg/dL *
• 2023-09-18 Creatinine 0.90 mg/dL
• 2023-09-11 Creatinine 0.58 mg/dL
• 2023-09-05 Creatinine 0.51 mg/dL
• 2023-08-22 Creatinine 0.44 mg/dL
• 2023-08-13 Creatinine 0.43 mg/dL
• 2023-08-09 Creatinine 0.44 mg/dL

2023-09-27

After reviewing both the PharmaCloud database and the HIS5 records, no reconciliation issues were identified.

After the initiation of FOLFIRINOX + pembrolizumab in 2022-02, the CEA level had been remained in the single digits between 2022-06 and 2023-02.

Then platinum-based CCRT was initiated in early 2023-09, and there was a slight decrease in the double-digit CEA level.

• 2023-09-15 CEA (NM) 14.341 ng/ml
• 2023-08-25 CEA (NM) 14.737 ng/ml
• 2023-07-04 CEA (NM) 12.402 ng/ml
• 2023-06-20 CEA (NM) 10.795 ng/ml
• 2023-04-13 CEA (NM) 11.154 ng/ml
• 2023-02-22 CEA (NM) 12.664 ng/ml
• 2023-02-10 CEA (NM) 7.731 ng/ml
• 2023-01-13 CEA (NM) 8.882 ng/ml
• 2023-01-13 CEA (NM) 9.221 ng/ml
• 2022-11-02 CEA (NM) 7.296 ng/ml
• 2022-08-29 CEA (NM) 6.091 ng/ml
• 2022-06-29 CEA (NM) 3.417 ng/ml
• 2022-06-28 CEA (NM) 4.084 ng/ml
• 2022-04-12 CEA (NM) 12.119 ng/ml
• 2022-02-11 CEA (NM) 37.004 ng/ml

Based on the lab results from 2023-09-25, both AST and ALT readings are < 2x ULN (silymarin in use), with an eGFR of 55. Therefore, there is no need for medication dose adjustment.

2023-09-06

Our gastroenterologist prescribed a two-month supply of Nexium (esomeprazole) on 2023-08-17, however the drug is currently absent from the active medication list. Please verify whether this drug is no longer needed for the patient’s condition.

2022-03-31

• Pancreatic adenocarcinoma with or without BRCA1/2 or PALB2 mutations, FOLFIRINOX is preferred; this patient has been receiving this regimen since 2022-02-10.
• Results of liver and kidney function tests reported on 2022-03-30 were normal, CBC readings were slightly lower, the latter should not be likely to affect treatment in this hospital stay.
• No issue with current medication.

700335852

231026

[lab data]

2023-08-03 RPR/VDRL Nonreactive
2023-08-03 HBsAg Nonreactive
2023-08-03 HBsAg (Value) 0.31 S/CO
2023-08-03 Anti-HCV Nonreactive
2023-08-03 Anti-HCV Value 0.11 S/CO
2023-08-03 HIV Ab-EIA Nonreactive
2023-08-03 Anti-HIV Value 0.09 S/CO
2023-08-03 Anti-HBc Nonreactive
2023-08-03 Anti-HBc-Value 0.11 S/CO

[exam findings]

• 2023-10-24 Aortography - thoracic
  • Diagnostic aortography was performed
  • Imaging findings:
    • Type I aortic arch.
    • No critical stenosis of bilateral proximal carotid and vertebral arteries.
• 2023-10-24 Carotid angiography Bilat, Vertebral angiography
  • Diagnostic intraarterial angiography of brain vasculature by way of bilateral internal carotid and left vertebral arteries was performed
  • Imaging findings:
    • Short segmental moderate stenosis of left distal ICA (petrous-cavernous segment) with wall irregularity. Compatible with encasement by tumor. Suggest placement of one stent.
    • One wide-neck saccular aneurysm (neck:5.5mm, diameter:6.8mm, depth:3.3mm) over right distal ICA (petrous segment). Suggest stent-assisted coiling.
• 2023-10-24 CT - brain
  • Cranial CT scans from the vertex to the mid-maxillary level were performed with i.v. contrast injection.
  • Impression:
    • The brain shows normal grey and white matter attenuation without evidence of focal lesion. There is no intracranial hemorrhage seen.
    • The size of the lateral and third ventricles appears normal.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal.
    • Mass lesion (5.0cm) over left nasopharyngeal space. Compatible with nasopharyngeal cancer. Invasion of left carotid space by this tumor. Encasement of left ICA by this tumor. Suggest check cerebral angiography and stenting.
• 2023-10-24 ECG
  • Atrial fibrillation with rapid ventricular response
  • Incomplete right bundle branch block
  • Nonspecific ST abnormality
• 2023-09-20 Transrectal Ultrasound of Prostate, TRUS-P
  • Prostate
    • Size of prostate: 4.5 (T) cm x 2 (L) cm x 4.4 (AP) cm = 22 cc
    • Size of adenoma: 3.5 (T) cm x 1.6 (L) cm x 2.8 (AP) cm = 8.3 cc
  • Seminal vesicles
    • Symmetricity:
      • Size: L’t 1.1 x 0.4 cm
      • Size: R’t 1.3 x 0.4 cm
• 2023-09-17 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Left ventricular hypertrophy
  • Nonspecific T wave abnormality
• 2023-08-11 CT - chest
  • no neoplastic LAP in chest and abdomen.
  • extensive emphysema and interstitial fibrosis in RLL, favor smoking related lung disease. extensive 3V-CAD.
  • extensive LAP in the neck due to lymphoma.
  • chronic cystitis?
• 2023-08-07 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with 30% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
• 2023-08-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (146 - 32) / 146 = 78.08%
    • LVEF (%) = 78
    • M-mode (Teichholz) = 78
  • Conclusion:
    • Dilated LV; normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 2.
    • Normal RV systolic function.
    • Aortic valve sclerosis with mild AS (AVA (Doppler) = 1.79 cm² ,Mean aortic pressure gradient = 9 mmHg); moderate MR; mild TR; mild PR.
    • Marked sinus bradycardia during exam.
• 2023-08-04 PET scan
  • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on the same side of the diaphragm and involving multiple bone or bone marrow as mentioned above (stage IV).
• 2023-08-02 MRI - nasopharynx
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:3(T_value) N:3(N_value) M:____(M_value) STAGE:____(Stage_value)
• 2023-07-25 Aspiration Cytology - thyroid
  • Left neck mass — Positive for malignant tumor, in favor of lymphoma
    • NOTE: Correlation with biopsy result and clinical findings is recommended.
      
  • Smears show non-cohesive high-grade tumor cells with large hyperchromatic nuclei, irregular nuclear contour, mitotic activity, variable-sized nucloeli and scanty cytoplasm.
• 2023-07-25 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopharynx, left, biopsy — Diffuse large B-cell lymphoma, non-GCB type
    
  • Section shows several pieces of respiratory epithelium lined tissue with infiltration of large lymphoid cells.
  • The immunohistochemical stains show CD3(-), CD20(+), CD56(-), CK(-), CD10(-), BCL2(+), BCL6(-), Cyclin D1(-), C-MYC(+), and MUM1(+). The Ki-67 is > 90%.
• 2023-07-25 SONO - head and neck soft tissue
  • Clinical Impression/Intent: left neck level II mass
  • Sonographic Impression: left neck level II confluent LAP, R/O malignancy
  • Diagnosis: left neck level II confluent LAP, R/O malignancy, s/p FNA

[MedRec]

• 2023-08-01 ~ 2023-08-16 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Nasopharynx diffuse large B-cell lymphoma, non-GCB type, BCL6(-), C-MYC(+) and BCL2(+), stage IV
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Hyperlipidemia, unspecified
    • Insomnia, unspecified
    • Constipation, unspecified
  • CC
    • Left tinnitus with left neck mass noted for 2 months+ odynophagia and blood tinged sputum in the morning noted for 2 weeks.
  • Present illness
    • This 75-year-old man has history of diabetes mellitus and hypertension for years under regular medication control.
    • According to the patient’s statement, left neck palpable mass noted for 2 years. The left neck mass about 1cm in size initially. Due to left neck mass enlarge with left side tinnitus, left nasal blood tinged discharge noted in recent 2 months, he came to our ENT OPD for help. Physical examination revealed left nasopharyngeal tumor, left neck palpable mass 6 cm in size. Nasopharyngeal and left neck mass biopsy was done.
    • After the biopsy, left odynophagia and left headache were complained.
    • The pathology revealed diffuse large B-cell lymphoma, non-GCB type.
    • Under the diagnosis of large B-cell lymphoma, he was admitted for cancer work up.
  • Course of inpatient treatment
    • After admission, arrange a series of study and examination. The neck MRI revealed oropharynx, nasopharynx and Pterygoid structures tumor, with unilateral lymph nodes extension below the caudal border of cricoid. The whole body PET scan revealed compatible with lymphoma involving multiple lymph node regions on the same side of the diaphragm and involving multiple bone or bone marrow as mentioned above (stage IV).
    • Due to left headache persist, pain control with Volna-K 1# po q6h, Acetal 1#po prnq6h for pain control.
    • Under the impression of large B-cell lymphoma, we consult hema-oncologist for further evaluation, hepatitis and AIDS, Syphilis titer were done.
    • The hema-oncologist has explained to the family about further work up examination and the follow up treatment include bone marrow aspiration, port-A implantation and chemotherapy etc. The patient’s family agreed with the treatment plan.
    • Bone marrow was done on 2023/08/07, pathology Section shows piece(s) of bone marrow with 30% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present. Confirmed as the IV stage after discussion at the team meeting. The port-A implantation are scheduled on 2023/08/08.
    • 2D echo was done before chemotherapy on 2023/08/07 showed LVEF: 78%, 1. Dilated LV; normal LV systolic function with normal wall motion, 2. Concentric LVH, dilated LA; LV diastolic dysfunction Gr II, 3. Normal RV systolic function, 4. Aortic valve sclerosis with mild AS (AVA(Doppler) = 1.79 cm², Mean aortic pressure gradient = 9 mmHg); moderate MR; mild TR; mild PR, 5. Marked sinus bradycardia during exam.
    • Discussion with family members about disease condition and treatment plan on 2023/08/09, they understand and consent to treatment. Follow up whole CT image on 2023/08/11 showed no neoplastic LAP in chest and abdomen, extensive emphysema and interstitial fibrosis in RLL, favor smoking related lung disease. extensive 3V-CAD, extensive LAP in the neck due to lymphoma, chronic cystitis?
    • He received chemotherapy with R-miniCHOP (Rituximab 375mg/m2, Cyclophosphamide 400mg/m2, Adriamycin 25mg/m2, Vincristine 1mg, Prednisolone 40mg) on 2023/08/11~2023/08/15(C1).
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Tramacet 37.5 & 325mg/tab 1# PO Q6H, Limadol 100mg/2mL/amp 50mg IVD PRNQ8H for pain control.
      • Euricon 50mg/tab 1# PO QD before chemotherapy. IVF for avoid tumor lysis syndrome.
      • Type 2 diabetes mellitus with Diet control an check finger sugar. Uformin 500mg/tab 1# PO TIDCC and Trajenta 5mg/tab 1# PO QD was give for blood sugar control.
      • Hypertension with Sevikar F.C. 5 & 20mg/tab 1# PO QD.
      • Hyperlipidemia with CRESTOR 10mg/tab 1# PO QW1357.
      • Insomnia with Anxiedin 0.5mg/tab 1# PO HS.
      • Constipation with Through 12mg/tab 1# PO HS.
    • Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, he was discharged on 2023/08/16 and OPD followed up later.       
  • Discharge diagnosis
    • Euricon (benzbromarone 50mg) 1# QD
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg)
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Through (sennoside 12mg) 1# HS
• 2023-04-16 SOAP Metabolism and Endocrinology
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular [E08.319]
    • Mixed hyperlipidemia [E78.2]
    • Essential hypertention, unspecified [I10]
    • Chronic kidney disease, stage 3 (moderate) [N18.3]
    • Nontoxic multinodular goiter [E04.2]
    • Hepatitis [K75.81]
  • Prescription
    • Crestor (rosuvastatin 10mg) 1# QW1357
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
    • Trajenta (linagliptin 5mg) 1# QD
    • Uformin (metformin 500mg) 1# TIDCC
• 2017-03-14 SOAP Cardiology
  • Diagnosis:
    • HCVD, unspecified, without CHF [I11.9]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Dyslipidemia ; other and unspecified hyperlipidemia [E78.4]
  • Prescription
    • Eurodin (estazolam 2mg) 1# HS
    • Eazide (trichlormethiazide 2mg) 1# QD
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
• 2017-03-14 SOAP Metabolism and Endocrinology
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Mixed hyperlipidemia [E78.2]
    • Essential hypertention, unspecified [I10]
    • Nontoxic multinodular goiter [E04.2]
    • Arterial embolism and thrombosis of lower extremity [I74.4]
  • Prescription
    • Trajenta (linagliptin 5mg) 1# QD
    • Glucobay (acarbose 100mg) 0.5# TIDAC
    • Robestar (rosuvastatin 10mg) 1# QD
    • Uformin (metformin 500mg) 1# TIDCC
• 2017-03-14 SOAP Nephrology
  • Diagnosis: Renal failure, unspecified, uremia NOS [N19]

[consultation]

• 2023-10-12 Radiation Oncology
  • Q
    • This 75-year-old man patient is a case of Nasopharynx diffuse large B-cell lymphoma with multiple lymph node and bone invasion, non-GCB type, BCL6(-), C-MYC(+) and BCL2(+), stage IV s/p chemotherapy with R-miniCHOP from 2023/08/11~2023/09/26 for 3 cycles.
    • This time, for left neck lymph node pain with progression (8x6cm -> 9x8cm). Now, for evaluate radiotherapy to left neck lymph node. Thank you.
  • A
    • Due to left neck lymph node pain with progression (8x6cm -> 9x8cm), palliative RT is indicated.
    • CT-simulation will be arranged on 10/19.
    • Plan to deliver at least 32.5 Gy/ 13 fx to the NP tumor and Lt neck LAPs.
    • RT will start around 10/23.
    • Possible tumor lysis symdrome should be monitored during the treatment.
• 2023-08-02 Hemato-Oncology
  • Q
    • This 75-year-old man has history of DM and H/T for years under regular medication control.
    • The left neck palpable mass noted for 2 years. The left neck mass about 1cm in size initially. Due to left neck mass enlarge with left side tinnitus, left nasal blood tinged discharge noted in recent 2 months, he came to our ENT OPD for help. Physical examination revealed left nasopharyngeal tumor, left neck palpable mass 6 cm in size. Nasopharyngeal and left neck mass biopsy was done.
    • The pathology revealed diffuse large B-cell lymphoma, non-GCB type.
      
    • Under the diagnosis of large B-cell lymphoma, he was admitted for cancer work up. We request your consultation for further management.
  • A
    • Arrange PET scan for staging.
    • We will arrange bone marrow tomorrow.
    • Consult GS for port A insertion.
    • Please arrange our OPD after discharge.

[radiotherapy]

[immunochemotherapy]

• 2023-10-16 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP, DC Adriamycin 25mg/m2 for prepare radiotherapy to left neck lymph node)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-26 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + doxorubicin 25mg/m2 30mg NS 50mL 24hr + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-01 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + doxorubicin 25mg/m2 30mg NS 50mL 24hr + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-11 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + doxorubicin 25mg/m2 30mg NS 50mL 24hr + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-26

[withhold doxirubicin until heart problems are ruled out]

Based on the PharmaCloud database, no medication discrepancies were found.

Given that the ECG from 2023-10-24 indicated atrial fibrillation with rapid ventricular response, incomplete right bundle branch block, and nonspecific ST abnormality, it may be prudent to temporarily suspend the use of doxorubicin in the planned R-miniCHOP until cardiac symptoms improve.

2023-10-11

On 2023-09-06, our endocrinologist provided a repeat prescription for Crestor (rosuvastatin), Kentamin (Vit B1, B6, B12), Sevikar (amlodipine, olmesartan), Trajenta (linagliptin), and Uformin (metformin) to manage the patient’s existing conditions, these drugs are currently in use. Since this hospital stay, blood glucose levels have consistently ranged from 120 to 200 mg/dL. There are no inconsistencies in medication.

Recent lab results indicate that the WBC count remains above 3K/uL and there is no evidence of tumor lysis syndrome. While the LDH level remains in the normal range, the B2 microglobulin level reached 3646 ng/mL in mid-Sep. There’s no need to adjust the dose of the current medications, as the patient’s kidney and liver function tests are within normal limits.

2023-08-09

No recent lab results for LDH or beta-2-microglobulin were found in HIS5. If needed, initiate testing to establish a baseline prior to treatment.

700013816

231025

[lab data]

2023-10-25 HBV DNA-PCR (quantitative) 143000 IU/mL
2023-10-24 Anti-HBs 0.66 mIU/mL

2023-10-24 HBsAg Reactive
2023-10-24 HBsAg (Value) 222.81 S/CO

2023-10-24 Anti-HCV Nonreactive
2023-10-24 Anti-HCV Value 0.08 S/CO

2023-07-29 Anti-HBc Reactive
2023-07-29 Anti-HBc-Value 6.96 S/CO

2023-06-30 HLA A-high 11:01
2023-06-30 HLA A-high 33:03
2023-06-30 HLA B-high 46:01
2023-06-30 HLA B-high 58:01
2023-06-30 HLA C-high 01:02
2023-06-30 HLA C-high 03:02

2023-06-30 HLA DQ-high 02:01
2023-06-30 HLA DQ-high 03:03

2023-06-30 HLA DR-high 03:01
2023-06-30 HLA DR-high 09:01

2023-06-08 HBsAg (NM) Negative
2023-06-08 HBsAg Value (NM) 0.652
2023-06-08 Anti-HCV (NM) Negative
2023-06-08 Anti-HCV Value (NM) 0.076

2023-06-07 Aspergillus Ag Negative
2023-06-07 Aspergillus Ag Value 0.07 Ratio

[exam findings]

• 2023-10-23 ECG
  • Normal sinus rhythm
  • Low voltage QRS
  • Nonspecific ST abnormality
  • Prolonged QT
• 2023-10-23 CT - abdomen
  • Abdominal CT without IV enhancement revealed:
    • Minimal infiltration at perirenal fat over bilateral sides is found. r/o pancreatitis.
    • Cardiomegaly is noted.
    • Bilateral mild pleural effusion is found.
    • Calcified coronary arteries is found.
    • Increased pulmonary vasculature is found.
  • Imp:
    • Minimal infiltration at perirenal fat over bilateral sides is found. r/o pancreatitis.
    • Mild bilateral pleural effusion
• 2023-10-23 KUB
  • Compression fracture of L2.
  • Non-specific small bowel and colon gas pattern.
  • A calcified spot at RLQ.
• 2023-10-23 ECG
  • Sinus rhythm with Premature atrial complexes
  • Prolonged QT
• 2023-10-20, -10-09 CXR
  • S/P PICC catheter insertion via right forearm.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-10-09 SONO - artery
  • Patent bilateral lower limbs arteries.
  • Tissue edema at bilateral lower limbs.
• 2023-10-06 SONO - vein
  • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
  • Bilateral posterior vein engorgement, with perforator veins draining off lower limb soft tissue edema
• 2023-09-14 Patho - bone marrow biopsy
  • Bone marrow, iliac creast, biopsy — Negative for malignancy (1~2 % of blasts)
  • Microscopically, it shows normal ellularity of bone marrow (approximately 30%) and presence of trilineage hematopoietic cells. Myeloid and eythroid tatio is 3:1. Both myeloid and erythroid lineages demonstrate maturation. Megakaryocytes are present in normal in numbers (2 of HPF)and demonstate no significant morphologic abnormalities. Blast-like cells (CD117+, 1~2%) are present. Monocytic lineage cells are highlighted by CD68 ＆ CD163 and demonstate no significant morphologic abnormalities.
  • Immunohisotchemical stain reveals CD34 (<1%), CD20 (<1%), CD138 (focal+, 1~2%), MPO (+), CD71 (+), TdT (-), CD61 (+).
• 2023-09-13 Cardiac Catheterization
  • We try to puncture left basilic vein by peripheral echo guiding successful, but wire could not enter vessel
  • Then we try to pucnture right basilic vein successful. Then micro-sheath advanced. Because of prior wire demage. Another terumo wire and micro-puncture site was used.
  • Final, after successful pucnture. PICC catheter was advanced to SVC and RA junction smoothly.
• 2023-07-24 Patho - bone marrow biopsy
  • Bone marrow, iliac creast, biopsy — Acute monocytic / monoblastic leukemia
  • Microscopically, it shows hypercellularity of bone marrow (approximately > 90%) and markedly proliferation of monocytic lineage of immature mononuclear leukemic cells (highlighted by CD68 ＆ CD163). Erythroid lineage is decreased in numbers and demonstrate maturation. Megakaryocytes are present in normal in numbers (3 per HPF) and demonstate no significant morphologic abnormalities.
    
  • Immunohisotchemical stain reveals CD34 (<1%), CD20 (<1%), CD138 (focal+, 1~2%), MPO (+, >95%), CD71 (focal+, 2%), CD68 (+, >95%), TdT(<1%)., CD163 (+, 60%), CD117 (+, 5~10%).
• 2023-06-12, -06-09 CXR
  • s/p PICC inserted via Lt arm, tip in SVC
  • extensive heterogeneous consolidation in both lungs in progression
  • moderate enlarged cardiac silhoutte
• 2023-06-07 Cardiac Catheterization
  • We perform PICC under the cath room and fluroscopy guiding
    • Left basilic vein was puncture by peripheral echo guiding. Terumo wire in basilic to axillary vein.
    • The sheath advanced to puncture site and
    • A peripherally inserted central catheter (PICC) was implanted to SVC under the fluroscopy guiding.
  • Conclsuion
    • PICC was implanted via left brachial vein successful.
• 2023-06-07 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Compatible with acute monoblast/monocytic leukemia
  • The sections show hypercellular marrow (85%). The marrow space is replaced by a population of medium to large-sized immature cells with round to oval, ocasional distorted nucleus, and abundant cytoplasm. Numerous mitotic figures can be found.
  • IHC: CD34 (<3% +), CD117(10% +), MPO(30%+), and CD68(70% +). The finding is compatible with acute monoblastic/monocytic leukemia. Suggest bone marrow smear, flow cytometry and clinic correlation.
• 2023-06-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (178 - 93) / 178 = 47.75%
    • 2D (M-simpson) = 48
  • Conclusion:
    • Dilated LV with hypokinesia of posterior wall, lateral wall; impaired LV systolic function.
    • Preserved RV systolic function.
    • Gr II LV diastolic dysfunction and impaired RV relaxation; moderately dilated LA.
    • Degenerative changes of mitral valve with severe MR; moderate TR; mild PR; dilated aortic root with mild AR.
    • Possible moderate to severe pulmonary hypertension (the estimated systolic PA pressure > 62 mmHg).
    • Mild aortic root calcification.
• 2023-06-06 CXR
  • S/P nasogastric tube insertion
  • S/P endotracheal intubation with the tip beyond the carina
  • extensive, multifocal consolidation, in both lungs
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2023-06-05 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2023-06-01 CXR
  • Ground glass opacity in LLL.
  • Atherosclerosis of the aorta.
• 2023-06-01 ECG
  • Sinus rhythm with Premature atrial complexes
  • Otherwise normal ECG

[MedRec]

• 2023-07-22 ~ 2023-08-23 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Acute monoblastic/monocytic leukemia, Karyotype：46~47,XY,+11[cp4]
    • Chronic renal failure, stage 4
    • Hypokalemia
    • hypoalbuminemia
    • Hypocalcemia
  • CC
    • for regular chemotherapy
  • Present illness
    • This 70 y/o male with type 2 DM without treatment.
    • According to his statement, he suffered from fever for one month and shortness of breath on exertional for 2 weeks. He went to our OPD for help then referred to ER for WBC 72170/uL, Plat 48K, Hgb 6.9g/dL. Leukocytosis with white count 100280/uL, Hb:7.0 g/dl, PLT:47K, hypocalcemia (Ca:1.97 mmol/L) and elevated LDH (865U/L). Urine examination revealed no pyuria. Chest film revealed no pneumonia. Feburic self-paid and blood transfusion 1U/day by hematology suggested. Under the impression of acute leukemia, he was admitted to evaluation and management on 2023/06/02, but dyspnea devloped happened, so be transffered to ICU on 2023/06/06.
    • Bone marrow was done on 2023/6/6 and report showed compatible with acute monoblast/monocytic leukemia s/p first chemotherapy as 7-3 on 2023/06/20.
    • This time, he denied fullness in this week and he was admitted for refular chemotherapy on 2023/07/22.
  • Course of inpatient treatment
    • After admission, he received bone marrow and pending report. DC Hydrea during hospitalization. Potassium and Calcium are correct during hospitalization. Comfirm VS for newly chemotherapy as FLAI. Blood transfusion frequency for anemia and thrombocytopenia. Antibiotics as Cefepime and Targocid for neutropenic fever control. No evidence of bacterermia. Proctologist was consulted for anal pain, who diagnosis of acute anal fissure over 1 o’clock, no pus now. Transamine for few bleeding sign. After treatment, his WBC with neutrophil recovery and no fever. PICC was removed on 2023/08/23. Under the stable condition, he can be discharged on 2023/08/23. OPD follow up is arranged.
  • Discharge diagnosis
    • Tresiba Flex Touch (insulin degludec) 6 unit HS SC
    • Concor (bisoprolol 1.25mg) 1# BID
    • MgO 250mg 1# TID
    • Trajenta (linagliptin 5mg) 1# QD
    • Const-K ER (potassium chloride 750mg 10mEq) 1# QD
    • Ulstop (famotidine 20mg) 1# QD
• 2023-06-12 POMR Chest Medicine Progress Note
  • Problem List
    • R/I acute myeloid leukemia, Pending bone marrow biopsy
      • Assessment: serious
        • 20230608 HBsAg(-), Anti-HCV(-)
        • Hydroxyurea 1# QD (20230607 ~ 9)
        • 20230606 Bone marrow
      • Plan
        • BT with LPR 1U and LPRBC 2u on 20230612 for thrombocytopenia and anemia
        • Consider chemotherapy if Oncology suggest
        • Blood transfusion with LPRBC 2u and LRP 1PH on 20230612, s/p Lasix 0.5amp iv injection
    • Bilateral pneumonia, suspect leukemic lung with hypoxic respiratory failure post intubation on 2023-06-06
      • Extubation on 20230609
      • Assessment: serious
      • Plan
        • Nasal cannula supply
        • Antibiotics with Targocid plus Mepem (since 20230606) were prescribed
        • Anti-fungus agent with Mycamine (since 20230606)
        • Sevatrim oral form(IV form 20230606 ~ 10, since 20230610) for cover PJP
        • Kalimate 2pk qid was given for correct hyperkalemia (Baktar side effect)
        • Collect K qd
        • 20230605 Pending CMV and PJP result
    • EFrEF with vere MR
      • Assessment: serious
        • 20230607 Heart echo EF 48%, severe MR
      • Plan
        • Concor 1# BID
        • Diuretic with Lasix 0.5# PO QD
    • Type 2 Diabetes mellitus
      • Assessment
        • HbA1c 6.5% on 20230605
      • Plan
        • RI 14u SC TIDAC as sliding scale and Toujeo 10u SC HS
        • Tragenta 1# QD
    • Acute kidney injury and imbalance electrolyte
      • Assessment: impairment renal function
      • Plan:
        • Closely monitor renal function and electrolyte
        • Correct hypocalcemia with Calcium gluconate 1amp IVD QD
        • Add MgSO4 1amp iv infusion loading for correct hypo-Mg
  • Attending Physician’s Rounds Record and Comment
    • keep O2 support, closely monitor his respiratory pattern and O2 saturaiton
    • keep Targocid, Meropenem, Micafungin and oral Baktar for infection control, trace culture result
    • give PRBC and PLT transfusion to correct anemia and thrombocytopenia, regular hemogram f/u, if prograssive leukopenia (ANC < 500), may add G-CSF
    • keep Kalimate to correct hyperkalemia
    • because of CXR still showed pulmonary congestion, keep Diuretic used to keep I/O negative balance for CHF and severe MR
    • wait Bone marrow biopsy result
    • explained his condition to himself and his family
    • consult Hema doctor f/u, if possible, may let him transfer to Hema general ward
• 2023-06-01 SOAP Hemato-Oncology
  • S
    • Referred from clinic for WBC 72K, PLT 48K, HGB 6.9 (20230601)
    • fever in recent days for 1 month
    • Exertional shortness of breath (dyspnea on exertion) for 2 wks
  • A
    • Suspected acute leukemia with hyperviscosity
    • Suspected coexisting infection
  • P
    • Marked leukocytosis –> refer to ER for emergent treatment and admission

[consultation]

• 2023-06-08 Cardiology
  • Q
    • for severe MR
    • This is a 70 y/o male with type 2 DM without treatment. The impression of acute leukemia, he was admitted to Hema ward on 20230602. Due to acute hypoxic respiratopry failure, he received intubation then transffered to MICU on 20230606. At MICU, antibiotic with Targocid, Mepem, Sevatrim, Mycamine (since 20230606) for infection control. F/u Bone marrow on 20230606 (pending result), Oral chemotherapy with hydroxyurea was precribed. Arrange 2-D echo on 20230607 for heart function evaluation and which revealed EF 48%, severe MR. We really need your help for treatment suggestion, thank you!!
  • A
    • This is a 70 years old man with suspected acute leukemia, acute hypoxic respiratory failure. We were consulted for severe MR management.
    • Labs
      • Worsening renal function
    • Impression
      • Heart failure with mildly reduced EF, dilated LV with hypokinesia of posterior and lateral wall, with severe primary mitral regurgitation, with moderate to severe pulmonary HTN.
      • Acute respiratory failure with bilateral pneumonia r/o pulmonary congestion
      • Acute on chronic renal impairment, r/o prerenal type.
      • r/o acute leukemia;
    • Suggestion
      • Surgical intervention for MR is not suitable at present due to poor general condition (underlying hematolic malignancy + sepsis).
      • Keep lasix + concor use; may consider adding low dose candesarten if Cr < 2.0.
• 2023-06-06 Infectious Disease
  • A
    • 70-year-old DM male patient is a fresh case of AML, that bone marrow study not done yet.
      • Persistent fever is noted before and during hospitalization, that leukemic fever likely.
      • Serial CxR films showed rapid onset bilateal perihilar infiltrations, especially right lung, that leukemic lung is the first consideration.
      • Possibility of PJP infection also exist, that sputum PJP-PCR study necessary.
      • IV steroid is necessary, as well as intubation for severe hypoxemia.
    • Suggestion:
      • Continue the present Mepem, Targocid and Mycamine.
      • Decrease Sevatrim dosage to 2 vials iv q12h due to AKI.
      • Send sputum for bacterial culture, PJP-PCR.
      • Check cryptococcal/Aspergillus antigen, and CMV viral load too.

[note]

Prevention of Hepatitis B Reactivation During Immunosuppressive Therapy - 2023-10-25 - https://www.hepatitis.va.gov/hbv/reactivation-prevention.asp

• Table 1. Immunosuppressant Medications by Class

Medication Class	Agents
TACE: Trans arterial chemoembolization, HCC: Hepatocellular carcinoma	Doxorubicin Epirubicin (USED in TACE for HCC)
B-cell depleting agents	Obinutuzumab, Ocrelizumab, Ofatumumab, Rituximab
Anthracycine derivatives	Doxorubicin, Epirubicin (USED in TACE for HCC)
TNF inhibitors	Adalimumab, Certolizumab, Etanercept, Infliximab
Other cytokine inhibitors and integrin inhibitors	Abatacept, Mogamulizumab, Natalizumab, Ustekinumab, Vedolizumab
Tyrosine kinase inhibitors	Imatinib, Nilotinib
Proteasome inhibitors	Bortezomib, Carfilzomib, Ixazomib
Traditional immunosuppressive agents	Azathioprine, 6-Mercaptopurine, Methotrexate
Corticosteroids	Prednisone, Prednisolone, Methylprednisone, Dexamethasone

• Table 2. HBV Reactivation Risk Determination

Medication Class	HBsAg+, HBcAb+	HBsAg-, HBcAb+
B cell depleting agents	High risk; Use prophylaxis	High risk; Use prophylaxis
Anthracycine derivatives	High risk; Use prophylaxis	Moderate risk; Use prophylaxis
Corticosteroids ≥ 10 mg/day for ≥ 4 weeks	High risk; Use prophylaxis	Moderate risk; Use prophylaxis
Corticosteroids < 10 mg/day for ≥ 4 weeks	Moderate risk; Use prophylaxis	Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
HCC treatments: TACE, Surgical resection or Immunotherapy	High risk; Use prophylaxis	Lack of data; Use Prophylaxis
HCC: Local Ablation, Systemic therapies	Moderate risk; Use prophylaxis	Lack of data; Use Prophylaxis
TNF inhibitors	Moderate risk; Use prophylaxis	Moderate risk; Use prophylaxis
Other cytokine inhibitors and integrin	Moderate risk; Use prophylaxis	Moderate risk: Use prophylaxis
Tyrosine kinase inhibitors	Moderate risk; Use prophylaxis	Moderate risk; Use prophylaxis
Proteasome inhibitors	Moderate risk; Use prophylaxis	Moderate risk; Use prophylaxis
Traditional immunosuppressive agents	Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months	Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
Intra-articular steroids	Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months	Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
Corticosteroids: any dose for ≤ 1 week	Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months	Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months

• Table 3. Recommended Nucleos(t)ide analogues for HBV

Nucleos(t)ide Analogue	QD Dose	Potential Side Effects	Use in HIV	Lowest CrCl Without Dose Adjustment	Renal Dose Reductions (CrCl, mL/min)

[chemotherapy]

• 2023-09-23 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-3 + idarubicin 10mg/m2 16mg NS 100mL 10min D1 (FLAI)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + palonosetron 250ug D1-3 + NS 250mL D1-3
• 2023-09-19 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-2 + idarubicin 10mg/m2 16mg NS 100mL 10min D2 (FLAI)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1-2 + NS 250mL D1-2
• 2023-07-31 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-2 + idarubicin 10mg/m2 16mg NS 100mL 10min D2 (FLAI)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1-2 + NS 250mL D1-2
• 2023-07-28 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-3 + idarubicin 10mg/m2 16mg NS 100mL 10min D1,3 (FLAI)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + palonosetron 250ug D1-3 + NS 250mL D1-3
• 2023-06-20 - daunorubicin 45mg/m2 75mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-7
  • dexamethasone 4mg D1-7 + diphenhydramine 30mg D1-7 + palonosetron 250ug D1-7 + NS 250mL D1-7

FLAI (Fludarabine 25 mg/sqm/day days 1–5, Ara-C 2 gr/sqm/day days 1–5, Idarubicine 10 mg/sqm/day days 1, 3, 5) https://ashpublications.org/blood/article/106/11/1857/137804/Fludarabine-Based-Regimen-FLAI-Is-an-Effective https://doi.org/10.1182/blood.V106.11.1857.1857

The FLAI regimen is given as follows: (2023-10-25 GBard)

• Fludarabine: 25 mg/m² intravenously (IV) over 30 minutes on days 1-5
• Cytarabine: 200 mg/m² IV over 24 hours on days 1-5
• Idarubicin: 12 mg/m² IV over 30 minutes on days 1-3

The FLAI regimen is used as an induction treatment for newly diagnosed patients with Acute Myeloid Leukemia (AML), except acute promyelocytic leukemia (APL). The regimen includes the following drugs: (2023-10-25 BingChat https://ashpublications.org/blood/article/104/11/878/75705/Efficacy-and-Toxicity-of-FLAI-vs-ICE-for-Induction https://doi.org/10.1182/blood.V104.11.878.878)

• Fludarabine (FLUDA): 25 mg/sqm/day for 5 days
• Cytarabine (also known as ARA-C or HDAC): 2g/sqm/day for 5 days
• Idarubicin (IDA): 10mg/sqm/day for 5 days

FLAI Regimen Dosing and Schedule: (2023-10-25 ChatGPT)

• Fludarabine (Fludara):
  • Dose: Typically around 30 mg/m^2/day.
  • Schedule: Administered intravenously over 30 minutes daily for 5 days, usually from day 1 to day 5.
• Cytarabine (Ara-C):
  • Dose: Typically around 2 g/m^2/day.
  • Schedule: Administered intravenously over 4 hours daily, immediately after the Fludarabine infusion, usually from day 1 to day 5.
• Idarubicin:
  • Dose: Typically around 8-10 mg/m^2/day.
  • Schedule: Administered intravenously over 30 minutes daily, usually from day 1 to day 3.

Fludarabine, Cytarabine, and Attenuated-Dose Idarubicin (m-FLAI) 2023-10-25 https://doi.org/10.1182/blood.V118.21.3626.3626

• The m-FLAI regimen was comprised of
  • fludarabine (25mg/m2, days 1–4),
  • cytarabine (1000mg/m2, days 1–4), and
  • attenuated-dose idarubicin (5mg/m2, days 1–3)

==========

2023-10-25

[HBV reactivation]

Hepatitis B virus (HBV) that has been reactivated is treated with the medication Baraclude (entecavir) today.

[HRP > Patient Safety Incident Notification > Medication Incident - HBV reactivation]

Patient medical record No. 700013816.

The lab results from 2023-07-29 indicated a reactive Anti-HBc, but there were no previous Anti-HBc test results for reference. Multiple chemotherapy sessions were administered on 2023-06-20 (standard 7+3), 2023-07-28, 2023-07-31, 2023-09-19, and 2023-09-23 (FLAI), both before and after this test result.

Due to the lack of timely preventive measures to counteract the potential reactivation of HBV infection, which can be triggered by the immunosuppressive effects of the treatment, reactivated hepatitis developed. As a response to this event, Baraclude (entecavir) was added to the patient’s active medication list on 2023-10-25.

2023-10-25 HBV DNA-PCR (quantative) 143000 IU/mL

2023-10-24 ALT 1986 U/L
2023-10-23 ALT 2487 U/L
2023-10-23 ALT 2645 U/L
2023-10-20 ALT 44 U/L
2023-10-17 ALT 37 U/L
2023-10-06 ALT 52 U/L

2023-10-24 AST 1635 U/L
2023-10-23 AST 3211 U/L
2023-10-23 AST 3758 U/L
2023-10-20 AST 36 U/L
2023-10-17 AST 27 U/L
2023-10-06 AST 28 U/L

2023-07-29 Anti-HBc Reactive
2023-07-29 Anti-HBc-Value 6.96 S/CO

There are multiple clinical practice guidelines that offer a approach to screening and managing hepatitis B virus (HBV). For example, the American Society of Clinical Oncology (ASCO) guideline recommends that all patients who are about to start systemic anticancer therapy be tested for HBV. Patients with chronic HBV who are receiving systemic anticancer therapy should receive antiviral prophylaxis throughout the course of treatment and for at least 12 months afterwards.

Ref: Hepatitis B Virus Screening and Management for Patients With Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update. J Clin Oncol. 2020 Nov 1;38(31):3698-3715. doi: 10.1200/JCO.20.01757. Epub 2020 Jul 27. PMID: 32716741.

2023-06-28

• Patient body weight 64.7kg => CrCl 27mL/min. Considering the patient’s CrCl falls within the range of 20 to 50 mL/min, the levofloxacin dosage should be adjusted. Instead of the initially intended daily dose of 750mg, it is recommended to administer 750mg of levofloxacin every other day.
  • 2023-06-28 BUN 81 mg/dL
    
  • 2023-06-28 Creatinine 2.20 mg/dL
    
  • 2023-06-28 eGFR 31.52
• Fluconazole in patients with CrCl ≤50 mL/minute: Reduce dose by 50%. 2# switch to 1# QD is recommended.

2023-06-12

• The patient’s renal function is showing signs of improvement, but still remains inadequate. The administration of furosemide should continue to ensure a net outflow in the fluid balance, thus helping to alleviate pulmonary congestion, congestive heart failure (CHF), and mitral regurgitation (MR). Please note that the oral bioavailability of furosemide varies greatly, but on average it’s around 50% of the intravenous (IV) dose.
  • 2023-06-12 Creatinine 2.17 mg/dL
    
  • 2023-06-10 Creatinine 2.51 mg/dL
    
  • 2023-06-09 Creatinine 2.90 mg/dL
    
  • 2023-06-07 Creatinine 3.14 mg/dL

2023-06-06

[tube feeding - Concor]

• The manufacturer’s instructions for Concor (bisoprolol 5mg/tab) advise that it should be swallowed with a drink of water and not be chewed. If the patient is receiving tube feeding, the Simple Suspension Method (SSM) may be used. In the simple suspension method, the packaged tablets can be dissolved in 55-degree Celsius water and left for 5-10 minutes, then can be flowed through a feeding tube. This method involves disintegrating tablets and capsules in warm water before suspending them for administration. This method could be applicable for administering Concor tablets through a feeding tube.

[assessment]

Since the start of Hydrea (hydroxyurea) treatment on 2023-06-02, there has been a noticeable reduction in the patient’s WBC count from a peak of 105K/uL. However, along with this, It is also seen a concurrent suppression of the patient’s HGB and PLT levels, despite the administration of blood transfusions on 2023-06-01 and 2023-06-05.

• 2023-06-06 WBC 66.82 x10^3/uL
  

• 2023-06-05 WBC 99.17 x10^3/uL
  

• 2023-06-04 WBC 105.86 x10^3/uL
  

• 2023-06-03 WBC 105.55 x10^3/uL
  

• 2023-06-02 WBC 100.28 x10^3/uL
  

• 2023-06-01 WBC 75.10 x10^3/uL
  

• 2023-06-06 HGB 7.8 g/dL
  

• 2023-06-05 HGB 7.9 g/dL
  

• 2023-06-04 HGB 6.9 g/dL
  

• 2023-06-03 HGB 7.4 g/dL
  

• 2023-06-02 HGB 7.0 g/dL
  

• 2023-06-01 HGB 6.3 g/dL

• 2023-06-06 PLT 44 x10^3/uL
  

• 2023-06-05 PLT 62 x10^3/uL
  

• 2023-06-04 PLT 37 x10^3/uL
  

• 2023-06-03 PLT 43 x10^3/uL
  

• 2023-06-02 PLT 47 x10^3/uL
  

• 2023-06-01 PLT 63 x10^3/uL

2023-06-06 lab Cre 2.63mg/dL, eGFR 25.72, CrCl 27. Tarcocid (teicoplanin) for CrCl <30 mL/minute:

• If the usual indication-specific dose is 6 mg/kg once daily：6 mg/kg every 72 hours or 2 mg/kg once daily
• If the usual indication-specific dose is 10 mg/kg once daily：10 mg/kg every 72 hours or 3.3 mg/kg once daily
• If the usual indication-specific dose is 12 mg/kg once daily：12 mg/kg every 72 hours or 4 mg/kg once daily

The maintenance dose, which stands at 700mg Q3D, is equivalent to 9.5 mg/kg. This is within the reasonable therapeutic range.

700034834

231025

[lab data]

2023-10-11 Anti-HBc Nonreactive
2023-10-11 Anti-HBc-Value 0.38 S/CO
2023-10-11 Anti-HBs 53.10 mIU/mL
2023-10-11 HBsAg Nonreactive
2023-10-11 HBsAg (Value) 0.35 S/CO
2023-10-11 Anti-HCV Nonreactive
2023-10-11 Anti-HCV Value 0.28 S/CO

[exam findings]

• 2023-10-13 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with 40 % cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
• 2023-10-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 27) / 108 = 75.00%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA
    • Mild MR, TR
    • Moderate AR
• 2023-10-11 PET scan
  • Increased FDG uptake in stomach (Deauville score: 5), compatible with the diffuse large B-cell lymphoma.
    
  • Increased FDG uptake in lymph nodes in bilateral neck regions, left SCF, right axilla (Deauville score: 5), left upper back (Deauville score: 4), abdomen including the spleen, pelvis, and bilateral inguinal regions (Deauville score: 5), highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    
  • Diffuse large B-cell lymphoma, stage IIIS (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-09-27 CT - abdomen
  • CC: epigastric pain, discomfort for 1 month, BW from 85 Kgs to 75 Kgs.
  • 20230919 gastroscopy: One large fungated mass with ulcerative surface was noted at 2nd portion duodenum, AW site.
  • Biopsy and pathology: diffuse large B cell lymphoma
  • Findings:
    • There are multiple enlarged nodes in the hepatoduodenal ligament, celiac trunk, mesentery, para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain, bilateral internal iliac chain, and bilateral inguinal area that are c/w malignant lymphoma.
    • There is wall thickening at the duodenum 2nd portion that is c/w malignant lymphoma.
    • There is mild to moderate left side hydroureteronephrosis and delayed contrast excretion of left kidney that is c/w obstructive uropathy. The etiology is lymphoma in left external iliac chain with passive compression the left M/3 ureter.
      • In addition, a renal cyst 1.3 cm in left upper pole is noted.
    • There is a poor enhancing lesion 1.4 cm in the spleen that may be lymphoma with spleen involvement.
    • There is a gallstone 0.7 cm.
  • Impression:
    • Malignant lymphoma is noted. Please correlate with PET scan.
• 2023-09-20 Patho - stomach biopsy
  • Duodenum, 2nd portion, biopsy — Diffuse large B-cell lymphoma, non-germinal-center B-cell typel
  • The sections show a picture of diffuse large B-cell lymphoma with following features:
    • Specimen: Duodenal 2nd portion
    • Procedure: Biopsy
    • Tumor site: Duodenal 2nd portion
    • Histologic type: Diffuse large B-cell lymphoma, non-germinal-center B-cell type
  • Immunophenotyping: CK(-), CD3(-), CD56(-), CD20(+), BCL2(+), BCL6(+), CD10(-), MYC(-) and MUM1(-)
• 2023-09-19 Esophagogastroduodenoscopy, EGD
  • Diagnosis:
    • Superficial gastritis
    • Duodenal ulcerative tumor, suspicious lymphoma or adenocarcinoma, s/p biopsy
  • Suggestion:
    • pursue pathology and arrange CT for duodenal cancer survey

[MedRec]

• 2023-09-26 SOAP Hemato-Oncology He JingLiang
  • S: DLBCL of stomach
  • P: arrange admission for staging and R-COP
  • Prescription
    • Through (sennoside 12mg) 1# HS
• 2023-09-25 SOAP Gastroenterology Chen JiangHua
  • S: for patho result -> diffuse large B cell lymphoma -> referred to oncologist
• 2023-09-15 SOAP Gastroenterology Xu RongYuan
  • S
    • epigastric pain, discomfort for one months
    • BW from 85 Kgs to 75 Kgs
  • Prescription
    • Ulstop (famotidine 20mg) 1# BID
    • Emetrol (domperidone 10mg) 1# TIDAC
• 2020-09-22 ~ 2020-11-06 POMR Infectious Disease Yang QingHui
  • Discharge diagnosis
    • Gram-negative sepsis, unspecified
    • Bacteremia
    • Chronic osteomyelitis, right ankle and foot s/p operation
    • Atherosclerosis of native arteries of extremities with intermittent claudication, right leg
    • Essential (primary) hypertension
    • Gout, unspecified
    • Chronic ulcer with osetomyelitis with wound culture: Bacteroides fragilis and Fusobacterium spp., Staph. auerus, Serrentia marsensus, Escherichia coli, Pseudomonas auerginso
    • Pseudomonas auerginosa and Escherchia coli positive sepsis due to chronic ulcer with chronic osteomyelitis.
    • Chronic ulcer with osteomyelitis s/p debridment on 2020/10/05.
    • pending for HBO
    • Anemia of chornic inflammation (Chronic oseteomyelitis with wound ulcer)
  • CC
    • Fever and chills off and on for four days
  • Present illness
    • A 73-year-old male has past history of 1). Hypertension, 2). Gout, 3). Peripheral arterial occlusion disease, 4). Varicose veins of bilateral limbs, and 5). Chronic osteomyelitis of right foot post sequestrectomy for osteomyelitis.
    • He was a chief officer before. He denied travel, occupation, contact or cluster history recently, nor allergy history.
    • This time, he had intermittent fever with chills since 2020-09-18, runny nose was also noted. There was a chronic ulcerative wound over his right sole, with discharge under chronic osteomyelitis status for long times (for years). He denied dizziness or headache, no cough or sputum or dyspnea, no cheat pain or abdomen pain, no nausea or vomit, no urinary pain or hematuria, no limbs edema. Then he came to our hospital for help.
    • In the emergency department, the temperature was 40.0’C, the pulse 105 beats per minute, the blood pressure 116/58 mmHg, the respiratory rate 23 breaths per minute, and the oxygen saturation 96%. The physical examination revealed a chronic ulcerative wound over his right sole, with yellow discharge.
    • A laboratory testing revealed a peripheral-blood leukocyte count of 10.490 cells per cubic millimeter, with 88.3% polymorphonuclear cells. A biochemistry testing revealed glucose level of 141 mg/dL, C-reactive protein level of 14.43 mg/dL, creatinine level of 1.4mg/dL, and lavtic acid was 4.3mg/dL. A x ray of right foot revealed deformity of 3-5th metatarsal bones, especially 5th metatarsal bone with bone destruction and sclerotic change, compatible with chronic osteomyelitis, and osteopenia of visible bones. The patient is administrated with Brosym injection. He is hospitalized on 2020/09/22.
  • Course of inpatient treatment
    • After admission, patient received antibotic with Oxacillin and Brosym iv for sepsis control. Collect blood culture and yield E-coli noted. Fever is subside after medication. PS was consulted for right foot wound evalutaion, the wound debridement was perfomted on 9/28, he will arrange operation again at necxt week for close wound.
    • Wound culture yield Pseudomonas and OSSA, K.P, Serretia injecton, kept on current antibiotic treatment and wound care. Abdomen echo was perfomted for fever and R/O IAI, fatty liver and GB stone is noted, without IAI. During hospitalization, osteomyelitis scan was performed for HBO therapy, kept pending answer. More elevat of blood pressure is noted, we give add anti-hypertension used and noted his blood pressure became stable.
    • On 10/05, he received Deep debridement + fasciocutaneous flap coverage for chronic ulcer with osteomyelitis is found about 4 x 12 cm in size over the right lateral sole. Wound is improving and less bleeding, later we added pletaal. Post operation fever was noted and infection markers are increasing, so we added iv invanz along with ciprofloxacin. Blood culture was followed and showed GNB (Micro-organism report is still pending) and Wound culture revealed Enterococcus fecalis. Patient is relatively stable.    
    • This week, we continue antibiotic therapy : invanz and ciprofloxacin. Hyperbarric oxygen treatment was started. We noted his blood pressure is relatively stable and we taperred antihypertensive medication. Daily wound dressing and nature of the wound is improving.
    • Another week showing improving of his foot wound condition and no more newer culture results under invanz and ciproxin. Patient was afebrile however, wound was dehiscent partially and we called Dr.Zhang and suggest NS : BI2 wound dressing. Patient antibiotic were shift to per oral form (cefixime and cipro) this week. He is currently under HBO management. Due to stable condition and under antibiotic used under time, so he can be arranged for discharge today, take oral antibiotic back home, INF, PS, CV OPD follow up is arranged.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H if fever > 38’C or pain
    • Cinolone (ciprofloxacin 250mg) 2# BIDAC
    • Euricon (benzbromarone 50mg) 1# QD
    • fusidic acid 2% BID EXT for buttock wound
    • Ceficin (cefixime 100mg) 2# Q12H
    • Diovan (valsartan 160mg) 1# QD hold if SBP < 120mmHg
    • Nebilet (nebivolol 5mg) 0.5# QD
• 2017-12-06, -09-13, -06-21, -03-29, -01-04 SOAP Cardiology Huang XuanLi
  • Diagnosis
    • Arterial embolism and thrombosis of lower extremity [I74.4]
    • Essential hypertention, unspecified [I10]
    • Neuralgia,neuritis,and radiculitis,unspecified [M54.10]
    • Gout, unspecified [M10.9]
    • Edema [R60.9]
    • Allergic rhinitis cause unspecified [J30.9]
  • Prescription x3
    • Isoptin (verapamil 240mg) 0.5# QD
    • Euricon (benzbromarone 50mg) 1# QD
    • Pletaal (cilostazol 100mg) 0.5# BIDAC
    • Blopress (candesartan 8mg) 1# QN

[consultation]

• 2023-10-25 Infectious Disease
  • Q
    • for Neutropenia fever evaluation
    • This 73-year-old male patient has past history of 1). Hypertension, 2). Gout, 3). Peripheral arterial occlusion disease, 4). Varicose veins of bilateral limbs, and 5). Chronic osteomyelitis of right foot post sequestrectomy for osteomyelitis 6) diffuse large B cell lymphoma. He denied travel, occupation, contact or cluster history recently, nor allergy history. Due to epigastric pain. Upper G-I panendoscopy was performed on 2023/09/19 and revealed Superficial gastritis; Duodenal ulcerative tumor, suspicious lymphoma or adenocarcinoma, s/p biopsy.
    • Duodenum biopsy pathology showed Diffuse large B-cell lymphoma, non-germinal-center B-cell typel.
    • He received C1 R-COP on 2023/10/13, then he suffered from fever (BT: 39.2C), 2023/10/23 wbc: 640/uL, Band: 3.2%, Neurophoil: 65.6%, ANC: 440, Lenograstim 250mcg, followed-up cultures, and the antibiotic with Cefim was given. We need your help for infection control, thanks a lot!!
  • A
    • Thi is a case of diffuse large B-cell lymphoma, non-germinal-center B-cell type.
    • Please use cefim 2g iv q8h for q8h for neutropenic fever.
    • G-CSF use
    • Protesctive isolation and keep oral and anal region hygiene.
    • Re-evaluation clinical conidtion closely and consider add anti-MRSA agents if the patient’s condition get worse.
    • Please f/u the B/C results closely.

[immunochemotherapy]

• 2023-10-13 - rituximab 375mg/m2 700mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-COP, Endoxan 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2023-10-25

[tube feeding]

Const-K 750mg is an extended-release tablet that contains 10 mEq of potassium. One Const-K tablet provides less potassium than a single banana (which contains about 2.2 mEq/inch or 0.9 mEq/cm).

The tablet can be crushed into fine particles and swallowed with water if injectable potassium supplementation is not preferred.

[elevated PCT and CRP]

On 2023-10-24, lab results showed a moderate amount of gram-positive cocci bacteria, gram-negative bacteria, and gram-positive rods in the (sputum) sample, as well as a high number of neutrophils and a low number of epithelial cells. PCT and CRT levels were also elevated and continued to rise over these 2 days (2023-10-24 and 2023-10-25). After consultation with an infectious disease specialist, cefepime was started on 2023-10-24 and is currently being administered.

• 2023-10-25 Procalcitonin(PCT) 3.67 ng/mL
  

• 2023-10-24 Procalcitonin(PCT) 0.12 ng/mL

• 2023-10-25 CRP 10.5 mg/dL
  

• 2023-10-24 CRP 6.7 mg/dL

• G(+) Cocci 2+, GNB 2+, GPB 4+, Neutrophil/LPF > 25, Epithilial cell/LPF < 10

The patient’s white blood cell count has passed its nadir on 2023-10-23 and returned to normal. The recovery of the patient’s immune system should help them fight off bacterial infections.

• 2023-10-25 WBC 4.43 x10^3/uL
  
• 2023-10-24 WBC 2.26 x10^3/uL *
  
• 2023-10-23 WBC 0.64 x10^3/uL ***
• 2023-10-20 WBC 1.25 x10^3/uL **
• 2023-10-18 WBC 5.10 x10^3/uL
  
• 2023-10-16 WBC 7.96 x10^3/uL
  
• 2023-10-13 WBC 4.68 x10^3/uL
  
• 2023-10-12 WBC 4.53 x10^3/uL

700768893

231025

[exam findings]

• 2023-10-03 CT - brain
  • No evidence of intracranial hemorrhage.
• 2023-08-24, -08-02, -08-01 CXR
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-07-29 KUB
  • Calcifications in the pelvic cavity, could be due to phleboliths.
• 2023-07-29 ECG
  • Sinus tachycardia
  • Right atrial enlargement
  • Nonspecific ST abnormality
• 2023-07-13 EGD
  • Gastric cancer, borrmann type IV
  • Reflux esophagitis LA Classification grade A
• 2023-06-05 CT - abdomen
  • Indication: Gastric cancer s/p C/T
  • Abdominal CT with and without enhancement revealed:
    • Diffuse gastric wall thickening at antrum is found. In comparison with CT dated on 2023-01-11, the lesion is stationary.
    • The GB is well distended without soft tissue lesion
    • There is no evidence of destructive bone lesion.
    • Dilated IHDs and CBD is found.
    • s/p enterostomy with its orifice at RLQ.
    • The urinary bladder is partially distended without evidence of abnormal soft tissue lesion.
    • No evidence of abnormal soft tissue mass at pelvic cavity.
    • No definite inguinal or pelvic sidewall LAP
    • The spleen, pancreas, both kidneys and adrenals are intact.
  • Imp:
    • Diffuse gastric wall thickening, stable.
    • Dilated IHDs and CBD. Suggest close observation.
• 2023-02-10 Lower GI Series (colon filling study)
  • Filling LGI series show
    • No evidence of abnormal filling defect along the course from rectum into descending colon.
    • Increased intestinal gas is found.
    • There is no evidence of destructive bone lesion.
• 2023-02-06 CXR
  • Blunted left costophrenic angle.
• 2023-02-06 ECG
  • Normal sinus rhythm
  • Low voltage QRS
• 2023-02-06 Flow volume loop
  • moderate restrictive impairment
• 2023-02-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (54 - 16) / 54 = 70.37%
    • M-mode (Teichholz) = 69
  • Adequate LV systolic function with normal resting wall motion
  • Trivial MR and trivial TR
  • Preserved RV systolic function
• 2023-01-13 Patho - doudenum biopsy
  • Labeled as “duodenum, SDA”, biopsy (B)— benign duodenal tissue with marked chronic inflammation and mild to moderate dilatation of lymphatics.
• 2023-01-13 Patho - stomach biopsy
  • Stomach, GC, biopsy — Adenocarcinoma.
  • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and isolated neoplastic signet ring-like cells.
  • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0). CD68 (-).
• 2023-01-11 CT - abdomen
  • History:
    • 20220927 CT：Pneumoperitoneum. Swelling and wall thickening of the terminal ileum and ascending colon.
    • Emergent S/P right hemicolectomy and terminal ileostomy: A-colon perforation, Compatible with diverticulitis with perforation and suppurative peritonitis
  • Indication: weight loss
  • Impression:
    • There is dilatation of IHDs, CHD, CBD, and pacreatic duct.
      • Please correlate with serum alk-p and bilirubin level.
    • There is edematous wall thickening of the distal esophagus, stomach, and duodenum. Please correlate with gastroscopy.
    • Adhesion bands induce mechanical high grade small bowel obstruction is highly suspected.
      • please correlate with clinical condition.
    • There is edematous wall thickening of the transverse-and descending colon. Please correlate with colonoscopy to R/O ulcerative colitis or Crohn disease.
• 2023-01-10 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
• 2023-01-10 SONO - abdomen
  • Gallbladder sludge
  • CBD dilatation and IHD dilatation
• 2022-12-26 Patho - stomach biopsy
  • Stomach, unspecified site, biopsy — Non-atrophic chronic gastritis, Helicobacter Pylori: NOT present
• 2022-12-23 Esophagogastroduodenoscopy, EGD
  • Giant folds of stomach with poor distention upon air inflation, r/o inflitrated type malignancy, s/p CLO test and biopsy
  • Reflux esophagitis LA Classification grade A
• 2022-10-14 CXR
  • Focal sclerotic change of left humerus.
  • Blunted bilateral costophrenic angles.
• 2022-10-12 CXR
  • Bilateral pleural effusion.
  • Ground glass opacity in bilateral lower lungs.
  • Some calcifications at left humerus.
• 2022-10-10 CXR
  • Ground glass opacity in RLL.
  • Patch density at LLL.
  • Focal sclerotic change at left humeral head.
• 2022-10-04 CTA - chest
  • Indication: pulmonary embolism
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Status post endotracheal tube placement.
      • Consolidation over both lower lungs with bilateral pleural effusion is found.
      • Increased pulmonary vasculature is found.
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • There is no evidence of mediastinal LAP
      • Patent airway is found.
    • Visible abdomen:
      • Moderate ascites at abdominal cavity is found mostly around pancreas is found. Please exclude the possibility of pancreatitis.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • Minimal infiltration at mesentery is found.
      • Suggest clinical correlation
  • Imp:
    • No evidence of pulmonary embolism nor aortic dissection is found.
    • Increased pulmonary vasculature is found.
    • BIlateral pleural effusion and consolidation over bilateral lower lungs.
    • Moderate ascites at abdominal cavity is found mostly around pancreas is found. Please exclude the possibility of pancreatitis.
• 2022-09-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (92 - 38) / 92 = 58.70%
    • M-mode (Teichholz) = 58.5
  • Normal chamber size
  • Adequate LV and RV systolic function
  • Mild MR and TR , trivial AR
  • No regional wall motion abnormalities
• 2022-09-29 SONO - chest
  • Bilateral thorax: small amount pleural effusion; thoracocentesis was not performed due to high risk of complications.
• 2022-09-27 Patho - colon resection (non tumor)
  • PATHOLOGIC DIAGNOSIS
    • Ascending colon, right hemicolectomy — Compatible with diverticulitis with perforation and suppurative peritonitis
  • MACROSCOPIC EXAMINATION
    • Operation procedure: Right hemicolectomy
      
    • Specimen site: Right colon
      
    • Specimen size: 25 cm (ascending colon), 8 cm (ileum), and 7 cm (appendix) in length, respectively
      
    • Grossly, the surface of intestine is coated by fibrinous exudate. There is a subtle diverticulum with a perforated hole in ascending colon is present. The appendix is congested. The ileum is unremarkable.
    • Representative parts are taken for section and labeled: A1= ascending colon with perforation, A2-A4= colon + pericolic soft tissue, A5-A6= appendix
  • MICROSCOPIC EXAMINATION
    • The sections of ascending colon show a picture compatible with diverticulitis with perforation, composed of diverticulum with transmural necrosis, moderate neutrophil infiltration, subserosal fibrosis, granulation tissue, and acute serositis. Suppurative peritonitios with bacterial colonies and abscess formation are present.
    • The sections of appendix show mucosal hyperplasia and periappendicitis.
    • The sectiobns of ileum show acute serositis.
• 2022-09-27 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2022-09-27 CTA - chest
  • Clinical history: 60y/o female patient with sudden low abdominal pain since 2 hours ago, epigastric pain for half month.
  • With and without contrast enhancement CT: CTA, Chest
    • Presence of ascites and pneumoperitoneum.
    • Swelling/thickening at terminal ileum.
    • Enlarged mesentery lymph nodes in right lower abdomen.
    • No abnormal fluid accumulation in the mediastinum and pleural space.
  • Impression:
    • Pneumoperitoneum with ascites, suspected hallow organ perforation.
    • Swelling/thickening at terminal ileum.
• 2022-09-27 ECG
  • Sinus rhythm with ventricular premate complexes
  • Nonspecific ST abnormality
  • Prolonged QT

[MedRec]

• 2023-07-25 SOAP Hemato-Oncology
  • Taking “Astragalus Root” (huang2qi2) since the beginning of chemotherapy
• 2023-07-18 SOAP Hemato-Oncology
  • P: Changing regimen from FLOT to FOLFOX

[consultation]

• 2023-02-23 Hemato-Oncology
  • Q
    • Gastric cancer for neoadjuvant chemotherapy
    • This 60 y/o female with past history of ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27.
    • However, poor intake, poor appetite with body weight loss was still persisted after operation.
    • Further UGI scope was performed which revealed enlarged Gastric folds prob Scirrhous s/p biopsy. Pathology showed adenocarcinoma. IHC stains: CK highlights neoplastic cells. Her2/neu: negative. (score=0). CD68 (-).
    • She was admitted to our ward for nutrition support first then further oepration was performed on 2023/02/20. Operation finding showded severe intraperitoneal adhesion (frozen peritoneal), huge gastric ca with possibly peritoneal spread. We discussion with her family then further chemotherapy will be consider first. We need your help for further managememt for chemotherapy. Port-A insertion will be arrange on 2023/02/22 PM. Thanks for your time!!
  • A
    • This 60 year old woman is a case of previously untreated, unresectable, non-HER2-positive gastric cancer with possibly peritoneal spread (pending pathology result). She had history of ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27. We are consulted for further treatment.
    • Please check PD-L1, HbsAg, AntiHbc, Anti HCV. Please arrange port A insertion. And arrange chest CT+/-contrast for complete staging.
    • Chemotherapy +/- immunotherapy is indicated in this patient. Arrange our OPD after discharge. Thanks for your consultation.
• 2023-02-06 Anesthesiology
  • Q
    • CVC insertion for nutrition with TPN
    • This 60 y/o female was a case of 1) Ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27. 2) Gastric cancer.
    • This time, she sufferred from poor appetite with vomit then BW weight loss was noted in recent months. We need your help for CVC insertion with nutrition support. Thanks for your time!!
  • A
    • Procedure
      • After positioning via Trendelenburg position,head rotated, elevated shoulder, the skin was sterilized and anesthetized with 2% lidocaine 2 m.l..
      • The right IJV was difficult to cannulated.
      • We performed 7 fr CVC insertion to left internal jugular vein with ultrasound-guided under Seldinger technique
      • The pt tolerant the procedure well.
      • There was no sign of hematoma, pneumothorax, infection after the procedure.
    • The recommandation is as followed:
      • Please check chest roentgenography for localization.
      • Change IV set QD if TPN used or Q4D if general fliud.
      • Change OP site at least every week. IF loosening or blood accumulation please change it ASAP.
      • We do not recommand routinely change the CVC unless there are some infectious signs.
• 2022-10-19 Cardiac surgery
  • Q
    • For further evaluation of D-dimer elevation, deep vein thrombosis ???
    • This 60 y/o female suffered from sudden low abdominal pain for hours, and epigastric pain for half month.
      • CT: Pneumoperitoneum with ascites.
      • Ascending colon diverticulitis with perforation was diagnosed. Operation of Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27.
      • During hospitalization. D-dimer elevation was noted and Clexane 30mg SC QD was give since 2022/10/14. Bilateral legs no distention, and freely movable.
      • D-dimer
        • 2022-09-30 05:58 2100.45 ng/mL(FEU)
          
        • 2022-10-04 12:28 > 10000.00 ng/mL(FEU)
        • 2022-10-09 07:50 7286.88 ng/mL(FEU)
          
        • 2022-10-10 05:17 6349.13 ng/mL(FEU)
          
        • 2022-10-12 05:09 8695.92 ng/mL(FEU)
          
        • 2022-10-14 07:28 9250.27 ng/mL(FEU)
          
        • 2022-10-19 07:42 8570.57 ng/mL(FEU)
          
    • So we consult you for further evaluation and management of blood D-dimer elevation the problem. (is it possible to swift oral medication?).
  • A
    • This 60 y/o female, history reviewed as above and herself examined, consulted for elevated D-dimer under clexane therapy
      • Chest CTA 2022/10/04 no pulmonary embolism
      • PE both limb soft, without tender swelling, already off-bed ambulation, dyspnea (-)
    • Recommendation
      • no clinical evidence of significant DVT
      • may arrange duplex PRG (lower limbs sonography for peripheral vessel) to exclude DVT possibility, then DC clexance accordingly
• 2022-10-07 Thoracic Medicine
  • Q
    • for Left pleural effusion.
    • This 60 y/o female had history of gastric ulcer. Under the impression of sigmoid colon with perforation, fecal peritonitis + necrosis of omentum and septic shock s/p emergent Hartman procedure on 2022/09/27. CXR showed Left pleural effusion on 2022/10/07. We need your help for treatment assessment (chest echo?? tapping??). Thank you so much!!!
  • A
    • Series image showed progressive bilateral pleural effuison, Left side > right side.
    • severe hypoalbuminemia : <1.9 —> 2.3 —> 2.3
    • 20221004 CT showed: peritonitis with ascites, reactive bilateral pleural effusion
    • Suggestion:
      • Please take the permit. We will arrange chest echo for chest tapping +/- 14Fr. pig-tail catheter insertion for her.
      • Change antibiotics to Unasym or consult infection to adjust antobiotics use
      • Albumin replacement to keep Albumin level = 3.5 at least
      • Lasix for remove third space edema
      • thanks and f/u prn.
• 2022-09-27 Thoracic Medicine
  • Q
    • This 60 y/o female had history of gastric ulcer. According to her family’s history, she had got lower abdominal pain since last night. Epigastric pain had been noted for half month. At ER, dyspnea with chest pain and cold sweating were also noted. Vital signs showed BP 115/67mmHg, HR 93bpm, BT 36.9’C, RR 18. Lab data revealed: WBC 13K, CRP 1.0, Troponin within normal range, no elevated Bilirubin or Lipase. CT showed: Pneumoperitoneum with ascites, r/o hallow organ perforation and swelling terminal ileum. Brosym was prescribed and operation was arranged. Resection of A colon with ileostomy was perforemed. Under the impression of Pneumoperitoneum with ascites due to A colon perforation, she was admitted to our ICU for further care.
    • Consult purpose: decrease saturation with Bilateral pleural effusion, r/o lung compartment syndrome. consider Bronchoscopy?
  • A
    • S: short of breath
    • O:
      • 20220929 bed-side chest sono: bilateral small amount pleural effusion
      • 20220929 CRP=37, WBC=27.5K
      • 20220927 albumin < 1.5
      • 20220927 BW=63.1 Kg –> 20220929 BW=66.5Kg
      • 20220928 CXR: bilateral lung consolidation
      • 20220929 breath sound: clear
    • A:
      • ARDS, moderate to severe degree; favor secondary to intra-abdmonial infection
      • pneumoperitoneum s/p operation
    • P:
      • Bronchoscopy was relatively contra-indicated due to high oxygen demand [FiO2=100% on 20220929 PM3:00]. Bronchoscopy probably causes desaturation during and after the procedure.
      • arrange cardiac echo and check serum D-dimer and NT-proBNP for suspected pulmonary embolism and congestive heart failure
      • follow up ABG/CXR QD
      • prone position was relatively contra-indicated due to septic shock status and large surgical wound over anterior abdominal wall
      • check serum Aspergillus Ag, serum cryptococcus Ag, serum Mycoplasma IgM, serum Chlamydia IgM, and urine legionella Ag, urine streptococcus Ag for pathogen survey
      • check sputum TBPCR, TB culture, acid-fast stain and aerobic culture for pathogen survey
• 2022-09-27 General and DigestiveSurgery
  • A
    • P,E showed regid abdomen, with muscle guarding
    • diffuse local tenderness and knocking pain, right
    • Lab and CT showed neumoperitoneum , in favor of PPU
    • Emergency op is indicated

[chemotherapy]

• 2023-09-11 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-08-09 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-06-27 - (FLOT)
• 2023-06-13 - (FLOT)
• 2023-05-30 - (FLOT)
• 2023-05-16 - (FLOT)
• 2023-04-25 - (FLOT)
• 2023-04-11 - (FLOT)
• 2023-03-23 - (FLOT)
• 2023-02-24 - docetaxel 35mg/m2 50mg D5W 160mL 1hr + oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 200mg/m2 270mg NS 250mL 2hr + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (FLOT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-20

[elevated bilirubin level with high DBI to TBI ratio]

Lab bilirubin level:

• 2023-10-20 Bilirubin total 1.14 mg/dL
  

• 2023-10-20 Bilirubin direct 0.48 mg/dL
  

• 2023-10-20 DBI/TBI 42.11 %

• 2023-10-13 Bilirubin total 1.30 mg/dL
  

• 2023-10-13 Bilirubin direct 0.54 mg/dL
  

• 2023-10-13 DBI/TBI 41.54 %

The direct and total bilirubin levels on 2023-10-20 appear to be slightly lower than those on 2023-10-13. Despite this decrease, the ratio of direct bilirubin (DBI) to total bilirubin (TBI) continues to be elevated, which could typically signify issues with the liver’s capacity to secrete bilirubin into the bile or an obstruction within the bile ducts, leading to a buildup of conjugated bilirubin in the bloodstream. It’s noteworthy that oxaliplatin, a component of the FOLFOX regimen, is linked to a 13% incidence of increased serum bilirubin. However, it’s been over a month since the last FOLFOX cycle was administered during the previous hospitalization.

2023-10-16

[hypocalcemia]

corrected calcium level for hypoalbuminemia

• calcium 1.94 mmol/L, albumin 2.8 g/dL, normal albumin 4 g/dL => corrected calcium 8.7 mg/dL, equivalent to 2.2 mmol/L. ref: https://www.mdcalc.com/calc/31/calcium-correction-hypoalbuminemia

injectable calcium supplements with Bfluid

• Two injectable calcium supplements are available from stock: Vitacal (calcium chloride, equivalent to 5.44 mEq/amp) and Calglon (calcium gluconate, equivalent to 4.65 mEq/amp).

• Bfluid 1000 mL contains 5 mEq of calcium per liter and can be supplemented with a maximum of an additional 5 mEq of calcium per liter.

2023-09-11

[leukopenia, anemia]

FOLFOX regimen was administered on 2023-08-09 and 2023-09-11, there was no observed leukopenia (WBC < 3K/uL) since 2023-08-25, however, there was still anemia (HGB < 8mg/dL) observed on 2023-09-11.

2023-09-11 WBC 3.72 x10^3/uL
2023-09-07 WBC 5.61 x10^3/uL
2023-09-04 WBC 6.04 x10^3/uL
2023-08-31 WBC 8.23 x10^3/uL
2023-08-28 WBC 22.74 x10^3/uL
2023-08-25 WBC 8.85 x10^3/uL
2023-08-23 WBC 1.87 x10^3/uL 2023-08-21 WBC 1.08 x10^3/uL 2023-08-17 WBC 2.59 x10^3/uL * 2023-08-14 WBC 1.60 x10^3/uL ** 2023-08-09 WBC 3.03 x10^3/uL
2023-08-07 WBC 3.90 x10^3/uL
2023-08-01 WBC 7.93 x10^3/uL

2023-09-11 HGB 7.9 g/dL 2023-09-07 HGB 9.3 g/dL 2023-09-04 HGB 10.3 g/dL 2023-08-31 HGB 8.6 g/dL 2023-08-28 HGB 9.7 g/dL 2023-08-25 HGB 9.3 g/dL 2023-08-23 HGB 10.2 g/dL 2023-08-21 HGB 8.1 g/dL 2023-08-17 HGB 7.9 g/dL 2023-08-14 HGB 8.0 g/dL * 2023-08-09 HGB 9.1 g/dL 2023-08-07 HGB 9.6 g/dL 2023-08-01 HGB 12.4 g/dL

A blood transfusion was performed on 2023-09-11 without a problem.

2023-08-11

[Astragalus Root]

The patient has been consistently using Astragalus Root since starting chemotherapy (2023-07-25 Onc Opd). To assess whether Astragalus Root might impact the effectiveness of chemotherapy, a literature search was conducted, and a relevant article was found: “Meta-Analysis of Astragalus-Containing Traditional Chinese Medicine Combined With Chemotherapy for Colorectal Cancer: Efficacy and Safety to Tumor Response. Front Oncol. 2019;9:749. Published 2019 Aug 13. doi:10.3389/fonc.2019.00749”

Here is a summary of the key points from the research article:

• The article is a meta-analysis evaluating the efficacy and safety of combining Astragalus-containing traditional Chinese medicine (TCM) with chemotherapy for treating colorectal cancer, compared to chemotherapy alone.
• 22 randomized controlled trials with a total of 1409 patients were included. Trials used various oral, injected or external TCM preparations containing Astragalus.
• The meta-analysis found combining Astragalus-based TCM with chemotherapy significantly improved tumor response rate and quality of life compared to chemotherapy alone.
• Combination therapy also reduced chemotherapy side effects including myelosuppression, nausea/vomiting, diarrhea and neurotoxicity.
• No significant differences were found between groups for liver or kidney dysfunction side effects.
• Limitations include generally low quality of included trials and all Chinese studies, reducing applicability. More rigorous research is needed.
• Overall, the meta-analysis suggests Astragalus-containing TCM combined with chemotherapy may have benefits for colorectal cancer, but further high-quality studies are warranted.

Based on the findings of this study, there is currently no evidence to suggest that the patient should discontinue the use of Astragalus Root.

2023-03-20

• Leukopenia was observed on 2023-03-08, approximately 2 weeks after the patient received her first cycle of FLOT regimen chemotherapy, which started on 2023-02-24. The patient then received Granocyte (lenograstim 250ug) for three consecutive days (since 2023-03-08) and has not experienced any further episodes of leukopenia.

  • 2023-03-15 WBC 9.76 x10^3/uL
    
  • 2023-03-08 WBC 1.76 x10^3/uL
    
  • 2023-02-23 WBC 5.75 x10^3/uL
    
  • 2023-02-21 WBC 6.51 x10^3/uL

• According to a study, preoperative FLOT chemotherapy appears to be safe and feasible for the treatment of resectable locally advanced gastric cancer. The FLOT regimen used in the study consisted of docetaxel (60 mg/m2), oxaliplatin (85 mg/m2), leucovorin (200 mg/m2), and 5-fluorouracil (2,600 mg/m2 as a 24 hr infusion). The study suggests that FLOT may be more effective in reducing morbidity and improving overall survival compared to initial surgery followed by chemotherapy. The patient received a reduced version of the FLOT regimen, which includes docetaxel 35mg/m2, oxaliplatin 75mg/m2, leucovorin 200mg/m2, and fluorouracil 2600mg/m2. (ref: Docetaxel, oxaliplatin, leucovorin, and 5-fluorouracil (FLOT) as preoperative and postoperative chemotherapy compared with surgery followed by chemotherapy for patients with locally advanced gastric cancer: a propensity score-based analysis. Cancer Manag Res. 2019;11:3009-3020. Published 2019 Apr 10. doi:10.2147/CMAR.S200883).

• The dose used in this patient was lower than what is recommended in our in-hospital “Prescription Collection of Chemotherapy for Gastric Cancer” protocol (dated 2022-06-21). The protocol recommends a dose of docetaxel 50 mg/m2 IV D1, oxaliplatin 85 mg/m2 IV D1, and 5-FU 1200 mg/m2 IV continuous infusion (over 24 hours daily) on D1 and D2.

• There is no need to adjust the dosage at this time. It is recommended to continue monitoring the patient’s blood cell counts to evaluate the response after the second cycle of treatment.

700552963

231024

[exam findings]

• 2023-09-19 SONO - abdomen
  • Liver cyst, S4
• 2023-03-15 Patho - breast mastectomy with regional lymph nodes
  • PATHOLOGIC DIAGNOSIS
    • Breast, left, partial mastectomy — Invasive carcinoma of no special type
    • Resection margin, breast, left, partial mastectomy — Free
    • Lymph nodes, sentinel and axillary, left, lymphadenecomy — Metastatic carcinoma (2/11)
    • AJCC 8 th edition, Pathology stage: pT2N1a(cM0); Anatomic stage IIB; Prognostic stage IB
  • MACROSCOPIC EXAMINATION
    • Breast Size: 3.8 x 2.5 x 2.0 cm
    • Skin: Not included
    • Nipple: Not included
    • Tumor Size: 2.5 x 2.0 x 1.5 cm
      
    • Resection Margin: Free, 0.2 cm from the deep margin
    • Lymph node: Sentinel and axilla, left
    • Representative parts are taken for section and labeled: F2023-00100 FSA1= 12’, 3’, 6’ margins, FSA2= 9’ and deep margins, FSB= left axilla sentinel LNs, A1-A5= tumor. S2023-04655= left axilla LNs
  • MICROSCOPIC EXAMINATION
    • Disease Type
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 2.5 x 2.0 x 1.5 cm
        
      • Histologic grade (Nottingham histologic score): Grade 2 (score=6)
      • Skin involvement: Not applicable
      • Muscle involvement: Present
      • Ductal carcinoma in situ: Absent
    • Margins: Negative, Closest margin ( 2 mm from deep margin)
    • Nodal status: Positive (sentinel 1/3; axillary 1/8)
      • numbers
        • number of lymph node examined: 3 (sentinel), 8 (axilla)
        • number with macrometastases (> 2mm): 1 (sentinel), 1 (axilla)
        • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
        • number with isolated tumor cells (<= 0.2mm and <=200 cells): 0
      • Extranodal extension: Present
    • Treatment Effect: No presurgical neoadjuvant therapy received
    • Lymphovascular invasion: Presnt
    • Perineural invasion: Absent
  • IMMUNOHISTOCHEMICAL STUDY (Data from VGH)
    • ER (Ab): Positive (95%)
    • PR (Ab): Positive (90%)
    • HER-2/Neu (Ab): Negative (score= 1+)
    • Ki-67: 28%
• 2023-03-14 Frozen Section
  • 3’, 6’, 9’, 12’, upper and deep margins, breast, left, frozen section — Free of carcinoma
  • Sentinel lymph nodes, axilla, left, frozen section — Metastatic carcinoma (1/3)
• 2023-03-14 Lymphoscintigraphy
  • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the left axilla.
  • IMPRESSION: Probably a sentinel lymph node at the left axillary region.
• 2023-03-13 SONO - abdomen
  • fatty liver: minimal
• 2023-03-09 Tc-99m MDP bone scan
  • Increased activity in the lower C- and lower L-spines. Degenerative change may show this picture.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
• 2023-03-09 SONO - breast
  • Diagnosis
    • Bil. fibroadenomas as described
    • Left breast cancer
  • Treatment
    • explain the finding
  • Suggestion and Plan
    • further treatment
  • BI-RADS:
    • score 6. known biopsy-proven malignancy

[consultation]

• 2023-08-28 Radiation Oncology
  • Q
    • This 57-year-old female patient denied any past history including hypertension, DM, HBV or heart disease. She denied cancer history. She had COVID infection on 2022/11.
    • She noted a palpable mass at left breast by health examination in VGH. Core needle biopsy revealed invasive carcinoma, ER(95%+) PR(90%+) HER2/neu(1+) Ki 67 28%. CA-153 11.912 U/ml, CEA 2.452 ng/ml. Due to personal reason, she came to our OPD for help.
    • Breast sono showed a lesion, left 6’/0.43 cm , size: 1.19x1.67cm. Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. Under surgery of left partial mastectomy + ALND on 2023/03/14.
    • Pathology invasive carcinoma with axillary LN metastasis, pT2N1aM0; Anatomic stage IIB; Prognostic stage IB.
    • Adjuvant chemotherapy Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles was plan.
    • AI and radiotherapy for axillary LN after chemotherapy.
    • Under the impression of left breast invasive carcinoma with axillary LN metastasis, she was admitted for 8th adjuvant chemotherapy Taxotere 75mg/m2. We need your help for radiotherapy. Thank you so much!!
  • A
    • Subjective:
      • Previous RT: denied.
      • Other disease: HTN, thyroid CA s/p thyroidectomy, HCVD, hyperlipidemia and insomnia.
      • Family history: denied.
      • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
      • Married. Caregiver: her husband. Job: accountant (rest now). Mild or no economic stress at least.
      • Language: Mandarin. Taiwanese.
      • Religion: Buddism
    • Objective:
      • General Condition-ECOG: 1.
      • PE, 2023/8/28: No palpable SCF LAPs.
      • Pathology, 2023/03/14
        • Breast, left, partial mastectomy — Invasive carcinoma of no special type, 2.5 cm, free margin (2 mm from closest deep margin); LVSI(+). ER(95%+); PR(90%+); HER2/neu(1+); Ki 67 28%.
        • Lymph nodes, sentinel and axillary, left, lymphadenecomy — Metastatic carcinoma (2/11), ECS(+).
        • AJCC 8 th edition, Pathology stage: pT2N1a(cM0); Anatomic stage IIB; Prognostic stage IB.
      • Images:
        • Breast sonogram, 2023/03: a lesion, left 6’/0.43 cm, size: 1.19x1.67cm.
        • CXR, liver echo, bone scan, 2023/03: negative for metastasis.
    • Diagnosis: Left breast cancer, invasive carcinoma, s/p partial mastectomy + ALND on 2023/03/14, pT2N1a cM0; Anatomic stage IIB; Prognostic stage IB s/p adjuvant chemotherapy Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles (last on 2023/8/28); ECOG =1.
    • Plan: Adjuvant RT to left breast and SCF lymphatics for 5000cGy/25 fractions then boost scar to 6000cGy/30 fx is suggested for locoregional control. CT simulation is arranged on 9/06, 10:30. Possible RT toxicity is told. Diet education is given.

[surgical operation]

• 2023-03-14
  • Surgery: Partial mastectomy (round-block) + axillary lymphnode dissection        
  • Finding
    • a 2.5x2x1.5 cm slight firm mass in lt breast
    • SLN 1(+)/3   

[chemotherapy]

• 2023-08-28 - docetaxel 75mg/m2 115mg NS 250mL 1hr (D, Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + famotidine 20mg
• 2023-08-07 - docetaxel 75mg/m2 115mg NS 250mL 1hr (D, Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-07-17 - docetaxel 75mg/m2 115mg NS 250mL 1hr (D, Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-06-21 - docetaxel 75mg/m2 114mg NS 250mL 1hr (D, Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-05-31 - cyclophosphamide 600mg/m2 900mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 52mg D5W 250mL 2hr (AC(Lipo), Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
• 2023-05-08 - cyclophosphamide 600mg/m2 924mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo), Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
• 2023-04-17 - cyclophosphamide 600mg/m2 920mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo), Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL + Granisetron 1mg + aprepitant 125mg PO D1
• 2023-03-25 - cyclophosphamide 600mg/m2 920mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo), Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL + Granisetron 1mg + aprepitant 125mg PO D1

==========

2023-10-24

[grade 3 diarrhea]

The patient experienced grade 3 diarrhea (characterized by an increase of seven or more stools per day over baseline, the patient had a total of 8 bowel movements on 2023-10-23). However, the last administration of docetaxel, known to cause diarrhea in 23% to 43% of cases (with severe cases being <=6%), occurred almost two months ago, on 2023-08-28. This timeline makes it improbable that the recent severe diarrhea was solely a result of the previous docetaxel treatment.

Currently, the patient is on both loperamide and buscopan to manage the symptoms.

Additionally, it’s important to note that the patient’s current medication, abemaciclib, can also induce diarrhea. It’s advisable to temporarily discontinue abemaciclib until the diarrhea subsides to <= grade 1, after which the medication can be cautiously reintroduced.

700526640

231023

[exam findings]

• 2023-10-21, -10-11, -09-25 KUB
  • Ascites is noted. Please correlate with sonography.
  • Spondylosis of the L-spine is noted.
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5 and L5-S1.
• 2023-09-17 CT - abdomen
  • Findings
    • Cystic tumors in the pelvic cavity, up to 7.4cm. R/O recurrent tumors.
    • Presence of ascites with peritoneal nodularity, r/o carcinomatosis.
    • There are liver tumors, up to 3.4cm in right lobe, could be due to liver metastasis. Progression.
    • Unremarkable change of the spleen, pancreas and both kidneys.
    • S/P hysterectomy.
    • R/O calcified granuloma in left lower lung.
    • Right lower lung nodule, r/o lung metastasis.
  • Impression:
    • Peritoneal carcinomatosis.
    • Liver metastasis with progression.
    • R/O calcified granuloma in left lower lung.
    • Right lower lung nodule, r/o lung metastasis.
• 2023-09-17 KUB
  • Small bowel ileus.
  • Lumbar spondylosis.
  • Disc space narrowing at L4/5 level.
• 2023-09-15 Vein Sonography
  • No evidence of DVT, bilateral lower legs
  • Right CFV trivial reflux
  • Right LSV trivial reflux, involved right sphenofemoral junction (SFJ); proximal GSV size 0.41 cm,
  • Left LSV mild reflux, involved left sphenofemoral junction (SFJ); proximal GSV size 0.42 cm,
  • Left CFV mild reflux
  • Both SSV without reflux.
• 2023-09-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 16) / 78 = 79.49%
    • M-mode (Teichholz) = 78
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Aortic valve calcification with moderate AS
    • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Trivial MR, moderate TR
    • Preserved RV systolic function
• 2023-08-13 Gynecologic ultrasonography
  • s/p staging operation(ATH + BSO + BPLND)
  • A 76.7x70.0mm pelvic mass was noted, suspected hematoma?
• 2023-08-10 Gynecologic ultrasonography
  • ATH + BSO
  • R/O RT mass: 91mm X 82mm, no blood flow
• 2023-06-21 Vein Sonography
  • No evidence of DVT, bilateral lower legs
  • Both LSV trivial reflux
• 2023-06-15 Patho - ovary (non-tumor)
  • Soft tissue, pelvic, exploratoy laparotomy — Metastatic serous carcinoma
  • The sections show a picture of metastatic serous carcinoma, composed of papillary fronds lined by pleomorphic polygonal neoplastic cells, with high mitotic activity. Solid sheets of neoplastic cells admixed with reactive mesothelial cells can be found also.
• 2023-05-30 MRI - pelvis
  • S/P hysterectomy with recurrence in the pelvic cavity, progression.
  • Stationary liver tumor, r/o liver metastasis.
  • Ascites with peritoneal enhancement, r/o peritoneal carcinomatosis.
  • Lymphocele in the pelvic cavity with regression.
• 2023-02-16 ENT Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 20 dB HL, normal to moderately severe SNHL
    • L’t : 19 dB HL, normal to moderate SNHL
  • Tymp
    • R’t : Type A
    • L’t : Type As
  • ART
    • R’t : absent
    • L’t : absent except Ipsi 500-1k Hz.
• 2023-01-16 MRI - pelvis
  • S/P hysterectomy, r/o recurrent tumor in the pelvic cavity (near right vaginal stump and cul-de-sac), progression.
  • Liver tumor, 1.3cm in S8. progression, r/o liver metastasis.
  • Lymphocele in the pelvic cavity.
• 2022-10-31 MRI - pelvis
  • S/P hysterectomy. R/O recurrent tumor in the cul-de-sac and right vaginal stump.
  • Stationary liver tumor (metastatic?), 1.1cm in S8.
  • Lymphocele in the pelvic cavity.
• 2022-08-01 Patho - uterus with or without SO non-neoplastic/prolapse
  • PATHOLOGIC DIAGNOSIS
    • Uterus, endometrium, ATH — Serous carcinoma
    • Ovary, left, BSO — Involved by serous carcinoma
    • Lymph nodes, pelvic and para-aortic, bilateral, BPLND+PALND— Metastatic serous carcinoma (21/36)
    • Omentum, infracolic omentectomy — Invoved by serous carcinoma
    • CDS, right, excision — Involved by serous carcinoma
    • AJCC 8 th edition, Pathology stage: ypT3aN2aM1; stage IVB; FIGO stage IVB
  • MACROSCOPIC EXAMINATION
    • Procedure: ATH+BSO+infracolic omentectomy+BPLND+para-aortic LN dissection
    • Specimen Size: 12 x 8 x 5 cm (uterus), 3.0 x 2.5 x 2.0 cm (Rt ovary), 4.5 x 0.8 cm (Rt tube), 3.0 x 2.5 x 2.0 cm (Lt ovary), 4.5 x 0.8 cm (Lt tube), 28 x 15 x 2.0 (omentum), and right CDS
    • Specimen Integrity: Intact
    • Tumor Site: Endometrium
    • Tumor Size: No definite mass can be identified grossly
    • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, and bilateral para-aortic
    • Representative parts are taken for section and labeled as: A1-A2= left iliac LNs, B= left obturator LNs, C1-C2= right iliac LNs, D= right obturator LNs, E= left para-aortic LNs, F= right para-aortic LNs G1-G2= left ovary and fallopian tube, G3-G4= right ovary and fallopian tube, G5-G6= cervix, G7-G10= uterine corpus, H1-H2= omentum, I= right CDS.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Serous carcinoma
    • Histologic Grade: High-grade
      
    • Adenomyosis: Not identified
    • Uterine Serosal Involvement: Present
    • Cervical Stromal Involvement: Present
    • Other Tissue/Organ Involvement: Left ovary involvement
    • Peritoneal/Ascitic Fluid: Pending
    • Margins: Involved by carcinoma
    • Lymphvascular Invasion: Present
      • Regional Lymph Nodes: Metastatic serous carcinoma (21/36)
      • number of lymph node examined: 7 (left iliac), 5 (left obturator), 2 (right iliac), 8 (right obturator), 6 (left para-aortic), 8 (right para-aortic)
      • number with metastases: 5 (left iliac), 3 (left obturator), 1 (right iliac), 1 (right obturator), 5 (left para-aortic), 6 (right para-aortic)
    • Pathologic Stage
      • Primary Tumor: ypT3a (tumor involving the serosa and adnexa)
      • Regional Lymph Nodes: ypN2a (metastasis to para-aortic lymph nodes ＞2mm)
      • Distant Metastasis: Metastasis to omentum
    • FIGO Stage: Stage IVB
    • AdditionalPathologic Findings
      • Cervix: Involved by carcinoma
      • Myometrium: Involved by carcinoma and leiomyoma
      • Ovary, right: No remarkable change
      • Ovary, left: Involved by carcinoma
      • Fallopian tubes, blateral: No remarkable change
      • Omentum: Involved by carcinoma
      • CDS, right: Involved by carcinoma
• 2022-07-19 Bronchodilator Test
  • Normal spirometry
  • without significant response to bronchodilator
• 2022-07-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 21) / 75 = 72.00%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild AS, AR, TR
• 2022-07-11 CXR + Lat. LT
  • Spondylosis of the T-spine
  • A nodular opacity projecting in the left lower medial lung, retrocardiac area, shows stationary. Old calcified granuloma is highly suspected. Follow up is indicated.
• 2022-07-11 CT - abdomen
  • Findings
    • Low density lesion at S8 of liver about 1.69cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-05-03, the lesion is stationary.
    • Wall thickening at endometrium is found. Endometrial cancer is considered. In regression.
    • The GB is well distended without soft tissue lesion
  • Imp:
    • Endometrial cancer, in regression.
    • Liver meta. Stable.
• 2022-05-10 Patho - endometrium curretage/biopsy
  • DIAGNOSIS:
    • A. Labeled as “endometrium”, Dilataion and curettage with frozen section (F2022-218FSA) — Serous adenocarcinoma, high grade.
      • IHC stains: PAX-8 (+), WT-1 (focal +), Napsin-A (-), p53 (aberrant type), p16 (<70%).
    • B. Labeled as “left pelvic mass”, clinically left ovary obscured, SILS biopsy with frozen section (F2022-218FSB) — Serous adenocarcinoma, high grade.
      • IHC stains: PAX-8 (+), WT-1 (focal +), Napsin-A (-), p53 (aberrant type). ER: (-), PR (-).
  • Note: Ovarian origin is favored.
• 2022-05-06 Ascites tapping
  • Course: 18G needle was inseted at RLQ under echo guided insertion.
  • Findings: 3000 ml yellowish color ascites were drained.
• 2022-05-05 Patho - stomach biopsy
  • Stomach, antrum, biopsy — Chronic active gastritis, H pylori present
• 2022-05-05 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Suspected gastric ulcer scar
    • Gastric erosive lesion, suspected healing ulcer, s/p biopsy
    • Deformed prepyloric antrum
    • Duodenal ulcer scars
  • CLO test: Positive
  • Suggestion:
    • PPI therapy
    • Pursue pathology and CLO test result
• 2022-05-05 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (66 - 18) / 66 = 72.73%
    • M-mode (Teichholz) = 72
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA,
    • Mitral inflow EA fusion due to tachycardia
    • Mild AR, AS, TR
    • 5.Presence of left pleural effusion
• 2022-05-05 Colonoscopy
  • Colon polyps, probable adenoma (without polypectomy)
  • Colon diverticulosis
  • Failure of cecal intubation
• 2022-05-04 Flow volume loop
  • mild restrictive impairment
• 2022-05-03 CT - abdomen
  • Findings
    • Prominent ascites with multiple soft tissue tumors in the peritoneum, could be due to peritoneal carcinomatosis.
    • Prominent density in the uterine cavity.
    • Liver cyst, 1.9cm in left lobe.
    • Low density nodules in right lobe of the liver, up to 1.7cm in S7, r/o liver metastasis.
    • S/P right mastectomy.
    • Outpouching lesions in ascending and descending colon, suggesting diverticula.
    • R/O calcifie granuloma in left lower lung.
  • Impression:
    • Peritoneal carcinomatosis and liver metastsis.
    • Prominent density in the uterine cavity. Suggest GYN study.
    • Liver cyst.
    • S/P right mastectomy.
    • Colon diverticulosis.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M1(M_value) STAGE:IVb(Stage_value)
• 2022-05-03 Gynecologic ultrasonography
  • R/O Endometrial hyperplasia: 39.0mm (solid + fluid)
  • Ascites
  • R/O Rt mass: 50x44mm
• 2022-04-30 Ascites tapping
  • paracentesis under direct sonography-guidance: an IC cath (18 gauge) was inserted into peritoneal cavity at RLQ: 2000cc yellowish ascites was drained out
• 2022-04-30 SONO - abdomen
  • Diagnosis:
    • Peritoneal tumors, multiple, favor seeding
    • Ascites, massive
    • Hepatic tumor favor hemangioma
    • Hepatic cyst
      
    • Susp. parenchymal liver disease
  • Suggestion:
    • paracentesis

[MedRec]

• 2023-07-06 SOAP Radiation Oncology Huang JingMin
  • A: Serous carcinoma of the uterine endometrium, AJCC 8 th edition, Pathology stage: ypT3aN2aM1; stage IVB; FIGO stage IVB, s/p neoadjuvant chemotherapy and Debulking surgery (ATH + BSO + BPLND + paraaortic LN dissection + infracolic omentectomy), and chemotherapy, with relapse, s/p excision.
    
  • P: Radiotherapy is indicated for this patient with the following indicators: tumor recurrence
    • Goal: palliation
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT and IVRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-07-13.
• 2023-07-04 SOAP Hemato-Oncology Xia HeXiong
  • P: Arrange admission for Lipo-Dox with or without Carboplatin or CCRT with plaitnum first followed by C/T
• 2023-07-04 SOAP Obstetrics and Gynecology Huang SiCheng
  • P: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-06-29.
    • Treatment plan: Systemic therapy and consult radiation oncology
• 2023-06-12 ~ 2023-06-26 POMR Obstetrics and Gynecology Yan XuanShang
  • Discharge diagnosis
    • Endometrial cancer
    • Pelvic cystic mass tumor–>Excision of intraabdominal tumor, malignant on 2023-06-14
    • Female pelvic peritoneal adhesions (postinfective) -> Adhesionolysis on 2023-06-14
  • CC
    • Constipation and dysuria for about 2 weeks.
  • Present illness
    • This is a 79 y/o, G4P2SA2 woman with a medical history of:
      • Endometrial cancer, high grade serous adenocarcinoma, with peritoneal carcimatosis and liver metastases, s/p SILS biopsy + dlatation and curettage and port-A insertion, s/p palliative chemotherapy (III) with Taxol / Carboplatin (2022/05/17, 2022/06/13, 2022/07/04)
      • Debulking surgery + HIPEC on 2022/08/01. Pathology report show endometrial cancer, high grade serous adenocarcinoma with stage: ypT3aN2aM1; stage IVB; FIGO stage IVB s/p palliative chemotherapy.
      • Hypertension under medical control
      • Diabetes mellitus under medical control
      • Right breast cancer, status post oeration and chemotherapy.
    • The patient, who has a history of endometrial cancer and was previously followed up at our OPD, presented this time with complaints of constipation and dysuria for approximately 2 weeks. There is no associated abdominal pain or fever. She denies symptoms such as nausea, vomiting, and tarry or bloody stool.But have lower limbs mild weakness and numbness. Laboratory data revealed elevated levels of BUN (46 mg/dL), creatinine (2.58 mg/dL), and a decreased hemoglobin level (9.8 g/dL). Additionally, CA125 was measured at 1365.6 U/mL, and CA199 was measured at 337.15 U/mL. Urine examination showed the presence of occult blood (2+) and ediment-RBC = 3-5 /HPF, Sediment-WBC = >=100 /HPF.
    • An MRI of the pelvis conducted on 2023-05-30, revealed the following findings: 1. S/P hysterectomy with recurrence in the pelvic cavity, progression. 2. Stationary liver tumor, r/o liver metastasis. 3. Ascites with peritoneal enhancement, r/o peritoneal carcinomatosis. 4. Lymphocele in the pelvic cavity with regression.
    • After discussing patient’s symptom with the patient, she decided to undergo further surgery. She was admitted on 2023-06-12, for debulking surgery, exploratory laparotomy, and HIPEC, scheduled for 2023-06-14.
  • Course of inpatient treatment
    • The patient was admitted on 2023-06-12 and underwent Excision of intraabdominal tumor, malignant + Adhesionolysis the next day. Her postoperative course was uneventful. Eating and urination by self voiding was smooth. The vital sign was stable after surgery. She is discharged on 2023-06-26 and her followup appointment is scheduled on next week.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# TID
    • Cephalexin (cephalexin 500mg) 1# TID
    • Uretropic (furosemide 40mg) 0.5# QD
    • Wecoli (bethanechol 25mg) 1# QD
• 2022-05-16 SOAP Gastroenterology Chen ZhiXiang
  • S
    • Refer for NUC (nucleotide analogue) prophylaxis for occult HBV
    • Scheduled neo C/T for endometrial ca tomorrow
• 2022-05-02 ~ 2022-05-12 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Ovary cancer,suspected with cancer peritonitis
    • Right breast cancer s/p op and chemotherapy
    • Hypertension
    • Diabetes mellitus
    • Old CVA with left lower limbs mild weakness
    • Reflux esophagitis
    • colon polyps
  • CC
    • abdominal distenetion, poor appetite, acid regurgitation sensation, body weight loss, thinner in stool shape in recent 1 month
  • Present illness
    • This 78 year-old female has the histories of
      • Old CVA with left lower limbs mild weakness
      • Hypertension
      • Diabetes mellitus
      • right breast ca status post oeration and chemotherapy
    • She came to GI OPD due to progressive abdominal distenetion, poor appetite, acid regurgitation sensation, body weight loss, thinner in stool shape in recent 1 month.She denied nausea, vomiting, abdominal pain, tarry or bloody stool and no hematuria, no cough, no dyspnea, no cold sweating, no fever, no chills, no chest or back pain. She also denied TOCC history. Blood analysis showed leukocytosis (11.36x10^3/uL), and left shift (SEG: 78.8 %), no anemia (Hb: 12mg/dL), normal PT/aPTT level, normal renal function, no electrolyte imbalance, normal hepatobiliary enzyme (ALT: 6 U/L, AST: 13 U/L, TBI: 0.42 mg/dl, DBI: 0.15 mg/dl, ALP: 143 IU/L).
    • Under the impression of cancer peritonitis. She was admitted to GI ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission ward, abdominal CT was performed on 5/3 for cancer survey and revealed: 1) Peritoneal carcinomatosis and liver metastsis. 2) Prominent density in the uterine cavity. Suggest GYN study. 3) Liver cyst. 4) S/P right mastectomy. 5) Colon diverticulosis.
    • Due to the abdominal CT report, the GYN Doctor was consulted and the suggestion was given as follows: 1) suspect ovarian cancer 2) Check CA125, CA199, CEA, Albumin, FDPdimer 3) transfer to GYN ward after EGD and colonscope, operation will be arranged next week.
    • GYN sonography was done on 05/03 and showed 1) suspect ovarian cancer. 2) R/O Endometrial hyperplasia: 39.0mm (solid + fluid). 3) Ascites. 4) R/O Rt mass: 50x44mm. The Chest Medicine Department was also consulted for CXR report with solitary pulmonary nodule at left pulmonary hilar region and suggestion was given as follows: 1) The left lung nodule is stationary compared with previous CXR and may be related to previous old TB calcified lesion -> Keep F/U 2) However, 1 tiny nodule over RLL, cause unknown, should survey the etiology of the ascites.
    • EGD was performed on 05/05 and reveled 1) Reflux esophagitis LA Classification grade A. 2)Superficial gastritis, s/p CLO test. 3) Suspected gastric ulcer scar. 4) Gastric erosive lesion, suspected healing ulcer, s/p biopsy. 5) Deformed prepyloric antrum. 6) Duodenal ulcer scars.
    • The followed pathological report of stomach biopsy menifested chronic active gastritis, H pylori present.
    • Colonscopy was performed and reveled 1) Colon polyps, probable adenoma. 2) Colon diverticulosin.
    • Oral PPI was used with Nexium. After asccites tapping, her symptom relieved.
    • Cardiac sonography and pulmonary fuction test were also arranged for pre-operation prepare.
    • Aspirin was held for operation next week since 5/4.
    • The patient was transferred to GYN ward on 5/6 for further surgery. After transfer to GYN ward, we closely monitor her general condition and clinical presentation. No special complaint was noted and preoperative anesthesia evaluation was done 05/06.
    • She accepted SILS biopsy + Dilatation and curettage and Port-A insertion via left subclavian vein on 2022/05/09. Frozen section revealed endometrium adenocarcinoma and washing cytology revealed metastatic carcinoma. Her postoperative status was stable and tolerable wound pain was told. She was then discharged on 2022/05/12 under stable condition and follow-up at OPD.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • MgO 250mg 2# QID
    • cephalexin 500mg 1# QID

[surgical operation]

• 2023-08-12
  • Surgery: Cul-do centesis
  • Finding: Vaginal bulging from 11-5 o’clock of direction; suspect pseudo cyst over CDS by TVS about 9cm; dark-brown fluid about 220ml was drained out
    • EBL 5ml Cx and BT: nil
• 2023-06-14
  • Operation
    • Excision of intraabdominal tumor, malignant
    • Adhesionolysis
  • Finding
    • s/p midline incision with severe adhesion of small bowel and large bowel
    • A cystic tumor mass in the pelvic cavity with papillary tumor nest was encountered
    • Drain: 19Fr Blake drain x1, in the pelvic cavity

[radiotherapy]

• 2023-07-21 ~ 2023-09-01 - 4500cGy/25 fractions of the pelvic, and 5400cGy/30 fractions of the vaginal cuff mucosa area.

[chemotherapy]

• 2023-10-13 - docetaxel 35mg/m2 60mg NS 200mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

• 2023-09-23 - docetaxel 35mg/m2 60mg NS 200mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

• 2023-08-30 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-08-23 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-08-08 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-07-27 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-07-20 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-04-21 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-04-07 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-03-22 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-03-08 - topotecan 0.75mg/m2 1.25mg NS 40mL 0.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-02-20 - topotecan 0.75mg/m2 1.25mg NS 40mL 0.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-02-06 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-10-25 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 250mg NS 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2022-10-04 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 240mg NS 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2022-09-13 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2022-08-01 - [liposome doxorubicin 35mg/m2 60mg D5W 250mL + carboplatin AUC 5 450mg NS 250mL] IP 90min (HIPEC)

• 2022-07-04 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2022-06-13 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2022-05-17 - paclitaxel 160mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

==========

2023-10-23

Lab data

• 2023-10-23 Neutrophil 80.6 %
  

• 2023-10-23 WBC 5.01 x10^3/uL
  

• 2023-10-23 HGB 7.8 g/dL
  

• 2023-10-23 PLT 295 *10^3/uL

• 2023-10-23 Albumin(BCG) 2.8 g/dL
  

• 2023-10-23 Creatinine 1.14 mg/dL
  

• 2023-10-23 eGFR 48.87 ml/min/1.73m^2

The patient has anemia, hypoalbuminemia, and altered renal function (calculated CrCl 44 mL/min).

If the patient is scheduled to receive the same dose of docetaxel as before, there is no need to adjust the dose for any degree of kidney dysfunction. However, anemia (and/or hypoalbuminemia with edema) may need to be treated before chemotherapy can begin.

2023-10-13

[leukopenia]

Lab data showed leucopenia on 2023-10-05 at 2.26K/uL.

• 2023-10-12 WBC 13.14 x10^3/uL
• 2023-10-11 WBC 15.84 x10^3/uL
• 2023-10-09 WBC 34.63 x10^3/uL
• 2023-10-05 WBC 2.26 x10^3/uL *
• 2023-09-28 WBC 6.10 x10^3/uL
• 2023-09-20 WBC 4.82 x10^3/uL
• 2023-09-17 WBC 6.34 x10^3/uL

The most recent chemotherapy treatments prior to the leukopenia event were docetaxel (35mg/m2 60mg) on 2023-09-23 and carboplatin (AUC 2 100mg) on 2023-08-30, the latter as part of CCRT.

According to the updated lab data in WBC level, there is no more leukopenia occurs after the event.

The hype of WBC level after the leukopenia event might be due to Granocyte (lenograstim 250ug) x 4 days since 2023-10-05.

2023-09-19

MgO, metformin, linagliptin, aspirin, trichlormethiazide, bisoprolol, olmesartan, rosuvastatin, and quetiapine were prescribed at NTUH on 2023-07-28 as a repeat prescription. These drugs were refilled on 2023-08-18, and with the exception of MgO, which might no longer be necessary, all the other drugs have been added to the active medication list.

701090517

231023

[MedRec]

• 2023-09-27 SOAP Cardiology Zhou XingHui
  • Prescription x3
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Concor (bisoprolol 1.25mg) 1# QD
    • Diovan (valsartan 160mg) 0.5# QD
    • Plavix (clopidogrel 75mg) 1# QD
    • Crestor (rosuvastatin 10mg) 1# QD
    • Ezetrol (ezetimibe 10mg) 1# QD
• 2023-09-27 SOAP Urology Xu JunKai
  • Prescription x3
    • Betmiga (mirabegron 50mg) 1# QD
    • Urief (silodosin 8mg) 1# QD

==========

2023-10-23

This patient is in the hospital to have his gastrointestinal problems examined further. He is currently taking the medications prescribed by our urologist and cardiologist on 2023-09-27, and there are no discrepancies with these drugs.

701366805

231020

{High grade serous carcinoma FIGO stage IIIC, right ovarian cancer with peritoneal seeding s/p operation} (not completed)

[lab data]

• CA125
  • 2022-04-22 401.9 U/mL
    
  • 2022-03-30 1091.2 U/mL
• 2022-04-14
  • Anti-HBs 2.99 mIU/mL
    
  • Anti-HBc Nonreactive
    
  • Anti-HBc-Value 0.14 S/CO
    
  • Anti-HCV Nonreactive
    
  • Anti-HCV Value 0.15 S/CO
    
  • HBsAg Nonreactive
    
  • HBsAg (Value) 0.44 S/CO
• 2022-03-31
  • Anti-HCV Nonreactive
    
  • Anti-HCV Value 0.16 S/CO
    
  • Anti-HBc Nonreactive
    
  • Anti-HBc-Value 0.13 S/CO
    
  • HBsAg Nonreactive
    
  • HBsAg (Value) 0.42 S/CO

[exam findings] (not completed)

• 2022-05-10 Aspiration Cytology - LN
  • Left parotid tumor: Favor benign, pleomorphic adenoma
    
  • Two wet cellular smears show epithelial cells arranged in cord, nest or trabecular patterns and mononuclear cells in background resemble myoepithelial cells as well as chondromyxoid material in focal area. It maybe compatible with pleomorphic adenoma. Confirmatory biopsy is advised, if clinically indicated.
• 2022-05-10 SONO - head and neck soft tissue
  • clinical impression/intent: right parotid tumor, previous cytology: atypia
  • sonographic impression: right parotid tumor
• 2022-04-07 Patho - ovary (non-tumor)
  • Diagnosis
    • Ovary, right, oophorectomy — High grade serous carcinoma seeding on serosa
    • Fallopian tube, right, salpingectomy — High grade serous carcinoma seeding on serosa
    • F2022-00146:
      • Omentum, omentectomy — High grade serous carcinoma, metastatic (please see microdescription)
      • Ovary, left?, excision — Consistent with high grade serous carcinoma
  • Microscopic description
    • Sections show ovary and fallopian tube with high grade serous carcinoma seeding on serosa.
    • F2022-00146:
      • Sections show omentum with metastatic solid sheets and papillary tumor and psammoma bodies.
      • The cystic tumor reveals ovarian stroma with psammoma bodies. The lining epithelium is mostly denuded, and only scant tumor lining epithelial is seen.
      • The immunohistochemical stains reveal PAX(+), p53(aberrant expression +), WT-1(+), GATA3(-), Napsin A(-), PR(-), and Calretinin(-). The results are consistent with high grade serous carcinoma arising from ovary. Please correlate with the clinical presentation and image study.
      • Lymphovascular invasion is found. No fallopian tube is seen.
• 2022-04-06 Body fluid cytology - ascites
  • Pathologic diagnosis: positive for malignancy
  • The smears show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
• 2022-04-06 Frozen Resection
  • Preliminary diagnosis:
    • Pelvic mass, excision — Carcinoma, wait IHC for tumor origin
• 2022-03-30 Gynecologic ultrasonography
  • Suspected rt adnexal mass: 124mm x 93mm, malignancy cannot be ruled out
  • Ascites (+)
• 2022-03-25 CT - abdomen, pelvis
  • Findings:
    • There are lobulated enhancing soft tissue lesions in the omentum (omentum cake) and mesentery of the pelvis, and ascites that may be primary peritoneal serous carcinoma.
      • The differential diagnosis include ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB. Please correlate with CA125 and CT-guided biospy of the omentum lesion.
  • Impression:
    • Primary peritoneal serous carcinoma is highly suspected.
    • The differential diagnosis include ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB. Please correlate with CA125 and CT-guided biospy of the omentum lesion.

[consultation]

• 2022-03-31 Hemato-Oncology
  • A
    • Impression:
      • Primary peritoneal serous carcinoma is highly suspected.
      • The differential diagnosis including stomach cancer, ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB.
    • Suggestion:
      • Arrange PES to check UGI tract lesions, GYN ultrasound and CT-guided biospy of the omentum lesion
      • may check LDH, anti Hbc, HbsAg, Anti HCV
      • Thanks for your consultation, we wound like to follow up this case. If there is any problem, please feel free to let us known.
• 2022-03-31 Obstetrics and Gynecology
  • A
    • Objective
      • The abdomen CT on 03/25 reported: There are lobulated enhancing soft tissue lesions in the omentum (omentum cake) and mesentery of the pelvis, and ascites that may be primary peritoneal serous carcinoma.
      • Lab data: CA125 1091.2 (0~35)
      • Echo: Right ovarian cystic mass 13 cm with solid part was noted, with small amount ascite, suspected ovarian cancer
    • Plan
      • please check CA199, CEA, Albumin, D-Dimer
      • check Esophagogastroduodenoscopy (EGD) and low gastrointestinal endoscopy

[surgical operation]

• 2022-04-06
  • Operation
    • Enterolysis
  • Finding
    • Multiple peritoneal seedings including tumor nodules in small bowel and mesentery
    • Adhesion of small bowel and large bowel
• 2022-04-06
  • Surgery
    • Pelvic mass, peritoenal carcinomatosis?
    • Perineal cake
    • Operation:
      • RSO and omentectomy
  • Finding
    • Uterus: 4x3cm, grossly normal, with severe adhesion to pelvic wall
    • RAD: grossly normal,adhesion to pelvic wall and the mass
    • LAD: Severe adhesion to the mass
    • CDS: Severe adhesion/partial obliterated
    • During the procedure, omentum attached to the anterior wall of the pelvic cavity, adhesion lysis was performed before we entered the pelvic cavity. (due to perineal cake, severe adhesion was found during the procedure)
    • Residual tumor over colon and pelvic with size 1x1 cm.
    • Estimated blood loss: 1000 ml
    • Blood transfusion: 2 U
    • Complication: nil        

[chemoimmunotherapy] (not completed)

• 2023-10-19

• 2023-09-13

• 2023-08-17

• 2023-07-24

• 2023-06-29

• 2023-05-31

• 2023-04-26

• 2023-03-08

• 2023-02-03

• 2022-12-20

• 2022-11-29

• 2022-10-24

• 2022-09-12

• 2022-08-12

• 2022-07-19 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr

• 2022-06-27 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr

• 2022-06-01 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr

• 2022-05-04 - paclitaxel 160mg/m2 3hr + carboplatin 600mg 2hr

Ovarian Cancer Continue Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN Evidence Blocks, Version 1.2022 - January 18, 2022, p42,43

• Principles of Systemic Therapy
  • Primary Systemic Therapy Regimens - Epithelial Ovarian/Fallopian Tube/Primary Peritoneal
    • Primary Therapy for Stage I Disease
      • High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
        • Preferred Regimens
          • Paclitaxel/carboplatin q3weeks
        • Other Recommended Regimens
          • Carboplatin/liposomal doxorubicin
          • Docetaxel/carboplatin
        • Useful in Certain Circumstances
          • For carcinosarcoma:
            • Carboplatin/ifosfamide
            • Cisplatin/ifosfamide
            • Paclitaxel/ifosfamide (category 2B)
      • Mucinous carcinoma (stage IC)
        • Preferred Regimens
          • 5-FU/leucovorin/oxaliplatin
          • Capecitabine/oxaliplatin
          • Paclitaxel/carboplatin q3weeks
        • Other Recommended Regimens
          • Carboplatin/liposomal doxorubicin
          • Docetaxel/carboplatin
        • Useful in Certain Circumstances
          • None
      • Low-grade serous (stage IC)/Grade I endometrioid (stage IC)
        • Preferred Regimens
          • Paclitaxel/carboplatin q3weeks +- maintenance letrozole (category 2B) or other hormonal therapy (category 2B)
          • Hormone therapy (aromatase inhibitors: anastrozole, letrozole, exemestane) (category 2B)
        • Other Recommended Regimens
          • Carboplatin/liposomal doxorubicin
          • Docetaxel/carboplatin
          • Hormone therapy (leuprolide acetate, tamoxifen) (category 2B)
        • Useful in Certain Circumstances
          • None
    • Primary Therapy for Stage II-IV Disease
      • High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
        • Preferred Regimens
          • Paclitaxel/carboplatin q3weeks
          • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
        • Other Recommended Regimens
          • Paclitaxel weekly/carboplatin weekly
          • Docetaxel/carboplatin
          • Carboplatin/liposomal doxorubicin
          • Paclitaxel weekly/carboplatin q3weeks
        • Useful in Certain Circumstances
          • IP/IV paclitaxel/cisplatin (for optimally debulked stage II-III disease)
          • For carcinosarcoma:
            • Carboplatin/ifosfamide
            • Cisplatin/ifosfamide
            • Paclitaxel/ifosfamide (category 2B)
      • Mucinous carcinoma (stage IC)
        • Preferred Regimens
          • 5-FU/leucovorin/oxaliplatin +- bevacizumab
          • Capecitabine/oxaliplatin +- bevacizumab (category 2B for bevacizumab)
          • Paclitaxel/carboplatin q3weeks
          • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
        • Other Recommended Regimens
          • Paclitaxel weekly/carboplatin weekly
          • Docetaxel/carboplatin
          • Carboplatin/liposomal doxorubicin
          • Paclitaxel weekly/carboplatin q3weeks
        • Useful in Certain Circumstances
          • None
      • Low-grade serous/Grade I endometrioid
        • Preferred Regimens
          • Paclitaxel/carboplatin q3weeks +- maintenance letrozole (category 2B) or other hormonal therapy (category 2B)
          • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
          • Hormone therapy (aromatase inhibitors: anastrozole, letrozole, exemestane) (category 2B)
        • Other Recommended Regimens
          • Paclitaxel weekly/carboplatin weekly
          • Docetaxel/carboplatin
          • Carboplatin/liposomal doxorubicin
          • Paclitaxel weekly/carboplatin q3weeks
          • Hormone therapy (leuprolide acetate, tamoxifen) (category 2B)
        • Useful in Certain Circumstances
          • None
    • Primary Systemic Therapy Recommended Dosing
      • IV/IP Paclitaxel/cisplatin
        • Paclitaxel 135 mg/m2 IV continuous infusion Day 1;
        • Cisplatin 75-100 mg/m2 IP Day 2 after IV paclitaxel;
        • Paclitaxel 60 mg/m2 IP Day 8
        • Repeat every 21 days x 6 cycles
      • Paclitaxel/carboplatin q3weeks
        • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 5-6 IV Day 1
        • Repeat every 21 days x 3-6 cycles
      • Paclitaxel weekly/carboplatin q3week
        • Dose-dense paclitaxel 80 mg/m2 IV Days 1, 8, and 15 followed by carboplatin AUC 5-6 IV Day 1
        • Repeat every 21 days x 6 cycles
      • Paclitaxel weekly/carboplatin weekly
        • Paclitaxel 60 mg/m2 IV followed by carboplatin AUC 2 IV
          • Days 1, 8, and 15; repeat every 21 days x 6 cycles (18 weeks)
      • Docetaxel/carboplatin
        • Docetaxel 60-75 mg/m2 IV followed by carboplatinm AUC 5-6 IV Day 1
        • Repeat every 21 days x 3-6 cycles
      • Carboplatin/liposomal doxorubicin
        • Carboplatin AUC 5 IV + pegylated liposomal doxorubicin 30 mg/m2 IV
        • Repeat every 28 days for 3-6 cycles
      • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7)
        • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 5-6 IV, and bevacizumab 7.5 mg/kg IV Day 1
        • Repeat every 21 days x 5-6 cycles
        • Continue bevacizumab for up to 12 additional cycles
      • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (GOG-218)
        • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 6 IV Day 1. Repeat every 21 days x 6 cycles
        • Starting Day 1 of cycle 2, give bevacizumab 15 mg/kg IV every 21 days for up to 22 cycles
    • Primary Systemic Therapy Recommended Dosing for Elderly Patients (age >70 years) and/or Those with Comorbidities
      • Paclitaxel 135/carboplatin
        • Paclitaxel 135 mg/m2 IV + carboplatin AUC 5 IV given every 21 days x 3-6 cycles
      • Paclitaxel weekly/carboplatin weekly
        • Paclitaxel 60 mg/m2 IV over 1 hour followed by carboplatin AUC 2 IV over 30 minutes
        • Days 1, 8, and 15; repeat every 21 days x 6 cycles (18 weeks)

==========

2022-07-20

Lab results 2022-07-19 indicated liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. TPR, PB during this hospitalization is relatively stable.

2022-06-28

No BRCA1/2 lab results were found. Patients with BRCA1/2-mutated clear cell carcinoma or carcinosarcoma may benefit from maintenance therapy with PARPi (poly ADP ribose polymerase inhibitor) if CR or PR is achieved after primary treatment with surgery and platinum-based first-line therapy

700926088

231019

[exam findings] (not completed)

• 2023-09-11 CT - chest
  • Comparison was made with CT dated on 2023/1/5
    • Lungs:
      • interval significant increase in size of LUL tumor (6.6cm in longest dimension) with pleural tails and surrounding with inferior ground-glass opacity, that involves the hilum and adjacent mediastinal fat.
      • an ill-defined peribronchovascular ground glass nodule at RUL.
    • Mediastinum and hila: mediastinal LAP in A-P window and Lt anterior perivascular space, and left hilum.
    • Vessels: mild coronary arterial calcification
      • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta..
      • Heart: normal in size of cardiac chambers.
    • Pleura: minimal Lt-sided effusion and left upper mediastial thickening.
    • Visible abdominal contents: left renal cyst (43x50 mm).
    • Visualized bones: compression fracture of T7 and L1 vertebral bodies.
  • Impression:
    • LUL lung cancer T4N2 s/p TKI, significant in progression LUL and stationary of the RUL tumor as compared with CT on 2023/01/05
• 2023-01-05 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Spiculated mass at left upper lobe and right upper lobe measuring 3.3cm and 2.52cm respectively. In comparison with CT dated on 2022-09-20, the lesion is stationary.
      • One subcutaneous nodule medial to left breast is found measuring 2.0cm in largest dimension. In enlargement. Suggest further inspection.
      • No evidence of bilateral pleural effusion.
      • Minimal opacity over right lower lobe is found.
    • Visible abdomen:
      • Left renal cyst measuring 5.3cm in largest dimension is found.
      • The spleen, liver, pancreas and adrenals are intact.
  • Imp:
    • Left upper lobe and right upper lobe lung cancer s/p TKI. stable
    • Subcutaneous nodule at left breast. 2.0cm, suggest further management.
• 2022-09-20 CT - chest
  • Findings
    • Lungs:
      • an ill-defined peribronchovascular ground glass nodule at RUL (21 mm in largest axial dimension)
      • a spiculated nodule with pleural tails and corona radiata at LUL (23mm in largest axial dimension).
      • mild subpleural reticulation at both lower lobes.
    • Mediastinum and hila: no enlarged LN.
      • Vessels: mild coronary arterial calcification
      • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
    • Visible abdominal contents: left renal cyst (43x50 mm).
      • diffuse thickening wall of the urinary bladder with lateral wall diverticulum.
    • Visualized bones: compression fracture of T7 and L1 vertebral bodies.
  • Impression:
    • lung cancer s/p TKI, slightly decrease in size of LUL and RUL tumors as compared with CT on 2022/06/27
    • mild interstial fibrosis in lower lobes of lungs.
• 2022-06-27 CT - lung
  • Findings
    • Lungs:
      • an ill-defined peribronchovascular ground glass nodule at RUL (23 mm in largest axial dimension)
      • a spiculated nodule with pleural tails at LUL (25 mm in largest axial dimension).
      • subpleural reticulation at voth lower lobes.
    • Mediastinum: no enlarged LN.
    • Hila: no enlarged LN.
    • Vessels: mild coronary arterial calcification
      • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
      • Central pulmonary arteries: normal caliber.
    • Visible abdominal contents: left renal cyst (43 x 50 mm).
      • S/P suprapubic cystectomy.
      • marked diffuse thickening wall of the urinary bladder.
      • with lateral wall diverticulum.
    • Visualized bones: compression fracture of T17 vertebral body.
  • Impression:
    • lung cancer s/p TKI, stationary in size of LUL and RUL tumors, compared with CT on 2021/12/15
    • mild interstial fibrosis in lower lobes of lungs.
• 2022-03-02 Neurosonography
  • Mild to moderate atheromatous lesions in L middle CCA; mild atheromatous lesions in R subclavian artery and R ICA.
  • Elevated flow velocity in R PCA (PS/ED = 234/97 cm/s), suggesting R PCA stenosis.
  • Normal extracranial carotid, vertebral, and other intracranial basal cerebral arterial flows.
• 2022-01-24 KUB + L-spine Lat
  • Bilateral clear psoas shadows. Dilated bowel gas pattern. L1 compression fracture. Degenerative change of the spine with marginal spur formation. Grade 1 degenerative spondylolisthesis at L4-5 level. Placement of urinary catheter.
• 2022-01-11 CT - abdomen
  • Compression fracture of L1.
  • Partial atelectasis at LLL.
  • Left renal cyst (5.0cm).
  • Atherosclerosis of aorta, iliac arteries.
  • S/P foley catheter indwelling.
• 2022-01-11 L-spine AP + Lat (including sacrum)
  • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s) L1.
  • Presence of spondylolisthesis at L4/5, grade I.
• 2022-01-07 L-spine Lat. only. (including sacrum)
  • L1 compression fracture
  • Gr.I spondylolisthesis and disc space narrowing at L4/5
  • Facet degeneration of lumbar spine
• 2021-12-15 CT - chest
  • Comparison made with previous CT dated on 2021/09/03
    • Lungs:
      • an ill-defined peribronchovascular ground glass nodule at RUL (23 mm in largest axial dimension)
      • a spiculated nodule with pleural tails at LUL (25 mm in largest axial dimension).
    • Mediastinum:
      • no enlarged LN.
      • minimal anterior pericardial effusion.
    • Hila: no enlarged LN.
    • Vessels: mild coronary arterial calcification
      • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
      • Central pulmonary arteries: normal caliber.
    • Visible abdominal contents: left renal cyst (43 x 50 mm).
    • Visualized bones: compression fracture of T17 vertebral body.
  • Impression:
    • lung cancer s/p TKI, decrease in size of LUL and RUL tumors, and no enlarged mediastinal LNs compared with CT on 2021/09/03
• 2021-09-03 CT - chest
  • Indication: Lung cancer s/p TKI
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Spiculated, dense plate like lesion at left upper lobe up to 3.03cm in largest dimension is found. In comparison with CT dated on 2021-05-04, the lesion is stationary.
      • Band like opacity with spicualted change at right upper lobe is also noted. r/o synchronous lung cancer.
      • Small lymph nodes are found at bilateral paratracheal region.
      • Calcified coronary arteries is found.
      • MIld pericardial effusion is found.
      • Calcified coronary arteries is found.
    • Visible abdomen:
      • Left renal cyst up to 5.6cm in largest dimension is found.
  • Imp:
    • Left upper lobe lung cancer with mediastinal lymphadenopathy, cT2N3Mx, stable.
    • Synchronous lung cancer at right upper lobe
• 2021-07-19 Patho - skin cyst/tag/debridement
  • Skin, eyelid, excision biopsy — Basal cell carcinoma, ulcerated with keroid pattern and pigmented pattern, involving the deep margin and un-oriented, unspecified side margins.
  • Section shows one piece of ulcerated skin with basal cells carcinoma infiltration, with keroid pattern and pigmented pattern, involving the deep margin and un-oriented, unspecified side margins.
  • IHC stain: Ber-EP4 (focal weak +), EMA (-), bcl-2 (diffuse +), CD10 (-).
• 2021-06-02 Patho - pleural/pericardial biopsy
  • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
    
  • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma and proliferating along the alveolar wall.
  • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(focal weak +), and CD56(-). The results are supportive for the diagnosis.
• 2021-05-25 MRI - brain
  • No brain nodule or metastasis
  • Old left middle corpus callosum infarct or demyelination?
  • Brain atrophy. Bilateral subcortical and periventricular white matter change (leukoaraiosis).
• 2021-05-20 Tc-99m MDP bone scan with SPECT
  • Increased activity in the lower C-spine, middle T- and lower L-spines. Degenerative change or compression fracture may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture. However, please correlate with other clinical findings for further evaluation.
  • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, bilateral wrists, knees and both feet, compatible with benign joint lesions.
• 2021-05-19 PET
  • Glucose-hypermetabolism in the left upper lung, compatible with the primary lung cancer.
    
  • Glucose-hypermetabolism in bilateral pulmonary hilar and bilateral mediastinal lymph nodes, probably lung cancer with regional lymoh nodes involvement.
    
  • Glucose-hypermetabolism in the right level V cervical lymph nodes, probably lung cancer with distant metastases, suggesting biopsy for further investigation.
    
  • Left upper lung cancer, cTxN3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2021-05-04 CT - lung
  • Smoking: quit for 30-40 years
  • 20210503 CxR: LLL bronchiectasis?
  • Findings
    • Lungs:
      • an ill-defined ground glass mass at RUL (32 mm in largest axial dimension)
      • a spiculated mass with pleural tails at LUL (35.4 mm in largest axial dimension).
      • a subpleural lobularlike GGO in RLL.
      • minimal fibrosis in LLL-posterobasal segment.
      • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
    • Mediastinum: small LNs in visceral and left anterior perivascular spaces. enlarged LN in subcarinal space.
      • minimal anterior pericardial effusion.
    • Hila: no enlarged LN.
    • Vessels: mild coronary arterial calcification
      • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
      • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no effusion or thickening or nodule.
    • Chest wall: unremarkable.
    • Visible abdominal contents:
      • normal appearance of gallbladder.
      • no abnormal density in visible portion of the liver, spleen, adrenal glands, pancreas, and kidneys.
      • no enlarged lymph node.
    • Visualized bones: compression fracture of T17 vertebral body.
  • Impression:
    • LUL cancer and RUL cancer, synchronous lung cancers? without regional LN metastasis.
• 2021-03-05 MRA - brain
  • IMP: Leukoaraiosis. General brain atrophy. Mild intracranial artherosclerosis.
• 2021-02-10 EEG
  • This EEG study recorded background alpha rhythm (9-10 Hz) and plenty beta activity with intermittent bilateral frontal fast activity with right side more prominent.
  • No epileptiform discharge.
• 2021-02-10 Clinical Dementia Rating, CDR
  • Score = 1, Mild
• 2021-02-10 Mini-mental state examination, MMSE
  • Score = 24, Mild
• 2021-01-12 NONO - nephrology
  • Bialteral chronic change of both kidneys.
  • Left renal cyst.
  • Foley in bladder.
• 2021-01-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (96 - 23) / 96 = 76.04%
    • M-mode (Teichholz) = 75
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Trivial MR, trivial AR, mild to moderate TR
    • Mild pulmonary hypertension
    • Preserved RV systolic function

[MedRec]

• 2023-10-13 SOAP Chest Medicine Yang MeiZhen
  • S: daughter: 0936 099 116, 0935 500 136
  • A
    • lung adenocarcinoma, cT4N3M1c, stage IVB
    • COPD
    • dementia, hearing impairment
• 2023-07-03 SOAP Neurology Xiao ZhenLun
  • Prescription x3
    • Crestor (rosuvastatin 10mg) 1# QD
    • Pletaal (cilostazol 100mg) 1# BID
    • Pentop (pentoxifylline 400mg) 1# BID
• 2023-06-19 SOAP Ophthalmology Zhan LiWei
  • A: catatact
  • Prescription x3
    • Alphagan P (brimonidine 0.15%) Q12H OU
• 2023-06-15 SOAP Hemato-Oncology Xia HeXiong
  • A: Patient escape from 2023-01
• 2022-03-29 SOAP Hemato-Oncology Xia HeXiong
  • P: patient has still vizimpro, indicating he does not take it everyday. Already request him to take it everyday.
• 2021-09-16 SOAP Hemato-Oncology Xia HeXiong
  • Prescription
    • Vizimpro (dacomitinib monohydrate 30mg) 1# QD
• 2021-09-07 SOAP Chest Medicine Yang MeiZhen
  • Prescription
    • Spiriva Respimat (tiotropium 2.5ug/puff, 60puff/bot) 2 puff QD INHL
    • Actein Effervescent (acetylcysteine 600mg) 1# BID
• 2021-07-08 SOAP Neurology Chen PeiYa
  • Prescription x3
    • Crestor (rosuvastatin 10mg) 1# QD
    • Pletaal (cilostazol 100mg) 1# BID
• 2021-07-06 SOAP Chest Medicine Yang MeiZhen
  • Prescription
    • Compesolon (prednisolone 5mg) 2# QD
    • Xyzal (levocetirizine 5mg) 1# HS
    • Antica Syrup (orciprenaline, bromhexine, doxylamine) 8mL BID
• 2021-07-06 SOAP Hemato-Oncology Xia HeXiong
  • O: AEs: 1. Gr 2 Skin rash; 2. Gr 1 diarrhea; 3. Gr 1 Oral mucositis
  • Prescription
    • Oralog Orabase (triamcinolone 5mg) 1# BID TOPI
    • Royalsense (clindamycin 10mg/g, 15g/tube) BID TOPI
• 2021-06-29 SOAP Hemato-Oncology Xia HeXiong
  • O
    • 2021/06/25 EGFR
      • EGFR G719X = not detected;
      • EGFR Exon19 del = not detected;
      • EGFR S768I = not detected;
      • EGFR T790M = not detected;
      • EGFR Exon20 ins = not detected;
      • EGFR L858R = detected;
      • EGFR L861Q = not detected;
    • 2021/06/25 ALK IHC
      • ALK IHC = Negative;
      • ALK IHC Sample No. S2021-8066;
    • 2021/06/23 PD-L1 (22C3)
      • PD-L1(22C3) = TPS<1%;
      • PD-L1(22C3) Sample No. S2021-8066;
    • 2021/06/23 PD-L1 (28-8)
      • PD-L1(28-8) = TC>=5% and <10%;
    • 2021/06/23 PD-L1 IHC XiaoYe;
  • P: Now on dacomitinib C1D1 on 2021-06-29
  • Prescription
    • Vizimpro (dacomitinib monohydrate 15mg) 3# QD
• 2021-06-22 SOAP Hemato-Oncology Xia HeXiong
  • Prescription
    • Iressa (gefitinib 250mg) 1# QD 7D
• 2021-06-15 SOAP Hemato-Oncology Xia HeXiong
  • S
    • COPD, Gout.
    • BUL cancer, adenocarcinoma, cT4N3M1c,stage IVB, lung to lung meta; ECOG=0, use Spiriva
    • PFT: mild OBS impairment, no BD response
    • smoking: quit for 30-40 years, NKA
  • O
    • 2021/06/02 PATHO-pleural /pericardial biopsy
      • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
  • A/P
    • Well educate and explain
    • May try TKI first
      • lung adenocarcinoma, cT4N3M1C, stage 4B
      • COPD
  • Prescription
    • Iressa (gefitinib 250mg) 1# QD 7D
• 2021-06-01 ~ 2021-06-02 POMR Chest Medicine Huang JunYao
  • Discharge diagnosis
    • Malignant neoplasm of unspecified part of left lung s/p CT guided biopsy
    • Malignant neoplasm of unspecified part of right lung
    • Chronic obstructive pulmonary disease, unspecified
  • CC
    • Incidental finding of bilateral lung tumors on a CT 2 weeks ago.
  • Present illness
    • This is a 79 year old man who was admitted to our hospital for CT guided biopsy.
    • The patient had underlying COPD on control with medications. During one of the recent OPD follow ups with our Pulmonologist, CT on 2021/05/04 made an incidental finding of LUL cancer and RUL cancer, which are likely to be synchronous lung cancers.
    • Whole body PET scan on 5/19 showed left upper lung cancer, cTxN3M1c, stage IVB, while brain MRI on 5/25 ruled out brain metastases.
    • This time, he was admitted to our hospital for scheduled CT guided biopsy.
  • Course of inpatient treatment
    • The patient underwent CT guided biopsy on 6/2 with no obvious complications. Follow up CXR four hours later showed no apparent hemathorax or pneumothorax.
    • Since the patient patient was eager to leave the hospital due to personal reasons, he was allowed to be discharged from our hospital on 6/2, and OPD follow up was arranged.        
  • Discharge prescription
    • Transamin (tranexamic acid 250mg) 1# BID
    • Sodicon (dextromethorphan 15mg) 1# TID
• 2021-03-18 SOAP Urology You ZhiQin
  • S
    • nocturia 3-4/night, freqency, small stream, straining, urgency, UUI(+) for months
    • improved medication, nocturia 1-2/night
  • Prescription
    • Harmalidge OCAS (tamsulosin 0.4mg) 1# QDAC
    • Vesicare (solifenacin 5mg) 1# HS
• 2021-03-05 SOAP Ophthalmology Peng YiJie
  • S
    • BV ou -> IOP poor control
    • One left upper eyelid mass for 1-2 years
    • HTN + for 30+ years
    • Asthma +
  • A/P
    • Start antiglaucomatic medication
    • f/u 1 month
  • Prescription
    • Lumigan (bimatoprost 0.1mg/mL) HS OU
    • Simbrinza (brinzolamide 10mg/mL, brimonidine 2mg/mL) BID OU

[consultation]

• 2023-10-18 Radiation Oncology
  • Q
    • This 82-year-old man patient is a case of BUL cancer, adenocarcinoma, cT4N3M1c,stage IVB, lung to lung metastases s/p TKI therapy.
  • A
    • Radiothearpy is indicated for tumor control. CT-simulation will be arranged on 10/23. Plan to deliver 30~45 Gy/ 10~15 fx to the LUL tumor, depending on the side effect. RT will start around 10/25 or 26. Thank you very much.

[chemotherapy]

• 2021-06-29 ~ undergoing - Vizimpro (dacomitinib)
• 2021-06-15 ~ 2021-06-28 - Iressa (gefitinib)

==========

2023-10-19

[reconciliation]

According to the PharmaCloud database, there’s no discrepancy between the previously prescribed medications.

The patient was diagnosed with BUL cancer, specifically adenocarcinoma, with metastases to both lung hila and bilateral mediastinal lymph nodes. Treatment was started on 2021-06-15 with Iressa (gefitinib) for two weeks before switching to Vizimpro (dacomitinib) from 2021-06-29.

The chest CT of 2023-09-11 showed significant disease progression in the LUL, while the RUL tumor remained stable compared to the previous CT of 2023-01-05. This may indicate disease heterogeneity and potential development of resistance in certain aspects of the disease after more than 2 years of use of Vizimpro.

700016937

231018

{pancreatic head cancer}

[exam findings]

• 2023-07-31 SONO - nephrology
  • Right hydronephrosis
• 2023-07-31 Bladder sonography
  • PVR: 72 ml
• 2023-07-14 MRI - L-spine
  • MRI of thoracic and lumbar spine without/with Gadolinium-based contrast enhancement shows:
    • fine alignment of thoracolumbar spine.
    • degenerative change of the spine with marginal spur formation and dehydrated discs at multiple levels.
    • patchy signal intensity change and faint bone marrow enhancement at left anterior corner of L1, L2, L3 vertebral bodies. This is already seen in the abdomen MRI done on 20221004, but not seen in the lumbar spine MRI on 20140506. There are other similar bone lesions in thoracic vertebrae. This could be degenerative change but bone metastases cannot be completely excluded. Suggest correlation with other image modality and close follow up.
    • prominent disc-osteophyte complexes at multiple levels, as well as bilateral facet arthroses and hypertrophic ligamenta flava, causing severe L3-4, L4-5 central canal stenosis.
    • no evidence of abnormal signal lesion nor pathological enhancement in visible spinal cord.
  • Impression:
    • Patchy bone marrow lesions in multiple thoracic and lumbar vertebral bodies, could be degenerative change but bone metastases cannot be excluded. Suggest correlation with other image modality and close follow up.
    • Degenerative spinal and disc disease.
    • Severe L3-4, L4-5 central canal stenosis.
• 2023-07-13 CT - abdomen
  • Findings
    • S/P operation. Focal fat stranding at mesenteric root without interval change r/o post-operative change.
    • Tiny liver cysts.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • S/P operation. No evidence of tumor recurrence.
• 2023-06-05 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot spots in several T- and L-spine, and increased activity in the maxilla, mandible, bilateral shoulders, S-I joints, hips, knees, and feet, in whole body survey.
  • IMPRESSION:
    • Hot spots in several T- and L-spine, the nature is to be determined (severe DJD or other nature ?), suggesting follow-up with bone scan in 3-6 months for investigation.
    • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, S-I joints, hips, knees, and feet.
• 2023-03-13 CT - abdomen
  • Indication: Pancreatic head cnacer (or Ampulla of Vater cancer) , pT3bN1 (3/28) cM0, pStage IIIA, s/p Whipple’s surgery
  • Abdominal CT with and without enhancement revealed:
    • s/p colon cancer op. and Whipple op.
    • Minimal soft tissue at mesenterric root is found. Post op. change? Suggest follow up.
    • Increased intestinal gas is found.
  • Imp:
    • s/p colon cancer op. and Whipple op.
    • Minimal soft tissue at mesenterric root is found. Post op. change? Suggest follow up.
• 2023-03-10, -02-01, 2022-12-21 CXR
  • Spondylosis of the T-spine
• 2023-02-14 MRI - brain
  • Indication: Malignant neoplasm of ampulla of Vater
  • Imp:
    • No acute infarct. No brain nodule or metastasis
    • Brain atrophy with bilateral periventricular ischemic/aging white matter change.
• 2022-10-27 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2022-10-25 CXR
  • Bilateral pleural effusion.
  • Ground glass opacities in bil. lungs.
• 2022-10-21 Patho - pancreas total/subtotal resection
  • Diagnosis:
    • Small intestine, ampulla of Vater, Whipple operation — Adenocarcinoma, moderately differentiated; AJCC 8th edition: pStage IIIA, pT3bN1(if cM0)
      • Pancreas, head, Whipple operation — Adenocarcinoma, by direct invasion
      • Common bile duct, distal, Whipple operation — Adenocarcinoma, by direct invasion
      • Stomach, partial gastrectomy — Negative for malignancy
      • Lymph node, peri-pancreas, dissection — Adenocarcinoma, metastatic (3/10)
      • Lmph node, peri-gastric, dissection — Negative for malignancy (0/13)
        
    • Pancreas head, excision — Negative for malignancy
    • Lymph node, site ?, excision — Negative for malignancy (0/1)
    • Lymph node, retroperitoneal cavity, excision — Negative for malignancy (0/4)
  • Gross Description:
    • Procedure: Pancreaticoduodenectomy (Whipple resection), partial pancreatectomy: Pancreas: 4.7 x 3.7 x 3.0 cm; Duodenum: 16.0 cm in length; Lessser curvature: 6.0 cm in length; Greater curvature: 9.0 cm in length; Common bile duct: 4.5 cm in length;
    • Tumor Site: ampulla of Vater and invasion to pancreatic head, duodenum, distal common bile duct, peri-pancreatic soft tissue
    • Tumor Size: 2.4 x 2.0 x 1.5 cm.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma; The immunohistochemical stains reveal CK7(+) and CK20(-).
    • Histologic Grade (applies to ductal carcinoma only) :G2: Moderately differentiated
    • Tumor Extension: Tumor invades ampulla of Vater, duodenal wall, pancreas head, peripancreatic soft tissues, distal common bile duct
    • Margins
      • All margins are uninvolved by invasive carcinoma and high-grade intraepithelial neoplasia
      • Distance of invasive carcinoma from closest margin: 2 mm.
      • Specify: posterior peripancreatic soft tissue resection margin
        
      • Gastric resection margin: 10 cm; Distal small intestine margin: 10.5 cm; Pancreatic margin: 3.5 cm; Common bile duct resection margin: 3.5 cm; Anterior peripancreatic soft tissue margin: 0.8 cm
    • Lymphovascular Invasion: Present
    • Perineural Invasion: Present
    • Regional Lymph Nodes: Number involved/examined: peri-pancreatic: 3/10; peri-gastric: 0/13; lymph node, site ?: 0/1; LN retroperitoneal: 0/4
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable): not applicable
        • Primary Tumor (pT): pT3b: Tumor extends into peripancreatic soft tissue
        • Regional Lymph Nodes (pN): pN1: Metastasis in one to three regional lymph nodes
        • Distant Metastasis (pM): if cM0
    • Additional Pathologic Findings: None identified
• 2022-10-07 Patho - duodenum biopsy
  • Diagnosis:
    • Major papilla, biopsy — adenocarcinoma, modertaely differentiated
  • Microscopically, it shows modertaely differentiated adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei,pleomorphism, and high N/C ratio.
  • Immunohistochemcial stain reveals CK(+), p53(focal+, 40%), Ki-67 index: 30%.
• 2022-10-07 Endoscopic Ultrasound, EUS
  • Prominent major papilla, favor ampulla vater tumor, s/p biopsy
  • CBD dilatation
  • Reflux esopgagitis Gr.A
  • Duodenal shallow ulcers, bulb and SDA
• 2022-10-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 7) / 53 = 86.79%
    • M-mode (Teichholz) = 87
  • Adequate LV,RV systolic function with normal wall motion
  • Impaired LV relaxation
• 2022-10-04 MRI - pancreas
  • History and indication: An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD
  • Findings
    • A soft tissue tumor (1.5x2.2cm) at pancreatic head.
    • S/P PTCD. Liver and renal cysts (3-5mm).
  • IMP: A soft tissue tumor (1.5x2.2cm) at pancreatic head suspected malignancy.
• 2022-10-01 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
  • Dilatation of the biliary tree (by CT images).
  • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
• 2022-09-30 CT - abdomen
  • History: T-COLON CA S/P R HEMICOLECTOMY 2005-07-21, cT3N1M0
    • 2022-09-24 Urine looked like black tea, Total bilirubin: 16.88 mg/dL (normal: < 1)
  • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD and pancreatic head area is suspected and it causing marked dilatation of the proximal CBD, CHD, and IHDs.
      • The pancreatic duct appears normal in size.
      • Cholangiocarcinoma at the distal CBD is highly suspected.
      • In addition, There are few enlarged nodes in the peripancreatic head area that may be metastatic nodes.
      • There are few enlarged nodes in left para-aortic space that may be non-regional metastatic nodes? Please correlate with PET scan.
    • S/P cholecystectomy, S/P right hemicolectomy, and S/P near total right hepatectomy? please correlate with clinical history.
    • Others
      • There is no focal abnormality in the spleen & both kidney.
      • There is no ascites.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • CHOLANGIOCARCINOMA at the distal CBD is highly suspected.
    • Please correlate with ERCP (Endoscopic Retrograde CholangioPancreatography) and EUS.
• 2022-09-24 SONO - kidney
  • bilateral renal stones
  • right hydronephrosis
• 2022-08-27 Transrectal Ultrasound of Prostate, TRUS-P
  • benign prostatic hyperplasia

[MedRec]

• 2023-08-28 SOAP Urology Xu JunKai
  • Prescription x3
    • Betmiga (mirabegron 50mg) 1# QD
    • Harnalidge (tamsulosin 0.4mg) 1# HS
    • Oxbu ER (oxybutynin 5mg) 1# QD
• 2023-08-28 SOAP Metabolism and Endocrinology Yu LiJiao
  • Prescription x3
    • Trajenta (linagliptin 5mg) 1# QD
• 2023-03-24 SOAP Hemato-Oncology
  • S: Owing to Leukopenia (WBC:2890, seg:33, ANC:971) was noted on 3/24 23 and hold C/T.
• 2022-12-17 SOAP Hemato-Oncology
  • A: Pancreatic head CA (or Ampulla of Vater CA) , pT3bN1 (3/28) cM0, pStage IIIA, s/p Whipple’s Op on 2022-10-20

[consultation]

• 2022-11-08 Urology
  • Q
    • for urinary pain and persisted U/A Bact 2+
    • This 73 years old male had the history of
      • T-colon cancer (T3N1M0, Duke’s C2) s/p right hemicolectomy + LN dissection on 2005-07-21, Cholecystectomy and Partial hepatectomy.
      • Ampulla of vater cancer s/p whipple with LN dissection on 2022/10/20
      • BPH with Cystitis by cystoscopy on 2022/10/01 and keep medication control
    • This time, he still sufferred urinary pain and oral medicaiton with Uropin support. But the symptom still persisted. On the other side, U/A with Bact 2+ and U/C still pending. Fever was also noted on 2022/11/05-06. Lab data with no leukocytosis but CRP showed 9.45. We need your help for evaluation for infection status. Thanks for your time!!
  • A
    • We will arrange non-invasive evaluation (UFM PVR)
    • sometimes the pain still painkiller
    • He has high bilirubin and good renal function
    • some painkiller with less burden on liver may be helpful
• 2022-10-07 Ophthalmology
  • Q
    • for DM retinopathy
  • A
    • For DR survey
    • T-colon cancer, newly-diagnosed DM
    • O
      • od s/p phaco + IOL insertion
      • os old trauma with K scar
      • BCVA od 1.0 os 0.1(NCCLENS)
      • IOP 17/17
      • Pupil 3/3 +/+
      • conj icteric ou
      • K od clear os linear scar from paracentral to peripheral
      • AC D/cl ou
      • Lens od pciol os ns++
      • Fd c/d 0.3 , disc pinkish, no DR change ou
    • A
      • No DR change at present ou
    • P
      • Control sugar
      • inform the risk of DR change, if worsen vision, come back asap
      • regular f/u yearly
• 2022-10-06 Metabolism and Endocrinology
  • Q
    • This 73 years old male had the history of T-colon cancer (T3N1M0, Duke’s C2) s/p right hemicolectomy + LN dissection on 2005-07-21, Cholecystectomy and Partial hepatectomy.
    • This time, he came to ER for dark urine, lethargy, poor appetite, poor activity and diarrhea for 2 months. Referred to ER from GI OPD due to high bilirubin. At MER, vital sign: BP:119/73; P:101; BT:36.4; RR:18; Con’s:E4V5M6, SPO2:97%, the CXR showed no active lung lesion. The KUB shows no ileus. Lab data revealed abnormal liver function. The abdomen CT reported 1. An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD and pancreatic head area is suspected and it causing marked dilatation of the proximal CBD, CHD, and IHDs.
    • The pancreatic duct appears normal in size. Cholangiocarcinoma at the distal CBD is highly suspected. In addition, There are few enlarged nodes in the peripancreatic head area that may be metastatic nodes. Under the impression of obstructive jaundice, he was admitted to our ward for further evaluation and treatment.
    • Due to HbA1C:8.0, we need your help
  • A
    • We were consulted for blood sugar control.
    • O:
      • BH: 165 cm, BW: 75 kg
      • Diet: TPN and try low fat, soft diet
      • Medication in OPD: nil (newly diagnosed)
      • Medication during hospitalization: Oliclinomel + RI 16U, Januvia 1# QD
      • Na: 134, K: 3.7
      • ALT: 61, TBI: 28.95
      • BUN/Cr: 19/0.93 (eGFR: 84.65)
      • F/S:
        • Date 10/4 10/5 10/6
        • QDAC 153 179 170
        • QLAC 202 321 222
        • QNAC 265 272
        • HS - -
      • Blood glucose: 182 mg/dL
      • HbA1c: 8.0
      • Urine ACR: unavailable
      • OPH OPD: nil
    • A: Type 2 DM, newly diagnosed
    • Suggestions:
      • DC Januvia. Avoid any other oral anti-diabetic agent
      • Adjust to 20U RI in each Oliclinomel
      • Use Apidra PRNTIDAC with sliding scales
        • F/S 201~250, Apidra 2U
        • F/S 251~300, Apidra 3U
        • F/S > 300, Apidra 4U
      • Check lipid profile, urine ACR
      • Consult OPH for DM retinopathy
      • At present no need nutritionist for DM diet education (self-paid TWD 600) (to consult right before discharge after appetite recovering)
      • Contact us if needed. I’d like to follow up this patient. Meta-OPD F/U.

[surgical operation]

• 2022-10-20
  • Surgery
    • Whipple operation with partial gastrectomy
    • retroperitoneal LN3,4sd,5,6,7,8,9,12,13,16 dissection
    • adhesivelyiss for 4 hrs due to previous rt hemicolectomy with LNdissection for T-colon ca and liver resection
  • Finding
    • severe small bowel adhesion
    • pancreatic head tumor 2 x 1.8 cm under papilla vater
    • CBD: 2.0 cm in diameter
    • P-duct 0.3cm with soft pancreas parenchyma
    • multiple LNat dodenal ligament and paraaorta area

[chemotherapy]

• 2023-10-17 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-19 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 480mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-21 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-12 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Irino 80% and LV, 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-05-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Irino and 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-04-25 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Irino and 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-04-03 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-03-10 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2400mg/m2 4075mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-02-14 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2022-12-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

Modified FOLFIRINOX chemotherapy for pancreatic cancer 2023-05-19 https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

• Cycle length: 14 days.
• Regimen
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 150 mg/m2 IV
    • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-19 https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

• Cycle length: 14 days.
• Regimen
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 180 mg/m2 IV
    • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 400 mg/m2 IV bolus
    • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
    • Day 1
  • FU
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

==========

2023-10-18

[reconciliation]

The patient is currently taking the following medications, as prescribed by their urologist and endocrinologist on 2023-08-28:

• Betmiga (mirabegron)
• Harnalidge (tamsulosin)
• Oxbu ER (oxybutynin)
• Trajenta (linagliptin)

There are no discrepancies noted in the patient’s medication list.

[CA199 goes up]

Please note that CA19-9 levels have been monotonically increasing in recent months. This might suggest that the disease has a tendency to gradually gain resistance.

• 2023-10-03 CA-199 (NM) 37.692 U/ml
• 2023-09-28 CA-199 (NM) 36.410 U/ml
• 2023-09-01 CA-199 (NM) 26.718 U/ml
• 2023-08-11 CA-199 (NM) 23.676 U/ml
• 2023-07-28 CA-199 (NM) 22.798 U/ml
• 2023-07-04 CA-199 (NM) 20.102 U/ml

2023-09-19

The medications Betmiga (mirabegron) and Harnalidge (tamsulosin) and Oxbu ER (oxybutynin) prescribed by our urologist, along with Trajenta (linagliptin) prescribed by our endocrinologist on 2023-08-28, are currently being taken by the patient with no discrepancies noted.

2023-08-21

Our endocrinologist’s repeat prescription (issued on 2023-06-05) for Trajenta (linagliptin) is currently on the active medication list, and there are no discrepancies noted.

2023-07-13

The patient recently refilled his prescription for Trajenta (linagliptin) on 2023-07-10 for managing his T2DM. This drug is accurately included in the active medication list, with no reconciliation issues identified.

2023-06-20

• According to the PharmaCloud database, all of this patient’s medical requirements have been addressed at our hospital over the past three months. As a result, no issues with medication reconciliation have been detected.

• The patient’s DM is currently managed with Trajenta (linagliptin 5mg) 1# QD. He had an increased preprandial serum glucose level of 170mg/dL on 2023-06-20 at 06:24. The most recent HbA1c level was 5.7% on 2023-05-31. This sudden rise could be a temporary fluctuation and is worth continuous monitoring.

2023-05-19

• The patient, with a body surface area (BSA) of 1.69 m2 calculated from a recorded height of 165 cm and weight of 62.2 kg (2023-05-18), is currently receiving a modified FOLFIRINOX regimen. This regimen includes oxaliplatin and irinotecan, but omits bolus fluorouracil.
• The dose of oxaliplatin is 100mg, which is equivalent to 59mg/m2, approximately 69% of the standard dose of 85mg/m2. Likewise, the dose of irinotecan is 200mg, equivalent to 118mg/m2, approximately 65% of the standard dose of 180mg/m2. The frequency of the treatment is every three weeks, in contrast to the standard every two weeks.
• The patient has a relatively advanced age of 73 years and a fair ECOG performance status of 1. He has had only one episode of leukopenia with WBC < 3K/uL (2.89K/uL on 2023-03-24). No other significant adverse events have been recorded. An abdominal CT scan performed on 2023-03-13 showed soft tissue at the root of the mesentery.
• Given these factors, and in the absence of contraindications or other clinical concerns, it might be beneficial to consider a gradual dose escalation. This could be done with the aim to bring the dose closer to the standard levels, in order to optimize therapeutic effect.

2023-03-13

• Since 2022-12-19, the patient has been receiving FOLFIRINOX with a reduced dosage of oxaliplatin (85 -> 60mg/m2) and irinotecan (180 -> 150mg/m2), skipping the 5-FU bolus to prevent adverse reactions. Bilirubin (direct and total) returned to normal range in 2022-12, but ALT readings have fluctuated between normal and not exceeding 110U/L after treatment. As of the 2023-03-10 lab data, BUN 29mg/dL, Creatinine 0.95mg/dL, and eGFR 82.60. No dosage adjustment is currently needed for the patient’s FOLFIRINOX regimen.

2023-02-02

• It was noted that the blood sugar level did not exceed 180 mg/dL, which was an improvement over the prior hospital stay.

• Renal sonography (2022-09-24) found bilateral renal stones, and calcium oxalate crystals in urine (2023-02-01). Primary hyperoxalurias are rare inborn errors of glyoxylate metabolism characterized by the overproduction of oxalate, which is poorly soluble and is deposited as calcium oxalate in various organs. The kidney stones in this patient should be less likely to be associated with primary hyperoxaluria.

  • Patients with kidney stones should consume enough fluids to consistently produce at least 2 liters of urine per day. At the present time, the patient is being hydrated with NS 500mL Q12H since this hospital admission.
  • It is recommended that all patients with calcium oxalate stones limit their intake of high oxalate foods, supplemental vitamin C, sucrose, and fructose. However, excessive restriction of oxalate is unlikely to be beneficial. Patients should continue to consume a variety of fruits and vegetables while avoiding those that are very high in oxalate. Intake of sugar and/or fructose increases urine calcium independently of calcium intake and has been associated with an increased risk of kidney stones.
  • Urine pH was 5.5 (2023-02-01) WNL, however, calcium oxalate stones are not pH dependent in the physiologic range. In recent lab results, there were no readings for calcium, oxalate, citrate, and uric acid in urine.
  • In the event that high urine calcium is detected, it is recommended that patients with recurrent calcium oxalate stones who have higher than desired urine calcium be treated with a thiazide diuretic in order to lower urinary calcium excretion.
    • All patients receiving a thiazide diuretic should maintain a low-sodium diet, which is essential for the diuretic to effectively lower urinary calcium.
    • Urinary calcium and sodium excretion should be monitored after the institution of thiazide therapy. A repeat 24-hour urine collection should be performed one to two months after initiating therapy.
    • If the urine calcium does not fall as desired or the thiazide is not well tolerated, an alternative therapy is administration of 40 to 60 mEq of alkali per day as potassium bicarbonate or potassium citrate (citrate is rapidly metabolized to bicarbonate).

701489999

231018

[lab data]

2023-07-31 Anti-HBc (NM) Positive
2023-07-31 Anti-HBc Value (NM) 0.636
2023-07-31 Anti-HBs (NM) Positive
2023-07-31 Anti-HBs value (NM) 677.000 mIU/mL
2023-07-31 Anti-HCV (NM) Negative
2023-07-31 Anti-HCV Value (NM) 0.043
2023-07-25 HBsAg (NM) Negative
2023-07-25 HBsAg Value (NM) 0.418

2023-07-25 CA-199 (NM) 354.780 U/ml
2023-07-25 CEA (NM) 31.940 ng/ml

[exam findings]

• 2023-09-18 SONO - abdomen
  • Findings
    • Liver
      • Homogenous liver parenchyma.
      • One hyperechoic tumor with hypoechoic rim was noted at S4, 3.9cm.
      • One hyperechoic tumor with hypoechoic rim was noted at S7, 2.8cm.
      • One 0.4cm hyperechoic lesion with PAS was noted at S4.
    • Pancreas
      • Some parts of pancreas blocked by bowel gas, especially head and tail
    • Spleen
      • No splenomegaly
  • Diagnosis:
    • Liver tumors, S4 and S7
    • Liver calcification, S4
• 2023-08-11 All-RAS + BRAF gene mutation analysis
  • ALL-RAS: Detected (NRAS codon 61 CAA>AGA, p.Q61R)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-08-09 MRI - pelvis
  • Findings:
    • There is segmental irregular wall thickening of the rectosigmoid junction, measuring 5 cm in size, with direct adhesion the uterus that is c/w adenocarcinoma (T4b).
    • There are seven enlarged nodes in the adjacent mesocolon (N2b).
    • There are two poor enhancing masses 4.5 cm in S4 and 2.8 cm in S7 of the liver that are c/w liver metastases (M1a).
    • There are several masses in the uterus, showing hypointensity on T2WI that are c/w myomas. The largest one 6 cm in size.
  • IMP:
    • Rectal cancer is noted.
    • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for colon cancer: T4b N2b M1a, stage: IVA
• 2023-07-21 CT - abdomen
  • CC: Dark red bloody stool passage off and on and noted again these days, Mucoid bloody stool passage
    • 20230720 colonoscopy: One mass in the sigmoid colon, 15 cm AAV, R/O malignancy
  • Findings:
    • There is segmental irregular wall thickening of the rectosigmoid junction, measuring 5 cm in size that is c/w adenocarcinoma (T3).
    • There are four enlarged nodes in the adjacent mesocolon (N2a).
    • There are two poor enhancing masses 3.7 cm in S4 and 2 cm in S7 of the liver that are c/w metastases (M1a).
    • There are several mild poor enhancing masses in the uterus that are c/w myomas. Please correlate with GYN. sonography.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
• 2023-07-21 Patho - colorectal polyp
  • DIAGNOSIS: Intestine, large, rectosigmoid junction, 15 cm from anal verge, biopsy — adenocarcinoma
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2023-07-20 Colonoscopy
  • Diagnosis:
    • Siogmoid polyp s/p polypectomy
    • Rectosigmoid cancer s/p biopsy
    • Severe melanosis coli
    • Large mixed hemorrhoids

[MedRec]

• 2023-08-07 SOAP Nutrition Consultation
  • S
    • Occupation: Homemaker
    • Dietary Habits:
      • Breakfast (6-7 AM): Meal replacement (Shou Mei Li) with or without a slice of thick toast (butter spread) / Boiled egg
      • Morning Snack: 1 can of Ensure (consistently consumed daily)
      • Lunch: Half a bowl of porridge + 2 and a half pieces of tilapia fish + 2/3 portion of greens
      • Afternoon Snack: 1 Kiwi
      • Dinner: Same as lunch
    • Exercise: Light jogging once a day, for 40 minutes including warm-up
    • Fluid Intake: 1500-2000 ml
  • A
    • Anthropometry:
      • BMI kg/m2: normal / over weight / obesity
      • Current energy intake: adequate / inadequate
      • Nutrition problem:
        • Ensure 1-2
  • P
    • Goal: BS control
    • Education topic: DM diet principle, 6 Food Groups and food groups contain CHO, eating-out principles, Food exchange list, protein restricted diet education,Balance diet
    • Meal planning: kcal
      • Cereal : ex/d
      • Meat/Bean-choose low fat protein (soy products, egg): ex/d
      • Green vegetable: ex/d
      • Fruits: ex/d
      • Low fat milk: ex/d
      • Oil: ex/d
      • Increase physical activity: 3 times/ week, 30 min/time
      • Decrease alcohol: ex/d →
      • SMBG with diet recoard
• 2023-07-27 SOAP Hemato-Oncology
  • P
    • CCRT with FOLFOX and followed by FOLFOX with or wtihout bevacizumab and cetuximab (need further discussion with family).
    • Admission for CCRT with FOLFOX
• 2023-07-27 SOAP Radiation Oncology
  • P
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectosigmoid tumor bed area.
    • The treatment planning of radiotherapy will be started at 1030, 2023-08-02.
• 2023-07-27 SOAP Colorectal Surgery
  • A/P
    • Suggest pre-op chemotherapy + target therapy then colectomy + hepatectomy
    • Arrange MRI for differential uterine invasion; T4b ? or T3 ?
    • Refer to Radiotherapy for reducing size, better resectability

[chemotherapy]

• 2023-10-17 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-25 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-09 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-18

[liver function]

The patient experienced a transient elevation in liver function test readings in mid-Sep, with peak values of 106 U/L for AST, 225 U/L for ALT, and 1.06 mg/dL for total bilirubin on 2023-09-18. However, the liver function test abnormalities have resolved, and there is no evidence of sustained liver injury at present.

• 2023-10-17 AST 33 U/L

• 2023-10-05 AST 21 U/L

• 2023-09-25 AST 45 U/L

• 2023-09-22 S-GOT/AST 51 U/L

• 2023-09-18 S-GOT/AST 106 U/L

• 2023-09-14 S-GOT/AST 96 U/L

• 2023-09-07 S-GOT/AST 31 U/L

• 2023-08-25 S-GOT/AST 21 U/L

• 2023-08-09 S-GOT/AST 29 U/L

• 2023-07-20 S-GOT/AST 15 U/L

• 2023-10-17 ALT 41 U/L

• 2023-10-05 ALT 25 U/L

• 2023-09-25 ALT 86 U/L

• 2023-09-22 S-GPT/ALT 110 U/L

• 2023-09-18 S-GPT/ALT 225 U/L

• 2023-09-14 S-GPT/ALT 136 U/L

• 2023-09-07 S-GPT/ALT 40 U/L

• 2023-08-25 S-GPT/ALT 17 U/L

• 2023-08-22 S-GPT/ALT 17 U/L

• 2023-08-09 S-GPT/ALT 13 U/L

• 2023-07-20 S-GPT/ALT 11 U/L

• 2023-10-17 Bilirubin total 0.61 mg/dL
  

• 2023-10-05 Bilirubin total 0.44 mg/dL
  

• 2023-09-25 Bilirubin total 0.50 mg/dL
  

• 2023-09-22 Bilirubin total 0.68 mg/dL
  

• 2023-09-18 Bilirubin total 1.06 mg/dL
  

• 2023-09-14 Bilirubin total 0.74 mg/dL
  

• 2023-09-07 Bilirubin total 0.68 mg/dL
  

• 2023-08-25 Bilirubin total 0.50 mg/dL
  

• 2023-08-22 Bilirubin total 0.40 mg/dL
  

• 2023-08-09 Bilirubin total 0.87 mg/dL
  

• 2023-07-20 Bilirubin total 1.25 mg/dL

The patient received 4 cycles of FOLFOX chemotherapy, administered on 2023-08-09, 2023-08-24, 2023-09-25, and 2023-10-17. Oxaliplatin, a drug used in FOLFOX, is associated with increased serum alanine aminotransferase (36%), increased serum alkaline phosphatase (42%), increased serum aspartate aminotransferase (54%), and increased serum bilirubin (13%). It is possible that oxaliplatin caused the elevated liver function test results in this patient.

In mid-Sep, the patient was prescribed BaoGan (silymarin), a herbal supplement that is thought to protect the liver, to mitigate the risk of liver damage.

In addition, FOLFIRI, an alternative chemotherapy regimen that contains irinotecan, is also associated with increased serum bilirubin (84%) and increased serum alkaline phosphatase (13%).

[RAS mutation detected]

Patients with colorectal cancer (CRC) who have an RAS mutation (2023-08-11 Lab result, NRAS mutation detected) are less likely to respond to targeted therapies that target EGFR. This is because NRAS mutations can activate the RAS-MAPK pathway downstream of EGFR, making the tumor resistant to anti-EGFR therapies.

The following targeted therapies are less likely to be effective in the setting of CRC with an NRAS mutation:

• Cetuximab (Erbitux)
• Panitumumab (Vectibix)

700186762

231017

• 2023-10-13 SONO - breast
  • Diagnosis
    • Left fibroadenoma as described
    • s/p bil. breast operation
  • BI-RADS: 2. benign finding
• 2023-08-11 Mammography
  • Impression:
    • Dense breast.
    • S/P right mastectomy.
    • Benign coarse calcifications in left breast.
    • Suggest clinical correlation and follow up.
  • BI-RADS:
    • Category 2: benign findings. - annual screening.
• 2023-07-03 PET
  • In comparison with the previous study on 2023/01/16, the glucose hypermetabolic lesion at the T12 spine comes to more evident; other lesions including in some T- and L-spine, sacrum, bilateral pelvic bones and bilateral femurs disappear or become less evident, indicating breast cancer with disassociated response to current therapy.
    
  • However, glucose hypermetabolic lesions in the uterus are numerous and show more prominent, malignant neoplasm of uterus should be considered, suggesting biopsy for further evaluation.
  • Increased FDG accumulation in the colon and bilateral kidneys, physiological FDG uptake is more likely.
• 2023-05-11 ECG
  • Sinus rhythm with Premature ventricular complexes
  • ST & T wave abnormality, consider lateral ischemia
  • Abnormal ECG
• 2023-03-10 Patho - endometrium curretage/biopsy
  • Uterus, endometrium, hysteroscopic endometrial curettage — squamous metaplasia
  • Microscopically, it shows pieces of bland squamous epithelial tissue fragments.
  • Immunohistochemical stain reevals p16(-) and Ki-67 (-).
• 2023-02-17 Gynecologic ultrasonography
  • R/O Uterine myoma
  • R/O Nabothian cyst: 48mmx26mm
  • R/O Endometrial thickening, EM: 14.6mm
• 2023-02-10 SONO - abdomen
  • Diagnosis:
    • Fatty liver, severe
    • Poor assessment of biliary tract and PV
    • Pancreas not shown
    • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
  • Suggestion:
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
    • Because of poor echo window, infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
• 2023-01-16 PET
  • In comparison with the previous study on 2022/08/02, the glucose hypermetabolism in some T- and L-spines, sacrum, bilateral pelvic bones and bilateral femurs is slightly more evident. Multiple bone metastases in stable condition may show this picture. Please correlate with other clinical findings for further evaluation.
  • At least four focal areas of increased FDG uptake in the uterus, the nature is to be determined (benign or even malignant neoplasm of uterus or other nature ?), suggesting pelvis CT or MRI for further evaluation.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters, physiological FDG accumulaton is more likely.
• 2022-08-02 PET
  • In comparison with the previous study on 2021/12/10, the glucose hypermetabolism in some T- and L-spines, sacrum, bilateral pelvic bones and bilateral femurs is slightly less evident. Multiple bone metastases with partial response to the current therapy may show this picture. Please correlate with other clinical findings for further evaluation.
  • Some focal areas of increased FDG uptake in the anterior pelvic region. The nature is to be determined (some kind lesions of the uterus? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulaton is more likely.
• 2022-04-29 MRA - brain
  • An old lacune in left basal ganglion.
• 2022-04-26 Neurosonography
  • wall thickening on bil. common carotid arteries
  • normal flow and flow velocities on bil. extracranial carotid and vertebral arteries
  • poor left temporal windows
  • the transcranial doppler study of insonated right ACA, bil. MCA, PCA, VA and BA were normal
• 2022-04-19 CT - brain
  • No definite intracranial lesion
• 2022-02-22 Nerve Conduction
  • Finding
    • Motor nerve conduction study
      • Normal motor nerve conduction study in the left median nerve.
      • Conduction block noted over the left ulnar nerve across elbow level (more than 10m/s difference).
    • F-wave
      • Normal F-wave latencies in the left median and ulnar nerves.
    • Sensory nerve conduction study
      • Prolonged sensory peaked latency with decreased SNCV and normal SNAP amplitudes in the left median nerve (4D-wrist segment)
      • Prolonged sensory peaked latency with normal SNCV and normal SNAP amplitudes in the left median nerve (midpalm-wrist and 1D-wrist segments)
      • Normal sensory nerve conduction study in the left median nerve (forearm segment)
      • Normal sensory nerve conduction study in the left ulnar and superficial radial nerves.
  • Conclusion
    • Left median neuropathy at the wrist, demyelinated type.
    • Left ulnar motor neuropathy across the elbow, conduction block noted.
• 2021-12-10 PET
  • A large focal area of mildly increased FDG uptake in the anterior pelvic region. The nature is to be determined (enlarged uterus? other nature?). Please correlate with other clinical findings for further evaluation.
  • Faint glucose hypermetabolism in multiple T- and L-spines, sacrum, bilateral pelvic bones and bilateral femurs. Either multiple bone metastases of faint FDG uptake or multiple bone metastases with response to the current therapy may show this picture. Please also correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulaton is more likely.

[MedRec]

• 2021-11-25 SOAP General Surgery Li ChaoShu
  • S: MBCa
  • O Koo Foundation Sun Yat-Sen Cancer Center OPD
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Endocrine therapy） Letrozole FEMARA FILM-COATED TABLETS 2.5MG 28 28 110/11/18 21
      
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Antihistamines for systemic use） Levocetirizine Dihydrochloride XYZAL FILM-COATED TABLETS 5MG 28 28 110/11/18 21
      
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Antineoplastic agents） Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/11/18 14
      
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Drugs for treatment of bone diseases） Denosumab XGEVA 1 1 110/11/18 0
      
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Corticosteroids，dermatological preparations） Betamethasone (Valerate) RINDERON-V CREAM 0.06% 7 1 110/11/18 0
      
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Endocrine therapy） Letrozole FEMARA FILM-COATED TABLETS 2.5MG 28 28 110/10/18 0
      
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Antineoplastic agents） Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/10/18 0
      
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Endocrine therapy） Letrozole FEMARA FILM-COATED TABLETS 2.5MG 30 30 110/09/13 0
      
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Endocrine therapy） Letrozole FEMARA FILM-COATED TABLETS 2.5MG 30 30 110/09/13 0
      
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Antineoplastic agents） Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/09/13 0
      
    • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 （Antineoplastic agents） Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/09/13 0
• 2020-09-04 SOAP Rehabilitation Qiu JiaYi
  • S
    • Right breast cancer s/p MRM + ALND (LNs 10/25) on 2019-06 s/p RT x 30 times with right shoulder limitation and lympehdema
    • Past Hx.: Left MCA infarction with nearly total recovery in 20170607
    • PH: HTN, hyperlipidemia
  • O
    • Body weight: 62.8 kg
    • Rt: 17.5 cm (wrist), 24.5cm (elbow), 31cm (axilla)
    • Lt: 17cm (wrist), 24cm, 30.5cm (axilla)
    • Skin: soft (pitting) edema, elevation reduces swelling, dry skin
    • ISL stage: II (early): limb elevation rarely reduces swelling
    • Other complications: Frozen shoulder +
  • Imp
    • right breast cancer s/p MRM with secondary right adhesive capsulitis and lymphedema
  • Plans
    • Consider PT: IFC, PROM, therapeutic, mobilization for Rt shoulde first, circulator for RUE; then add MLD.

[chemotherapy]

• 2023-10-13 - fulvestrant 500mg IM 5min

==========

2023-10-17

[leukopenia]

Based on the HIS5 lab data, a leukopenia event was recorded on 2023-10-13 with a count of 1.83K/uL (marked with an asterisk in the following table). The most recent chemotherapy administered was 500mg of fulvestrant on the same day, very close in time to the WBC data collection, leaving open the possibility that the actual medication administration occurred after the blood sample was taken. Moreover, according to UpToDate, the occurrence of neutropenia (2%; grade 3: 1%; grade 4: <1%) is relatively low compared to other chemotherapy drugs. For these two reasons, it’s less likely that this drug was the main contributor to the neutropenia observed on 2023-10-13.

• 2023-10-13 WBC 1.83 x10^3/uL *
• 2023-06-26 WBC 3.41 x10^3/uL
• 2023-05-11 WBC 3.23 x10^3/uL
• 2023-03-02 WBC 3.24 x10^3/uL
• 2023-01-16 WBC 4.02 x10^3/uL

701361625

231016

[exam findings]

• 2023-08-19 CT - abdomen
  • Indication: Low rectal adenocarcinoma post operation with pelvic lymph node metastasis, status post Robotic low anterior resection and loop ileostomy on 2023/03/10, pT1N1b(3/19)cM0, pStage IIIA s/p chemotherapy with FOFLOX from 2023/04/18~
  • With and without contrast enhancement CT of abdomen shows:
    • s/p LAR and ileostomy. No local recurrent tumor.
    • Small para-aortic lymph nodes.
  • Impression
    • Low rectal adenocarcinoma, s/p LAR and ileostomy
    • Small para-aortic lymph nodes. Suggest clinical correlation and follow up evaluation.
• 2023-07-19 All-RAS + BRAF gene mutation
  • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-03-10 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, rectum, previously post Transanal minimally invasive surgery with local excision (2022-03-02), now rectal trsection — no residual primary tumor. Margins free.
    • Lymph node, pericolonic, dissection — metastatic adenocarcinoma (3/19), no extranodal extension. - IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • pTx pN1b (if cM0); pStage: IIIA, at least.
  • Gross Description:
    • Procedure - previously post Transanal minimally invasive surgery with local excision (2022-03-02), now rectal trsection
    • Tumor Site - Rectum 12.5 3.5 x 3.5 cm
      
    • Tumor Size: no rpimary tumor in this specimen.
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as: A1-5: roevious excision site; A6-8 and X1-2: epri-rectal lymph nodes; B: separated proximal margin; C: separated distal margin.
  • Microscopic Description:
    • Histologic Type - Adenocarcinoma
    • Histologic Grade - G2: Moderately differentiated
    • Tumor Extension - No evidence of primary tumor
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved
    • Distance of tumor from margin: > 5mm (radial margin)
      
    • Lymphovascular Invasion: Not identified
    • Perineural Invasion: Not identified
    • Tumor Budding - none.
    • Type of Polyp in Which Invasive Carcinoma Arose: no primary tumor in this specimen.
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes
      • Number of Lymph Nodes Involved/Examined: 3/19
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition): IIIA, at least.
      • TNM Descriptors (not applicable)
        • Primary Tumor (pT) - No residual of primary tumor
        • Regional Lymph Nodes (pN) - pN1b: Two or three regional lymph nodes are positive
        • Distant Metastasis (pM) - if cM0
    • Additional Pathologic Findings - None in this specimen identified
    • Ancillary Studies : result of S2023-4391 A6 : IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
• 2023-02-21 PET
  • Increased FDG uptake in two focal areas in the right pararectal region. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the stomach. Inflammatory process may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
• 2023-02-14 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Clinical rectal cancer s/p. There are enlarged lymph nodes, up to 1cm in perirectal region, progression as compare with CT study on 2022-09-01.
    • R/O liver cyst, 1.5cm in S4.
    • Low density tumor, 1.7cm in the uterus, r/o uterine myoma.
  • Impression
    • Clinical rectal cancer s/p. Progressive enlarged perirectal lymph node as compare with CT study on 2022-09-01, r/o metastatic lymph node.
    • R/O liver cyst.
    • R/O uterine myoma.
• 2023-02-14 Colonoscopy
  • Rectal cancer s/p op
  • No evidence of recurrence
• 2023-02-14 Esophagogastroduodenoscopy, EGD
  • Suspect duodenal SET, 2nd portion
  • Gastric polyps, body, GC
  • Reflux esophagitis LA Classification grade A (minimal)
  • Superficial gastritis
• 2022-09-01 CT - abdomen
  • History and indication: Rectal cancer at 5 cm from AV s/p polypectomy stage I
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Rectal cancer s/p operation. Small LNs (4mm, 5mm) at right pararectal region without interval change.
    • Renal cysts (up to 0.7cm).
    • Liver cysts (up to 1.8cm).
• 2022-03-03 Patho - colon segmental resection for tumor
  • DIAGNOSIS:
    • Intestine, large, rectum, 5 cm from anal verge, transanal minimally invasive surgery (s/p polypectomy) — No residual malignant tumor — Margin free
    • Lymph node., regional, transanal minimally invasive surgery — Negative for malignancy (0/1)
  • Microscopically, it shows full-layer of colorectal tissue with a scar at the mucosa. The muscularis propria and perirectal soft tissue are not remarkable. One regional lymph node is not remarkable.
  • Immunohistochemical stain reveals CK(-).

[MedRec]

• 2022-02-17 SOAP Colorectal Surgery
  • 20220113 Rectal cancer at 5 cm from AV s/p polypectomy stage I was diagnosed at ShuangHe Hospital, pT1, margin < 1mm

[surgical operation]

• 2023-03-10
  • Surgery
    • Robotic LAR + Loop ileostomy    
  • Finding
    • Perirectal nodules R/O lymph nodes metastasis Redundant sigmoid colon adhesion to omentum
• 2022-03-02
  • Surgery
    • Transanal minimally invasive surgery (TAMIS) for local excision    
  • Finding
    • Rectal cancer at right anterior wall 5 cm from AV s/p polypectomy, pT1 , margin not involve < 1mm.
    • Whole layer resection of the tumor base deep to vaginal wall anteriorly and perirectal fat

[chemotherapy]

• 2023-10-13 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-09-22 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-09-07 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-08-21 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-07-28 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-07-10 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-06-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-05-30 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-05-02 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-04-18 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-10-16

The current FOLFOX regimen was initiated on 2023-04-18, during which time multiple leukopenia events occurred (indicated in the table below with “**” for WBC < 2K/uL and “*” for WBC < 3K/uL). Since July, the regimen has eliminated the 5-FU bolus and reduced oxaliplatin from 85 mg/m2 to 75 mg/m2. Since these adjustments, there has only been one case of WBC < 2K/uL on 2023-10-05, primarily due to the intermittent administration of Granocyte (lenograstim) based on the patient’s condition. The most recent lab data (2023-10-12) showed a WBC of 4.15K/uL, indicating no current evidence of leukopenia.

• 2023-10-12 WBC 4.15 x10^3/uL
• 2023-10-05 WBC 1.86 x10^3/uL **
• 2023-09-18 WBC 3.35 x10^3/uL
• 2023-09-07 WBC 4.37 x10^3/uL
• 2023-08-31 WBC 23.24 x10^3/uL
• 2023-08-18 WBC 7.02 x10^3/uL
• 2023-08-14 WBC 2.62 x10^3/uL *
• 2023-08-07 WBC 2.04 x10^3/uL *
• 2023-07-28 WBC 11.71 x10^3/uL
• 2023-07-24 WBC 2.70 x10^3/uL *
• 2023-07-10 WBC 2.52 x10^3/uL *
• 2023-06-26 WBC 3.33 x10^3/uL
• 2023-06-19 WBC 1.55 x10^3/uL **
• 2023-06-12 WBC 2.10 x10^3/uL *
• 2023-05-29 WBC 4.57 x10^3/uL
• 2023-05-22 WBC 2.49 x10^3/uL *
• 2023-05-16 WBC 1.50 x10^3/uL **
• 2023-04-28 WBC 2.94 x10^3/uL *
• 2023-03-09 WBC 6.31 x10^3/uL
• 2022-02-18 WBC 4.91 x10^3/uL

700204091

231013

[exam findings]

• 2023-09-12 CT - abdomen
  • History and indication: Right ovarian endometrioid carcinoma, pT2bN0cM0, FIGO stage IIB s/p OP and treatment
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. A cystic lesion (2.7cm) at right pelvic wall.
    • Grade 4 fatty liver.
    • Renal cysts (up to 4.1cm).
    • Some LNs (up to 1.3cm) at bil. inguinal regions.
  • IMP:
    • S/P hysterectomy. A cystic lesion (2.7cm) at right pelvic wall.
    • Grade 4 fatty liver.
• 2023-08-29 Anoscopy
  • DRE/Anoscopy: normal anal tonicity; mixed hemorrhoids with congestion and fissure at posterior
• 2023-07-04 SONO - nephrology
  • L’t Kidney - Cyst:(Max) Upper pole 3.9 x 3.0 cm 2.7 x 3.1 cm
  • Diagnosis: left renal cyst
• 2023-06-15 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 15 dB HL, LE 21 dB HL
  • Bil WNL
• 2023-05-18 Patho - uterus with or without SO non-neoplastic/prolapse
  • PATHOLOGIC DIAGNOSIS
    • Ovarian tumor, right, frozen (F2023-00229) — Endometrioid carcinoma and endometrioma
      • Fallopain tube, right, ditto — Free of tumor invasion
    • Ovarian cyst, left, debulking surgery — Endometrioma and free of tumor invasion
      • Fallopain tube, left, ditto — Free of tumor invasion
    • Cervix, uterus, debulking surgery — Free of tumor invasion
      • Endometrium, uterus — Free of tumor invasion, proliferative phase
      • Myometrium, uterus — Free of tumor invasion, leiomyomas and adenomyosis
    • Uterosacral area mass, ditto — Endometrioid carcinoma
    • R’t peri-ureter tissue, ditto — Endometrioid carcinoma and endometriosis
    • R’t suspensory (IP), ditto — Free of tumor invasion
    • Omentum, omentectomy — Free of tumor invasion
    • Lymph nodes
      • Lymph node, left iliac, dissection — Free of tumor metastasis (0/5)
      • Lymph node, left obturator, dissection — Free of tumor metastasis (0/10)
      • Lymph node, right iliac, dissection — Free of tumor metastasis (0/11)
      • Lymph node, right obturator, dissection — Free of tumor metastasis (0/25)
      • Lymph node, left paraaortic, dissection — Free of tumor metastasis (0/12)
      • Llymph node, right paraaortic, dissection — Free of tumor metastasis (0/6)
    • Bilateral prametria — Free of tumor invasion
    • AJCC Pathologic staging — pT2bN0, if cM0, stage IIB / FIGO stage IIB
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: frozen sections and debulking surgery
    • Specimen type: uterus and left adnexa, pelvic and paraaortic LNs and omentum
    • Specimen size:
      • Right opened ovarian tumor (frozen): 5.2 x 4.8 cm with blood clot and one papillary tumor 1.2 x 0.7 cm
      • Right fallopian tube: 4.5 cm in length, 0.6 cm in diameter
      • Left ovarian cyst: 3.7 x 2.7 cm
      • Left fallopian tube: 3.7 cm in length, 0.7 cm in diameter
      • Uterus: 11 x 7 x 5 cm in size and 415 gm in weight, multiple myomas, up to 5.8 x 5.3 x 4.4 cm
      • Omentum: 31 x 9 x 0.5 cm
    • Uterosacral area mass: three pieces, up to 1.3 x 0.6 x 0.4 cm
    • R’t peri-ureter tissue: one piece, 3.7 x 2.6 x 2.1 cm
    • R’t suspensory (IP): one piece, 2.8 x 1.8 x 1.3 cm
    • Tumor site: R’t ovary, uterosacral area mass and R’t peri-ureter tissue
    • Tumor appearance: cystic tumor with papillary tumor at R’t ovary
    • Specimen integrity: opened ovarian tumor
    • Lymph node: pelvic and paraaortic LNs
    • Representative sections as A: left iliac LNs, B: left obturator LNs, C: right iliac LNs, D1-D3: right obturator LNs, E: L’t paraaortic LNs, F: R’t paraaortic LNs, G1-G3: uterine corpus, G4-G5: low segment of corpus + cervix, G6-G7: corpus, G8-G9: cervix, G10: endometrium, G11: myoma, G12-G14: adenomyosis, G15-G16: bilateral parametrium, H: right suspensory (IP), I: uterosacral area mass, J: omentum, K: right peri-ureter tissue [Reference: frozen section, F2023-00229 FSA1: R’t ovarian papillary nodule, FSA2: R’t ovarian cyst, A1-A2: R’t ovarian cyst and A3: R’t fallopian tube, B1: L’t fallopian tube, B2-B3: L’t ovarian cyst]
  • MICROSCOPIC EXAMINATION
    • Histologic type: Endometrioid carcinoma, endometrioma and endometriosis
      
    • Histologic grade: Grade 1
    • Contralateral ovary involvement: Absent
    • Tumor side ovarian surface involvement: Absent
    • Contralateral ovary surface involvement: Absent
    • Right tube involvement: Absent
    • Left tube involvement: Absent
    • In situ adenocarcinoma in right ＆/or left fallopian tube: Absent
    • Right adnexa soft tissue involvement: Absent
    • Left adnexa soft tissue involvement: Absent
    • Pelvic soft tissue involvement: Present
    • Uterine serosa involvement: Absent
    • Omentum involvement: Absent
    • Uterine Cervix involvement: Absent, chronic cervicitis with Nabothian cysts
    • Endometrium involvement: Absent
    • Myometrium involvement: Absent, leiomyomas and adenomyosis
    • Appendix involvement: Not received
    • Lymph nodes metastasis: Free of tumor metastasis (0/69) in total number
    • Uterosacral area mass: endometrioid carcinoma
    • R’t peri-ureter tissue: endometrioid carcinoma and endometriosis
    • Immunohistochemistry (F2023-00229 FSA1): PAX-8 (+), vimentin (+), ER (+), WT-1 (-) and P53 (wild type)
    • Ascites cytology: Negative
• 2023-05-17 Frozen Section
  • Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma
• 2023-04-25 Patho - colon biopsy
  • Colorectum, splenic flexure, s/p biopsy removal — Hyperplastic polyp
• 2023-04-25 Patho - stomach biopsy
  • Stomach, AW side of antrum, biopsy — Ulcer, H pylori present
  • Stomach, LC side of prepyloric antrum, biopsy — Ulcer, H pylori NOT present
• 2023-04-24 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A-
  • Gastric ulcers, antrum, s/p biopsy at antrum (AW) and prepyloric antrum (LC)
• 2023-04-24 Colonoscopy
  • Colon polyp, splenic flexure, s/p biopsy removal
  • Diverticulosis, descending colon
  • Internal hemorrhoid
• 2023-04-19 CT - abdomen
  • Findings:
    • There is a homogeneous enhancing mass 6.4 cm in the uterus that is c/w myoma.
    • There is cystic lesion in bilateral adnexa with mild wall thickening but no mural nodule and septum.
      • Cystic adenocarcinoma of the ovary is highly suspected.
      • In addition, there are few small soft tissue nodules in right L3 peri-ureter area that may be tumor seeding (T2b)?
      • The right and left adnexal cystic lesion are measured 6.4 cm and 3.6 cm, respectively. Please correlate with GYN. sonography and CA125.
    • Two renal cyst 4 cm and 1.5 cm in left upper pole is noted.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T2b(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIB(Stage_value)
• 2023-04-14 Gynecologic ultrasonography
  • R/O Rt Ovarian mass: 68x49mm (papillary: 16x14mm, no blood flow)
  • Adenomyosis
  • Uterine myoma

[MedRec]

• 2023-06-01 SOAP Hemato-Oncology
  • O

    • Cancer Multidisciplinary Team Meeting Conclusion, Date: 20230525

      Treatment Plan:
      • Postoperative adjuvant chemotherapy (referral to Dr. Xia HeXiong)
      • Provide Ovarian Cancer Treatment Shared Decision-Making (SDM) form and explanation of the condition (including genetic testing and targeted therapy).
  • P
    • Arrange admission for 24hr CCr, audiomtery and C/T with TP
• 2023-05-16 ~ 2023-05-25 POMR Obstetrics and Gynecology
  • Discharge diagnosis
    • Malignant neoplasm of right ovary
    • Leiomyoma of uterus, unspecified
    • Female pelvic peritoneal adhesions (postinfective)
    • Debulking surgery on 20230517
  • CC
    • Irregular menstrual cycles with short intervals.
  • Present illness
    • This is a 47 year old famle, G3P2AA1 (NSD x2, with no severe complications), LMP was 20230416. She had hypertension (under medicine control) and kindey cyst (suggested regular follow up), no surgery history, no known allergens.
    • ACCORDING TO THE PATIENT, SHE HAD IRREGULAR MENSTRUAL CYCLES WITH SHORT INTERVALS SINCE APRIL 2023 (03/27, 04/04 are previous cycles, mild menstrual pain). THEREFORE, SHE WENT TO OB/GYN CLINICS FOR HELP. She was informed elevated CA125 and CA199, then she was introduced to Dr. Huang. AT DR. HUANG OPD, TRANSVAGINAL SONOGRAPHY SHOWED Myoma 6051 / 3020 mm IN SIZE, ROV mass 68*49 mm (papillary:16x14mm,no blood flow).
    • CT was performed on 04/19, the findings are as followed: 1. Uterine myoma 6.4 cm. 2. Cystic lesions in bilateral adnexa.
    • UNDER THE IMPRESSION OF UTERINE MYOMA AND OVARAIN TUMOR, MALIGNANCY CANNOT BE RULE OUT, After the evaluation, the paitent was arranged with LSC myomectomy + BSO on 20230517, she was admitted to our ward day before for the pre-operation preparation.
  • Course of inpatient treatment
    • The patient was admitted on 20230516 due to ovarian tumor. The frozen section initial diagnosis:Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma. She underwent Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy on 20230517. The AJCC Pathologic staging — pT2bN0, if cM0, stage IIB / FIGO stage IIB. The GYN tumor board conference suggest the patient to receive chemotherapy on 20230525. Her postoperative course was uneventful. Self voiding was smooth. She was discharged on 20230525. Her follow up appointment is scheduled on 20230601. Keep intraperitoneal Port for chemotheraphy.      
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Actein (acetylcysteine 200mg) 1# TID
    • cephalexin 500mg 1# QID
    • MgO 250mg 1# TID

[consultation]

• 2023-07-04 Urology
  • Q
    • for USK evaluation
    • This 47-year-old woman, a patient of Right ovarian endometrioid carcinoma, pT2bN0cM0, FIGO stage IIB s/p Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy), bilateral DBJ insertion and Tenckhoff tube insertion on 2023/05/17 . DBJ was removed on 20230605. We need expertise to evaluate her condition thanks!
  • A
    • we will arrnage USK to evaluate Tx effect after DBJ insertion
• 2023-05-18 Urology
  • Q
    • For on D-J catheterization.
    • This 47-year-old female with ovarin cancer was admitted for Debulking surgery at 20230517.
    • We need your evaluation of her condition for on D-J catheterization.
  • A
    • intrapoerative finding showed tumor attached to right low ureter
    • Bilateral DBJ was inserted
    • tumor was dissected from right low ureter
    • For better healing and stablization after operation, DBJ may be kept for one month til 2023/06/05
    • I had explained to her on 2023/05/18 09:30

[surgical operation]

• 2023-05-17
  • Surgery
    • Operation: Tenckhoff tube insertion
  • Finding
    • Tenckhoff tube over RLQ
  • Procedure
    • Under ETGA, GYN and GU performed operation at first. GS was consulted. Inserted a Tenckhoff tube with exit site over RLQ. Closed the wound with 1# Vicryl and skin staples.
• 2023-05-17
  • Surgery
    • DBJ insertion, bilateral        
  • Finding
    • A 6 Fr 24 cm double-J catheter was inserted to left ureter.
    • A 6 Fr 24 cm double-J catheter was inserted to right ureter.
    • Bladder mucosa seems fair
    • no urin eleakage
    • Pelvic tumor is found medial to low ureter. After dissection, pelvic tumor is dissected from right low ureter as much as possible.
  • Procedure
    • With ETGA, the patient was in lithotomy position. Disinfection and draping the operation field were done as usual methods. Cystoscopy was performed to identify the ureteral orifices. After retrograde insertion of guidewire. A 6 Fr 24 cm double-J catheter was inserted to left ureter. A 6 Fr 24 cm double-J catheter was inserted to right ureter. A 14Fr Foley was inserted. Through open wound by gyn doctor, a firm pelvic tumor is found medial to right low ureter. After fine and blunt dissection, pelvic tumor is dissected from right low ureter as much as possible. The patient stood the procedures well. 
• 2023-05-17
  • Surgery
    • Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma
  • Procedure
    • Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy + )
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: AVFL, with multiple uterine myomas(intramural type, 6x5 / 3x2cm)
      • Some papillary tissue over right uteroscaral ligament, medial to ritght ureter, s/p excision
    • Adnexa:
      • Severe adhesion between bilateral adnexa and posterior uterien wall + cul-de-sac, s/p adhesiolysis
      • LOV cystic mass, 5x4 cm, intraoperative rupture with chocolate-like contents
      • ROV cystic mass, 7x5 cm, intraoperative rupture with papillary tissue and -chocolate-like contents
      • Some papillary lesions was noted over right suspensory ligament and right pelvic lateral wall, s/p excision
    • CDS: severe adhesion
    • Ascites: little, s/p washing cytology
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
    • Omentum: diffuse chocolate spots was noted, suspect related to previous rupture of chocolate cyst; infracolic omentectomy was done.
    • Liver: grossly normal & smooth; Subdiaphragmatic surface: miliary tumor seeding(-)
    • Appendix: grossly normal
    • Previous rupture of chocolate was highly suspected, with diffused chocolate spots over the pelvic wall and and bowel adhesion were noted.
    • After the operation, optimal debulking surgery was achieved; Residual tumor: R0
    • Estimated blood loss: 400ml
    • Blood transfusion: LPRBC 2u
    • Complication: nil
    • 15Fr-Jvac x2 at bilateral Cul-de-sac
    • Antiadhesion agent: interceed x 1 piece

[immunochemotherapy]

• 2023-10-13 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-12 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-15 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-24 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-03 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-14 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr (adjuvant Avastin 15mg/kg IVD Q3W x 6 + 12~15 for 15mo)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-13

After reviewing the PharmaCloud database and the hospital’s HIS5 records, no medication reconciliation issues were identified.

2023-08-15

The patient received a 28-day refill of rabeprazole on 2023-08-10. While the active medication list does not show any current use of PPIs, Stogamet (cimetidine) is being used. Therefore, there are no medication reconciliation concerns.

2023-07-25

There are no medication reconciliation issues identified after reviewing the PharmaCloud database and HIS5 records.

2023-07-04

• After reviewing the PharmaCloud database, there is no prior prescription that is still valid now from other healthcare providers or other departments in this hospital.
• However, there is no records of Norvasc refilled in the past few weeks, and this drug should be a prescription medicine which can only be ordered by a doc, and this drug has been included as a patient-carried item in the active medication list, please check if the self-carried Norvasc does not pass its expired date.

700363763

231013

[lab data]

2023-07-17 CMV viral load assay 6060 IU/mL
2023-07-07 CMV viral load assay 331 IU/mL

2023-04-25 MTBC PCR DETECTED CFU/ml
2023-04-25 MTBC PCR Value 10000 - 100000 CFU/ml

[exam findings]

• 2023-07-11 CT - abdomen
  • History and indication: Rectal cancer with obstruction post T-loop colostomy on 4/7 23.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Much regression of rectal cancer. Some tiny LNs at pelvic cavity.
    • Nodules (up to 14mm) at bil. lungs.
    • Renal cysts (up to 1.2cm).
    • Wall thickening of urinary bladder.
    • Small amount pericardial effusion.
    • Atherosclerosis of aorta, iliac arteries.
    • Presence of scoliosis of the lumbar spine.
    • S/P NG tube indwelling.
  • IMP:
    • Much regression of rectal cancer. Some tiny LNs at pelvic cavity.
    • Nodules (up to 14mm) at bil. lungs.
    • Wall thickening of urinary bladder.
• 2023-07-10 CXR (erect)
  • Atherosclerotic change of aortic arch
  • Scoliosis of the T-spine with convex to right side.
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2023-05-15, -05-08, -05-03, -04-27 CXR
  • Port-A catheter inserted via left subclavian vein, its tip overlies Rt paratracheal stripe
  • A poorly defined mass over LUL
  • areas of hyperlucency and decreased upper lung vascular markings due to emphysematous change of both lungs upper lung predominance
  • there is also areas of pulmonary fibrosis in the lungs
  • mild enlarged cardiac silhoutte
• 2023-04-24 Patho - lung transbronchial biopsy
  • Lung, left, CT-guide biopsy — necrotizing granulomatous inflammation with marked interstitial fibrosis
  • Sections show alveolar lung tissue with marked interstitial fibrosis and necrotizing granulomatous inflammation. Several Langhan’s multinuclear giant cells are also seen.
  • The AFB special stain is positive. The PAS special stain is negative. No definite malignancy is found. The immunohistochemical stain of CK reveals no invasive tumor.
• 2023-04-22, -04-20 CXR
  • Patch density at LUL.
  • Blunted left costophrenic angle.
  • Presence of scoliosis of the lumbar spine.
• 2023-04-19 PET
  • Increased FDG uptake at the R-S junction of colon, compatible with rectal malignancy.
    
  • Increased FDG uptake in bilateral peri-rectal lymph nodes, highly suspected rectal cancer with regional lymph nodes metastases.
    
  • Increased FDG uptake in bilateral upper lungs, highly suspected the secondary (priority, colon cancer with lung mets) or another primary (left or right upper lung?) cancer, suggesting biopsy, if necessary, for investigation.
  • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, and in a left SCF lymph node, highly suspected rectal cancer with distant lymph nodes metastases (priority) or lung cancer with regional lymph nodes metastases.
    
  • Highly suspected rectal cancer with regional and distant lymph nodes, as well as bilateral upper lungs metastases, cTxN2M1b, stage IVB (AJCC 8th ed.), or double cancers of rectum and lung, by this F-18 FDG PET scan.
• 2023-04-18 All RAS + BRAF
  • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-04-14 CT - chest
  • Indication: colon cancer with lung metastases
  • Findings
    • Spculated mass at left upper lobe with central lucency is found measuring 3.2cm in largest dimension. In comparison with CT dated on 2020-08-10, the lesion enlarged. Lung cancer is favored.
    • Severe centrilobular Emphysematous change over both lungs is found.
    • Minimal reticulation at bilateral lower lungs is found.
    • Tiny atelectatic change at left lower lobe with minimal left pleural effusion is found.
    • Small lymph nodes are found in the mediastinum. Stationary.
  • Imp: Left upper lobe spiculated mass. r/o lung cancer.
• 2023-04-07 Patho - colon biopsy
  • Colon tumor, rectum, 10 cm above anal verge, biopsy — Adenocarcinoma
  • Microscopically, the sections show a picture of adenocarcinoma characterized by glandular tumor cell infiltrate with stromal desmoplasia.
  • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
• 2023-04-01 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of S-colon with adjacent fat stranding and colon dilatation. Some LNs at pelvic cavity.
    • Nodules (up to 7mm) at bil. basal lungs.
    • Renal cysts (up to 1.2cm).
    • Atherosclerosis of aorta, iliac arteries.
    • Presence of scoliosis of the lumbar spine.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2022-09-05 CXR
  • upper lung hyperlucency and decreased upper lung vascular markings due to emphysema
  • ill-defined nodular opacity at LUL and several nodular opacities at RUL, stationary as compared with previous image
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • Mild dextroscoliosis of the T-spine
• 2022-07-25 CT - brain
  • Findings
    • Generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
  • Imp: Brain atrophy.
• 2020-08-10 CT - chest
  • Indication: RUL nodule
  • Comparison: none prior CT dated on 2017 2018 2019
    • Lungs and large airways:
      • extensive centrilobular emphysema over bilateral lungs upper predominance.
      • ill-defined, dumbell-like nodular opacity in LUL (37-mm in longest dimension) and several solid nodular opacities up to 24-mm in longest dimension in RUL, and minimal fibrotic change at lung apex in the same lobe. several small calcified granulomas in posterior RUL too.
    • Mediastinum: no LAP or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion,
    • Hila: unremarkable.
    • Vessels:
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
    • Heart: dilated RV and RA?
    • Pleura: no effusion.
    • Chest wall and lower neck: unremarkable.
    • Visible abdomen: no abnormal density in visible portion of the liver, spleen, pancreas, kidneys, adrenal glands, and GB.
      • Mild atherosclerotic change of the abdominal aorta.
    • Visualized bones: unremarkable.
  • Impression:
    • newly developed nodular lesions in both upper lobes compared
    • with CT on 2019/03/26, malignancy or MTB?
    • extensive emphysema.
• 2020-03-02 CXR
  • Increased lung volume and areas of lucency and dirty marking due to emphysematous change of both lungs upper lung predominance
  • a small nodular opacity over RUL and a small nodular opacity (ill-defined) over LUL, may be malignant lesions, suggest do CT study Thoracic aortic arch calcified atheriosclerotic plaque
  • mild levoscoliosis of the L-spine
• 2019-12-09 Bronchodilator test
  • mild obstructive ventilatory impairment
• 2019-03-26 CT - chest
  • Comparison: none prior CT dated on 2017 2018 2019
    • Lungs and large airways:
      • extensive centrilobular emphysema over bilateral lungs upper predominance. minimal fibrotic change at RUL. a 6mm subpleural nodule or atelectatic lung tissue at RML.
    • Mediastinum: no LAP or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion,
    • Hila: unremarkable.
    • Vessels:
      • Aorta: normal in caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Pulmonary arteries: normal in caliber.
    • Heart: normal in size.
    • Pleura: small effusion with parietal pleural thickening, Rt.
    • Chest wall and lower neck: unremarkable.
    • Mild atherosclerotic change of the abdominal aorta.
    • Visualized bones: unremarkable.
  • Impression:
    • Rt pleural effusion, exudate.
    • a 6mm subpleural nodule or atelectatic lung tissue at RML.
    • extensive emphysema.

[MedRec]

• 2023-09-01 SOAP Chest Medicine Huang GuoLiang
  • Prescription
    • AKruiT-4 (RIF 150mg, INH 75mg, PZA 400mg, EMB 275mg) 3# QDAC
    • Vit B6 (pyridoxine 50mg) 1# QD
    • Smecta (dioctahedral smectite 3mg) 1# BIDAC
• 2023-08-04 SOAP Chest Medicine Chen XinYi
  • Prescription
    • AKruiT-4 (RIF 150mg, INH 75mg, PZA 400mg, EMB 275mg) 3# QDAC
    • Vit B6 (pyridoxine 50mg) 1# QD
    • Actein Effervescent (acetylcysteine 600mg) 1# BID

[consultation]

• 2023-07-10 Gastroenterology
  • Q
    • for abnormal liver function and jaundice
    • This 79-year-old man, a patient of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. Owing to high TBI 2.98mg/dl was noted during anti-TB drugs related. We need expertise to evaluate his condition thnaks!
  • A
    • This 79-year-old male was a case of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. We are consulted for bilirubin elevation.
      • Communicating with a pen at bedside.
      • No abdomen pain noted
    • A: Bilirubin elevation, suspect drug-induced cholestasis, r/o biliary obstruction
    • P:
      • Pending on Abdomen CT report
      • Check AST, ALT, ALP, rGT, TBI/DBI, ALB, PT, APTT to complete liver study
      • Regular monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
      • Contact us, if any porblems
• 2023-07-10 Chest Medicine
  • Q
    • for Tuberculosis of lung & anti-TB drugs evaluation
    • This 79-year-old man, a patient of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. Owing to high TBI :2.98mg/dl was noted during anti-TB drugs related. We need expertise to evaluate his condition thnaks!
  • A
    • Suggestion:
      • hold anti-TB medication
      • arrange liver echo or abdominal CT to define liver condition. May consult GI
      • for much sputum, do sputum culture, airway clearance, give amikin inhalation for anti-inflammatory effects.
• 2023-06-26 Gastroenterology
  • Q
    • Due to the coffee ground noted via NG and tarry stool found via colostomy, we rechecked lab data for him which was revealed decreased level of Hb (12.3 -> 7.8). Thus, we need your expertise for evaluation of PES due to suspected Upper GI bleeding. Thanks!
  • A
    • 79 male with rectal cancer, s/p chemotherapy and colonostomy. However, due to tarry stool with coffee ground, we are consulted.
      • conscious: clear
      • chest: intubation
      • abdomen: soft and flat
    • impresson
      • UGI bleeding
    • suggestion
      • well inform-consent to the patient and the family, including the indication, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, etc.), and the alternatives (conservative treatment, etc.)
      • if the patient and the family all understand the EGD intervention, would take the risk, and sign the permit for EGD, we would arrange EGD
      • Proton pump inhibitor use
      • Avoid anticoagulants/antiplatelets use, and correct bleeding tendency if any;
      • Arrange adequate blood transfusion and fluid resuscitation for fear of hypovolemic shock;
      • Inform us to follow up if bleeding condition progression or any other GI problem progression
• 2023-06-23 Infectious Disease
  • A
    • Consultation for Mepem antibiotic
      • 79-year-old rectal cancer, COPD and pulmonary TB male patient has a new episode of severe pneumonia, BLL with respiratory failure and severe sepsis now.
      • He was just discharged from our Onco ward two days ago.
      • Use of Mepem acceptable before further culture report available.
    • Suggestion:
      • Continue Mepem for one week first
      • Check blood and sputum culture report.
• 2023-05-24 Dermatology
  • Q
    • This is 78 y/o man who has underlying disease of 1) COPD, 2) Hypertension, 3) GERD, 4) Rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stage IIIC, 5) Tuberculosis of lung under treatment.
    • This time, he complained of abdominal pain and distention for 3 days accompanied with constipation lasting a week. The patient denied chest tightness(-), headache(-), dizziness(-), radiated pain(-), shoetness of breating(-) nauseas(-) and vomitting(-), diarrhea(-). He also denied TOCC history.
    • For skin rash off and on was noted, we need your further evaluation and management. Thanks a lot!!! There are photos on the caregiver’s mobile phone.
  • A
    • The patient had sufferred from discrete reddish swelling papules on the abdomen without pruritus on and off for weeks.
    • xerotic dry skin with post-screthec lesions over four limbs.
      
    • Under the impression of acute urticaria and xerotic dermatits.
    • The following sugeetion:
      • for urticaria, consider keep allegra 1# bid po use -> consider shift to xzyal 1# HS po use if condition turn to stable.
        
      • for xerotic dermatitis, currently apply lotion extensively. Mycomb cream 2 tube topical bid use over itchy reddish papules and sinphraderm 1 tube topical QN use over dry scales.
• 2023-04-28 Hemato-Oncology
  • Q
    • Consult our CRS and then operation of T-colostomy was performed for rectal cancer obstruction on 2023/04/07. General condition is stationary and then transfer to ward on 2023/04/13.
    • Follow chest CT: Left upper lobe spiculated mass, suspect lung cancer, cT2aN0M0 on 2023/04/14.
    • We needs your expert experience for further evaluation and neoadjuvant CCRT. Thaks a lot!!
  • A2 - 2023-04-28
    • This 78 year old man is a case of Rectal cancer with obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM1a stage IVa and suspect lung cancer, cT2aN0M0 on 2023/04/14. We are consulted for further evaluation and CCRT.
    • Please arrange PET CT scan, arrange port A insertion.
    • Please check All-RAS-BRAF, anti HCV, anti HBc, anti HBs, HBsAg.
    • We will discuss with patient about further systemic treatment. Thanks for your consultation.
  • A1 - 2023-04-20
    • Please consult chest surgeon for further OP evaluation. If not suitable operation, may arrange CT guide biopsy for tissue proof (left upper lung lesion).
    • In addition, may also check TB sputum culture. Pending the result. Thanks for your consultation.
• 2023-04-26 Chest Medicine
  • Q
    • For further treatment of TB (Sputum Acid-fast Stain: Positive, MTBC PCR: detected) and take over
      • The uncle of Deputy Director Zheng Jingfeng
      • For deaf and mute individuals, please use written communication
  • A
    • Sputum Acid-fast Stain: Positive, MTBC PCR: detected. recommends isolation and treatment by Infection Control Team.
    • We takeover and give TB medication.
• 2023-04-18 Radiation Oncology
  • A
    • A: Adenocarcinoma of the rectum, stage T4aN2aM1a (stage IVA).
    • P: Neoadjuvant CCRT is indicated for this patient with the following indicators: stage T4aN2aM1a (stage IVA)
      • Goal: palliation
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectal tumor bed.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-04-24.
• 2023-04-07 Colorectal Surgery
  • Q
    • The sigmoidoscopy reveals Rectal cancer obstruction.
    • On 4/7 night, intubation for aspiration pneumonia with acute respiratory failure.
    • Due to Rectal cancer obstruction. consult for colostomy evaluaution. Thanks
  • A
    • RS colon cancer with obstruction for almost 1 week.
    • persist abdomen fullness and aspiration pneumonia
    • CRP: 8 yesterday
    • suggest T colostomy under risk, because bowel inflammation will worse for lont time obstruction.
• 2023-04-07 Infectious Disease
  • A
    • Consultation for Mepem antibiotic
    • Rectal cancer with colon obstruction and severe sepsis case.
    • Serial CxR films showed newly developed pneumonia.
    • Please continue Mepem for 5 days first.
    • Check blood and sputum culture report.

[surgical operation]

• 2023-04-07
  • Surgery
    • T colostomy
  • Finding
    • Severe dilation of T colon and mild ischemia
    • T colon ulcer

[radiotherapy]

[chemotherapy]

• 2023-10-12 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-09-21 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-09-07 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-08-08 - leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX without Ox)
  • dexamethasone 4mg + NS 250mL
• 2023-06-13 - leucovorin 20mg/m2 25mg NS 250mL 10min D1-5 + fluorouracil 225mg/m2 300mg NS 100mL 10min D1-5 (CCRT)
  • [dexamethasone 4mg + NS 250mL] D1-5
• 2023-05-16 - fluorouracil 225mg/m2 300mg NS 100mL 10min D1-5 (CCRT)
  • [dexamethasone 4mg + NS 250mL] D1-5

==========

2023-10-13

After reviewing the PharmaCloud database and the hospital’s HIS5 records, no medication reconciliation issues were identified.

2023-09-05

[tube feeding]

As the adsorbent properties of this product may interfere with the rates and/or levels of absorption of other substances, it is recommended not to administer any other drugs at the same time as SMECTA. ref: https://www1.ndmctsgh.edu.tw/pharm/pic/medinsert/005SME01E.pdf

[hyperbilirubinemia follow-up]

2023-09-04 Bilirubin total 1.55 mg/dL
2023-08-11 Bilirubin total 1.61 mg/dL
2023-08-07 Bilirubin total 2.16 mg/dL
2023-07-17 Bilirubin total 1.43 mg/dL
2023-07-12 Bilirubin total 2.04 mg/dL
2023-07-10 Bilirubin total 2.98 mg/dL

2023-09-04 Bilirubin direct 0.74 mg/dL
2023-08-11 Bilirubin direct 0.64 mg/dL
2023-08-07 Bilirubin direct 1.03 mg/dL
2023-07-17 Bilirubin direct 0.59 mg/dL
2023-07-12 Bilirubin direct 1.06 mg/dL
2023-07-10 Bilirubin direct 1.61 mg/dL

At present, the patient’s bilirubin levels are lower than what was observed in mid-July, even after resuming AKruiT-4 on 2023-08-04.

It’s worth noting that AKruiT-4 is being administered alongside Smecta, which is not advisable. Smecta has the potential to alter the rate or level of AKruiT-4 absorption.

2023-07-13

[optional addition of Genurso for hyperbilirubinemia]

The addition of Genurso (ursodeoxycholic acid 100mg) #1 or #2 TID might be considered to help alleviate the patient’s hyperbilirubinemia. ref: Anti-Tuberculosis Drug Induced Liver Injury and Ursodeoxycholic Acid. Journal of Tuberculosis Research, Vol.8 No.2, 2020. https://doi.org/10.4236/jtr.2020.82007

2023-07-12

[approach to hepatotoxicity caused by antituberculous drugs]

AKuriT-4 was ceased on 2023-07-10, with bilirubin levels subsequently falling, though they still remain above twice the upper limit of normal (ULN).

• 2023-07-12 Bilirubin total 2.04 mg/dL
  
• 2023-07-10 Bilirubin total 2.98 mg/dL
  
• 2023-06-26 Bilirubin total 2.15 mg/dL

As per the “Approach to hepatotoxicity caused by first-line antituberculous drugs in adults” from UpToDate (https://www.uptodate.com/contents/image?imageKey=ID%2F109447), when the bilirubin level is less than 2mg/dL and the enzyme levels are less than twice the upper limit of normal, either a regimen made up of liver-sparing drugs (like ethambutol, a fluoroquinolone or linezolid) may be considered or the gradual reintroduction of first-line agents may be done.

Another study released in the New England Journal of Medicine in 2021 titled “Four-Month Rifapentine Regimens with or without Moxifloxacin for Tuberculosis” deduced that the effectiveness of a four-month regimen based on rifapentine, with or without moxifloxacin, was not inferior to the standard six-month regimen in the treatment of tuberculosis. The manufacturer’s guidelines for rifapentine do not include suggestions for dose adjustments in patients with hepatic impairment. It is believed that the pharmacokinetics of rifapentine in patients with varying degrees of hepatic impairment are similar to those in healthy volunteers.

2023-06-07

[following up on bilirubin and albumin levels]

• Laboratory data indicates that both total and direct bilirubin levels have started to decrease, though they have not yet returned to the normal range. This suggests that the current AKuriT-4 regimen is less likely to have a continuously damaging effect on the liver.
  • 2023-06-06 Bilirubin total 1.24 mg/dL
    
  • 2023-06-06 Bilirubin direct 0.53 mg/dL
    
  • 2023-05-29 Bilirubin total 1.54 mg/dL
    
  • 2023-05-29 Bilirubin direct 0.74 mg/dL
• Moreover, the patient’s albumin level has dropped to a record low of 2.3g/dL. Given that the patient’s kidney function appears normal (Cre 0.98 mg/dL, eGFR 78, BUN 16 mg/dL), the possibility of protein loss due to nephrotic syndrome is less likely. With bowel movements recorded at less than or equal to 3 since June, protein-losing enteropathy also appears less likely. If we rule out malnutrition as a cause, reduced albumin synthesis such as that seen in liver disease could potentially be the reason, warranting further investigation. Please monitor for signs of edema.
  • 2023-06-06 Albumin 2.3 g/dL
    
  • 2023-05-29 Albumin 2.6 g/dL

2023-06-01

[AKuriT-4 follow-up]

• Today, after discussing the patient’s condition with the attending physician and nurse practitioner, I learned that the changes in the patient’s liver function indicators have already been discussed with Dr. Su from the thoracic department. It is believed that there is no need to adjust the medication at this time.

2023-05-31

• A blood transfusion was performed on 2023-05-15 due to the patient’s low hemoglobin (HGB) levels. However, recent lab results still show a decreasing trend in HGB and a stool occult blood test result of 2+, which could suggest the possibility of ongoing GI bleeding. Although the patient is currently on a PPI (esomeprazole), if an upper GI source is suspected, the addition of tranexamic acid may be beneficial to control bleeding.
  • 2023-05-29 HGB 11.0 g/dL
    
  • 2023-05-26 HGB 12.0 g/dL
    
  • 2023-05-15 HGB 9.1 g/dL
    
  • 2023-05-26 stool OB 2+
• Furthermore, the patient’s serum albumin levels seem to be dropping. It’s recommended that the patient increase his protein intake, and nutritional support might be needed. If these measures are implemented and hypoalbuminemia persists, it might be necessary to consider adding an albumin supplement.
  • 2023-05-29 Albumin 2.6 g/dL
    
  • 2023-05-15 Albumin 2.6 g/dL
    
  • 2023-05-08 Albumin 2.9 g/dL
    
  • 2023-05-03 Albumin 2.9 g/dL
    
  • 2023-04-27 Albumin 3.1 g/dL
• This patient is currently being treated for lung TB with AKuriT-4 (rifampin 150mg + isoniazid 75mg + pyrazinamide 400mg + ethambutol 275mg) since 2023-04-26. Rifampin is associated with hepatotoxicity, which can manifest in various patterns including asymptomatic abnormal liver function tests, isolated jaundice or hyperbilirubinemia, symptomatic self-limited hepatitis, or even fulminant hepatic failure and death. Despite the patient’s AST and ALT levels being within normal range as of 2023-05-29, there has been a continuous increase in the patient’s bilirubin levels in 2023-05. This continuous increase in the patient’s bilirubin levels might potentially suggest rifampin-induced hepatotoxicity, particularly once other causes of elevated bilirubin, such as hemolysis, have been ruled out.
  • 2023-05-29 Bilirubin total 1.54 mg/dL
    
  • 2023-05-26 Bilirubin total 1.07 mg/dL
    
  • 2023-05-15 Bilirubin total 0.79 mg/dL
    
  • 2023-05-08 Bilirubin total 0.80 mg/dL
    
  • 2023-05-03 Bilirubin total 0.62 mg/dL
    
  • 2023-05-29 Bilirubin direct 0.74 mg/dL
    
  • 2023-05-26 Bilirubin direct 0.44 mg/dL
    
  • 2023-05-15 Bilirubin direct 0.29 mg/dL
    
  • 2023-05-03 Bilirubin direct 0.14 mg/dL

700711453

231013

{not completed}

[exam findings]

• 2023-10-06 SONO - abdomen

  • Diagnosis:
    • Suspected chronic liver parenchyma disease
    • Liver tumor, right. Propable metastases
    • Suspected liver cyst, right
    • Pancreatic tumor, body
    • S/p PTGBD
    • Mild IHD dilatation, bil
    • Suboptimal examination of liver, especially the subcostal view due to poor echo window
  • Suggestion:
    • Please correlate with other image, liver function test and follow AFP, CA-199
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed

• 2023-10-05 Abdomen - standing (diaphragm)

  • Calcified pelvic mass, probably calcified uterine fibroid.
  • marginal spurs of multiple vertebral bodies of L-spine due to spondylosis.
  • S/P Percutaneous gallbladder drainage.

• 2023-10-02 Percutaneous Gall Bladder Drainage, PTGBD

• 2023-10-02 CT - abdomen

  • Abdominal CT with and without enhancement revealed:
    • Severely dilated IHDs and CBD and proximal pancreatic duct is found. The GB is severely distended with wall thickening. Mass like lesion at pancreatic body with extending to celiac trunk is found. In comparison with CT dated on 2023-06-24, the mass enlarged
    • There is one low density lesio at S5/6 measuring 3.5cm is found. Traction of right lobe liver surface is found.
    • Calcified dot at uterus is found. Myoma calcification is consiered.
  • Imp:
    • Pancreatic body tumor with celiac trunk lymphadenopathy and compression of pancreatic duct and biliary tree, causing severe cholecystitis. Suggest further treatment.

• 2023-10-02 ECG

  • Sinus tachycardia with Premature atrial complexes
  • T wave abnormality, consider anterior ischemia
  • Abnormal ECG

• 2023-06-24 CT - abdomen

  • History and indication: Malignant neoplasm of pancreas
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Much regression of pancreatic cancer (1.1cm) and liver metastases (2.0cm). Fat stranding at upper mediastinum with vascular encasement.
    • Some calcifications (up to 3.4cm) at pelvic cavity. R/O uterine myoma (2.5cm).
    • Colonic diverticula.
    • Atherosclerosis of aorta.
  • IMP:
    • Much regression of pancreatic cancer (1.1cm) and liver metastases (2.0cm). Fat stranding at upper mediastinum with vascular encasement.

• 2023-03-30 Patho - pancreas biopsy

  • Pancreas, EUS FNB — Ductal adenocarcinoma, poorly differentiated
  • The sections show a picture of ductal adenocarcinoma, composed of nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasm arranged in solid and cribriform patterns, embedded in fibrous stroma. Subtle mucin secretion is present.

• 2023-03-30 Patho - liver biopsy needle/wedge

  • Liver, EUS FNB — Adenocarcinoma, consistent with metastatic pancreatic ductal adenocarcinoma.
  • The sections show a picture of adenocarcinoma, composed of liver tissue with nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasma in fibrous stroma. Focal ductal differentiation and mucin secretion are present. The finding is consistent with metastatic pancreatic ductal adenocarcinoma.

• 2023-03-28 Patho - liver biopsy needle/wedge

  • Liver, CT-guided biopsy — Adenocarcinoma, pancreatobiliary-type, compatible with metastatic pancreatic ductal adenocarcinoma.
  • The sections show a picture of adenocarcinoma, pancreatobiliary-type, moderately differentiated, composed of nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasma in fibrous stroma. Focal ductal differentiation and mucin secretion are present.
  • IHC shows: CK7(+), CA19-9(+), CK20(-), and Hepatocyte(-). The finding is compatible with metastatic pancreatic ductal adenocarcinoma.

• 2023-03-17 CT - abdomen

  • CC: Severe epigastric hunger pain and loss 6 kgs (42 to 36 Kgs) for 2 months.
    • 2023/03/14 Ca 19-9 > 150
  • Past history: Hearing impairment. Uterine myoma.
  • Findings:
    • There is an ill-defined poor enhancing mass measuring 2.6 cm in the pancreatic body-tail junction, causing the upstream pancreatic duct dilatation that is c/w adenocarcinoma.
      • In addition, there is soft tissue lesions in the celiac trunk area with encasement that is c/w tumor invasion (T4).
    • There is an ill-defined poor enhancing mass measuring 3.3 cm in right lobe liver that is c/w metastasis (M1).
      • In addition, there is another poor enhancing lesion 0.8 cm in S4 of the liver. Metastasis is also highly suspected.
    • There are three calcified masses in the pelvis, the largest one 3.3 cm, that are c/w uterine fibroids.
    • The gallbladder shows small size. please correlate with clinical condition.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T4 (T_value) N:N0 (N_value) M:M1 (M_value) STAGE:IV

• 2022-11-09 ENT SONO - head and neck soft tissue

  • Clinical Impression/Intent：right thyroid tumor
  • Sonographic Impression：right thyroid isoechoic tumor, margin clear, with microcalcification

• 2021-02-03 ENT SONO - head and neck soft tissue

  • Clinical Impression/Intent：thyroid nodule?
  • Sonographic Impression：bilateral thyroid nodule

• 2021-01-27 ENT Hearing Test

  • Tymp bil type A
  • ART
    • RE absent
    • LE 1000-4000 Hz reduced thretholds
  • PTA:
    • Reliability FAIR
    • Average RE >120 dB HL, LE 53 dB HL
    • RE profound SNHL
    • LE mild to profound SNHL

• 2018-03-19 Pure Tone Audiometry

  • Reliabilty Fair
  • R’t : >120 dB HL, profound HL
  • L’t : 49 dB HL, mild to severe SNHL

[MedRec]

[Consultation]

[chemotherapy]

• 2023-09-05 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-08-29 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-08-15 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-08-08 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-07-25 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-07-11 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-07-04 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-06-20 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-06-13 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-05-30 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-05-23 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-05-09 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-05-02 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-04-18 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-04-10 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

[note]

gemcitabine 2023-04-11 https://www.uptodate.com/contents/gemcitabine-drug-information

• Pancreatic cancer, locally advanced or metastatic:
  • IV: Initial:
    • 1,000 mg/m2 over 30 minutes once weekly for 7 weeks followed by 1 week rest; then administer on days 1, 8, and 15 every 28 days or
  • Off-label dosing/combinations: IV:
    • 1,000 mg/m2 days 1, 8, and 15 every 28 days (in combination with paclitaxel [protein bound]) or
    • 1,000 mg/m2 over 30 minutes days 1, 8, and 15 every 28 days (in combination with capecitabine) or
    • 1,000 mg/m2 over 30 minutes weekly for up to 7 weeks followed by 1 week rest; then weekly for 3 weeks out of every 4 weeks (in combination with erlotinib) or
    • 1,000 mg/m2 over 30 minutes days 1 and 15 every 28 days (in combination with cisplatin) or
    • 1,000 mg/m2 infused at 10 mg/m2/minute every 14 days (in combination with oxaliplatin).

==========

2023-10-13

The patient’s body weight was recorded as 33.7kg on 2023-10-09. It may be prudent to monitor for potential adverse reactions as administering standard doses to underweight individuals may increase the risk of side effects.

700736980

231013

{Neuroendocrine carcinoma}

[exam findings]

• 2023-09-12 KUB
  • Lumbar spondylosis.
• 2023-09-12 SONO - nephrology
  • Chronic renal parenchymal disease, moderate degree
  • Right renal cyst
  • Left hydronephrosis, mild to moderate degree
  • Left renal cysts
  • r/o mass lesion in the pelvic area
• 2023-08-25 CT - chest
  • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate with lung mets
  • Findings
    • Lungs:
      • no interval change of a subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with CT on 2023/04/25.
      • resolution of Rt apical lung solid nodule.
      • a new small nodule at LLL-S9.
      • dependent subpleural nodular consolidations at both lower lobes
      • mild subpleural paraseptal emphysema at both apical lung regions.
    • Mediastinum and hila: no enlarged LN or mass.
      • moderate calcified plaques of the LAD and right coronary arteries.
        
    • Visible abdominal-pelvic contents:
      • progressive increase in size of infiltrative prostate tumor with adjacent organs invasion and Lt pelvic side metastatic LAP compared with CT (2023/04/25).
      • many small hepatic and renal cysts (up to 2.0cm)
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • prostate with regional organs involvement and pelvic metastatic LAP and lung metastases,in progression compared with CT (2023/04/25).
    • suspect lower lobes infection or organzing pneumonia.
• 2023-06-07 All-RAS + BRAF mutation
  • Tissue Block No: S2023-03264
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-03 MRI - pelvis
  • With and without enhancement MRI: Pelvis
    • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. with progression .
    • No significant nodule in the liver.
    • Enlarged lymph nodes in left obturator, bilateral internal iliac regions, perirectal regions, could be due to metastatic lymph node.
      
    • No ascites.
    • Non-enhancing nodules in bilateral kidneys (up to 2cm in left kidney), r/o renal cysts.
  • Impression:
    • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression.
    • R/O bilateral renal cysts.
• 2023-04-25 CT - chest
  • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate with lung mets
  • Comparison was made with previous CT dated on 2023/02/02
    • Lungs:
      • no interval change of a small subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with CT on 2023/02/02.
      • a new solid nodule at Rt apical lung (7mm)
      • minimal subpleural fibrosis at both lower lobes and RML.
      • mild subpleural paraseptal emphysema at both apical lung regions.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels:
      • mild calcified plaques of the LAD and right coronary arteries.
    • Aorta: normal caliber of thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal-pelvic contents:
      • progressive in size of infiltrative prostate tumor with adjacent organs invasion and Lt pelvic side metastatic LAP compared with previous abd. CT (2022/06/17) and MRI (2022/10/26).
      • many hepatic and renal cysts (up to 2.0cm)
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression: prostate with regional organs involvement and pelvic metastatic LAP and lung metastases.
• 2023-03-21 SONO - nephrology
  • Chronic renal parenchymal disease, mild to moderate degree
  • Bilateral renal cysts
• 2023-03-07 ENT Hearing Test
  • Tymp: Bil type A.
  • PTA
    • Reliability FAIR
    • Average RE 29 dB HL; LE 31 dB HL.
    • RE normal to moderate SNHL.
    • LE normal to moderately severe SNHL.
• 2023-02-02 MRI - pelvis
  • With and without enhancement MRI: Pelvis
    • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. with partial response.
    • Non-enhancing nodules in bilateral kidneys (up to 2cm in left kidney), r/o renal cysts.
  • Impression:
    • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. With partial response.
    • R/O bilateral renal cysts.
• 2023-02-02 CT - chest
  • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate s/p C/T
  • Imp: No evidence of recurrent/residual tumor in the study.
• 2022-10-26 CT - chest
  • Indication: Prostate NEC with rectal invasion s/p C/T
  • Comparison was made with previous CT dated on 2022/06/17
    • Lungs:
      • no interval change of a small subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with previous CT on 2022/06/17.
      • minimal subpleural fibrosis at both lower lobes.
      • mild subpleural paraseptal emphysema at both apical lung regions.
    • Vessels:
      • mild calcified plaques of the LAD and right coronary arteries.
    • Visible abdominal-pelvic contents:
      • many hepatic and renal cysts (up to 2.0cm)
    • Visualized bones:
      • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression: four small lung nodules up to 7mm, stationary, some may be intrapulmonary LNs.
• 2022-10-26 MRI - pelvis
  • Clinical history: 61 y/o male patient with Prostate NEC with rectal invasion s/p C/T.
  • With and without enhancement MRI: Pelvis
    • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Stationary.
    • Non-enhancing nodules in bilateral kidneys (up to 1.7cm in right kidney), r/o renal cysts.
  • Impression:
    • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Stationary.
    • R/O bilateral renal cysts.
• 2022-09-06 SONO - nephrology
  • Chronic renal parenchymal disease, mild degree
  • Bilateral renal cysts
• 2022-06-17 CT - abdomen, pelvis
  • Findings
    • Prior CT identifed a well-defined heterogeneous mass in between the rectum and prostage, measuring 9 cm in size, is noted again, marked decreasing in size that is c/w neuro-endocrine carcinoma S/P C/T with partial response.
    • Prior CT identified a soft tissue nodule at RLL of the lung measuring 7 x 4 mm at lung window setting is noted again, stationary. Follow up is indicated.
    • Liver and renal cysts (up to 2.0 cm).
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, and spleen.
  • Impression
    • Neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response.
• 2022-04-08 MRI - brain
  • No evidence of intracranial lesion.
• 2022-03-11 Pure Tone Audiometry, PTA
  • PTA
  • Reliability FAIR
  • Average RE 30 dB HL; LE 36 dB HL.
  • R’t normal to moderate SNHL.
  • L’t normal to moderately severe SNHL.
• 2022-03-01 Patho - prostate needle biopsy
  • “pelvic tumor/peri-prostatic tumor, 9 cm with possible prostatic and recal invasion”, needle biopsy — neuroendocrine tumor.
  • IHC stains:
    • CD56 (+): neuroendocrine origin,
    • CK7 (- to equivocal), CK20 (-): dis-favor rectal adenocarcinoma,
    • vimentin (-): dis-favor sarcoma,
    • CD3 (-), CD20 (-): non-lymphoma,
    • PSA (-): non-prostatic origin.
    • Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
• 2022-02-24 Transrectal Ultrasound of Prostate, TRUS-P
  • huge pelvic mass with suspected prostate invasion
• 2022-02-24 Sigmoidoscopy
  • A hard, portuding lesion with intact mucosa was noted at rectum, anterior wall.
• 2022-02-21 CT - abdomen, pelvis
  • A heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion suspected malignancy.
  • A nodule (4mm) at RLL.

[MedRec]

• 2023-09-17 POMR Urology You Chicin
  • Course of Inpatient treatment
    • After admission, pre-operation survey was within normal range. Cystoscopic exam was smoothly done on 2023/09/18. After operation, There were no fever or infetious signs noted. We had suggested the patient to receive PCN to reserve his renal function on 09/19. However, the patient refused to receive PCN during this admission and he would like to discuss with Doctor Xia.
    • Urination was normal after removing Foley in 09/19 morning. We arranged his discharge on 2023/09/19 and his follow-up at Doctor You’s out-patient clinic on 2023/09/26.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Transamin (tranexamic acid 250mg) 1# BID
• 2023-09-12 SOAP Nephrology Hong SiCun
  • Prescription x3
    • Pentop (pentoxifylline 400mg) 1# QD
• 2023-08-24 ~ 2023-09-01 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy with Etoposide/Carboplatin from 2022/03/14~2022/08/09 for 6 cycles with extracapsular, seminal vesicle and left pelvic side wall invasion and pelvic lymph nodes metastases s/p chemotherapy with Topotecan(1.5mg/m2) from 2023/05/12~2023/07/27 (5th dose), disease progression, s/p chemotherapy with FOLFOX from 2023/08/29~
    • Chronic viral hepatitis B without delta-agent
    • Gout, unspecified
    • Essential (primary) hypertension
    • Anemia due to antineoplastic chemotherapy
    • Chronic kidney disease, stage 2 (mild)
    • Hordeolum externum right lower eyelid
    • Hypomagnesemia
    • Constipation, unspecified
  • CC
    • For further anti-cancer management
  • President illness
    • This 62-year-old man patient suffered from anal protruding mass with pain and bleeding in 2022/02. The abdominal CT scan on 2022-02-21 showed a heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion, in addition with a suspicious metastatic nodule (4mm) at RLL. The sigmoidoscopy on 2022-02-24 showed the possibility of external compression, rectum and mixed hemorrhoid.
    • The TRUS biopsy for pelvic tumor was done on 2022-03-01 and the report of biopsy showed IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma, IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
    • Port-A catheter insertion was done on 2022-03-11. Chemotherapy with EP (Etoposide 80mg x3 days, Carboplatin AUC:6) on 2022/03/14(C1). 2022/04/08(C2), 2022/05/16(C3), 2022/06/14(C4), 2022/07/06(C5), 2022/08/09(C6).
    • Brain MRI on 2022/04/08 showed no evidence of intracranial lesion.
    • The follow-up abdominal CT scan on 2022-06-17 showed neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response. Then he was treated with oral etoposide.
    • The follow-up Chest CT on 2023-04-25 showed prostate with regional organs involvement and pelvic metastatic LAP and lung metastases. Pelvis MRI on 2023-05-03 showed 1. Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression. 2. R/O bilateral renal cysts. He received chemotherapy with Topotecan (1.5mg/m2, D1~D5)(self pay) on 2023/05/12(C1), 2023/06/06(C2), 2023/06/28(C3), 2023/07/12(C4), 2023/07/27(C5). Taken altogether, his disease was in progression.
    • This time, he presented with right side lower eyelid redness and protrusion for 2-3days.
    • Now, he was admitted to ward for chest CT for re-staging and receive palliative chemotherapy with Topotecan(C6)(reduce Topotecan dose(total dose 1.8mg) for prevention thrombocytopenia after chemotherapy).
  • Course of inpatient treatment
    • After admission, Right side lower eyelid redness and protrusion for 2-3days was noted, consult oph for right side lower eyelid redness and protrusion evaluation, Hordeolum, od, s/p I&C with Cravit 1gtt QID od + Tetracycline oint 1qs BID od.
    • Chronic kidney disease, stage 2 (Cr.:1.52 mg/dL, BUN:26 mg/dL), given NS 500ml IVF Q8H hydration and Pentop 1# po QD, before chemotherapy.
    • Anemia due to antineoplastic chemotherapy, BT PRBC 2unit on 2023/08/24 for correction.
    • Arranged chest CT for cancer survey on 2023/08/25 showed prostate with regional organs involvement and pelvic metastatic LAP and lung metastases, in progression compared with CT (2023/04/25). suspect lower lobes infection or organzing pneumonia.
    • He received FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) due to disease progression, from 2023/08/29~2023/08/31(C1D1) smoothly.
    • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
    • Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC.
    • Gout with Feburic 80mg 0.5# po QD.
    • Hypertension with Concor 5mg/tab 1# PO QD.
    • Hypomagnesemia with Magnesium Sulfate 10%, 20mL/amp 1amp IVD BID was given for support.
    • Constipation with Through 12mg/tab 2# PO HS.
    • Post chemotherapy with Oxalip, given B-Red 1mg/mL/amp 1amp IM ST for avoid sensory peripheral neuropathies on 2023/08/31.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/09/01 and OPD followed up later.       
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Feburic (febuxostat 80mg) 0.5# QD
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Concor (bisoprolol 5mg) 1# QD
    • Through (sennoside 12mg) 2# HS
• 2023-07-12 ~ 2023-07-16 POMR Hemato-Oncology
  • Discharge diagnosis
    • Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy with Etoposide/Carboplatin from 2022/03/14 to 2022/08/09 for 6 cycles with extracapsular, seminal vesicle and left pelvic side wall invasion and pelvic lymph nodes metastases s/p chemotherapy with Topotecan (1.5mg/m2) from 2023/05/12~    
    • Chronic viral hepatitis B without delta-agent
    • Gout, unspecified
    • Chronic kidney disease, stage 2 (mild)
    • Essential (primary) hypertension
  • CC
    • For further anti-cancer management
  • Present illness
    • This 62-year-old man patient suffered from anal protruding mass with pain and bleeding in 2022/02. The abdominal CT scan on 2022-02-21 showed a heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion, in addition with a suspicious metastatic nodule (4mm) at RLL. The sigmoidoscopy on 2022-02-24 showed the possibility of external compression, rectum and mixed hemorrhoid.
    • The TRUS biopsy for pelvic tumor was done on 2022-03-01 and the report of biopsy showed IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma, IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
    • Port-A catheter insertion was done on 2022-03-11. Chemotherapy with EP (Etoposide 80mg x3 days, Carboplatin AUC:6) on 2022/03/14(C1). 2022/04/08(C2), 2022/05/16(C3), 2022/06/14(C4), 2022/07/06(C5), 2022/08/09(C6). Brain MRI on 2022/04/08 showed no evidence of intracranial lesion. The follow-up abdominal CT scan on 2022-06-17 showed neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response. Then he was treated with oral etoposide.
    • The follow-up Chest CT on 2023-04-25 showed prostate with regional organs involvement and pelvic metastatic LAP and lung metastases. Pelvis MRI on 2023-05-03 showed 1. Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression. 2. R/O bilateral renal cysts. He received chemotherapy with Topotecan (1.5mg/m2, D1~D5) (self pay) on 2023/05/12(C1), 2023/06/06(C2), 2023/06/28(C3). Taken altogether, his disease was in progression. Now, he was admitted to ward for palliative chemotherapy with Topotecan (C4) (reduce Topotecan dose (total dose 1.8mg) for prevention thrombocytopenia after chemotherapy) on 2023-07-12.
  • Course of inpatient treatment
    • After admitted, Palliative chemotherapy with Topotecan (C4) (reduce Topotecan dose (total dose 1.8mg) for prevention thrombocytopenia after chemotherapy) on 2023-07-12 ~ 2023-07-16.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC. Chronic kidney disease, stage 2 (mild) (Cr.:1.26mg/dL, BUN:27mg/dL) with NS 500ml IVF BID and Pentop 1# po QD. Gout with Feburic 80mg 0.5# po QD. Hypertension with Concor 5mg/tab 1# PO QD.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/07/16 and OPD followed up later.
  • Discharge prescription
    • Febric (febuxostat 80mg) 0.5# QD
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Acetal (acetaminophen 500mg) 1# PRNQ6H for fever, BT > 38’C or bone pain after G-CSF
    • Granocyte (lenograstim 250ug) QD SC on 2023/07/20, 2023/07/21, 2023/07/22
• 2023-06-13 SOAP Nephrology
  • S: UPCR < 0.1 -> 1.71 -> 1.43
  • Prescription x3
    • Pentop (pentoxifylline 400mg) 1# QD
• 2022-11-01 SOAP Nephrology
  • S: UPCR < 0.1
    • ChatGPT:
      • In the medical context, UPCR stands for Urine Protein to Creatinine Ratio. This is a test often used to estimate the amount of protein being excreted in the urine, and to assess and monitor kidney function.
      • Proteinuria (protein in the urine) is a common finding in many renal diseases. Creatinine, on the other hand, is a waste product that’s typically excreted at a constant rate.
      • The ratio of protein to creatinine can provide a good estimate of protein excretion over 24 hours without needing a 24-hour urine collection. High levels of protein in the urine, indicated by a high UPCR, can be a sign of kidney disease.
  • Prescription x2
    • Pentop (pentoxifylline 400mg) 1# QD
• 2022-10-04 SOAP Nephrology
  • S: Cr 1.89, add Trental (pentoxifylline) and follow up one month
  • Prescription
    • Pentop (pentoxifylline 400mg) 1# QD
• 2022-09-06 SOAP Nephrology
  • S
    • CKD for follow up
    • r/o carboplatin associated kidney injury, suggest follow up at regular interval
  • A/P
    • Admission for C/T EP on 2022-07-06. Using carboplatin due to impaired renal function
    • NEC, Stage IV
• 2022-07-27 SOAP Hemato-Oncology Xia HeXiong
  • Admission for C/T EP (Carboplatin) on 2022-08-03. Using carboplatin due to impaired renal function
  • Considered hold platinum after 6 cycles of chemotehrapy, and might shift IV VP-16 to oral VP-16 after 6 cycles of EP on 2022-08-03
  • NEC, Stage IV
  • Avoid K+ food

[consultation]

• 2023-08-24 Ophthalmology
  • Q
    • The patient is an 62-year-old male with a history of Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy with Etoposide/Carboplatin from 2022/03/14~2022/08/09 for 6 cycles with extracapsular, seminal vesicle and left pelvic side wall invasion and pelvic lymph nodes metastases s/p chemotherapy with Topotecan(1.5mg/m2) from 2023/05/12~, HTN, Chronic kidney disease, stage 2.
    • He presented with lower eyelid redness and protrusion for 2-3days, we need your further evaluation and management.
  • A
    • For right lower eyelid swelling
    • S
      • Past hx:
        • Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy
        • HTN
        • Chronic kidney disease, stage 2
      • OPH hx: dneied
      • NKDA
    • O
      • nVA: 20/25 ou
      • PT: 13/14mmHg
      • pupil: 3mm, +/+, no RAPD
      • Hordeolum at right lower eyelid
      • K: cl ou
      • AC: D/C ou
      • lens: NS+ ou
    • A:
      • Hordeolum, od, s/p I&C
    • P:
      • pressure patch for 30mins, avoid water contact
      • Cravit 1gtt QID od + Tetracycline oint 1qs BID od
      • pus culture has been arranged
      • Inform the risk of progression, come back earlier if s/s worsen
      • OPD f/u
• 2022-05-10 Oral and Maxillofacial Surgery
  • Q
    • The 61y/o male has neuroendocrine carcinoma under chemotherapy. He has toothache at the second to last molar on the lower right. He took amoxicillin for 2-3 days, but in vain, so we need your help for management. Thanks!
  • A
    • Dear doctor, this is a 61-year-old male iwth neuroendocrine carcinoma and was admitted for chemotherapy.
    • He complained of biting pain recently and we are therefore consulted
    • After examiantion (radiologic study), fractured root of right lower first molar was noted
    • Assessment:
      • Tooth fractureo of #46
    • Plan:
      • Explain the findings to the patient and his family members
      • Premedication (Continue using the current inpatient antibiotic, Augmentin.)
      • Arrange extraction of tooth 46 on Thursday (05/12) in the morning.

[surigcal operation]

• 2023-09-18
  • Surgery: Cystoscopic exam
  • Finding
    • enlarged prostate
    • tumor invasion of bladder neck
    • bilateral UO could not be found due to tumor invasion

[chemotherapy]

• 2023-10-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-20 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-29 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 400mg/m2 740mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-27 - topotecan 1.5mg/m2 1.8mg NS 60mL 30min D1-5
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
• 2023-07-12 - topotecan 1.5mg/m2 1.8mg NS 60mL 30min D1-5 (even lower topotecan)
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
• 2023-06-28 - topotecan 1.5mg/m2 2.0mg NS 60mL 30min D1-2 + topotecan 1.5mg/m2 1.8mg NS 60mL 30min D3-5 (reduce dose for prevention thrombocytopenia after chemotherapy)
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
• 2023-06-06 - topotecan 1.5mg/m2 2.0mg NS 60mL 30min D1-5 (lower topotecan)
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
• 2023-05-12 - topotecan 1.5mg/m2 2.5mg NS 80mL 30min D1-5
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
• 2022-08-09 - etoposide 80mg/m2 140mg 1hr D1-3 + carboplatin AUC 6 450mg 2hr D1
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-07-06 - etoposide 80mg/m2 140mg 1hr D1-3 + carboplatin AUC 6 450mg 2hr D1
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-06-14 - etoposide 80mg/m2 137mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-05-16 - etoposide 80mg/m2 140mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-04-07 - etoposide 80mg/m2 139mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-03-14 - etoposide 80mg/m2 140mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-13

According to the PharmaCloud database, there are no recent records of the patient seeking services from other medical facilities. In addition, Pentop (pentoxifylline) prescribed by our nephrologist on 2023-09-12 is currently being used without any discrepancies noted.

The 5FU bolus was omitted from the FOLFOX regimen during this hospital stay due to a reduced WBC count, recorded at 3.08K/uL on 2023-10-12.

2023-09-21

According to PharmaCloud, there are no records of this patient seeking medical care at other facilities in the past three months. Our nephrologist has issued a repeat prescription for Pentop (pentoxifylline) to manage his CKD, and the medication is currently being used with no discrepancies identified.

2023-07-28

[reconciliation]

On 2023-07-07, the patient renewed prescriptions for bisoprolol and valsartan. Currently, only bisoprolol is listed as an active medication, and valsartan has not been included. As the patient’s blood pressure has consistently remained within the normal range during this hospital stay, there may not be an immediate need to reintroduce valsartan. Nevertheless, it is crucial to continue monitoring the patient’s blood pressure to assess if any further adjustments to the medication regimen are necessary.

[renal function follow-up]

This month (July), compared to previous months, the serum creatinine has returned to the normal range, and currently, no medications require renal dosage adjustment.

[thrombocytopenia]

Since starting topotecan on 2023-05-12, the patient has experienced several episodes of thrombocytopenia. Blood transfusions were administered on 2023-06-14, 2023-06-28, and 2023-07-27 in response to these events. In addition, the dosage of topotecan was sequentially reduced from 2.5 mg to 2.0 mg and then to 1.8 mg. Despite these measures, thrombocytopenia has been observed to date, but no PLT less than 50K/uL has been observed.

2023-07-25 PLT 90 10^3/uL
2023-07-11 PLT 94 10^3/uL
2023-06-28 PLT 474 10^3/uL
2023-06-20 PLT 89 10^3/uL
2023-06-12 PLT 390 10^3/uL
2023-06-01 PLT 95 10^3/uL
2023-05-25 PLT 15 10^3/uL
2023-05-10 PLT 283 10^3/uL
2023-04-27 PLT 244 *10^3/uL

2023-07-13

[reconciliation]

The patient recently renewed his prescriptions for bisoprolol and valsartan on 2023-07-07. Currently, only bisoprolol is incorporated into the active medication list, while valsartan has been left out. Given that the patient’s blood pressure measurements have consistently fallen within the normal spectrum during this hospital stay, reintroduction of valsartan may not be mandatory at this point. However, it remains important to continually monitor the patient’s blood pressure to establish whether further alterations in his medication regimen are warranted.

2023-06-29

[reconciliation]

• This patient regularly renews his prescriptions for Biso (bisoprolol) and Dafiro (valsartan, amlodipine) for his primary hypertension at a local pharmacy. Currently, the patient is only prescribed Concor (bisoprolol), with valsartan and amlodipine excluded. As the patient’s blood pressure readings have remained within the normal range during this hospitalization, it may not be necessary to reintroduce valsartan and amlodipine at this time. However, it is prudent to continue to monitor the patient’s blood pressure to determine if further adjustments to his medication regimen are necessary.

[thrombocytopenia]

• This patient initiated topotecan therapy on 2023-05-12, with two additional cycles administered on 2023-06-06 and 2023-06-28. The platelet levels are compiled in the following table, where “*” represents PLT < 100K/uL and “**” represents PLT < 50K/uL.

  • 2023-06-28 PLT 474 x10^3/uL
  • 2023-06-20 PLT 89 x10^3/uL *
  • 2023-06-12 PLT 390 x10^3/uL
  • 2023-06-01 PLT 95 x10^3/uL *
  • 2023-05-25 PLT 15 x10^3/uL **
  • 2023-05-10 PLT 283 x10^3/uL

• Intravenous Topotecan is linked with a considerable incidence of thrombocytopenia. As per UpToDate, Grade 4 thrombocytopenia occurs in 27% to 29% of patients. The lowest point (nadir) typically occurs around day 15, and the duration of the thrombocytopenia typically lasts for 3 to 5 days.

• The dose of topotecan was reduced from 2.5g to 2.0g starting from the second cycle and was further reduced to 1.8g for the last three days of the five-day administration period. This was a strategy intended to prevent further thrombocytopenia in the patient. In addition, blood transfusions were conducted on 2023-06-14 and 2023-06-28 to alleviate the impact of this side effect.

• Currently, the patient’s platelet count (PLT) is slightly above the ULN. Although there are no current signs of thrombocytopenia, it remains critical for the healthcare team to regularly monitor the patient’s CBC as is standard procedure.

2023-06-07

[reconciliation]

• This patient recently visited a local clinic on 2023-06-05 for acute tonsillitis and was prescribed cimetidine, acetaminophen, fenoterol, glycyrrhiza extract, and cetirizine. In addition, he was prescribed mefenamic acid and cresolsulfonate for his acute upper respiratory tract infection on 2023-06-01, with each prescription having a short duration of only 3 days. Since there are no related symptoms listed in the admission note or current medical problem list, there appear to be no medication reconciliation issues for these conditions.
• In addition, the patient’s prescription for bisoprolol and valsartan for hypertension management was refilled on 2023-04-28 at a local pharmacy. Currently, valsartan is not listed on the active medication list, but according to the TPR panel, the patient had no record of elevated blood pressure during this hospitalization. Therefore, there is no evidence that the current regimen of Concor (bisoprolol 5 mg) 1# PO is inappropriate.

[assessment]

• As the patient’s renal function is compromised, with a Cockcroft-Gault formula calculated CrCl of 44 mL/min, a review of the need of adjustment to the topotecan dose should be considered.
  • 2023-06-01 Creatinine 1.51 mg/dL
    
  • 2023-06-01 eGFR 50.02
    
  • 2023-06-01 BUN 39 mg/dL
• Suggestions for modifying topotecan dosage:
  • Manufacturer’s labeling (calculate CrCl with Cockcroft-Gault method using ideal body weight): CrCl >= 40 mL/minute: No dosage adjustment necessary.
  • Kintzel 1995: CrCl 46 to 60 mL/minute: Administer 80% of usual dose.
  • O’Reilly 1996b: CrCl >= 40 mL/minute: No dosage adjustment necessary in minimally pretreated patients; however, due to an increased potential for dose-limiting toxicities, reduce the dose from 1.5 mg/m2 to 1 mg/m2 in heavily pretreated patients.
• The dose of Topotecan given this time has been decreased by 20% from the 1.5mg/m2 administered on 2023-05-12. The current dosage appears to be without issue.

2022-08-10

• 2022-08-09 blood creatinine 1.66 mg/dL => CrCl 40 mL/min
• Etoposide for patients with CrCl 15 to 50 mL/minute: Administer 75% of normal dose.
• Entecavir for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours.

701090824

231013

[exam findings]

• 2023-09-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 20) / 79 = 74.68%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR, mild AR, mild TR
    • Impaired LV relexation
    • Preserved RV systolic function
• 2023-08-09 PET
  • Glucose hypermetabolism in the left pleura and left pleural effusion, compatible with the metastatic sarcoma.
    
  • Glucose hypermetabolism in bilateral pulmonary hilar and mediastinal lymph nodes, the nature is to be determined (reactive or metastatic lymph nodes or other nature ?). Please correlate with other clinical findings for further evaluation.
  • Several small nodular lesions in the right middle and right lower lungs show no increased FDG uptake, suggesting no evidence of tumor metastasis by this F-18 FDG PET scan.
• 2023-08-04 Patho - pleural/pericardial biopsy
  • Pleura, left, decortication — metastatic sarcoma
  • Sections show fibroadipose tissue with round tumor cells arranged in reticular network of lace-like strands and cords within myxoid stroma.
  • The immunohistochemical stains reveal CK(-), EMA(-), Vimentin(+), CD34(-), TTF-1(-), and S-100(focal +). The mucicarmine special stain is positive. The morphology is compatible with metastatic myxoid sarcoma.
• 2023-08-01 CT - chest
  • left remnant lung fibrosis with volome loss and massive Lt pleural effusion, increased volume of pleural effusion.
  • nodular parietal or extrapleural fat space thickening.
  • suspect metastatic nodules in Rt lung.
  • suspect mild fibrosis at RLL and RUL, stable.
• 2023-05-02 CT - chest
  • left remnant lung fibrosis with volome loss and moderate Lt pleural effusion, increased volume of pleural effusion
  • suspect mild fibrosis at RLL and RUL, stable.
• 2023-03-23 Bronchodilator Test
  • mild restrictive ventilatory impairement, FEV1/FVC= 82%, FVC = 75%, FEV1= 78%, positive for provocation
  • negative for provocation
  • without significant reversibility
• 2023-01-31 CT - chest
  • left remnant lung fibrosis with volome loss and small Lt pleural effusion, stable, post treatment related?
  • suspect mild fibrosis at RLL and RUL, stable.
• 2022-10-25 CT - chest
  • left remnant lung fibrosis with volome loss, post treatment related? and small Lt pleural effusion, stable.
  • suspect mild fibrosis at RLL and RUL, stable.
• 2022-07-26 CT - chest
  • left remnant lung fibrosis with volome loss, post treatment related? and small Lt pleural effusion.
  • suspect mild fibrosis at RLL and RUL.
• 2022-04-26 CT - chest
  • left remnant infection or inflammation (drug-related disease?)
  • with small Lt pleural effusion.
  • suspect mild fibrosis at RLL and RUL.
• 2022-01-18 PET
  • Glucose hypermetabolism in the left lateral chest wall and posteromedial aspect of left lung. Post-operative inflammation may show this picture.
  • Mild glucose hypermetabolism in the right pulmonary hilar region and a mediastinal lower right paratracheal lymph node. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2022-01-17 MRI - brain
  • No brain nodule or metastasis. Mild cortical brain atrophy.
• 2021-09-29 ECG
  • Sinus tachycardia
  • Incomplete right bundle branch block
  • Possible Inferior infarct , age undetermined
  • Abnormal ECG
• 2021-12-29 Patho - lung total/lobe/segmental
  • Diagnosis
    • Lung, left lower lobe, VATS lobectom — Pulmonary myxoid sarcoma, FNCLCC grade 2
      
    • Lymph node, LN 5, left. dissection — Negative for malignancy (0/4)
      
    • Lymph node, LN 7, left. dissection — Negative for malignancy (0/7)
      
    • Lymph node, LN 9, left. dissection — Positive for tumor (3/3)
      
    • Lymph node, LN 11, left. dissection — Positive for tumor (2/2)
      
    • Lymph node, LN 12, left. dissection — Positive for tumor (1/2)
      
    • TNM Pathology stage: pT1N1(if cM0); AJCC prognostic stage: There is no recommended prognostic grouping at this time.
      
  • Immunohistochemical study: CK(-), EMA(-),CK(-), CK7(-), CK20(-), Vimentin (+), CD34(-), SMA(-), TTF-1(-), S100(-), Napsin A(-).

[MedRec]

• 2023-08-22 SOAP Hemato-Oncology Xia HeXiong
  • S: For further management of the disease
    • Right hip chondrosarcoma 14 years ago, s/p OP, s/p R/T
    • Pulmonary myxoid sarcoma, Left lung, FNCLCC grade 2, s/p OP, s/p R/T
    • Metastatic sarcoma s/p decortication on 2023-08-02
  • A/P: Because R/T to residual metastic sarcoma of right lung is not feasible, palliative C/T with IA/IE will be considered. Arrange heart echo.
• 2023-08-01 ~ 2023-08-11 POMR Thoracic Surgery Xie MinXiao
  • Discharge diagnosis
    • Left pleural effusion, suspect tumor recurrence status post thoracoscopis decortication of pleura on 2023-08-02
    • Left lower lung carcinoma status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29
    • Hypertensive heart disease with heart failure
  • CC
    • progressing dyspnea for one month
  • Present illness
    • This 69-year-old man with the history of hypertension, heart failure and hyperlipidemia under medication control. Left lower lung pulmonary myxoid sarcoma, FNCLCC grade 2 status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29 and radiotherapy.
    • According to the patient himself, he suffered from left chest pain after the operation, sometimes radiated to back, neck, and head. He took pain-killer if needed for almost two years. In the rescent one month, he had progressing dyspnea. Accompanied with poor appetite, body weight loss 5kg in one month was also told. He also complaint about constipation.
    • He was under regular follow up at chest and CS OPD, CT done on 2023-08-01 showed left remnant lung fibrosis with volome loss and massive left pleural effusion, increased volume of pleural effusion, nodular parietal or extrapleural fat space thickening, suspect metastatic nodules in right lung.
    • After discussing with the patient and his family on the benefits of surgical treatment as well as subsequent risks and possible complications, he was admitted for thoracoscopis decortication of pleura on 2023-08-02.
  • Course of inpatient treatment
    • After admission, pre-op assessment was done. Operation of thoracoscopis decortication of pleura was performed smoothly on 8/2. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Left chest tube with LPS -18 cmH2O and left pig-tail were done.
    • Tumor recurrence was suspected so Hema doctor was consulted. The chest tube was removed on 8/7 and the pig-tail was removed on 8/11 before discharge. The pathology report revealed metastatic sarcoma. PET scan showed glucose hypermetabolism in the left pleura and left pleural effusion, bilateral pulmonary hilar and mediastinal lymph nodes, suspect metastatic sarcoma.
    • We followed up chest x-ray which revealed improvement of left pleural effusion. Under stable condition, he discharged today and CS, HEMA OPD follow up were arranged.
  • Discharge Prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Sindine (povidone iodine aq soln) 1# QD
    • MgO 250mg 1# TID
    • Actein 200mg 1# TID
• 2022-03-28 SOAP Radiation Oncology Chang YouKang
  • RT dose: 6600cGy/33 fractions (6 MV photon) to LLL sacrcoma bed, bronchial stump & lymphatics, 2022/02/07 to 3/28.
  • RT Side effect evaluation, 3/28: Radiation dermatitis, grade 0; N/V, grade 0; esophagitis, grade 0; pneumonitis, grade 0.
  • Plan: Adjuvant RT finishes today.
• 2022-01-17 SOAP Radiation Oncology Chang YouKang
  • O: Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 20220111
    • Suggest adding a PET scan.
  • IMP:
    • Pulmonary myxoid sarcoma, FNCLCC grade 2 with group 9, 11, 12 LN metastasis (6+/18) s/p LLL lobectomy and LN dissection on 2021/12/29.
    • Favoring second primay malignancy.
  • Plan:
    • Adjuvant RT to LLL bronchus and regional lymphatics for 6600cGy/33 fractions is suggested for locoregional control.
    • CT simulation on 2/08 13:30. Possible esophagitis and pneumonitis is told. Diet education.
• 2022-01-13 SOAP Thoracic Surgery Xie MinXiao
  • A: Pulmonary myxoid sarcoma, FNCLCC grade 2. Primay or meta.??
  • P: refer to radio-oncologist for adjuvant RT.
• 2021-12-28 ~ 2021-12-31 POMR Thoracic Surgery Xie MinXiao
  • Discharge diagnosis
    • Left lower lung carcinoma status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29
    • Hypertensive heart disease with heart failure
    • Hyperlipidemia, unspecified
  • CC
    • Left chest wall pain and coughing intermittently.
  • Present illness
    • This 67-year-old man with a history of hypertension and hyperlipidemia under medication control.
    • According to the patient complained of he finished the COVID-19 vaccine on 2021/10/26. Because of general malaise,so he went to the emergency room of MacKay memorial hospital for medical treatment. Chest CT showed lung nodule in left lower lobe and biopsy showed chronic imflamation in MacKay memorial hospital.
    • He because have ​left chest wall pain and coughing intermittently, so he refer to chest surgeon for further evaluation and treatment.
    • After discussing with the patient and his family on the benefits of surgical treatment as well as subsequent risks and possible complications, he was admitted for VATS left lower lobe wedge and lymph node dissection under lung nodule in left lower lobe.
  • Course of inpatient treatment
    • After admission, pre-op assessment was done. Operation of video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis at 2rd admission day (2021/12/29). No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Left chest tube with LPS -18 cm H2O was done. Chest tube was removed at post-op 2rd day. He was discharged under stable hemodynamics at post-op 2th day. Continue to follow up at the chest surgical clinic.
  • Discharge prescription
    • Actein (acetylcysteine 200mg) 1# TID
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
    • Deflam-K (diclofenac 25mg) 1# TID
    • MgO 250mg 1# TID
• 2021-12-18, 2018-08-04, -08-30 SOAP Orthopedics Yao DingGuo
  • Diagnosis: Malignant bone neoplasm, lower limb, short bones [C40.20]

[consultation]

• 2023-08-04 Hemato-Oncology
  • Q
    • This is a 69-year-old man with the history of hypertension, heart failure and hyperlipidemia under medication control. Left lower lung pulmonary myxoid sarcoma, FNCLCC grade 2 status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29. He also underwent radiotherapy.
    • This time, he was admitted for thoracoscopis decortication of pleura on 2023-08-02 due to pleural effusion, suspect tumor recurrence. Multiple tumor seeding over left pleural cavity and pericardium was found. Bloody effusion was noted about 1650mL. We plan to remove chest tube and arrange PET scan next week. We need your help for further evaluation and treatment suggestion. Thank you very much.
  • A
    • Primary pulmonary sarcoma is extremely rare and mostly metastatic, and primary pulmonary myxoid sarcoma PPMS is a rare low-grade malignant sarcoma.
    • Suggestion:
• Pending pathology result (Recurrent? De novo?).
• We will follow up this case. Thanks for your consultation.

[surgical operation]

• 2023-08-02   - Op Method: VATS decortication+ close drainage.
  • Finding:
    • Multiple tumor seeding over left pleural cavity and pericardium. Bloody effusion was noted about 1650mL.
    • One 28 Fr. straight chest tube was inserted via left 8th ICS, another one pig-tail was inserted via left 7th ICS.
• 2021-12-29
  • Op Method: VATS LLL lobectomy + RLND + pneumolysis .
  • Finding:
    • One tumor mass was noted over LLL, size about 3.0cm in diameter.
    • Some adhesion was noted over left pleural cavity, especially around the tumor site.
    • Frozen section: carcinoma.
    • One 24 Fr. straight chest tube was inserted via left 8th ICS.

[radiotherapy]

[chemotherapy]

• 2023-09-04 - mesna 800mg NS 250mL 1hr (before ifosfamide) D1-5 + ifosfamide 1500mg/m2 2400mg NS 500mL 1hr D1-5 + doxorubicin 37.5mg/m2 60mg NS 500mL 24hr D1-2 + mesna 800mg NS 250mL (4hr after finishing ifosfamide) D1-5 + mesna 800mg NS 250mL (8hr after finishing ifosfamide) D1-5
  • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + palonosetron 250ug D1 + NS 250mL D1-5 + aprepitant 125mg PO D1-3

==========

2023-10-13

[reconciliation]

The patient was prescribed a 28-day course of Concor (bisoprolol) and Livalo (pitavastatin) at Taipei City Hospital on 2023-09-27. While the former is currently being administered, the latter does not appear on the list of active medications. Please verify that the use of pitavastatin is no longer necessary.

[hypercalcemia]

Observed hypercalcemia warrants an evaluation of the PTH level to assess the likelihood of hyperparathyroidism.

• 2023-10-13 Ca (Calcium) 4.07 mmol/L
• 2023-10-12 Ca (Calcium) 3.85 mmol/L
• 2023-08-01 Ca (Calcium) 3.11 mmol/L

Recommended Actions:

• Hydration with Isotonic Saline: Replenishes intravascular volume and enhances the excretion of calcium in the urine.
• Calcitonin Administration: Disrupts bone resorption by interfering with osteoclast activity and encourages the excretion of calcium in the urine.
• Loop Diuretic Usage: Amplifies the excretion of calcium in the urine by inhibiting its reabsorption in the loop of Henle.
• Glucocorticoid Therapy: Reduces the absorption of calcium in the intestines and curtails the production of 1,25-dihydroxyvitamin D by activated mononuclear cells in patients suffering from granulomatous diseases or lymphoma.

If the initial interventions are ineffective, the following alternatives could be contemplated:

• Bisphosphonate: Disrupts bone resorption by interfering with the recruitment and functionality of osteoclasts.
• Calcimimetic: Acts as an agonist for calcium-sensing receptors, diminishing PTH (useful in cases of parathyroid carcinoma or secondary hyperparathyroidism in CKD).
• Denosumab: Curbs bone resorption through the inhibition of RANKL.

2023-09-21

[pancytopenia]

Pancytopenia was noted in mid-Sep, likely attributed to the initiation of the doxorubicin + ifosfamide regimen on 2023-09-05, approximately 10 days after its commencement. Following treatment with a blood transfusion on 2023-09-18, and the initiation of a consecutive 5-day course of Granocyte (lenograstim) on the same day, pancytopenia has shown successful improvement.

2023-09-20 WBC 3.63 x10^3/uL
2023-09-18 WBC 0.20 x10^3/uL 2023-09-15 WBC 0.66 x10^3/uL 2023-09-11 WBC 8.43 x10^3/uL
2023-09-01 WBC 8.80 x10^3/uL

2023-09-20 HGB 10.3 g/dL 2023-09-18 HGB 7.4 g/dL ** 2023-09-15 HGB 9.4 g/dL * 2023-09-11 HGB 10.9 g/dL 2023-09-01 HGB 13.2 g/dL

2023-09-20 PLT 138 10^3/uL 2023-09-18 PLT 25 *10^3/uL ** 2023-09-15 PLT 65 *10^3/uL ** 2023-09-11 PLT 141 10^3/uL 2023-09-01 PLT 259 *10^3/uL

701377724

231012

[exam findings]

• 2023-07-25 MRI - pelvis
  • Findings
    • S/P hysterectomy.
    • S/P double J catheter, right side.
    • Unremarkable change of the liver, spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
  • Impression:
    • S/P hysterectomy.
    • S/P double J catheter, right side.
    • Suggest follow up.
• 2023-07-20 CT - abdomen
  • History and indication: Malignant neoplasm of cervix uteri
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy.
    • Atrophy of left kidney. S/P right side double J catheter insertion. Fat stranding along right renal pelvis and ureter.
    • S/P Port-A infusion catheter insertion.
    • Grade 4 fatty liver.
  • IMP:
    • S/P hysterectomy. No evidence of tumor recurrence.
    • S/P right side double J catheter insertion. Fat stranding along right renal pelvis and ureter.
• 2023-07-10 Bladder Sonography
  • PVR 6 mL
• 2023-06-23 All-RAS + BRAF gene mutation analysis
  • Cell block No: F2022-00402 FsA1
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 12 GGT>TGT, p.G12C)
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-15 Pure Tone Audiometry, PTA
  • Reliability FAIR
    • Average RE 23 dB HL; LE 15 dB HL.
    • RE WNL with 2k Hz A-B gap.
    • LE normal to moderate SNHL with 4k Hz A-B gap.
• 2023-04-28 PET
  • Two glucose hypermetabolic lesions in the left pelvic side wall region, compatible with recurrent malignancy.
  • Glucose hypermetabolism in two left paraaortic lymph nodes and a left common iliac lymph node, compatible with metastatic lymph nodes.
  • Glucose hypermetabolism in some bilateral supraclavicular lymph nodes, suggesting distant lymph node metastases.
  • Glucose hypermetabolism in the right hip joint. Inflammation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2023-04-17 MRI - pelvis
  • Clinical history: 50 y/o female patient with cervical adenocarcinoma s/p CCRT.
  • With and without contrast enhancement MRI: Pelvis
    • S/P hysterectomy.
    • There is focal soft tissue (1.5cm) in left pelvic side wall region, r/o recurrent tumor.
      
    • Mild left hydronephrosis.
    • T2 hyperintensity lesions, up to 2cm in left pelvic cavity, r/o lymphocele.
    • There is paraaortic lymph node (1.4cm) in the paraaortic region, r/o paraaortic lymph node metastasis.
  • Impression:
    • S/P hysterectomy with lymphocele in left pelvic cavity.
    • R/O recurrent tumor in left pelvic side wall region.
    • R/O metastatic lymph node in paraaortic region.
• 2023-01-11 CT - abdomen
  • S/P hysterectomy.
  • There is no evidence of tumor recurrence.
• 2022-12-31, -12-07 SONO - nephrology
  • Right hydronephrosis
• 2022-10-14 Intravenous Pyelography, IVP
  • Intravenous pyelography and post-voiding study:
    • S/P double J catheter insertion in place, right side.
    • Mild right hydronephrosis.
• 2022-08-29 Patho - uterus with or without SO non-neoplastic/prolapse
  • Diagnosis:
    • Utrus, cerivx, hysterectomy with frozen section (F2022-402FS) and separated “cervix” tissue (S2022-14312G) — adenocarcinoma, grade 3. with exocervical margin and parametrial invasion.
      • IHC stain: p16 (30-40% neoplastic glands show nuclear staining; Correlation of HPV molecular test might be considered), Vimentin (-), p53 (+, abberant), Napsin-A (-), ER (+, 25 %, strong intensity)
    • Uterus, endometrium, hysterectomy — involved by tumor, lower uterine segment
    • Uterus, myometrium, hystrectomy — myomas x2. No malignancy
    • Lymph node, bilateral pelvic and para-aortic, dissection (S2022-14312A-F) — free, for details, see microscopic description.
    • Adnexae, bilateral, salpingo-oophorectomy (S2022-14312H-I) —free
    • Omemtume, omentectomy (S2022-14312J) — free.
    • pT2b, at least. pN0 (if cM0); FIGO pathological stage: IIB, at least.
  • Gross description:
    • Procedure (select all that apply) - staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy)
      • Uteurs: 10 x 7 x 5 cm with cauliflower shaped tumor occupying cervix and endocervix (details see below) and two myomas up to 1.5 x 1.2 x 1.2 cm in size. Left ovary: 2.5 x 2 x 1.5 cm. The tube: 4.5 x 0.8 x 0.8 cm. Right ovary: 2.5 x 2 x 1.5 cm; right tube: 4.5 x 0.8 x 0.8 cm; Omentum: 21 x 10 x 2cm. Bilateral adnexae and ometum are grossly free.
        
    • Tumor Size:
      • Greatest dimension: 4.5 cm
      • Additional dimensions (centimeters): 2.5 x 2.5 cm, involving distal cut end and bilateral para-metrium.
    • Tumor Site (select all that apply)- cerivx and endocervix, involving lower uterine segment, distal cut end and bilateral para-metrium.
    • Sections are taken and labeled as:
      • Tissue for frozen section: F2022-402FSA1-3: cervical tumor.
      • Tissue for formalin fixation:
      • F2022-402 Uteurs: A1-2: myomas; A3-10: additional sampling of cervical tumor (with margins inked in black); A11-12: tumor involving serosal surface.
      • S2022-14312 A: 01: left iliac lymph nodes; B: 02. left obturator lymph nodes; C: right iliac lymph nodes; D: right obturator lymph nodes; E: left para-aortic lymph nodes; F: right para-aortic lymph nodes; 07: separated tissue laveled as “cervix”; H1-2: left adnexa; I1-2: right adnexa; J: omentum.
  • Microscopic Description:
    • Histologic Type - Adenocarcinoma, NOS, p16: <70%.
      
    • Histologic Grade: G3: Poorly differentiated
    • Stromal invasion:
      • Depth of stromal invasion: 9 mm, to deep 1/3 of the cervix.
    • Silva Pattern of Invasion (applicable only to invasive endocervical adenocarcinomas):
      • Pattern C: Glands or papillary structures with little intervening stroma or mucin lakes with tumor cells within the cervical stroma and filling a 4x filed (5mm)
    • Other Tissue/ Organ Involvement (select all that apply):
      • Bilateral parametrium - involved
      • Bilateral ovary - free
      • Bilateral fallopian tube - free
      • Omentum- free
    • Margins:
      • Ectocervical Margin: Not Free (Cancer present)
      • Radial (Circumferential) Margin: Not Free
    • Lymphovascular Invasion: Present
    • Regional Lymph Nodes: described as follows
      • Site: (Positive: positive nodes number/total number) (Negative: 0/total number33) :
      • Pelvic Lymph Nodes:
        • Right iliac: Negative: 0/ 4
        • Left iliac: Negative: 0/ 5
        • Right obturator: Negative: 0/ 12
        • Left obturator: Negative: 0/ 5
        • Para-aortic Lymph Nodes:
        • Right para-aortic: Negative: 0/ 2
        • Left para-aortic: Negative: 0/5
    • Distant Metastasis: (if cM0).
      • NOTE1: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.” … “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, Medical Department and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
    • Additional Pathologic Findings :None identified
    • Special Study: p16 immunohistochemistry: (30-40% neoplastic glands show nuclear staining)
    • Comment(s)- correlation of HPV molecular test might be considered.
• 2022-08-27 CT - abdomen
  • Imaging Report Form for Endometrial Carcinoma
    • Impression ( Imaging stage ) : T:Tx(T_value) N:Nx(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2022-08-27 Gynecologic ultrasonography
  • Findings
    • Uterus Position: AVF
      • Size: 77 x 58 mm
      • Myoma: 24 x 15 mm, 22 x 18 mm
    • Endometrium
      • Thickness: 10.6 mm
    • Adnexae
      • ROV Size: 38 x 18 mm
      • LOV Size: 22 x 15 mm
  • IMP: R/O hematoma accumulation at cervix 49 x 35 mm
• 2022-06-08, -06-03 Gynecologic ultrasonography
  • IMP
    • Adenomyosis
    • Uterine myoma
• 2022-05-03 Gynecologic ultrasonography
  • Other: RT adnexae free
  • IMP
    • R/O Mild Adenomyosis
    • Uterine myoma

[MedRec]

• 2022-08-28 ~ 2022-09-13 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of cervix uteri, unspecified
    • Acute posthemorrhagic anemia
  • CC
    • Heavy and continued menstrual bleeding with dysmenorrhea for 2 months
  • Present illness
    • This 50-year-old lady, G0P0, no sexual history, without any systemic disease, was admitted to our ward for ATH and possible BSO in figuration of malignancy due to heavy and continued menstrual bleeding for 2 months.
    • According to the patient, she had been at her usual health status until last year, her menstrual cycle had stopped for half year, but another menstrual cycle began again since 2021/12/24, and the period had persisted until now. About 6 months ago (2022/02), she visited GYN OPD, and myoma was noticed. Her menstrual cycle was regular then, with duration/interval of 6-7/26-28 days. At OPD in 2022/05, GYN sonar was done and showed mild adenomyosis and myomas in size of 1.7x1.2cm and 2.1x1.2cm. In 2022/06, her menstrual amount increased a lot with blood clots, and she visited our ER, and she would change her night sanitary pad per 5 minutes then. GYN sonar was also done and showed adenomyosis and myomas in size of 2.5x2.4cm and 3.2x2.2cm. She also received blood transfusion. CA-125 showed 46.3U/mL. In 2022/08, she started to notice dysmenorrhea, too. And painkillers could not relieve her pain. For these 2 days, she again experienced large amount of vaginal bleeding and came to our ER.
    • At our ER on 08/27, her vital signs were T/P/R: 35.4/98/20, BP: 130/80 mmHg. Her Hb decreased from 9.3 to 8.5 in a day, and she received blood transfusion 4U. GYN sonar showed hematoma accumulation at cervix in size of 4.9x3.5cm. Today, she fainted at ER toilet, and Hb decreased from 9.4 to 8.5 in 7 hours. Due to above condition, she was admitted to our ward for ATH and possible BSO in figuration of malignancy and received further management.
  • Course of inpatient treatment
    • After admission, emergent staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy) was done on 8/28. Because she had anemia and mild loss of blood during the surgery, blood transfusion with pRBC was done. Bilateral drainage tube were inserted during the surgery. A total amount of 50ml clear red fluid was drained. However, drainage increased on 9/1 (vs amount on 8/31) with a yellowish color and was sent to measure its creatinine level. Creatinine result was 22.2mg/dL, suggesting a possible urinary tract injury.
    • The patient did not have unstable vital signs, abdominal pain, or other peritoneal signs. A Foley catheter was inserted. GU doctor was consulted and abdominal CT was arranged on 9/3. Right distal ureteral leak was reported. We had well exaplained the current condition, including the benefits of surgery, to the patient with GU man on 9/4. After discussed, laparoscopic urinary tract repair surgery will perform by GU surgeon on 9/6. Followed lab on 9/4 show hypoalbuminemia and hypokalemia and self paid albumin and potassium supplement were prescribed.
    • Note
      • 2022/09/05: pathology report
        • Cervical cancer, adenocarcinoma, grade 3
        • Complicated with exocervical margin and parametrial invasion.
        • Staging: pT2bN0Mx, FIGO stage: IIB
      • 2022/09/06: double J insertion
      • 2022/09/08: Gynecological Cancer Discussion Meeting
        • Oncology radiation contacted for the planning of further treatment
      • 2022/09/12: Cystography via foley catheter
  • Discharge prescription
    • Ceficin (cefixime 100mg) 2# BID
    • Metrozole (metronidazole 250mg) 1# QID
    • MgO 250mg 2# QID
    • Through (sennoside 12mg) 1# HS
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# QID if wound pain
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID

[consultation]

• 2022-09-09 Radiation Oncology
  • A
    • A: Adenocarcinoma, grade 3, of the uterine cervix, with exocervical margin and parametrial invasion, stage pT2bN0 (cM0); FIGO pathological stage: IIB, s/p staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy).
    • P: CCRT is indicated for this patient with the following indicators: exocervical margin and parametrial invasion, stage pT2bN0 (cM0); FIGO pathological stage: IIB, and staging surgery
      • Goal: curative
      • Treatment target and volume: pelvis
      • Technique: VMAT/IGRT and IVRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, 5040cGy/28 fractions of the cervical and parametrial involved margin area, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface area by IVRT.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her sister. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0930, 2022-9-22.
• 2022-09-09 Infectious Disease
  • Q
    • This 50-year-old lady, G0P0, no sexual history, without any systemic disease. This is a case of cervical Cancer, adenocarcinoma, grade 3.with exocervical margin and parametrial invasion. pT2b, at least. pN0 (if cM0); FIGO pathological stage: IIB, at least. Status post hysterectomy and bilateral salpingo-oophorectomy on 2022/08/28. Complicated with right distal ureteral leak post double J insertion on 2022/09/06. We sent ascites (drainage from cul-de sac) for bacteria culture. The report showed growth with pseudomonas putida. As a result, we need your expertise and help for antibiotic use. Thank you.
  • A
    • Ascites culture: Pseuodomonas putida, Chryseobacter indologens
    • Cr: 0.51, CRP:0.43
    • Impression: Complicated intra-abdominal infection is impressed
    • Suggestion:
    • Empirical antibiotics with finibax 500mg iv q8h is suggested
    • Please adjust antibiotics according to clinical condition and culture susceptibility results.
• 2022-09-02 Urology
  • Q
    • This 50-year-old lady diagnosed with endometrial tumor r/o malignancy and received staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection+ para-aortic lymphnode dissection + infracolic omentectomy ) on 2022/08/28.
    • Bilateral drainage tube were inserted during the surgery.
      
    • However, drainage increased and we had sent this fluid to check its creatinie. Cr was 22.2mg/dL and urinary tract injuries should be considered.
    • As we discussed at phone, we need your help for evaluation. Thanks a lot!
  • A1
    • This 50 y/o female received staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy) on 2022/08/28. Increasing drainage amount with suspected urine leakage was found today. Since she still had urine output aroung 500ml/8hr, complete transection of ureter was not likely. Please arrange CTU for further evaluation first.
  • A2 2022-09-03 13:33:52
    • CT showed right lower ureter leakage
    • The deficit of ureter may be 2.5cm in ureter reimplantation setting
    • Surgical repair may be carried out on 2022/09/06 afternoon
    • Therefore, we may have plenty of time to explain situation to her and her family.
• 2022-08-28 Obstetrics and Gynecology
  • A
    • GYN Note
      • still hypermenorrhea with blood clots
      • stronly requested admission
    • Hb-9.4 post blood transfusion packRBC 4u
    • sex[-]
    • Imp:
      • uterine myoma
      • adenomyosis
      • cervical lesion?
      • anemia
      • hypermenorrhea with blood clots
    • Plan
      • Phone contact with Professor Huang SiCheng
      • Arrange admission under service of Professor Huang SiCheng
• 2022-08-27 Obstetrics and Gynecology
  • Q
    • Returning visit 2022-08-27 19:48
    • Excessive vaginal bleeding, hospitalization requested.
  • A
    • Due to persistent symptoms, she visited our ER again, and we were consulted for evaluation.
    • C.C.
      • Massive vaginal bleeding with blood clots for 2 days. The patient needs to be wrapped in an adult diaper, as sometimes it immediately becomes full when standing up.
    • Physical examiantion
      • Vital signs stable, afebrile
      • Active vaginal bleeding (+)
      • Pad: moderate amount of bleeding, with scanty blood clots
    • Lab
      • WBC: 7.66K
      • Hb: 9.3 -> 9.1 -> 8.5 g/dL (08/27 1am -> 7am -> 8pm)
    • Image
      • US: (1) EM: 10.6mm (2) Uterine myomas: 24X15mm, 22X18mm (3) Adenomyosis
    • Impression
      • Abnormal vaginal bleeding, cause to be determined
    • Suggestion
      • Please recheck CBC after transfusion is completed. If Hb improves and her vital signs are stable, may consider discharge with medication.
      • Please prescribe Naposin 1# TID X 2 days + Ergometrine 1# BID x 2 days after discharge. Please be sure to inform the patient to continue taking the other medications prescribed earlier, but please stop Keto and start taking Naposin! (This has been communicated to the patient, please remind again, thank you)
      • OPD follow-up at Dr. Zeng’s clinic on W3.
      • The patient has been fully informed that this is a case of abnormal bleeding. Emergency treatment will be given in the emergency room and life signs will be ensured to be stable. Further examinations and treatment will be carried out in the following outpatient follow-up. The patient expressed that they would like to return to Dr. Zeng’s clinic.
• 2022-08-27 Obstetrics and Gynecology
  • Q
    • Triage Level: 2 Vaginal bleeding > Heavy vaginal bleeding
      • The chief complaint is vaginal bleeding starting from 5 o’clock in the evening.
      • Menstrual period started on 2021/12/14 and has not stopped till now,
      • no trauma or other concerns, GYN Dr. Shao Zhixuan said to hang in the department of internal medicine first.
      • Also experiencing menstrual pain.
  • A
    • This 50y female, sex(-), LMP: 2021/12, D/I: 5/28-30, history of adenomyosis s/p Visanne use and Leuplin on 2022/08/13, intermittent vaginal bleeding and spotting since 2021/12, episodes of massive vaginal bleeding twice in 2022/06, was admitted this time due to massive vaginal bleeding with blood clots tonight.
    • S:
      • denied systemic disease or surgical history
      • mild dizziness, no SOB
      • intermittent vaginal bleeding and spotting since 2021/12
      • massive vaginal bleeding with blood clots tonight
    • O:
      • TAS + TRS: UT 77x61x58mm, ant 22x18mm, post 24x15mm, RO 38x18mm, LO 22x15mm, R/O hematoma at cervix 49x35mm
      • PE: hymen was intact, blood clots (+), pelvic exam cannot be approached
      • BP: 130/80, HR 98, Hb: 9.3
    • A:
      • DUB, R/O perimenopausal status; cervical lesion cannot be ruled out
    • P:
      • pRBC 2u was given at ER
      • Please prescribe NSAID (keto, naproxen…), transamine, oxytocin for uterine contraction; Fe supplement after discharge
      • Consider further image for cervical lesion such as CT or MRI
      • Suggest F/U at Dr. Zeng LunNa OPD next week and discuss if surgical intervention is needed
• 2022-06-04 Obstetrics and Gynecology
  • A
    • KEEP Acetaminophen PO, Ergonovine PO, Transamin PO for 3 days
    • OPD follow-up, already booked an appointment with Dr. Tseng on Wednesday
    • The patient visited emergency room yesterday and came to the emergency room again today for the same reason. Additional prescription of Visanne, 1 tablet orally at bedtime for 5 days (please remind the patient to take it before sleeping)
    • Please take a blood sample, Please check LH, FSH, E2, CA125
• 2022-06-03 Obstetrics and Gynecology
  • Q
    • Triage Level: 3 Vaginal bleeding > Coagulation abnormality - moderate or mild bleeding. Family said the patient’s period has been going on for 6 months and seeing a doctor hasn’t helped. Just now there was a particularly large amount of blood loss, causing dizziness and weakness.”
      • large amount of vaginal bleeding just now
      • Changing a diaper every five minutes
      • denied sex intercourse
      • no abd pain, no chest pain, no N/V, no diarrhea
    • 2022/05/03 Gynecologic ultrasonography
      • Uterus: 10.0 x 5.3cm
      • Myometrum: Anterior/Posterior wall: 2.07/2.03 cm
      • myoma: 1.7x1.2cm, 2.1x1.2cm
      • EM: 0.81cm
      • Mild Adenomyosis
  • A
    • S
      • 49y/o, female, sex(-), LMP: 2021/12/14
      • Hx: Adenomyosis, Danazol since 5/3
      • vaginal bleeding for 6 month
    • O:
      • pregnancy test (-), WBC: 7420, Hb: 7.7
      • CRP: 1.64,
      • sono: Uterus: 11.2x5cm, EM: 0.54
      • myoma: 33x23mm, 22x15mm
      • bilateral adnexa free
      • CDS: no fluid
    • IMP:
      • Adenomyosis
      • Uterine myoma
    • P:
      • Acetaminophen PO, Ergonovine PO, Transamin PO for 3 days
      • OPD follow

[surgical operation]

• 2022-12-20
  • Surgery
    • Endoscopic internal dilatation of right ureter    
  • Finding
    • Right lower ureter stricture, no contrast extravasation during retrograde pyelography    
    • A 7Fr. 24cm DBJ inserted to right ureter
• 2022-08-28
  • Surgery
    • Diagnosis: endometrial tumor r/o malignancy s/p staging surgery.
    • Operation: staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy)   - Finding
    • endometrial tumor r/o malignancy s/p staging surgery.
    • Frozen: malignancy
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder, peritoneum dut to tumor mass accupied, severe adhesion to bowel. frzen pelvis.
    • Adnexa:
      • LOV: 3x2x2 cm, smooth surface.
      • ROV: 3x2x2 cm, smooth surface.
      • Fallopian tube: bilateral grossly normal
    • CDS: invisible due to tumor mass occupied
    • Ascites: bloody, minimal
    • Bilateralpelvic lymph nodes: normal(-), enlarged(-), indurated(+)
    • Bilateralpara-aortic lymph nodes: normal(-), enlarged(-), indurated(+)
    • Omentum: grossly normal
    • Insert two JVAC over cu-de-sac
    • After the operation, optimal debulking surgery was achieved.
    • R0: no residual tumor
    • Estimated blood loss:
    • Blood transfusion: PRBC 6u FFP 6u
    • Complication: nil.

[radiotherapy]

[chemotherapy]

• 2023-10-12 - bevacizumab 15mg/kg 1200mg NS 250mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-15 - bevacizumab 15mg/kg 1200mg NS 250mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-22 - bevacizumab 15mg/kg 1200mg NS 250mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-27 - bevacizumab 15mg/kg 1200mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-04 - bevacizumab 15mg/kg 1200mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-09 - bevacizumab 15mg/kg 1200mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-16 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr (If NHI approved, Avastin will be changed to 1200mg)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-17 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-10 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-03 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-27 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-20 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-13 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1

G-CSF

• Granocyte (lenograstim 250ug)
  • 2023-10-04 ~ 2023-10-05 OPD 2D
  • 2023-09-20 ~ 2023-09-22 IPD 3D
  • 2023-09-07 ~ 2023-09-08 OPD 2D
  • 2023-08-30 ~ 2023-09-13 OPD 14D?
  • 2023-08-28 ~ 2023-08-30 IPD 3D
  • 2023-08-09 ~ 2023-08-10 OPD 2D
  • 2023-07-31 ~ 2023-08-02 IPD 3D
  • 2023-07-10 ~ 2023-07-12 IPD 3D
  • 2023-07-13 ~ 2023-07-15 OPD 3D
  • 2023-06-14 ~ 2023-06-16 IPD 3D
  • 2023-05-25 ~ 2023-05-27 OPD 3D

==========

2023-10-12

There were no medication reconciliation issues when reviewing PharmaCloud and HIS5 records.

[Leukemia has been managed more effectively]

Leukopenia has become less severe and less frequent following the intermittent administration of prophylactic/therapeutic Granocyte (lenograstim) in accordance with chemotherapy cycles. This approach has improved the management of this side effect.

• 2023-10-11 WBC 3.54 x10^3/uL
  
• 2023-10-04 WBC 2.45 x10^3/uL *
  
• 2023-09-27 WBC 4.34 x10^3/uL
  
• 2023-09-14 WBC 3.82 x10^3/uL
  
• 2023-09-07 WBC 2.55 x10^3/uL
  
• 2023-08-30 WBC 3.34 x10^3/uL
  
• 2023-08-16 WBC 3.31 x10^3/uL
  
• 2023-08-09 WBC 2.66 x10^3/uL *
  
• 2023-07-20 WBC 6.37 x10^3/uL
  
• 2023-07-13 WBC 1.05 x10^3/uL **
• 2023-07-03 WBC 4.49 x10^3/uL

2023-08-22

[reconciliation]

Currently, the patient’s medication records are not accessible on PharmaCloud. However, after reviewing the HIS5 records, no medication reconciliation issues were found.

[leukopenia]

At this time, the patient is not experiencing severe leukopenia. Any leukopenia events that have occurred since the start of the [bevacizumab paclitaxel cisplatin] regimen on 2023-05-26 have been treated with G-CSF administrations without reducing the dose of paclitaxel or cisplatin.

• 2023-08-16 WBC 3.31 x10^3/uL
• 2023-08-09 WBC 2.66 x10^3/uL * 2023-08-09 2-day G-CSF
• 2023-07-20 WBC 6.37 x10^3/uL 2023-07-31 3-day G-CSF
• 2023-07-13 WBC 1.05 x10^3/uL ** 2023-07-10 6-day G-CSF
• 2023-07-03 WBC 4.49 x10^3/uL
• 2023-06-21 WBC 3.73 x10^3/uL
• 2023-06-14 WBC 3.03 x10^3/uL 2023-06-14 3-day G-CSF
• 2023-06-01 WBC 5.07 x10^3/uL
• 2023-05-25 WBC 1.16 x10^3/uL ** 2023-05-25 3-day G-CSF
• 2023-05-11 WBC 6.21 x10^3/uL
• 2023-05-01 WBC 7.21 x10^3/uL

2023-07-04

Based on the PharmaCloud database, this patient has exclusively attended our hospital for outpatient and inpatient services across the departments of urology, obstetrics and gynecology, radiation-oncology, and hemato-oncology in the past three months. No issues were found during medication reconciliation.

2023-06-09

[reconciliation]

• According to the PharmaCloud database, this patient has only visited our hospital for outpatient and inpatient services in the departments of urology, obstetrics and gynecology, radiation-oncology and hemato-oncology in the past three months. No medication reconciliation issue identified.

[more intensive hydration]

• Serum creatinine and BUN both show an upward trend and BUN has exceeded the upper limit of normal. Hypomagnesemia was also observed. Cisplatin-induced nephrotoxicity might present as kidney injury and/or as electrolyte disturbances (eg, hypomagnesemia). A total of 1350mL of fluid was supplemented during the regimen administration (NS 250mL before cisplatin, 100mL simultaneously with bevacizumab, 500mL simultaneously with cisplatin, D5W 500mL with paclitaxel), this already takes hydration into consideration. It might be considered increasing the NS volume (for instance, introducing 500mL of NS both before and after the administration of cisplatin), and encourage the patient to hydrate more during the day.
  • 2023-06-01 Creatinine 0.84 mg/dL
    
  • 2023-05-25 Creatinine 0.85 mg/dL
    
  • 2023-05-13 Creatinine 0.82 mg/dL
    
  • 2023-05-11 Creatinine 0.75 mg/dL
    
  • 2023-05-01 Creatinine 0.78 mg/dL
    
  • 2023-04-26 Creatinine 0.79 mg/dL
    
  • 2023-04-13 Creatinine 0.86 mg/dL
    
  • 2023-03-16 Creatinine 0.60 mg/dL
    
  • 2023-02-16 Creatinine 0.57 mg/dL
    
  • 2023-01-19 Creatinine 0.50 mg/dL
    
  • 2023-06-01 BUN 31 mg/dL
    
  • 2023-05-25 BUN 22 mg/dL
    
  • 2023-05-01 BUN 19 mg/dL
    
  • 2023-04-13 BUN 19 mg/dL
    
  • 2023-03-16 BUN 13 mg/dL
    
  • 2023-02-16 BUN 15 mg/dL
    
  • 2023-01-19 BUN 10 mg/dL
    
  • 2023-06-01 Mg (Magnesium) 1.8 mg/dL
    
  • 2023-04-26 Mg (Magnesium) 2.2 mg/dL

[leukopenia]

• This patient last received paclitaxel and cisplatin on 2023-05-15 and a WBC nadir of 1.16K/uL was noted on 2023-05-25. Paclitaxel carries a Boxed Warning regarding bone marrow suppression and recommends frequent peripheral blood cell counts for all patients receiving the drug. Granocyte (lenograstim 250ug) was administered for three consecutive days starting on 2023-05-25.

• According to the reimbursement guidelines of the Taiwan National Health Insurance, the use of G-CSF is allowed for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an absolute neutrophil count (ANC) of less than 500/uL after chemotherapy. This patient meets the specified criteria (neutrophil 14.7%), so G-CSF can be prescribed to manage leukopenia following this round of chemotherapy.

  • 2023-06-01 WBC 5.07 x10^3/uL
    
  • 2023-05-25 WBC 1.16 x10^3/uL
    
  • 2023-05-11 WBC 6.21 x10^3/uL
    
  • 2023-05-01 WBC 7.21 x10^3/uL
    
  • 2023-05-25 Neutrophil 14.7 %

700575779

231009

[exam findings]

• 2023-09-28 L-spine flex. & ext. (including sacrum)
  • Presence of spondylolisthesis at L3/4, L4/5, grade I.
• 2023-09-28 C-spine flex. & ext. view
  • There is no evidence of spondylolisthesis or subluxation
• 2023-09-13 CT - abdomen
  • Findings: Comparison: prior CT dated 2023/06/09.
    • Prior CT identified malignant lymphoma (confluent lymphadenopathy) in the abdomen and pelvis, encasing all visceral artery and vein, are noted again, decreasing in size that is c/w lymphoma S/P C/T with partial response.
      
    • Prior CT identified lymphoma 2.8 cm in S8/4 of the liver dome is noted again, decreasing in size to 1.2 cm that is c/w liver lymphoma S/P C/T with partial response.
    • Prior CT identified splenomegaly (the greatest anterior-posterior dimension: 14 cm) is noted again, mild decreasing in size to 12 cm.
  • Impression:
    • Malignant lymphoma S/P C/T show partial response.
    • Liver and spleen lymphoma S/P C/T show partial response.
• 2023-09-11 ECG
  • Normal sinus rhythm
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2023-07-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 18) / 81 = 77.78%
    • LVEF (%) = 78
    • M-mode (Teichholz) = 78
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; trivial TR.
• 2023-07-13 EGD
  • Reflux esophagitis LA Classification grade A
  • Bile reflux
  • Superficial gastritis
• 2023-06-15 PET
  • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm.
  • Increased FDG uptake in some focal areas in both lobes of the liver and in a focal area in the left lobe of the thyroid gland. Lymphoma involving the liver and left lobe of the thyroid gland should be considered. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Mildly increased FDG uptake in some focal areas in the spleen and in the bone marow of the skeleton. Lymphoma involving the spleen and bone marrow can not be ruled out.
• 2023-06-15 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy— Positive for B cell lymphoma
  • Microscopically, it shows aggregations of B lymphomatous cells. .
    
  • Immunohisotchemical stain reveals CD34(-), CD117(-), CD20 (l+), CD138 (focal +, 1~2%), MPO(+), CD71(+ at erythroid cells), CD10(+), TdT(-), CD61(+ at megakaryocytes).
• 2023-06-14 Patho - peritoneum biopsy
  • Lymph node, abdomen, CT-guide biosy — follicular lymphoma with focal high grade transformation
  • Section shows predominent small to medium sized lymphoid cells with focal large lymphoid cells (mainly in one strip).
  • The immunohistochemical stains of small to medium sized lymphoid cells reveal CD3(-), CD5(-), CD20(+), CD10(+), BCL2(+), BCL6(-), and Cyclin D1(-).
  • The immunohistochemical stains of large lymphoid cells reveal CD3(-), CD5(-), CD20(+), CD10(-), BCL2(+), BCL6(+), Cyclin D1(-), MUM1(+), C-MYC(-), and Ki-67 is about 50%.
• 2023-06-09 CT - abdomen
  • Findings:
    • There is huge mass (confluent lymphadenopathy) in the abdomen and pelvis, measuring 22 cm (the largest dimension), with encasing all visceral artery and vein that is c/w lymphoma. Please correlate with PET scan.
    • There is a poor enhancing mass 2.8 cm in S8/4 of the liver dome that may be liver lymphoma. Please correlate with MRI.
    • There is splenomegaly and the greatest anterior-posterior dimension measuring about 14 cm.
      • Lymphoma with spleen involvement is highly suspected.
    • Left side Pleura effusion is noted.
    • There is mild ascites in the cul-de-sac.
  • Impression:
    • Malignant lymphoma is highly suspected. Please correlate with PET scan.
    • Liver and spleen lymphoma is also suspected.
• 2023-06-09 SONO - nephrology
  • Interpretation:
    • Mild bilateral hydronephrosis
    • Splenomegaly
    • Gall stones
    • Ascites
    • r/o abdominal mass lesion with bilateral ureter compression
  • Suggestion:
    • Contrast CT scan for further investigation
• 2023-05-12 Gynecologic ultrasonography
  • Findings
    • Uterus Position : AVF
      • Size: 72 * 43 mm
      • Myometrum: Anterior/Posterior wall: / cm
      • Myoma: Myoma: 19 x 17 mm ,
      • Congenital Anomaly:
    • Endometrium:
      • Thickness: 9.7 mm , Fluid: , Type:
      • Endometrial polyp: * mm , Doppler Flow : S/D: RI:
    • Adnexae:
      • ROV:
        • SIZE: 24 * 22 mm , Doppler Flow : S/D: RI: * mm
      • LOV:
        • SIZE: * mm , Doppler Flow : S/D: RI: * mm
      • FOLLICLE R:
      • FOLLICLE L:
    • CUL-DE-SAC: with fluid
      
    • Other: LT adnexae:free
  • IMP: Uterine myoma

[MedRec]

• 2023-06-13 ~ 2023-06-19 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Follicular lymphoma with multiple lymph nodes on both sides of the diaphragm, liver and left lobe of the thyroid gland, spleen and bone marrow, Lugano stage at least III, FLIPI score:2 ,Intermediate Risk, PS:0
    • COVID-19, virus identified
    • Low back pain
  • CC
    • left flank pain for one week and body weight loss 4kg in one month.
  • Present illness
    • This 50 year-old denied any systemic disease before. She had suffered from left flank pain for one week and also body weight loss 4kg in one month. Therefore, she came to nephrology OPD for help on 2023/06/09.
    • Renal echo showed: 1) Mild bilateral hydronephrosis, 2) Splenomegaly, 3) Gall stones, 4) Ascites5. r/o abdominal mass lesion with bilateral ureter compression.
    • CT of abdominal was performed on 2023/06/09 which revealed A huge mass (confluent lymphadenopathy) in the abdomen and pelvis, measuring 22 cm (the largest dimension), with encasing all visceral artery and vein that is c/w lymphoma. Malignant lymphoma is highly suspected. Liver and spleen lymphoma is also suspected.
    • She was referred to ONC OPD today and was admitted for further management
  • Course of inpatient treatment
    • After admission, CT guide biopsy on 2023/06/14 showed follicular lymphoma with focal high grade transformation. Bone marrow aspiration and biopsy on 2023/06/15 and pending. PET scan on 2023/06/15 showed there was increased FDG uptake in some focal areas in both lobes of the liver, in a focal area in the left lobe of the thyroid gland, in some focal areas in the spleen and in the bone marow of the skeleton.
    • Pain control with Sketa 1 tab Q8H. However, sorethroat and cough with sputum was noted on 2023/06/18 and the Covid-19 showed positive. We applied the Paxlovid for 5days since 6/19.
    • With the relatively stable condition, she was discharged on 2023/06/19 and will OPD follow up later.
  • Discharge prescription
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Actein Effervescant (acetylcysteine 600mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# PRNQID
• 2023-06-13 SOAP Hemato-Oncology Gao WeiYao
  • O: 2023/06/09 CT: ABD - whole abdomen, pelvis
    • Malignant lymphoma (10x17 cm) is highly suspected. Please correlate with PET scan.
    • Liver and spleen lymphoma is also suspected.

[immunochemotherapy]

• 2023-10-06 - rituximab 375mg/m2 690mg NS 500mL D1 + cyclophosphamide 750mg/m2 1380mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-09-11 - rituximab 375mg/m2 685mg NS 500mL D1 + cyclophosphamide 750mg/m2 1375mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-08-17 - rituximab 375mg/m2 700mg NS 500mL D1 + cyclophosphamide 750mg/m2 1400mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-07-24 - rituximab 375mg/m2 680mg NS 500mL D1 + cyclophosphamide 750mg/m2 1360mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-07-03 - rituximab 375mg/m2 680mg NS 500mL D1 + cyclophosphamide 750mg/m2 1360mg NS 250mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2

==========

2023-10-09

Based on the PharmaCloud database, the patient has no records of visiting other clinics. Additionally, after consultations in our medical departments, no repeat prescriptions were issued, and no medication discrepancies were identified.

On 2023-09-13, a CT scan indicated a partial response after the patient underwent 4 treatment cycles (1 R-COP followed by 3 R-CHOP). The treatment appears to remain effective to date.

700720541

231006

[lab data]

2023-02-14 Anti-HBc Nonreactive
2023-02-14 Anti-HBc-Value 0.14 S/CO
2023-02-14 Anti-HBs 0.00 mIU/mL
2023-02-14 Anti-HCV Nonreactive
2023-02-14 Anti-HCV Value 0.06 S/CO
2023-02-14 HBsAg Nonreactive
2023-02-14 HBsAg (Value) 0.33 S/CO

[exam findings]

• 2023-05-04 Patho - uterus with or without SO non-neoplastic/prolapse Y1
  • PATHOLOGIC DIAGNOSIS
    • Endometrium, low uterine segment, radical hysterectomy — Undifferentiated carcinoma
    • Myometrium, uterus, ditto — Tumor invasion, less than half thickness
    • Cervix, uterus, ditto — Stromal invasion
    • Ovary, left, ditto — Free of tumor invasion
    • Fallopian tube, left, ditto — Free of tumor invasion
    • Ovary, right, ditto — Free of tumor invasion
    • Fallopian tube, right, ditto — Free of tumor invasion
    • Lymph node, L’t iliac, dissection — Free of tumor metastasis (0/8)
    • Lymph node, L’t oburator, ditto — Free of tumor metastasis (0/7)
    • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/3)
    • Lymph node, R’t oburator, ditto — Tumor metastasis (0/7)
    • Lymph node, L’t paraaortic, ditto — Free of tumor metastasis (0/2)
    • Lymph node, R’t paraaortic, ditto — Free of tumor metastasis (0/7)
    • Parametria, bilateral — Free of tumor invasion
    • Omentum, partial omentectomy — Free of tumor invasion
    • AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: radical hysterectomy
    • Specimens include: uterus with bilateral adnexa, partial omentum, pelvic and paraaortic lymph nodes
    • Specimen size:
      • uterus: 6.7 x 5.2 x 5.0 cm in size, 72 gm in weight
      • right ovary: 1.8 x 1.6 x 0.7 cm
      • left ovary: 1.9 x 0.9 x 0.6 cm
      • right fallopian tube: 6.3 cm in length, 0.4 cm in diameter
      • left fallopian tube: 5.5 cm in length, 0.5 cm in diameter
    • Tumor site: low uterine segment
    • Tumor size: 3.7 x 2.7 x 2.4 cm
    • The myometrium: 1.2 cm in thickness, tumor invasion less than half thicknes
    • The cervix: endocervical stroma is invaded by tumor
    • Bilateral adnexa: no remarkable change
    • Omentum: 5.5 x 4.5 x 1.0 cm, no remarkable change
    • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs, right obturator LNs, L’t paraaortic LNs and R’t paraaortic LNs
    • Representative sections as A: L’t iliac LNs, B: L’t obturator LNs, C: R’t iliac LNs, D: R’t obturator LNs, E: L’t paraaortic LNs, F: R’t paraaortic LNs, G1: R’t F-tube, G2: R’t ovary, G3: L’t F-tube, G4: L’t ovary, G5: R’t parametrium, G6: L’t parametrium, G7-G8: uterine corpus to cervix, G9-G15: tumor, G16: cervix and H: omentum
  • MICROSCOPIC EXAMINATION
    • Histology type: endometrioid undifferentiated carcinoma
    • Histology grade: undifferentiated
    • Depth of invasion: less than half thickness of myometrium
    • Lymphovascular invasion: Not identified
    • The cervical stroma involvement: Present
    • Resection margins of the cervix: Free, 1.7 cm away from tumor
    • Additional pathologic findings: moderate tumor-infiltrating lymphocytes
    • Lymph nodes: free of tumor metastasis (0/35) in total number
    • Vaginal stump: free of tumor invasion
    • Perineural invasion: Not identified
    • Ascites: Negative for malignancy
    • Immunohistochemistry: CK7(+), PAX-8(+), Vimentin(+), ER(+), P16(-), P40(-) and P53(wild type) for tumor
• 2023-04-20 MRI - pelvis
  • Findings: Soft tissue tumor in the uterine cervical region, regression size (from 4.8cm to 3cm) as compare with MRI study on 2023-02-09. Clinical biopsy proven cervical malignancy.
  • Impression: Cervical malignancy with regression size.
• 2023-02-20 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 26 dB HL; LE 13 dB HL.
  • RE normal to moderate SNHL.
  • LE normal to mild mixed type HL.
• 2023-02-09 MRI - pelvis
  • Finding: Soft tissue tumor in the uterine cervical region, 4.8cm. Clinical biopsy proven cervical malignancy.
  • Imaging Report Form for Cervical Carcinoma
    • Impression ( Imaging stage ) : T:T1b3(T_value) N:N0(N_value) M:M0(M_value) STAGE IB3 (Stage_value)
  • Impression: Cervical malignancy, cstage T2a2N0M0.
• 2023-01-31 CT - abdomen
  • Finding: Soft tissue tumor, 5.3cm in the uterine cervical region, r/o cervical myoma.
  • Impression: Cervical region tumor, myoma?
• 2023-01-30 Patho - cervix biopsy
  • Labeled as “cervix”, biopsy — poorly differentiated carcinoma.
  • Section shows poorly differentiated carcinoma with solid nests and papillary-like structures.
  • IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-).
• 2023-01-30 Gynecologic ultrasonography
  • A mass:47x31mm, RI:0.59

[MedRec]

• 2023-07-07 SOAP Rheumatology Chen JunXiong
  • S: 2023 0707 urticaria flare last day first attack over limbs, trunk, under regular chemothrapy
  • O: acute urticaria
  • Prescription
    • Xyzal (levocetirizine 5mg) 1# HS
    • Allegra (fexofenadine 60mg) 1# TID
    • Compesolon (prednisolone 5mg) 2# PRNBID
• 2023-06-15 SOAP Hemato-Oncology Xia HeXiong
  • Plan: CCRT with weekly carboplatin (due to impaired renal function, and self pay) followed by TP x 3 cycles
• 2023-06-01 SOAP Radiation Oncology Huang JingMin
  • A: Undifferentiated carcinoma of the uterine cervix, stage cT2a2N0M0, s/p neoadjuvant chemotherapy and surgery (Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomy).
  • P: Radiotherapy is indicated for this patient with the following indicators: stage cT2a2, s/p neoadjuvant chemotherapy and surgery
    • Goal: curative
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT +/- IVRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, +/- 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-06-08.
• 2023-05-02 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of endometrium
    • Endometrial cancer,stage II, post radical hysterectomy on 2023-05-03
    • Paralytic ileus
  • CC
    • intermittent postmenopausal bleeding for 6 months        
  • Present illness
    • This 55 y/o woman, G0P0, sex +, menopause in 2021. She had MEDICAL history of hyperlipidemia without control. She denied any food or drug allergy, and anticoagulants or hormone use. She had regular pap smear in 2021 and the result showed WNL.
    • Abnormal postmenopause bleeding was noted by patient for 6 months. According to patient statement, the discharge was pink initially. Then, the color change to brown and pus-like content, with increasing volume. No pain or burning sensation. She denied fever, weight loss, poor appetite, urinary frequency or urgency, dysuria, nocturia.
    • She came to our GYN OPD for help on 2023/01/30. PV revealed necrotic tissue and mass at os.
    • Biopsy was done and showed poorly differentiated carcinoma. IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-).
    • CT in 2023/01/31 showed 5.3 cm tumor in cervical region. She was diagnosed as poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
    • After 3 cycles of neoadjuvant chemotherapy (Intaxel + Carboplatin), she was admitted for radical hysterectomy on 2023/05/03.   - Course of inpatient treatment
    • The patient was admitted on 2023-05-02 due to cervical cancer.
    • She underwent Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomyon 2023-05-03.
    • The pathology stage: Endometrium, low uterine segment, radical hysterectomy — Undifferentiated carcinoma. AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II.
    • The GYN tumor board conference suggest the patient to receive CCRT on 2023-05-11.
    • Postoperative course was uneventful. Self voiding was smooth. She was discharged on 2023-05-24. Her follow up appointment is scheduled on 2023-06-01.
  • Discharge prescription
    • Naproxen (naproxen 250mg) 1# PRNQ6H
    • Anxiedin (lorazepam 0.5mg) 1# PRNHS
    • cephalexin 500mg 1# QID
    • MgO 250mg 1# QID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
• 2023-02-17 ~ 2023-02-22 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3
  • CC
    • for chemotherapy
  • Present illness
    • The 54 y/o woman has been well in the past. Menopause on 2021.
    • This time, her vagina has yellow-green discharge since 2022/09/09. Due to symptoms persisted for a while without improvement, so she came to our GYN OPD for help and pelvis MRI showed Cervical malignancy, cstage T2a2N0M0 on 2023/02/09.
    • Pathology showed poorly differentiated carcinoma. IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-) on 2023/2/3.
    • Port-a insertion on 2023/2/9. Under the impression of poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
    • Plan as Neo-adjuvant x 3th then radical surgery then adjuvant treatment, so she was admitted for first chemotherapy as self paid of TP on 2023/02/17.
  • Course of inpatient treatment
    • After admission, she received 24H CCr and PTA before neo-adjuvant x 3th then radical surgery then adjuvant treatment.
    • Premedication as Dorison 20mg q6h x 2 dose since 2/20 2300 and 2/21 0500.
    • C1 selfpaid of Intaxel (175mg/m2) + Carboplatin (AUC 6) on 2023/2/21.
    • Under the stable condition, she can be discharged on 2023/2/22. OPD follow up is arranged.
  • Discharge prescription
    • Mopride (mosapride citrate 5mg) 1# TID
    • Roumin (prochlorperazine maleate 5mg) 1# TID
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
• 2023-02-14 SOAP Hemato-Oncology Xia HeXiong
  • P: Admission for C/T with PF or TP
• 2023-02-10 SOAP Obstetrics and Gynecology Huang SiCheng
  • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-02-09. Neo-adjuvant x 3th then radical surgery then adjuvant treatment
• 2023-02-07 SOAP Urology You ZhiQin
  • S: cervical cancer, for r/o bladder invasion
  • O: CUS: no bladder invasion
• 2023-02-06 SOAP Obstetrics and Gynecology Zhu ChunHong
  • O: 2023/01/31 CT ABD: Soft tissue tumor, 5.3cm in the uterine cervical region, r/o cervical myoma. Impression: Cervical region tumor, myoma? - interpretation about report, most possibility was cervical cancer

[consultation]

• 2023-09-14 SOAP Neurology
  • Q
    • This 55-year-old woman patient is a case of Endometrial undifferentiated carcinoma with cervical invasion status post Radical hysterectomy on 2023/05/03, pT2N0, if cM0, stage II, FIGO stage II, s/p neoadjuvant chemotherapy with TP for 3 cycles, s/p Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomyon on 2023/05/03 and concurrent chemoradiotherapy with Carboplatin from 2023/06/21~2023/08/10, and adjuvant chemotherapy with TP from 2023/08/24~. She was admitted for adjuvant chemotherapy with TP(C2). This time, for dezziness in 2023/05. No hypertension and chest pain was noted. Now, for evaluate dizziness examine and therapy. Thank you.
  • A
    • She complained of intermittent dizziness during turning head to left or right since May, 2023. She denied headache, double vision, facial palsy, slurred speech, focal weakness or clumsiness, sensory deficit, and unsteady gait.
    • NE
      • GCS: E4V5M6
      • EOM: free and full
      • pupil 3mm/3mm, light reflex +/+
      • no facial palsy
      • No tongue deviation
      • No dysarthria
      • MP: upper 5/5, lower 5/5
      • Sensory: intact
      • FNF and HKS: no dysmetria
      • Romberg test: negative
      • Gait: steady, no falling
      • Tandem gait: steady
    • Asssessment
      • peripheral vertigo while head turning left-right
      • anemia
    • Suggestion
      • Keep observation of neurological signs. There was no focal neurological deficit currently.
      • Arrange BAEP.
      • Add Diphenidol 1# TIDPRN if dizziness.
      • Consult ENT doctor for vestibular system survey and treatment.
      • Treat anemia.

[surgical operation]

• 2023-05-03
  • Surgery
    • Diagnosis: poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
    • Procedure: Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomy
  • Finding
    • Uterus: Avfl, 5x3 cm; cervix:enlarged with multiple papillary tissues.
    • RAD: grossly normal.
    • LAD: grossly normal.
    • CDS: little ascites s/p washing cytolgy, no adhesion bands.
    • Right parametrium: size : 3 cm, Induration (-);
    • Left parametrium: size : 3 cm, Induration (-);
    • Vagina cuff: 3 cm , gross tumor (-), section margin free (+)
    • Bilateral pelvic/ paraaortic lymph nodes: Enlarged
    • Omentum: multiple hard, infracolic omentectomy was done.
    • Adhesion between pelvic wall and bowels, s/p adhesiolysis
    • Estimated blood loss: 600ml
    • Blood transfusion: pRBC 2u
    • Complication: none  

[radiotherapy]

[chemotherapy]

• 2023-10-06 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 550mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-09-15 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 550mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-08-24 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 550mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-08-03 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-26 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-20 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-13 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-06 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-29 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-23 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-08 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-03-18 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-02-21 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-10-06

There was no medication reconciliation issue identifed.

Leukopenia (WBC 1.16K/uL) was noted on 2023-09-07, approximately 2 weeks after the patient received the paclitaxel + carboplatin regimen on 2023-08-24. With Granocyte (lenograstim) administered for 3 days in early Sep, 4 days in mid-Sep, and 4 days in late Sep, the WBC finally reached above 3K/uL. Close monitoring of the WBC count may be necessary at this time.

2023-10-04 WBC 3.15 x10^3/uL 2023-09-28 WBC 2.66 x10^3/uL 2023-09-13 WBC 3.33 x10^3/uL 2023-09-07 WBC 1.16 x10^3/uL * 2023-08-23 WBC 3.41 x10^3/uL

2023-08-24

After examining both PharmaCloud and HIS5 records, no medication discrepancies were found.

700731401

231006

[exam findings]

• 2023-09-18 Nasopharyngoscopy
  • NPC recurrence
  • ant. mild epistaxis
  • mucositis with condidiasis
• 2023-09-11 Pure Tone Audiometry
  • Reliabilty Fair
  • PTA
    • R’t : >100 dB HL, severe to profound mixed type HL
    • L’t : >109 dB HL, profound mixed type HL.
• 2023-08-04 Patho - nasopharyngeal/oropharyngeal biopsy
  • PATHOLOGIC DIAGNOSIS
    • Nasopharynx, right and left, biopsy — Keratinizing squamous cell carcinoma, well differentiated
    • Nasal cavity, #1 and #2, right, biopsy — Keratinizing squamous cell carcinoma, well differentiated
  • MICROSCOPIC EXAMINATION
    • The sections all five parts show a picture of keratinizing squamous cell carcinoma, composed of irregular islands of well differentiated squamous cells with keratinization, mild nuclear atypia, and focal stromal invasion.
• 2023-07-19 PET
  • Increased FDG uptake in bilateral nasopharyngeal regions, highly suspected tumor recurrence.
    
  • Increased FDG uptake in lymph nodes in the right neck and right supraclavicular fossa, probably metastatic (priority) or reactive nodes.
    
  • Increased FDG uptake in a level III level lymph node of the left neck, probably reactive node.
    
  • Increased FDG uptake at the C1 spine, highly suspected tumor invasion.
    
  • increased FDG uptake in the stomach, probably benign in nature, suggesting follow-up.
    
  • NPC s/p treatment with tumor recurrence, by this F-18 FDG PET scan.

[MedRec]

• 2023-08-17 SOAP Hemato-Oncology Xia HeXiong
  • Plan:
    • TPC x3 -> CCRT (Dr. Wang)
    • Admission on 2023-09-04 for 24 hours CCr and Audiometry and TPF
• 2023-08-16 SOAP Oral and Maxillofacial Surgery He ChengHan
  • S: Pre-CCRT dental evaluation
  • O:
    • Panoramic findings:
      • Missing: 36,37,45,46
      • Impaction: nil
      • Crown and Bridge: 15,26,47
      • Caries: nil
      • Periodontal condition: chronic periodontitis
    • Periodontitis of tooth 46, mobility Gr(II), widened PDL space
  • Problem:
    • Squamous cell carcinoma of nasopharynx
    • periondontitis of tooth 47
  • Plan:
    • Explain the risk/benefit of the treatment to the patient (Inform about the risk of inferior alveolar nerve numbness and inform that if the tooth is not extracted, subsequent tooth infection may lead to cellulitis.)
    • Sign informed consent.
    • Block anesthesia of right mandible.
    • Complicated extraction of tooth 47
    • Suture the gingiva with Vicryl 4-0.
    • Prescribe Acetal and cephalexin
    • Teach the patient how to do home care and OPD follow-up.
• 2023-08-02 POMR Ear Nose Throat Huang YunCheng
  • Discharge diagnosis
    • Bilateral nasopharyngeal tumor status post bilateral nasopharyngeal tumor biopsy on 2023/08/03
    • Chronic osteomyelitis with draining sinus, unspecified site
    • Chronic sinusitis, unspecified
    • Essential (primary) hypertension
  • CC
    • Right otorrhea and purulent rhinorrhea for one month.
  • Present illness
    • This 67-year-old man has history of nasopharyngeal cancer post CCRT 30 years ago at TSGH. He is regular follow up at our ENT OPD. The patient complaint purulent rhinorrhea and right otorrhea noted for one month. At our ENT OPD, physical examination revealed right external auditory canal granular tumor, biopsy was done. The pathology revealed squamous cell hyperplasia with acute and chronic inflammation. We arrange whole body PET scan shwoed NPC s/p treatment with tumor recurrence, by this F-18 FDG PET scan.
    • Under the impression of nasopharyngeal granular tumor suspect recurrence cancer, surgical biopsy was suggested.
    • After well explanation about the surgical details, he was admitted for the operation.
  • Course of inpatient treatment
    • After patient was admitted, pre-operative evaluation was done. The patient underwent the operation of bilateral nasopharyngeal tumor biopsy. Post the operation, cool soft diet, pain control with Ultracet 1# po q6h were given. There was no active tongue bleeding. Appetite and amount of food intake improved day by day. Under relative stable condition, the patient was discharge today and continue OPD follow up.    

[chemmotherapy]

• 2023-09-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 70mg/m2 120mg NS 500mL 24hr D2 + MgSO4 10% 20mL 1hr furosemide 20mg 30min NS 500mL (after CDDP) D3 + fluorouracil 1000mg/m2 1800mg D5W 500mL 24hr D3-7 (TPF Q3W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

[the possibility of fever associated with the drugs being used]

Based on UpToDate database, it’s noted that Tapimycin (piperacillin, tazobactam) and Ulstop (famotidine), which the patient is currently taking, have been reported to be associated with fever as an adverse reaction. The incidence rate for the former is 2%, while for the latter, it is less than 1%.

2023-10-02

[Dipeptiven dosage and administration]

(Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf)

Dipeptiven 100 mL (alanyl glutamine 20g) can be diluted with NS 250-1000 mL. After dilution, it can be stored at room temperature for 24 hours.

A maximum daily dosage of 2 g amino acids/or protein per kg bodyweight should not be exceeded in parenteral/enteral nutrition. The supply of alanine and glutamine via Dipeptiven should be taken into consideration in the calculation. The proportion of the amino acids supplied through Dipeptiven should not exceed approx. 30% of the total amino acids/protein supply.

• Patients with total parenteral nutrition
  • The rate of infusion depends on that of the carrier solution and should not exceed 0.1 g amino acids/kg body weight per hour.
  • Dipeptiven should be mixed with a compatible amino acid carrier solution or an amino acid containing infusion regimen prior to administration.
• Patients with total enteral nutrition
  • Dipeptiven is continuously infused over 20-24 hours per day. For peripheral venous infusion, dilute Dipeptiven to an osmolarity ≤ 800 mosmol/L (e.g. 100 mL Dipeptiven +100 ml saline).
• Patients with combined enteral and parenteral nutrition
  • The full daily dosage of Dipeptiven should be administered with the parenteral nutrition, i.e. mixed with a compatible amino acid solution or an amino acid contained in infusion regimen prior to administration.

If the patient is still on port-A, based on his body weight of about 70kg, IV infusion is recommended not less than 3 hours (20g / (0.1g/kg/hr x 70kg)), 4 to 6 hours would be even better.

700030886

231005

[exam findings]

• 2023-09-19 Patho - bone marrow biopsy
  • Bone marrow, iliac, clinically recurrent T cell lymphoma, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • IHC stains: CD30: (-); CD3: 5 %; CD20: 1%, CD4 and CD8: no predominant subpopulation. CD68: 25 %.(of the nucleated cells).
• 2023-09-12 PET scan
  • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, liver, spleen and multiple bones/bone marrow of the skeleton (stage IV).
  • In comparison with the previous study on 2023/03/17, more new FDG avid lesions are noted, suggesting lymphoma in progression.
• 2023-07-12 CT - abdomen
  • Findings: Comparison prior CT dated 2023/03/08.
    • Prior CT identified a poor enhancing lesion 1.5 cm in S7 of the liver at portal venous phase image is not noted in the current CT.
    • Prior CT identified two cysts in S2/3 and S1 of the liver are noted again, stationary.
    • Prior CT identified multiple enlarged nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space are noted again, marked decreasing in size.
      • It is c/w angioimmunoblastic T-cell lymphoma S/P C/T with partial response.
    • There are several gallstones (< 1.8 cm).
  • Impression:
    • Angioimmunoblastic T-cell lymphoma S/P C/T show partial response.
• 2023-03-30 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lymphadenopathy at both sides of the mediastinum is found.
      • Bilateral lower neck lymphadenopathy is also found.
    • Visible abdomen:
      • Low density lesion at S7 of liver measuring 1.46cm in largest dimension. Lymphoma is compatible.
      • Mild splenomegaly is found.
      • Enarlged lymph nodes are found near EG junction is noted.
  • Imp:
    • Lymphadenopathy at mediastinum. Bilateral lower neck and EG junction
    • Liver low density nodule. S7, lymphoma is favored.
• 2023-03-30 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with angioimmunoblastic T-cell lymphoma with bone marrow involvement
  • The sections show slightly hypercellular marrow (40%). The myeloid series show good maturation. The megakaryocytes are increased in number. Paratrabecular and interstitial micronodular infiltration with atypical cells, many small lymphocytes, scattered CD68+ histiocytes and eosinophils, and subtle fibrosis are evident.
  • IHC, the atypical cells reveal: CD20(-), CD3(+), CD30(focal+) and BCL6(+). The finding is compatible with angioimmunoblastic T-cell lymphoma with bone marrow involvement. Suggest bone marrow smear evaluation and clinic correlation.
• 2023-03-23 Patho - bone marrow biopsy
  • Lymph node, right neck, excisional biopsy — Angioimmunoblastic T-cell lymphoma
  • Microscopically, the section shows a picture of totally effacement of nodal architecture and marked vascular proliferation associated with aggregates of atypical large lymphoid cells mixed with small lymphocytes, which immunohistocehmcial stains show CD30(+, focal), CD3(+, diffuse), CD20(-), Bcl-2(+, focal), C-MYC (+, 20%), CD10(-) , Bcl-6(+, scatter), CK(-), Ki-67: increased activity and PD-1(+, focal). According to above histopathologic findings, it indicates a case of angioimmunoblastic T-cell lymphoma.
• 2023-03-17 PET
  • Prominently increased FDG uptake in multiple left neck and left supraclavicular lymph nodes. Lymphoma should be considered. Please correlate with the pathologic findings for further evaluation.
  • Mildly to moderately increased FDG uptake in multiple right neck lymph nodes, some mediastinal, left axillary and bilateral pulmonary hilar lymph nodes. Lymphoma can not be ruled out.
  • Mildly increased FDG uptake in some abdominal lymph nodes in the gastrohepatic ligament and para-aortic space. Lymphoma is less likely.
  • Increased FDG uptake in a focal area in the segment 7 of the liver. The nature is to be determined (inflammatory pseudotumor? neuro-endocrine tumor? other nature?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG uptake in the stomach. Inflammation is more likely. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Mildly increased FDG uptake in the left adrenal gland and in a focal area in the pituitary fossa. Benign nature such as adenoma may show this picture.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
• 2023-03-15 MRI - liver, spleen
  • Findings:
    • There is a well-defined homogeneous mass measuring 2.3 cm at S2 of the liver, showing isointensity on both T1WI and T2WI. Dynamic study, this mass reveals well enhancement on arterial phase images but rapidly return to be iso-intensity on portal venous phase and delayed phase images.
      • Focal nodular hyperplasia (FNH) is highly suspected.
    • There is a well-defined, homogeneous mass 1.5 cm in S7 of the liver, showing hypointensity on T1WI, mild hyperintensity on T2WI, and marked hyperintensity on DWI. During dynamic study, this tumor shows peripheral contrast enhancement in arterial phase and portal-venous phase images, and homogeneous enhancement in delayed phase images.
      • Sclerosing hemangioma is highly suspected.
      • The differential diagnosis includes inflammatory pseudotumor and neuro-endocrine tumor.
      • In addition, there are two poor enhancing lesions in S2/3 and S1 of the liver that may be cysts.
    • There are multiple enlarged nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space. The largest one 1.9 x 1.3 cm in the hepatoduodenal ligament,
      • Reactive nodes are highly suspected.
      • The differential diagnosis includes lymphoma and metastatic nodes.
      • Please correlate with PET scan.
    • There are several gallstones (< 1.8 cm).
    • There is mild hyperplasia of left adrenal gland.
  • Impression:
    • FNH 2.3 cm in S2 of the liver is noted.
      • Follow up sonography is indicated.
      • Otherwise, please correlate with primovist-enhanced MRI.
    • Sclerosing hemangioma 1.5 cm in S7 of the liver is highly suspected.
      • The differential diagnosis includes inflammatory pseudotumor and neuro-endocrine tumor.
    • Reactive nodes are highly suspected.
      • The differential diagnosis includes lymphoma and metastatic nodes.
      • Please correlate with PET scan.
• 2023-03-13 Patho - stomach biopsy
  • Stomach, mid body, LC side, biopsy — chronic gastritis with intestineal metplasia and H.pylori infection
  • Microscopically, it shows chronic gastritis with lymphoplasmacytic infiltrate and focal intestinal metaplasia. Mild Helicobacter-like bacilli are seen.
• 2023-03-13 EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Chronic superficial gastritis with erosions and focal atrophic gastritis, s/p CLO test
    • Gastric xanthoma
    • Gastric mucosal lesion, suspected intestinal metaplasia, mid body, LC, s/p biopsy
  • CLO test: Positive
  • Suggestion:
    • PPI therapy
    • Pursue CLO test and pathology
    • Endoscopic follow-up
• 2023-03-08 CT - abdomen
  • Findings:
    • There is a homogeneous enhancing lesion 2.3 cm at S2 of the liver in arterial phase images but no contrast washout (isodensity) in portal venous phase and delayed phase images.
      • FNH is highly suspected.
      • The differential diagnosis includes HCC.
      • Please correlate with MRI.
    • There is a poor enhancing lesion 1.5 cm in S7 of the liver at portal venous phase image. However, this lesion is not identified in non-enhanced, arterial phase images and delayed phase images.
      • Please correlate with MRI.
      • In addition, there are two poor enhancing lesions in S2/3 and S1 of the liver that may be cysts.
    • There are multiple enlarged nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space.
      • Lymphoma is highly suspected.
      • The differential diagnosis includes metastatic nodes.
    • There are several gallstones (< 1.8 cm).
  • Impression:
    • FNH 2.3 cm in S2 of the liver is highly suspected.
      • The differential diagnosis includes HCC. Please correlate with MRI.
    • A poor enhancing lesion 1.5 cm in S7 of the liver, nature?
    • Lymphoma is highly suspected.
      • The differential diagnosis includes metastatic nodes.
• 2023-03-06 SONO - abdomen
  • Diagnosis:
    • Hepatic hypoechoic lesion, left lobe, nature?
    • Splenic lesion, nature?
    • Gall stone
  • Suggestion:
    • correlated with other images
• 2023-02-20 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (123 - 43) / 123 = 65.04%
    • M-mode (Teichholz) = 65
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH; impaired LV relaxation.
    • Normal RV systolic function.
    • Aortic valve sclerosis with no AS and AR; mild MR; mild TR; mild PR.
    • Dilated aortic root and ascending aorta; aortic root calcification.
• 2023-02-07 SONO - abdomen
  • Gall stone
  • Splenic lesion?
• 2023-02-05 CT - abdomen
  • Some LNs (up to 1.8cm) at retroperitoneum.
  • Gallbladder stones (up to 1.5cm).

[MedRec]

• 2023-08-24 SOAP Cardiology Duan DeMin
  • Prescription x3
    • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
    • Concor (bisoprolol 5mg) 0.5# QD
    • Through (sennoside 12mg) 2# HS
• 2023-07-24 SOAP Oral and Maxillofacial Surgery He ChengHan
  • S: toothache for a while
  • O:
    • Panoramic findings:
      • Missing: 18-14,25,27,28,37,36,31,41
      • Impaction: nil
      • Crown and Bridge: 23,24-26
      • Caries: 32
      • Periodontal condition: chronic periodontitis
    • deep caries of tooth 32, poor prognosis.
  • A: deep caries of tooth 32
  • P:
    • Take panoramic film for evaluation
    • Explain the findings
    • Suggest removal of the lower left side premolar after the body condition stabilized post-chemotherapy.
• 2023-07-19 SOAP Hemato-Oncology Xia HeXiong
  • P
    • Arrange PET-CT for Re-stagingafter 6 cycles of C/T
    • Already mention PBSCT again
    • Request patient RTC by themself after removing tooth
• 2023-07-06 SOAP Hemato-Oncology Xia HeXiong
  • P
    • Granocyte on D6-8
    • Strongly request him visit Endocrinologist for DM
  • Prescription
    • Smecta (dioctahedral smecitite 3mg) 1# TIDAC
• 2023-06-28 SOAP Neurology Chen PeiYa
  • S: CC: involuntary mouth movement (compressing lips) noted since chemotherapy
  • Prescription
    • Switane (trihexyphenidyl 2mg) 0.5# BID
• 2023-04-12 SOAP Hemato-Oncology Xia HeXiong
  • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-04-10.
    • Angioimmunoblastic T-cell lymphoma stage IV, IPI: 3(Age, stage, BM+Sella)
    • CHOP ± steam cell transplantation.
• 2023-03-27 ~ 2023-04-07 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Angioimmunoblastic T-cell lymphoma of right neck with lymphadenopathy at mediastinum, with bilateral lower neck and EG junction and liver, bone marrow involvement, stage IV
    • Liver tumor, suspected focal nodular hyperplasia
  • CC
    • fever up to 39 degree for 3 days
  • Present illness
    • This is a 73 years old male with underlying disease of hypertension, type 2 DM, hyperlipidemia, hepatic tumor, suspected lymphoma, regularly followed up at our CV, GI and meta OPD.
    • This time, fever up to 39 degree for 3 days, after excisional biopsy of right neck on 2023-03-23. Otherwise, there was no URI or UTI symptoms, abdominal pain, diarrhea, dysuria, nausea or vomit. TOCC history was unremarkable.
    • Due to the fever, he came to our ED for help. At ED, vital signs showed BP:125/62mmHg; HR:93 bpm; BT:37.8’C; RR:16 bpm/min; Con’s:E4V5M6, SPO2:95%. The laboratory data showed normalized white count, elevated of CRP level(26.42mg/dl), hyponatremia were also noted. The urinalysis showed no UTI picture, such as pyuria or bacteriuria. The CXR film revealed no active lung lesion.
    • Under the impression of fever cause unknown, he was admitted to our INF ward for further evaluation and management on 2023-03-27.
  • Course of inpatient treatment
    • After admission we gave abx and survey for the cause of fever, atypical antigen, autoimmune disease, virus inf. were included. However, we connected with the pathologist and the patho of neck LN showed Angioimmunoblastic T-cell lymphoma.
    • Follow up Chest CT showed lymphadenopathy at mediastinum, bilateral lower neck and EG junction, liver low density nodule. S7, lymphoma is favored.
    • After explain with family and family, he received chemotherapy with CHOP (Endoxan 750mg/m2, Doxorubicin 50mg/m2, Vincristine 1.4mg/m2 (max 2mg), Compesolon 5mg/tab PO QD on 2023/4/3-3/7 60mg/m2) on 2023/04/03.
    • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H for nausea and vomiting. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/04/07 and OPD followed up later.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2023-03-23 SOAP Ear Nose Throat Guo YanJun
  • S: for neck mass biopsy
  • O: R’t level V neck mass about 2x1.5cm excisision done
• 2023-03-22 SOAP Ear Nose Throat Guo YanJun
  • S
    • Referred from ID OPD for arrangement of excisional biopsy for pathological confirmation of TB.
    • Serum TB antigen test positive noted on 3-18
  • O
    • PH: DM, HTN, lipid
    • Allergy(-)
    • External ear canal clean
    • Ear drum intact
    • Nasal septum: deviated to R
    • Nasal cavity: fair inf. turbinate
    • Oral cavity: N-P
    • Oropharynx :fair
    • Nasopharynx: smooth via scope
    • Larynx: epiglottis ok, vocal cords fail
    • Neck: R level V 1.5cm and L level V 1.7cm firm movable oval masses without tenderness.
    • Scope: smooth nasopharynx, oropharynx, hypopharynx.
• 2023-03-22 SOAP Infectious Disease Peng MingYe
  • S
    • Referred from Onco OPD for positive IGRA report on Mar 18
    • suspect liver lymphoma case
    • Underlying DM, HCVD, thoracic aneurysm, GB stone
  • O
    • 20230318 IGRA (+)
    • 20230317 PET
    • 20230315 MRI of liver
    • 20230313 UGI PES
  • A
    • Positive IGRA suggest at least latent TB, can not be used for TB LN diagnosis, LN biopsy still necessary.
  • P
    • refer to ENT OPD for Neck LN excisional biopsy highly recommended for pathology, for TB-PCR and TB culture
• 2023-03-21 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • MTB (+) -> Refer to Infection for further management
    • If TB i under control, then refer to ENT for LN Excisional Biopsy
• 2023-03-10 ~ 2023-03-17 POMR Gastroenterology Chen HongDa
  • Discharge diagnosis
    • Suspected lymphoma
    • Liver tumor, suspected focal nodular hyperplasia
    • Reflux esophagitis LA Classification grade A
    • Chronic superficial gastritis with erosions and focal atrophic gastritis, rapid urease test:positive.
    • Mixed hemorrhoid, mild
  • CC
    • was scheduled for liver tumor study.
  • Present illness
    • This is a 73 years old male with underlying disease of hypertension, type 2 DM, hyperlipidemia. He is regularly followed up at our CV and meta OPD. He was just discharged from our hopital on 2/13 due to intra-abdominal infection.
    • Follow up abdominal echo on 3/6 reveal a hepatic hypoechoic lesion, left lobe, nature need to be ruled out.
    • He then receive CT and it reveal
      • Focal nodular hyperplasia 2.3 cm in S2 of the liver is highly suspected. The differential diagnosis includes HCC. Please correlate with MRI.
      • A poor enhancing lesion 1.5 cm in S7 of the liver, nature?
      • Lymphoma is highly suspected.
    • He denied fever, chillness, decreased appetite, cold sweating or recent body weight loss found. He also denied any discomfort in recent days.
    • PE show no icteric slcera, no murphy sign. Blood test showed no leukocytosis but elevated of CRP.
    • Tumor markers(CEA, CA19-9 and AFP) all showed negative finding. CXR show bilateral clear lung field.
    • Under the impression of 1.) Hepatic tumor 2.) Favor lymphoma. He was admitted to our ward for further survey and treatment.
  • Course of inpatient treatment
    • After admission, Antibiotic with Ciproxin IV form total three days then shifted to oral form used for infection control.
    • Tumor marker with AFP was checked and hepatitis markers with HBsAg, Anti HCV were all follow up that showed negative finding.
    • Oncologoist was consulted for management of favor lymphoma who suggested 1. check LDH level 2. consult the General surgen for intra-abdominal LN excisional biopsy 3. liver biopsy.
    • Upper GI endoscopy and colonscopy were all performed which revealed reflux esophagitis LA Classification grade A; chronic superficial gastritis with erosions and focal atrophic gastritis, s/p CLO test (+); Gastric xanthoma and gastric mucosal lesion, suspected intestinal metaplasia, mid body, LC, s/p biopsy on EGD. Colonscopy showed mixed hemorrhoid, mild. Oral form PPI with Nexium 1# po QDAC was used.
    • GS was consulted for lymph node biopsy and management of GB stones who explained the risk and possibility of surgery and may do PET by himself payment for further survey.
    • ID man was also consulted for management of elevated of CRP who suggested 1. Check U/A, urine culture, check PSA level. 2. Serum QuantiFERON-TB study for possible latent TB or active TB. 3. Consider laparoscopy for open biopsy.
    • Liver MRI with contrast was done on 3/15 that report showed 1.FNH 2.3 cm in S2 of the liver is noted. 2.Sclerosing hemangioma 1.5 cm in S7 of the liver is highly suspected. 3.Reactive nodes are highly suspected. The differential diagnosis includes lymphoma and metastatic nodes. Please correlate with PET scan.
    • on 3/16 AM: the medical condition was explained to the patient, his wife, and niece (although the patient had been informed of the explanation timing in the past couple of days, he still mentioned that his son and daughter were too busy to come to the hospital). explained EGD, Colonoscopy report. reply of consultation of oncologist, GS surgeon, infection physician. Liver MRI report.
    • for abdominal lymph adenopathy: both benign or malignant etiology was considered: we’ve suggested lymph node biopsy: but patient and family refused lymph node biopsy
    • we’ve also suggested percutaneous biopsy for liver tumor (FNH was suspected): but patient and family also refused liver biopsy; they requested for PET scan; arranged PET scan
    • PET scan was done on 3/17 without complications. There was no abdominal pain nor poor appetite found during admitted. Under a stable condition, he was discharged first and further GI/ID/Oncology OPD were arranged later.
  • Discharge prescription
    • Cinolone (ciprofloxacin 250mg) 2# BIDAC
    • Nexium (esopeprazole 40mg) 1# QDAC
• 2017-02-09 SOAP Metabolism and Endocrinology Yu LiJiao
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertention, unspecified [I10]
    • Pure hypercholesterolemia [E78.0]
  • Prescription x3
    • Uformin (metformin 500mg) 1# QD
    • Tulip (atorvastatin 20mg) 0.5# Q4D
    • Aprovel (irbesartan 300mg) 1# QD

[consultation]

[chemotherapy]

• 2023-10-02 - gemcitabine 1000mg/m2 1800mg NS 250mL 1hr + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr (GemOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-09-20 - gemcitabine 1000mg/m2 1800mg NS 250mL 1hr + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr (GemOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-08-16 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-26 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-28 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-19 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-03 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-05

The repeat prescription for Exforge (amlodipine, valsartan), Concor (bisoprolol), and Through (sennoside) was issued by our cardiologist on 2023-08-24, and the patient refilled these medications on 2023-09-11. The medications are currently in use with no discrepancies found.

700563689

231005

[exam findings]

[MedRec]

• 2023-08-29 SOAP Rheumatology Chen JunXiong
  • Diagnosis
    • Rheumatoid arthritis [M05.70]
    • Essential hypertention, unspecified [I10]
    • Constipation [K59.00]
    • Peristent disorder of initiating or maintaining sleep [F51.09]
    • Other specified gastritis, without mention of hemorrhage [K29.30]
  • Prescription x3
    • Eurodin (estazolam 2mg) 1# PRNHS
    • Salazine (sulfasalazine 500mg) 1# QD
    • Celebrex (celecoxib 200mg) 1# PRNQD
    • Plaquenil (hydroxychloroquine 200mg) 1# QD
    • MgO 250mg 1# QD
    • Compesolon (prednisolone 5mg) 1# QD
• 2023-08-02 SOAP Hemato-Oncolgoy Xia HeXiong
  • O: Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 2023/07/13
    • Treatment Plan: 1. Adjuvant chemotherapy after surgery. 2. Staging consensus: T1c1N0M0.
  • P: Arrange admission for adjuvant chemotherapy with TP x6
• 2023-07-04 ~ 2023-07-14 POMR Obstetrics and Gynecology Zeng LunNa
  • Discharge diagnosis
    • Malignant neoplasm of left ovary
    • Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems involvement
    • Unspecified hydronephrosis
    • Debulking surgery on 2023-07-06
  • CC
    • Incidental computed tomography (CT) finding of left pelvic mass (105mmx68mm) on 2023/06/21
  • Present illness
    • This is a 62-year-old-woman, Gravidity2 Parity2 (G2P2) (vaginal delivery x2) with rheumatic arthritis and hypertension under medication. She came to our hospital this time due to incidental CT finding of left pelvic mass (105mmx68mm) on 2023/06/21.
    • She was in her ususal status until 2023/06/21, when Left upper qaudrant (LUQ) pain was noted. She visited our emergency department, where whole body CT with contrast was done. A 10cm well-defined pelvic mass with cystic and soft-tissue components and enhancement of solid parts was found. The tumor also caused compression of urinary bladder and left ureter, resulting in moderate hydronephrosis.
    • Gynecologist was consulted, and abdominal echo and tranvaginal echo showed a pelvic mass measuring 105mmx86mm with ascites, uterus: 5.8x3.6cm, endometrium: 1.12cm. She was first admitted to treat her acute problem of urinary tract infection, left percutaneous nephrostomy (PCN) was also performed. After compeleting the treatment, she came to our gynecology out patient department for surgical evaluation.
    • According to the patient, urinary frequency had been noted for about five years. She denied abodminal distension, no abdominal pain, no nausea or vomit, no constipation nor diarrhea, no bloody or tarry stool, no vaginal spotting or discharge. There was decrease appetite since last November, due to teeth problems, therefore a decrease of 12 kilogram (kg) was noted ever since.
    • Lab data showed normal CA125 (32.2 U/ml), normal CEA (2.08 ng/ml), normal CA199 (25.58 U/ml). Under the impression of pelvic mass, favor left ovarian origin, surgical intervention was suggested. After well explained and discussion with patient, she agreed operation.
    • Under the impression of pelvic mass, favor left ovarian origin, we will arrange admission for preoperative evaluation and preparation including panendoscopy and colonscopy as well as debulking surgery.
  • Course of inpatient treatment
    • After admission, the patient underwent upper GI panendoscope and colonoscope on 2023/07/05, both showed no signs of tumor lesions. On 07/06, she underwent debulking surgery (total hysterectomy + bilateral salphingo-ophorectomy + bilateral pelvic lymph node dissection + infracolic omentectomy) and insertion of bilateral double-J. Perioperative blood loss was 1400ml. therefore transfusion with 4u LPRBC, ferrum injection 2 amp ST, trasamin 500mg BID (07/06~07/07) were given.
    • Post-operation hemoglobulin: 8.9g/uL increased to 9.2g/uL. We checked KUB on 7/7, which showed intact left PCN and bilateral double-J, therefore, left PCN was removed in the afternoon. Left lower quadrant pain improved evidently afterwards.
    • Surgical wound was vertical, 13cm in total, there was no active woozing, no discharge.
    • Desaturation to SpO2 around 80% room air was noted on 7/9 evening, with tachypnea (22-24/min), so was fever up 39.1’C. Fever routine was performed, U/A showed pyuria, nitrite: 1+, bacteria:3+. Lab: leuocytosis with bandemia. Chest xray showed blunting of right CP angle, which resolved slightly on 7/10 CXR. Therefore empirical cravit 750mg QD was prescribed (7/9~7/10), tazocin to cover anerobes due to possible aspiration peumonia (7/11), doripenam as recommended by infection (7/12~7/13), oral cravit(7/14~).
    • Due to bilateral lung atelectasis with unstable SpO2, we consulted chest man. Aggressive chest percussion was recommended, and we also checked sputum culture, which later showed mixed growth and candida albicans. Abdominal distension with vomit were also noted, with improved a bit after abdominal massage. We also added primperan 10mg Q8H and MgO 1# QD to facilate bowel movement. Afterwards, the patient showed evident improvement in spirits and appetite. Flatus and defecation was smooth, wound pain also improved gradually.
    • Since 7/9, there had been no fever. Much yellowish sputum was still noted, so we continued actein treatment and gave oxygen support with nasal cannula when needed, and also encourage ambulation. We followed-up lab data on 7/12, CRP decreased from 16.6 to 6.4, no more bandemia. Chest Xray also showed no lower lung atelectasis.
    • Pathology report showed ovarian caner, clear cell adenocardinoma, high grade, pT1c1 pN0 (if cM0), FIGO stage 1C1. Therefore, tumor broad was arranged on 2023/07/13, and after discussion, consensus was reached to start chemotherpay for this patient. Therefore, oncolgist Dr. Shia visited the patient on 7/13 and explained on details regarding further treatment, including insertion of port-A.
    • Under stable conditions, the patient is discharged on 2023/07/14 with follow-up at gynecology and oncology outpatient department. We also arranged rheumatology follow-up for this patient to evaluate her ongoing rheumatic arthritis.
  • Discharge prescription
    • Cinolone (ciprofloxacin 250mg) 2# BIDAC
    • Gaslan (dimethylpolysiloxane 40mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
• 2017-01-16 SOAP Rheumatology Chen JunXiong
  • Diagnosis
    • Rheumatoid arthritis [M05.70]
    • Essential hypertention, unspecified [I10]
    • Constipation [K59.00]
    • Peristent disorder of initiating or maintaining sleep [F51.09]
    • Other specified gastritis, without mention of hemorrhage [K29.30]
  • Prescription x3
    • Eurodin (estazolam 2mg) 1# PRNHS
    • Salazine (sulfasalazine 500mg) 1# BID
    • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
    • folic acid 4mg 4# QW
    • Trexan (methotrexate 2.5mg) 4# QW
    • Celebrex (celecoxib 200mg) 1# PRNBID
    • Plaquenil (hydroxychloroquine 200mg) 1# BID
    • MgO 250mg 1# QD
    • Compesolon (prednisolone 5mg) 1# QD
• 2017-01-16 SAOP Obstetrics and Gynecology Xu YaoRen
  • O
    • 2016-12-23 cell-block pathology: Atypical squamous cells (ASCUS)
  • Diagnosis
    • Nonspecific abnormal papanicolaou smear of cervix [R87.610]
    • Erosion and ectropion of cervix [N86]
  • Prescription
    • Lindacin (clindamycin 150mg) 2# Q6H

[consultation]

[surgical operation]

[chemotherapy]

• 2023-09-08 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 4 200mg NS 250mL 2hr (Q3W. carbo eGFR 36 CCr 23 AUC 4)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-08-17 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 4 360mg NS 250mL 2hr (Q3W. carbo eGFR 65 AUC 4)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-05

Most of the medications prescribed by our rheumatologist are immunomodulators and primarily immunosuppressive. As the patient is currently undergoing chemotherapy, it is advisable to monitor any changes in immune function or rheumatoid arthritis symptoms.

700906364

231005

[exam findings]

• 2023-09-25 CT - chest
  • Comparison was made with CT on 2023/07/31
    • Lungs: s/p post op change with staple lines in lt lung and Rt lower lung.
      • multiple pleural-based solid nodular abnormalities in left lung, and nodular thickening at left interlobar fissure, stationary. several small soft-tissues nodules at RLL.
    • Mediastinum and hila: small LNs in vsceral space
    • Pleura: small Lt-sided effusion with loculation.
  • Impression:
    • lung and pleural metastases, stationary compared with CT on 2023/07/31
• 2023-09-06 PET
  • Glucose hypermetabolic lesions in a celiac lymph node and in several left pulmonary hilar and mediastinal lymph nodes, highly suspected recurrent tumor with distant lymph nodes metastases.
    
  • Glucose hypermetabolic lesions in the right pulmonary hilar and mediastinal lymph nodes, probably metastatic or reactive nodes.
  • FDG-avid lesions in the right lower lung pleura, in the right upper and lower lungs with pleurae involvement, and in the left rib cage, highly suspected recurrent tumor with lung and bone metastases.
    
  • Glucose hypermetabolic lesions in the right fronto-temporal region of the skull, probably metastasis or post-traumatic change.
  • Recurrent rectal cancer s/p treatment with distant lymph nodes, lung and bone metastases, yrcTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-08-15 Patho - stomach biopsy
  • Stomach, antrum, biopsy — chronic gastritis with Helicobacter infection
  • Microscopically, it shows chronic gastritis with lymphoplasmacytic infiltrate. Helicobacter-like bacilli are seen.
• 2023-08-14 EGD
  • Reflux esophagitis LA Classification grade A
  • Suspect Barrett’s esophagus, EC junction, s/p biopsy(B)
  • Superficial gastritis, s/p biopsy(A)
  • Gastric subepithelial lesion, AW of high bpdy
• 2023-07-31 CT - chest
  • Comparison was made with previous CT dated on 2023/04/26
    • Lungs: s/p post op change with staple lines in lt lung and Rt lower lower lung.
      • multiple pleural-based solid nodular abnormalities in left lung, and nodularity thickening at left interlobar fissure, stationary.
      • several small soft-tissues nodules at RLL.
    • Mediastinum and hila: small LNs in vsceral space
    • Vessels:
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
    • Pleura: small Lt-sided effusion with loculation.
  • Impression:
    • lung and pleural metastases, stationary compared with CT on 2023/04/26
• 2023-06-01 CXR
  • Few nodular opacity projecting in the left lung are suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Spondylosis and Scoliosis of the L-spine with convex to right side.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2023-05-05 All RAS + BRAF
  • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-02 L-spine flex & ext
  • Presence of spondylolisthesis at L3/4, grade I.
• 2023-05-02 Bone densitometry
  • Hip BMD performed by DXA revealed:
    • Hip, BMD is 0.574 gms/cm2, about 2.5 SD below the peak bone mass ( 68 %) and 0.0 SD at the mean of age-matched people ( 100 %).
    • IMP: osteoporosis
  • L-spines BMD (AP view) performed by DXA revealed:
    • AP L-spines, BMD of L1-4 0.742 gms/cm2, about 2.5 SD below the peak bone mass ( 73 %) and 0.2 SD above the mean of age-matched people ( 105 %).
    • IMP: osteoporosis
• 2023-04-26 CT - chest
  • lung and pleural metastases, in progresion compared with CT on 2023/01/18.
• 2023-04-17 Colonoscopy
  • No definite mucosal lesion was seen except diverticula at S-colon
• 2023-04-13 CXR
  • Few nodular opacity projecting in the left lung are suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Spondylosis and Scoliosis of the L-spine with convex to right side.
• 2023-01-18 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis and Scoliosis of the L-spine with convex to right side.
• 2023-01-18 CT - abdomen
  • S/P LAR with autosuture retention over the rectum.
  • Prior CT identified two solid nodule in RLL and LLL of the lung are noted again, stationary.
• 2023-01-18 CT - chest
  • lung and pleural metastases, stationary.
• 2022-10-26 CT - chest
  • recurrent left lung and pleural metastases, stationary.
• 2022-07-22 CT - chest
  • Left lower lobe meta. Stationary.
• 2022-02-15 CT - chest
  • recurrent left lung and pleural metastases.
• 2021-09-01 CT - chest
  • no new lung nodule.
• 2021-05-06 CT - chest
  • s/p left upper lobe and left lower lobe op.
  • no evidence of recurrent tumor in the study.
• 2020-12-30 Patho - lung wedge biopsy
  • pathologic diagnosis
    • Lung, left upper lobe (frozen section specimen), wedge — Metastatic colorectal adenocarcinoma
      
    • Lung, left lower lobe, wedge — Metastatic colorectal adenocarcinoma
      
    • Lymph nodes, LN 9, dissection — Negative for malignancy (0/3)
      
    • Parietal pleura, biopsy — Metastatic colorectal adenocarcinoma
  • microscopic examination
    • Tumor Focality: Multiple tumors over LUL, LLL, and parietal pleura
      
    • Histologic Type: Metastatic colorectal adenocarcinoma
      
    • Spread Through Air Spaces (STAS): Not identified
      
    • Visceral Pleura Invasion: Present
      
    • Lymphovascular Invasion: Present
      
    • Lymph nodes, LN 9: Negative for metastatic carcinoma (0/3)
      
    • IHC for tumor cells: CK7(-), CK20(+), and CDX2(+)
• 2020-12-29 Frozen resection
  • Lung, LUL, frozen section — Adenocarcinoma, compatible with metastatic colorectal carcinoma
• 2020-12-11 CT - chest
  • Left upper lobe and left lower lobe nodules. suspected lung mets.
  • Focal Pleural thickening. suspected pleural seeding.
• 2020-12-01 CT - abdomen
  • Left basal lung nodules. Nature? Suggest chest CT
• 2020-09-01 CT - abdomen
  • Post-op at the colon.
  • Right adrenal tumor, suggest follow up.
  • Uterine tumor, suspected myoma.
• 2019-12-30 CT - abdomen
  • Rectal cancer s/p operation. No evidence of tumor recurrence.
• 2018-08-13 CT - abdomen
  • Status post LAR with stable condition.
• 2017-08-31 CT - abdomen
  • Rectal cancer s/p operation. No evidence of tumor recurrence.
• 2017-03-18 CT - abdomen
  • Rectal CA, s/p operation. No evidence of tumor recurrence
• 2013-end pathology
  • adenocarcinoma, metastatic (7/34)
  • pathology stage: pStage IIIC, pT3N2b(cMx),
  • IHC stain of EGFR: weak positive on 30% to 40% of the neoplastic glands.
• 2013-11-29 CT - abdomen
  • rectal cancer with LNs & lung mets (T2N1M1a)

[MedRec]

• 2023-07-26 SOAP Neurosurgery Huang GuoFeng
  • O
    • There is pain in the lower back or buttocks, which can extend to one or both sides of the lower limbs while walking.
    • There is intermittent limping (Neurogenic Claudication), and after walking for a few minutes or steps, there is increased numbness and weakness in the lower limbs.
    • There are also symptoms such as shooting pain in the calf and numbness in the feet, which require rest for some time to obtain relief.
    • The patient reports a decrease in sensation and severe numbness in the L5-S1 dermatome, as well as muscle weakness (rated 4-5) with no increase in deep tendon reflexes. Bladder and sphincter function are normal, and gait is slow. Hip joint and both lower limb pulses are normal. The root tension sign is positive, and the patient experiences worsening pain (rated 6 out of 10) that can reach 8 out of 10, making walking difficult. The pain is relieved when lying down but is exacerbated when standing up, preventing the patient from walking. The patient has been experiencing severe back pain and sciatica for a long time, and conservative treatment, including rehabilitation and medication, has been ineffective. Clinical instability is being ruled out, and SLRT is positive on the left side. Fabor test is negative, and deep tendon reflexes are decreased. The patient can walk on their toes and heels without issue.
  • Diagnosis
    • [M48.56XA] Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture
  • Prescription x3
    • U-Ca (calcitriol 0.25ug) 1# QD 84D
    • Evista (raloxifene 60mg) 1# QD 28D
• 2021-01-12 SOAP Hemato-Oncology Zhang ShouYi
  • S: 68 y/o female. a pt of Rectal CA, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR on 12/24 13 by Dr Xiao GuangHong, s/p CCRT by Dr Huang JingMin & Post-CCRT adjuvant C/T wt sLV-5FU (2 days) Q2W x 12 finishing in Oct 2014, recurrence wt lung mets & pleura mets s/p lung metastasectomy in Dec 2020.
• 2017-03-25 SOAP Hemato-Oncology Zhang ShouYi
  • S: 64 y/o female. a pt of Rectal CA, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR on 12/24 13 by Dr Xiao GuangHong, s/p CCRT by Dr Huang JingMin & Post-CCRT adjuvant C/T wt sLV-5FU (2 days) Q2W x 12 finishing in Oct 2014, was noted to have the CA by physical checkup without particular discomfort in Dec 2013.

[consultation]

• 2023-06-05 Nephrology
  • Q
    • For hyponatremia & poor appetite
    • This 71-year-old woman, a patient of Rectal cancer, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR in 12 2013, s/p CCRT, adjuvant sLV-5FU Q2W x12 in 10 2014, recurrence with lung, pleura metastasis, s/p lung metastasectomy in 12 2020, s/p palliative FOLFIRI/Avastin x12 in 07 2021, recurrence with lung metastasis in 02 2022, s/p palliative mFOLFOX x12 in 01 2023, in progresion in 04 2023, s/p palliative FOLFIRI. She was admitted for C/T. She complained of general weakness, poor appetite post C/T and Na report from 136 -> 116 -> 111 mmol/L was noted. We need expertise to evaluate her condition thanks!
  • A
    • We visited the patient at the bedside and evaluated her condition. Her consciousness was clear, and not in respiratory distress. All four of her limbs were not edematous. The patient said she did not want to eat with nausea sensation since 2023-06-02, and she did not have vomiting or diarrhea. The caregiver observed that the patient speaked inherencetly recently.
    • Chemotherapy: FOLFIRI
    • Blood test showed severe hyponatremia.
      • 2023-06-05 Na (Sodium) 111 mmol/L
        
      • 2023-06-04 Urine osmolarity 542 mOsm/Kg
        
      • 2023-06-04 Na (Urine) 136 mmol/L
        
      • 2023-06-04 Blood Osmolality 241 mOsm/Kg
        
      • Cortisol, TSH, free T4 WNL
    • Our impressions are as follows:
      • Hypo-osmotic hypo/euvolemic hyponatremia, suspected to be SIADH related to irinotecan
      • Hypomagnesemia, hypokalemia, hypocalcemia, hypophosphatemia also identified
    • Our advices are as follows:
      • Check BUN, Cr, Uric acid
      • Record daily I/O and BW; - Restrict free water intake to 1000mL/day
      • Keep 3% NaCl 10ml/hr and monitor serum Na Q6H ~ Q8H; change in Na levels should not exceed 6-8 mEq/L within any 24-hour period
      • DC 0.298% IV fluid, adjusted to Constat-K 1# QID
      • Check serum K, Mg, P and urine K, Mg, P, Cr, urinalysis simultaneously on 2023-06-06
    • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance. Thank you.

[surgical operation]

• 2020-12-29 VATS, LUL and LLL wedge + lymph node sampling
  • multiple scattered whitish to translucent nodules about 5mm~10mm on visceral and parietal pleura suspected rectal metastasis parietal biopsy, LLL wedge biopsy and lymph node sampling
  • a volcano like solid nodule about 1.5cm in diameter in LUL S1 segment after wedge biopasy
• 2013-12-24 Laparoscopic LAR + Thoracoscopic wedge or Partial resection of the Lung

[radiotherapy]

• early 2014

[chemoimmunotherapy] (not completed)

• 2023-09-05 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 480mg NS 250mL 2hr + fluorouracil 2400mg/m2 2850mg 46hr (FOLFIRI Q2W, 20% off)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3

• 2023-08-15 - FOLFIRI

• 2023-07-17 - FOLFIRI

• 2023-07-03 - FOLFIRI

• 2023-06-01 - FOLFIRI

• 2022-03-08 ~ 2023-01-13 - FOLFOX

• 2021-02-01 ~ 2021-07-27 - FOLFIRI plus bevacizumab

• 2021-01-18 - FOLFIRI

• 2014-04-03 ~ 2014-10-07 - PF, post CCRT adjuvant, 12 cycles

• 2014-02-10 ~ 2014-03-13 - 5-Fu based

==========

2023-10-05

Vemlidy (tenofovir alafenamide 25mg) 1# QD prescribed by our gastroenterologist on 2023-09-30 is currently in use. No medication discrepancy was found.

Please note that both tumor markers CA-199 and CEA have started to show a slight upward trend after bottoming out in August. This may indicate a change in the balance of the treatment and the disease.

2023-09-22 CA-199 (NM) 1277.40 U/ml 2023-08-25 CA-199 (NM) 1125.26 U/ml 2023-08-18 CA-199 (NM) 743.66 U/ml 2023-08-01 CA-199 (NM) 931.32 U/ml 2023-07-18 CA-199 (NM) 1470.34 U/ml 2023-06-20 CA-199 (NM) 867.59 U/ml

2023-09-22 CEA (NM) 96.979 ng/ml 2023-08-25 CEA (NM) 87.270 ng/ml 2023-08-18 CEA (NM) 81.753 ng/ml 2023-08-01 CEA (NM) 61.346 ng/ml 2023-07-18 CEA (NM) 98.554 ng/ml 2023-06-20 CEA (NM) 66.050 ng/ml 2023-04-25 CEA (NM) 47.692 ng/ml 2023-01-18 CEA (NM) 5.127 ng/ml 2022-10-28 CEA (NM) 5.562 ng/ml

2023-09-06

No medication reconciliation issues were identified after reviewing the PharmaCloud database and hospital HIS5 records.

2023-07-18

After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were found.

2022-04-20

• This patient diagnosed with rectal cancer with LNs and lung mets in late 2013, recurrence monitored in late 2020, patient receives FOLFIRI (plus bevacizumab) from 2021-02-01 to 2021-07-27, following VATS, LUL and LLL on 2020-12-29, and recurrence detected again in early 2022. She is currently treated with FOLFOX since 2022-03-08.
• Lab data reported on 2022-04-19 revealed that liver and kidney function, serum electrolytes, and blood cell counts were generally normal. The nursing note does not indicate any intolerances so far since this hospitalization.
• Depending on the patient’s financial situation and there are no contraindications, targeted and/or immunotherapy treatments might also be considered.

701499491

231005

[MedRec]

• 2023-10-03 SOAP Medical Emergency
  • S: (the following text seems to be from Sun Yat-Sen Cancer Center earlier CT)
    • CT Scan #A
    • Clinical History and Indications: metastatic neuroendocrine carcinoma of the pancreas with LNs of retroperitoneum, mediastinum, pleura and pericardial, with right 10th rib bone and liver metastasis, on palliative C/T.
    • Findings comparison CT: 2023/04
      • lung, airway: reticular opacities, right lower lung, no obvious change
      • lower neck, axilla: small lymph node(s), short axis <10mm
      • mediastinum, pulmonary hila: small lymph node(s), short axis <10mm
      • pleura, pericardium, chest wall: right pleural effusion; no pericardial effusion;
      • heart, great blood vessels: atherosclerosis;
      • hepatobiliary system: multiple metastasis in both lobes, size and number increase; dominant tumor 6cm right lobe S7, bigger; gallbladder wall thickening; minimal dilatation of bilateral intra-hepatic ducts;
      • mass lesion 77mm, replacing pancreatic body, bigger; atrophy of pancreatic tail;
      • enlarged lymph nodes, 39mm and 20mm, gastro-hepatic space, bigger;
      • spleen, adrenal glands: left adrenal gland metastasis, no obvious change
      • kidneys: no hydroneprhosis;
      • retroperitoneum: tumor involvement of upper retroperitoneum, tumor encasement of celiac trunk and SMA root, no obvious change; metastasis in left para-aortic space 42mm, no obvious change; tumor compression of left renal vein;
      • peritoneum, mesentery, GI tract: no evident ascites; small nodular lesion(s) in peritoneal cavity, no obvious change
      • pelvis: no enlarged lymph node; no evident mass lesion
      • bone: right chest wall mass lesiond <= 48mm with bony destruction of right ribs, more evident;
    • Impression and Suggestions
      • progression of liver metastasis;
      • progression of right chest wall metastasis;
      • bigger of tumor at pancreatic body;
      • bigger of gastro-hepatic space lymph nodes; no obvious change of retroperitoneum metastasis;
      • the overall picture suggests progressive disease
    • CT Scan #B
    • Clinical History and Indications Pancreatic carcinoma with multiple metastases, on palliative C/T.
      • Findings
        • Lymph nodes: a. in the mediastinum, less than 10 mm: — the node in the subcarinal region is smaller as compared with previous CT scan on 2023/01/31, probably metastasis. — other nodes are less than 10 mm and show no obvious change.
          • metastatic lymph nodes in the gastrohepatic ligament, up to 22 mm, larger.
          • in the para-aortic region, up to 15 mm, larger.
          • in the hepatic hilum, 12 mm. No obvious change.
        • Small right pleural effusion, stable.
        • Lung: minimal reticular opacities/atelectasis in right lower lobe. No obvious change.
        • Liver:
          • multiple metastasis with progression.
          • intrahepatic bile duct dilatation. No obvious change.
        • Pancreas: ill-defined soft tissue infiltration in the body, compatible with pancreatic cancer. No obvious change.
          • dilatation of the pancreatic duct, more obvious
          • tumor involves the left adrenal gland and encases the celiac artery, superior mesenteric artery, left renal vein.
        • Kidney:
          • suspicious a subcentimeter cyst in left kidney, stable.
          • subcentimeter stones in both kidneys. No hydronephrosis.
        • Spleen: no focal lesion.
        • Gallbladder: suspicious small stones.
        • Nodules in the right peritoneum and renal hilum, up to 10 mm, either stable or smaller, probably metastasis. (scan 7/80, 84)
        • Bone:
          • focal mixed density change in right 9th and 10th rib, probably metastasis, already noted on previous CT.
          • soft tissue around the right 10th rib, newly demonstrated, probably extraosseous tumor extension. (scan 7/63-73)
        • Back region: soft tissue defect in right lower back, at the level of right 9th and 11th ribs. Suggest clinical correlation.
      • Impression and Suggestions
        • Pancreatic carcinoma. No obvious change.
        • Metastatic lymph nodes in the gastrohepatic ligament and the para-aortic region, larger.
        • Hepatic metastasis with progression.
        • Peritoneal metastasis, either stable or smaller.
        • Suspicious bony metastasis in the ribs, already note d on previous CT.

==========

2023-10-05

This patient has been receiving treatment at the Koo Foundation Sun Yat-Sen Cancer Center in the past. The only prescription medication from that center that is still valid to date is Megest Oral Suspension (megestrol acetate). This drug is not currently included in the active medication list. If the patient continues to experience cachexia or poor appetite, it is advisable to reintroduce this medication.

700301189

231003

[exam findings]

• 2023-10-03 CT - brain
  • Mild swelling of left parietal and occipital scalp.
• 2023-10-02, -08-30, -08-02, -07-21, -07-12, -06-14, -06-01, -05-27 CXR
  • Bilateral Pleura effusion is noted.
  • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
  • Spondylosis of the T-spine
  • Enlargement of cardiac silhouette.
• 2023-06-26 CT - chest
  • PH: adenocarcinoma of low rectum s/p transanal local excision (2019/04/15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+), s/p radiotherapy & C/T
  • Chest and Abdominal CT with and without enhancement revealed:
    • Chest:
      • Nodular and cavitatory lesion at left lower lobe is found. In comparison with CT dated on 2023-03-21, the lesions decreased in size or became less compact
      • S/p port-A placement with its tip at left brachiocephalic vein.
      • Minimal bilateral pleural effusion with pleural thickening is found.
    • Visible abdomen:
      • Low density nodule at uncinate process of the pancreas is found measuring 1.2cm. Another mass like lesion at pncreatic tail measuring 2.7cm is noted. In comparison with CT dated on 2023-03-21, the lesion enlarged.
  • Imp:
    • Diffuse lung meta. In regression.
    • Bilateral pleural meta.
    • Pancreatic tail tumor and uncinate process nodule. In enlargmennt. Pancreatic cancer is favored.
• 2023-03-28, -03-27, -03-24, -03-22 CXR
  • Pneumo-mediastinum is highly suspected.
  • Left Pleura effusion is noted.
  • Focal pneumothorax at right CP angle.
  • Subcutaneous emphysematous change over bilateral lower neck, bilateral axillary and right lateral chest wall.
  • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
  • S/P pigtail catheter implantation at right CP angle with focal pneumothorax.
• 2023-03-22 SONO - chest
  • Pleural effusion, moderate, right
  • Atelectasis, RLL
  • Organized pleurae, left
• 2023-03-21 CT - chest
  • Comparison was made with previous CT dated on 2022/08/26
    • Lungs: multiple randomly distributed pulmonary nodules of varying sizes, consistent with metastatic lesions.
      • dependental partial relaxation atelectasis of RLL.
      • massive Rt and moderate Lt, bilateral pleural effusions, with parietal pleural thickening.
      • multiple subleural bulla lung cyst in bilateral apical lungs
    • Mediastinum and hila: no enlarged LN or mass.
    • Aorta: normal caliber of thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal-pelvic contents: hypodense lesions in pancreatic tail up to 19mm.
      • several small hepatic cysts.
      • unremarkable of the spleen, GB, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
      • no obvious bowel wall thickening of colon and rectum based on CT images.
      • extensive spondylosis and degenerative spinal canal and lateral recesses stenosis at L4-S1 levels.
  • Impression:
    • bilateral pulmonary metastases and exudative pleural effusion, in progression and new pancreatic tail tumors (metastases d/d primary cancer) as compared with previous CT study on 2022/08/26
• 2023-03-21 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Septal infarct, age undetermined
• 2022-09-23 Patho - lung transbronchial biopsy
  • Lung, right, CT-guide biopsy—adenocarcinoma, moderately differentiated, metastatic, consistent with colorectal origin
  • Sections show neoplastic cribriform glandular cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal CK7(-), CK20(+), TTF-1(-), and CDX2(+). The results are consistent with metastatic colorectal adenocarcinoma.
• 2022-08-26 CT - chest
  • Bilateral lung meta. Stable
  • Consolidation over left lower lobe, please monitor superimposed pneumonitis.
• 2022-05-13 CT - chest
  • Multiple lung meta with necrotic or solid nodular appearance. In progression.
  • Small lymph nodes are found in the mediastinum.
• 2022-04-06 CXR
  • Multiple nodules at RLL.
• 2022-01-07 CT - abdomen
  • There is no evidence of wall thickening in the rectum. Please correlate with colonoscopy.
• 2022-01-07 Colonoscopy
  • Previous surgical scar at low rectum was found. No recurrent.
• 2020-12-04 CT - abdomen
  • There is no evidence of wall thickening in the rectum. Please correlate with colonoscopy.
• 2020-12-04 Colonoscopy
  • No definite mucosal lesion was seen from rectum to cecum. Previous surgical scar at low rectum was seen without recurrent evidence
• 2019-12-10 CT - abdomen
  • Clinical history: 73 y/o male patient with
    • 2019-04-08: He had been to KFSYSCC for second opinion, but they suggest him to receive surgery at our hospital, he refused APR, thus, transanal local excisin + CCRT is first choice
    • 2019-05-03: adenocarcinoma of low rectum s∕p transanal local excision (2019-04-15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+)
    • 2019-06-14: for CEA report (suggest CTC), s∕p 22th R∕T, refuse chemotherapy, anal pain, 2019-07-19: finished R/T, no discomfort, refuse C/T
    • 2019-11-01: no discomfort, for follow-up programs.
  • With and without contrast enhancement CT of abdomen - whole:
    • Small gallbladder stone.
    • Liver cysts, up to 0.8cm in left lobe.
    • Unremarkable change of the spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
  • Impression:
    • Clnical lower rectal cancer s/p, suggest follow up.
    • Small gallbladder stone.
    • Liver cysts.
• 2019-04-16 CT - abdomen
  • There are few small gas bubbles in the perirectal space, near anal verge. please correlate with clinical condition.
  • Few tiny gallstones are suspected.
• 2019-04-16 Surgical pathology Level IV
  • PATHOLOGIC DIAGNOSIS
    • Large intestine, rectum, transanal local excision —- Adenocarcinoma, moderately differentiated
      
    • Resection margins: involved, left
      
    • Lymph node, mesocolic, dissection —- Not received
    • Lymph node, IMA / SMA, dissection —- Not received
    • AJCC 8th edition Pathology stage: pStage I, pT2Nx(if cM0)
  • MACROSCOPIC EXAMINATION
    • Operation procedure: transanal local excision
    • Specimen site: rectum
      
    • Specimen size: 2.8 x 1.7 x 1.4 cm
      
    • Tumor size: 1.5 x 1.0 cm
    • Tumor location: anterior: 0.3 cm; right: 0.4 cm; posterior: 0.6 cm; left: involved; deep: 0.8 cm
    • Depth of invasion grossly: muscularis propria
    • Mucosa elsewhere: congestion
    • Two separated tissue fragments measuring up to 2.0 x 0.7 x 0.5 cm are found.
    • All for section and labeled as: A1-2: cross section from right (green) to left (blue); A3: anterior; A4: posterior; A5: separated tissue fragments.
  • MICROSCOPIC EXAMINATION
    • Histology: adenocarcinoma; The immunohistochemical stains reveal CK(+) and CD56(-).
    • Histology Grade: moderately differentiated
    • Depth of invasion: muscularis propria
    • Angiolymphatic invasion: Not identified.
      
    • Perineural invasion: Present.
      
    • Discontinuous extramural tumor extension: Not identified.
      
    • Circumferential (radial) margin of rectum: Uninvolved, 8 mm from the margin,
    • Lymph node metastasis, mesocolic: not received
      
    • Lymph node metastasis, IMA / SMA: not received
      
    • Extranodal involvement: not received
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): pT2:Tumor invades the muscularis propria
      • Regional Lymph Nodes (pN): Nx
      • Distant Metastasis (pM): if cM0
    • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
    • Additional pathologic findings: S2019-3459: IHC stain— PMS2(+), EGFR(+), MSH-2(+), MSH-6(+), MLH-1(+)
    • TNM descriptors: unknown
      
    • Tumor regression grading S/P CCRT: patient not received
• 2019-04-15 ECG
  • Normal sinus rhythm with sinus arrhythmia
  • ST abnormality, possible digitalis effect
  • Abnormal ECG
• 2019-03-28 CT - abdomen
  • Imaging Report Form for Colorectal Carcinoma
    • TxN0Mx

[consultation]

• 2023-03-27 Thoracic Surgery
  • Q
    • This is a 77 years old male with adenocarcinoma of low rectum s/p transanal local excision in 2019 with lungs metastases, stage IVa.
    • Complained about shortness of breath for 15+ days, exertional dyspnea. He came to ER on 2023/03/21, and was admitted on 2023/03/22.
    • Pig tail was inserted on 2023/03/22 for pleural effusion, output:1400 on 2023/03/22.
    • However, patient complained about exertional coughing/pain in the evenging, CXR showed focal pneumothorax. at 23:38 on 2023/03/22.
    • Symptom improved with rest. Educated about emptying air from the bag to the patient and caretaker.
    • Subcutaneuos emphesema was observed on 2023/03/24 over right lower neck and right axillary and right lateral chest wall.
    • After discussing with our VS, he suggested to put local compression over the pig tail insertion spot due to relatively asymptomatic manifestation.
    • Patient tolerated the situation well excpet exertional shortness of breath, until 2023/03/26 evening when he complained about enlarged area of subcutaneuos emphysema
    • LPS 18cm H2O was connected to pig tail on 2023/03/26, 22:57
    • His SpO2 remained 94-99%, stable TPR.
    • We would like to consult your expertise, thank you!
  • A1
    • S
      • This 77 y.o male was a case of Rectal Ca, Adenocarcinoma, post OP in 2019 with lung metastasis, stage IVa now. This time, he was admitted due to progressive dyspnea and bilateral pleural effusion noted on CXR on 2023-03-21. Chest echo + right pig-tail insertion for effusion drainage was done on 2023-03-22. Unfortunately, little subcutaneous emphysema and right focal pneumothorax was noted since 2023-03-24 by CXR. This condition not improvement after conservative treatment and LPS 18cm H2O. Follow up CXR on 2023-03-27 showed prograssive right subcutaneous emphysema and we were consulted for further treatment.
    • O
      • 2023-03-27 CXR: bilateral subcutaneous emphysema, pneumomediastinum, left CP angle blunting due to pleural effusion and right pig-tail in position.
    • Suggestion
      • keep right pig-tail drainage with LPS 15-20cm H2O, if necessary, may try two bottle drainage system
      • please consult Chest surgeon to evaluate his subcutaneous emphysema condition and the indication of surgical treatment or not
  • A2
    • may replace pigtail with chest tube. Bigger calibre would offer adequate chest drainage to release patient’s subcutaneous emphysema.

[SOAP]

• 2022-08-19 Colorectal Surgery
  • A
    • adenocarcinoma of low rectum s/p transanal local excision (2019-04-15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+), s/p R/T
  • P
    • APR is refused, so arrange CCRT (R/T + UFUR by patient choice, BUT he refuse chemotherapy!)
    • F/U CEA + CXR (2022-07), CT (2022-12), colonoscopy (2022-12)
    • 2022-08-19 he did not receive CT-gioded biopsy for lung lesions (personal reason), re-check chest CT

[surgical operation]

• 2019-04-15
  • Diagnosis: Adenocarcinoma of low rectum, cT1N0M0
  • PCS code: 74211B - Extensive excision of sacrococcygealrectal villous adenoma or malignacy
  • Finding
    • A 1.5cm tumor was identified at 3-5cm above anal verge of anterior aspect of low rectum.
    • Friable tumor pieces was pelling off after putting anal retractor.
    • Full-thickness local rectal excision was performed as possible to gain a safe margin.
    • Normal saline irrigation and hemostasis was done. Blood loss was about 10-20ml.
    • The wound was closed with 4/0 vicryl.
• 2017-10-12
  • Diagnosis: back tumor
  • PCS code: 62011C - Excision of skin or subcutaneous tumor (Except face) - 2 to 4 cm
  • Finding: back tumor 3cm, x1
  • Procedure: Under LA, the tumor was excised. The wound was closed with 3-0 viryl and 4-0 Nylon.

[immunochemotherapy]

• 2023-10-02 - Avastin + FOLFIRI
• 2023-08-31 - Avastin + FOLFIRI
• 2023-08-02 - Avastin + FOLFIRI
• 2023-07-12 - Avastin + FOLFIRI
• 2023-06-23 - Avastin + FOLFIRI
• 2023-06-02 - Avastin + FOLFIRI
• 2023-05-05 - FOLFIRI
• 2023-04-07 - FOLFIRI

==========

2023-08-04

The recently refilled repeat prescription for Vemlidy (tenofovir alafenamide) on 2023-07-05 is being utilized without any reconciliation issues detected.

2023-03-29

On 2023-03-24, a Port-A was inserted for the patient who previously refused chemotherapy.

All the oral/inhaled medications in the active prescription are appropriate for his respiratory symptoms, including Sodicon (dextromethorphan), Butanyl (terbutaline), and Ipratran (ipratropium bromide).

700547380

231003

[exam findings]

• 2023-09-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (75.9 - 14.9) / 75.9 = 80.34%
    • M-mode (Teichholz) = 80
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Mild MR, TR and PR
    • No regional wall motion abnormalities
• 2023-08-25 Nerve Conduction Velocity, NCV
  • Findings
    • Slowed NCVs in bilateral ulnar CMAPs above elbow.
    • Normal sensory NCV study in both arms.
  • Conclusion
    • This abnormal NCV study suggestd bilateral ulnar neuropathy acrossed elbow.
• 2023-08-22 C-spine AP + Lat
  • mild anterior and posterior spur formation at the middle C-spine.
  • moderate decreased disc spaces in the C4/5 and C5/6 discs.
• 2023-08-09 CT - brain
  • No definite intracranial abnormality.
• 2023-07-26 CT - chest
  • Findings
    • Lungs: a part solid nodule, solid component < 5mm (6.4mm) at RLL, and 5mm granuloma at S9 of the same lobe. normal appearance of RUL, RML, and left lung.
    • Chest wall and visible lower neck: an enhancing tumor (28.3x28mm) at upper portion of the Rt breast, a 9.2mm lymph node at Rt axilla.
  • Impression:
    • Rt breast cancer (28.3x28mm) and a 9.2mm lymph node at Rt axilla.
    • RLL part solid nodule 6.4mm,possibly early ca d/d inflammation, suggest F/U low dose CT at 6-12 months later. RLL 5mm granuloma too.
• 2023-07-17 Patho - breast biopsy (no need margin)
  • Breast, right, 12/2, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (+, 90%, strong intensity), PR (-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67 (20%), E-cadherin (+).
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2023-07-17 Patho - lymphnode biopsy
  • Lymph node, right, axillary, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (+, 100%, strong intensity), PR (-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67 (20%), E-cadherin (+).
  • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.

[MedRec]

• 2023-09-05 ~ 2023-09-08 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Malignant neoplasm of unspecified site of right female breast
    • Right breast invasive carcinoma, cT1N1M0, stage IIA, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR (-, 0%, intensity), Her2/neu: negative (score = 1+), Ki-67 (20%), E-cadherin (+)
  • CC
    • for prepare chemotherapy.
  • Present illness
    • This 59 years old female had denied any underlying disease. According to the patient and family, the patient suffered from suspect L’t breast lesion form mammography on 2017/05/11. Due to sign and symptom exacerbation, the patient called at our OPD for help. Mammography and breast sono were done on 2017/07/12 showed regional microcalcifications in left breast, upper portion, probably benign finding-short interval follow-up suggested.
    • Sono showed Bil. fibroadenomas as described. Due to bilateral breast lump with calcification for several years, long-term follow up until 2022 loss follow up.
    • Last half year, feel discomftable, visted to our GS OPD follow up. Breast SONO was done on 2023/07/07 showed highly suspicious of malignancy, with sonographic positive axillary LAP, suggested core-needle biopsy was arranged on 2023/07/17.
    • Pathology showed Lymph node, right, axillary, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER(+, 100%, strong intensity), PR(-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67(20%), E-cadherin(+); Breast, right, 12/2, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67(20%), E-cadherin(+).
    • Then, CT image was done on 2023/07/26 showed Rt breast cancer (28.3x28mm) and a 9.2mm lymph node at Rt axilla, RLL part solid nodule 6.4mm, possibly early ca d/d inflammation, suggest F/U low dose CT at 6-12 months later. RLL 5mm granuloma too.
    • Brain CT was survey on 2023/08/09 shoaed No definite intracranial abnormality. Diagnosis was right breast invasive carcinoma, cT1N1M0, stage IIA, no special type, NST. IHC stains: ER(+, 100%, strong intensity), PR(-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67(20%), E-cadherin(+).
    • This tims, she was admitted for prepare chemotherapy.
  • Course of inpatient treatment
    • After admission, arrange 2D echo before chemotherapy with Epirubicin + Cyclophosphamide on 2023/09/06 showed LVEF:80%, Normal chamber size, Adequate LV and RV systolic function, Mild MR, TR and PR, No regional wall motion abnormalities. Then, she received chemotherapy with Epirubicin (90mg/m2) + Cyclophosphamide (600mg/m2) on 2023/09/06 smoothly. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. BP drop was noted, IVF for support. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/08 and OPD followed up later.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC

[chemotherapy]

• 2023-10-02 - epirubicin 90mg/m2 120mg NS 100mL 30min + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-09-06 - epirubicin 90mg/m2 120mg NS 100mL 30min + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-03

[leukopenia]

2023-09-28 WBC 5.63 x10^3/uL 2023-09-21 WBC 1.66 x10^3/uL * 2023-09-13 WBC 4.32 x10^3/uL 2023-09-05 WBC 5.12 x10^3/uL

The leukopenia observed on 2023-09-21 at 1.66K/uL occurred approximately 2 weeks after her first administration of epirubicin and cyclophosphamide. Granocyte (lenograstim 250ug) was administered for 3 consecutive days beginning on 2023-09-21.

The second dose of epirubicin and cyclophosphamide was administered on 2023-10-02 and prophylactic G-CSF was considered and prescribed in advance for 2023-10-09 to 2023-10-11 during the double tenth consecutive holidays. Leukopenia is expected to be less severe this time.

701060439

231003

[exam findings]

• 2023-09-18 Tc-99m MDP bone scan
  • Increased activity in the skull base, maxilla, L2 -3 spines, bilateral sternoclavicular junctions and right scapula, the nature is to be determined, suggesting further investigation and follow-up with bone scan in 3 months.
  • Suspected benign lesions at bilateral shoulders, S-I joints, and hips.
• 2023-09-16 CT - facial bone
  • One large protuding mass (3.4cm) arising from left-side of the nose, showing heterogeneous enhancement. Highly suspect malignancy. Suggest tissue proof.
  • No involvement of the nasal bone by this tumor.
• 2023-09-15 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis with scoliosis of the T-spine with convex to right side

[MedRec]

• 2023-09-14 SOAP Hemato-Oncology Gao WeiYao
  • O: She was found to have skin tumor during her stay at nursing home at Taichung (Nursing head 5A mother)
  • A: Nose skin tumor
• 2023-09-14 SOAP Radiation Oncology Huang JingMin
  • S:
    • For radiotherapy due to squamous cell carcinoma of the nose skin.
    • PI: the patient suffered from squamous cell carcinoma of the nose skin. She was transferred from TaiZhong
  • O:
    • ECOG: 2
    • PE: neck and bil SCF: neg; nose: a huge tumor over left side nasal area. Sit on a wheelchair.
    • Pathology (SE22304418, 2023-08-09):
      • Skin, 3 o’clock, biopsy - involved by invasive carcinoma.
      • Skin, 6 o’clock, biopsy - severe dysplasia.
      • Skin, 9 o’clock, biopsy - involved by invasive carcinoma.
      • Skin, 12 o’clock, biopsy - involved by invasive carcinoma.
      • Skin, tumor body, biopsy - squamous cell carcinoma, moderately differentiated.
    • A: Squamous cell carcinoma, moderately differentiated of the left nasal area.
    • P: Radiotherapy is indicated for this patient with the following indicators: unresectable tumor over left nasal area
      • Goal: pallaition
      • Treatment target and volume: left nasal area and possible involved area.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 6000cGy/30 fractions of the left nasal tumor bed area.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-09-20.
• 2023-09-13 SOAP Plastic and Reconstructive Surgery Lu ChunDe
  • S: SCC, protrusion mass
  • O:
    • 8cm protrusion mass
    • radiotherapy first,
    • waiting for shrinkage of tumor, then considering surgery excision
• 2017-07-13 SOAP Psychosomatic Medicine Li JiaFu
  • Diagnosis
    • Chronic fatigue syndrome [R53.82]
    • Generalized anxiety disorder [F41.1]
    • Major depressive disorder single episode, unspecified [F32.9]
    • Nonorganic sleep disorder, unspecified [F51.9]
    • Dementia in conditions classified elsewhere without behavioral disturbance [F02.80]
    • Senile dementia, uncomplicated [F03.90]

[consultation]

• 2023-09-22 Gastroenterology
  • Q
    • The 79 y/o woman living in TaiChung nusring home, who is 5A HN’s mother. Newly diagnosis of SCC of nose, stage II. Due to she easy choking and can’t NG insertion, so we need your help for percutaneous endoscopy gastrostomy.
  • A
    • 79 years old female with SCC of nose, stage II and plan to CCRT. However, for PEG insertion, we are consulted.
    • O
      • conscious: E4VaM4
      • chest: smooth breath pattern, N/C: 3L
      • abdomen: soft and flat
      • Lab
        • 2023-09-21 S-GOT/AST 15 U/L
          
        • 2023-09-21 S-GPT/ALT 11 U/L
          
        • 2023-09-21 Creatinine 1.16 mg/dL
          
        • 2023-09-21 WBC 8.93 x10^3/uL
          
        • 2023-09-21 PLT 154 *10^3/uL
          
      • CT scan impression:
        • One large protuding mass (3.4cm) arising from left-side of the nose, showing heterogeneous enhancement. Highly suspect malignancy. Suggest tissue proof.
        • No involvement of the nasal bone by this tumor.
    • Impression
      • Dysphagia
      • SCC of nose, stage II
    • Suggestion
      • Complication of PEG was informed to family
        • Minor: Wound infection, Tube leakage to abdominal cavity (peritonitis), Stoma leakage, Inadvertent PEG removal, Tube blockage, Pneumoperitoneum, Gastric outlet obstruction, Peritonitis
        • Major: Aspiration pneumonia, Hemorrhage, Buried bumper syndrome, Perforation of bowel, Necrotizing fasciitis, Metastatic seeding
      • Plan for PEG insertion on 10/4.
      • Please also discuss gastrostomy with the general surgery
• 2023-09-21 General and Gastroenterological Surgery
  • Q
    • The 79 y/o woman living in TaiChung nusring home. Newly diagnosis of SCC of nose, stage II. Due to she easy choking and can’t NG insertion, so we need your help for gastrostomy.
  • A
    • O:
      • vital signs: stable, no fever
      • abdomen: soft, ovoid, decrease bowel sound, no tenderness, no rebounding pain
      • lab data: see chart
        
    • A: SCC of nose, stage II.
    • P: Due to no operation room available and less general anesthesia and surgical risk, consult GI for percutaneous endoscopy gastrostomy is suggested.
• 2023-09-15 Oral and Maxillofacial Surgery
  • Q
    • The 79 y/o woman living in TaiChung nusring home. This time, her left nose has mass and pathology showed squamous cell carcinoma, moderately differentiated of the left nasal area. Due to RT Director Huang suggested tooth extraction, so we need your help for management.
  • A
    • We are consulted for pre-RT dental evaluation.
    • O
      • General appearnce:ill looking
      • dementia was observed, uncooperative
    • intraoral examination:
      • multiple deep carious retained root of tooth 24, 25, 44 and 45 was noticed.
    • Plan:
      • Because the patient cannot cooperate, the tooth may not be extracted under local anesthesia.
      • It is recommended that cancer treatment be given priority. If the family considers tooth extraction before radiotherapy, another explanation will be arranged.

==========

2023-10-03

[tube feeding]

Concor 5mg — Please use the Simple Suspension Method (SSM) to place the tablet in warm drinking water and leave for 5-10 minutes, possibly stirring or gently shaking the container, until the tablet is dissolved, then can be passed through a feeding tube. This method involves dissolving tablets and capsules in warm water before suspending them for administration. This method could be used to administer Concor tablets through a feeding tube.

Const-K 750mg — The potassium content in fruits is relatively low, such as only about 2.2 mEq/inch or 0.9 mEq/cm in bananas. This means that consuming about two to three bananas is required to provide 40 mEq. Const-K is a type of extended-release tablet that contains 10 mEq/tab. One Const-K tablet provides less potassium than a single banana. If injectable potassium supplementation is not preferred, the tablet should be crushed into fine particles and taken with water.

701277889

231003

[exam findings]

• 2023-04-24 Patho - breast mastectomy with regional lymph nodes
  • Diagnosis
    • Breast, left, partial mastectomy with frozen section (F2023-187) — invasive carcinoma, NST, no special type.
    • Margin: free
    • Lymph node, left, axillary sentinel, biopsy (S2023-187) — Free
    • pT2 pN0 (if cM0); anatomic stage: IIA, at least, pathology prgnostic stage group: IIA, at least.
    • IHC stains: (using block: F2023-187A5): ER (-), PR (-), Her2/neu: positive (score=3+), Ki-67: 90%, p53 (-).
  • Gross Description
    • Procedure- partial mastectomy:10.5 x 8 x 3 cm. Skin: 5.5 x 2.0 cm. No nipple..
    • Lymph node sampling (if lymph nodes are present in the specimen)- Sentinel lymph node(s)
    • Specimen laterality- left
    • Sections are taken and labeled as:
      • Tissue for frozen section: F2023-187FS: deep margin.
      • Tissue for formalin fixation: F2023-187: A1-4: 12, 3, 6, 9 o’clockmargins; A5-6: tumor; A7: skin. S2023- 7821: sentinel lymph node.
  • Microscopic Description
    • For Invasive Carcinoma
      • Histologic type: Invasive carcinoma, NST
      • Size of invasive carcinoma (mm): 27 mm
      • Histologic grade (Nottingham histologic score): grade II (score 6,7)
      • Extent of tumor (required only if the structures are present and involved)
      • Skin involvement: Absent
      • Chest wall invasion deeper than pectoralis muscle: no chest wall tissue.
    • For Ductal Carcinoma In Situ- no DCIS.
      • Tumor size (mm)- no DCIS.
      • Nuclear grade- no DCIS.
      • Architectural pattern- no DCIS.
      • Tumor necrosis- no DCIS.
    • Margins:
      • Negative, Closest margin (10 mm from deep margin)
    • Nodal status: Negative (sentinel)
      • No. examined: 1
      • No. macrometastases (> 2 mm): 0
      • No. micrometastases (> 0.2 ~ 2 mm and/or > 200 cells): 0
      • No. isolated tumor cells (<= 0.2 mm and <= 200 cells): 0
    • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)- no presurgical chemotherapy.
    • Immunohistochemical Study
      • IHC stains: (using block: F2023-187A5): ER (-), PR (-), Her2/neu: positive (score=3+), Ki-67: 90%, p53 (-).

[MedRec]

• 2023-12-08 ~ 2023-12-09 POMR General and Gastroenterological Surgery Li ChaoShu
  • Discharge diagnosis
    • Left breast invasive carcinoma, pT2N0M0, stage IIA. ER (-), PR (-), Her2/neu: positive (3+), Ki-67: 90%. ECOG:0.
    • Post adjuvant chemotherapy with Ogivri (trastuzumab)
    • Carrier of viral hepatitis B
    • Agranulocytosis secondary to cancer chemotherapy
    • Dermatitis, unspecified
  • CC
    • adjuvant treatment for breast cancer
    • Two weeks after chemotherapy, multiple blisters and abscesses appeared on the soles of both feet.
  • Present illness
    • This 43-year-old female patient had Carrier of viral hepatitis B, but denied diabetes mellitus, hypertension, heart disease. She denied any TOCC histories in recent 3 months.
    • She noted a palpable mass at the left breast over 1 month. She came to Dianthus MFM Clinic for help. She accepted core needle biopsy and diagnosis of left breast cancer at Dianthus MFM Clinic. She didn’t return Dianthus MFM Clinic for the report. Thus, she came to our hospital for a second opinion. Breast sonography showed a lesion, left 1.5 o’/ 6 cm, size: 2.34 x1.36 cm, rule out malignancy suggesting biopsy.
    • She underwent of left partial mastectomy + sentinel lymph node dissection on 2023/04/24. The pathology showed invasive carcinoma, pT2N0M0, stage IIA. ER:(-), PR:(-), Her2/neu: positive (score=3+), Ki-67: 90%.
    • Tc-99m MDP whole body bone scan revealed no evidence of bone metastasis. Chest CT showed liver is intact. CEA：0.428 ng/ml、CA-153: 14.102U/ml on 2023/4/21. After well explain including pathology and the possible treatment modality were well explained to the patient.
    • She completed 8 courses adjuvant chemotherapy with Lipo dox + Endoxan for 4 cycles since 2023/05/19 then shift to Taxotere 75mg/m2 and Ogivri 8mg/m2 since 2023/08/18~2023/10/23. We refer to CGMH for R/T(proton) since 11/20.
    • Under the impression of left invasive carcinoma, pT2N0M0, stage IIA. This time, she was admitted to 6th target therapy with Ogivri (trastuzumab) 6mg/m2.
  • Course of inpatient treatment
    • After admission, 6th target therapy with Ogivri (trastuzumab) was given. No discomfort after chemotherapy.
    • Consult dermatology department for severe hand-foot syndrome who suggst 1. predinisolon 1 / Bid, 2. Zaditen (ketotifen) 1 / Bid, 3. Sinpharderm x 1 tube/bid, 4. Mycomb x 2 tubes/bid use.
    • Under the stable condition, she was discharged today and arrange next admission three weeks later.
  • Discharge prescription
    • Asthan (ketotifen 1mg) 1# BID
    • Compesolon (prednisolone 5mg) 1# BID
    • Sinpharderm Cream (urea) BID TOPI
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
• 2023-04-23 ~ 2023-04-26 POMR General and Gastroenterological Surgery Li ChaoShu
  • Discharge diagnosis
    • Malignant neoplasm of unspecified site of left female breast
    • Left breast cancer, cT1aN0M0, stage IA status post left partial mastectomy+sentinel lymph node dissection on 2023-04-24; ECOG 0
    • Carrier of viral hepatitis B
  • CC
    • She noted a palpable mass at left breast over 1 month.
  • Present illness
    • This 48-year-old female patient denied any systemic disease. She denied a cancer history. She denied any TOCC histories in recent 3 months.
    • She noted a palpable mass at the left breast over 1 month. Then she came to Dianthus MFM Clinic OPD for help, Dianthus MFM Clinic diagnosis that she got left breast cancer. She came to our hospital for a second opinion. Breast sonography showed a lesion, left 1.5 o‘/ 6 cm, size: 2.34 x1.36 cm, r/o malignancy suggesting biopsy. She accepted Core needle biopsy at Dianthus MFM Clinic, but she doesn’t return Dianthus MFM Clinic for the report. She had no dizziness, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, or body weight loss. PE: symmetrical bilateral breasts. A hard, non-tender, movable mass and irregular margin at left breast around 2 x1.5 cm without discharge. The nipple was dimpling without exudative nor bloody discharge and no retraction. The right left skin had no cellulite change.
    • Under the impression of left breast invasive carcinoma, she was admitted for surgery of partial mastectomy + SLNB.
  • Course of inpatient treatment
    • This is a 48-year-old woman who underwent partial mastectomy + SLND today. During the surgery, IOUS was used to define the margins and location and partial mastectomy was done without complications. After admission, patient education with wound care was done. Due to her stable condition, she will be be discharged and followed up at our OPD.
  • Discharge prescription
    • MgO 250mg 1# TID
    • Antica syrup (orciprenaline, bromhexine, doxylamine) 10mL TID
    • Acetal (acetaminophen 500mg) 1# TID

[consultation]

• 2023-12-08 Dermatology
  • Q
    • for skin rush over bilateral foot
    • Adjuvant chemotherapy with Lipo dox + Endoxan for 4 cycles then Taxotere 75mg/m2 for 4 cycles with ogivri injection were suggest.
    • Under impression of left breast invasive carcinoma, she was admitted for 6th adjuvant chemotherapy with ogivri.
    • This time, she complained of multiple broken skin wounds and pain on the soles of both feet. We need your help with treatment and management.
  • A
    • This patient suffered from multiple vesicles on bil soles for days.
    • Imp: dyshidrotic dermatitis
    • Suggestion:
      • predinisolon 1 / Bid
      • Zaditen 1 / Bid
      • Sinpharderm x 1 tube/bid
      • Mycomb x 2 tubes/bid

[surgical operation]

• 2023-04-24
  • Operation
    • BCT + SLND   
    • IOUS     
  • Finding
    • IOUS: a tumor mass over left breast, 1 o’clock/3cm location, was encountered.
    • Clinical tumor status:
      • Tumor size: 2cm (cT1c) 　 - Gross skin invasion: No 　 - Gross pectoral fascia invasion: No 　 - Tumor location: right side, lateral upper quadrum (1’/3cm) 　 - Clinical T stage: cT1c (<3 cm)
    • Clinical nodal status: 　 - Axillary dissection: SLND using isotope detection 　 - Gross LNs: negative LAPs 　 - Clinical N stage: cN0(sn)
    • OP status: 　 - Procedures: BCT + SLND 　 - Pre-OP tissue prove: CNB 　 - Nerve preservation: not encountered 　 - Drainage: nil 　 - PostOP elastic bandage: Yes 　 - PostOP skin flap: No 　 - Closure of wound: two-layer, 3-0 Vicryl and 5-0 Nylon
    • Path of frozen section: free margins
    • Biobank: blood + normal tissue + tumor

[chemotherapy]

• 2023-12-08 - trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)

• 2023-11-18 - trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)

• 2023-10-23 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)

  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL + filgrastin 150ug SC + glutathione 1500mg NS 200mL 20min

• 2023-10-02 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 395mg NS 250mL 90min (maintenance dose)

  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL + filgrastim 150ug SC + glutathione 1500mg NS 200mL 20min

• 2023-09-08 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 389mg NS 250mL 90min (maintenance dose)

  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL

• 2023-08-18 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 8mg/kg 514mg NS 250mL 90min (loading dose)

  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL

• 2023-07-28 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr

  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL

• 2023-06-30 - liposome doxorubicin 30mg/m2 49mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 986mg NS 500mL 1hr

  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL

• 2023-06-09 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 990mg NS 500mL 1hr

  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL

• 2023-05-19 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr

  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL

==========

2023-12-11

This patient has received six doses of Ogivri (trastuzumab) on the following dates: 2023-12-08, 2023-11-18, 2023-10-23, 2023-10-02, 2023-09-08, and 2023-08-18. The initial four doses were administered in combination with docetaxel. The patient reported skin symptoms approximately two weeks after the fifth dose of trastuzumab (2023-11-18), suggesting a possible link to trastuzumab.

Trastuzumab is known to potentially cause dermatologic adverse reactions, including skin rash (4% to 18%), acne vulgaris (2%), nail disease (2%), and pruritus (2%).

The discharged medications include those recommended by our dermatologist; it is advised to continue monitoring for changes in symptoms.

[glutathione - peripheral neuropathy]

Additionally, the pre-chemotherapy medications on 2023-10-02 and 2023-10-23 included glutathione. The 2020 ASCO systematic review of neuroprotectants for prevention of chemotherapy-induced peripheral neuropathy (CIPN) concluded that glutathione should not be offered for prevention of CIPN to patients receiving treatment with paclitaxel plus carboplatin, and that N-acetyl cysteine should not be offered to patients receiving potentially neurotoxic chemotherapy [1]. This position was also taken in the 2020 joint ESMO/EONS/EANO guidelines [2].

[1] Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. [2] Systemic anticancer therapy-induced peripheral and central neurotoxicity: ESMO-EONS-EANO Clinical Practice Guidelines for diagnosis, prevention, treatment and follow-up. Ann Oncol 2020; 31:1306.

2023-10-03

[diarrhea]

Both docetaxel and trustuzumab have been reported to be associated with diarrhea (23% to 43% and severe diarrhea <= 6% for the former and 7% to 25% for the latter).

In the event of diarrhea, it is recommended that loperamide (2 mg/cap) be used with an initial 2# followed by 1# every 2 to 4 hours or after each loose stool; for diarrhea persisting > 24 hours, administer 1# every 2 hours (or 2# every 4 hours). Continue until 12 hours have passed without loose stools. Doses > 8# per day may not provide benefit; consider alternative therapy if diarrhea persists >= 48 hours.

[leukopenia]

2023-10-02 WBC 6.23 x10^3/uL 2023-09-14 WBC 1.56 x10^3/uL 2023-09-08 WBC 6.62 x10^3/uL 2023-09-01 WBC 14.67 x10^3/uL 2023-08-25 WBC 1.67 x10^3/uL 2023-08-18 WBC 5.34 x10^3/uL 2023-07-28 WBC 7.35 x10^3/uL 2023-06-30 WBC 6.00 x10^3/uL 2023-06-09 WBC 6.17 x10^3/uL 2023-05-26 WBC 7.59 x10^3/uL 2023-05-12 WBC 11.26 x10^3/uL 2023-04-18 WBC 8.85 x10^3/uL

Leukopenia was observed on 2023-09-14 and 2023-08-25, approximately 1 week after the administration of docetaxel + trastuzumab (on 2023-09-08 and 2023-08-18), prophylactic G-CSF might be considered.

[G-CSF administration timing]

G-CSF is usually started no earlier than 24 hours after administration of chemotherapy. Continuation until the absolute neutrophil count following the nadir exceeds 10,000/microL, as specified in the G-CSF package insert, is known to be safe and effective. However, a shorter duration that is sufficient to achieve clinically adequate neutrophil recovery is a reasonable alternative, considering issues of patient convenience and cost. G-CSF should not be given in the day or days prior to the next cycle of chemotherapy, or on the same day as chemotherapy or radiation therapy is administered. Ref:

• Supportive therapies in the prevention of chemotherapy-induced febrile neutropenia and appropriate use of granulocyte colony-stimulating factors: a Delphi consensus statement. Support Care Cancer. 2022 Dec;30(12):9877-9888. doi: 10.1007/s00520-022-07430-7. Epub 2022 Nov 5. PMID: 36334157; PMCID: PMC9715510.
• Pegfilgrastim on the Same Day Versus Next Day of Chemotherapy in Patients With Breast Cancer, Non-Small-Cell Lung Cancer, Ovarian Cancer, and Non-Hodgkin’s Lymphoma: Results of Four Multicenter, Double-Blind, Randomized Phase II Studies. J Oncol Pract. 2010 May;6(3):133-40. doi: 10.1200/JOP.091094. PMID: 20808556; PMCID: PMC2868638.

700201636

231002

[exam findings]

• 2023-09-11, -09-10, -09-07, -09-04, -09-01, -08-14, -08-08, -08-07, -07-20, -07-18, -07-13, -07-12, -06-26, -06-19, -06-01, -05-29, -05-25, 05-22, -04-19 Body fluid cytology - ascites
  • Negative
• 2023-05-22 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 10 dB HL; LE 21 dB HL
  • R’t WNL.
  • L’t normal to mild CHL.
• 2023-04-20 Patho - soft tissue biopsy/simple excision (non lipoma)
  • PATHOLOGIC DIAGNOSIS
    • Lesser omentum, excision — Metastatic serous carcinoma
    • Soft tissue, abdominal wall #1 and #2, excision — Foreign body granuloma
    • Soft tissue, LUQ, excision — Foreign body granuloma
  • MACROSCOPIC EXAMINATION
    • The specimen is submitted in four parts. Part (1) consists of six pieces of gray-white and firm soft tissue, labeled “abdominal wall tumor #2”, measuring up to 3.0 x 2.5 x 0.5 cm. All for section as: A1-A4. Part (2) consists of a piece of soft tissue, received for frozen section, labeled “abdominal wall tumor #1”, measuring 5.5 x 2.9 x 0.5 cm. On section, an white and firm nodule is noted, measuring 2.5 x 1.0 x 0.4 cm. Representative parts are taken for section as: F2023-00178 and FSA1. Part (3) consists of a piece of pinkish white soft tissue, received for frozen section, labeled “lesser omentum tumor”, measuring 1.2 x 1.0 x 0.3 cm. All for section as: F2023-00178FSB-ink green. Part (4) consists of a piece of soft tissue, received for frozen section, labeled “LUQ tumor”, measuring 1.0 x 0.9 x 0.3 cm. All for section as: F2023-00178FSB without ink.
  • MICROSCOPIC EXAMINATION
    • The sections of “lesser omentum tumor” show a picture of metastatic serous carcinoma, composed of pleomorphic polygonal tumor cells, arranged in solid and papillary patterns. The sections of “abdominal wall tumor #1 and #2” and “LUQ tumor” show a picture of foreign body granuloma, composed of foreign material surrounded by histiocytes and foreign body type giant cells.
• 2023-04-17 SONO - abdomen
  • mild fatty liver
  • fatty infiltration of pancreas
• 2023-03-08 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2023-02-08 PET
  • The left subphrenic lesion shown on the previous abdomen CT reveals increased FDG uptake, highly suspected tumor seeding.
    
  • Increased FDG uptake in bilateral pulmonary hilar regions, probably reactive nodes.
    
  • Increased FDG uptake in bilateral palatine tonsils, probably chronic inflammation/infection process.
    
  • Increased FDG uptake in the lower abdomen and left pelvis, probably physiological uptake of FDG in the colon. However, tumor seeding should be excluded.
    
  • Left ovarian cancer s/p treatment with highly suspected tumor seeding in the left subphrenic region, by this F-18 FDG PET scan.
• 2023-01-31 CT - abdomen
  • History and indication: ovary cancer with peritonal seeding
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. S/P Port-A infusion catheter insertion. A nodule at left subphrenic region.
    • A calcified spot (3.7cm) at S6 of liver.
  • IMP: S/P hysterectomy. A nodule at left subphrenic region r/o tumor seeding.
• 2022-09-17 Gynecologic Ultrasonography
  • Bilateral adnexae: free
  • ATH
  • No obvious uterine or ovarian lesion
• 2022-08-10 CT - abdomen
  • History: Ovarian CA. pT3bN0Mx; FIGO stage IIIB, s/p debulking surgery on 8/26 19 by Dr Zhen LunNa, s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Jan 2020 & recurrence wt peritoneal seeding in Jan 2021, s/p debulking wt HIPEC on 3/24 21 by Dr Li ZhaoShu,
  • Impression: S/P hysterectomy. There is no evidence of tumor recurrence.
• 2022-02-17 CT - abdomen
  • History and indication: ovary cancer with peritonal seeding
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. S/P Port-A infusion catheter insertion.
    • A calcified spot (3.7cm) at S6 of liver.
  • IMP: S/P hysterectomy. No evidence of tumor recurrence.
• 2021-10-06 CT - abdomen
  • History and Indication: Recurrent Ovarian CA.
  • Impression:
    • S/P hysterectomy
    • Prior CT identified several soft tissue nodules (up to 0.8cm) in the omentum of left upper abdomen are not noted again, that is compatible with tumor seeding S/P C/T show complete response.
• 2021-03-25 Patho - soft tissue biopsy/simple excision (non lipoma)
  • DIAGNOSIS:
    • Soft tissue , greater omentum, left, cytoreductive surgery — High-grade serous carcinoma, recurrent
      
    • Soft tissue , omentum, frozen biopsy — foreign body suture granuloma
      
    • Description: Microscopically, the sections show high grade serous carcinoma composed of irregular branching and highly cellular of neoplastic papillae and solid sheets of tumor cells with small papillary clusters spearated by hyaline fibrous stroma. Section FSA shows a foreign body suture granuloma.
      
    • Immunohistochemical stain reveals PAX8(+), CK7(+), CK20(-), WT-1(+).
• 2021-02-23 SONO - abdomen
  • Diagnosis: ovarian cancer s/p OP
  • Suggestion: further laparoscopy and maybe CRS
• 2021-02-06 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2021-01-30 CT - abdomen
  • Clinical history: 49 y/o female patient with Ovarian CA s/p Op ＆ C/T.
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P hysterectomy and oophorectomy.
    • There are soft tissue nodules (up to 0.8cm) in mensentery of left upper abdomen
  • Impression:
    • S/P hysterectomy and oophorectomy.
    • Soft tissue nodules in LUQ, r/o peritoneal carcinomatosis.
• 2020-08-12 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2020-08-01 CT - abdomen
  • S/P hysterectomy. No evidence of tumor recurrence.
• 2020-04-08 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2020-02-15 CT - abdomen
  • S/P hysterectomy. No evidence of tumor recurrence.
• 2019-12-25 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2019-08-27 Surgical Pathology Level VI
  • PATHOLOGIC DIAGNOSIS
    • Ovary, left, debulking surgery — High-grade serous carcinoma
      • Fallopian tube, left, ditto — Free from tumor invasion
    • Ovary, right, ditto — High-grade serous carcinoma
      • Fallopian tube, right, ditto — Free from tumor invasion
    • Cervix, uterus, ATH — Free of tumor invasion
      • Endometrium — Hyperplasia with nuclear atypia and free of tumor invasion
      • Myometrium — Free of tumor invasion
    • Omentum, omentectomy — High-grade serous carcinoma
    • Appendix, appendectomy — Involved by tumor in muscular wall
    • Soft tissue, “tumor”, excision — Carcinoma
    • Lymph nodes
      • Lymph node, R’t pelvic 1, dissection — Free of tumor metastasis (0/14)
      • Lymph node, R’t pelvic 2, ditto — Free of tumor metastasis (0/1)
      • Lymph node, L’t pelvic 3, ditto — Free of tumor metastasis (0/6)
      • Lymph node, L’t pelvic 4, ditto — Fat tissue only
    • AJCC Pathologic staging: pT3bN0Mx; FIGO stage IIIB at least
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: ATH, BSO, pelvic tumor excision, omentectomy, appendectomy, lymph node dissection
    • Specimen type: Uterus, bilateral adnexa, pelvic tumor, omentum, appendix & 4 bottles of lymph nodes
    • Specimen size:
      • R’t ovary: 2.2 x 1.4 x 1.3 cm
      • R’t fallopian tube: 4 x 0.7 x 0.6 cm
      • L’t ovary: 3.3 x 1.7 x 1.1 cm
      • L’t fallopian tube: 4 x 1.2 x 1.1 with paratubal cyst, 1.2 cm in diameter
      • Uterus: 9.1 x 6.2 x 5 cm in size and 125 gm in weight
      • Cervix: Nobothian cysts
      • Endometrium: thickness, 0.7 cm
      • Myometrium: No significant change
    • “Tumor” soft tissue: one small piece, 3.2 x 2.3 x 0.9 cm in size
    • Omentum: one piece, 17.5 x 6.3 x 3.3 cm in size
    • Appendix: 3.7 x 0.7 x 0.7 cm in size
    • Tumor site: bilateral ovary and peri-adnexal soft tissue
    • Tumor size: a few foci, up to 1.0 x 0.4 cm in dimension
      
    • Tumor appearance: Papillary and solid
      
    • Specimen integrity: Intact
    • Lymph nodes: R’t pelvic 1 (5 gm), R’t pelvic 2 (0.2 gm), L’t pelvic 3 (2 gm) and L’t pelvic 4 (0.2 gm)
    • Representative sections as: A1: R’t ovary, A2-A3: R’t F-tube, A4-A7: L’t ovary + F-tube, A8-A15: endometrium, myometrium, endocervix and cervix, A16: endometrium + myometrium, B1-B4: omentum, C: appendix, D: “tumor” soft tissue, E1-E2: R’t PLN1, F: R’t PLN2, G: L’t PLN3 and H: L’t PLN4
  • MICROSCOPIC EXAMINATION
    • Histologic type: High-grade serous carcinoma [IHC stains: CK7(+), WT-1(+), PAX-8(+), P53(+, 100%), ER(+)]
    • Histologic grade: High grade
    • Contralateral ovary involvement: Present
    • Tumor side ovarian surface involvement: Present
    • Contralateral ovary surface involvement: Present
    • Right tube involvement: Absent
    • Left tube involvement: Absent
    • In situ adenocarcinoma in right &/or left fallopian tube: Absent
    • Right adnexa soft tissue involvement: Present
    • Left adnexa soft tissue involvement: Present
    • Pelvic soft tissue involvement: Present (“tumor”)
    • Uterine serosa involvement: Absent
    • Omentum involvement: Present
    • Uterine Cervix involvement: Absent. chronic cervicitis with Nabothian cyst
    • Endometrium involvement: Absent. Hyperplasia with nuclear atypia
    • Myometrium involvement: Absent
    • Appendix: Involved by tumor
    • Lymph nodes metastasis: Free of tumor metastasis, total number: 0/21
• 2019-08-10 Gynecologic Ultrasonography
  • Suspected RT ovarian mass

[chemotherapy]

• 2023-09-28 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4

• 2023-09-07 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-08-31 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4

• 2023-08-11 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-08-04 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4

• 2023-07-14 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-07-10 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4

• 2023-06-23 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-06-16 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4

• 2023-05-29 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-05-22 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4

• 2023-04-19 - [liposome doxorubicin 30mg/m2 50mg D5W 100mL + carboplatin AUC 5 675mg NS 250mL] 90min IP (HIPEC)

• 2022-07-25 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-07-01 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-06-10 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-05-17 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-04-21 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-03-31 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-03-11 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-02-16 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-01-26 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-01-05 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2021-12-15 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2021-11-24 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2021-10-04 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2021-09-10 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-08-18 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-07-29 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-07-02 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-05-31 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-04-27 - docetaxel 60mg/m2 95mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-03-23 - [liposome doxorubicin 30mg/m2 40mg D5W 100mL + carboplatin AUC 5 600mg NS 250mL] 90min IP (LipoDox dose reduced)

• 2020-01-14 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + acetaminophen 500mg PO + granisetron 2mg + NS 250mL

==========

2023-10-02

Leukopenia was observed in mid-Sep with a nadir of 1.31K/uL, occurring after the administration of paclitaxel + cisplatin through IV on 2023-08-31, and paclitaxel through IP on 2023-09-07. Granocyte (lenograstim 250ug) has been administered for 3 consecutive days beginning on 2023-09-14, and no instances of leukopenia have been reported thus far.

2023-09-28 WBC 4.17 x10^3/uL
2023-09-21 WBC 7.00 x10^3/uL
2023-09-14 WBC 1.31 x10^3/uL ** 2023-09-10 WBC 1.96 x10^3/uL *
2023-09-07 WBC 3.70 x10^3/uL

2023-09-01

According to data from both PharmaCloud and HIS5, the patient has only been treated in the hemato-oncology department at our facility. Consequently, no issues with medication reconciliation have been found.

2023-08-07

Based on the records from the PharmaCloud and HIS5, the patient exclusively utilizes healthcare services at the hemato-oncology department in our hospital. As a result, no medication reconciliation discrepancies have been detected.

2023-07-11

According to the PharmaCloud database, the patient only receives medical services from our hospital. Therefore, there are no identified medication reconciliation issues.

2023-06-19

• The PharmaCloud database reveals that all medical needs of this patient have been met at our hospital in the last three months. Consequently, no medication reconciliation issues have been identified.

• The patient’s serum potassium level was slightly low at 3.3mmol/L as of 2023-06-16, and it has been trending downwards. It might be helpful to recommend that the patient consume more potassium-rich foods.

  • 2023-06-16 K(Potassium) 3.3 mmol/L
    
  • 2023-06-07 K(Potassium) 3.7 mmol/L
    
  • 2023-05-29 K(Potassium) 3.9 mmol/L

700998220

231002

[MedRec]

• 2023-07-06 SOAP Gastroenterology Chen JiangLin
  • S
    • 49 y/o
    • 2023/07/06 partial response (hiccup)
    • 2023/06/15 belching, and acid reflux, bloating (+), long time.
    • PH: nephrotic symdrome
    • ABC(-)
  • O
    • 2023/06/15 GERDa
  • Prescription
    • Mopride (mosapride citrate 5mg) 1# BIDAC
    • Gaslan (dimethylpolysiloxane 40mg) 1# BID
    • Dexilant (dexlansoprazole 60mg) 1# QD
    • Flupine (fludiazepam 0.25mg) 1# BID
• 2023-07-04 SOAP Hemato-Oncology He JingLiang
  • P: Chemotherapy Velcade (bortezomib 3.5 mg/vial) 2 mg SC ST
  • Prescription
    • Thado (thalidomide 50mg) 1# HS
    • Limeson (dexamethasone 4mg) 5# QD
    • Ulstop (famotidine 20mg) 1# BID
• 2023-05-19 SOAP Hemato-Oncology Wan XiangLin
  • P
    • Apply for major disease and approved
    • Chemotherapy with VTD (C1W1 20230526)
• 2023-03-30 SOAP Nephrology Peng QingXiu
  • A
    • Renal biopsy 2023-03-20
    • R/O IgA nephropathy with amyloidosis
  • P
    • DC carvedilol
    • DO workup for Monoclonal gammopathy.
• 2023-03-19 ~ 2023-03-21 POMR Nephrology Peng QingXiu
  • Discharge diagnosis
    • Nephrotic syndrome with other morphologic changes, s/p renal biopsy
  • CC
    • Foamy urine(+) for 3 months and both leg edema ++
  • Present illness
    • This is a 49 y/o female with history of GERD. She denied systemic diseases, operation history, pregnancy, or allergic history. TOCC(-)
    • This time, she suffered from bilateral lower limbs edema for 7 months since 2022/08. Her edema relived while legs elevation, and exacerbated while waking or sitting. There was also foamy urine noted recently.
    • She denied leg pain, abnormal sensation of bilateral limbs, neck swelling, dysuria, urinary frequency or medication history.
    • Due to above condition, she had visited LMD and our CV and Nephrologic OPD.
    • Cervical ultrasound was done and revealed normal volume of thyroid in LMD. Mildly elevated D-dimer (1448.20 ng/mL(FEU)) and NT-proBNP (1237 pg/mL) were noted, excluding deep vein thrombosis (DVT) or heart failure (HF) induced bilateral legs edema.
    • Cardiac ultrasound on 3/10 showed LVEF 63% and impaired LV relaxation with restrictive physiology.
    • Normal value of C3, C4, IgG, IgM, and IgM indicated negative antoimmune kidney disease.
    • However, her albumin was low (2.7 on 3/11 -> 2.9 on 3/18) and high urine microalbumin (1268.88 mg/dL) was noted, despite normal eGFR (122.29).
    • Her ACR = microalbumin(mg/dL)/ urine creatinine(mg/dL) was within normal range 7.63 (<30).
    • Under the impression of bilateral lower limbs edema with high microalbuminuria and normal ACR ration, r/o nephrotic diseases, she was admitted for kidney biopsy and further survey.
  • Course of inpatient treatment
    • During the hospitalization, the hemograms, biochemistry testing. Renal biopsy was done, for urine analysis revelaed protein 4+. Post biopsy an examination.
    • Renal echo was performed on 2023/03/20. Showed pelvic heterogenous mass, r/o uterine myoma or pelvic mass. Suggestion: GYN OPD follow up. No hematura.
    • Under stable condition, she can be discharge on 2023/03/21. OPD follow up is arranged.   
  • Discharge prescription
    • Crestor (rosuvastatin 10mg) 1# QD
    • Uretropic (furosemide 40mg) 1# QD

[chemotherapy]

VTd regimen

==========

2023-10-02

[tube feeding]

The potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred, please crush the tablet into particles and administer it with water.

[diarrhea]

2023-09-02 Lab showed triglycerides (TG) 394 mg/dL and LDL-C 168mg/dL, Atozet (ezetimibe, atorvastatin) was initiated by our nephrologist. Due to recent diarrhea, Atozet is discontinued today. However, the possibility that Velcade (bortezomib) in VTd regimen (2023-05-26 started) may also be associated with diarrhea cannot be completely excluded.

By the way, a statin can be administered as an alternate day frequency with a similar efficacy and may have a lower incidence of side effects. Ref: Efficacy and Safety of Alternate-Day Versus Daily Dosing of Statins: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther. 2017 Aug;31(4):419-431. doi: 10.1007/s10557-017-6743-0. PMID: 28741244.

701067842

231002

[exam findings]

• 2023-09-26, -09-01, -08-31, -07-26, -07-25, -07-03, -06-13, -06-12 Body fluid cytology - ascites
  • Negative
• 2023-07-21 CT - abdomen
  • Findings
    • S/P hysterectomy. There is a cystic lesion 4.2 x 2.8 cm in left anterior pelvis sidewall that is c/w lymphocele.
    • S/P Tenckhoff tube insertion from right lower abdominal wall and the tip located at the right lower perihepatic space.
    • Prior CT identified a cystic lesion 3.9 x 2.4 cm in left cardiac-phrenic angle is noted again, stationary.
  • Impression
    • S/P hysterectomy.
    • There is no evidence of tumor recurrence.
• 2023-07-10 MRI - sella
  • No evidence of intracranial lesion.
• 2023-05-25, -05-23 Body fluid cytology - ascites
  • Suspicious malignancy
• 2023-04-21 Patho - uterus with or without SO non-neoplastic/prolapse
  • PATHOLOGIC DIAGNOSIS
    • Ovaries, bilateral, BSO — Clear cell carcinoma
    • Uterus, ATH — Parametrium involved by carcinoma
    • Cul-de sac, debulking — Involv ed by carcinoma
    • Omentum, infracolic omentectomy — Involved by carcinoma
    • Peritoneal mass, debulking — Involved by carcinoma
      
    • Lymph nodes, pelvic and para-aortic, bilateral, BPLND — Negative for malignancy (0/34)
    • AJCC 8 th edition, Pathology stage: pT3cN0; stage IIIC; FIGO stage IIIC
  • MACROSCOPIC EXAMINATION
    • Procedure: ATH + BSO + omentectomy + BPLND + para-aortic LN dissection + Cul-de sac and peritoneal tumor excision
    • Specimen Size:
      • Five pieces, up to 5.5 x 5.0 x 3.2 cm (Lt ovary, received for frozen section), four pieces up to 4.9 x 3.2 x 2.9 cm (Lt ovary), 3.5 x 0.6 cm (Lt tube), four pieces, up to 9.3 x 7.8 x 2.5 cm (Rt ovary), 4.0 x 0.6 cm (Rt tube), 7.1 x 6.0 x 3.8 cm and 95 gm (uterus), four pieces up to 1.8 x 1.5 x 0.5 cm (Cul-de sac), five pieces up to 3.6 x 0.8 x 0.4 cm (peritoneal mass), 28.5 x 8.8 x 1.5 cm (omentum)
    • Specimen Integrity
      • Right ovary: Capsule ruptured
      • Left ovary: Capsule ruptured
      • Right fallopian tube: Serosa intact
      • Left fallopian tube: Serosa intact
    • Tumor Site: Bilateral ovaries
    • Ovarian Surface Involvement: Present
    • Fallopian tube Surface Involvement: Absent
    • Tumor Size: Can not be assessed because of fragmented tumor tissue
    • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic
    • Representative parts are taken for section and labeled as: F2023-00181FSA1, FSA2, A1-A6= left ovary. S2023-07635A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1-G2= left ovary, G3= left fallopian tube, H1-H3= right ovary, H4= right fallopian tube, I1= cervix, I2-I3= uterine corpus, I4-I6= parametrium, J= Cul-de sac, K1-K2= omentum, L= peritoneal mass.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Clear cell carcinoma
    • Histologic grade: High grade
    • Implants: Present
    • Other Tissue/Organ Involvement: Parametrial involvement
    • Peritoneal Fluid: Positive for malignant cells
    • Regional Lymph Nodes: All lymph nodes are negative for tumor cells
      • number of lymph node examined: 8 (left iliac), 7 (left obturator), 1 (right iliac), 5 (right obturator), 6 (left para-aortic) and 7 (right para-aortic)
      • number with metastases >10 mm: 0
      • number with metastases 10mm or less: 0
      • number with isolated tumor cells (<=0.2mm): 0
    • Cul-de sac: Involved by carcinoma
    • Peritoneal mass: Involved by carcinoma
    • Omentum: Involved by carcinoma
    • Pathologic Stage
      • Primary Tumor: pT3c (macroscopic peritoneal metastasis beyond the pelvis and > 2cm in size)
      • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
      • Distant Metastasis: Not applicable
    • FIGO Stage: Stage IIIC
    • Lymphovascular invasion: Absent
    • Perineural invasion: Absent
    • Additional Pathologic Findings:
      • Cervix: Chronic cervicitis with Nabothian cysts and squamous metaplasia
      • Endometrium: Proliferative phase
      • Myometrium: Adenomyosis
      • Ovary, left: Endometrosis
      • Fallopian tube, right: Para-tubal cyst
    • IHC, tumor cells reveal: WT1(-), Napsin A(+), ER(-), and p53(no aberrant expression)
• 2023-04-21 Body fluid cytology - ascites
  • 40 cc, pink, turbid — Malignancy
  • Smears show several clusters of atypical hyperchromatic and pelomorphic cells. Malignancy is favored. Please correlate with the clinical presentation.
• 2023-04-20 Frozen Section
  • Ovary, left, frozen section — Malignant (carcinoma)
• 2023-04-17 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Massive ascites is found.
    • Cystic change at bilateral ovaries measuring 11.7cm at right ovary and 5.4cm at left side is found. Some solid component is also found. Ovarian cancer is considered.
    • Tiny enhanced dots at mesentery is found. Mesenterric meta is favored.
    • The liver, spleen, pancreas, both kidneys and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
    • Normal heart size.
    • The lung fields are clear.
    • No pleural effusion is found.
  • Imp:
    • Bilateral ovarian cystic tumors with largest one at right side msm 11.7cm. Ovarian cancer is considered.
    • Peritoneal seeding is also found.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-04-07 Gynecologic ultrasonography
  • R/O RT Ovarian mass: 109 x 85 (septum RI: 0.42)
  • Asites(+)
• 2023-01-04 CT - abdomen
  • Indication
    • LMP: 2022-12-27, sex(+), dysmenorrhea sometimes, duration: 6 days
      • CA-125: 37.71
    • 20230104 sono: A cystic mass 7.3 x 5.4 cm in right adnexa with solid mural nodule 3.1 cm. R/O right ovarian mass.
      • Left ovarian cyst 2 cm.
    • 20230104 CA125, CEA, and CA199: normal
  • Findings:
    • There is a well-defined cystic lesion in right adnexa 7 cm in size (the largest dimension) with central solid mural nodule (2.6 cm in size).
      • The differential diagnosis include cystic adenoma and cystic adenocarcinoma.
    • There is a cystic lesion with wall thickening at left adnexa, measuring 4 x 2.4 cm in size.
  • Impression:
    • A cystic lesion with mural nodule at right adnexa, nature?
    • The differential diagnosis include cystic adenoma and cystic adenocarcinoma.
• 2023-01-04 Gynecologic ultrasonography
  • R/O Lt Ovarian cyst
  • R/O RT Ovarian mass (septum RI: 0.63)

[consultation]

• 2023-06-12 Dermatology
  • Q
    • A case of clear cell carcinoma of Bilateral ovarian, pT3cN0M0, stage IIIC; FIGO stage IIIC, status post debulking surgery on 2023/04/20
    • She was admitted for IP and IV chemotherapy with Taxol plus Carboplatin.However, she complained of skin rash over bilateral legs, we need your expertise for further management, thanks
  • A
    • This patient suffered from multiple erytheamtous papules on limbs for days.
    • Imp: Insect bite
    • Suggestion:
      • Dexamthson 1 / Qd
      • Ulex cream x5 tubes / bid
      • Zaditen 1 / Bid

[surgical operation]

• 2023-04-20
  • Surgery
    • Diagnosis: Huge ovarian mass, bilateral
      • Frozen section: malignant, suspect carcinom
    • Operation:
      • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy (BY GENERAL SURGEON))   - Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder, peritoneum and bilateral adnexa due to the tumor burden. Multiple papillary mass was noted over anterior wall.
    • Adnexa:
      • LOV: huge ovarian mass about 10 X 10 X 8 cm in size, with heterogeneous and rough surface, partial rupture with hemorrhagic content
      • ROV: ovarian mass about 6 X 5 X 5 cm in size
      • Fallopian tube: tensely connected to the bowel and adjacent tissues due to adhesion
    • CDS: massive ascites
    • Ascites: light yellowish, at least 4000 mL
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
    • Omentum: multiple hard, variable nodules noted; infracolic omentectomy was done by general surgeon.
    • Optimal debulking was achieved, Residual tumor:R0.
    • Estimated blood loss: 850 mL
    • Blood transfusion: LpRBC 2U
    • Complication: nil
• 2023-04-20
  • Operation
    • Excision of intraabdominal tumor: pelvic peritoneum + omentectomy
    • Tenckhoff tube insertion
  • Finding
    • Several tumor seedins in pelvic peritoneum with massive ascites
    • Tenckhoff tube: over RLQ
  • Procedure
    • Under ETGA, GYN performed operation at first. Made omentectomy. Excised the seeding tumor in pelvic peritoneum. Inserted a Tenckhoff tube over RLQ. Finally, GYN commenced further operation.

[chemotherapy]

• 2023-09-27 - paclitaxel 135mg/m2 215mg NS 250mL 3hr + carboplatin AUC 5 650mg NS 250mL 2hr + [paclitaxel 40mg/m2 64mg + cisplatin 30mg/m2 48mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-08-31 - paclitaxel 135mg/m2 215mg NS 250mL 3hr + carboplatin AUC 5 650mg NS 250mL 2hr + [paclitaxel 40mg/m2 64mg + cisplatin 30mg/m2 48mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-07-25 - paclitaxel 135mg/m2 215mg NS 250mL 3hr + carboplatin AUC 5 650mg NS 250mL 2hr + [paclitaxel 40mg/m2 63mg + cisplatin 30mg/m2 47mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-06-30 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-06-12 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-05-22 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr + NS 500mL 1hr (before chemotherapy) + NS 500mL 1hr (after chemotherapy)
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL

==========

2023-07-03

• As per the PharmaCloud database and our in-house HIS5 records, our institution has been the sole provider of medical services to this patient over the past three months. In addition to our Hematology-Oncology department, the patient also attended appointments in our Metabolism and Endocrinology department on 2023-06-05 and our Obstetrics and Gynecology department on 2023-05-04. However, no prescriptions were issued by these two departments. All current medications were prescribed by our Hematology-Oncology department, with no medication reconciliation discrepancies detected.

701373808

231002

{why 2023-07-25 exemestane shifted to letrozole?}

[MedRec]

• 2023-09-19 SOAP Hemato-Oncology Xia HeXiong
  • P: On 2023-09-19, because the tumor marker and size in progression, suggest admission for furrther evaluation and decide what CT regimen will be used. Admission for Heart Echo. CT scan.
  • Prescription
    • Stogamet (cimetidine 300mg) 1# BID
    • Xyzal (levocetirizine 5mg) 1# QD
    • Aromasin (exemestane 25mg) 1# QD [Steroidal AI]
    • Through (sennoside 12mg) 1# HS
    • Femara (letrozole 2.5mg) 1# QD [Non-steroidal AI]
    • Dulcolax (bisacodyl 5mg) 1# QN
    • Sinbaby Lotion (ZnO, diphenhydramine, dibucaine, etc) BID TOPI
    • Silverzine (silver sulfadiazine) BID EXT
• 2023-07-25 SOAP Hemato-Oncology Xia HeXiong
  • P: Shift exemestaine (Steroidal AI) to letrozole (Non-steroidal AI) on 2023-07-25
  • Prescription x2
    • Stogamet (cimetidine 300mg) 1# BID
    • Xyzal (levocetirizine 5mg) 1# QD
    • Futisone Cream (fluticasone) BID EXT
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Aromasin (exemestane 25mg) 1# QD [forgot to be DC]
    • Through (sennoside 12mg) 1# HS
    • MgO 250mg 1# TID
    • Femara (letrozole 2.5mg) 1# QD [newly added today]
    • Dulcolax (bisacodyl 5mg) 1# QN
    • Sinbaby Lotion (ZnO, diphenhydramine, dibucaine, etc) BID TOPI
    • Silverzine (silver sulfadiazine) BID EXT
• 2023-05-30 SOAP Hemato-Oncology Xia HeXiong
  • A/P: On 2023-05-30, already mention
    • For dirty urine, need to change foley, need to do urine routine and culture
    • Antibiotics is for weeks. Patient should be back if urine is not clean and sent to ER
  • Prescription x2
    • Stogamet (cimetidine 300mg) 1# BID
    • Xyzal (levocetirizine 5mg) 1# QD
    • Futisone Cream (fluticasone) BID EXT
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Aromasin (exemestane 25mg) 1# QD
    • Through (sennoside 12mg) 1# HS
    • MgO 250mg 1# TID
    • cephalexin 500mg 1# Q6H (14D, not repeated)
• 2023-05-02 SOAP Hemato-Oncology Xia HeXiong
  • A/P: Only sister in law shows up on 2023-05-02.
    • Already mention
      • Disease extent: local left breast, bone and regional LN mets
      • Should consider C/T with Anti-HER2
      • If they do not take C/T and Anti-HER2 -> consider Hormonal therapy. But I would say Hormonal therapy (Aromasin, tamoxifen or Faslodex) will be less effect because Her2 (+). Moreover, visceral crisis (spinal cord compression).
        
      • Already mention the R/T to local primary -> will control for some time and will be to and from during R/T. (Patient is bed-ridden)
  • Prescription
    • Stogamet (cimetidine 300mg) 1# BID
    • Xyzal (levocetirizine 5mg) 1# QD
    • Futisone Cream (fluticasone) BID EXT
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Aromasin (exemestane 25mg) 1# QD
    • Through (sennoside 12mg) 1# HS
    • MgO 250mg 1# TID
• 2023-04-14 ~ 2023-04-18 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Left breast invasive carcinoma, no special type, ER+, PR-, HER2/Neu 3+, with multiple bone metastasis and Rt breast metastases, status post palliative radiotherapy
  • CC
    • Left breast newly emerged lump for 2 months  
  • Present illnesee
    • Neurosurgeon was consulted and surgery was not recommended. Palliative radiotherapy 30 Gy/ 10 fx was administered for spine metastasis.
    • Tamoxifen 1# po bid was given during admission and due to nodule regrowth at Left breast, under suspicion of no response of tamoxifen, letrozole 1# QD was given from 2023/01/07.
    • The patient had not receive any chemotherapy till now.
    • From 2023-02, the patient started to note newly emerged, progressively enlarging left breast lump. Furthermore, on 2023/04/13 she started to feel pain in her left breast lump, therefore she came to our hospital for 2nd opinion and was admitted for lung contrast CT for evaluation of metastatic lesion.
  • Course of inpatient treatment
    • After admission, lung contrast CT done on 4/15 showed Left breast cancer with left axillary, intramuscular and chest wall lymphadenopathy and bone meta.
    • Biopsy for left breast newly emerged lump was done on 4/17, with pathology report pending.
    • Bone scan to follow up for metastatic lesion was done on 4/18.
    • The family hesitated to receive chemotherapy for fear of deterioration of the patient’s performance status.
    • The patient has been informed that because of HER2/Neu 3+, she must be treated with herceptin and perjeta, and that because the disease has progressed, target plus chemotherapy must be used for control, but the patient currently only wants to use hormone therapy (letrozole). The patient has been told to invite all family members to participate in a family meeting, but the patient’s sister-in-law insists on hearing the explanation of the disease and going home to discuss it with her family members. In the end, the patient was still unwilling to undergo targeted and chemotherapy treatments, so she was discharged. And further discussion with the patient will be in the outpatient appointment.
• 2023-03-31 SOAP Hemato-Oncology Gao WeiYao
  • P: encourage ER admission for her breakthrough neuropathic pain (spinal cord compression ??) (20230331)
  • Prescription
    • Switane (trihexyphenidyl 2mg) 1# BID
    • Through (sennoside 12mg) 2# HS
    • Winsumin (chlorpromazine 50mg) 2# BID
    • Stogamet (cimetidine 300mg) 1# BID
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Xyzal (levocetirizine 5mg) 1# QD
    • Futisone Cream (fluticasone) BID EXT
    • Femara (letrozole 2.5mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
• 2022-04-25 ~ 2022-05-11 POMR Hemato-Oncology Zhang ShouYi
  • Discharge diagnosis
    • Malignant neoplasm of unspecified site of left female breast
    • Left side breast cancer with multiple bone metastasis S/P radiotherapy, Invasive carcinoma, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67(40 %), p63 (-), E-cadherin (+), stromal tumor infiltrating lymphocytes: <5%.
  • CC
    • both lower legs weakness & parapleiga progression were also noted for 3-4 days.
  • Present illness
    • This 58-year-old female, a pt of suspected L breast CA with spine mets & cord compression with parapleiga since 4/22 22, s/p sent to Far Eastern H (FEMH) ER where image study done, T-spime MRI at FEMH showd spine mets & cord compression with parapleiga.
    • She suffered from initial presentation of L breast tumor for one years ago & paraplegia since 4/22 22. She came to our hemato-oncologic clinic on 4/25 22 for L breast tumor.
    • Owing to both lower legs weakness & parapleiga progression were also noted for 3-4 days.
    • Under the impression of suspected L breast CA with spine mets & cord compression with parapleiga. She was admitted for further survey.
  • Course of inpatient treatment
    • After admission, image study with breast sono (4/26 22) showed Left breast Size: 5.6x3.47 cm, Left breast tumor with left axillary lymph node, r/o malignancy suggest biopsy.
    • Sono-guided biopsy was done on 4/26 22 for left breast tumor.
    • The pathology (4/28 22) proved Invasive carcinoma, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67(40 %), p63 (-), E-cadherin (+), stromal tumor infiltrating lymphocytes: <5%.
    • We consulted NS for operation evaluation and advisted to Surgical intervention will not be recommended for the patient.
    • Radiologist was consulted for radiotherapy evaluation and advisted to Plan to deliver 30 Gy/ 10 fx to the spine mets mentioned above. RT will start around 4/27 or 28. XRT started since 4/28 to 5/11 22 and intravenous Dexa 4mg qd was added.
    • The bone scan (4/28 22) showed Highly suspected cancer with bone mets in the skull, some T- and L-spine, and right acetabulum (the most prominent).
    • Tamoxifen 1# po bid was given since 5/3 22. She was discharged on 5/11 22 under stable condition and will follow-up at OPD.
• 2022-04-25 SOAP Hemato-Oncology Zhang ShouYi
  • S: 58 y/o female, a pt of suspected L breast CA wt spine mets & cord compression wt parapleiga since 4/22 22, s/p sent to Far Eastern Memorial Hospital ER where image study done.

==========

2023-10-02

According to the PharmaCloud database, this patient just refilled a 28-day supply of Switane (trihexyphenidyl), Ativan (lorazepam), Winsumin (chlorpromazine), and Denosin (desloratadine) for her schizophrenia at the Bali Psychiatric Center of the Ministry of Health and Welfare on 2023-09-13. Except for lorazepam, all other medications are currently in use. If agitation, restlessness, or antipsychotic-induced akathisia continues to be observed, reintroduction of lorazepam may be considered.

700526788

231001

[exam findings]

• 2023-10-03 ECG
  • Normal sinus rhythm
  • Septal infarct, age undetermined
  • T wave abnormality, consider inferior ischemia
  • T wave abnormality, consider anterolateral ischemia
• 2023-09-09 SONO - abdomen
  • liver parenchymal disease, mild fatty liver
  • mild splenomegaly
  • gallbladder stones, sludge
  • mild gallbladder wall thickening
  • fatty infiltration of pancreas
• 2023-08-08 SONO - nephrology
  • Bilateral chronic change with left small sized kidney.
  • Irregular bladder wall, cause?
• 2023-08-02 ECG
  • Sinus tachycardia
  • T wave abnormality, consider inferior ischemia
  • Abnormal ECG
• 2023-07-12 ECG
  • Sinus tachycardia with Premature atrial complexes
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2023-07-12 CTA - chest
  • A calcification (4mm) at right lung.
  • Left pleural effusion with adjacent lung collapse.
  • Fat stranding at right perirenal region.
  • Grade 4 fatty liver.
  • Gallbladder stone (3.2cm).
• 2023-07-12 CT - brain
  • Brain atrophy.

[MedRec]

• 2023-09-09 SOAP Gastroenterology Wang JiaQi
  • S
    • RUQ pain for 1-2 wks. fever (-)
    • vomiting this morning (+). poor appetite.
    • GB stones with cholecystopathy
  • O
    • PE: abdomen: soft and flat
    • PH: DM (+), HT (+)
    • US: liver parenchymal disease, mild fatty liver, mild splenomegaly, gallbladder stones, sludge, mild gallbladder wall thickening, fatty infiltration of pancreas (2023, 9/9)
  • Prescription
    • Acetal (acetaminophen 500mg) 1# TID
    • Mopride (mosapride citrate 5mg) 1# TID
    • Alusa (aldioxa 100mg) 1# TID
• 2023-08-16 SOAP Infectious Disease Peng MingYe
  • A: Prolonged antibiotic for recurrent UTI, continue Ceficin for another 2 more weeks
  • P: Education and medications
  • Prescription
    • Ceficin (cefixime 100mg) 2# Q12H
• 2023-08-03 POMR Infectious Disease Peng MingYe
  • Discharge diagnosis
    • Sepsis due to Escherichia coli [E. coli]
    • Bacteremia
    • urinary tract infection
    • Pneumonia, unspecified organism
    • Type 2 diabetes mellitus with unspecified complications
    • obesity
    • Calculus of gallbladder, 3.2 cm; ABD CT, 2023-07-12
    • Essential (primary) hypertension
  • CC
    • Fever since last night, Aug 01, with vomiting once with gastric juice.
    • No abdominal pain or diarhrea
  • Present illness
    • This 72-year-old female patient has underlying diseases of hypertension, diabetes mellitus, gall bladder stone. She was recently discharged from our Infection ward due to Escherichia coli UTI with sepsis on July 20, 2023. She has no allergies to food or drugs, no food allergy, no history of travel, occupation, contact or cluster recently.
    • This time, she suffered from recurrent fever since the night of Aug 01 and vomiting once with gastric juice noted. She denied abdomianl pain or diarrhea, no any URI symptoms. She was taken to our ED for hlep in the early morning of yesterday, Aug 02. At ED, fever 39.8C detected. The laboratory data showed normal whote cell count and CRP 1.4 only. Urinalysis showed typical UTI picture with bacteriuria and pyuria. The CXR showed increase of bilateral lung marking, the influenza and COVID tests all showed negative result. Under the impression of recurrent urinary tract infection, she was admitted to our INF ward for further management on Aug 03, 2023.
  • Course of inpatient treatment
    • After admission, empirical antibiotic Brosym was given for ifnection control. Urine and blood culture all showed Escherichia coli that E.coli urosepsis confirmed.
    • There is no more fever after admission and gradual improvement with more spiritful and oral intake. Lab data rechecked on 8/8 shwoed normal white count and much lower CRP level, 2.1. Renal echo wass done on Aug 8, whcih showed small left kidney size, no renal stone or hydronephrosi. CxR showed no infiltration on 8/7.
    • She is discharged on 2023/8/10 with oral Ceficin back home. OPD follow up is arranged.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ6H (if BT > 38)
    • Through (sennoside 12mg) 2# HS
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Const-K (KCl 10mEq 750mg) 1# QD
    • Bisadyl supp (bisacodyl) 2# PRNQOD RECT (if no stool passage)
    • Ceficin (cefixime 100mg) 2# Q12H
• 2023-07-12 POMR Infectious Diesease Hong BoBin
  • Discharge diagnosis
    • Sepsis due to Escherichia coli [E. coli]
    • Urinary tract infection, site not specified
    • Calculus of gallbladder, 3.2 cm; ABD CT, 2023-07-12
    • Metabolic syndrome
    • Hyperlipidemia, unspecified
    • Essential (primary) hypertension
    • Type 2 diabetes mellitus without complications
  • CC
    • Fever, chills, chest pain, and cough for three days, then consciousness loss with hyperglycemia one day.
  • Present illness
    • A 72-year-old female has past medical history of hypertension, diabetes mellitus, gall bladder stone, and Escherichia coli sepsis. She has no allergies to food or drugs, no food allergy, no history of travel, occupation, contact or cluster recently. Unknown of job.
    • She presented in the emergency department with the symptoms of fever, chills, chest pain, and cough for three days, then she was found consciousness loss last night, the finger sugar showed 383mg/dL by the emergency medical technician. The temperature 41.4°C, the pulse 128 beats per minute, the blood pressure 164/82 mmHg, the respiratory rate 22 breaths per minute, and the oxygen saturation 97%, regain consciousness E4V4M6. The physical examination showed pale conjunctiva, normal light reflex of bilateral pupils, bilateral symmetric expansion of chest, coarse sound, soft abdomen without tenderness, no pitting edema, muscle power: right side 3, left upper 4, and left lower 3.
    • A blood serum tests showed leukocytes with neutrophil predominant 61.6%, band 3.5%, hyperglycemia, elevated C-reactive protein and creatinine and creatine kinase and prothrombin time and d-dimer and troponin-I and lactic acid. Urinalysis showed pyuria. Chest x ray showed ground glass opacities in bilateral lungs. A computer tomography of the brain showed brain atrophy. A computed tomography angiography of the chest revealed left pleural effusion with adjacent lung collapse, no aortic dissection. Brosym was given. She was hospitalized on 2023-07-12.
  • Course of inpatient treatment
    • During the hospital stay, we use parenteral cefuroxime for empirical treatment of urosepsis. The foley catheter indwelling for monitor urine amount. The adequate fluid supplement. On critical condition. Insulin as sacle for hyperglycemia control.
    • Laboratory examination revealed improvemeent, but elevated CK noted. Sodium Bicarbonate was addition for urine alkalization. Blood culture yields Escherichia coli. We give de-escalation of antibiotics to cefazolin. Urine culture yields Escherichia coli.
    • Laboratory examinaiton revealed improvement, but anemia is noted. Blood transfusion with LPRBC one unit supplement for two days. Urinalysis showed no pyuria. Foley catheter was removal, urination voiding is smooth, residual urine showed 60 ml. No more fever occurs.
    • Glycemia under insulin control. She is discharged on July 20, 2023.
  • Discharge prescription
    • cephalexin 500mg 1# TID

==========

2023-10-04

The patient refilled the repeat prescription for Norvasc (amlodipine), Tulip (atorvastatin), Ankomin (metformin), and Ozempic Injection (semaglutide) on 2023-09-09. However, she is not currently taking these drugs. It is recommended that her serum glucose and blood pressure levels be monitored to determine if and when these medications should be reintroduced.

700372532

230928

[diagnosis] - 2023-03-15 admission note

• Malignant neoplasm of rectum
• Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema

[past history]

• Type 2 diabetes mellitus and hyperlipidemia for 4-5 years under medications treatment.
• Past operation: left middle finger post traumatic amputation 30+ years ago            

[allergy]

• NKDA     

[family history]

• Father died: AMI
• Mother: diabetes
• There is no family history of cancer, mental diseases or asthma

[exam findings]

• 2023-07-10 Neurosonography
  • Mild atheromatous lesions in R subclavian artery, R CCA bifurcation, and L ICA.
  • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows.
• 2023-06-20 CT - abdomen
  • History and indication: ca of colon
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon and liver operation. A patchy density (2.3cm) at RML. Recurrent metastases at right liver operative margin (much regression).
    • Some calcifications in prostate.
    • Tiny gallbladder stones.
    • Degeneration and spondylosis of L-S spine.
    • Atherosclerosis of aorta, iliac and coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P colon and liver operation. A patchy density (2.3cm) at RML. Recurrent metastases at right liver operative margin (much regression).
• 2023-02-13 Microsonography
  • Clinical Diagnosis: IRC and ME os
  • Report: 207/482 um, IRC and ME os
• 2023-02-09 CT - abdomen
  • History and indication: colon cancer with recurrent liver mets S/P op & C/T
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon and liver operation. Right pleural effusion with adjacent lung collapse. Recurrent metastases at right liver operative margin.
    • Some calcifications in prostate.
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • Normal appearance of gallbladder.
    • Patency of portal vein.
    • Degeneration and spondylosis of L-S spine.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac and coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P colon and liver operation. Right pleural effusion with adjacent lung collapse. Recurrent metastases at right liver operative margin.
• 2022-12-27 Patho - pleural/pericardial biopsy
  • Diaphragm, right, partial resection — Adenocarcinoma, moderately differentiated, compatible with metastatic colonic adenocarcinoma of liver with diaphragm invasion
  • The sections show a picture of adenocarcinoma, moderately differentiated, composed of low columnar neoplastic cells arranged in tubular and cribriform patterns with dirty necrosis. The surgical margin is close to tumor. The finding is compatible with metastatic colonic adenocarcinoma of liver with diaphragm invasion.
• 2022-12-27 Patho - liver partial resection
  • PATHOLOGIC DIAGNOSIS
    • Liver, S7, S7 resection — Metastatic colonic adenocarcinoma
      
    • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
  • MACROSCOPIC EXAMINATION
    • Procedures: S7 resection
    • Specimen Size: 11 x 8.0 x 5.0 cm and 120 gm
      
    • Tumor Focality: Solitary
      
    • Tumor Site: S7
      
    • Tumor Size: 3.2 x 3.0 x 2.2 cm
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Not cirrhotic
      
    • Sections are taken and labeled as: A1-A2= tumor + margin, A3-A4= tumor + capsule
  • MICROSCOPIC EXAMINATION
    • Diagnosis: Metastatic colonic adenocarcinoma
      
    • Histologic grade: Moderately differentiated
      
    • Tumor growth pattern: Pushing
      
    • Tumor pseudocapsule: Present
      
    • Tumor necrosis: Moderate (15%)
      
    • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 1.5 cm from resection margin
        
    • Vascular invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
    • Non-neoplastic liver parenchyma: Moderate lymphocytic portal inflammation and regeneration of hepatocytes
    • Fatty Change: Absent
• 2022-12-26 ECG
  • Normal sinus rhythm
  • Left ventricular hypertrophy with repolarization abnormality
• 2022-11-24 Whole body PET scan
  • A mild glucose hypermetabolic lesion in the segment 7 of the liver. Liver metastasis of low FDG uptake can not be ruled out. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in a focal area in the right iliac bone. The nature is to be determined. Please follow up other imaging modalities for further evaluation.
  • Mild glucose hypermetabolism in bilateral shoulders and hips. Inflammatory process may show this picture.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2022-11-14 CT - abdomen
  • Indication: Malignant neoplasm of rectum
  • Abdominal CT with and without enhancement revealed:
    • Hepatic tumor at right liver surface with marginal enhancement and central necrosis is found. Hepatic metastasis is considered. In comparison with CT dated on 2022-04-25, the lesion enlarged.
    • Hypervascular hepatic tumor at S5/6 of liver up to 0.8cm in largest dimension. Hemangioma is considered.
    • s/p RAR.
    • The spleen, pancreas, both kidneys and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
  • Imp: colon cancer s/p RAR with liver metastasis, in progression.
• 2022-08-22 SONO - abdomen
  • Findings
    • Normal echogenicity of the liver.
    • Presence of gallbladder stones and polyps.
    • Patency of PV, HVs, IVC and aorta in hepatic portion.
  • Impression:
    • GB stones and polyps.
• 2022-05-30 MRA - brain
  • Acute infarcts in right upper medulla oblongata. Intracranial artherosclerosis.
• 2022-04-25 CT - abdomen
  • S/P colon and liver operation. No evidence of tumor recurrence.
• 2022-01-27 SONO - abdomen
  • Gallbladder stones (up to 0.56cm).
• 2021-11-01 CT - abdomen
  • S/P colon and liver operation. No evidence of tumor recurrence.
• 2021-04-20 Patho - conjunctiva biopsy/pterygium
  • Labeled as “sclera od”, trabeculectomy od — fibrotic tissue
• 2021-04-12 Patho - colorectal polyp
  • Intestine, large, cecum, 120 cm from anal verge, biopsy — tubular adenoma
• 2021-04-09 CT - abdomen
  • Indication: rectal CA, pT3N2aM0, stage IIIB s/p CCRT from 2018-03 to 2018-05 and LAR wt protective ileostomy on 2018/06/07
    • 20180507 CT: hemangioma 0.8 cm in S5
    • 20190708 CT: hemangioma 0.8 cm in S5.
    • 20191230 CT: two metastases 0.7 cm in S7 and 1.3 cm in S6?
    • 20200204 MRI: two metastases in S7 and S6?
    • Metastases confirmed by pathology after resection
  • FINDINGS:
    • There are focal defect in S7 and S6 of the liver that are compatible with metastases S/P surgical enucleation.
      • There is no evidence of tumor recurrence.
    • S/P LAR with autosuture retention over the rectum.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
    • Others
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion in the mesentery and omentum.
  • IMP:
    • No evidence of tumor recurrence in the liver.
• 2021-04-09 Colonoscopy
  • The scope reach the cecum under poor colon preparation.
  • Two small and sessile polyp was noted in the cecum size 0.7 cm. (120 cm from anal verge)
• 2020-10-19 CT - abdomen
  • S/P colon and liver operation. No evidence of tumor recurrence.
• 2020-02-25 Patho - liver partial resection
  • PATHOLOGIC DIAGNOSIS:
    • Liver, S7 with partial S6, segmental hepatectomy — Metastatic colorectal adenocarcinoma
      
    • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
      
  • MACROSCOPIC EXAMINATION
    • Procedures: Segmental hepatectomy of S7 with partial S6
      
    • Specimen Size: 12.0 x 7.5 x 5.5 cm and 180 gm
      
    • Tumor Focality: Solitary
      
    • Tumor Site: S6
      
    • Tumor Size: 2.2 x 2.0 x 1.7 cm
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Not cirrhotic
      
    • Sections are taken and labeled as: A1-A4= tumor, A5- A6= non-neoplastic liver
      
  • MICROSCOPIC EXAMINATION
    • Diagnosis: Metastatic colorectal adenoarcinoma
      
    • Histologic grade: Moderately differentiated
      
    • Tumor growth pattern: Infiltrating
      
    • Tumor pseudocapsule:Absent
      
    • Tumor necrosis: Moderate (10%)
      
    • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 0.4 cm
        
    • Vascular invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
      
    • Non-neoplastic liver parenchyma: Perivenular congestion, regeneration of hepatocytes, and mild lymphocytic and neutrophil portal inflammation
      
    • IHC: CK7(-), CK20(+) and CDX2(+)
• 2020-02-24 MRI - liver, spleen
  • History and indication: R/I recurrence of liiverr mets.
  • IMP: Progressive enlargement of right liver tumors (S6-7, 1.0cm, 1.7cm), metastases shoulde be ruled out.
• 2019-12-30 CT - abdomen
  • Rectal cancer s/p operation. Right liver hemangioma (8mm). Poor enhancing tumors (6mm, 9mm) in S6-7 of liver suspected metastases.
• 2019-01-21 CT - abdomen
  • Status post LAR with autosuture at the rectum.
  • There is no evidence of tumor recurrence.
• 2018-06-08 Surgical pathology Level VI
  • PATHOLOGIC DIAGNOSIS
    • Rectum, s/p CCRT, laparoscopic assisted LAR and protective colostomy —- Adenocarcinoma, moderately differentiated
    • Resection margins: free
    • Lymph node, mesocolic, s/p CCRT, dissection —- Metastatic adenocarcinoma (4/11) with extranodal extension (1/4).
    • Lymph node, IMA / SMA, dissection — N/A.
    • AJCC 8th edition Pathology stage: ypT2N2a (if cM0); ypStage: IIIB.
    • NOTE: cM might be the same or might be upgraded when additional clinical and image findings are available for evaluation.
  • MACROSCOPIC EXAMINATION
    • Operation procedure: s/p CCRT, laparoscopic assisted LAR and protective colostomy
    • Specimen site: rectum
      
    • Specimen size: 9 cm in length
      
    • Tumor size: 3 x 2 cm
    • Tumor location: 3 cm and 2 cm away from the two resection margins, respectively
    • Depth of invasion grossly: muscularis propria
    • Mucosa elsewhere: free
    • Tissue for sections: A1-4: tumor; A5-6: lymph nodes.
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
    • Histology Grade: moderately differentiated
    • Depth of invasion: muscularis propria
    • Angiolymphatic invasion: Present.
    • Perineural invasion: Not identified.
    • Discontinuous extramural tumor extension: Not identified.
    • Circumferential (radial) margin of rectum: Uninvolved, 5 mm from the margin.
    • Lymph node metastasis, mesocolic: (4/11)
      
    • Lymph node metastasis,, IMA / SMA: N/A.
    • Extranodal involvement: Present.
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT) ypT2: Tumor invades the muscularis propria
      • Regional Lymph Nodes (pN) ypN2a: Four to six regional lymph nodes are positive
      • Distant Metastasis (pM) (if cM0); ypStage: IIIB.
      • NOTE: cM might be the same or might be upgraded when additional clinical and image findings are available for evaluation.
    • Type of polyp in which invasive carcinoma arose: Not identified
    • Additional pathologic findings: None identified.
    • TNM descriptors: y (Post-treatment).
      
    • Tumor regression grading S/P CCRT:
      • Grade 3 (dominant fibrosis outgrowing of 50% of the tumor mass).
• 2018-02-06 Surgical pathology Level IV
  • Clinical diagnosis:
  • Neoplasm of unspecified nature of digestive system;
  • Pathological diagnosis:
    • Rectum, 8 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • MICROSCOPIC DESCRIPTION:
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

• 2023-08-28 SOAP Metabolism and Endocrinology Qiu QuanTai
  • Prescription x3
    • Toujeo (insulin glargine) 12 unit QDAC SC
    • Through (sennoside 12mg) 1# PRNHS
    • Crestor (rosuvastatin 10mg) 1# QD
    • Kludone (gliclazide 60mg) 1# BIDAC
    • Dibose (acarbose 100mg) 1# TIDAC
    • Olmetec (olmesartan medoxomil) 1# QD
    • Trulicity (dulaglutide) 1.5mg QW SC
    • Uretropic (furosemide 40mg) 0.5# PRNQD (hold if SBP < 100 mgHg)
    • Smecta (dioctahedral smectite 3mg) 1# TIDAC
• 2023-08-28 SOAP Metabolism and Endocrinology Qiu QuanTai
  • A: 2023 ~ additional chemotherapy again (taking steroids will make the blood glucose as high as 3XX)

[consultation]

• 2022-05-30 Neurology
  • Q
    • l’t arm weakness since this morning. unsteady sensation.
    • hx of DM, HTN.
  • A
    • S
      • This 58 y/o man with a Hx of DM, HTN, dyslipidemia, and rectal CA with liver mets, Dx in Jan 2018, s/p CCRT under regular OPD follow-up. He was in ADL independent status.
      • This time, he suffered from acute left side numbness at 2PM on 5/28 while driving with left neck pain. Left limbs weakness was noted on the next day morning on awakending. Due to persisted symptoms, he came to our ER. There was no vomiting, diplopia, choking, slrred speech, convulsion, headache, fever or recent head trauma.
    • O
      • NE
        • GCS: E4V5M6
          
        • VF: no hemianopia
        • light reflex: 3/3 -/+ (cata/cata (right eye glaucoma s/p OP
        • EOM: free
          
        • no nystagmus
        • no facial palsy
          
        • PPS: left face V-I,II,III hypoesthesia (equivocal
      • Muscle power:
        • RUE/LUE: 5/4
        • RLE/LLE: 5/4
      • PPS: left hypoesthesia
      • FNF & HKS: no dysmetria
      • gait: tilt to left
      • NIHSS 000 000 1010 01000 =3
      • Lab Bil 1.17, CEA 5.465
      • brain MRA: Acute infarcts in right upper medulla oblongata
    • Impression
      • Acute infarcts in right upper medulla oblongata
    • Suggestion
      • aspirin 100mg 1# ST and QD
      • clopidogrel 300mg ST and 75 mg QD
      • famotidine 1# ST and BID
      • N/S run 60 ml/hr
      • hold OPD anti-hypertensive medication and control BP < 220/120
      • admit to ward under Dr Xiao’s service
      • closely monitor neurological signs
• 2020-09-10 Ophthalmology
  • Q
    • This 57-year-old man patient is a case of colon cancer with liver metastasis s/p operation. He was admitted for chemotherapy. This time, glaucoma with high intraocular pressure. Now, for follow-up. Thank you.
  • A
    • S: for f/u IOP
    • O
      • OPHx: DMR complicated with NVG s/p several IVILs ou and cryotherapy od and full PRP ou
      • recent IOP, od on 9/7 W1 up to 40 was noted –＞ diamox 1# qid + combigan + xalatan
      • PT: 10/12 mmHg
      • VAcNC: OD 20/200 OS 20/200
      • conj: not injected ou
      • K: cl ou
      • AC:deep/cell trace - 1+ od, deep /clear os
      • c/d: pale disc 0.6-7 od, 0.5 os
    • P:
      • tapper the diamox to 1# bid

[surgical operation]

• 2022-12-26
  • Surgery
    • open S7 resection with rt diaphram partial resection and repair
  • Finding
    • S7 hepatic tumor 3.2 x 3.0 x 2.0 cm with direct invasion to diaphragm
• 2020-07-27
  • Surgery: 0 IVI Lucentis    ou    
  • Finding: retinal edema    ou 
• 2020-02-24
  • Surgery
    • S7 and partial S6 resection
    • laparoscope
  • Finding
    • AN illed define heteroechoic tumor at S7 1.7 cm and 1.5 cm tumor at S6
    • mild adhesion
• 2019-08-16
  • Diagnosis: Exudative senile macular degeneration
  • PCS code: 86201B
• 2019-07-05
  • Diagnosis: Proliferative diabetic retinopathy OU
  • PCS code: 86201B
• 2019-05-24
  • Diagnosis: DME ou
  • PCS code: 86201B
• 2019-04-19
  • Diagnosis: DME ou
  • PCS code: 86201B
• 2018-11-22
  • Diagnosis: Rectal cancer s/p LAR and ileostomy
  • PCS code: 73020C
  • Findings: Loop-ileostomy was taken down and resection with re-anastomosis was achieved using GIA 75/4.8. The procedure was smooth.
• 2018-06-07
  • Diagnosis: Adenocarcinoma of rectum, cT3N2M1 s/p CCRT
  • PCS code: 74205B
  • Finding
    • Rectal cancer s/p CCRT was noted at middle rectum.
    • The laparoscopy procedure was converted to open method due to difficult to apply endo-GIA instrument.
    • The anastomosis was then achieved using SDH-33. Cutting ends are intact and even. Air test is ok.
    • TISSEEL 2ml was used at anastomosis site.
    • Loop-ileostomy was done at LLQ abdomen. A drain in pelvos.
• 2018-02-07
  • Diagnosis: Rectal Ca
  • PCS code: 47080B
  • Findings: We identify the cephaic vein & use cutdown method to insert the Echo Port 7 Fr cathter into it. We also use intra-operative EKG to check its position

[chemoimmunotherapy]

• 2023-08-17 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg IVD + NS 250mL + aprepitant 125mg D1-3
• 2023-07-31 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5100mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg IVD + NS 250mL + aprepitant 125mg D1-3
• 2023-07-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5150mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 0.5mg IVD + NS 250mL
• 2023-06-20 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5150mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-05-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5125mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-04-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5180mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-04-06 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5170mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-03-15 - irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 735mg NS 250mL 2hr + fluorouracil 2800mg/m2 5155mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-02-24 - irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 729mg NS 250mL 2hr + fluorouracil 2800mg/m2 5100mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-02-09 - irinotecan 160mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2020-09-10 - oxaliplatin 85mg/m2 146mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4810mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2020-08-27 - FOLFOX
• 2020-08-13 - FOLFOX
• 2020-07-30 - FOLFOX
• 2020-07-16 - FOLFOX
• 2020-07-02 - FOLFOX
• 2020-06-18 - FOLFOX
• 2020-05-28 - FOLFOX
• 2020-05-14 - FOLFOX
• 2020-04-30 - FOLFOX

==========

2023-09-28

The drugs prescribed by our endocrinologist have been added to the active medication list with no discrepancies found.

2023-08-18

A 28-day supply of Ulstop (famotidine), Bokey (aspirin), Saline (nicametate), and Vemlidy (tenofovir alafenamide) are refilled on 2023-08-05, all added to the active formulary with no reconciliation issues found.

2023-08-01

Our neurologist prescribed Ulstop (famotidine), Bokey (aspirin), Saline (nicametate citrate) on 2023-07-17, our ophthalmologist prescribed Xalatan (latanoprost), Azarga (brinzolamide, timolol), Alphagan (brimonidine) eye drops on 2023-07-31. These drugs are included in the active medication list without a reconciliation issue.

2023-07-11

[reconciliation]

The prescription of Alphagan (brimonidine tartrate), Azarga (brinzolamide), and Xalatan (latanoprost) eye drops were refilled at a local pharmacy on 2023-06-26, with a valid 28-day duration for his glaucoma diagnosis. However, these drugs are not currently included in the patient’s active medication list. Please check whether these medications are still required for the patient.

2023-06-21

• This patient receives medical services exclusively at our hospital. In addition to hematology and oncology, the patient also sees metabolism and endocrinology for type 2 DM, hyperlipidemia, primary hypertension, constipation; ophthalmology for glaucoma; and neurology for previous stroke.
• The patient received a refillable prescription from Metabolism and Endocrinology on 2023-06-05 for Toujeo (insulin glargine), Through (sennoside), Crestor (rosuvastatin), Kludon (gliclazide), Dobose (acarbose), Olmetec (olmesartan), and Trulicity (dulaglutide). From the ophthalmology department, the patient was prescribed Xalatan (latanoprost), Azarga (brinzolamide, timolol), and Alphagan (brimonidine) on 2023-05-08. The neurology department prescribed Ulstop (famotidine), Bokey (aspirin), and Saline (nicametate) on 2023-04-24.
• All of these medications have been added to the current formulary, except for the eye drops from the ophthalmology department. Please remind the patient to continue using them to prevent his glaucoma from worsening.

2023-04-07

• During this hospitalization, the patient received his first dose of Avastin (bevacizumab) as part of the FOLFIRI chemoimmunotherapy regimen. Although the patient had previously received 3 cycles of FOLFIRI, monitoring for bleeding and thrombosis may still be necessary as these symptoms may be related to the use of bevacizumab.
• The preprandial FS glucose levels on 2023-04-06 and 2023-04-07 morning were 218 and 249, respectively. If the readings exceed 200 for more than two consecutive days, the insulin dose may need to be increased.

2023-03-16

• The patient’s blood sugar level has been well controlled during his current hospitalization.
• He has a history of acute infarcts in the right upper medulla oblongata and was found to have intracranial atherosclerosis on a brain MRA performed on 2022-05-30. On 2023-03-16 at 13:14, his SBP was measured to be 182mmHg. If the patient continues to have persistently high blood pressure, the addition of amlodipine may be considered.

700480867

230928

U-Vanco (vancomycin) was changed from 1000mg Q12H to 1500mg Q12H on 2023-09-24 because the trough was 4.9mg/dL on that day. Since the updated trough level is even lower today (2023-09-28) at 4.3mg/dL, it is recommended that the dose be increased to 2000mg Q12H (Cre 0.32mg/dL, eGFR 377).

700603106

230926

[exam findings]

• 2022-12-21 PET
  • Glucose hypermetabolic lesions in the right chest wall, compatilbe with recurrent breast tumor s/p operation.
    
  • Glucose hypermetabolic lesions in bilateral tonsils, probably chronic inflammation/infection process.
    
  • Increased FDG uptake in bilateral kidneys and left ureter, probably physiological uptake of FDG.
    
  • Right breast cancer with tumor recurrence s/p operation, no evidence of residual or metastatic tumor, by this F-18 FDG PET scan.
• 2022-12-19 Patho - breast simple/partial mastectomy
  • Diagnosis
    • S2022-22806: Skin, right chest wall, resection margin, second wide excision —- Negative for malignancy
    • F2022-00612: Skin and foft tissue, right chest wall, wide excision —- invasive carcinoma of no special type, recurrent
  • Gross Description
    • S2022-22806: The specimen submitetd in formalin consists of a rim of skin and soft tissue measuring 5.2 x 0.9 x 0.8 cm. The width of the rim is 0.4 cm. All for section in 4 cassettes: A1: from 12 o’clock to 3 o’clock; A2: from 3 o’clock to 6 o’clock; A3: from 6 o’clock to 9 o’clock; A4: from 9 o’clock to 12 o’clock.
    • F2022-00612: The specimen submitetd in fresh consists of a piece of skin and soft tissue measuring 4.3 x 2.7 x 1.6 cm. On cutting, a gray, invasive tumor, measuring 3.0 x 2.2 x 1.5 cm is seen. The tumor is very close (＜ 0.1 cm) to deep and 6 o’clock resection margins and 0.1 cm away from the 12, 3, and 9 o’clock resectino margins. Representative sections are taken and labeled as: FsA1: through section from 12 o’clock (ink black) to 6 o’clock (ink orange) resection margin; FsA2: 3 o’clock resection margin; FsA3: 9 o’clock resection margin. After formalin fixation, additional sections are taken and labeled as: X1-2.
      
  • Microscopic Description
    • S2022-22806: Sections show skin and soft tissue without malignancy.
    • F2022-00612
      • For Invasive Carcinoma
        • Histologic type: Invasive carcinoma of no special type, recurrent
        • Size of invasive carcinoma (mm): 30 x 22 x 15 mm
        • Histologic grade (Nottingham histologic score): grade II (score 7)
          • Tubule formation: score 3
          • Nuclear pleomorphism: score 2
          • Mitotic count: score 2
        • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Present (without ulceration)
          • Chest wall invasion deeper than pectoralis muscle: Invasion to superficial skeletal muscular tissue without deeper than pectoralis muscle
      • For Ductal Carcinoma In Situ: not applicable
      • Margins:
        • S2022-22806: Negative for malignancy
        • F2022-00612: The tumor is very close (< 0.1 cm) to deep and 6 o’clock resection margins and 0.1 cm away from the 12, 3, and 9 o’clock resectino margins.
          
      • Nodal status: not received
      • Treatment Effect: not applicable
        
      • Immunohistochemical Study
        • ER (Ab): Positive (90%, strong) (Internal control: positive)
        • PR (Ab): Positive (60%, moderate) (Internal control: positive)
        • Her-2/neu (Ab): Negative (1+)
        • Ki-67: 20%
• 2022-12-18 CT - chest
  • Findings
    • S/P right breast operation. A soft tissue nodule (2.3cm) at right chest wall.
    • Some LNs at bil. neck.
    • A calcified spot (2.6mm) at right lung margin.
    • A hypodense nodule (0.9cm) at left hepatic lobe. Grade 4 fatty liver.
  • IMP:
    • A soft tissue nodule (2.3cm) at right chest wall.
• 2019-04-23 Gynecologic ultrasonography
  • R/O RT ovarian cyst
  • Uterine myoma
• 2018-10-23 MRI - breast
  • S/P right mastectomy.
  • Stipple enhancement in left breast, but no significant early enhancement. Suggest clinical correlation and follow up.
• 2017-09-05 Gynecologic ultrasonography
  • Uterine myoma
  • EM: 3.6mm
• 2017-03-07 Gynecologic ultrasonography
  • Uterine myoma

==========

2023-09-26

This patient has been consistently taking cyclin-dependent kinase inhibitor Verzenio (abemaciclib 150mg) 1# BIDCC and aromatase inhibitor Femara (letrozole 2.5mg) 1# QD for months.

Dyspnea, with a frequency ranging from 6% to 18%, has been associated with the use of letrozole. Abemaciclib, on the other hand, has been linked to interstitial lung disease (ILD) and/or pneumonitis, with the frequency not yet defined.

In the event that ILD is confirmed, the abemaciclib dosage should be adjusted as follows:

• Grade 1 or 2: No abemaciclib dosage modification is required.

• Persistent or recurrent grade 2 toxicity that does not resolve to baseline or grade 1 within 7 days (despite maximal supportive measures): Withhold abemaciclib until toxicity resolves to baseline or to ≤ grade 1 and then resume abemaciclib at the next lower dose.

• Grade 3 or 4: Discontinue abemaciclib.

701186682

230926

[exam findings]

• 2023-07-21 SONO - abdomen
  • Propable liver calcification, right
  • S/p cholecystectomy
  • Suspected fatty infiltration of pancreas
  • Small amount ascites
  • C/w ESRD
• 2023-06-21 Joint soft tissue sonography
  • Finding: Ill-defined anechoic effusion with posterior enhancement and mild compressible just below the OP wound of the axilla site.
  • Impression And Suggestions: Right axilla post-OP wound effusion or serosanguineous mass accumulation.
• 2023-05-31 Tc-99m MDP bone scan
  • A hot spot at a mid-T spine and increased activity at L2-4 spines, the nature is to be determined (post-traumatic reaction, early bone mets or other nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
  • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, elbows, S-I joints, knees, and feet.
• 2023-05-31 Patho - breast mastectomy with regional lymph nodes
  • PATHOLOGIC DIAGNOSIS
    • Breast, right, partial mastectomy — Invasive carcinoma of no special type
    • Resection margin, breast, right, partial mastectomy — Free
    • Lymph nodes, sentinel and non sentinel, right axilla, lymphadenecomy — Negative for malignancy (0/8)
    • AJCC 8 th edition, Pathology stage: pT1cN0(cM0); Anatomic stage IA; Prognostic stage IA
  • MACROSCOPIC EXAMINATION
    • Breast Size: 10.5 x 6.0 x 3.5 cm
    • Skin Size: 5.0 x 1.0 cm
    • Nipple: Not included
    • Tumor Size: 1.8 x 1.4 x 1.2 cm
      
    • Resection Margin: Free, 2.4 cm from the deep margin
    • Lymph node: Sentinel (SLN1 and SLN2), and non-sentinel
    • Representative parts are taken for sections and labeled; A1= 12’ and 6’ margins, A2= 3’ and 9’ margins, A3-A4= skin + tumor, A5= tumor + base margin, B=SLN1, C= SLN2, D= non SLN.
  • MICROSCOPIC EXAMINATION
    • Histo
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 1.8 x 1.4 x 1.2 cm
        
      • Histologic grade (Nottingham histologic score): Grade 2 (score= 6)
      • Skin involvement: Absent
      • Ductal carcinoma in situ: Present with intermediate nuclear grade; Extensive DCIS: Negative
    • Margins: Negative; Closest margin: >10 mm from closest lateral margins and 24 mm from deep margin
    • Nodal status: Negative (0/8)
      • number of lymph node examined: 3 (SLN1), 2 (SLN2), 3 (non SLN)
      • number with macrometastases (> 2mm): 0
      • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
      • number with isolated tumor cells (<= 0.2mm and <= 200 cells): 0
    • Treatment Effect: No presurgical neoadjuvant therapy received
    • Lymphovascular invasion: Presnt
    • Perineural invasion: Absent
  • IMMUNOHISTOCHEMICAL STUDY (S2023-09128)
    • ER (Ab): Positive (weak, 10%)
    • PR (Ab): Negative
    • HER-2/Neu (Ab): Negative (score= 1+)
    • Ki-67: 20%
• 2023-05-30 Lymphoscintigraphy
  • Probably a sentinel lymph node at the right axillary region.
• 2023-05-11 Patho - breast biopsy (no need margin)
  • Breast, right ( 2 / 3.5), core needle biopsy— Invasive carcinoma of no special type
  • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
  • Immunohistochemical study:
    • ER (Ab): Positive (weak, 10%)
    • PR (Ab): Negative
    • Her-2/neu (Ab): Negative (1+)
    • Ki-67 index: 20%
    • CK5/6: Negative
    • p63: Negative
• 2023-05-08 Mammography (magnification)
  • BI-RADS category 4C, High suspicion for malignancy. Tissue diagnosis is suggested.
• 2023-04-21 Cardiac Catheterization
  • Past Medical History
    • The patient has a history of DM for years with OHA control, HCVD with antiHTN and ESRD with PD since 2022-09.
  • Indication
    • The patient was referred with Refrcatory angina and Th-201 scan (++). The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
  • Approach
    • Percutaneous access was performed through the right radial artery
      
  • Catheters
    • Left coronary angiography was performed using 6Fr JL3.5 catheter and Right coronary angiography was performed using 6Fr JR4 catheter.
  • Procedure
    • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 cc. The patient was treated with Heparin and NTG.
  • Finding Summary
    • Syntax Score = 2
    • Left Main : patent
    • Left Anterior Descending : heavy calcification at P- to M-LAD with mild atherosclerosis at P-LAD
    • Left Circumflex : patent
    • Right Coronary : about 50 % eccentric stenosis at M-RCA
  • In conclusion : CAD, SVD-RCA
  • Recommendation : Medical treatment
• 2023-02-16 Myocardial perfusion SPECT with persantin
  • Probably mild to moderate myocardial ischemia at the apical anterolateral wall and posterior wall and mild myocardial ischemia at the septum and mid anterior wall.
• 2023-02-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (119 - 29.3) / 119 = 75.38%
    • M-mode (Teichholz) = 75.4
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Calcified mitral annulus with mild MR, mild TR and PR
    • AV sclerosis with mild AR
    • No regional wall motion abnormalities

[MedRec]

• 2023-07-27 SOAP Gastroenterology
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
• 2023-07-20 ~ 2023-07-21 POMR General and Gastroenterological Surgery
  • Discharge diagnosis
    • Right breast invasive carcinoma, pT1cN0M0 stage IA. ER : Positive (weak, 10%), PR: Negative, Her-2/neu : Negative (1+), Ki-67 index: 20%. ECOG:0.
    • End stage renal disease
    • Type 2 diabetes mellitus
    • Papillary thyroid carcinoma status post left thyroidectomy, pT1aNx pStage I status post radical lateral neck lymph node dissection and right thyroidectomy and re-implant of parathyroid gland on 2020/04/28
    • Hypo-osmolality and hyponatremia
    • Abnormal results of liver function studies
    • Anemia in chronic kidney disease
    • Hypoalbuminemia
    • Hyperbilirubinemia
  • CC
    • for 2nd adjuvant chemotherapy
  • Present illness
    • This 55-year-old post menopausal woman has
      • Hypertension
      • Type 2 Diabetes Mellitus
      • Chronic kidney disease stage 5 status post implantation of continuous ambulatory peritoneal dialysis catheter on 2022/08/01
      • Uterine myoma status post
      • Bilateral thyroid papillary carcinoma, pT1aN0M0, stage I
      • Coronary artery disease with medicine control
      • Gallbladder stones status post.
    • She denied any TOCC histories in recent 3 months.
    • She was diagnosed with right breast cancer then underwent of right partial mastectomy and sentinel lymph node biopsy on 2023/05/30. The finally pathlogy revealed invasive carcinoma, pT1N0M0 stage IA. IHC revealed ER (Ab): Positive, PR (Ab): Negative, HER-2/Neu (Ab): Negative, Ki-67: 20%. Tc-99m MDP whole body bone scan showed no obvious lesion for metastasis.
    • Under the impression of right breast cancer, pT1cN0M0 stage IA, she was admitted to our ward for 2nd adjuvant chemotherapy.
  • Course of inpatient treatment
    • After admission, 5-Fu 1047mg in Saline 100ml, Lipodox 55mg in Saline 250ml and Endoxan 800mg in saline 500ml were administered. There was no special complaint. Under the stable condition, she was discharged today and will be arranged next course adjuvent chemotherapy 3 weeks later.
  • Discharge prescription
    • Emend (aprepitant 125mg) 1# QD
    • Limeson (dexamethasone 4mg) 1# BID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Through (sennoside 12mg) 2# PRNHS
    • Sinpharderm Cream (urea) BID TOPI
• 2023-07-20 SOAP Cardiology
  • Prescription x3
    • Cardiolol (propranolol 10mg) 1# BID
    • Nirandil (nicorandil 5mg) 1# BID
    • Bokey (aspirin 100mg) 1# QD
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID

[consultation]

• 2023-05-31 Nephrology
  • Q
    • This is a 55 years old female patient. She was under PD in our hospital. This time, she was admitted for surgery of partial mastectomy + SLNB on 2023/05/30. We need your consult for combine care. Thank you so much!!
  • A
    • We will arrange PD for the patient during the course of hospitalization.
    • If you need to remove more or less water, please feel free to contact us.
• 2022-08-16 Urology
  • Q
    • For Tenckhoff catheter insertion.
    • This 54-year-old woman has history hypertenion under medical control for 20 years, diabetes mellitus under medical control for 20 years, chronic kidney disease, stage V, thyroid papillary carcinoma s/p left thyroidectomy and parathyroid hyerplasia s/p parathyroidecotomy of left side.
    • Due to progression renal function failure was noted (01/20, Cr: 4.68 mg/dl => 03/17, Cr: 7.32 mg/dl => 6/07, Cr:9.24 mg/dl => 7/05, Cr:9.71 => 8/16, Cr:14.66mg/dl ). Prepare Tenckhoff catheter insertion was suggested for prepare Peritoneal dialysis. After well explained his condition to the patient and his family, she was admitted for further management.
  • A
    • We will arrange PD tube insertion tomorrow, thank you!

[chemotherapy]

• 2023-09-01 - fluorouracil 600mg/m2 1049mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-08-11 - fluorouracil 600mg/m2 1047mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-07-20 - fluorouracil 600mg/m2 1047mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-06-27 - fluorouracil 600mg/m2 1070mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-09-26

[anemia]

The last dose of FAC regimen was administered on 2023-09-01 and blood transfusion was performed on the same day, after almost 4 weeks on 2023-09-25 HGB was still below 7g/dL. The recovery of hematopoietic capacity may not be able to catch up, if anemia becomes symptomatic or considered severe, additional blood transfusion might be needed.

2023-09-25 HGB 6.4 g/dL
2023-09-22 HGB 6.8 g/dL
2023-09-01 HGB 6.0 g/dL

[oral mucositis]

For oral mucositis, ASCO recommends using normal saline or salt and soda rinses, 2% viscous lidocaine swish and spit, modifying the diet, using 2% morphine mouthwash swish and spit, and administering systemic opiates based on increasing symptom burden. Ref: Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020;16(3):103-109. doi:10.1200/JOP.19.00652

The patient may benefit from using Nincort Oral Gel (triamcinolone acetonide) as a means of relieving symptoms. Additionally, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available at this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).

2023-09-05

[anemia]

• Recent HGB lab results
  • 2023-09-01 HGB 6.0 g/dL
    
  • 2023-08-26 HGB 6.0 g/dL
    
  • 2023-08-11 HGB 6.2 g/dL
    
  • 2023-07-31 HGB 5.8 g/dL
    
  • 2023-07-20 HGB 6.8 g/dL
    
  • 2023-07-04 HGB 7.2 g/dL
    
  • 2023-06-26 HGB 8.1 g/dL
• The patient received blood transfusions on 2023-08-11 and 2023-09-01 due to low hemoglobin levels.

2023-08-15

[anemia]

• Recent HGB lab results
  • 2023-08-11 HGB 6.2 g/dL
    
  • 2023-07-31 HGB 5.8 g/dL
    
  • 2023-07-20 HGB 6.8 g/dL
    
  • 2023-07-04 HGB 7.2 g/dL
    
  • 2023-06-26 HGB 8.1 g/dL
• In the table above, the patient received FAC (lipo) on both 2023-07-20 and 2023-08-11. In addition, a blood transfusion was performed on 2023-08-11 (a previous transfusion was performed on 2023-05-30). Following the transfusion, the patient’s HGB (hemoglobin) level is expected to have increased.

[restaging]

On 2023-05-31, a bone scan indicated the need for further monitoring of an active spot in the mid-T spine and heightened activity in the L2-4 spines to ascertain potential bone metastasis. Furthermore, an abdominal sonography on 2023-07-21 showed a slight presence of ascites. If the disease is ultimately confirmed to have metastasized, restaging may be necessary.

2023-07-24

[anemia]

• Recent HGB lab results

  • 2023-07-20 HGB 6.8 g/dL
    
  • 2023-07-04 HGB 7.2 g/dL
    
  • 2023-06-26 HGB 8.1 g/dL
    
  • 2023-06-20 HGB 8.0 g/dL
    
  • 2023-06-01 HGB 8.6 g/dL

• This patient received two cycles of FAC (5FU + LipoDox + Endoxan) on 2023-06-27 and 2023-07-20. Prior to treatment, the hemoglobin (HGB) level remained above 8 g/dL, but after the first cycle, the level decreased to 7.2 g/dL and further decreased to 6.8 g/dL on the day of the second cycle administration.

• Pegylated liposomal doxorubicin is known to be associated with anemia (grade 3: 5%, grade 4: <1%), and anemia is also common in patients receiving cyclophosphamide and/or fluorouracil.

• As the patient has end-stage renal disease (ESRD) with impaired hematopoietic function, appropriate administration of epoetin alfa is required in addition to iron supplementation. In emergency situations or as needed, blood transfusion should still be considered to maintain hemoglobin levels.

700930475

230925

[MedRec]

• 2023-09-15 SOAP Hemato-Oncology Gao WeiYao
  • A
    • Suspected metastatic malignant tumor of left neck
    • Recurrent squamous cell carcinoma of left buccal mucosa, pT4aN0M0, psatge IVa post of operation with close surgical margin (2023) status post CCRT and target therapy
    • S/P NG feeding (20230915)
  • P
    • symptom relief
    • patient has already signed the DNR
    • SUGGEST admission for chemotherapy and explained the risk of palliative chemotherapy.
• 2022-11-10 ~ 2022-11-14 POMR Oral and Maxillofacial Surgery He ChengHan
  • Discharge diagnosis
    • Squamous cell carcinoma of left buccal mucosa, cT3N0M0 post of operation on 2022.
    • Squamous cell carcinoma of left face skin, cT1NxMx, ctsage I post of excision of the soft tissue tumor on the left chin area on 2022/11/11.
    • Squamous cell carcinoma of left buccal mucosa, pT1N0M0 post of operation on 2015.
    • Essential (primary) hypertension
    • Type 2 diabetes mellitus
    • Hyperlipidemia
  • CC
    • A firm mass of my left chin area for 3 months were noted .
  • Present illness
    • This 70 years-old male patient suffered from skin pigmentation of left face with local indurated mass on the left lower face and admitted to ward for surgery intervention.
    • According to his statement, he had was received series of treatment such as
      • 1. Squamous cell carcinoma of left buccal mucosa, pT1N0M0 s/p operation on 2015/08/31.
      • 2. Scar contracture of left buccal mucosa s/p operation on 2016/01/20, 2016/06/20 and 2016/08/31.
      • 3. Squamous cell carcinoma of left buccal mucosa, cT3N0M0 post of operation on 2022, with PNI invasion and close surgical margin.
    • He received post-op finished CCRT were also noted since 2022/03 ~ 2022/05. Then he is regular followed up to our O.S clinic.
    • This time, he found a firm skin skin around the left mouth angle for several mouths without infection sign or abnormal sensation. After discuss with himself and he was admitted to ward for further managemen.
  • Course of inpatient treatment
    • After admission, we had arrange operation and evaluation anesthesia was done. He received excision of the soft tissue tumor on the left chin area under GA on 2022/11/11. Postoperatively, empirical antibiotic agent with Cefa 1g q8h was prescribed. Intraoral and extraoral wound change dressing qd. Mouth gargling with Parmason solution q2h and cool high protein soft diet were educated. The frozen report showed SCC. We had well explained to patient the condition and choice of treatment options.
    • Because his general condition was acceptable after the this operation, he was discharged this morning and OPD follow up.
  • Discharge prescription
    • amoxicillin 250mg 2# Q8H
    • UFT (tegafur 100mg, uracil 224mg) 2# BID
• 2017-03-02 SOAP Oral and Maxillofacial Surgery Xu BoZhi
  • Diagnosis
    • Malignant cheek mucosa neoplasm [C06.0]
• 2017-01-31 SOAP Metabolism and Endocrinology Guo XiWen
  • Diagnosis
    • DM w/o mention of complication, IDDM Type, juvenile type, uncontrolled [E10.65]
    • Essential hypertension , malignant [I10]
    • Mixed hyperlipidemia [E78.2]
  • Prescription
    • Preterax (perindopril 2mg, indapamide 0.625mg) 1# BID
    • Januvia (sitagliptin 100mg) 1# QD
    • Uformin (metformin 500mg) 1# TIDCC
    • NovoNorm (repaglinide 1mg) 3# TIDAC

[chemotherapy]

• 2023-06-28 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
  • dexamethasone 4mg + diphenhydramine 30mg
• 2023-06-21 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
  • dexamethasone 4mg + diphenhydramine 30mg
• 2023-06-08 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
  • dexamethasone 4mg + diphenhydramine 30mg
• 2023-05-31 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
  • dexamethasone 4mg + diphenhydramine 30mg
• 2023-05-19 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
  • dexamethasone 4mg + diphenhydramine 30mg
• 2023-05-12 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
  • dexamethasone 4mg + diphenhydramine 30mg
• 2023-05-05 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
  • dexamethasone 4mg + diphenhydramine 30mg
• 2023-04-28 - cetuximab 250mg/m2 400mg 2hr + cisplatin 28mg/m2 50mg NS 500mL 3hr (Erbitux + cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-04-19 - cetuximab 400mg/m2 700mg 2hr + cisplatin 40mg/m2 70mg NS 500mL 3hr (Erbitux + cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-12-08 - docetaxel 40mg/m2 70mg NS 150mL 1hr D1 + cisplatin 40mg/m2 70mg NS 250mL 3hr D1 + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr D2 + leucovorin 100mg/m2 170mg in 5-FU (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-11-30 - docetaxel 40mg/m2 70mg NS 150mL 1hr D1 + cisplatin 40mg/m2 70mg NS 250mL 3hr D1 + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr D2 + leucovorin 100mg/m2 170mg in 5-FU (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-05-04 - carboplatin AUC 2 150mg NS 300mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-04-25 - carboplatin AUC 2 150mg NS 300mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-04-19 - carboplatin AUC 2 150mg NS 300mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-04-13 - carboplatin AUC 2 150mg NS 300mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-03-28 - carboplatin AUC 2 150mg NS 300mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-03-18 - carboplatin AUC 2 150mg NS 300mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

==========

701230006

230925

[MedRec]

• 2023-08-24 SOAP Neurology Chen PeiYa
  • Prescription x3
    • Lixiana (edoxaban 30mg) 0.5# QD
    • Actein (acetylcysteine 600mg) 1# QD
    • Through (sennoside 12mg) 1# HS
    • Lanoxin (digoxin 0.25mg) 0.5# QD
    • Mesyrel (trazodone 50mg) 0.5# HS
• 2023-07-28 SOAP Hemato-Oncology Gao WeiYao
  • S: The aged man was admitted for severe thrombocytopenia, but his family refused bone marrow exam during his hospitalization.
  • A:
    • Thrombocytopenia, unspecified
    • Heart failure, unspecified
    • Unspecified atrial fibrillation
• 2023-07-23 ~ 2023-07-24 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Severe thrombocytopenia. nature to be determined.
    • Heart failure, unspecified
    • Unspecified atrial fibrillation
  • CC
    • generalized petechiae over 4 limbs for few days noticed
  • Present illness
    • This 94y/o male has past medical history of
      • Right MCA infarct s/p rt-PA
      • NSTEMI, Af with heart failure
    • This time, generalized petechiae over 4 limbs for few days noticed. Thus he was sent to ER for help. At ER, he denied trauma and any discomforts, except took medicine: edoxaben, cephalexin last week for toe infection, and chinese herbs for a while. Lab show WBC = 8.23 x10^3/uL; HGB = 12.0 g/dL; PLT = 2 x10^3/uL (5/2 PLT 159k). PT and aPTT is in normal range, thus r/o coagulation disorders. Under the impression of isolated thrombocytopenia, he is admitted for further survey.
  • Course of inpatient treatment
    • After admission, patient was arranged for LRP transfusion and repeating the complete blood count (CBC) and reviewing the peripheral blood smear, obtaining prior platelet counts if available, and assessing other hematologic abnormalities. We have consulted hospice care for families at the same time but there was no indication for hospice share care at current unless complication of thrombocytopenia in future. After explained the risk and benefit of bone marrow aspiration for families, they still refused for it and AAD was registered.
• 2020-02-14 ~ 2020-03-23 POMR Neurology Chen PeiYa
  • Discharge diagnosis
    • Cerebral infarction, unspecified
    • Right middle cerebral artery territory large infarction post r-tpa (2020-02-14), with hemorrhagic transformation , follow by brain MRA on 2020-02-17
    • Modified ranking scale 4
    • Non-ST elevation (NSTEMI) myocardial infarction
    • Heart failure
    • Atrial fibrillation
    • Pneumonia
  • CC
    • Acute onset speechlessness and left limbs weakness for 1 day
  • Present illness
    • This 91-year-old male patiet denied of any past medical history. However, he fell down about half an year ago and poor gait was noted since then.
    • On 2/14 he was still normal around 7:00am. However, acute onset left limbs weakness was noted around 7:30am while he was in toilet. He was brought to ER.
    • For acute CVA call, neurologist was consulted. Initial NIHSS was 15 and right MCA infarction was impressed. For no contraindication of rt-PA therapy, IV TPA therapy was given at 10:00am. However, due to suspicious pulmonary edema and severe edema over bilateral legs were found, IAT was held due to high risk and possibilty of difficulty ET extubation. Initial EKG revealed AFIB RVR with unspecific TWI at lateral lead, and lab survey showed elevated trop-I (hs-Troponin I = 1600.6 ). CV doctor also consulted at ER and the impression and suggestion were NSTEMI with acute pulmonary edema and (AFIB, CHA2DS2-Vas = 4), follow-up cardiac enzymes and cardia echo, with gentle negative I/O therapy.
    • Hence he was admitted to neurology ICU for intensive monitor under impression of (1) Right MCA infarction s/p tPA therapy, (2) r/i NSTEMI with acute pulmonary edema, (3) Atrial fibrillations (CHA2DS2-Vas =4).
  • Course of inpatient treatment
    • During SICU stay, we closely monitored BP and gave adequate IV hydration to keep perfusion. Famotidine was used for stress ulcer prevention.
    • For NSTEMI, we followed once cardiac enzymes which showed improvement (Troponin I: 1600(ER)>1615), and clinically no chest discomfort were complained.
    • For Pulmonary edema and bilateral lower limbs pitting edema (3+~4+), we gave Lasix IV to keep I/O balance and added aldactin for hypokalemia.
    • Repeated brain CT on 2/15 showed no ICH and therefore we added aspirin. However, brain MRI on 2/17 disclosed right MCA large infarction with hemorrhagic transformation and thus Bokey was discontinued.
    • Digoxin #1 QD was given initially for AfRVR, and the dosage was tapered since 2/21 for bradyarrythmia. His spirit was rather lethargic since 2/17 but yet could still maintain GCS E3-4V4M6.
    • For hypoalbuminemia, we suggested transient self-paid albumin therapy (2/22~2/24) and the family agreed.
    • With relatively stablized condition, the patient was transfered to ward for further management on 2/24.
    • After transfer to ward, the patient was still presented with exertional dyspnea and positive I/O. We discussed with cardiologist for NSTEMI and associated heart failure management.
    • Busix was used to replace Lasix and Concor will be considered later if indicated.
    • With diuretics treatment, pulmonary edema was much improved and the patient could take off oxygen supplement.
    • For antiplatelet resumption, we repeated brain CT to follow up hemorrhagic transformation on 3/2 and then added back Plavix 1# QD for no hemorrhage noted.
    • For more stable condition, we used Lixiana 30 mg 1# QD since 3/13 for better stroke prevention.
    • Rehabilitation and acupuncture therapy were arranged.
    • However left hip pain at certain position was noted when doing rehabilitation activity and fell down history about 6 months ago was mentioned.
    • We did left hip plain film on 3/11 and found partial union of left femoral neck fracture. Orthopedist was consulted and suggested pain control and rehabilitation as usual CVA patient without indication for operation.
    • On 3/12 morning the patient complained chest tightness when rehabilitation, we arranged associated survey in case of heart ischemia but the results were normal.
    • In the afternoon we explained all the associated condition to the family and disccused about future discharge plan which would be PAC plan.
    • During the last week before discharge, we tried to taper diuretics and discussed with cardiologist to make sure heart condition. Follow-up laboratory survey and CXR showed fair results.
    • With stablized and improved condition, he was discharged on 2020/03/23 with oral medication and will be transferred to other hospital for intensive rehabilitation under PAC plan.

==========

2023-09-25

Mesyrel (trazodone) is the only oral medication on the list of active medications that can be fed by tube.

701486100

230921

[lab data]

2023-06-27 Anti-HBc Reactive
2023-06-27 Anti-HBc-Value 1.04 S/CO
2023-06-27 Anti-HCV Nonreactive
2023-06-27 Anti-HCV Value 0.10 S/CO
2023-06-27 Anti-HBs 229.48 mIU/mL
2023-06-27 HBsAg Nonreactive
2023-06-27 HBsAg (Value) 0.32 S/CO

[exam findings]

• 2023-09-15 Bronchodilator Test
  • mild restrictive ventilatory impairment with small airway disease, FEV1/FVC = 76%, FVC = 62 -> 58%, FEV1 = 59 -> 52% , MMEF 44 -> 29%
• 2023-09-08 CT - abdomen
  • History:
    • Beta-Thalassemia: IVS-2nt 654 (C to T), heterozygous
    • Hypertension. Thyroid ca post-thyroidectomy in 2017
    • Rectosigmoid colon cancer with para-aortic LAP cT3N2bM1a, stage IVA s/p LAR on 2020-03-31 at FuRen Univ Hospital, s/p FOLFIRI & A-FOLFOX
    • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
    • 20230522 CT: R/O multiple metastatic LNs in abdomen and pelvis.
    • 20230627 CT-guided biopsy: Metastatic adenocarcinoma, colon origin.
    • 20230721 CT: multiple metastatic LNs in abdomen and pelvis show progressive disease.
  • Findings: Comparison prior CT dated 2023/07/21.
    • Prior CT identified multiple metastatic nodes in para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain, and bilateral internal iliac chain are noted again, decreasing in size.
      • It is c/w multiple metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
    • S/P LAR with autosuture retention over the rectum.
    • S/P cholecystectomy.
    • There is a small poor enhancing lesion 6 mm in the spleen. Follow up is indicated.
    • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
  • Impression:
    • Multiple metastatic nodes S/P C/T show partial response.
• 2023-07-21 CT - abdomen
  • Imp: Prior CT identified multiple metastatic nodes in para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain, and bilateral internal iliac chain are noted again, increasing in size. please correlate with clinical condition.
• 2023-06-27 Patho - lymph node region resection
  • Lymph node, plevis, left, CT-guide biopsy — Metastatic adenocarcinoma, in favor of colorectal origin
  • Microscopically, it shows lymphoid tissue with presence of nests of metastatic adenocarcinoma.
  • Immunohistochemical stain of CK20 is positive at tumor cells.
• 2023-06-09 Gynecologic ultrasonography
  • R/O Bilateral Ovarian cyst
  • Uterine myoma

[MedRec]

• 2023-07-17 SOAP Hemato-Oncology Xia HeXiong
  • S
    • << GS-US-570-6015 (IRB No: 11-FS-150) ICF Process >>
      • The subject has been provided the informed consent form (GS-US-570-6015_site 17413_Main ICF V6.1.1_02May2023_Chinese) and were fully explained the content of the informed consent form on 2023/07/14 by investigator and study Coordinator. The subject had enough time to ask all questions regarding the study. The subject brought the consent form back to consider whether to participate.
      • The subject understood the (GS-US-570-6015_site 17413_Main ICF V6.1.1_02May2023_Chinese) and signed on 2023/07/17. A copy of the signed informed consent form was provided to the subject.
      • GS-US-570-6015_Emergency Medical Support and Subject Card_v2.0_04May2022_ZH-TW has dispensed to subject on 2023/07/17 by PI/SC.
  • O
    • 2023.07.17
      • Subject No.: 17413101_initial: BLS
      • Ethnicity: Not Hispanic or Latino
      • Race: Asian
      • Country: TAIWAN
      • Never use alcohol
      • Never use tobacco
      • BH : 156.1 cm / BW : 71.9 Kg
      • Vital signs (assessed in a seated position after resting): 35.9’C/72/20 BP: 119/70 mmHg at 09:44 AM
      • Physical Examination:
        • Head, eyes, ears, nose and throat - Normal, specify
          
        • Cardiovascular - Normal, specify
        • Dermatological - Normal, specify
          
        • Musculoskeletal - Normal, specify
          
        • Respiratory - Normal, specify
          
        • Gastrointestinal - Intermittent diarrhea and abdominal distention
          
        • Neurological system - Normal, specify
          
      • ECOG Performance Status: 0
      • Childbearing Potential: NA, menopause around 52 years.
      • Collect 12-lead ECG at 09:41 AM
      • Collect central Hematology & Coagulation & Chemistry &
      • Endocrine function and basal cortisol & Hepatitis serology & HIV serology at 08:53 AM
      • Collect U/A at 09:50 AM
  • P
    • 2023.07.17
      • Anticipate to arrange the freshly cut unstained FFPE slides on 2023.07.17.
      • Arrange Neck & Chest & Abd & Pelvis CT on 2023.07.21.
    • Actein for prevention of contrast-induced nephropathy.
  • Prescription
    • Actein Effervescent (acetylcysteine 600mg) 1# BID 4D, use 2 days before CT from 2023-07-19 to 2023-07-22
• 2023-07-12 SOAP Hemato-Oncology Xia HeXiong
  • S: CRC with multiple LNs mets s/p OP and C/T
  • O: 2023/06/27 HGB = 8.3 g/dL
  • P: Blood transfusion with pRBC
  • Prescription
    • Benamine (diphenhydramine 30mg/amp) ST IVD before blood transfusion
    • furosemide 20mg ST IVD after 2U pRBC
    • NS 500mL ST IVD for drug and blood transfusion
    • Hepac Lock Flush 100 USP units/mL 10mL ST IRRI
• 2023-06-27 ~ 2023-06-28 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Rectosigmoid colon ca with para-aortic LAP CT3N2bM1a, stage IVA s/p LPS LAR on 2020-03-31, pT3N2bM1a, stage IVA (21/22), EGFR positive, KRAS: wild type, s/p FOLFIRI & A-FOLFOX 
    • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
    • Essential (primary) hypertension
    • Type 2 diabetes mellitus without complications
    • Chronic diarrhea
    • Chronic viral hepatitis B without delta-agent
  • CC
    • for CT guide biopsy of left plevis LNs
  • Present illness
    • The 64 years-old woman has past history of
      • Beta-Thalassemia: IVS-2nt 654 (C to T), heterozygous
      • Hypertension. Thyroid ca post-thyroidectomy in 2017
      • Rectosigmoid colon cancer with para-aortic LAP CT3N2bM1a, stage IVA s/p LPS LAR on 109-3-31, pT3N2bM1a, stage IVA (21/22), EGFR positive, KRAS: wild type (2020), s/p FOLFIRI & A-FOLFOX
      • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
    • In the beginning, she suffered from bloody stool for 1 years on 2020/03, visited to FuRen University Hospital, colonoscopy was done showed Rectosigmoid colon tumor, s/p biopsy showed tubulovillous adenocarcinoma with high grade dysplasia at least. Chest to pelvic CT was done on 2020/03/28 showed CRC cT3N26M1a (para-A LN) stage IVA, s/p laparoscopic LAR: mod-differentiated LN (21/22) pT3N2bMx on 2020/03/31. She received chemotherapy with FOLFIRI x 8 (no avastin ?) from 2020/04/22 ~ 08/20. 2020/11/10 CEA / Ca-199 4.45 / 14.4. CT guide biopsy was done on 2020/11/12 showed adenocarcinoma, CK7, TTF-1(+), (-)CK20 & CDX2, c/w primary lung adenocarcinoma.
    • Follow up bone scan on 2020/12/09 showed focal uptake in ant aspec of Lt 4th rib. Chest to abd CT was done on 2021/01/25 showed post OP change of RUL no liver mets. PET was done on 2021/03/15 showed PD in left lower neck & mediastinal, paraaortic to elvic LN, rTON2M1a. Bone scan was done on 2021/03/17 showed 1. No apparently interval changes in areas mentioned above, benign natures could be considered first. Follow up Colonoscopy on 2021/11/15 showed polyps, and the Pathology showed adenocarcinoma, Hyperplastic. CT image was folloe up on 2022/02/08 showed LAP in PD. Then, she received capecitabine, C1D1 on 2021/11/06 ~. Denied TOCC history in recent three months. Accroding to the CT image at Taipei Medical University Hospital on 2023/05, report showed progression of pelvis LNs was found. This time, she admitted to our ONC ward for CT guide biopsy of left pelvis LNs on 2023/06/27.

[consultation]

• 2023-06-28 Diagnostic Radiology
  • Q
    • The patient is an 64-year-old female with a history of colon cancer s/p in 2020 (TMUH), HTN, DM, Lung adenocarcinoma s/p in 2021 (TMUH), Thyroid cancer s/p in 2016 (XiYuan Hospital), Lymphoma of the left neck.
    • For CT guide biopsy of pelvis LNs, we need your further evaluation and management. Thanks a lot!!!
  • A
    • Dear Dr.: According to the clinical condition and imaging findings, biopsy is indicated.

[immunochemotherapy]

• 2023-09-12 - GS-1811 10mg 0.4mL D5W 99.6mL 1hr + zimberelimab 360mg 12mL D5W 238mL 1hr
  • acetaminophen 500mg PO (1hr before GS-1811)
• 2023-08-22 - GS-1811 10mg 0.4mL D5W 99.6mL 1hr + zimberelimab 360mg 12mL D5W 238mL 1hr
  • acetaminophen 500mg PO (1hr before GS-1811)
• 2023-08-01 - GS-1811 10mg 0.4mL D5W 99.6mL 1hr + zimberelimab 360mg 12mL D5W 238mL 1hr

==========

2023-09-21

The lab data indicate an elevated TSH, decreased T3, normal T4, and normal Thyroglobulin levels. This could potentially suggest a subclinical hypothyroidism. It’s noted that there are no records of hypothyroidism in this patient’s history in HIS5. Is there a connection to GS-1811?

2023-09-15 TSH (NM) 9.395 uIU/ml 2023-09-15 Free T4 (NM) 1.165 ng/dl 2023-09-15 T3 (NM) 66.083 ng/dl 2023-09-15 Thyroglobulin 0.322 ng/ml

2023-08-24 TSH (NM) 25.789 uIU/ml 2023-08-24 Free T4 (NM) 1.337 ng/dl 2023-08-24 T3 (NM) 87.021 ng/dl 2023-08-24 Thyroglobulin <0.3 ng/ml

2023-07-31

[prophylactic antiviral therapy prior to immunosuppressive agent use]

The patient’s hepatitis B serology results were as follows: HBsAg (-), anti-HBc (+), anti-HBs (+), indicating that she is immune due to natural infection but remains at risk for reactivation if exposed to immunosuppressive agents.

• 2023-06-27 Anti-HBc Reactive
  
• 2023-06-27 Anti-HBc-Value 1.04 S/CO
  
• 2023-06-27 Anti-HBs 229.48 mIU/mL
  
• 2023-06-27 HBsAg Nonreactive
  
• 2023-06-27 HBsAg (Value) 0.32 S/CO

Given this information, if immunosuppressive agents are part of the treatment plan, it is recommended that prophylactic antiviral therapy be considered. Options include either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD. This preventive measure can help reduce the risk of possible reactivation of HBV infection due to the immunosuppressive effects of treatment.

• ref: Pharmacy FAQ - Hepatitis B reactivation and screening. http://www.bccancer.bc.ca/pharmacy-site/Documents/Pharmacy%20FAQs/Pharmacy-FAQ-Hepatitis-B.pdf

701485811

230919

[exam findings]

• 2023-07-04 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 31 dB HL; LE 40 dB HL.
  • RE normal to moderate SNHL.
  • LE normal to moderately severe SNHL but have A-B gap at 4k Hz.
• 2023-06-10 MRI - larynx
  • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T: T3(T_value) N: N3(N_value) M: M0(M_value) STAGE: IVB(Stage_value)
• 2023-06-09 PET scan
  • Glucose hypermetabolism in the left hypopharynx, compatible with primary hypopharyngeal malignancy.
  • Glucose hypermetabolism in a focal area in the left neck level II to III regions, compatible with a metastatic lymph node.
  • Mild glucose hypermetabolism around bilateral hips. Post-operative change may show this picture.
  • Increased FDG uptake/accumulation in bilateral inguinal regions. The nature is to be determined (hernia? other nature?). Please correlate with other clinical findings for further evaluation.
• 2023-06-08 Patho - larynx biopsy
  • Hypopharynx, left, biopsy — Squamous cell carcinoma, moderately differentiated
  • The sections a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident.
• 2023-06-08 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A (minimal)
  • Superficial gastritis, s/p CLO test
  • Gastric erosions, multiple
  • Duodenal shallow ulcers, bulb, SDA
• 2023-06-08 SONO - abdomen
  • Suspected chronic liver parenchyma disease
  • Suspected fatty infiltration of pancreas
  • Suboptimal examination of liver,especially the subcostal view due to poor echo window
• 2023-06-07 CXR
  • Degenerative joint disease of T-spine with marginal osteophytes.
• 2023-06-07 Nasopharyngoscopy
  • left hypopharyngeal tumor, s/p biopsy under flexible laryngoscope with working channel

[MedRec]

• 2023-09-11 SOAP Oral and Maxillofacial Surgery He ChengHan
  • O - Panoramic findings:
    • Missing: 11, 14, 15, 16, 17, 18, 21, , 25, 26, 27, 28, 31, 32, 34, 35, 36, 37, 38, 41, 46, 47, 48
      
    • Impaction: nil
      
    • Crown and Bridge: nil
      
    • Caries: 24, 33, 41, 45
      
    • Residual root: 12, 22
    • Periodontal condition: chronic periodontitis
  • P
    • Take panoramic film for evaluation
    • Explain the findings
    • well inform the risk of radiation-related infection if not extract hopelss tooth (The patient and family members indicated understanding and chose not to extract the tooth.)
• 2023-09-08 SOAP Radiation Oncology Wang YuNong
  • Plan: He will visit OS Dr. Ho next Mon. CT-simulation will be arranged 1 wk after the last teeth extraction (if indicated). Plan to deliver 50 Gy/ 25 fx to the bil. neck and hypopharynx. Then boost the hypopharyngeal tumor and LAPs to 70 Gy/ 35 fx. Need to arrange admission for CCRT.
• 2023-08-15 SOAP Hemato-Oncology Xia HeXiong
  • P: On 2023-08-15, May consider CCRT with carboplatin. Wife would like to consider proton. After his condition is better, will start CCRT.
• 2023-08-08 SOAP Hemato-Oncology Xia HeXiong
  • O
    • Cancer Treatment, Radiation/Targeted Therapy Side Effects Assessment (2023-08-08)
      • Physical Condition: G3: Bedridden for over 50% of the time while awake
        • Management of Physical Condition: Supportive therapy
      • Other: Grade 4 ammonia (NH3) elevation. Hepatic encephalopathy
        • Lab (suppl.)
          • 2023-07-10 Blood ammonia 26 umol/L
            
          • 2023-07-07 Blood ammonia 49 umol/L
            
          • 2023-07-06 Blood ammonia 418 umol/L
            
          • 2023-07-06 Blood ammonia 733 umol/L
• 2023-06-13 SOAP Hemato-Oncology Xia HeXiong
  • A: left hypopharyngeal cancer, cT3N3bM0, stage IVb
  • P: explanation about induction chemotherapy +- CCRT or CCRT, op not recommended because left LAP attached on left ICA
    • After SDM (Induction C/T or CCRT), patient would like to take induction chemotherapy.

[chemotherapy]

• 2023-07-04 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + carboplatin AUC 5 300mg NS 250mL 2hr D2 + fluorouracil 1000mg/m2 1700mg D5W 500mL 24hr D2-5 (TPF, Q3W)
  • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4

==========

2023-07-05

[renal dose for carboplatin, metoclopramide and cimetidine]

2023-07-04 Cre 1.56mg/dL, eGFR 46.6, weight 75.9kg => CrCl 45mL/min. The patient has kidney impairment, which might necessitate dose adjustments for some medications in the active list:

• Carboplatin (in TPF regimen): For patients with a CrCl between 10 and 50 mL/minute, it’s recommended to administer approximately 50% of the usual dose (Aronoff 2007).
• Metoclopramide: For patients with a CrCl between 10 and 60 mL/minute, it’s recommended to administer approximately 50% of the usual total daily dose.
• Cimetidine: For patients with a eGFR between 10 and 50 mL/minute, it’s recommended to administer 50% of the normal dose (Aronoff 2007).

Please review the dosages and clinical conditions accordingly to ensure safe and effective therapy for the patient.

700523579

230918

[exam findings]

• 2023-09-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (177 - 135) / 177 = 23.73%
    • M-mode (Teichholz) = 24
  • Conclusion:
    • Dilated LA, LV, RA, RV and IVC; severely abnormal LV systolic function with global hypokinesia
    • Mild to moderate MR, mild TR and mild PR
    • Minimal pericardiac effusion
    • Preserved RV systolic function

==========

2023-09-19

According to the PharmaCloud database, this patient has received Glivec (imatinib) prescribed at Cardinal Tien Hospital for at least the last 3 months. BCR-ABL tyrosine kinase inhibitors, such as imatinib, dasatinib, nilotinib, bosutinib, ponatinib, and asciminib, have been associated with varying degrees of cardiovascular adverse reactions. Taking imatinib as an example, its incidence includes chest pain (7% to 11%), edema (11% to 86%; severe edema: 2% to 11%), peripheral edema (20% to 41%), cold extremity (≤1%), flushing, heart failure (≤1%), hypertension (4%), hypotension (≤1%), palpitations (5%), pericardial effusion (≤6%), Raynaud’s disease (≤1%), subdural hematoma (≤1%), syncope (≤1%), tachycardia (≤1%), and <1%: acute myocardial infarction, angina pectoris, atrial fibrillation, cardiac arrhythmia, left ventricular dysfunction (ref: UpToDate). The discontinuation of the drug is considered to be appropriate in this case (LVEF 24%).

2023-09-18

Imatinib has been associated with various cardiovascular side effects, including: chest pain (7% to 11%), edema (11% to 86%; severe edema: 2% to 11%), peripheral edema (20% to 41%), cold extremity (≤1%), flushing, heart failure (≤1%), hypertension (4%), hypotension (≤1%), palpitations (5%), pericardial effusion (≤6%), Raynaud’s disease (≤1%), subdural hematoma (≤1%), syncope (≤1%), tachycardia (≤1%) and <1%: acute myocardial infarction, angina pectoris, atrial fibrillation, cardiac arrhythmia, left ventricular dysfunction.

It’s important to note that other drugs in the same class as imatinib may also have cardiovascular adverse reactions.

• Dasatinib: >10%: peripheral edema, cardiac conduction disturbance (7%; including cardiac arrhythmias [tachycardia, ventricular arrhythmia, ventricular tachycardia] and palpitations), cardiac disorder (≤4%; including cardiomyopathy, heart failure, left ventricular dysfunction, ischemic heart disease, reduced ejection fraction), chest pain, edema (1% to 4%), flushing, hypertension, pericardial effusion (1% to 4%), prolonged QT interval on ECG (≤1%) and <1%: Abnormal T waves on ECG, acute coronary syndrome, angina pectoris, cardiomegaly, coronary artery disease, deep vein thrombosis, embolism, hypotension, livedo reticularis, myocarditis, pericarditis, pleuropericarditis, prolongation P-R interval on ECG, pulmonary embolism, syncope, thrombophlebitis, thrombosis, troponin increased in blood specimen.

• Nilotinib: hypertension (10% to 11%), occlusive arterial disease (9% to 15%; including limb stenosis), peripheral edema (9% to 15%), prolonged QT interval on ECG (children and adolescents: >30 msec from baseline: 28%; adults: >60 msec from baseline: 4%; adults: >500 msec: <1%), angina pectoris, cardiac arrhythmia (including AV block, atrial fibrillation, bradycardia, cardiac flutter, extrasystoles, and tachycardia), cerebral ischemia (1% to 3%), chest discomfort, chest pain, flushing, ischemic heart disease (5% to 9%), palpitations, pericardial effusion (≤2%), peripheral arterial disease (3% to 4%) and <1%: Acute myocardial infarction, arteriosclerosis, cardiac failure, cerebral infarction, coronary artery disease, coronary artery disease, facial edema, heart murmur, hypertensive crisis, intermittent claudication, ischemic stroke, syncope, transient ischemic attacks.

• Bosutinib: chest pain (8% to 12%), edema (15% to 19%), hypertension (8% to 11%), coronary artery disease (3%), heart failure (2% to 5%), pericardial effusion, prolonged QT interval on ECG and <1%: Pericarditis.

• Ponatinib: cardiac arrhythmia (17% to 25%; ventricular arrhythmia: 3%), edema (≤41%), heart failure (6% to 16%), hypertension (31% to 53%; severe hypertension: 3% to 13%), occlusive arterial disease (13% to 31%; including carotid, vertebral, and middle cerebral artery and renal artery stenosis), peripheral edema (17%), acute myocardial infarction (2%), atrial fibrillation (8%), bradycardia (≤1%; including leading to pacemaker implantation), cerebral infarction (grade 3/4: 2%), cerebrovascular occlusion (7%), coronary artery disease (grade 3/4: 2%), deep vein thrombosis (2%), pericardial effusion (4%), peripheral arterial disease (occlusive: grades 3/4: 3%), pulmonary embolism (2%), reduced ejection fraction (3%), syncope (2%), venous thromboembolism (4% to 10%) and <1%: atrial flutter, atrial tachycardia, complete atrioventricular block, hypertensive crisis, prolonged QT interval on ECG, retinal thrombosis, sinus bradycardia, sinus node dysfunction, subdural hematoma, superficial thrombophlebitis, supraventricular tachycardia, tachycardia, ventricular tachycardia.

• Asciminib: hypertension (14%), increased serum creatine kinase (30%), cardiac arrhythmia (<10%), edema (<10%), heart failure (<10%), palpitations (<10%), prolonged QT interval on ECG (<10%)

700529576

230918

[diagnosis] - 2023-03-27 discharge note

• Malignant neoplasm of extrahepatic bile duct
• Urinary tract infection, site not specified

[past history]

• Type 2 DM
• Hypertension
• Dyslipidemia

        

[allergy]

• NKDA         

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-04-23 CXR

  • Boderline cardiomegaly
  • Tortuosity of the aorta with atherosclerotic change.
  • Increased lung markings over both lungs.
  • Degenerative joint disease of T-spine with marginal osteophytes.

• 2023-04-18 SONO - abdomen

  • liver cyst, both lobe
  • post cholestectomy
  • post stenting to bilateral IHD

• 2023-04-13 CXR

  • Ground glass opacity in bilateral lower lungs.
  • S/P operation with retention of surgical clips.
  • S/P CBD stenting.

• 2023-04-11 CXR

  • Ground glass opacity in LLL.

• 2023-03-24, -03-17 CXR

  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.

• 2023-03-21 CT - abdomen

  • History and indication: Klatskin tumor (Cancer that forms in the area where the left and right hepatic ducts join just outside the liver and form the common hepatic duct. Bile ducts carry bile from the liver and gallbladder to the small intestine. Klatskin tumor is a type of extrahepatic bile duct cancer. Also called perihilar bile duct cancer and perihilar cholangiocarcinoma. 2023-04-14 https://www.cancer.gov/publications/dictionaries/cancer-terms/def/klatskin-tumor)
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction. With and without-contrast CT of abdomen-pelvis revealed:
    • S/P CBD stenting. Dilatation of bil. IHD and distention of gallbladder.
    • Mild enlargement of left thyroid gland. Minimal ascites.
    • Mild bronchiectasis at LLL.
    • R/O right renal cyst (2.5cm).
    • Normal appearance of spleen, pancreas, adrenals.
    • Degeneration and spondylosis of L-S spine.
    • No enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
    • S/P foley catheter indwelling.
  • IMP:
    • S/P CBD stenting. Dilatation of bil. IHD and distention of gallbladder.
    • Mild bronchiectasis at LLL.

• 2023-03-17 KUB

  • S/P plastic stent implantation in between the IHDs and duodenum
  • S/P Foley’s catheter insertion at the urinary bladder.
  • Fecal material store in the colon.
  • Spondylosis of the L-spine is noted.

• 2023-03-15, -03-12 CXR

  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Widening of the upper mediastinum is noted, which may be innominate vessel or tumor. Please correlate with standing p-a view or CT.

• 2023-02-12 ECG

  • Sinus tachycardia
  • Possible Left atrial enlargement
  • Left axis deviation
  • Abnormal ECG

• 2023-01-09 Nasopharyngoscopy

  • via right nasal cavity: patent right nose, patent right E tube orifice, NPx seemed smooth

• 2022-12-28 Cholangiography

  • Cholangiography via bil. PTCD catheters administration revealed:
    • Patency of the catheters. Mild migration of right PTCD catheter.
    • Obstruction of left proximal IHD.
    • Partial obstruction of right proximal IHD.
    • S/P operation with retention of surgical clips.

• 2022-12-28 Endoscopic Retrograde CholangioPancreatography, ERCP

  • diagnosis:
    • Klatskin tumor, post bilateral PTCD, status post bilateral stricture balloon dilation and stenting to right anterior branch and right IHDs
    • Non-visualized GB
  • suggestion:
    • Please keep antibiotics treatment for high post ERCP cholangitis risk

• 2022-12-26 Percutaneous Transhepatic Cholangio-Drainage, PTCD

• 2022-12-23 Patho - gallbladder (benign lesion)

  • A: Gallbladder, cholecystectomy — chronic cholecystitis
    
  • B: Lymph node, group 12a, excision — negative for malignancy (0/1)
  • C: Lymph node, group 12c, excision — negative for malignancy (0/1)
  • F2022-00624 - Lymph node, zone 12 and 8, excision — Negative for malignancy (0/2)

• 2022-12-12 Percutaneous Transhepatic Cholangio-Drainage, PTCD

• 2022-12-12 SONO - abdomen

  • C/W hilar tumor with left IHD and right IHD branch (B6) dilation
  • Renal cysts, RK
  • Hepatic cysts, both lobe

• 2022-12-11, -11-08 CXR

  • Atherosclerosis of the aorta.
  • Enlargement of right hilum.

• 2022-11-11 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (77.3 - 24.4) / 77.3 = 68.43%
    • M-mode (Teichholz) = 68.4
    • 2D (M-simpson) = 64.4
  • Normal AV with mild AR
  • Normal MV with trivial MR
  • Normal LV chamber size and wall thickness
  • Preserved LV and RV systolic function
  • Mild PR, trivial TR, normal IVC size

• 2022-11-22 Flow volume chart

  • mild obstructive ventilatory impairment

• 2022-11-21 SONO - abdomen

  • C/W hilar tumor with left IHD and right IHD branch (B6) dilation
  • ERBD in situ (ERBD: Endoscopic Retrograde Biliary Drainage)
  • Renal cysts, RK

• 2022-11-17 CT - abdomen

  • S/P CBD stenting.
  • Dilatation of bil. IHD and distention of gallbladder.
  • Mild bronchiectasis at LLL.

• 2022-11-12 MRI - MR Cholangiography, MRCP

  • History and indication: Jaundice
  • IMP: In favor of Klatskin tumor with bil. proximal IHD invasion. Some LNs at hepatic hilar region.

• 2022-11-11 Patho - liver biopsy needle/wedge

  • Bile duct, tip of cytoplogy brush, ERCP — Negative for malignancy

• 2022-11-10 Endoscopic Retrograde CholangioPancreatography, ERCP

  • Diagnosis
    • Klastin tumor with obstructive jaundice, suspicious Bismuth-Corlette classification type I, s/p EPBD + brush cytology + ERBD (right IHD)
    • Duodenal ulcer, shallow, bulb
    • Duodenitis, bulb
  • Suggestion
    • On NPO except water tonight
    • f/u Hb, serum AST/ALT, T-bil, lipase on the next morning (11/11)
    • PPI Rx.

• 2022-11-09 CT - abdomen

  • History and Indication: obstructive jaundice.
    • 20221108 CA199:811 U/mL (<35), CEA and AFP:normal.
  • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is a soft tissue mass in the trifurcation of both lobe IHDs and CHD, measuring 1.5 cm in size, causing IHDs dilatation and this mass directly attached the S4 liver.
      • Klatskin tumor (T2b) is highly suspected.
      • In addition, There are four enlarged nodes in the hepatoduodenal ligament (N2).
    • There are several enlarged nodes in gastrohepatic ligament, para-aortic space and para-cava space that may be non-regional lymph nodes metastases (M1).
    • There is linear calcification in the gallbladder fossa. please correlate with clinical condition.
    • There are several renal cysts on both kidney and the largest one measuring 2.4 cm in size at right upper pole.
    • Others
      • There is no focal abnormality in the pancreas, spleen & both kidney.
        
      • There is no ascites.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
    • IMP:
      • Klatskin tumor is highly suspected.
      • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for perihilar CCC: T2b N2 M1, stage:IVB

• 2021-04-13 Bone densitometry - hip

  • Hip BMD performed by DXA revealed:
  • Hip, BMD is 0.637 gms/cm2, about 1.9 SD below the peak bone mass (75 %) and 0.4 SD above the mean of age-matched people (108%).
  • IMP: osteopenia

[MedRec]

• 2023-09-07 SOAP Orthopedics Li YiXuan
  • S
    • right hand contusion
    • Herpes zoster of right hand and palm
  • Prescription
    • Toricam (piroxicam) ASORDER TOPI
• 2023-08-10 SOAP Dermatology Zhou WeiTing
  • S: painful eruption over right upper limb for days.
  • O:
    • Segmental papules, vesicles and crust formation with shooting tenderness over right upper limbs for days.
    • Impression: herpes zoster on the right C10 region.
  • Prescription
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# TID
    • Famvir (famciclovir 250mg) 1# TID
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNQID
    • Orolisin (chlorpheniramine 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# PRNQID
    • Silverzine (silver sulfadizaine) BID EXT
    • Xyzal (levocetirizine 5mg) 1# HS

[consultation]

• 2023-01-09 Ear Nose Throat
  • Q
    • For left ear tinnitus
    • This 81 y/o female was a case of Klastin tumor with obstructive jaundice, T2bN2M1, stage:IVB, s/p ERBD on 2022/11/10. This time, she was admitted for further operation. However, TBI showed 15.21 was noted. Abdomen echo was performed which showed C/W hilar tumor with left IHD and right IHD branch (B6) dilation. Right side PTCD insertion was done smoothly on 2022/12/12. Operation was perfomred which revaled CHD tumor with direct bification and right portal vein invasion and severe fatty liver was noted, then no further operation is proceed due to high risk of hepatic failure. Due to persisted of TBI > 6, left side PTCD was inserted on 2022/12/26. In recent, she felt left ear tinnitus for 2 days. No other cold side were noted in recently. We need your help for further assessment for this patient. Thanks for your time!!
  • A
    • S:
      • Left tinnitus for 2 days, high frequency, especially when talking? Autophony?
      • hearing loss-, aural fullness-, dizziness-
      • NO-, Rhinorrhea+, Sneezing+
    • O:
      • Bil TM intact, EAC clean
      • Bil TM atrophic scar
      • Scope:
        • via right nasal cavity: patent right nose, patent right E tube orifice, NPx seemed smooth
        • the patient can’t tolerate the nasopharyngoscopy and refused further exam
      • Hearing exam:
      • Rinne test: Bil AC > BC
      • Weber: no lateralization
    • A:
      • Left tinnitus, cause?
      • DDx: patulous E tube
    • Plan:
      • may try kentamin if no contraindication
      • The patient refused further exam currently (PTA/typanometry or complete nasopharyngoscopy)
      • The patulous E tube may be improved by lying down or lower the head
      • Please arrange ENT OPD f/u
• 2022-12-23 Radiation Oncology
  • A:
    • A: Klatskin tumor with bil. proximal IHD and portal vein invasion, s/p open cholecystectomy. LN 8,12, dissection.
    • P: Radiotherapy is indicated for this patient with the following indicators: unresectable Klatskin tumor
      • Goal: palliation
      • Treatment target and volume: Klatskin tumor and peripheral involved nodal lesions.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the Klatskin tumor and peripheral involved nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2023-01-19.

[surgical operation]

• 2022-12-22
  • Surgery
    • open cholecystectomy
    • LN 8,12, dissection
  • Finding
    • CHD tumor with direct bification and right portal vein invasion
    • regional LN8 and 12 enlarge
    • severe fatty liver

[MedRec]

• 2023-05-24 SOAP Hemato-Oncology
  • S: supportive treatment with oral UFT
  • Prescription
    • UFT (tegafur 100mg, uracil 224mg) 1# BID 7D
• 2023-05-17 SOAP Hemato-Oncology
  • Plan
    • explain the clinical condition to patient’s daugther
    • suggest oral chemotherapy with UFUR
  • Prescription
    • UFT (tegafur 100mg, uracil 224mg) 1# BID 7D
• 2023-01-30 SOAP Hemato-Oncology
  • explain to pt & her son about the indication & risk / benefit of palliative CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T

[radiotherapy]

• 2023-01-19 ~ undergoing - 3960cGy/22 fractions (15 MV photon) of the Klatskin tumor and peripheral involved nodal lesions.

[chemotherapy]

• 2023-05-17 ~ undergoing - UFT (tegafur 100mg, uracil 224mg) 1# BID

• 2023-02-06 - fluorouracil 200mg/m2 300mg NS 500mL 24hr D1-5

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

• 2023-02-02 - fluorouracil 200mg/m2 300mg NS 500mL 24hr D1-2

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

[note]

Principles of Systemic Therapy — NCCN Clinical Practice Guidelines in Oncology - Biliary Tract Cancers - Version 2.2023 - May 10, 2023 - BIL-C

• Neoadjuvant Therapy
  • Preferred Regimens
    • None
  • Other Recommended Regimens
    • FOLFOX
    • Capecitabine + oxaliplatin
    • Gemcitabine + capecitabine
    • Gemcitabine + cisplatin
    • Durvalumab + gemcitabine + cisplatin
    • Gemcitabine + cisplatin + albumin-bound paclitaxel (category 2B)
  • Useful in Certain Circumstances
    • None
• Adjuvant Therapy
  • Preferred Regimens
    • Capecitabine (category 1)
  • Other Recommended Regimens
    • FOLFOX
    • Capecitabine + oxaliplatin
    • Gemcitabine + capecitabine
    • Gemcitabine + cisplatin
    • Capecitabine + cisplatin (category 3)
    • Single agents:
      • 5-fluorouracil
      • Gemcitabine
  • Useful in Certain Circumstances
    • None
• Agents Used with Concurrent Radiation
  • 5-fluorouracil
  • Capecitabine
• Primary Treatment for Unresectable and Metastatic Disease
  • Preferred Regimens
    • Durvalumab + gemcitabine + cisplatin (category 1)
  • Other Recommended Regimens
    • Gemcitabine + cisplatin (category 1)
    • FOLFOX
    • Capecitabine + oxaliplatin
    • Gemcitabine + albumin-bound paclitaxel
    • Gemcitabine + capecitabine
    • Gemcitabine + oxaliplatin
    • Gemcitabine + cisplatin + albumin-bound paclitaxel (category 2B)
    • Single agents:
      • 5-fluorouracil
      • Capecitabine
      • Gemcitabine
  • Useful in Certain Circumstances
    • Targeted therapy
      • For NTRK gene fusion-positive tumors:
        • Entrectinib
        • Larotrectinib
      • For MSI-H/dMMR tumors:
        • Pembrolizumab
      • For TMB-H tumors:
        • Nivolumab + ipilimumab (category 2B)
      • For RET gene fusion-positive tumors:
        • Pralsetinib (category 2B)
        • Selpercatinib for CCA (category 2B)
• Subsequent-Line Therapy for Biliary Tract Cancers if Disease Progression
  • Preferred Regimens
    • FOLFOX
  • Other Recommended Regimens
    • FOLFIRI (category 2B)
    • Regorafenib (category 2B)
    • Liposomal irinotecan + fluorouracil + leucovorin (category 2B)
    • See also: Preferred and Other Recommended Regimens for Unresectable and Metastatic Disease above
  • Useful in Certain Circumstances
    • Nivolumab (category 2B)
    • Lenvatinib + pembrolizumab (category 2B)
    • Targeted therapy
      • For NTRK gene fusion-positive tumors:
        • Entrectinib
        • Larotrectinib
      • For MSI-H/dMMR tumors:
        • Pembrolizumab
        • Dostarlimab-gxly (category 2B)
      • For TMB-H tumors:
        • Nivolumab + ipilimumab
        • Pembrolizumab
      • For BRAF V600E-mutated tumors:
        • Dabrafenib + trametinib
      • For CCA with FGFR2 fusions or rearrangements:
        • Futibatinib
        • Pemigatinib
      • For CCA with IDH1 mutations
        • Ivosidenib (category 1)
      • For HER2-positive tumors:
        • Trastuzumabk + pertuzumab
      • For RET gene fusion-positive tumors:
        • Selpercatinib for CCA
        • Pralsetinib (category 2B)

Principles of Systemic Therapy — NCCN Clinical Practice Guidelines in Oncology - Hepatocellular Carcinoma - Version 1.2023 - March 10, 2023 - HCC-G

• First-Line Systemic Therapy
  • Preferred Regimens
    • Atezolizumab + bevacizumab (Child-Pugh Class A only) (category 1)
    • Tremelimumab-actl + durvalumab (category 1)
  • Other Recommended Regimens
    • Sorafenib (Child-Pugh Class A [category 1] or B7)
    • Lenvatinib (Child-Pugh Class A only) (category 1)
    • Durvalumab (category 1)
    • Pembrolizumab (category 2B)
  • Useful in Certain Circumstances
    • Nivolumab (Child-Pugh Class B only)
    • Atezolizumab + bevacizumab (Child-Pugh Class B only)
    • For TMB-H tumors:
      • Nivolumab + ipilimumab (category 2B)
• Subsequent-Line Systemic Therapy if Disease Progression
  • Options
    • Regorafenib (Child-Pugh Class A only) (category 1)
    • Cabozantinib (Child-Pugh Class A only) (category 1)
    • Lenvatinib (Child-Pugh Class A only)
    • Sorafenib (Child-Pugh Class A or B7)
  • Other Recommended Regimens
    • Nivolumab + ipilimumab (Child-Pugh Class A only)
    • Pembrolizumab (Child-Pugh Class A only)
  • Useful in Certain Circumstances
    • Ramucirumab (AFP >=400 ng/mL and Child-Pugh Class A only) (category 1)
    • Nivolumab (Child-Pugh Class B only)
    • For MSI-H/dMMR tumors -Dostarlimab-gxly (category 2B)
    • For RET gene fusion-positive tumors:
      • Selpercatinib (category 2B)
    • For TMB-H tumors:
      • Nivolumab + ipilimumab (category 2B)

==========

2023-09-18

According to the PharmaCloud data, this patient has only sought medical care at our hospital in the past three months. No discrepancies or problems were identified during the medication reconciliation process for this patient.

2023-05-29

• The patient’s treatment was changed to UFT (a combination of Tegafur and Uracil) on 2023-05-17. There is limited data on the tolerability of UFT in older adults. However, in a study with a control group of 39 patients over 70 years of age who had undergone resection for colorectal cancer and received UFT alone, adverse events were rare and all were grade 2 or less (Reference: Cancer Biother Radiopharm. 2009;24(1):35-40). Given the patient’s advanced age, the chosen drug appears to be appropriate.

• The drug UFT is approved in Taiwan and other countries, but is not approved by the FDA, Health Canada, or the European Medicines Agency (EMA), and is therefore not recommended by the NCCN guidelines. UFT consists of a 1:4 molar combination of tegafur (a prodrug of 5-FU) and uracil (which competitively inhibits the degradation of 5-FU, resulting in sustained plasma and intratumoral concentrations). As tegafur is a prodrug of 5-FU, which has already been used in this patient in concurrent chemoradiotherapy (CCRT), the efficacy of this approach should be continuously monitored as always.

2023-04-14

• Amsulber (ampicillin, sulbactam) is used due to 2023-04-13 CRP 2.1mg/dL and CXR showed ground glass opacities in bilateral lower lungs.

• Baogan (silymarin) is being used for the patient’s elevated AST and ALT.

2023-03-13

• PharmaCloud database indicates that the medications prescribed within the last 3 months are currently being used properly with no reconciliation issues.

701059574

230918

[MedRec]

• 2023-07-28 SOAP Gastroenterology Su WeiZhi
  • Prescription x2
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Mopride (mosapride citrate 5mg) 1# TID
    • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# TID
• 2023-07-18 SOAP Metabolism and Endocrinology Hu YaHui
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Dyslipidemia ; other and unspecified hyperlipidemia [E78.5]
    • CRI; Unspecified disorder of kidney and ureter [N18.9]
    • Anemia, unspecified [D64.9]
    • Goiter, unspecified [E04.9]
    • Allergic rhinitis [J30.9]
  • Prescription
    • Allegra (fexofenadine 60mg) 1# QD
    • Crestor (rosuvastatin 10mg) 0.5# QW135
    • Ezetrol (ezetimibe 10mg) 1# QD
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
    • Trajenta (linagliptin 5mg) 1# QD
    • Ulstop (famotidine 20mg) 0.5# QD

==========

2023-09-18

Some of the medications prescribed by our gastroenterologist on 2023-07-28 and by our endocrinologist on 2023-07-18 do not appear in the active medication list. Please verify if these omitted medications are still necessary for the patient’s treatment.

701469284

230915

[exam findings]

• 2023-02-10 MRI - nasopharynx
  • Indication: SCC of right buccal mucosa.
  • Past history: He is an oral cancer patient and has received operations in TSGH in 2011.
  • Neck MRI without/with Gadolinium-based contrast enhancement shows:
    • status post previous surgery with old intraoral flap at the right mandibular gingiva.
    • a large well-enhancing mass (largest diameter about 5.3cm) at right buccal region with direct invasion and destruction of right maxilla and right hard palate, with mass protruding medially into oral cavity. The fat plane between the tumor and inferior portion of medial/lateral pterygoid and temporalis muscles is blurred, with interstitial edema of the masticator space, tumor invasion to masticator space is suspected. T4b disease is favored.
    • slightly enlarged lymph nodes at right retropharyngeal space, bilateral level Ib and II, largest diameter about 1.7cm. N2c disease is suspected.
    • bilateral symmetric pharyngeal mucosa.
    • abnormal high signal change of left mandibular bone marrow with enhancement. However this lesion do not show hot spot in bone scan. Nature is to be determined.
  • Impression:
    • Advanced right buccal cancer, image staging favor AJCC T4bN2c.
    • Bone marrow signal change at left mandible, nature to be determined.
  • Oralcavity
    • Impression (Imaging stage) : T:4b N:2c M:0 STAGE:IVB
• 2023-02-09, -02-06 CXR
  • Normal heart size. No mediastinal widening. No active lung lesion. Intact bony thorax. S/P Port-A. S/P CVP line from left? Surgical clips at right side of the neck.
• 2023-02-08 Tc-99m MDP bone scan
  • Hot spots in the right aspect of the maxilla, the nature is to be determined (advanced oral cancer or other nature ?), suggesting PET scan for further evaluation.
  • Suspected benign lesions in some T- and L-spine, right sternoclvicular junction, bilateral shoulders, S-I joints, and knees.
• 2023-02-07 SONO - abdomen
  • Possible small liver cyst, left lobe
• 2023-02-06 ECG
  • Sinus bradycardia
  • Voltage criteria for left ventricular hypertrophy
  • ST elevation, consider early repolarization, pericarditis, or injury
• 2023-01-27 Patho - gingival/oral mucosa biopsy
  • Labeled as “right maxillary gingiva”, biopsy — squamous cell carcinoma.
  • IHC stain: p16 (-).

[MedRec]

• 2023-08-31 SOAP Oral and Maxillofacial Surgery Xia YiRang
  • O: 40% tumor shrinkage due to radiation therapy is noted. radiation-related painful mucositis is noted.
• 2023-08-28 SOAP Oral and Maxillofacial Surgery He ChengHan
  • O: 20% tumor shrinkage due to radiation therapy is noted. radiation-related painful mucositis is noted.

[consultation]

• 2023-05-26 Family Medicine
  • Q: This 52-year-old male suffered from an aggressive malignant tumor at his right maxillary gingiva, buccal and palate mucosa with bone destruction since few months ago. His SCC at the right buccal mucosa , maxillary gingiva, and palatal mucosa was classified as cT4bN2cM0, cStage IVB with terminal stage. We need your End-of-life co-care
  • A: 52-year-old male, Squamous cell carcinoma of right maxillary ginvia, buccal mucosa and platal mucosa with bone destruction, cT4bN2cM0, cstage IVB
    • This time suffer from disease progression, in process of induction chemotherapy
    • Consciousness E4V5M6, ECOG 2
    • We will arrange hospice combine care and follow up his condition
    • Indication: upper gum SCC (Major: Malignant neoplasm of upper gum)
    • Plan: Hospice combined care
• 2023-05-23 Radiation Oncology
  • A: Squamous cell carcinoma of the right upper gingivobuccal mucosa and hard palate, AJCC stage cT4bN2cMo, s/p induction chemotherapy with progression.
  • P: Radiotherapy is indicated for this patient with the following indicators: stage cT4bN2cMo, s/p induction chemotherapy with progression
    • Goal: palliation
    • Treatment target and volume: the right upper gingivobuccal mucosa and hard palate tumor, peripheral involved, to bilateral neck.
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 5000cGy/25 fractions of the right upper gingivobuccal mucosa and hard palate tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the right upper gingivobuccal mucosa and hard palate tumor and involved nodal lesions.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-5-31.
    • Please complete pre-RT dental evaluation and management.
• 2023-02-10 Gastroenterology
  • Q
    • This 52 year old male suffered from an aggressive malignant tumor of right maxillary and mandibular gingiva, buccal mucosa and palate for a few months. SCC of right buccal mucosa, maxillary gingiva, and palatal mucosa which combined with bone destruction, cT4aN0M0. We will arrange induction chemotherapy with Taxotere, Cisplatin, 5-Fu for him.
    • However, his data showed HbsAg (-), Anti-HBc (-) , Anti-Hbs (+) and Anti-HCV (+). We need your further evaluation and suggestion. Thanks !!
  • A
    • The patient is not in the ward, and has no plans to return to the ward after being contacted. I’ve explained to him over the phone, and he has expressed understanding.
      • Blood Draw: DAA medication pre-examination items (no need to redraw if previously done).
        • ALT, AST, Albumin, BUN, Creatinine, Bil(D), Bil(T), HbsAg, a-Fetoprotein, HCV RNA PCR, CBC, PT
    • Well explained to the patient low incidnece of HCV reactivation during or after chemotherapy according to previous reports
    • GI OPD f/u for treatment and echo

[chemotherapy]

• 2023-09-11 - cisplatin 36mg/m2 60mg NS 300mL 3hr + methotrexate 30mg/m2 50mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-09-04 - cisplatin 36mg/m2 60mg NS 300mL 3hr + methotrexate 30mg/m2 50mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-08-21 - cisplatin 36mg/m2 60mg NS 300mL 3hr + methotrexate 30mg/m2 50mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-06-13 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 50mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-05-24 - docetaxel 36mg/m2 50mg NS 100mL 1hr D1 + cisplatin 36mg/m2 50mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-05-17 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-04-28 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-04-21 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-04-06 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-03-13 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-03-06 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-02-20 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-02-13 - docetaxel 40mg/m2 60mg NS 100mL 1hr D1 + cisplatin 40mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-03-28 ~ 2023-04-04 UFT (tegafur 100mg + uracil 224mg) 2# BID

==========

2023-09-15

[oral mucositis]

Since 2023-06-13, the patient has been intermittently receiving radiotherapy. Regarding chemotherapy, after the last TPFL (docetaxel + cisplatin + 5-FU + LV) treatment on 2023-06-13, the patient transitioned to cisplatin + methotrexate starting from 2023-08-21. While oral mucositis could potentially be caused by chemotherapy, it’s important to note that the influence of radiotherapy cannot be entirely ruled out.

According to the recommendations in the article “Management of Cancer Therapy-Associated Oral Mucositis” (https://ascopubs.org/doi/full/10.1200/JOP.19.00652), management options for mucositis severity include bland rinses (normal saline or salt and soda), 2% viscous lidocaine swish and spit, gabapentin, 2% morphine mouthwash swish and spit, doxepin-containing mouthwashes, and systemic opiates, depending on the severity of mucositis.

2023-06-02

• As the chemotherapy regimen has been ongoing since 2023-02-13, the patient’s WBC level remained within an acceptable range until April. However, a leukopenia event was observed following the most recent treatment cycle which began on 2023-05-24, as evident from the data on 2023-05-29. The patient was discharged on 2023-05-31, and it was noted in the discharge summary that “Filgrastim (G-CSF) 150mcg SC QD (self-paid) was prescribed for the prevention of neutropenia.” Nonetheless, the list of discharge prescriptions - loperamide, metoclopramide, zinc gluconate, and acetaminophen - does not include G-CSF. G-CSF is a reasonable medication in this context.
  • 2023-05-29 WBC 1.58 x10^3/uL
    
  • 2023-05-24 WBC 2.78 x10^3/uL
    
  • 2023-05-15 WBC 4.61 x10^3/uL
    
  • 2023-05-01 WBC 2.54 x10^3/uL
    
  • 2023-04-26 WBC 3.19 x10^3/uL
    
  • 2023-04-19 WBC 3.57 x10^3/uL
    
  • 2023-04-11 WBC 5.17 x10^3/uL
    
  • 2023-04-06 WBC 5.11 x10^3/uL
    
  • 2023-03-27 WBC 3.48 x10^3/uL
    
  • 2023-03-20 WBC 6.35 x10^3/uL
    
  • 2023-03-15 WBC 4.22 x10^3/uL
    
  • 2023-03-13 WBC 3.39 x10^3/uL
    
  • 2023-03-06 WBC 5.74 x10^3/uL
    
  • 2023-02-24 WBC 3.62 x10^3/uL
    
  • 2023-02-20 WBC 8.05 x10^3/uL
    
  • 2023-02-06 WBC 5.55 x10^3/uL
• For non-hematological malignancy patients who have experienced leukopenia of less than 1000/uL, or an absolute neutrophil count (ANC) less than 500/uL following chemotherapy, national health insurance covers the use of filgrastim and lenograstim. However, the patient’s WBC count does not yet meet this criterion, hence the need for self-payment. Please confirm the prescription status of Filgrastim.

700731896

230912

• diagnosis - 2022-12-02 admission note
  • Acute kidney failure, unspecified
  • Dyspnea, unspecified
  • Malignant neoplasm of cecum
  • Secondary malignant neoplasm of retroperitoneum and peritoneum
  • Secondary malignant neoplasm of liver and intrahepatic bile duct
  • Essential (primary) hypertension

[lab data]

2022-09-09 Anti-HBc Reactive
2022-09-09 Anti-HBc-Value 2.22 S/CO
2022-09-09 Anti-HBs 81.03 mIU/mL
2022-09-09 HBsAg (quantative) Nonreactive
2022-09-09 HBsAg Value (quantative) 0.00 IU/mL
2022-09-09 Anti-HCV Nonreactive
2022-09-09 Anti-HCV Value 0.11 S/CO

[exam finding]

• 2023-08-21 CT - abdomen
  • History and indication: adenocarcinoma of cecum with total small bowel obstruction and carcinomatosis and liver metastases, stage IVC
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P ileostomy. Mild progression of cecal cancer, liver metastases and peritoneal carcinomatosis with ascites.
    • Bil. pleural effusions. Small liver cysts. Mild splenomegaly.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P ileostomy. Mild progression of cecal cancer, liver metastases and peritoneal carcinomatosis with ascites. Bil. pleural effusions. Mild splenomegaly
• 2023-08-17 MRI - brain
  • No brain nodule. No evident acute infarct.
• 2023-07-25 SONO - abdomen
  • Indication: abdominal pain
  • Findings:
    • At least 4-5 hyperechoic lesions with faint acoustic shadows were noted at right lobe and possible S4. The largest one is about 1cm at S7.
    • Splenomegaly about 13.5cm.
    • Small to moderate amount ascites
    • Tiny echogenic lesions were noted on the peritoneum. (eg. liver surface)
  • Diagnosis:
    • Liver tumors
    • Splenomegaly
    • Ascites
    • c/w carcinomatosis
• 2023-07-03, -06-20, -05-22, -05-14 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Spondylosis with scoliosis of the T-spine with convex to right side
• 2023-06-20 KUB
  • Spondylosis of the L-spine is noted.
  • One segmental small bowel in LMQ abdomen shows mild dilatation.
  • Follow up is indicated. Otherwise, Please correlate with CT.
• 2023-06-19 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in both rib cages, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, and hips.
• 2023-05-25 CT - abdomen
  • History and indication: adenocarcinoma of cecum with total small bowel obstruction and carcinomatosis and liver metastases, stage IVC
  • IMP:
    • S/P ileostomy. Stable condition of cecal cancer, liver metastases and peritoneal carcinomatosis. Minimal ascites.
    • Minimal pleural effusion.
• 2023-05-11 KUB
  • Degeneration of bony structures.
  • Stool retention in bowl.
• 2023-04-12 KUB
  • Disk space narrowing with spurs formation at L3-L4, L4-L5, and L5-S1 levels due to spondylosis
  • mild dextroscoliosis of the L-spine
• 2023-04-12 CXR
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch;. dilated ascending aorta
  • skin folds over Lt hemithorax otherwise clean lung fields based on plain image
  • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
  • Mild dextroscoliosis of the T-spine
• 2023-04-12 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
• 2023-02-06 CT - abdomen
  • S/P ileostomy. Mild regression of cecal cancer and liver metastases but mild progression of peritoneal carcinomatosis.
• 2023-01-12 SONO - nephrology
  • Bilateral chronic change of both kidneys.
• 2022-12-22 SONO - kidney
  • Normal echogenicity of the bil. kidneys.
  • Normal cortical thickness of the kidneys.
  • No evidence of urolithiasis.
  • No evidence of hydronephrosis.
• 2022-12-02 CXR
  • Sinus tachycardia
  • T wave abnormality, consider lateral ischemia
  • Abnormal ECG
• 2022-11-15 CXR
  • enlarged cardiac silhoutte may be prominent cardiophrenic angle mediastinal fat pad/ supine position
• 2022-11-09 CXR
  • enlarged cardiac silhoutte may be prominent cardiophrenic angle mediastinal fat pad/ supine position
  • marginal spurs of multiple vertebral bodies of T-L spine due to spondylosis.
• 2022-10-24 CXR
  • S/P nasogastric tube insertion
    
  • Enlargement of cardiac silhouette.
  • Spondylosis with scoliosis of the T-spine with convex to right side
• 2022-10-17 CXR
  • appropriately positioned gastric tube
  • Port-A catheter inserted into SVC via left subclavian vein.
  • enlarged cardiac silhoutte may be due to dilated cardiac chambers and prominent cardiophrenic angle mediastinal fat pad/ supine position
  • Rt and Lt subpulmonary effusion?
• 2022-10-14, -10-12, -10-10 CXR
  • enlarged cardiac silhoutte may be due to dilated cardiac chambers and prominent cardiophrenic angle mediastinal fat pad/ supine position
  • Rt and Lt subpulmonary effusion?
  • appropriately positioned gastric tube
• 2022-10-07 CXR
  • Port-A catheter inserted into SVC via left subclavian vein.
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta. dilated ascending aorta
  • enlarged cardiac silhoutte may be due to dilated cardiac chambers (LVD) or LVH and prominent cardiophrenic angle mediastinal fat pad/ supine position?
  • Rt and Lt subpulmonary effusion?
  • appropriately positioned gastric tube
• 2022-09-07 CT - abdomen, pelvis
  • Inidcation:
    • epigastric pain for one month,
    • abdominal fullness with crampying pain, intermittent
  • Findings:
    • There is ill-defined Eqivocal soft tissue mass-like lesion in the RLQ abdomen, near the cecal base, appendix, and ileocecal valve area, that may be adenocarcinoma. The differential diagnosis include metastasis.
      • In addition, this mass lesion causinig mechanical small bowel obstruction.
    • There is long segmental symmetrical mild wall thickening of the small intestine at the lower abdomen and upper pelvis causing marked dilatation of the proximal small bowel that may be tumor seeding or Crohn disease?
    • There is ascites, soft tissue lesions in the RLQ omentum and the mesentery that may be carcinomatosis. Please correlate with ascites cytology.
    • There is Eqivocal wall thickening of the sigmoid colon that may be primary adenocarcinoma or tumor seeding? Please correlate with colonoscopy.
    • There are three poor enhancing mass measuring 0.8 cm in S8 dome, 0.6 cm in S8, and 1.8 cm in S6 of the liver. Metastases are highly suspected.
    • The pancreas shows small size that is c/w senile atrophy.
    • Abdominal aorta shows atherosclerosis and ectasia 2.7 cm.
    • There is a enlarged node in pre-cava space measuring 2.2 x 1 cm that may be metastatic node.
    • There is no focal abnormality in the gallbladder, biliary system, spleen & both kidney. .
    • The IVC are grossly unremarkable.
    • There is no evidence of intrinsic or extrinsic bladder mass.
  • Impression:
    • Adencoarcinoma of the cecum or appendix causing high grade small bowel obstruction, carcinomatosis, and liver metastases is highly suspected.
    • The differential diagnosis include metastases, origin?
    • Please correlate with colonoscopy.
• 2022-09-07 KUB
  • Presence of ileus.
  • Degeneration and spondylosis of L-S spine.
  • A calcified spot at left pelvic cavity.
• 2022-09-07 CXR
  • Presence of ileus.
  • Interstitial pattern at bil. lower lungs.

[consultation]

• 2023-05-18 Infectious Disease
  • Q
    • This 82-year-old man patient is a case of Lung cancer with lymph nodes and bone metastases, cT4N3M1b, stage IVA. This time, for Pneumonia, bilateral lung with Antibiotic with Tapimycin 4.5gm iv Q6H from 2023/04/26~. Cytomegaloviral disease with Valcyte F.C 450mg 2# po QD. Chronic obstructive pulmonary disease with Medason 40mg iv BID from 2023/04/27~, Symbicort Rapihaler 2 puff INHL BID and Spiriva Respimat 2 puff INHL QD. Pneumocystosis jirovecii pneumonia (2023/05/02 P.jiroveci DNA-Sp showed Positive) with Antibiotic with Sevatrim 400mg & 80mg 10ml IV Q8H from 2023/05/01~. O2 Mask 5L 31% use, SpO2:95%. Now, for evaluate antibiotic therapy. Thank you.
  • A
    • KP bacteremia on May 14, possible Port-A related.
    • Urine culture disclosed MRSH and Enterococcus faecalis mixed infections, with low colony count.
    • There is complete defervescence since yeterday morning under Brosym and Targocid use.
    • Change of antibiotic regimen should be not necessary.
    • Please keep Targocid for one week, and follow up urine culture 4-5 days later.
    • Port-A blood culture should be rechecekd tomorrow to see if there is sterile blood.
    • Brosym can be replaced by Cipro or Cravit on May 21 as sequential therapy.
• 2022-10-13 Dermatology
  • Q
    • For skin rash
    • This 68-year-old male has past history of
      • hypertension
      • Adencarcinoma of the cecum with total small bowel obstruction and carcinomatosis, liver metastases, stage IVC status post Loop ileostomy on 2022/09/09~09/17.
    • Current problem: Due to skin rash around back, chest, abdomen and inguinal area, so we need your help for evaluation. Thanks!!
  • A
    • The patient had sufferred from diffuse fine reddish papules with minimal pruritus on the trunk, majorly on the compression sweat area.
    • several erythematous annular lesions with active borders over lower legs.
      
    • Under the impression of milaria over trunk and tinea pedis over foot and lower leg.
    • The following sugeetion:
      • for trunk, keep body position change and avoid too long compression, consider Sinbaby 1 bot topical PRN use for occlusion if pruritus development
      • for lower leg and foot, Exelderm 1 tube topical bid use on the lower leg and foot area.
• 2022-10-13 Metabolism and Endocrinology
  • Q
    • For abnormal thyroid function (20221012 (nuclear medicine) Free T4: 1.81, TSH: 0.078, T3: 58.119), so we need your help for evaluation. Thanks!
  • A
    • S: For abnormal TFT
    • O:
      • TPR- 37.1/79/12; BP-147/88
      • free T4-1.810, T3-58.119, TSH-0.078
      • HbA1C-6.4
      • No sig. blood flow on bedside thyroid echo
    • A:
      • Favor sick euthyroidism or low T3 syndrome
      • Suspected DM
    • Suggestions:
      • It is unnecessary to medication for thyroid at this timing
      • Just to follow free T4, T3 and TSH after 1 week is fine
      • Any problem, please call me
• 2022-10-12 Cardiology
  • Q
    • Lab 2022-10-12
      • Mg (Magnesium) 1.5 mg/dL
        
      • Na (Sodium) 138 mmol/L
        
      • K(Potassium) 4.0 mmol/L
        
    • Current problem: For short run VT with pulse around 8 sceonds, so we need your help for evaluation
  • A
    • O
      • BUN: 28
      • Cr: 0.66
      • Hb: 9.4
    • Suggestion:
      • Please add carvedilol (6.25mg) 0.5#bid-1#bid if no contraindication
      • Follow-up on call, Thanks.
• 2022-10-07 Gastroenterology
  • Q
    • Lab 2022-09-09
      • Anti-HBc Reactive
        
      • Anti-HBc-Value 2.22 S/CO
        
      • Anti-HBs 81.03 mIU/mL
        
      • HBsAg Nonreactive
        
      • HBsAg Value 0.00 IU/mL
        
      • Anti-HCV Nonreactive
        
      • Anti-HCV Value 0.11 S/CO
        
    • Current problem: Due to chemotherapy will be conducted, we need your help for evaluation of prescription anti-Hepatitis B virus drug.
  • A
    • The patient has Adencoarcinoma of the cecum with total small bowel obstruction and carcinomatosis, liver metastases, stage IVC status post Loop ileostomy on 2022/09/09. This time, he was admitted for respiratory distress, AKI with hyperkalemia, start hemodialysis for oligouria, acidosis during this hospitalization. For planned chemotherapy, and his lab data: HBc(+), we are consulted for HBV therapy.
    • Lab
      • Anti-HBc Reactive
        
      • HBsAg Nonreactive
        
    • Impression
      • Resolved HBV infection
      • Acute kidney injury with metabolic acidosis, hyperkalemia, now under hemodialysis
      • Adencarcinoma of the cecum, plan for chemotherapy
    • Suggestion
      • Currently, chemotherapy has not been scheduled, and the NHI only covers HBV insurance covers drugs from one week before chemotherapy to half a year after chemotherapy; and the renal function is not stable, which will affect the dosage of anti-HBV drugs; please call the gastroenterology department to evaluate medicine if the date of chemotherapy has been determined.
• 2022-10-04 Nephrology
  • A
    • Consult for AKI and renal function impairment
    • Lab data:
      • VBG PH: 7.372, PCo2: 31.5, HCO3: 17.9, BE: -7.6
      • WBC: 16.94, HbL: 17.4, Plt: 314
      • CK :436, CLMB: 37.9, TroponinI: 595.4
      • Na: 115, K: 6.6
      • BUN/ cre: 12/0.47(9/12)-＞ 139/7.83(9/29)-＞ 218/15.83(10/4)
      • CEA: 507.17,CA 199: 1052.27
      • U/O: decrease ( no foley)
      • GPT: 281, GOT: 93, T bil :1.52,albumin:5.1
      • BP:70/50mmHg, SOB
    • Impression:
      • Acute kidney injury stage 3 suspect prerenal, septic shock and dehydration
    • Suggestion:
      • Admit ICU
      • Correct metabolic acidosis with sodium bicarbonate 20ml per hr
      • Correct hyperkalemia with D50+ RI, kalimate
      • Correct hyponatremia with 3% NS
      • Suggest IV adequate Hydration
      • Explain family about Emergent CRRT
      • We will arrange RRT if family agree
      • Thank you for your consultation !
• 2022-09-07 Colorectal Surgery
  • Q
    • epigastric pain for one month
    • panendoscopy at local clinic found DU
    • abdominal fullness with crampying pain, intermittent
    • deny abd op Hx
  • A
    • this patient told me that he got this problem abdout 2-3 months ago and start to feel abdomen distension about one wks ago
    • CT revealed that carcinomatosis was found
    • pt still passage of gas and stool now
    • there’s no need for emergency surgery now
    • thanks for your consultation

[chemoimmunotherapy]

• 2023-08-23 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + atropine 1mg SC
• 2023-08-09 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-21 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-02 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-18 - (Avastin + FOLFOX, Q2W)
• 2023-03-29 - (Avastin + FOLFOX, Q2W)
• 2023-03-16 - (Avastin + FOLFOX, Q2W)
• 2023-02-15 - (FOLFOX, Q2W)
• 2023-02-02 - (FOLFOX, Q2W)
• 2023-01-16 - (FOLFOX, Q2W)
• 2022-12-22 - (FOLFOX, Q2W)
• 2022-11-25 - oxaliplatin 75mg/m2 135mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
• 2022-11-07 - oxaliplatin 65mg/m2 120mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
• 2022-10-24 - oxaliplatin 65mg/m2 120mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
• 2022-10-11 - leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg 4500mg 46hr

==========

2023-07-04

[renal function follow-up]

Given the recent serum Cre and BUN records, it appears that the patient’s AKI status has been resolved for some time. Therefore, this might be marked as an inactive or resolved item in the medical problem list.

• 2023-06-27 Creatinine 1.10 mg/dL
  
• 2023-06-20 Creatinine 1.06 mg/dL
  
• 2023-06-19 Creatinine 0.99 mg/dL
  
• 2023-06-14 Creatinine 1.62 mg/dL
  
• 2023-06-27 BUN 20 mg/dL
  
• 2023-06-20 BUN 10 mg/dL
  
• 2023-06-19 BUN 11 mg/dL
  
• 2023-06-14 BUN 27 mg/dL

2022-12-05

• On 2022-12-05, both serum creatinine and BUN were lower than on 2022-12-03 (Cre 3.63 -> 1.90 mg/dL; BUN 71 -> 48 mg/dL), which indicates that the patient’s kidney function has improved.
• The administration of KCl in normal saline is used to treat hypokalemia (2.9 mmol/L 2022-12-05) as well as hyponatremia (127 mmol/L 2022-12-05).
• In the past three days, the blood pressure has remained approximately 110/60 +- 10 mmHg; in the event that successive data points show BP lower than 100/60, Norvasc (amlodipine) could be held (while Carvedilol is continued for his 90 +-20 heart rate; 2022-10-12 short run VT with pulse around 8 sceonds).

2022-09-08

• It is suspected that the patient has cecum or colon cancer and is undergoing a workup. There is no issue with the active prescription.

701001983

230912

[diagnosis] - 2023-03-20 admission note

• Malignant neoplasm of gallbladder
• Encounter for antineoplastic chemotherapy
• Insomnia, unspecified
• Unspecified viral hepatitis B without hepatic coma
• Constipation, unspecified

[past history]

• Left multiple lower neck LAP with cystic like change at level III, IV, Vb
• Left thyroid tumor, small, favor benign.            

[allergy]

• NKDA             

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-05-09, -04-10, -04-06 Abdomen - Standing (Diaphragm)
  • S/P plastic stent implantation from right lobe IHD to duodenum.
• 2023-04-13 Patho - stomach biopsy
  • Stomach, body, biopsy — Non-atrophic chronic gastritis
  • The sections show gastric body mucosal tissue with congestion, edema, mild chronic inflammatory cell infiltration, no neutrophil infiltration, no intestinal metaplasia, no gastric atrophy, and no Helicobacter pylori colonization.
• 2023-04-13 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis, lower esophagus, LA classification, grade A
  • Superfical gastritis, antrum
  • Gastric polyp, multiple, body, s/p biopsy
  • Post ERBD
• 2023-04-12 CT - abdomen
  • History: 20230110 MRI: gallbladder cancer with cystic duct, CHD extension, LNs and liver metastases.
  • Findings:
    • Prior CT identified a mass lesion (3.8x7.5cm) in gallbladder is noted again, marked decreasing in size that is c/w gallbladder cancer S/P C/T with partial response.
    • Prior CT identified several metastatic LNs at hepatic hilar region are noted again, marked decreasing in size that is c/w metastatic LNs S/P C/T with partial response to near complete response.
    • Prior CT identified several metastases in both hepatic lobes are noted again, decreasing in size that is c/w liver metastases S/P C/T with partial response.
    • Prior CT identified a nodule (1.3cm) at right breast is noted again, stationary.
    • There is an ill-defined faint poor enhancing area in S4-8 of the liver, nature? Follow up is indicated.
    • S/P plastic stent implantation in between right lobe IHD and duodenum. However, mild dilatation of IHDs is still noted.
  • Impression:
    • Gallbladder cancer with liver and LNs metastases S/P C/T show partial response.
• 2023-03-22 CT - brain
  • Indication: Gallbladder cancer with Common bile duct compression and multiple liver metastases, cT3N2M1, stage IV
  • IMP: no evidence of brain tumors.
• 2023-03-20 CXR
  • Mild Scoliosis of the T-spine with convex to right side.
  • Atherosclerotic change of aortic arch
• 2023-03-06 CXR
  • Scoliosis of the T-spine with convex to right side.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2023-01-16 Patho - lymphnode biopsy
  • Labeled as “subclavian lymph node, left”, biopsy — metastatic adenocarcinoma with neuroendocrine feature.
  • Section shows lymph node almost completely replaced by metastatic adenocarcinoma, demonstrating glands and short papillary structure.
  • IHC stains: CK7 (diffuse +), CK20 (-), TTF-1 (focal +), CK19 (diffuse +), PAX-8 (focal +), thyroglobulin (equivocal), Napsin-A (-), CD56 (focal +), synaptophysin (focal +). Extranodal extension is not present.
• 2023-01-11 SONO - breast
  • A round right breast tumor (#2).
  • Enlarged left axillary lymph nodes, suspect lymphadenopathy.
  • BI-RADS category 4, Suspicious abnormality. Biopsy should be considered.
• 2023-01-11 Endoscopic Retrograde CholangioPancreatography, ERCP
  • Diagnosis
    • Middle CBD stricture, s/p plastic stent placement (8.5 Fr. 9 cm )
    • Chronic cholangitis
    • Reflux esophagitis, Gr. A
  • Suggestion:
    • f/u amylase & lipase
• 2023-01-10 MR Cholangiography, MRCP
  • History and indication: Acute cholecystitis
  • IMP: In favor of gallbladder cancer with cystic duct, CHD and CHD extension, LNs and liver metastases. Right breast tumor.
• 2023-01-09 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Poorly differentiated carcinoma with marked neuroendocrine differentiation
  • The sections show a picture of sheets of poorly differentiated neoplastic cells with marked tumor necrosis, embedded in fibrous stroma. No definite glandular formation can be identified.
  • IHC shows: CK(+), CK7(+), CK20(-), CD56(+), and Synaptophysin(+). Either neuroendocrine carcinoma or mixed carcinoma with marked neuroendocrine differentiation should be considered.
• 2023-01-08 CT - abdomen
  • Lobulated mass-like lesions within the gallbladder with heterogeneous enhancement. Suspected malignancy.
  • Several hypoperfusion nodular lesions over right hepatic lobe, may be metastatic lesions.
  • Dilated CBD and IHDs.
    
  • S/P hystorectomy.
  • Suspect confluent lobulated nodes over hepatic hilum.

[MedRec]

• 2023-09-08 SOAP Ear Nose Throat
  • Prescription
    • Allegra (fexofenadine 60mg) 1# QD
    • Shitan (bromhexine 8mg) 1# BID
    • Anxokast (montelukasf 10mg) 1# HS
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD

[consultation]

• 2023-01-17 Radiation Oncology
  • A
    • A: Poorly differentiated carcinoma with marked neuroendocrine differentiation of the gallbladder, with liver metastasis.
    • P: Radiotherapy is indicated for this patient with the following indicators: tumor with metastasis and pain
      • Goal: palliation
      • Treatment target and volume: gallbladder tumor, peripheral involved, to metastatic liver tumor
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the gallbladder tumor, peripheral involved, to metastatic liver tumor
      • The treatment planning of radiotherapy will be started at 0830, 2023-02-06.
• 2023-01-12 Hemato-Oncology
  • Q
    • for chemotherapy
    • This is a 64 yesr old female patient. Under impressed of gallbladder cancer with liver metastases. We need your professional evaluation for this patient. Thank you so much!!
  • A
    • This 64 year old woman is a case of gall bladder cancer with liver metastasis (liver biopsy: Poorly differentiated carcinoma with marked neuroendocrine differentiation). We are consulted for chemotherapy.
    • Please arrange port A insertion and check HbsAg, Anti Hbc, Anti HCV. We will discuss with patient about further palliative chemotherapy (regimen such as cisplatin + etoposide). Please arrange our OPD after discharge.
• 2023-01-12 Ophthalmology
  • Q
    • This time she felt headache due to high intraocular pressure at night. We need your help for professional assessment. Thank you so much!!
  • A
    • S
      • Left eyelid twitching and mild fullness
    • O
      • denied bv ou, headache occasionally
      • denied past hx
      • denied oph hx
      • nka
      • VAcNC od 20/70 os 20/70
      • IC 13/14mmHg
      • Pupil 3/3 +/+
      • Conj np ou
      • K clear ou
      • AC shallow / clear ou
      • Lens ns+++
    • A
      • no acute ocular problem at present
    • P
      • Inform the red flags, if worsen vision, come back asap
      • suggest oph opd f/u for prophylatic LI ou
      • opd f/u

[radiotherapy]

• 2023-02-14 ~ 2023-03-30 - 1800cGy/10 fractions of the gallbladder tumor, peripheral involved, to metastatic liver tumor, and 4500cGy/25 fractions of the gallbladder tumor, peripheral involved area.

[chemotherapy]

• 2023-07-20 - etoposide 70mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 70mg/m2 110mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-06-02 - etoposide 70mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 70mg/m2 110mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-05-09 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-03-20 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 115mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-02-10 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-01-16 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-03-21

• High-grade neuroendocrine carcinomas (NEC) with poor differentiation tend to have a high likelihood of developing distant metastases and a concerning prognosis, even when they appear to be clinically localized. For the treatment of metastatic gastrointestinal and pancreatic NEC, it is often recommended to use a two-drug platinum-based regimen, usually consisting of cisplatin or carboplatin combined with etoposide.

• The ideal treatment duration remains undetermined. Generally, the goal is to administer 4 to 6 cycles of therapy. However, if a patient continues to respond positively to the treatment and experiences minimal side effects, it may be suitable to extend chemotherapy until the maximum possible response is achieved. ref: UpToDate. https://www.uptodate.com/contents/high-grade-gastroenteropancreatic-neuroendocrine-neoplasms

• Neuroendocrine tumors, metastatic carcinoma

  • etoposide
    • 100 mg/m2 on days 1, 2, and 3 every 4 weeks (in combination with cisplatin) until disease progression or unacceptable toxicity. ref: https://pubmed.ncbi.nlm.nih.gov/11571721/
    • 130 mg/m2 as a continuous infusion on days 1, 2, and 3 every 4 weeks (in combination with cisplatin) until disease progression or unacceptable toxicity. ref: https://pubmed.ncbi.nlm.nih.gov/1712661/
    • 100 mg/m2 on days 1, 2, and 3 every 3 weeks (in combination with cisplatin) for up to 6 cycles. ref: https://pubmed.ncbi.nlm.nih.gov/23406729/
  • cisplatin
    • 45 mg/m2/day as a continuous infusion on days 2 and 3 every 4 weeks (in combination with etoposide) until disease progression or unacceptable toxicity. ref: https://pubmed.ncbi.nlm.nih.gov/11571721/ https://pubmed.ncbi.nlm.nih.gov/1712661/
    • 80 mg/m2 over 30 minutes on day 1 every 3 weeks (in combination with etoposide) for up to 6 cycles. ref: https://pubmed.ncbi.nlm.nih.gov/23406729/

• The patient’s current etoposide and cisplatin regimen does not exceed the mentioned dosage, making it suitable and not necessitating any dosage adjustments.